1. Community Management of Retinopathy of Prematurity Alex R. Kemper, MD, MPH, MS Sheri Carroll, MD David K. Wallace, MD, MPH November 13, 2007 CM-ROP

2. Overview ROP is common –4% of all at-risk infants, increases with the degree of prematurity –1,100-1,500 require laser treatment ROP is serious –400-600 cases of blindness annually –High physician liability ROP is preventable –Limiting excess oxygen exposure –Screening for early treatment

3. Challenges 1.The number of premature infants is increasing 2.The criteria for screening has expanded 3.Some require treatment earlier than in the past 4.There are regional shortages in the ophthalmology workforce 5.It is difficult to assure eye care around the time of transfer or discharge

4. Challenges 1.The number of premature infants is increasing 2.The criteria for screening has expanded 3.Some require treatment earlier than in the past 4.There are regional shortages in the ophthalmology workforce 5.It is difficult to assure eye care around the time of transfer or discharge

5. Screening Criteria Indirect ophthalmoscopy to screen for ROP is recommended for infants with –Birth weight ≤ 1,500 grams –Gestational age ≤ 30 weeks –Birth weight between 1,500 and 2,000 grams or gestational age of >30 weeks and an unstable clinical course –This is a change from the previous cutoff of 28 weeks Infants may require from 2 to 9 exams

6. Eye Care Workforce Total workforce is small –Screen: < 2,000 ophthalmologists –Treat: < 1,000 ophthalmologists For screening: –about equal numbers of general ophthalmologists and pediatric ophthalmologists –However, pediatric ophthalmologists do more exams For treating: –More retina specialists than pediatric ophthalmologists Main reasons for not providing these services – perceived lack of demand, liability risk, lack of training or experience

7. Transfer / Discharge No good data Data suggest –ROP follow-up missed in transfer from high acuity to lower acuity NICUs –Parents do not follow-up after discharge

8. More infants at risk!Fewer resources! No tolerance for missed cases!

9. New “High-Tech” Solutions Cameras with or without telemedicine Wide Angle Narrow Angle

10. New “High-Tech” Solutions Decrease the amount of hay without losing the needle.

11. New “High-Tech” Solutions Telemedicine will likely play an important role – there are important questions about: –Relative accuracy of different strategies –Costs and effectiveness –Where and how to implement – it is unlikely that there is “one way” to do things –Lots of very interesting and important opportunities

12. Next Steps Prior to developing any intervention to improve the quality of ROP services delivered, data are needed to identify modifiable factors Such work will also help define the long- term goals for improving care, including involvement in telemedicine initiatives

13. Objectives 1.Describe the criteria and methods used to identify children that need ROP care 2.Quantify the frequency and outcomes of eye exams 3.Evaluate the coordination of ROP care around the time of discharge or transfer CM-ROP

14. Design Short (2-page) survey of NICU director to provide an overview of ROP care within the NICU Chart audit to collect information related to ROP care before admission, during the NICU stay, and ROP care arrangements upon discharge or transfer –Each participating NICU will identify all children with a birth weight ≤1,500 grams or a gestational age ≤ 30 weeks admitted beginning February 1, 2007. Charts audits will be completed sequentially based on date of admission until 50 neonates have been identified for chart abstraction or June 30, 2007 (i.e., 6 months later) is reached. –$250 for participation CM-ROP

15. Outcomes Identify opportunities for quality improvement Tailor activities to NICU characteristics Be able to quantitatively evaluate change Share knowledge, including peer- reviewed publications Seek extramural funding for future ROP projects, focusing on care delivery in the “real world” CM-ROP

16. Questions? CM-ROP

17. Rates of Prematurity Pediatrics 119:345-360, 2007

18. ROP: Classification Aberrant development of immature retinal vessels in premature babies. Classification by ICROP based on 4 parameters: 1.Severity by stage 2.Location in the anterior-posterior dimension (3 zones) 3.Circumferential extent at the junction between the vascularized and avascular retina 4.Presence of abnormal vascular dilation and tortuosity of the posterior pole vessels (plus disease)