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Northern Alberta remote teleglaucoma program: clinical outcomes and patient disposition
ORIGINAL ARTICLE
Northern Alberta remote teleglaucoma program: clinical outcomes and patient disposition Sanam Verma, BSc.,* Sourabh Arora, MD,* Faazil Kassam, MD,† Marianne C. Edwards, MD,* Karim F. Damji, MD, MBA, FRCSC* ABSTRACT ● RÉSUMÉ Objective: To review the diagnostic outcomes and clinical referral pathways of patients assessed and managed through a collaborative care patient-centred teleglaucoma program. Study design: Retrospective cohort study. Methods: Eligible patients were those assessed by the referring optometrist or ophthalmologist to be open-angle glaucoma suspects or to have definite early open-angle glaucoma. A glaucoma specialist graded each case through virtual consultation. Clinical referral pathways were noted: in-person consultation with glaucoma specialist, repeat teleconsultation, collaborative glaucoma management with optometrist, or referral for nonglaucomatous ophthalmic pathology. Results: A total of 247 patients were referred to the program from 2008 to 2012. Of all teleconsults, 31.1% were diagnosed with glaucoma, 42.1% were suspects, and 26.7% were unaffected. Of all patients, 27% were referred for in-person glaucoma evaluation; 69% of patients could be managed by their referring optometrist, with 48% of patients requiring repeat teleconsultation. Treatment was initiated before being seen for 87% of patients with definite glaucoma and 28% of glaucoma suspects. Conclusions: Of all patients seen through the remote teleglaucoma program, most did not require an in-person consultation with an ophthalmologist and could be managed through distance collaboration. For the approximately one third who were diagnosed with glaucoma based on virtual assessment, medication was started in the majority of cases and in-person consultation was arranged. Further studies to validate and consider cost-effectiveness of this system are under way. Objet : Revue des résultats de diagnostic et des voies de référence clinique des patients évalués et orientés par un programme de Téléglaucome de collaboration des soins centré sur les patients. Nature : Étude rétrospective de cohorte. Méthodes : Les patients éligibles sont ceux que l’optométriste ou l’ophtalmologiste a désignés comme sujets au glaucome à angle ouvert ou qui ont définitivement un glaucome à angle ouvert précoce. Un spécialiste du glaucome a évalué chaque cas par consultation virtuelle. Les voies de référence clinique étaient notées ainsi : consultation personnelle d’un spécialiste du glaucome, téléconsultation répétée, gestion du glaucome en collaboration avec un optométriste ou référence pour pathologie ophtalmique non glaucomateuse. Résultats : En tout, 247 patients ont été référés au programme entre 2008 et 2012. Parmi toutes les téléconsultations, 31,1 % des patients reçurent un diagnostic de glaucome, 42,1 % une suspicion et 26,7 % une indemnité. 27 % des patients ont été orientés vers une évaluation du glaucome en personne. 69 % pouvaient être gérés par leur optométriste de référence, avec 49 % des patients ayant besoin de répéter la téléconsultation. Le traitement a été initié avant l’examen pour 87 % des patients définitivement atteints de glaucome et 28 % soupçonnés de glaucome. Conclusion : Parmi tous les patients du programme de téléglaucome à distance, la plupart n’ont pas eu besoin de consultation en personne chez un ophtalmologiste et purent être suivis par collaboration à distance. Pour environ le tiers, qui ont eu un diagnostic de glaucome par évaluation virtuelle, la médication a été commencée dans la majorité des cas et la consultation en personne organisée. D’autres études sur la validation et l’examen de l’efficacité des coûts de ce système se poursuivent.
