Kentucky Telemedicine Program Increases Diabetic Retinopathy Screening Rates

Large telemedicine diabetic retinopathy screening networks based in federally designated safety-net clinics may be able to increase screening access and compliance among otherwise underscreened populations.

Large telemedicine diabetic retinopathy (DR) screening (TDRS) networks based in federally designated safety-net clinics (FDSCs) may be able to increase screening access and compliance among otherwise underscreened populations, according to study results published in PLoS One. However, outcomes can vary greatly among clinics and further work to optimize program implementation is needed to maximize the model’s impact, the researchers wrote.

DR is a common microvascular complication resulting from diabetes and is the leading cause of incident blindness among adults. Although annual DR screening with early intervention has been proven to reduce the risk of severe DR-related vision loss and is recommended by the American Academy of Ophthalmology for all patients with diabetes, current screening rates in the United States remain low. Reduced screening rates are especially prevalent in vulnerable populations.

Effective treatments for DR are available, but missed opportunities for secondary prevention lead to overall decreased productivity, increased morbidity, and increased health care expenditures. Common barriers to conventional DR exams include geographic and logistic obstacles, lack of motivation, and specialist availability.

To help overcome these barriers and improve screening rates, the researchers of the present study began building a statewide TDRS network in 2013. “The partnership connected FDSCs across Kentucky to an academic medical center providing low-cost telemedicine services (image interpretation, reporting, and referral),” the authors said.

They analyzed results from the first 5 years of the program, called the Appalachia Diabetic Eye Network (ADEN), and assessed pre- and postimplementation screening rates from a subset of clinic sites.

Participating clinics were offered nonmydriatic fundus photography (nFP) cameras, interpretation and reporting resources, staff training, and ongoing technical support without charge for 3 years. After, a nominal charge was applied per screening for interpretation. However, during the study period all FDSCs provided TDRS to patients as a free service (not billed to insurance, no out-of-pocket cost), as cost of care is a significant patient-perceived barrier to TDRS utilization.

The current analysis includes data from an electronic chart review of all patients who participated in ADEN between February 2014 and January 2019. Twenty-two clinics remained in the network throughout the period, and “in many clinics, costs were offset by gains in performance-based bundled-care bonuses.”

The 22-FDSC network comprised 6 federally qualified health center and 1 rural health clinic multisite systems. Clinics averaged 5.9 providers per site while all but the 5 urban sites served rural populations.

Throughout the first 5 years, 13,923 TDRS exams were completed on 10,056 unique patients. Gender was evenly balanced, and the mean patient age was around 55. Patient surveys were also completed to assess intervention acceptability.

A total of 10,540 individual telescreening encounters were of sufficient quality to either rule out DR or identify a life- or sight-threatening pathology requiring referral. Of these, 3532 (33.5%) patients with ocular pathology were identified, 2319 (22.0%) patients had some level of DR with 1604 (15.2%) requiring specialist referral, and 808 (7.7%) patients required referral for other ocular pathologies.

The researchers found:

  • The mean screening rate for audited clinics in the year prior to program implementation was 29.9% (641/2147) and increased to 47.7% (1012/2124) in the program’s first year, doubling patients’ odds of being screened (odds ratio [OR] 2.2; 95% CI, 1.3-3.7; P = .003)
  • A total of 5709 patients were recommended for follow-up or specialist referral, and the overall rate of referral was 41.0% (5709/13,923 exams)
  • Diabetic pathology was found in 22% of adequate screenings
  • Gains in screening rates were sustained over 4 years following implementation (OR, 1.9; 95% CI, 1.1-3.1; P = .018) despite varied clinic screening performance (4-year averaged range, 22.9%-55.1%)
  • Odds of early detection of DR doubled for patients with consecutive screenings (OR, 2.2; 95% CI, 2.0-2.4; P < .001)
  • Surveyed patients preferred TDRS to specialist exams (82.5%; 776/941) and would recommend the service to friends (92.7%; 868/936)

In total, “The need for over 8000 specialist exams was eliminated; more than 2000 referable pathologies were detected; odds of patients’ being screened doubled, and gains were sustained over years; care continuity doubled the odds of early detection of referable pathology and increased odds of future screening compliance; and most patients preferred and endorsed the intervention over traditional specialist exams,” the researchers wrote.

Over 95% of screenings that indicated DR presence were for nonproliferative DR, presenting an opportunity for providers to forestall disease progression in susceptible patients.

TDRS had a gradability rate of over 75%, which is just below the range observed in similar studies of nFP screenings. However, the authors note inconsistent image quality is at least partly due to multilevel barriers and inadequate implementation.

In addition, varied increases in screening rates across clinics point to implementation challenges across different contexts and practices. These discrepancies also imply unidentified upstream, multilevel variables affecting the program’s success.

Lack of demographic and clinical data precluded regression analyses from identifying patient-level predictors of screening outcomes, marking a study limitation.

“Combined, our findings provide a useful framework for other stakeholders to implement sustainable large-scale TDRS programs compatible with social distancing, appropriate for vulnerable populations, and synergistic with care continuity,” the researchers concluded.

“Despite high patient acceptability, screening rates across our clinics were variable and aggregate performance lagged the national DR screening rate, suggesting that to achieve full intervention potential, optimal implementation is essential. Future studies should address poorly understood barriers to TDRS implementation at the level of professionals, health care institutions, and payer systems.”


de Carvalho AB, Ware SL, Lei F, Bush HM, Sprang R, Higgins EB. Implementation and sustainment of a statewide telemedicine diabetic retinopathy screening network for federally designated safety-net clinics. PLoS One. Published online November 4, 2020. doi:10.1371/journal.pone.0241767