Evaluation of Diabetic Retinal Screening and Factors for Ophthalmology Referral in a Telemedicine Network

Posted May 31, 2017

Key Points  

How well does telemedicine retinal screening affect retinal screening for patients with type 1 or 2 diabetes in rural and underserved settings in North Carolina?

This pre-post study found that the burden of advanced diabetic retinopathy requiring referral to an ophthalmologist was disproportionately high among minorities; factors associated with the need for referral included minority race/ethnicity, older age, and history of kidney disease and stroke. A total of 60% of referred patients completed an ophthalmology referral visit within the study period.

These data suggest that telemedicine increases rates of evaluation for diabetic retinopathy among patients in rural and underserved settings and may also increase access to care.


Retinal telescreening for evaluation of diabetic retinopathy (DR) in the primary care setting may be useful in reaching rural and underserved patients.

To evaluate telemedicine retinal screenings for patients with type 1 or 2 diabetes and identify factors for ophthalmology referral in the North Carolina Diabetic Retinopathy Telemedicine Network.

Design, Setting, and Participants
A preimplementation and postimplementation evaluation was conducted from January 6, 2014, to November 1, 2015, at 5 primary care clinics serving rural and underserved populations in North Carolina among 1787 adult patients with type 1 or 2 diabetes who received primary care at the clinics and obtained retinal telescreening to determine the presence and severity of DR. A total of 1661 patients with complete data were included in the statistical analysis.

Nonmydriatic fundus photography with remote interpretation by an expert.

Main Outcomes and Measures
Number of patients recruited, level of detected DR, change in rates of screening, rate of ophthalmology referral, percentage of completed referrals, and patient characteristics associated with varying levels of DR.

Of the 1661 patients (1041 women and 620 men; mean [SD] age, 55.4 [12.7] years), 1323 patients (79.7%) had no DR, 183 patients (11.0%) had DR without a need for an ophthalmology referral, and 155 patients (9.3%) had DR with a need for an ophthalmology referral. The mean rate of screening for DR before implementation of the program was 25.6% (1512 of 5905), which increased to 40.4% (1884 of 4664) after implementation. A total of 93 referred patients (60.0%) completed an ophthalmology referral visit within the study period. Older patients (odds ratio [OR], 1.28; 95% CI, 1.11-1.48) and African American patients (OR, 1.84; 95% CI, 1.24-2.73) or other racial/ethnic minorities (OR, 2.19; 95% CI, 1.16-4.11) had greater odds of requiring an ophthalmology referral compared with white and/or younger patients. Patients with higher hemoglobin A1c levels (OR, 1.19 per unit change; 95% CI, 1.13-1.25 per unit change) and longer duration of diabetes (OR, 1.76 per decade; 95% CI, 1.53-2.02 per decade) had greater odds of DR requiring an ophthalmology referral. History of stroke (OR, 1.65; 95% CI, 1.10-2.48) and kidney disease (OR, 1.59; 95% CI, 1.10-2.31) were strongly associated with DR and ophthalmology referral.

Conclusions and Relevance
When implemented in the primary care setting, retinal telescreening increased the rate of evaluation for DR for patients in rural and underserved settings. This strategy may also increase access to care for minorities and patients with DR requiring treatment.

To view the original version on The JAMA Network, visit: http://jamanetwork.com/journals/jamaophthalmology/article-abstract/2627936?amp%3butm_source=JAMA+OphthalmolPublishAheadofPrint&utm_campaign=18-05-2017

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