Glaucoma is a progressive optic neuropathy that is associated with significant visual impairment, reduction in quality of life, falls, motor vehicle accidents, and depression.1 Patients with glaucoma and glaucoma suspects constitute up to 5% of the global population older than 40 years, and glaucoma is the world’s second leading cause of blindness.2,3 Teleophthalmology is a branch of telemedicine that uses technology to aid in distance management of ophthalmic disease. This care model has been validated in patients with diabetic retinopathy, for example, at the University of Alberta using stereoscopic digital imaging.4,5 Teleconsults
provide a different modality for diagnosis, management, and navigating referral pathways in the medical system. This approach was demonstrated to be a useful tool in delivering care and screening patients for glaucoma.6,7 In 2008, a patient-centred teleglaucoma program was launched at the University of Alberta with the aim of improving access to specialist care, enhance clinical teaching and research in telemedicine, and promote early diagnosis to prevent glaucoma-related sequelae. As opposed to teleophthalmology as a method of screening for eye disease, this teleglaucoma program would provide
From the *Department of Ophthalmology, University of Alberta, Edmonton, AB; and †Division of Ophthalmology, Department of Surgery, University of Calgary, Calgary, AB
Correspondence to Karim Damji, Royal Alexandria Hospital, 2317, 10240 Kingsway Avenue, Edmonton AB T5H 3V9; [email protected]
S.V. and S.A. provided equal intellectual contribution as co-first authors. Originally received Aug. 2, 2013. Final revision Nov. 7, 2013. Accepted Nov. 7, 2013
Can J Ophthalmol 2014;49:135–140 0008-4182/14/$-see front matter & 2014 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2013.11.005
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Remote teleglaucoma patient outcomes—Verma et al. comprehensive management directly from a glaucoma specialist, continuity of care, and in-person examinations as needed to ensure high quality of care. Thirteen optometrists, a family physician with an interest in eye disease, and a comprehensive ophthalmologist have participated in the program. Each of the 15 sites has a core set of equipment that includes an intraocular pressure (IOP) measuring device, pachymetry equipment (for ultrasonic measurement of central corneal thickness), a visual field machine, and a retinal camera. The teleglaucoma assessment, completed by a fellowship-trained glaucoma specialist, involves integrating information from a standardized history, examination, digital stereoscopic optic nerve images, and other diagnostic tests such as visual fields and optic nerve imaging devices.8 The grading specialist recommends medical management and follow-up care for the patient. Studies to date have examined the applicability of technology in remote management of patients with glaucoma.9–11 However, few have looked at outcome measures and referral pathways in teleglaucoma usage.7,12
This study aims to examine the referral pathways/disposition of patients managed by collaborative care via teleconsultation. We anticipate that detailed patient eligibility criteria and current comanagement capabilities of eye care providers will permit the majority of patients to be cared for in their remote communities.
METHODS This is a retrospective study of all patients assessed through the “remote” teleglaucoma program from September 2008 to May 2012. Details of this “remote teleglaucoma” model have been previously described.8 The flow pathway for patients is described in Fig. 1. All patients were being managed by a local optometrist or medical doctor and were referred for a teleconsultation if they met the inclusion and exclusion criteria (Table 1). The model was designed to primarily assess glaucoma suspects and those with early-stage glaucoma; however, some cases of advanced disease were also referred. Participating referring
Fig. 1 — University of Alberta Remote Teleglaucoma Model
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Remote teleglaucoma patient outcomes—Verma et al. Table 1—Participants: glaucoma suspects or those with early stages of glaucoma as determined by referring practitioner Inclusion Criteria
Exclusion Criteria ● Patient extremely anxious about diagnosis and/or prognosis ● Advanced glaucoma (VCDR 4 0.85 and/or VF defect within 10 degrees of fixation) ● Extremely high IOP (Z35 mm Hg) ● Features suggestive of angle closure (closed or occludable angles and IOP elevation) ● Features suggestive of secondary open- and/or closed-angle glaucoma ● Cultural or language barrier ● Mental health issues (e.g., dementia) ● Discretion of referring or reporting centre
Open-angle glaucoma suspect: ● Age 4 50 y (with Z1 of the following) ● Black, Latino ● Myopia ● Family history of glaucoma ● Systemic risk factors such as migraine, steroids, thyroid disease, sleep apnea ● Suspicious features of optic disc and/or visual field test
VCDR, vertical cup/disk ratio; VF, visual field; IOP, intraocular pressure.
