Improving Patient Access to Diabetic Retinopathy Screening Through Telemedicine

From the 2019 HVPAA National Conference

Dr. Michael Kiritsy (LifeBridge Health), Ms. Tiffany Wandy (LifeBridge Health), Dr. Daniel Durand (LifeBridge Health)

Background

The LifeBridge Health (LBH) Accountable Care Organization (ACO) serves approximately 20,000 Medicare beneficiaries, many of whom have Type I or Type II diabetes. Diabetic retinopathy (DR) screening is extremely important in helping to preserve patient’s eyesight and overall functional status. However, like many other organizations, LBH has struggled with low compliance rates for DR screening. Most often, this resulted because of patient education and patient access to eye care barriers. As a result, LBH searched for a solution to improve DR screening care and improve ACO quality and financial performance.

Objective

Understanding that diagnosed DR provides primary care physicians (PCPs) with a new level of information to help manage and treat patients with diabetes, and knowing that easy access to this diagnostic exam is best for patient care, LBH sought a telemedicine solution that was easy for physicians and clinic teams to use. IRIS was the solution.

A pilot was initiated at three large primary care practice locations in the last quarter of 2017. Working with a dedicated LBH team, the practices created and implemented workflows, documented processes, and instilled best practices.

Methods

To measure whether implementation of this tool enabled providers to better meet the DR screening measure, we compared the DR screening performance of the pilot practices in a pre-post fashion. We included the final months of 2017 in the pre-period to account for workflow implementation. Manual chart abstraction of patients seen in the previous 4/6 weeks who were eligible for the measure was done to determine the proportion of patients who met the measure. This was done in all LBH PCP offices on an approximately quarterly basis. One of the three practice sites was changed in July 2018. We included the new practice and kept the old practice in the analysis. We compared the number of diabetes patients in the populations of each of the four practices to ensure patient population changes did not change significantly over the study period. A Two Sample Z-Test with a P-value of 0.05 was used to test for statistical significance.

Results

Across the three sites, 810 patients have been screened for DR as of April 2019. Of these, 33.1% (282 patients) were diagnosed with pathology. Approximately 15.6% (133 patients) were diagnosed with DR. We have also identified 87 patients who are considered “IRIS saves,” patients who had pathology identified that was serious enough to put them at imminent risk of losing their sight. For all patients requiring follow up, direct referrals were made to our in-network ophthalmologists at Krieger Eye Institute for treatment that these patients would not have otherwise received.

Statistical comparison of DR screening performance of practices pre and post implantation showed mean significant improvement from 38.5% to 47.2% (P=0.013).

Clinical Implications

The introduction of DR screenings at these offices allowed our PCPs to provide more comprehensive care to their patients with diabetes, eliminating the need for multiple appointments and office visits. Having IRIS in the practice was able to demonstrably improve performance in the DR screening measure. As a result, PCPs with IRIS helped facilitate access to care and made it easier for patients to make better choices related to their health outcomes. Our next focus is to examine HbA1c control, medication adherence, and cost/utilization in those diagnosed with DR compared to those with a negative screening.