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Telemedicine identifies need for ROP referrals
Non-physician image readers correctly identified 90% of infants with referral warranted ROP.
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Training non-physicians to remotely obtain and grade images to detect potentially serious retinopathy of prematurity reliably identifies patients needing referral, according to a study.
In a study published in JAMA Ophthalmology, researchers evaluated the effectiveness of a telemedicine system to detect referral-warranted ROP — that is, those that need an examination by an ophthalmologist — by comparing digital images obtained and graded by trained non-physicians with the same cases graded by ophthalmoscopic examination.
“A lot of ophthalmologists just don’t do ROP exams. I think what telemedicine can do is provide ROP screening in regions of the country and the world that have limited access and improve effectiveness of ROP detection programs in general,” lead study author Graham E. Quinn, MD, told Ocular Surgery News.
Patients and methods
The observational study enrolled 1,284 premature infants with birth weights less than 1,251 g at 13 North American neonatal intensive care units. Mean body weight of the infants was 864 g, and mean gestational age was 27 weeks. Retinal images were available for 1,257 infants.
Trained non-physicians obtained serial ROP images in both eyes with the RetCam Shuttle (Clarity Medical Systems), while ophthalmologists experienced in diagnosing ROP also conducted examinations. The images were graded remotely by trained non-physician readers, and findings were compared with results of the clinical exams.
The four non-physician readers who participated in joint didactic and image grading sessions practiced with training image sets and underwent a certification process.
“In our study, we had neonatal nurses, nurse practitioners, ophthalmic technicians and OCT technicians learn the skill of imaging, but it took a while for them to get up to speed. I think maintaining quality over time will be a major issue for people who try to implement a telemedicine system,” Quinn said.
“I think the clinician has to make sure that they are getting people who do quality imaging in the NICU. They have to help people develop the skill, monitor that skill and work closely with whoever is going to do it,” he said.
Sensitivity and specificity
A total of 5,520 pairs of diagnostic examinations and image-set gradings were evaluated in the study, with 78.6% of those pairs in agreement with one another.
“The non-physician readers correctly identified 90% of infants with referral-warranted ROP, meaning that we identified 90% of the infants on a single visit who had potential serious disease and who should be evaluated for possible treatment,” Quinn said.
“In about 40% of the cases, the image readers detected referral-warranted ROP about a week or two earlier than the physician did. In addition, I think one of the things that you really need to think about is the false negatives and the false positives,” Quinn said.
Sensitivity for detection of referral-warranted ROP was 81.9% with 90.1% specificity when image-set grading was compared with a diagnostic examination of one eye. When both eyes were taken into account, sensitivity was 90% and specificity was 87%.
Furthermore, negative predictive value was 97.3%, positive predictive value was 62.5%, and observed referral-warranted ROP rate was 19.4% in both eyes.
“We had a greater than 98% sensitivity for eyes that underwent treatment by the ophthalmologist, meaning that only a very small but important percentage of babies were indeed missed,” Quinn said.
Training non-physicians to obtain the images would not only be cost-effective but also would accommodate both the infant’s and the physician’s schedules, Quinn said.
“A telemedicine approach that uses non-physicians to get the images saves doctors time and allows them to have high-quality images that they can look at quickly in the quiet of their own space rather than in the nursery. That may help them make a more considered judgment,” Quinn said. – by Nhu Te
Reference:
Quinn GE, et al. JAMA Ophthalmol. 2014;doi:10.1001/jamaophthalmol.2014.1604.For more information:
Graham E. Quinn, MD, can be reached at the Division of Ophthalmology, The Children’s Hospital of Philadelphia, Wood Center, 1st Floor, Philadelphia, PA 19104; email: quinn@email.chop.edu.Disclosure: Quinn received support from the National Eye Institute for this project.