practitioner offices completed an orientation training session to clarify patient eligibility and features that would raise suspicion for glaucoma diagnosis. Consultations were uploaded onto the Secure Diagnostic Imaging (SDI)13 system, and the glaucoma specialist reviewing the cases created a report indicating a diagnosis of “definite” (including stage of disease, i.e., early, moderate, or advanced), “suspect” (including risk stratification, i.e., low, moderate, or high risk for progression), or “normal” for glaucoma, and a management plan was provided.3,14 Individual teleglaucoma patient reports were reviewed, and a database was established for all patients from 2008 to 2012, which included demographic data (such as age, sex, and postal code) and clinical information (such as medical history, IOP, interpretation of visual field tests and fundus photos, diagnosis, and management plan). The primary outcome evaluated was the disposition of the patients who fell into 1 of 4 categories: discharge and follow up as needed, repeat teleconsultation, in-person glaucoma evaluation, and referral for care unrelated to glaucoma. Simple summary statistics were computed. Secondary outcomes included diagnosis, treatment recommendations, and follow-up interval times. Information regarding diagnosis was extracted from reports, and for cases of definite glaucoma, there was further detail to classify cases as “mild,” “moderate,” or “advanced” stage. If the glaucoma specialist described a classification of “moderate-to-advanced” disease, we included it in the advanced group. Treatment goals were extracted from each report made by the glaucoma specialist. In some cases, treatment by topical glaucoma medications was recommended by the ophthalmologist and started by the optometrist, without the patient ever seeing the ophthalmologist in person. For recommended treatments more advanced than topical
medications, it was advised that the patient be referred to an ophthalmologist, or to the grading glaucoma specialist depending on complexity of the case and convenience of the patient. The time to follow-up and type of specialist being referred to were noted. All clinical information about patients pertaining to their repeat or follow-up visit with the teleprogram was included in a separate database; the same primary and secondary outcomes were extracted but analyzed separately.
RESULTS A total of 273 patients assessed through the remote teleglaucoma program from 2008 to 2012. Five patient records were removed because of reports that were repeated in the SDI database, and 1 patient was excluded from teleglaucoma because the patient was seen in person. From the remaining 267 cases, 20 teleglaucoma consultations were repeat visits, and there were 247 new patient consultations. The average age of these 247 patients was 59.5 ⫾ 17.2 years (range 6–94). There were 132 females and 114 males evaluated (Table 2). The percentage of all patients seen through teleglaucoma who were referred for in-person evaluation was 31% (76/247), and additional details regarding disposition were analyzed (Table 3). The percentage of all patients whose in-person evaluation was for assessment of glaucoma was 27% (66/247). The remaining 10 (4%) patients were referred to an ophthalmologist for in-person evaluation of another diagnosis that was detected through teleglaucoma, most frequently cataract, disk drusen, and age-related macular degeneration. Nine of these patients were believed to be without glaucoma
Table 2—Baseline demographic factors
Mean age, y Male/Female, n Mean IOP, mm Hg
Total
Definite Glaucoma
Glaucoma Suspect
Normal
59.5 ⫾ 17.2 114/132 17.86 ⫾ 4.6 OD 17.95 ⫾ 5.2 OS
67.3 ⫾ 13.7 35/42 18.8 ⫾ 5.4 OD 19.5 ⫾ 6.8 OS
60.6 ⫾ 13.7 51/53 17.7 ⫾ 4.3 OD 17.8 ⫾ 4.5 OS
48.8 ⫾ 20.3 29/37 17.0 ⫾ 3.9 OD 16.4 ⫾ 3.4 OS
Mean age +/ SD; mean IOP +/ SD.
