Telemedicine can increase access to diabetic retinopathy treatment

Seema Garg, MD, PhD, associate professor in the Department of Ophthalmology, is the lead author on two companion articles, as well as an author podcast published in JAMA Ophthalmology. Garg, a retina specialist with a particular interest in diabetic retinopathy, has been spearheading efforts since 2009 to implement and study telemedicine programs to improve early detection of diabetic retinopathy.

Telemedicine can increase access to diabetic retinopathy treatment click to enlarge Seema Garg, MD, PhD

Seema Garg, MD, PhD, associate professor in the Department of Ophthalmology, is the lead author on two companion articles as well as an author podcast published in JAMA Ophthalmology:  "Evaluation of Diabetic Retinal Screening and Factors for Ophthalmology Referral in a Telemedicine Network,"  and "Geographic Information Systems Mapping of Diabetic Retinopathy in an Ocular Telemedicine Network."   Garg, a retina specialist with a particular interest in diabetic retinopathy,  has been spearheading efforts since 2009 to implement and study telemedicine programs to improve early detection of diabetic retinopathy. After demonstrating success in a pilot program in collaboration with the UNC Department of Family Medicine, she was funded by The Duke Endowment to take her program state-wide.  

Garg and her team established the North Carolina Diabetic Retinopathy Telemedicine Network to implement a pragmatic approach to improve surveillance for diabetic retinopathy, the leading cause of preventable blindness in the United States and the leading cause of blindness among working-age Americans.  They recruited patients with diabetes who live in rural and underserved areas of North Carolina by collaborating with 5 clinical sites that serve this population (AHEC clinics).  At each site, they trained primary care staff to obtain digital retinal photographs that were then securely transmitted to Garg for remote evaluation. 

In the first paper, Garg's team demonstrated that when implemented in primary care settings, retinal tele- screening increased the rates of diabetic retinopathy evaluation in rural and underserved areas and increased access to care among minority populations and others at particularly high risk for vision loss.  Furthermore, they examined demographic and clinical factors that require ophthalmology referral.  Notably, these were minority race and older age, as well as history of kidney disease and stroke. 

In the first study of its kind, in the companion paper, Garg and colleagues demonstrated that Geographic Information Systems (GIS)-mapping is a useful technique for visualizing geographic access barriers to eye care for patients with diabetes.  By mapping the statewide distribution of providers serving the primary care needs of diabetic patients alongside ophthalmologists in North Carolina relative to the ZIP codes from which patients travel to reach the 5 AHEC clinics in their network, they showed that patient accessibility to these doctors is influenced by the geography and road networks that connect them.  This knowledge may help inform the future expansion of the telemedicine programs as they are now able to identify opportunities for strategic collaborations between primary care providers and ophthalmologists across the state. 

Garg believes that reducing vision loss from diabetic retinopathy is a public health imperative.  In these two manuscripts published in JAMA Ophthalmology, Garg and colleagues demonstrate that, in rural settings, telemedicine is extremely effective in improving access to retinal evaluation. Telemedicine screening can increase surveillance rates, reduce socioeconomic disparities, and increase access to care – ultimately preventing vision-threatening DR to improve visual outcomes and quality of life for patients with diabetes.

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