An initiative to improve follow-up of patients with diabetic retinopathy.

BACKGROUND: This study describes the implementation of an electronic medical record (EMR)-based initiative aimed at identifying and reducing the number of patients with diabetic retinopathy (DR) lost to follow-up (LTF). METHOD: Providers were enlisted to review the EMRs and re-engage patients with DR seen 1 year prior and who had not returned for care within the past 6 months. Binary logistic regression analysis was used to identify demographic, clinical and sociomedical factors associated with being LTF, as well as those predictive of re-engagement. RESULTS: Out of 673 patients with DR, 78 (12%) were identified as LTF. Patients LTF were more likely to be younger (p = 0.001) and have poorly controlled haemoglobin A1c (HbA1c ≥ 8%, p = 0.04) and cholesterol (LDL ≥ 100 mg/dL, p < 0.001) levels. These patients were also more likely to have completed fewer ophthalmology appointments (p < 0.001), and less likely to have had retinal imaging within the last year (p < 0.001). Charts reviewed 1 month after the EMR-based initiative revealed that 22 patients (28%) had been successfully re-engaged by providers, while 56 patients (72%) remained LTF. History of prior treatment for DR was associated with re-engagement by providers (p = 0.04). One month following the provider-based intervention, the LTF rate dropped to 8.3%, and by 1 year only 3.6% of the patients remained LTF. CONCLUSIONS: Electronic medical record-based tools can successfully identify DR patients as being LTF, offering an opportunity for providers to re-engage patients in a timely manner. Future studies are needed to determine the long-term impact of patient re-engagement on DR outcomes and efficiency of clinical practice.

Utilization of Remote Diabetic Retinal Screening in a Suburban Healthcare System.

PURPOSE: We conducted a cross-sectional study to assess the utilization of a tele-ophthalmology screening program in a low-risk, suburban population of patients with diabetes. METHODS: A total of 214 diabetic patients without previously documented diabetic retinopathy (DR) underwent point-of-care non-mydriatic fundus photography through their primary care providers at five Beth Israel Lahey Health locations. The characteristics of the patients who received remote screening were compared with those patients who were eligible for screening but did not take part in the program. Time-driven activity-based costing (TDABC) was implemented to examine the cost of screening by tele-ophthalmology compared with in-person examinations. RESULTS: Tele-ophthalmology screening was more likely to be provided for patients who were younger (OR 0.985; 95% CI 0.973-0.997, p=0.016), who were obese (OR 2.04; 95% CI: 1.47-2.84, p=0.008), who had an HbA1c above 8.0% (OR 1.60; 95% CI: 1.13-2.26, p=0.031), or who had an eye examination in the past year (OR 5.55; 95% CI: 3.89-7.92, p<0.001). Those patients newly diagnosed with DR because of the program were more likely to have diabetic nephropathy (OR 7.79; 95% CI: 1.73-35.05, p=0.007). TDABC identified a health system cost-savings of between $8 and $29 per patient screened by tele-ophthalmology compared with the cost of in-person eye examinations. CONCLUSION: Tele-ophthalmology presents an opportunity to reduce the costs of screening patients without prior evidence of DR, especially those who have completed a comprehensive eye examination within the prior year.