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Christopher J. Brady, Andrea C. Villanti, Omesh P. Gupta, Barbara Knight, Mark G. Graham, Robert C. Sergott; Diabetic Retinopathy Screening by Teleophthalmology in Urban Primary Care Offices. Invest. Ophthalmol. Vis. Sci. 2012;53(14):2889.
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To pilot a teleophthalmology strategy for high risk diabetic patients in an urban, academic primary care office. To define rates of diabetic retinopathy (DR). To define the economics of teleophthalmology screening for DR.
Adult diabetic patients presenting for routine medical care underwent 3-field non-mydriatic fundus photography by technicians without formal training in ophthalmic photography. The images were transmitted to an interpreting, non-vitreo-retinal ophthalmologist for grading. Quality of photos, degree of retinopathy, and incidentally noted pathology were recorded. Demographic and medical history data were collected and analyzed using descriptive statistics. The cost of the camera and software package as well as Medicare reimbursement rates were used to estimate the cost of the intervention. By identifying subjects with proliferative diabetic retinopathy (PDR), prior to becoming symptomatic from vitreous hemorrhage, we assumed pan-retinal photocoagulation could prevent vitrectomy. Medicare reimbursement rates for both procedures were compared and the cost-saving threshold was calculated.
One hundred two patients (204 eyes) were included in the study. 66% of the population was female, and the mean age was 52.8 years (SD 13.8). 3 of 102 subjects had no images and were excluded. 178 out of 198 (89.9%) of the eyes were gradeable. 24 out of 99 (24.2%) subjects had at least mild DR, 21 (87.4%) of whom did not know their status or believed they were free of DR. In the full sample 8 patients (8.1%) (12 eyes) were referred for urgent consultation by the interpreting ophthalmologist for possible vision-threatening DR. 2 of these patients (3 eyes) were thought to have PDR. An additional 5 patients (5.1%) (6 eyes) were referred for urgent consultation for possible non-diabetic pathology including glaucoma and macular degeneration. From a third-party payer perspective, the screening cost per patient was assumed to be $15.37. By diagnosing 1 case of PDR, $1477.54 was assumed to be saved. To recuperate start-up costs, 845 patients would need to be screened in order to identify 17 cases of PDR.
The vast majority of images were of sufficient quality to interpret. A substantial burden of DR was identified, most of which was previously undiagnosed, and one-third of which was possibly vision-threatening. If performed on a larger scale, diabetic retinopathy screening by teleophthalmology would be cost-saving. Teleophthalmology has previously been applied in rural and remote areas with insufficient eye care resources. The present study supports a role for teleophthalmology in primary care offices in urban areas where barriers to eye care are more complex.
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