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Remote teleglaucoma patient outcomes—Verma et al. Table 3—Disposition pathway Glaucoma-Related In-Person Follow-up with Ophthalmologist
Referred for Nonglaucoma Concern
66 (26.7%)
10 (4%)
All patients (N ¼ 247), n (%)
based on virtual examination. One of those patients was diagnosed virtually as a glaucoma suspect but was seen in person for assessment of a concomitant diagnosis of disk drusen. Most patients being assessed for glaucoma in person were recommended to follow-up with a glaucoma specialist (52/66, 79%), whereas 14 (21%) were referred to a comprehensive ophthalmologist. Among patients diagnosed with glaucoma, 51% required in-person examination, and a higher proportion of patients with advanced disease required in-person examination (Table 4). Thirty-one percent of patients were diagnosed with glaucoma, 42% as suspects, and 27% were thought to be normal or have a diagnosis other than glaucoma (Table 4). Of patients with glaucoma, 87% had treatment initiated remotely (Table 5). Diagnoses other than glaucoma were made in 26 patients (11% of all cases), the most frequent ones being disk drusen (15%) and cataracts (11.5%). Two patients were referred to comprehensive ophthalmology and 4 were referred to neuro-ophthalmology for nonglaucoma diagnosis. The mean time from patients’ visit with optometrist to a completed grading was 16.2 ⫾ 18.4 (range 0–121) days, whereas the time taken for the physician to complete the report once received was 6.5 ⫾ 6 (range 0–35) days. The number of patients who were seen for a second virtual visit through teleglaucoma was 20 of 267 (7.5 %). These patients were initially assessed through teleglaucoma, and after this initial consult, their mean follow-up interval until their second virtual consult was 8.25 ⫾ 3.8 months. At the time of this study, which was after these patients had their second teleconsultation, 5 patients (25%) were recommended to undergo in-person follow-up with a glaucoma specialist, whereas 13 (65%) could continue being managed through collaborative care and were recommended to have a third teleconsultation in the future. Two patients were discharged back to their optometrist to allow for reconsultation as needed because it was believed they did not need to be followed by an ophthalmologist.
Table 4—Patients requiring in-person examination by diagnosis Diagnosis No glaucoma Glaucoma suspect Definite glaucoma Early Moderate Advanced
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Patients, n 66 104 77 48 13 16
Requiring In-Person Examination, n (% of patients with given diagnosis) 9 28 39 25 4 10
(14%) (27%) (51%) (52%) (31%) (63%)
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Followed Only by Their Optometrist 171 (69%) (48% of patients had repeat teleconsultation, whereas 21% were discharged to referring primary eye care provider)
During this second virtual visit, medical management or laser therapy was suggested in 13 (65%) cases. There were 13 patients diagnosed with glaucoma, 5 glaucoma suspects, and 2 thought to have normal results.
