2017 Southern California Dissemination, Implementation and Improvement (DII) Science Symposium Optimizing Care in the Safety Net: Implementation and Evaluation of a Large-Scale Teleretinal Diabetic Retinopathy Screening Program in the Los Angeles County Department of Health Services Lauren Daskivich, MD, MSHS - Los Angeles County Department of Health Services For more information on DII, go to: https://ctsi.ucla.edu/patients-community/pages/dissemination_implementation_improvement

1. Lauren Patty Daskivich, MD, MSHS
Director, Ophthalmology and Eye Health Programs
LAC Department of Health Services
Optimizing Care in the Safety Net:
Implementation and Evaluation of a Large-Scale Teleretinal
Diabetic Retinopathy Screening Program in the Los Angeles
County Department of Health Services

2. Diabetic Retinopathy:
a safety net epidemic
 Diabetic retinopathy (DR) is damage to blood vessels of
the retina caused by diabetes
 Leading cause of blindness in working-age adults
 A large study of Latinos in Los Angeles showed a
prevalence close to 50%
 Leading cause of blindness in LA County

3. But it’s treatable…
 Early Treatment Diabetic Retinopathy Study
(ETDRS): effective treatment can reduce severe
vision loss by up to 94%
 At least 40-45% of US diabetics who may benefit
from earlier detection and treatment do not receive it
 US inner-city safety net clinic screening rates: < 25%

4. The problem…DHSFacilitiesand
CommunityPartners
Diabetic
patient seen at
primary care
clinic
LACountyDHSFacility
Patient
referred to
county health
facility for
routine
retinopathy
screening
>6-9monthsafterreferral
Patient
screened at
county health
facility, given
follow-up as
needed
Historical process for DR screening in LAC DHS

5. Our Teleretinal Solution
 Digital nonmydriatic camera images are effective for DR
screening
 High sensitivity and specificity
 Examples include VA, Joslin Vision Network, Indian Health Service, UK
National Health Service
 No studies evaluating the effectiveness of teleretinal
screening in a large, urban safety net health system

6. Diabetic patient
identified at PCP
visit
Patient sent for
teleretinal DR
screening at end of
PCP visit
Photographer uploads image
to software template and
submits
Images acquired
Images transmitted
to reading center
Images reviewed, report
generated back to PCP
PCP clinic submits
eConsult for eye care
appointment based on
diagnosis/triage
recommendations
Clinical Pathway for Teleretinal Imaging

7. Implementation: Building the LAC DHS
Teleretinal Program
With support of central/facility-based leadership:
 Obtained fundus cameras for 15 DHS primary care sites
 Identified and trained fundus photographers (LVN/Medical
Assistant level)
 Selected and implemented the software platform for
transmitting teleretinal images – EyePACS, LLC
 Certified DHS Optometrists as primary readers with QA
oversight by Ophthalmology
 Established a protocol for standardized referral timelines by
diagnosis
 Integrated referrals for abnormal results into eConsult, the new
web-based LAC specialty referral system

8. Evaluation: Partnership with
UCLA CTSI
Research question:
Are we truly meeting our goals of increasing the
number of patients screened and triaging those in
need of ophthalmology specialty care in a more
timely manner?
 Are we screening more patients for DR?
 Are wait times shorter?

9. Specific Aims
 Aim 1: to assess the change in proportion of diabetics
screened for diabetic retinopathy before and after
implementation of primary care-based teleretinal screening
 Aim 2: to evaluate the change in wait time from referral to
definitive treatment for diabetic retinopathy before and after
implementation of teleretinal screening
 Aim 3: to compare wait times by diagnosis for severity of
retinopathy to suggested time to treatment as defined by the
American Academy of Ophthalmology (AAO) Preferred Practice
Pattern

10. Methods
 Nonrandomized, quasi-experimental pretest-
posttest design
 Exposure at clinic level
 Historical controls
 Powered to detect a 15% difference in screening
rate/wait times (ICC = 0.02) between
intervention and control populations
 5 clinics with control and intervention groups
 120 subjects per clinic

11. Outcomes: Aims 1-3
Control (120 patients) Intervention (120 patients)
Teleretinal Screening
12 months 12 months
Pre-Post Analysis for Screening Rate for Diabetic Retinopathy:
Screening rate at clinics post-TRS intervention – Screening rate at clinics pre-TRS intervention
Pre-Post Analysis for Patient Wait Time for Ophthalmology Appointment:
Wait time for patients post-TRS intervention – Wait time for patients pre-TRS intervention
Pre-Post Analysis for Patient Wait Time for Definitive Ophthalmic Treatment for
Moderate/Severe NPDR and PDR:
Wait time for patients post-TRS intervention – Wait time for patients pre-TRS intervention
Primary Care
Clinic

12. Results – Aim 1
 Overall annual screening rates for DR increased 16.3% at all 15
targeted clinics (OR, 1.9; 95% CI, 1.3-2.9)
 40.6% before implementation
 56.9% after initiation of the program

13. Results – Aim 2
 Median time to screening for DR decreased 89.2%
 158 days (IQR, 68-324 days) before the intervention
 17 days (IQR, 8-50 days) after initiation of the program

14. Results
 Eliminated the need for over 14,000 visits
to eye clinic in the first 2 years of the
program
Daskivich LP, et al. JAMA Internal Med. Published online March 27, 2017.

15. LAC DHS Teleretinal DR
Screening Program Sites
 Study Sites:
 Claude C. Hudson CHC
 El Monte CHC
 Long Beach CHC
 Hubert H. Humphrey CHC
 Harbor UCLA
 Family Medicine/Lomita
 Other Active Sites:
 MLK-OPC
 Olive View UCLA
 Clinic A
 Clinic M
 Harbor ULCA
 Adult Medicine
 Edward Roybal CHC
 Rancho Los Amigos
 LAC+USC
 Wilmington HC
 High Desert Health System
 Mid Valley CHC
 Bellflower HC

16. Current Program Statistics
 Total Encounters to Date – 40,799
 No Referral Needed – 28,927
 Referred for Diabetic Retinopathy – 7,449
 Treatable DR – 3,083
 Referred for Other Eye Conditions – 4,423
11%
71%
11%
7%
Referable vs. Nonreferable Disease
Referable DR
Nonreferable
Other Referable
Condition
Treatable DR
18% Referred for DR

17. Volume by Year
0
200
400
600
800
1000
1200
1400
1600
Jan-14 Jan-15 Jan-16 Jan-17
Yearly

18. Summary and Next Steps
 Example of successful implementation of Teleretinal DR
Screening in a large urban safety net healthcare system
 Cameras placed
 CMA photographers trained, primary care workflows established
 3% ungradable rate
 Reading center with QA and protocols created and standardized
 Triaging with use of eConsult, integrating into EHR
 Evaluation showed screening more people much faster than
before
 Next steps: analysis of cost, time to treatment, and
appropriate screening intervals
 Goal is to improve access to and quality of care,
treating those that need it in a timely manner

19. Thank You
Questions?