Keeping an Eye on Diabetes
Diabetic retinopathy – damage to the eye’s retina caused by long-term diabetes – is the leading cause of blindness in working-age adults in the U.S. Detection and treatment can reduce vision loss, but, unfortunately, by the time a person has symptoms, permanent vision damage has begun. Thus, early detection, while the patient is asymptomatic, is critical.
Despite treatment guidelines recommending annual eye exams for every adult diabetic, not all patients receive them, especially those in rural locations, of low socioeconomic status or without health insurance. Screening rates in North Carolina are particularly low – only 20 to 30 percent of diabetics – in a state where 1 in 10 adults has diabetes. As Katrina Donahue, M.D., M.P.H., a family physician at University of North Carolina explains, many barriers stand in the way.
Diabetic retinopathy – damage to the eye’s retina caused by long-term diabetes – is the leading cause of blindness in working-age adults in the U.S. Detection and treatment can reduce vision loss, but, unfortunately, by the time a person has symptoms, permanent vision damage has begun. Thus, early detection, while the patient is asymptomatic, is critical.
Despite treatment guidelines recommending annual eye exams for every adult diabetic, not all patients receive them, especially those in rural locations, of low socioeconomic status or without health insurance. Screening rates in North Carolina are particularly low – only 20 to 30 percent of diabetics – in a state where 1 in 10 adults has diabetes. As Katrina Donahue, M.D., M.P.H., a family physician at University of North Carolina explains, many barriers stand in the way.
“Even when a family doctor makes the referral to an ophthalmologist, there may not be one available in the area,” she said. “This also means an additional appointment for the patient, at additional cost, for which the patient may have to take off work and find transportation to go some distance. To make matters worse, Medicaid does not reimburse for screening, as Medicare and private health insurance do.”
Donahue is using funding from NC TraCS Institute, UNC’s NIH Clinical and Translational Science Awards (CTSA), matched by funds from UNC School of Medicine and East Carolina University, to pilot a study of telemedicine as a way of getting diabetic patients the eye exams they need. Donahue, a family physician at UNC, is working with a team that includes Doyle Cummings, Pharm.D., from East Carolina University and Paul Bray from Bertie Memorial Hospital in Windsor, N.C. Using a teleretinal camera placed in a rural primary care practice in Bertie County, providers offered point-of-care retinal screening at an office visit. The procedure took only about 10 minutes and eyes did not have to be dilated. A licensed practical nurse (LPN) conducted the screening and an ophthalmologist read the scan remotely and sent results back to the primary care physician at the clinic. So far, 20% of patients in the study were detected as having retinal disease – patients who might otherwise have not received screening at all.
Another important part of the pilot was training of the LPN and comparison of her scan results with those of the ophthalmologist to determine whether screening costs could be reduced without compromising quality of care. Rich Davis, M.D., an ophthalmologist at UNC and an NC TraCS Research Navigator, trained the LPN in how to read the retinal scans. The LPN’s readings of the scans differed from the ophthalmologist’s in only one instance, and that was a false positive. So, she did not miss anyone’s eye disease.
“Donahue's pilot work is critically important to understand how primary care providers may incorporate a retinal screening program within the practice to improve retinal screening rates in adults with diabetes," said Davis.
At present the teleretinal camera used is expensive for small rural health clinics or private practices to purchase on their own (about $17,000) or to rent ($8,000-$10,000 annually). Donahue said manufacturers are working on ways to reduce costs to make the cameras more affordable. Likewise, future research may involve investigating ways to arrange for multiple clinics to share a single camera.
Donahue and colleagues have presented an abstract of their findings at the American Diabetes Association meeting this summer and are working on a manuscript for publication in Diabetes Care. They will present their findings back to the community, as part of the process of community-based participatory research. Donahue is director of the North Carolina Network Consortium, a collaboration between investigators at UNC, ECU, Duke University and medical practice networks in Mecklenburg and Robeson County who work together to forge academic and community partnerships in clinical research. They will also pursue additional funding to disseminate their findings and to further their work in telemedicine.
“We wouldn’t have done this without NC TraCS’ support,” said Donahue.