DISCUSSION Patients assessed through the “remote teleglaucoma” program were managed through collaborative care with optometrists, and most did not require an in-person examination with an ophthalmologist. Twenty-seven percent of patients were seen in person for glaucoma evaluation, and this was more likely for those of more advanced disease. Sixty-two percent of patients were found to be glaucoma suspects or normal for glaucoma, and a small percentage of these patients were recommended for an in-person examination (22%; Table 4). Almost half of all patients seen through teleglaucoma could be comanaged through continued teleconsultation (Table 3). This is especially relevant because in Alberta, optometrists can prescribe glaucoma medications with consultation from an ophthalmologist. Teleglaucoma is a platform that enables for this to happen efficiently. Devarajan et al.12 described their model of teleglaucoma, and it was noted that the benefit to their Hospital Eye Service was a 53% decrease in the absolute number of patients referred with suspected glaucoma; the cost saving was £117 per patient. They found that 47% of their patients’ required in-person evaluation. Our smaller percentage requiring evaluation (31%) may be attributable to the lower burden of disease in the patients selected for teleconsultation and stringent inclusion and exclusion criteria. The mean IOP among patients in our study with definite glaucoma was approximately 19 mm Hg, which is less than those with typical glaucoma diagnosis, reflecting some patients with normal tension glaucoma and some patients who were already being treated and required a second opinion, such as a change in medication. Patients who presented to the optometrist and were deemed urgent, with extremely elevated IOP, were referred directly to the ophthalmology service and not to the teleglaucoma program. When comparing teleglaucoma with other teleophthalmology projects, such as teleretina for diabetic retinopathy, similar referral patterns are apparent. A study of 5500 teleretina patients had 17% seen in person for additional testing or treatment and an additional 2% because of inability to image. Teleretina decreased the time to treatment, allowed treated patients to be followed
Remote teleglaucoma patient outcomes—Verma et al. Table 5—Management recommendations and referral intervals
Treatment initiated Time to in-person referral Time to repeat tele-examination
All Patients
Definite Glaucoma
Suspect Glaucoma
Normal for Glaucoma
96/247 (39%) 8.6 ⫾ 3.4 weeks 8.8 ⫾ 3.4 mo
67/77 (87%) 7.9 ⫾ 3.2 weeks 8.01 ⫾ 3.6 mo
29/104 (28%) 10.2 ⫾ 2.8 weeks 8.6 ⫾ 3.3 mo
0/66 3.7 ⫾ 2.1 weeks 10.8 ⫾ 2.6 mo
remotely, and prevented unnecessary referrals.15 This teleglaucoma program mirrors teleretina in terms of allowing remote management; 87% of patients with glaucoma had treatment initiated remotely. The increased proportion of patients in teleglaucoma requiring in-person examination may be related to the fact that glaucoma may be difficult to diagnose over just 1 visit because of IOP fluctuation, variability in performance on visual field testing, and challenges in detecting structural changes of the optic nerve. Our secondary outcome revealed 31% and 42% of referrals were definite glaucoma and suspects, respectively. In comparison, de Mul et al.7 demonstrated 4% and 1% of their patient population were definite glaucoma and suspects, respectively. However, our study examined teleophthalmology in a higher clinical suspicion setting, whereas de Mul et al.7 examined teleophthalmology as a screening tool. To facilitate a smooth transition into the program, the optometrists involved underwent an orientation as to the program operation, and specific inclusion and exclusion criteria so that the patients being referred had some suspicion of glaucoma. Previous studies have examined the delivery of glaucoma care via telemedicine. Bergua et al.10 determined that visualization of 3-dimensional images can be easily performed and applied in hospitals or decentralized research institutions.7 Studies by Khouri et al.16,17 found that digital imaging of the optic nerve in glaucoma provides all of the advantages of digital photography with “no loss of quality” over film. Our data add to these previous studies by demonstrating that teleglaucoma can facilitate consultation for patients residing distant from our centre, and effectively triage which patients should travel for an in-person examination. Efficiency is another advantage of this model, and accordingly, the time taken for the specialist to complete a virtual consultation after being received was, on average, 6.5 ⫾ 6 days. From the time the patient was seen by their optometrist, they receive specialist consultation after a mean of 16.2 ⫾ 18.4 days. In addition to glaucoma, 11% of all patients had other ophthalmologic concerns that were identified, with disc drusen and cataracts being the most common. The potential of using stereoscopic imaging techniques for nonglaucoma-related diagnosis needs to be further explored. This teleglaucoma program differs from other teleophthalmology programs in that it is not just a model for case detection, but it enables specialists to provide serial evaluations of diagnosis, management, and patient disposition. By collaborating with optometrists to enforce
