Barriers to Implementation of Teleretinal Diabetic Retinopathy Screening Programs Across the University of California.

Aim: To describe barriers to implementation of diabetic retinopathy (DR) teleretinal screening programs and artificial intelligence (AI) integration at the University of California (UC). Methods: Institutional representatives from UC Los Angeles, San Diego, San Francisco, Irvine, and Davis were surveyed for the year of their program's initiation, active status at the time of survey (December 2021), number of primary care clinics involved, screening image quality, types of eye providers, image interpretation turnaround time, and billing codes used. Representatives were asked to rate perceptions toward barriers to teleretinal DR screening and AI implementation using a 5-point Likert scale. Results: Four UC campuses had active DR teleretinal screening programs at the time of survey and screened between 246 and 2,123 patients at 1-6 clinics per campus. Sites reported variation between poor-quality photos (<5% to 15%) and average image interpretation time (1-5 days). Patient education, resource availability, and infrastructural support were identified as barriers to DR teleretinal screening. Cost and integration into existing technology infrastructures were identified as barriers to AI integration in DR screening. Conclusions: Despite the potential to increase access to care, there remain several barriers to widespread implementation of DR teleretinal screening. More research is needed to develop best practices to overcome these barriers.

The Development and Implementation of Preventive Medicine Resident Rotations in a Shelter Serving Asylum-Seekers at the US-Mexico Border.

Asylum-seekers present to the US-Mexico border with a variety of acute health needs. In December 2018, the County of San Diego Health and Human Services Agency partnered with the University of California, San Diego to provide health screenings to asylum-seekers at a humanitarian shelter administered by Jewish Family Services. The assessments screened for communicable diseases and acute conditions. Preventive medicine residents in the HRSA-funded UCSD-SDSU (University of California, San Diego-San Diego State University) Residency were trained to become an integral part of the program. Training included cultural competency, public health interface, protocol development and implementation, interdisciplinary teamwork, and quality improvement. Over 18 months, nearly 20000 asylum-seekers were screened, which allowed for the detection of an imported influenza outbreak and prevented any major public health incidents or medical errors. This health screening program for asylum-seekers provided an important experience for preventive medicine trainees. In turn, preventive medicine and other trainees were valuable contributors to the program.

Implementation Mapping of the Collaborative University of California Teleophthalmology Initiative (CUTI): A Qualitative Study Using the Exploration, Preparation, Implementation, and Sustainment (EPIS) Framework.

Background This study aimed to investigate the rationale, barriers, and facilitators of teleretinal camera implementation in primary care and endocrinology clinics for diabetic retinopathy (DR) screening across University of California (UC) health systems utilizing the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework. Methodology Institutional representatives from UC Los Angeles, San Diego, San Francisco, and Davis participated in a series of focus group meetings to elicit implementation facilitators and barriers for teleophthalmology programs within their campuses. Site representatives also completed a survey regarding their program's performance over the calendar year 2022 in the following areas: DR screening camera sites, payment sources and coding, screening workflows including clinical, information technology (IT), reading, results, pathologic findings, and follow-up, including patient outreach for abnormal results. Focus group and survey results were mapped to the EPIS framework to gain insights into the implementation process of these programs and identify areas for optimization. Results Four UC campuses with 20 active camera sites screened 7,450 patients in the calendar year 2022. The average DR screening rate across the four campuses was 55%. Variations between sources of payment, turn-around time, image-grading structure, image-report characteristics, IT infrastructure, and patient outreach strategies were identified between sites. Closing gaps in IT integration between data systems, ensuring the financial sustainability of the program, and optimizing patient outreach remain primary challenges across sites and serve as good opportunities for cross-institutional learning. Conclusions Despite the potential for long-term cost savings and improving access to care, numerous obstacles continue to hinder the widespread implementation of teleretinal DR screening. Implementation science approaches can identify strategies for addressing these challenges and optimizing implementation.

Implementing clinical informatics tools for primary care-based diabetic retinopathy screening.

