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Introduction: This article provides an overview of presentations and discussions from the inaugural Healthcare Delivery Science: Innovation and Partnerships for Health Equity Research (DESCIPHER) Symposium. Methods: The symposium brought together esteemed experts from various disciplines to explore models for translating evidence-based interventions into practice. Results: The symposium highlighted the importance of disruptive innovation in healthcare, the need for multi-stakeholder engagement, and the significance of family and community involvement in healthcare interventions. Conclusions: The article concluded with a call to action for advancing healthcare delivery science to achieve health equity.
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PURPOSE: To analyze the systemic and ocular outcomes in patients with young-onset type 2 diabetes (YO-DM2) based on grade of presenting diabetic retinopathy (DR). METHODS: Retrospective cohort study analysis of empaneled patients with type 2 diabetes <40 years old with retinopathy screening within the Los Angeles Department of Health Services between 01/01/2017-07/01/2021 were included. Patients were stratified based on presenting severity of DR determined on fundus photographs or clinical examination. Patient's systemic co-morbidities and ocular outcomes were then compared across each group. Procedural (e.g. intravitreal injections) and surgical interventions (e.g. pars plana vitrectomy) were documented as performed by the treating physician. RESULTS: 2795 patients were screened from 12,456 patients diagnosed with diabetes younger than age 40 (22.4 %). Of these, 1496 patients were diagnosed with type 2 DM. 1084 (72.4 %) of patients presented without DR, 307 (20.5 %) presented with non-proliferative diabetic retinopathy (NPDR), and 105 (7.0 %) of patients presented with proliferative diabetic retinopathy (PDR). Increasing presenting diabetic retinopathy severity was associated with longer duration of diabetes, greater systemic comorbidities (e.g. diabetic foot disease, neuropathy, chronic kidney or end stage renal disease), worse baseline and final visual acuity, and required more procedural and surgical interventions. CONCLUSIONS: Worse presenting DR severity in patients young-onset type 2 diabetes was associated with greater comorbid systemic and ocular disease with worse visual acuity outcomes. <1 % of patients without diabetic retinopathy or with mild NPDR were likely to progress to PDR. Diabetic kidney disease was an independent risk factor for developing neovascular glaucoma and retinal detachments. Prompt evaluation and intervention in patients with YO-DM2 may help reduce the associated systemic and ocular morbidity.
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Diabetes Mellitus Tipo 2 , Retinopatía Diabética , Humanos , Adulto , Retinopatía Diabética/diagnóstico , Retinopatía Diabética/epidemiología , Retinopatía Diabética/tratamiento farmacológico , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/epidemiología , Diabetes Mellitus Tipo 2/terapia , Estudios Retrospectivos , Ojo , Factores de RiesgoRESUMEN
COVID-19 has disproportionately affected socially vulnerable communities characterized by lower income, lower education attainment, and higher proportions of minority populations, among other factors (1-4). Disparities in COVID-19 incidence and the impact of vaccination on incidence disparities by community income were assessed among 81 communities in Los Angeles, California. Median community vaccination coverage and COVID-19 incidence were calculated across household income strata using a generalized linear mixed effects model with Poisson distribution during three COVID-19 surge periods: two before vaccine availability (July 2020 and January 2021) and the third after vaccines became widely available in April 2021 (September 2021). Adjusted incidence rate ratios (aIRRs) during the peak month of each surge were compared across communities grouped by median household income percentile. The aIRR between communities in the lowest and highest median income deciles was 6.6 (95% CI = 2.8-15.3) in July 2020 and 4.3 (95% CI = 1.8-9.9) in January 2021. However, during the September 2021 surge that occurred after vaccines became widely availabile, model estimates did not identify an incidence disparity between the highest- and lowest-income communities (aIRR = 0.80; 95% CI = 0.35-1.86). During this surge, vaccination coverage was lowest (59.4%) in lowest-income communities and highest (71.5%) in highest-income communities (p<0.001). However, a significant interaction between income and vaccination on COVID-19 incidence (p<0.001) indicated that the largest effect of vaccination on disease incidence occured in the lowest-income communities. A 20% increase in community vaccination was estimated to have resulted in an additional 8.1% reduction in COVID-19 incidence in the lowest-income communities compared with that in the highest-income communities. These findings highlight the importance of improving access to vaccination and reducing vaccine hesitancy in underserved communities in reducing disparities in COVID-19 incidence.
