Jani Pooja D, Forbes Lauren, Choudhury Arkopal, Preisser John S, Viera Anthony J, Garg Seema
Department of Ophthalmology, University of North Carolina at Chapel Hill2Department of Family Medicine, University of North Carolina at Chapel Hill.
Department of Ophthalmology, University of North Carolina at Chapel Hill.
JAMA Ophthalmol. 2017 Jul 1;135(7):706-714. doi: 10.1001/jamaophthalmol.2017.1150.
Retinal telescreening for evaluation of diabetic retinopathy (DR) in the primary care setting may be useful in reaching rural and underserved patients.
To evaluate telemedicine retinal screenings for patients with type 1 or 2 diabetes and identify factors for ophthalmology referral in the North Carolina Diabetic Retinopathy Telemedicine Network.
DESIGN, SETTING, AND PARTICIPANTS: A preimplementation and postimplementation evaluation was conducted from January 6, 2014, to November 1, 2015, at 5 primary care clinics serving rural and underserved populations in North Carolina among 1787 adult patients with type 1 or 2 diabetes who received primary care at the clinics and obtained retinal telescreening to determine the presence and severity of DR. A total of 1661 patients with complete data were included in the statistical analysis.
Nonmydriatic fundus photography with remote interpretation by an expert.
Number of patients recruited, level of detected DR, change in rates of screening, rate of ophthalmology referral, percentage of completed referrals, and patient characteristics associated with varying levels of DR.
Of the 1661 patients (1041 women and 620 men; mean [SD] age, 55.4 [12.7] years), 1323 patients (79.7%) had no DR, 183 patients (11.0%) had DR without a need for an ophthalmology referral, and 155 patients (9.3%) had DR with a need for an ophthalmology referral. The mean rate of screening for DR before implementation of the program was 25.6% (1512 of 5905), which increased to 40.4% (1884 of 4664) after implementation. A total of 93 referred patients (60.0%) completed an ophthalmology referral visit within the study period. Older patients (odds ratio [OR], 1.28; 95% CI, 1.11-1.48) and African American patients (OR, 1.84; 95% CI, 1.24-2.73) or other racial/ethnic minorities (OR, 2.19; 95% CI, 1.16-4.11) had greater odds of requiring an ophthalmology referral compared with white and/or younger patients. Patients with higher hemoglobin A1c levels (OR, 1.19 per unit change; 95% CI, 1.13-1.25 per unit change) and longer duration of diabetes (OR, 1.76 per decade; 95% CI, 1.53-2.02 per decade) had greater odds of DR requiring an ophthalmology referral. History of stroke (OR, 1.65; 95% CI, 1.10-2.48) and kidney disease (OR, 1.59; 95% CI, 1.10-2.31) were strongly associated with DR and ophthalmology referral.
When implemented in the primary care setting, retinal telescreening increased the rate of evaluation for DR for patients in rural and underserved settings. This strategy may also increase access to care for minorities and patients with DR requiring treatment.
在基层医疗环境中进行视网膜远程筛查以评估糖尿病视网膜病变（DR），对于覆盖农村及医疗服务不足地区的患者可能有用。
评估1型或2型糖尿病患者的远程医疗视网膜筛查，并确定北卡罗来纳州糖尿病视网膜病变远程医疗网络中眼科转诊的相关因素。
设计、地点和参与者：于2014年1月6日至2015年11月1日在北卡罗来纳州5家为农村及医疗服务不足人群提供服务的基层医疗诊所进行了实施前和实施后的评估，纳入了1787例在诊所接受初级护理并进行视网膜远程筛查以确定DR的存在及严重程度的1型或2型糖尿病成年患者。共有1661例具有完整数据的患者纳入统计分析。
采用非散瞳眼底摄影并由专家进行远程解读。
招募的患者数量、检测到的DR水平、筛查率的变化、眼科转诊率、完成转诊的百分比以及与不同DR水平相关的患者特征。
在1661例患者（1041例女性和620例男性；平均[标准差]年龄为55.4[12.7]岁）中，1323例患者（79.7%）无DR，183例患者（11.0%）有DR但无需眼科转诊，155例患者（9.3%）有DR且需要眼科转诊。该项目实施前DR的平均筛查率为25.6%（5905例中的1512例），实施后增至40.4%（4664例中的1884例）。在研究期间，共有93例转诊患者（60.0%）完成了眼科转诊就诊。与白人和/或年轻患者相比，老年患者（优势比[OR]，1.28；95%置信区间[CI]，1.11 - 1.48）、非裔美国患者（OR，1.84；95% CI，1.24 - 2.73）或其他种族/族裔少数群体（OR，2.19；95% CI，1.16 - 4.11）需要眼科转诊的可能性更大。糖化血红蛋白水平较高（每单位变化的OR，1.19；95% CI，每单位变化1.13 - 1.25）以及糖尿病病程较长（每十年的OR，1.76；95% CI，每十年1.53 - 2.02）的患者发生需要眼科转诊的DR的可能性更大。中风病史（OR，1.65；95% CI，1.10 - 2.48）和肾脏疾病（OR，1.59；95% CI，1.10 - 2.31）与DR及眼科转诊密切相关。
在基层医疗环境中实施时，视网膜远程筛查提高了农村及医疗服务不足地区患者DR的评估率。该策略还可能增加少数群体以及需要治疗的DR患者获得医疗服务的机会。
