Telehealth Encourages Patients with Diabetes in Racial and Ethnic Minority Groups to Return for in-Person Ophthalmic Care During the COVID-19 Pandemic

A scoping review of digital solutions in diabetes outpatient care: Functionalities and outcomes

BACKGROUND

Digital interventions are increasingly used in outpatient diabetes care to address growing healthcare demands and workforce limitations. This study investigates the functionalities of digital solutions and their impact on Quadruple Aim outcomes: enhancing population health, improving patient experience, supporting clinician well-being, and reducing healthcare costs.

METHODS

We followed Joanna Briggs Institute guidelines, searching PubMed, Embase, Cochrane, Scopus, and Web of Science (January 2019-February 2024). Included studies reported digital diabetes interventions with outcomes directly relevant to the Quadruple Aim. Each intervention was mapped to a digital solution horizon: Horizon 1 involves foundational digital workflows; Horizon 2 leverages real-time data to create analytics; Horizon 3 encompasses transformative uses, such as predictive analytics.

RESULTS

We identified 4,397 articles with 56 meeting the inclusion criteria. Interventions included telehealth (n = 15), mobile health (mHealth) (n = 20), combined telehealth and mHealth (n = 14), robotics (n = 1), electronic medical records (n = 1), and artificial intelligence (n = 5). Most interventions (n = 51) were categorised as Horizon 1, with 10 adopting Horizon 2, 5 using Horizon 3, and 10 spanning multiple horizons. Regarding Quadruple Aim outcomes, 44 studies addressed population health (41 positive), 31 targeted patient experience (29 positive), 4 focused on clinician well-being (3 positive), and 6 on cost reduction (4 positive).

CONCLUSION

Digital solutions have demonstrated measurable benefits, particularly in population health and patient experience. Most interventions remain at Horizon 1. Advancing these digital solutions to Horizon 2 and 3 is essential for system-wide transformation. Future research should include cost efficiency and clinician experience alongside evaluations of population health and patient experience.

Impact of a Patient Portal-Based Telehealth Outreach Program on Recall of Patients with Diabetic Retinopathy

Purpose: To evaluate the effectiveness of a patient portal telehealth outreach program to return patients with diabetic retinopathy (DR) lost to follow-up (LTFU) for eye care. Methods: Patients with DR receiving intravitreal injection (IVI) therapy who were >90 days beyond recommended return were deemed LTFU. Outreach messages were sent via a patient portal, when available, or through the U.S. mail. Patients received information on how to schedule a retinal examination and a symptom-screening questionnaire. The adherence rate to scheduled appointments was assessed 90 days postintervention. Labor costs were estimated based on communication time. Results: Among 359 patients with DR receiving IVIs, 22% were LTFU, overdue by a median of 362 days. Receiving fewer IVIs was the factor most strongly associated with becoming LTFU (8.9  ±  9.1 injections vs. 22 ± 20 injections, p < 0.001). The outreach program engaged 39 patients via the patient portal and 28 patients via the U.S. mail. A similar number of patients in each cohort was scheduled (13% vs. 14%, p = 0.862) and completed appointments (10% vs. 14%, p = 0.616). Whereas patient-portal messages took an average of 64 s to send at a labor cost of $0.35/message, each letter sent by mail took approximately 5 min to prepare at a total cost of $2.19. Conclusions: A patient portal-based telehealth outreach program is effective at returning patients with DR to eye care and can be implemented at a lower cost, compared with conventional mailed recall letters. Efforts are needed to increase digital health literacy and access to improve the efficiency of health care delivery.

Low Vision Services Are Underutilized by Patients with Vision Loss from Corneal Disease

PURPOSE

This study evaluated the rate at which patients with visual impairment primarily from corneal disease were referred for low vision (LV) services and assessed the visual outcomes from completed evaluations.

METHODS

This 1-year retrospective, cross-sectional study included patients with corneal disease limiting best-corrected visual acuity (BCVA) to ≤ 20/40. Outcome measures included the change in BCVA achieved after distance refraction by a LV specialist. Incremental costs per quality-adjusted life years (QALY) gained were calculated upon the better-seeing eye, by using a willingness-to-pay threshold of USD 50,000/QALY.

RESULTS

Of 3230 patients, 143 (4.4%) had visual impairment from corneal disease. The median age of those patients was 80 years (IQR: 66-88 years) and 64.3% were male. Just over half were referred for LV evaluations (53.2%), and most completed appointments (96.1%). Patients more likely to be referred had better vision in their worse-seeing eye (0.961 logMAR vs. 1.451 logMAR, P = 0.002) and were more frequently diagnosed with corneal dystrophies, degenerations, or ectatic disease (51.3% vs. 26.9%, P = 0.003) compared with other corneal conditions, but they were less likely to have immunologic conditions (2.6% vs. 13.4%, P = 0.016). In total, two-thirds of patients achieved improved BCVA for their better-seeing eye, with 32% gaining ≥ 2 lines. This translated into an average gain of 0.04 QALYs/patient at a cost of USD 3128/QALY. The estimated net monetary benefit was USD 1923/LV evaluation completed.

