New ways to improve retinal exam rates in patients with diabetes for better chronic care management
By Steve Martin | April 8, 2019 | Becker’s Hospital Review
The key to diagnosing the nation’s top cause of preventable blindness can now be found in the primary care physician’s office.
Diabetic retinopathy (DR) is responsible for causing up to 24,000 Americans to go blind annually, according to the U.S. Centers for Disease Control and Prevention (CDC). Yet this is a preventable problem. Early detection and treatment can prevent or delay blindness due to DR in 90 percent of people with diabetes, but 50 percent or more don’t get their eyes examined or are diagnosed too late for effective treatment, the CDC reports.
Unfortunately, the prevalence of DR has the potential to explode in the coming decades. The CDC predicts that between 2018 and 2050, based on overall population growth projections, the number of Americans with diabetes is expected to grow more than five-fold to 161 million, meaning that one in three Americans will have type 2 diabetes if current trends continue.
Similarly, the number of people with diabetic retinopathy is expected to surge by a comparable amount to one in five Americans—meaning there will be 65 million people in the United States suffering from retinal disease and the risk of blindness if the crisis is not addressed.
Given that clinical guidelines recommend that people with diabetes receive an eye exam annually, this places a significant burden on America’s eye care professionals. With that said, only about 15 percent of patients with diabetes fulfill those appointments, according to a recent study by the American Diabetes Association.
Most integrated health systems understand they have a problem with diabetic eye exam completion rates, but some aren’t aware that there is an alternative to the current approach of referring to an eye care specialist. By coupling DR testing in the primary care setting with a telemedicine solution that enables eye care professionals to remotely view and analyze ocular images, the U.S. healthcare system could begin to reduce the progression of DR, while speeding up and increasing the accuracy of diagnoses, reducing costs, and improving patient compliance.
Increasing convenience, efficiency
The vast majority of diabetes care management happens in the primary care office, where providers test patients’ HbA1c levels and administer diabetic foot exams, for example. This approach stands in stark contrast to current protocols for DR testing, which usually consist of the primary care physician (PCP) telling the patient they need an exam and referring them to an ophthalmologist to examine the retina for damage to blood vessels and nerve tissue.
This seemingly insignificant act of referring the patient to a specialist for yet another appointment brings about a host of issues and potential pitfalls. For one, the patient simply may not act on the referral, which happens frequently, given that half of patients with diabetes fail to get the annual eye exams that are recommended by clinical guidelines. But let’s say the patient does follow through on the PCP’s referral. In many cases, it takes months to even obtain an appointment. Then, the exam process may take several hours out of the patient’s day, when factoring in transportation, plus wait times in the lobby and exam room—all for an exam that could be performed in minutes, right in the PCP’s office.
Faster diagnosis, better process through telemedicine
Due in large part to technological advances in automation and telemedicine, some retinal imaging systems can now be operated in primary care settings. This wasn’t possible even a few years ago due to technological and cost limitations. Offering diabetic eye exams in primary care settings offers many benefits to patients, including convenience and cost savings.
Benefits to clinicians include faster diagnoses that lead to more efficient patient care and more satisfied patients, as well as enhanced opportunities to meet managed care quality measures associated with annual eye exams.
PCPs who use advanced retinal imaging systems are often surprised at the high rates of DR that patients in their practices exhibit—which illustrates that even clinicians who regularly treat these patients can underestimate the scale of DR.
How it works
The process of using this type of technology to improve DR diagnoses begins when a primary care staff member uses an automated retinal imaging system to take an image of a patient’s retina. Once captured, the image is uploaded to the cloud, where the system uses artificial intelligence to enhance each image, altering colors to make any structural damage more visible.
The automated system analyzes the images for signs of disease. If the solution identifies an image that may be positive for DR or other eye pathology, the system places this image in the queue for an eye care professional to review remotely as soon as possible. In the final steps, the eye care professional analyzes the image and the diagnosis is sent back to the patient’s medical record.
Not only does the patient benefit, the primary care practice also benefits, by offering more comprehensive diabetes care with this reimbursable diagnostic test that also helps meet quality measures.
This technology, which could lead to a reduction in the nation’s leading preventable cause of blindness, already exists. We just need to put it in the hands of more primary care physicians in the United States, so that more patients can benefit.
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