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COVID-19 , Cobertura de Vacunación , Humanos , Los Angeles/epidemiología , Incidencia , COVID-19/epidemiología , COVID-19/prevención & control , RentaRESUMEN
BACKGROUND: Photographs of the external eye were recently shown to reveal signs of diabetic retinal disease and elevated glycated haemoglobin. This study aimed to test the hypothesis that external eye photographs contain information about additional systemic medical conditions. METHODS: We developed a deep learning system (DLS) that takes external eye photographs as input and predicts systemic parameters, such as those related to the liver (albumin, aspartate aminotransferase [AST]); kidney (estimated glomerular filtration rate [eGFR], urine albumin-to-creatinine ratio [ACR]); bone or mineral (calcium); thyroid (thyroid stimulating hormone); and blood (haemoglobin, white blood cells [WBC], platelets). This DLS was trained using 123 130 images from 38 398 patients with diabetes undergoing diabetic eye screening in 11 sites across Los Angeles county, CA, USA. Evaluation focused on nine prespecified systemic parameters and leveraged three validation sets (A, B, C) spanning 25 510 patients with and without diabetes undergoing eye screening in three independent sites in Los Angeles county, CA, and the greater Atlanta area, GA, USA. We compared performance against baseline models incorporating available clinicodemographic variables (eg, age, sex, race and ethnicity, years with diabetes). FINDINGS: Relative to the baseline, the DLS achieved statistically significant superior performance at detecting AST >36·0 U/L, calcium <8·6 mg/dL, eGFR <60·0 mL/min/1·73 m2, haemoglobin <11·0 g/dL, platelets <150·0 × 103/µL, ACR ≥300 mg/g, and WBC <4·0 × 103/µL on validation set A (a population resembling the development datasets), with the area under the receiver operating characteristic curve (AUC) of the DLS exceeding that of the baseline by 5·3-19·9% (absolute differences in AUC). On validation sets B and C, with substantial patient population differences compared with the development datasets, the DLS outperformed the baseline for ACR ≥300·0 mg/g and haemoglobin <11·0 g/dL by 7·3-13·2%. INTERPRETATION: We found further evidence that external eye photographs contain biomarkers spanning multiple organ systems. Such biomarkers could enable accessible and non-invasive screening of disease. Further work is needed to understand the translational implications. FUNDING: Google.
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Aprendizaje Profundo , Retinopatía Diabética , Humanos , Estudios Retrospectivos , Calcio , Retinopatía Diabética/diagnóstico , Biomarcadores , AlbúminasRESUMEN
PURPOSE: To evaluate rates and risk factors associated with follow-up adherence to in-person glaucoma evaluations and confirmed glaucoma diagnosis in glaucoma suspects identified through teleretinal diabetic retinopathy screening (TDRS). DESIGN: Retrospective cohort study SUBJECTS: Patients with diabetes identified through teleretinal screening to have large or asymmetric cup-to-disc ratios in a Los Angeles County safety-net primary care-based TDRS program. METHODS: Retrospective chart review was performed to obtain demographic and clinical information for patients with cup-to-disc ratios concerning for glaucoma on TDRS. Patients who completed an in-person follow-up appointment within 1 year of teleretinal screening were adherent. Factors associated with follow-up adherence and diagnosis of glaucoma were analyzed with chi-square and independent t tests along with multivariable logistic regressions. MAIN OUTCOME MEASURES: The proportion of patients with suspected glaucoma who adhered with in-person follow-up examination, proportion of patients with confirmed glaucoma diagnosis, and factors associated with follow-up adherence and glaucoma diagnosis. RESULTS: Eight-hundred seventeen patients with optic discs suspicious for glaucoma were included. Five-hundred thirty-four (65.4%) patients successfully completed an in-person glaucoma evaluation. Among these patients, 62.9% and 24.5% received a diagnosis of glaucoma suspect and glaucomatous optic neuropathy, respectively. Compared with patients aged < 50 years, patients aged 50 to 64 years had 1.57 times higher odds of being adherent with in-person visits (P = 0.036), whereas no difference was seen in those aged ≥ 65 years. For every $10 000 increase in the zip code median income, patients had 11% lower odds of being adherent (P = 0.031). Compared with Latino patients, Black patients had 3.52 times (P < 0.001) higher odds of having confirmed glaucoma. CONCLUSION: The majority of patients referred as glaucoma suspects on TDRS completed a follow-up examination, and nearly a quarter of those examined received a confirmed glaucoma diagnosis. Patients aged ≥ 50 and < 65 years along with those from lower-income neighborhoods were more likely to follow up for an in-person evaluation. Compared with Latino patients, Black patients had a higher risk for a confirmed glaucoma diagnosis. This demonstrates the effectiveness of glaucoma detection in a large-scale TDRS program for a safety-net patient population. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any materials discussed in this article.
