Digital Retinal Imaging for Diabetics in a Family Medicine Residency Patient Centered Medical Home Nick Patel, MD Robert Newman, MD April 25,2010

Learning Objectives 1) Participants will understand that diabetic retinopathy continues to be a major cause of morbidity and the most common cause of blindness in the United States. 2) Participants will realize that there is poor compliance with annual retinopathy screening for diabetics, indicating a need for better screening methods, preferably at the point of care.

Learning Objectives 3) Participants will learn about non- mydriatic retinal imaging screening for diabetic retinopathy and its potential for improving annual screening rates in the Patient Centered Medical Home.

Statement of the Problem 20 million diabetics in US currently Projection for 48 million by 2050 Diabetic retinopathy-leading cause of blindness in US 12,000 to 24,000 new cases of blindness annually Treatment is available to prevent blindness

Problem Retinopathy is not reversible once it occurs, leading to visual loss. Thus, annual screening is essential- recommended by ADA Fewer than 50% of diabetics get annual screening-much less with uninsured population Barriers to obtaining it-cost, time, compliance More cost effective methods for screening must be developed.

Digital Retinal Imaging (DRI) Diabetes eye exam performed at point of care by nurse or MOA Multiple studies have demonstrated adequate sensitivity and specificity for screening in high risk populations. Sensitivity 92% and specificity 96% Sensitivity is 100 % for sight threatening retinopathy

DRI Camera

Proliferative Diabetic Retinopathy

Study Objective Implement a DRI system in a large FM academic residency program Nurse driven protocol-standing order for annual screening Primary outcome- Number of patients meeting annual screening Secondary outcomes-Percentages of patients with retinopathy, compliance with ophthalmology referral

Methods ECU Family Medicine-registry of 2000 diabetics 65% African American 15% uninsured, 35% Medicaid, 30% Medicare and 20% private insurance May, 2008-obtained DRI system from Digital Healthcare, Inc. Nurse driven protocol for annual screening implemented June 1, DRI nurse assigned daily-carries pager

DRI NURSE PROTOCOL Review problem list for Diabetes diagnosis If Diabetes is listed, load the Diabetes Template Check flow sheet for diabetic eye exam in last 12 month s If no, perform DRIIf yes, no DRI Patient can “opt out” of this process; however, nursing staff should explain purpose of this process Result letters are downloaded from the DRI secure website by nurse administrator or designee. A designated nurse will contact patient regarding result and forward to physician for document signature. Referral will be done by nurse and sent to managed care.

Methods Images obtained and transmitted for reading by ophthalmologist-report sent back and scanned into EMR Nurse protocol includes referral to ophthalmology for significant abnormalities Tracked referral compliance rate Control group-number of diabetics referred for eye exam for the year prior and their compliance with referral

Methods Patient satisfaction survey Started in November patients responded Rating of experience on a 1-10 Likert scale Space for comments

Results Total of 316 screened with DRI 207 (66%) had no retinopathy, background retinopathy (NPR) in 52 (16%), pre-proliferative retinopathy in 12 (4%), and proliferative retinopathy (PR) in 3 (1%) Inaccessible images in 42 (13%) 153 of screened group required referral to ophthalmalogy-89 (58%) showed for exam Abnormalities other than DR-glaucoma, macular degeneration

Treatment Group Results 7 patients had proliferative retinopathy requiring laser Rx 163 patients completed their retinal screening at point of care An additional 89 of screened had ophthalmologic exam An additional 136 referred to ophthalmology directly-78 showed (57%) Total screened= =330

Control Group Results Control group-those referred to ophthalmology for the year prior to DRI 283 referred 161 (57%) showed and thus completed screening Less than half the number compared to treatment group 24% had NPR and 2.2% had PR

Total Diabetic Patients Screened 161

Patient Satisfaction Survey 116 responses-started Nov % response rate 10 point Likert scale-0 is worst experience and 10 is the best Average score was 8.6 Many favorable comments-convenience, no extra cost, high tech equipment in primary care office

Results-Payer Mix Self pay-17% Medicaid-11% Medicare-41% BCBC-18% Other commercial insurance-13%

Discussion Procedures at point of care-good medicine and good for practice revenue Reimbursement issues-$45 from Medicare and BC/BS. Not paid by NC Medicaid. Cost is $25 per study paid to vendor. Separate fee billed by reading ophthalmologist. Camera cost is $25,000-grant funding

Discussion Literature suggests primary care MD’s can be readily trained to read images correctly- this would add revenue/study Training implications in residencies- teaching residents to read the images

Summary DRI implementation in our practice doubled the number screened compared to control year High patient satisfaction Strong case for DRI inclusion in Patient Centered Medical Home What is the cost of one case of blindness?