Patients who had eye exams within the past year are 5 times more likely to choose remote screenings for diabetic retinopathy, which save health systems up to $29 per patient, research from Clinical Ophthalmology says.
The American Diabetes Association recommends patients with diabetes are regularly screened for diabetic retinopathy. Researchers believe theirs is the first study to analyze a teleophthalmology program in a low-risk, well-insured population.
In 2019 and 2020, primary care physicians (PCPs) offered patients with diabetes mellitus a remote retinal screening for diabetic retinopathy. Following screenings with nonmydriatic fundus photography (nFP) and color fundus photography, PCPs referred patients with suspect diabetic retinopathy to ophthalmologists.
The 214 patients examined with teleophthalmology tended to be men (74% vs 63% χ 2 = 8.90, P =.003) with obesity (64% vs 54% OR 1.97 P =.008). They tended to have HbA1c of at least 8.0% (33% vs 23% OR 1.59 P =.005) and to have had an HbA1c measurement (91% vs 83% OR 1.97 P =.008) and a diabetic eye exam (73% vs 53% χ 2 = 50.553, P <.001) in the last year. Distance from the primary care clinic was linked with not having a primary care visit within the last year (OR 0.992 P =.006).
In multivariate analysis, the researchers found patients who had an eye exam in the past year were more than 5 times more likely to undergo the remote screening (73% vs 53% OR 5.55 P <.001). Patients who had obesity (64% vs 54% OR 2.04 P <.001) and those who had HbA1c of at least 8% (33% vs 23% OR 1.60 P =.008) were more likely to undergo remote screening. Patients who were older (mean 64.7 years vs 62.3 years OR 0.985 P =.016) were less likely to be screened remotely.
One of the 6 patients diagnosed with mild diabetic retinopathy through the screening was lost to follow-up. Seven of the 14 patients whose screening photographs were ungradable returned for an in-person evaluation. The rate of diabetic retinopathy (n=3) among the 7 was higher than the rate among the successfully screened population (χ2=11.10, P <.001).
Patients with known diabetic retinopathy had higher HbA1c (7.7% vs 7.2% P =.003). Patients diagnosed with diabetic retinopathy following the screenings were nearly 8 times more likely to have diabetic nephropathy (33% vs 6% OR 7.79 P =.007). Diagnosed nephropathy was about 3 times higher among patients with known diabetic retinopathy (OR 3.29 P <.001).
With time-driven activity-based costing (TDABC), the researchers estimated in-person dilated eye exams with an optometrist cost approximately $17.64 vs $41.53 with an ophthalmologist. Remote screenings cost about $3.40 for the labor of a medical assistant and $4.98 for a physician to grade the images. Positive (3%) or ungradable screening results (7%) prompt an in-person eye exam with an optometrist or ophthalmologist with a cost between $1.68 and $3.95, but they retain a cost-savings between $7.58 and $29.20 per patient.
Limitations of the study included lack of analysis of long-term benefits of teleophthalmology screening.
Kuo KH, Anjum S, Nguyen B, et al. Utilization of remote diabetic retinal screening in a suburban healthcare system. Clin Ophthalmol. 2021;15:3865-3875. doi: 10.2147/OPTH.S330913