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Retinopatía Diabética , Glaucoma , Humanos , Estudios Retrospectivos , Estudios de Seguimiento , Retinopatía Diabética/complicaciones , Retinopatía Diabética/diagnóstico , Glaucoma/diagnóstico , Glaucoma/epidemiología , Glaucoma/complicaciones , Tamizaje Masivo/métodosRESUMEN
PURPOSE: To validate retinal capillary density and caliber associations with diabetic retinopathy (DR) severity in different clinical settings. METHODS: This cross-sectional study assessed retinal capillary density and caliber in the superficial retinal layer of 3-mm OCTA scans centered on the fovea. Images were collected from non-diabetic controls and subjects with mild or referable DR (defined DR worse than mild DR) between February 2016 and December 2019 at secondary and tertiary eye care centers. Vessel Skeleton Density (VSD), a measure of capillary density, and Vessel Diameter Index (VDI), a measure of vascular caliber, were calculated from these images. Discriminatory performance of VSD and VDI was evaluated using multivariable logistic regression models predicting DR severity with adjustments for sex, hypertension, and hyperlipidemia. Area under the curve (AUC) was estimated. Model performance was evaluated in two different cohorts. RESULTS: This study included 594 eyes from 385 subjects. Cohort 1 was a training cohort of 509 eyes including 159 control, 155 mild non-proliferative DR (NPDR) and 195 referable DR eyes. Cohort 2 was a validation cohort consisting of 85 eyes including 16 mild NPDR and 69 referable DR eyes. In Cohort 1, addition of VSD and VDI to a model using only demographic data significantly improved the model's AUC for discrimination of eyes with any DR severity from controls (0.91 [95% CI, 0.88-0.93] versus 0.80 [95% CI, 0.76-0.83], p < 0.001) and eyes with referable DR from mild NPDR (0.90 [95% CI, 0.86-0.93] versus 0.69 [95% CI, 0.64-0.75], p < 0.001). The transportability of this regression model was excellent when implemented in Cohort 2 for the referable DR versus mild NPDR comparison. The odds ratio of having any DR compared to control subjects, and referable DR compared to mild DR decreased by 15% (95% CI: 12-18%), and 13% (95% CI: 10-15%), respectively, for every 0.001 unit increase in VSD after adjusting for comorbidities. CONCLUSION: OCTA-derived capillary density has real world clinical value for rapidly assessing DR severity.
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Angiografía , Capilares/diagnóstico por imagen , Retinopatía Diabética/diagnóstico por imagen , Gravedad del Paciente , Vasos Retinianos/diagnóstico por imagen , Tomografía de Coherencia Óptica , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de RiesgoRESUMEN
Background: The cost of eyeglasses is variably covered by medical insurance and thus is a significant barrier for patients in lower socioeconomic classes. We evaluated the efficacy of Recycle Vision (RV) at LAC+USC Medical Center, a monthly clinic run by volunteer medical students that provides free donated eyeglasses. Methods: A convenience sample of 30 patients was surveyed from August 1, 2019 to December 31, 2019. Patients' prescriptions were matched with available eyeglasses based on spherical equivalent and axis of astigmatism using Winglasses software algorithm; patients selected glasses from these options based on subjective improvement of vision. All participants consented to a phone follow-up survey 1 month after initial visit to gauge satisfaction with glasses and rate difficulty in completing daily activities pre- and post-RV visit on a scale of 1 to 5 (5 being the greatest), with a 100% response rate. Results: Of the 30 study participants, 90% received eyeglasses from RV, with reported improvement in ease of daily activities of 3.96. 67% of respondents stated that if RV clinic did not exist, they would not have obtained glasses elsewhere; cost was the most commonly (70%) cited barrier. Upon follow-up, average likelihood of patients referring friends/family to RV was 4.07 (SD 1.14). Conclusion: The majority of RV patients received free eyeglasses and had subsequent improvement in their quality of life. This pilot study demonstrates that programs offering free eyeglasses can effectively correct refractive error and can offer a practical public health solution to improve functionality for underserved populations.