CONCLUSIONS

Referring patients with corneal disease to LV services resulted in significant improvements in visual function at a reasonable cost.

Impact of teleretinal screening program on diabetic retinopathy screening compliance rates in community health centers: a quasi-experimental study

BACKGROUND

Diabetic retinopathy (DR) remains a leading cause of preventable blindness, with inadequate screening rates even in urban areas with high concentrations of medical professionals. While medical guidelines recommend annual diabetic retinopathy screening for patients with diabetes mellitus, adherence to these recommendations remains low. This study evaluates the impact of a novel teleretinal DR screening program on screening compliance across urban community health centers in Boston, Massachusetts.

METHODS

We conducted a quasi-experimental study comparing DR screening compliance between intervention and comparison community health centers before and after implementing a teleretinal screening program. Participants included patients diagnosed with diabetes mellitus with primary care providers at the studied sites. We defined compliance as completion of either teleretinal screening or a documented eye care professional examination within the previous 365 days. Monthly compliance rates were analyzed using two-way fixed effects regression and event study techniques.

RESULTS

The study included 10,247 patients with diabetes mellitus who received care at six participating sites, generating 222 monthly compliance rate estimates. Baseline compliance rates before implementation ranged from 25 to 40% across sites. The two-way fixed effects regression analysis revealed that the screening program significantly increased DR compliance rates by an average of 7.2% points (p < 0.001). Event study analysis showed positive effects across all sites, though the initial improvement tended to diminish over time.

CONCLUSIONS

Implementation of a community-based teleretinal DR screening program significantly improved compliance with annual screening guidelines in urban communities. These findings support the broader adoption of teleretinal screening as an effective strategy for preventing DR-related vision loss in vulnerable populations. Further research is needed to assess long-term clinical outcomes and optimize program sustainability.

Access to a Patient Portal is Associated with a Higher Rate of Diabetic Eye Examination Completion

PURPOSE

To evaluate factors associated with a higher completion rate of annual diabetic eye examinations.

METHODS

This retrospective, cross-sectional study included patients diagnosed with diabetes mellitus (DM) who were aged 18-75 years and receiving primary care in a suburban integrated delivery network (IDN). Patient demographic, sociomedical, biometric characteristics, and Healthcare Effectiveness Data and Information Set (HEDIS) measures within the Comprehensive Diabetes Care bundle were extracted from the electronic health record (EHR) and analyzed by using multivariate logistic regression to assess factors associated with completion of an eye exam (retinal) performed during the study year.

RESULTS

Among 19,901 primary care patients with DM, 35.15% completed an eye examination in 2021. After adjusting for demographic and biometric characteristics, the two factors most closely associated with completing a diabetic eye examination were having had a primary care office visit (adjusted odds ratio [aOR], 3.525; 95% confidence interval [CI], 3.210-3.871, p < 0.001) or an eye examination in the prior year (aOR, 2.948; 95% CI, 2.752-3.158, p < 0.001). The next most important factor to emerge was having an activated, online patient portal (PP; aOR, 1.737; 95% CI, 1.592-1.896; p < 0.001) or PP recently activated within the prior year (aOR, 1.387; 95% CI, 1.220-1.576, p < 0.001).

CONCLUSIONS

Surveillance for diabetic retinopathy relies on annual diabetic eye examinations yet adherence to that standard remains unacceptably low. Our study suggests that engagement of patients through an online PP could help increase this rate.

Factors Associated with Utilization of Teleretinal Imaging in a Hospital-Based Primary Care Setting

Regular eye examinations to screen for the initial signs of diabetic retinopathy (DR) are crucial for preventing vision loss. Teleretinal imaging (TRI) offered in a primary care setting provides a means to improve adherence to DR screening, particularly for patients who face challenges in visiting eye care providers regularly. The present study evaluates the utilization of TRI to screen for DR in an outpatient, hospital-based primary care clinic. Patients with diabetes mellitus (DM) but without DR were eligible for point-of-care screening facilitated by their primary care provider, utilizing a non-mydriatic, handheld fundus camera. Patient demographics and clinical characteristics were extracted from the electronic medical record. Patients who underwent TRI were more likely to be male, non-White, and have up-to-date monitoring and treatment measures, including hemoglobin A1c (HbA1c), microalbumin, and low-density lipoprotein (LDL) levels, in accordance with Healthcare Effectiveness Data and Information Set (HEDIS) guidelines. Our findings demonstrate that TRI can reduce screening costs compared to a strategy where all patients are referred for in-person eye examinations. A net present value (NPV) analysis indicates that a screening site reaches the break-even point of operation within one year if an average of two patients are screened per workday.

Diabetic microaneurysms detected by fluorescein angiography spatially correlate with regions of macular ischemia delineated by optical coherence tomography angiography

PURPOSE

To characterize the relationship between diabetic macular ischemia (DMI) delineated by optical coherence tomography angiography (OCTA) and microaneurysms (MAs) identified by fundus fluorescein angiography (FFA).

