Diabetic retinopathy is the most frequent cause of new cases of blindness among adults aged 20 to 74.¹ During the first two decades of disease, nearly all patients who have type 1 diabetes and more than 60% of patients who have type 2 diabetes also develop retinopathy. Despite this, research shows more than half of patients who have diabetes do not get their recommended annual eye exam, which could screen for and detect diabetic retinopathy as well as other eye diseases.²

Given these statistics, it’s important that people with diabetes be screened for diabetic retinopathy. “With timely intervention, we can reduce vision loss in 95% of (diabetic) patients,” said Jose Martinez, MD, Austin Retina Associates, Austin, TX, in an interview on the American Journal of Managed Care website.³

Ophthalmology practices can play a vital role in diabetic patient care by performing these screenings. To get started, the practitioners interviewed in this article recommended the following action steps.

Acquire referrals

To get these patients walking through your door, Peter Karth, MD, MBA, a vitreoretinal surgeon and partner at Oregon Eye Consultants in Eugene, OR, says that getting referrals from primary care physicians, physician assistants, nurse practitioners, diabetes nurse educators, and endocrinologists is key.

“We use traditional marketing methods, such as meeting doctors at social functions like grand rounds at the hospital, county medical society meetings, diabetes care conferences, nurse practitioner seminars, hospital holidays parties, and so forth,” he says. “During the COVID pandemic, we’ve had to move more toward remote continuing education events and phone chats during the pandemic.”

Referring physicians are also incentivized by the monetary value attached to diabetic screenings. An emphasis on patient referrals has risen in the last 5 years, Dr. Karth says, on the primary care side due to payments associated with Healthcare Effectiveness Data and Information Set and Star scores. “Health insurers and the government are starting to pay monitoring incentives for quality of care,” he says. “Diabetic eye screening (i.e., having a dilated exam) is a quality measure.”

Dr. Karth’s community private practice, which sees more than 20,000 patients annually, makes sure to send the referring physician documentation of a patient’s diabetic screening. “Communication and follow-up is critical to maintaining referring partners,” he says. “You have to close the loop. It’s the eye-care provider’s documentation that closes this loop and allows referring doctors to meet their quality metrics.”

Wilmer Eye Institute, a residency clinic in Baltimore, MD, performs community outreach, specifically within the Hispanic population of the city, to increase awareness for diabetic eye exams.

Karen Schafer, ABOC, clinic manager, explains that this began more than 20 years ago and has continued. “The clinic simply needed to fax a referral, and our appointment coordinator would set up an appointment,” she says. The residency clinic has 13,000 patient visits annually.

Olga Whyte, RN, BSN, a nurse at NYU Langone Eye Center at NYU Langone Health in New York, NY, says it markets this service internally within the practice and the greater health system. The ophthalmology team sees more than 60,000 patients annually.

Educate patients

Education gets patients interested in their well-being and leads to follow-up with providers. Therefore, clinical staff at NYU Langone Eye Center tell all diabetic patients that they will benefit from diabetic ophthalmology screening, which may include a dilated exam and further imaging.

Diabetics should be examined annually, if not more frequently, depending on their disease severity, says Allen C. Ho, MD, FACS, attending surgeon and director of retina research at Mid-Atlantic Retina and Wills Eye Hospital and professor of ophthalmology at Thomas Jefferson University, Philadelphia, Pa.

“Early detection, timely treatment, and follow-up care can help reduce disease severity and the risk of blindness caused by diabetic eye disease, including diabetic retinopathy and diabetic macular edema,” explains Dr. Ho.

Staff at Dr. Ho’s practices discuss the importance of annual eye exams with patients every time they see them, including messaging that patients who have diabetes may not have visual symptoms but could still have diabetic eye disease.

Optimize patient flow

Having patients move in and out of a practice quickly is paramount at any successful practice; this has only increased in importance due to COVID-19. At Dr. Ho’s practices, patients move through different stations for assessment, including check in, vision evaluation, and imaging.

“A visit should be no more than 1 hour—the shorter the better,” Dr. Karth says. Diabetic screening is integrated into Oregon Eye Consultants’ standard patient flow and is performed at any time of day every day. A patient is first worked up by a technician who dilates the eyes and checks vision, eye pressure, and other standard data points. The patient sees the doctor in an exam room for the exam and consultation. Then, imaging is performed as needed.

Ms. Shafer says that at Wilmer technicians work up patients and update EMR notes in the doctor’s exam room. This has reduced the number of patients in the waiting room and those waiting for testing.

At NYU Langone Eye Center, all patients are seen by a physician who orders testing as needed. Then, the physician reviews results and next steps with patients.

“We consider both clinical and non-clinical aspects of care to employ optimum patient flow,” Ms. Whyte says. This includes staffing allocation and task analysis; reviewing patient experiences; analyzing capacity and demand; building a template of schedules to ensure patient access; and using the EMR to track the stages of patient visits.

Offer remote services

COVID-19 has accelerated a movement toward remote imaging and in-office interpretation. “We were already tracking and building toward increasing the amount of virtual, remote, or telehealth visits to supplement in-office care,” Dr. Ho says. “Due to the coronavirus, some patients may fear in-person visits and instead delay care. For individuals with diabetes, along with most people over a certain age, it is critical that they seek regular exams and treatment, if necessary. We owe it to these patients to make visits as safe and easy as possible.”

Dr. Ho’s practices will soon launch a pilot for a hybrid type of visit in which a patient comes in for a retinal image and OCT and is in and out quickly in an efficient, socially distant, safe environment with limited wait times and limited contact with staff. Following image capture, patients will have a subsequent telehealth visit with their retina specialist to discuss scan implications, answer any questions, and discuss next steps.

Bill for services

After a visit, Oregon Eye Consultants bills the applicable eye code. Where applicable, the appropriate E&M code or diagnosis code for diabetic screening is used.

At NYU Langone Eye Center, all diabetic screenings and services are billed after each exam and the images have been interpreted. These exams may include multiple eye images and look at the microscopic architecture of the inner layers of the eye.

With Wilmer Eye Institute’s diabetic screening program, a residency clinic, exams are free if a patient is uninsured.

Final thoughts

As the practices in this article explain, the number of diabetic eye screenings can increase through a number of steps, including increasing referrals, improving the patient experience by maximizing patient flow, explaining the importance of screening to patients, and offering remote services. OP

REFERENCES

1. Fong DS, Aiello L, Gardner TW, et al. Diabetic Retinopathy. Diabetes Care. 2003 Jan; 26(suppl 1):s99-s102. https://care.diabetesjournals.org/content/26/suppl_1/s99 . Accessed June 29, 2020.
2. Sixty percent of Americans with diabetes skip annual sight-saving exams. AAO. October 20, 2016. Available at: https://www.aao.org/newsroom/news-releases/detail/sixty-percent-americans-with-diabetes-skip-exams . Accessed June 29, 2020.
3. Management of Diabetic Retinopathy. American Journal of Managed Care website. Published Dec. 24, 2019. https://www.ajmc.com/view/management-of-diabetic-retinopathy . Accessed Aug. 11, 2020.