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Importance: Diabetic retinopathy (DR) is the leading cause of blindness in adults of working age in the United States. In the Los Angeles County safety net, a nonvertically integrated system serving underinsured and uninsured patients, the prevalence of DR is approximately 50%, and owing to limited specialty care resources, the average wait times for screening for DR have been 8 months or more. Objective: To determine whether a primary care-based teleretinal DR screening (TDRS) program reduces wait times for screening and improves timeliness of needed care in the Los Angeles County safety net. Design, Setting, and Participants: Quasi-experimental, pretest-posttest evaluation of exposure to primary care-based TDRS at 5 of 15 Los Angeles County Department of Health Services safety net clinics from September 1, 2013, to December 31, 2015, with a subgroup analysis of random samples of 600 patients before and after the intervention (1200 total). Exposure: Primary care clinic-based teleretinal screening for DR. Main Outcomes and Measures: Annual rates of screening for DR before and after implementation of the TDRS program across the 5 clinics, time to screening for DR in a random sample of patients from these clinics, and a description of the larger framework of program implementation. Results: Among the 21â¯222 patients who underwent the screening (12â¯790 female, 8084 male, and 348 other gender or not specified; mean [SD] age, 57.4 [9.6] years), the median time to screening for DR decreased from 158 days (interquartile range, 68-324 days) before the intervention to 17 days (interquartile range, 8-50 days) after initiation of the program (P < .001). Overall annual screening rates for DR increased from 5942 of 14â¯633 patients (40.6%) before implementation to 7470 of 13â¯133 patients (56.9%) after initiation of the program at all 15 targeted clinics (odds ratio, 1.9; 95% CI, 1.3-2.9; P = .002). Of the 21â¯222 patients who were screened, 14â¯595 (68.8%) did not require referral to an eye care professional, 4160 (19.6%) were referred for treatment or monitoring of DR, and 2461 (11.6%) were referred for other ophthalmologic conditions. Conclusions and Relevance: A digital TDRS program was successfully implemented for the largest publicly operated county safety net population in the United States, resulting in the elimination of the need for more than 14â¯000 visits to specialty care professionals, a 16.3% increase in annual rates of screening for DR, and an 89.2% reduction in wait times for screening. Teleretinal DR screening programs have the potential to maximize access and efficiency in the safety net, where the need for such programs is most critical.
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Retinopatía Diabética/diagnóstico , Fondo de Ojo , Fotograbar , Atención Primaria de Salud , Telemedicina/métodos , Anciano , Atención Ambulatoria , Estudios Transversales , Femenino , Servicios de Salud , Estudio Históricamente Controlado , Humanos , Los Angeles , Masculino , Tamizaje Masivo , Persona de Mediana Edad , Oportunidad Relativa , Oftalmología , Optometría , Derivación y Consulta , Estudios RetrospectivosRESUMEN
BACKGROUND: Hard exudates (HE) are used as a surrogate marker for sight-threatening diabetic macular edema (DME) in most telemedicine-based screening programs in the world. This study investigates whether proximity of HE to the center of the macula, and extent of HE are associated with greater clinically significant macular edema (CSME) severity. A novel method for associating optical coherence tomography (OCT) scans with CSME was developed. METHODS: Eligible subjects were recruited from a DRS program in a community clinic in Oakland, California. Ocular fundus of each subject was imaged using 3-field 45-degree digital retinal photography and scanned using central 7-line spectral domain OCT. Two certified graders separated subjects into 2 groups, those with and without HE within 500 microns from the center of the macula. A modified DME severity scale, developed from Early Treatment Diabetic Retinopathy Study data and adapted to OCT thickness measurements, was used to stratify CSME into severe and nonsevere levels for all subjects. RESULTS: The probabilities of severe CSME in groups 1 and 2 were 14.4% (95% CI: 8.2%-23.8%) and 9% (95% CI: 2.4%-25.5%), respectively (P = .556). In post hoc analysis, increase in the number of sectors affected by HE within the central zone of the macula was associated with the increase in the probability of being diagnosed with severe CSME. CONCLUSION: We have proposed OCT-based classification of DME into severe and nonsevere CSME. Based on this limited analysis, severity of CSME is related more to extent of HE rather than proximity to the center of the macula.