UCLA CTSI-Los Angeles County Department of Health Services (DHS) Projects Principal Investigators: Lauren Daskivich (DHS), Carol Mangione (UCLA) Diabetic retinopathy (DR) is the leading cause of blindness among working-age Americans, and among Los Angeles Latinos—the ethnic majority of patients in the Los Angeles County (LAC) safety net—the prevalence of DR is ~50%. Despite evidence that early detection and treatment can prevent blindness from DR, a significant number of persons with diabetes in our system fail to receive annual screening examinations and/or sight-saving treatments due to lack of access to specialty care. To date, the effect of a system level intervention on improving access to eye care and definitive treatment for diabetic retinopathy in an urban medically underserved, or safety net, population has not been evaluated. The objective of this project is to evaluate the impact of teleretinal screening on access to specialty ophthalmic care for diabetic patients in LAC who need monitoring or treatment for diabetic retinopathy. We propose a pre-post analysis of the LAC teleretinal screening implementation, and we aim to evaluate the number of patients screened for diabetic retinopathy, the number presenting for timely ophthalmic follow-up care and treatment, and the cost of the program.

1. Lauren Patty Daskivich, MD, MSHS
LAC DHS
Carol M. Mangione, MD, MSPH
UCLA
Implementation of a Primary Care-
Based Teleretinal Screening Protocol for
the Los Angeles County Safety Net
___________________________

2. Diabetic Retinopathy
 Diabetic retinopathy (DR) is a leading cause of
blindness in working-age adults in the United States
 Prevalence of diabetic retinopathy in a large study of Latinos
in LA has been shown to be close to 50%
 THE leading cause of blindness in Los Angeles County
 Early Treatment Diabetic Retinopathy Study (ETDRS)
showed that severe vision loss from diabetic
retinopathy can be reduced by up to 94% by
effective treatments.
 At least 40-45% of diabetics who may benefit from
earlier detection and treatment of retinopathy are
not receiving it

3. Teleretinal Screening for Diabetic
Retinopathy
 High sensitivity and specificity when compared
to gold standard (7 standard field fundus
photographs and indirect ophthalmoscopy by an
ophthalmic physician)
 Sensitivity: 71-82%
 Specificity: 92-96%
 Recognized by the American Academy of
Ophthalmology
 No studies evaluating teleretinal screening in a
safety net setting

4. Clinical Pathway for Teleretinal
Imaging
Diabe&c pa&ent
iden&fied at PCP
visit
Pa&ent sent for
telere&nal screening
at end of PCP visit
Photographer uploads image
to so:ware template and
submits
Images acquired
Images transmi=ed
to reading center
Images reviewed, report
generated back to PCP
PCP clinic submits
eConsult based on
diagnosis/triage
recommenda&ons

5. Research Question
Program evaluation:
Are we truly meeting our goals of increasing the
number of patients screened and triaging those
in need of care in a more timely manner?
 Are we screening more patients for DR?
 Are wait times shorter?
 Does it cost less?

6. Methods
 Nonrandomized, quasi-experimental pretest-
posttest design
 Exposure at clinic level
 Historical controls
 Powered to detect a 15% difference (with a
0.02 intra-clinic correlation) between
intervention and control populations
 5 clinics with control and intervention groups
 120 subjects per clinic

7. Outcomes: Aims 1-3
Control (120 patients) Intervention (120 patients)
Teleretinal Screening
6 months 6 months
Pre-Post Analysis for Screening Rate for Diabetic Retinopathy:
Screening rate at clinics post-TRS intervention – Screening rate at clinics pre-TRS intervention
Pre-Post Analysis for Patient Wait Time for Ophthalmology Appointment:
Wait time for patients post-TRS intervention – Wait time for patients pre-TRS intervention
Pre-Post Analysis for Patient Wait Time for Definitive Ophthalmic Treatment for Moderate/
Severe NPDR and PDR:
Wait time for patients post-TRS intervention – Wait time for patients pre-TRS intervention
Primary Care
Clinic

8. Outcomes: Aim 4
 Complexity of societal vs. health systems
perspective
 What we can estimate
 Cost effectiveness of screening method – teleretinal
imaging vs. direct eye exam
 Number of cases of blindness prevented and
compare to national estimates of cost of blindness
 Area for collaboration with health economist

9. CERP Aims Addressed
 Aim 1 – Promote bidirectional knowledge exchange
between community and academia.
 Aim 2 – Build community and academic
infrastructure for sustainable partnered research
 Aim 4 – Build Health Services Research (HSR)
methods into partnerships to accelerate design,
production, and adoption of evidence-based
interventions

10. Action Status Expected Completion Date
IRB approval from UCLA and
LABioMed
Completed
IRB approval from USC Under Review January 2014
Pre-intervention data collection at 4
of 5 PC clinic sites
Completed
Pre-intervention data collection at
remaining PC site and 3
Ophthalmology clinics
Underway January 2014
Implementation of DHS Teleretinal
Screening Program
Underway January 2014 at study sites
(June 2014 all sites)
Post-intervention Data Collection at
5 Clinic Sites
Pending February - March 2014
Data Analysis and Preparation of
Extra-mural Grant Application
Pending April - June 2014
Timeline

11. Added Value from CTSI Funding
 Access to Health Services Research and
Biostatistical support available within the UCLA
CTSI
 Availability of the biostatistics core and health
economist to assist with data analysis
 Consultation to ensure that our quality assurance
mechanisms are sufficient
 Advice on the design of a cost analysis of this
intervention
 Advice regarding additional pilot funding to assist
with dissemination if this project is found to be
successful
 Research Assistant support

12. Next Steps and Products
 IRB approval obtained from UCLA, LABioMed; USC under review
 Major strides in implementation, including:
 Ensuring clinic access to fundus cameras for 13 DHS primary care sites
 Identifying and training fundus photographers (LVN/Medical Assistant
level)
 Selecting and implementing the software platform for transmitting
teleretinal images
 Creating a quality assurance mechanism for image acquisition and
evaluation
 Establishing appropriate triage mechanisms for abnormal screening
photographs integrated with eConsult, the new web-based LAC specialty
referral system
 Teleretinal Screening has begun at 2 sites and will rollout to 11 more
over the next 6 months
 Currently developing a protocol for standardized referral timelines
across LA County that will further streamline patient care