Geographic variation in diabetic retinopathy screening within the Veterans Health Administration.

AIMS: Diabetic retinopathy (DR) remains the leading cause of vision impairment among working-age adults in the United States. The Veterans Health Administration (VA) supplemented its DR screening efforts with teleretinal imaging in 2006. Despite its scale and longevity, no national data on the VA's screening program exists since 1998. Our objective was to determine the influence of geography on diabetic retinopathy screening adherence. METHODS: Setting: VA national electronic medical records. STUDY POPULATION: A national cohort of 940,654 veterans with diabetes (defined as two or more diabetes ICD-9 codes (250.xx)) without a history of DR. EXPOSURES: 125 VA Medical Center catchment areas, demographics, comorbidity burden, mean HbA1c levels, medication use and adherence, as well as utilization and access metrics. MAIN OUTCOME MEASURE: Screening for diabetic retinopathy within the VA medical system within a 2-year period. RESULTS: Within a 2-year time frame 74 % of veterans without a history of DR received retinal screenings within the VA system. After adjustment for age, gender, race-ethnic group, service-connected disability, marital status, and the van Walraven Elixhauser comorbidity score, the prevalence of DR screening varied by VA catchment area with values ranging from 27 % to 86 %. These differences persisted after further adjusting for mean HbA1c level, medication use and adherence as well as utilization and access metrics. CONCLUSIONS: The wide variability in DR screening across 125 VA catchment areas indicates the presence of unmeasured determinants of DR screening. These results are relevant to clinical decision making in DR screening resource allocation.

Meta-Analyses of Two Treatment Regimens for Retinal Vein Occlusion.

BACKGROUND AND OBJECTIVES: To pool available data on the change in best-corrected visual acuity (BCVA), central retinal thickness (CRT), and number of injections as reported by treat and extend (T&E) and pro re nata (PRN) regimens for retinal vein occlusion (RVO). MATERIALS AND METHODS: After PubMed was queried, separate random effect models were fitted to the data extracted and the Wald test was used to compare the estimates of the two independent meta-analyses. RESULTS: Fourteen T&E and 29 PRN studies were included in two independent meta-analyses. No significant difference was observed in BCVA (+14.74 [+11.52, +17.96] in T&E vs +15.90 [+14.24, + 17.56] in PRN, P = 0.530) or CRT improvements (-259.56 [-189.02, -330.09] in T&E vs -256.58 [-226.57, -286.48] in PRN, P = 0.939). More injections over 12 months were observed in T&E regimens (7.48 [6.32, 8.65] vs 5.13 [4.20, 6.06] in PRN, P = 0.002). CONCLUSION: Although more injections may be required, T&E achieves similar functional and anatomic benefits as compared to PRN regimens. [Ophthalmic Surg Lasers Imaging Retina 2023;54:244-250.].

Stakeholder perceptions affecting the implementation of teleophthalmology.

PURPOSE: Teleophthalmology has become the subject of heightened interest and scrutiny in the wake of the SARS-CoV-2 global pandemic. A streamlined implementation framework becomes increasingly important as demand grows. This study identified obstacles to teleophthalmology implementation through summative content analysis of key stakeholders' perceptions. DESIGN: Summative content analysis of transcribed interviews with key stakeholders (including patients, technicians, ophthalmic readers, staff, nurses, and administrators at two teleophthalmology clinic sites). METHODS: Keyword Were counted and compared to examine underlying meaning. Two analysts coded text independently using MAXQDA for summative qualitative content analysis to derive themes and hierarchical relationships as a basis for future refinement of TECS implementation. xMind ZEN was used to map conceptual relationships and overarching themes that emerged to identify perceived facilitators and barriers to implementation RESULTS: Analysis revealed two themes common to perceptions: (1) benefits of care, and (2) ease of implementation. Perceived benefits included efficiency, accessibility, and earlier intervention in disease course. The quality and quantity of training was heavily weighted in its influence on stakeholders' commitment to and confidence in the program, as were transparent organizational structure, clear bidirectional communication, and the availability of support staff. CONCLUSION: Using a determinant framework of implementation science, this report highlighted potential hindrances to teleophthalmology implementation and offered solutions in order to increase access to screening, improve the quality of care provided, and facilitate sustainability of the innovation.

Teleophthalmology and Inequities in Diabetic Eye Disease at Safety Net Hospitals.

Introduction: Teleophthalmology has emerged as a convenient and cost-effective intervention to increase access to screening for diabetic retinopathy (DR), a disease that disproportionately affects socially disadvantaged communities. However, a few studies have directly compared the detection of eye disease by teleophthalmology between socially and geographically diverse communities. This study compared the rates and severity of diabetic eye disease, as detected by teleophthalmology, between safety net and non-Safety Net Hospitals (non-SNHs). Methods: Retrospective chart review of patients screened for DR at county Safety Net Hospitals (SNHs) and non-SNHs in 150 cities and 30 states. The rates of DR, macular edema, suspected cataract, suspected glaucoma, and suspected age-related macular degeneration were compared. Relative risk and severity of disease in the county SNH population were calculated. Images were graded by the same group of IRIS readers, who used at least one image per eye with a 45° field centered between the optic disc and the macula. Participants with ungradable screening images were excluded. Results: Ninety-four thousand three hundred twenty-nine participants were screened for eye disease from September 1, 2016 to August 31, 2017. Among the screened participants (54% female; mean [SD] age, 58.7 [12.9] years), overall disease detection was 31% in the county SNH population and 23.6% in the non-SNH population. Compared with the non-SNH population, the county SNH population was twice as likely to screen positive for three or more concurrent eye conditions (1.2% vs. 0.7%) and had increased prevalence of DR (20.2% vs. 16.2%), macular edema (4.9% vs. 3.4%), suspected glaucoma (9.1% vs. 4.3%), suspected cataract (9.6% vs. 4.8%), and proliferative DR (2.1% vs. 1.0%). Conclusions: Increased diabetic eye disease prevalence and severity among people seen at SNHs highlights the need for continued resources to screen, treat, and manage disease. Teleophthalmology continues to be an important tool in efforts to mitigate health inequities and address barriers faced by underserved communities.