OBJECTIVES: To improve diabetic retinopathy (DR) screening rates through a primary care-based "teleretina" screening program incorporating clinical informatics tools. STUDY DESIGN: Quality improvement study at an academic institution. METHODS: Existing DR screening workflows using in-person eye examinations were analyzed via a needs assessment. We identified gaps, which clarified the need for expanding DR screening to primary care settings. We developed informatics tools and described associated challenges and solutions. We also longitudinally monitored imaging volume and quality. RESULTS: The needs assessment identified several gaps in baseline DR screening workflows. Health information technology (IT) considerations for the new primary care-based teleretina screening program included integrating the new program with existing information systems, facilitating care coordination, and decreasing barriers to adoption by incorporating automation and other features aimed at decreasing end-user burden. We successfully developed several tools fulfilling these goals, including integration with the ophthalmology picture and archiving communication system, a customized aggregated report in the electronic health record to monitor screenings, automation of billing and health maintenance documentation, and automated results notification to primary care physicians. Of 316 primary care patients screened between October 2020 and July 2021, 73 (23%) were found to have ocular pathology, including DR, glaucoma, age-related macular degeneration, and a range of other eye conditions that were previously undiagnosed. CONCLUSIONS: New models of health care delivery, including telemedicine workflows, have become increasingly important for complex diabetic care coordination and require substantial health IT engagement. This program illustrates how clinical informatics tools can make substantial contributions to improving diabetes care.

One In Five Fewer Heart Attacks: Impact, Savings, And Sustainability In San Diego County Collaborative.

Before 2011 rates of hospitalization for heart attacks were about the same in San Diego County as they were in the rest of California. In 2011 a multistakeholder population health collaborative consisting of partners at the federal, state, and local levels launched Be There San Diego. The collaborative's goal was to reduce cardiovascular events through the spread of best practices aimed at improving control of hypertension, lipid levels, and blood sugar and through patient and medical community activation. Using hospital discharge data for the period 2007-16, we compared acute myocardial infarction (AMI) hospitalization rates in San Diego County and the rest of the state before and after the demonstration project started. AMI hospitalization rates decreased by 22 percent in San Diego County versus 8 percent in the rest of the state, with an estimated 3,826 AMI hospitalizations avoided and $86 million in savings in San Diego. Results show that a science-based health collaborative can improve outcomes while lowering costs, and efforts are under way to ensure the collaborative's sustainability.

Development of a dipstick immunoassay to detect nucleopolyhedroviruses in Douglas-fir tussock moth larvae.

In this paper, we describe the development of a novel field detection system for the identification of Orgyia pseudotsugata nucleopolyhedrovirus (OpNPV) and OpNPV infections in Douglas-fir tussock moth (O. pseudotsugata) (DFTM) larvae, utilizing antibodies in a dipstick immunoassay. The dipstick method is sensitive to a minimum of 10ng of extracted virus protein, or approximately 1070 virus occlusion bodies, and is sufficiently sensitive to detect OpNPV infections in DFTM prior to mortality. Additionally, the method can be used to unambiguously detect virus in infected larvae without purification of the test sample. This research provides a novel tool for on-site assessment of the incidence of OpNPV in field populations of DFTM, and has the potential to improve the biological control of the DFTM by facilitating on-site pest management decisions.

Development and evaluation of methods to detect nucleopolyhedroviruses in larvae of the Douglas-fir tussock moth, Orgyia pseudotsugata (McDunnough).

Various molecular methods are used to detect pathogenic microorganisms and viruses within their hosts, but these methods are rarely validated by direct comparison. Southern hybridization, enzyme-linked immunosorbent assay (ELISA), and a novel DNA extraction/PCR assay were used to detect Orgyia pseudotsugata multiple nucleopolyhedrovirus (OpMNPV) in Douglas-fir tussock moth larvae. PCR was more sensitive than Southern hybridization and ELISA at detecting semipurified virus. ELISA, however, was the most accurate method for detecting virus within larvae, given that Southern hybridization and PCR produced false-negative results (31% and 2.5%, respectively). ELISA may be preferable in some applications because virus infections can be quantified (r(2) = 0.995). These results may be applicable to both applied and academic research that seeks to accurately identify the incidence of viruses and microorganisms that regulate insect populations.