Primary care optometry-based diabetic retinopathy clinics safely address backlog in care
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Key takeaways:
- The primary care optometrists and hospital consultants agreed on diabetic retinopathy status in patients, researchers found.
- The primary care service catered to patients unsuitable for virtual consultations.
A novel primary care optometry-based diabetic retinopathy service served as an efficient, safe alternative to hospital services and offered advantages over virtual clinics, according to a study conducted in the U.K. and published in Eye.
To address the increasing demand-capacity disparity in diabetic retinopathy (DR) services in the U.K., several hospitals have created virtual retina clinics that offer asynchronous image capture and review, according to the researchers. However, there are many inherent limitations to virtual clinics, including infrastructure, financial constraints or staffing issues.
“Additionally, many patients remain unsuitable for virtual assessment due to ocular conditions preventing adequate imaging (eg, media opacity, asteroid hyalosis, aphakia) or specific patient characteristics (eg, dementia, physical disabilities),” Dervla Dorrian, with the Cwm Taf Morgannwg University Health Board at Royal Glamorgan Hospital in South Wales, and colleagues wrote.
To address the backlog of patients within their institution, the researchers developed and implemented a primary care (PC) optometry-based DR review service in 2022 in association with Royal Glamorgan Hospital. This study was designed to determine the efficacy of the new model compared with data from the established hospital-based virtual DR clinics.
Patients seen at the hospital-based virtual DR service (started in 2019) underwent visual acuity, fundus photography and macular OCT scanning, with asynchronous review later by a consultant ophthalmologist. Comparatively, in the PC optometry DR review clinic, patients attended an optometry practice for a face-to-face review with imaging performed by a PC optometrist with additional training in DR.
The researchers compared the two clinics by concordance in DR grading between PC optometrists and consultant ophthalmologists, DR grading, management plans and the assessment of “ungradable” retinopathy referrals.
Dorrian and colleagues found that from January 2021 to September 2023, 1,760 patients attended appointments at the virtual DR clinic, and from August 2022 to September 2023, 954 patients attended PC review scheme appointments. Average nonattendance rate was notably lower for the PC clinic compared with the virtual clinic (5.2% vs. 21%).
The distribution of DR severity did not differ significantly between the virtual and PC groups, the researchers found. However, diabetic macular edema distribution was significantly different between the clinics (P < .0001), with virtual clinics having a higher proportion of patients with borderline and significant DME.
Further, fewer patients from the PC clinic required subsequent hospital face-to-face follow-up (24%) compared with the virtual clinic (36%). The PC clinic also had improved grading performance for low-risk patients with previously ungradable retinopathy referrals compared with the virtual clinic (88.4% vs. 75% gradable).
Regarding patients referred for consultant opinion, the researchers found that the PC optometrists and hospital consultant ophthalmologists substantially agreed on their DR severity grade assessments (weighted Kappa score, 0.61; 95% CI, 0.52-0.69) and DME status (0.69; 95% CI, 0.56-0.82).
The researchers noted several limitations to this study, one of which was the comparison analysis being limited to patients with more severe DR.
“The primary care-based DR review model addresses a critical care gap and underlines the potential of community-centered health care models to bolster capacity and improve patient accessibility and convenience,” Dorrian and colleagues wrote.
Future research should evaluate the cost effectiveness of this plan compared with traditional hospital-based virtual clinics, they added.
Perspective
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With the steady and ever-increasing prevalence of diabetes and DR worldwide, there is a growing demand for fundus evaluations that allow for retinopathy detection and grading so patients with vision-threatening complications, such as proliferation and significant macular edema, can be treated in a timely manner to prevent irreversible blindness.
This study underscores the important role that optometry plays in meeting this substantial demand for diabetic eye care while maintaining safe, effective and high-quality patient care.
There are advantages of supplementing virtual/hospital-based DR assessment services — with asynchronous image review by ophthalmology — with those conducted independently within community optometric practices. These include the ability to perform slit-lamp examination of the anterior segment to detect iris neovascularization and enhanced likelihood of staging retinopathy among patients with poor quality images, reduced nonattendance rate and decreased rate of unnecessary referrals to retinal specialists.
Utilizing data analysis to stratify patients into low- and high-risk profiles is advantageous so patients at high risk can be prioritized both time-wise and provider-wise.
This study reflects a shifting paradigm in optometric practice toward a medical care model that incorporates much needed multimodal imaging technology, taking low-risk diabetic eye care out of the hospital setting and therefore making it more accessible and convenient for patients.
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