METHODS

Patients with diabetic retinopathy (DR) who underwent OCTA and FFA were retrospectively identified. FFA images were cropped and aligned with their respective OCTA images using i2k Align Retina software (Dual-Align, Clifton Park, NY, USA). Foveal avascular zone (FAZ) and ischemic areas were manually delineated on OCTA images, and MAs were marked on the corresponding FFA images before overlaying paired scans for analysis (ImageJ; National Institutes of Health, Bethesda, MD, USA).

RESULTS

Twenty-eight eyes of 20 patients were included. The average number of MAs identified in cropped FFA images was 127 ± 42. More DMI was noted in the superficial capillary plexus (SCP; 36 ± 13%) compared to the deep capillary plexus (DCP; 28 ± 14%, P < 0.001). Similarly, more MAs were associated with ischemic areas in SCP compared to DCP (92.0 ± 35.0 vs. 76.8 ± 36.5, P < 0.001). Most MAs bordered ischemic areas; fewer than 10% localized inside these regions. As DMI area increased, so did associated MAs (SCP: r = 0.695, P < 0.001; DCP: r = 0.726, P < 0.001). Density of MAs surrounding FAZ (7.7 ± 6.0 MAs/mm2) was similar to other DMI areas (SCP: 7.0 ± 4.0 MAs/mm2, P = 0.478; DCP: 9.2 ± 10.9 MAs/mm2, P = 0.394).

CONCLUSION

MAs identified in FFA strongly associate with, and border areas of, DMI delineated by OCTA. Although more MAs are localized to SCP ischemia, the concentration of MAs associated with DCP ischemia is greater. By contrast, few MAs are present inside low-flow regions, likely because capillary loss is associated with their regression.

Effectiveness and Financial Viability of Telehealth Physician Extenders for Re-Engagement of Patients with Diabetic Retinopathy

Purpose: To assess the effectiveness and financial implications of employing a telehealth physician extender program to re-engage patients with diabetic retinopathy (DR) who are lost to follow-up (LTF). Methods: Established patients with DR unevaluated in the prior 12 months were identified as LTF, and randomized to receive a recall intervention or standard operating procedure (SOP). For the intervention, a telehealth physician extender performed outbound calls, offering each patient a symptom screening questionnaire following a physician-directed escalation pathway and assistance in scheduling a return appointment. All patients retained the ability to schedule an appointment by means of SOP. Appointment schedule and adherence rates were assessed 30 days after a 6-week intervention period. Call times were digitally measured to estimate intervention labor cost. Results: Four hundred twenty-five of 2,514 established patients with DR were LTF (17%). One hundred fifty-seven patients were assigned to the intervention group; the remaining 268 formed the SOP group. Sixty-six outbound calls reached patients (42%). At the time of program assessment, the intervention group demonstrated a higher rate of appointment scheduling (31% vs. 14%, p < 0.001) and adherence (14% vs. 7%, p = 0.020). The measured call duration was 2.3 ± 1.9 min, yielding an estimated cost of US$4.70 per appointment scheduled. Conclusion: Re-engagement by a telehealth physician extender improves the rate at which patients with DR return for eye care, and can be done at a reasonable cost. This method of improving adherence with follow-up should be readily translatable to other health care settings.

Missing Care: the Initial Impact of the COVID-19 Pandemic on CKD Care Delivery

BACKGROUND

Chronic kidney disease (CKD) is a common condition with adverse health outcomes addressable by early disease management. The impact of the COVID-19 pandemic on care utilization for the CKD population is unknown.

OBJECTIVE

To examine pandemic CKD care and identify factors associated with a high care deficit.

DESIGN

Retrospective observational study PARTICIPANTS: 248,898 insured individuals (95% Medicare Advantage, 5% commercial) with stage G3-G4 CKD in 2018 MAIN MEASURES: Predicted (based on the pre-pandemic period of January 1, 2019-February 28, 2020) to observed per-member monthly face-to-face and telehealth encounters, laboratory testing, and proportion of days covered (PDC) for medications, evaluated during the early (March 1, 2020-June 30, 2020), pre-vaccine (July 1, 2020-December 31, 2020), and late (January 2021-August 2021) periods and overall.

KEY RESULTS

In-person encounters fell by 24.1% during the pandemic overall; this was mitigated by a 14.2% increase in telehealth encounters, resulting in a cumulative observed utilization deficit of 10% relative to predicted. These reductions were greatest in the early pandemic period, with a 19.8% cumulative deficit. PDC progressively decreased during the pandemic (range 9-20% overall reduction), with the greatest reductions in hypertension and diabetes medicines. CKD laboratory monitoring was also reduced (range 11.8-43.3%). Individuals of younger age (OR 1.63, 95% CI 1.16, 2.28), with commercial insurance (1.43, 95% CI 1.25, 1.63), residing in the Southern US (OR 1.17, 95% CI 1.14, 1.21), and with stage G4 CKD (OR 1.21, 95% CI 1.17, 1.26) had greater odds of a higher care deficit overall.

CONCLUSIONS

The early COVID-19 pandemic resulted in a marked decline of healthcare services for individuals with CKD, with an incomplete recovery during the later pandemic. Increased telehealth use partially compensated for this deficit. The downstream impact of CKD care reduction on health outcomes requires further study, as does evaluation of effective care delivery models for this population.