stringent screening criteria, the consultations viewed by a specialist are more likely to have ocular pathology that can be safely managed through virtual consultation. Nonetheless, a possible limitation of the model is that without inperson clinical interaction, patients may receive less education about the disease, and their compliance rates may be lower. It is our belief that these risks are mitigated because patients still interact with eye care professionals, typically optometrists. A limitation of our study was that we did not assess whether patients attended follow-up appointments or whether the optometrists carried out recommendations made by the grader. Given the retrospective nature of the study, we were also limited by incomplete data. A future prospective study assessing the efficacy of the ophthalmologists in grading consultations virtually as compared with in-person examination would provide additional support for accuracy of the model, and is currently under way at our centre. Assessing the long-term outcomes and costs of the patients being managed remotely would prove that teleglaucoma is a safe and cost-effective model of health care delivery. Teleglaucoma has the ability to reduce travel times for patients and provide ocular care by an ophthalmologist despite significant geographical barriers. This study demonstrates the clinical outcomes of teleglaucoma and how it can potentially streamline patients to be referred for additional care as needed and benefit from specialist advice well before it would be possible to see them in clinic. Based on the results of our study, we would recommend a collaborative approach,18 and a key factor for success is using stringent criteria for consultations sent by optometrists. As this model improves through continued communication and feedback among health care providers, it is possible that the number of patients requiring in-person examination will decrease. As technology improves, it is also possible that reliability of clinical testing will improve such that fewer in-person assessments are needed. We recommend teleglaucoma models to adopt a degree of fluidity in their design, with the opportunity to adapt as technology, patient preferences, and health care provider relationships continue to evolve.
Disclosure: The authors have no proprietary or commercial interest in any materials discussed in this article. Acknowledgements: The authors acknowledge Samreen Amin and Abshir Moalin, who have provided support for the operation of the teleglaucoma program and the data collection. CAN J OPHTHALMOL — VOL. 49, NO. 2, APRIL 2014
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Remote teleglaucoma patient outcomes—Verma et al. REFERENCES 1. Haymes SA, Leblanc RP, Nicolela MT, Chiasson LA, Chauhan BC. Risk of falls and motor vehicle collisions in glaucoma. Invest Ophthalmol Vis Sci. 2007;48:1149-55. 2. Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol. 2006;90:262-7. 3. Canadian Glaucoma Society Committee on Interprofessional Collaboration in Glaucoma Care. Model of interprofessional collaboration in the care of glaucoma patients and glaucoma suspects. Can J Ophthalmol. 2011;46(6 Suppl):S1-21. 4. Rudnisky CJ, Tennant MT, Weis E, Ting A, Hinz BJ, Greve MD. Web-based grading of compressed stereoscopic digital photography versus standard slide film photography for the diagnosis of diabetic retinopathy. Ophthalmology. 2007;114:1748-54. 5. Rudnisky CJ, Hinz BJ, Tennant MT, de Leon AR, Greve MD. High-resolution stereoscopic digital fundus photography versus contact lens biomicroscopy for the detection of clinically significant macular edema. Ophthalmology. 2002;109:267-74. 6. Kumar S, Giubilato A, Morgan W, et al. Glaucoma screening: analysis of conventional and telemedicine-friendly devices. Clin Exp Ophthalmol. 2007;35:237-43. 7. de Mul M, de Bont AA, Reus NJ, Lemij HG, Berg M. Improving the quality of eye care with teleophthalmology: shared-care glaucoma screening. J Telemed Telecare. 2004;10:331-6. 8. Kassam F, Amin S, Sogbesan E, Damji KF. The use of teleglaucoma at the University of Alberta. J Telemed Telecare. 2012;18:367-73. 9. Li HK, Tang RA, Oschner K, Koplos C, Grady J, Crump WJ. Telemedicine screening of glaucoma. Telemed J. 1999;5:283-90.
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10. Bergua A, Mardin CY, Horn FK. Teletransmission of stereoscopic images of the optic nerve head in glaucoma via Internet. Telemed J e-health. 2009;15:439-44. 11. Pasquale LR, Asefzadeh B, Dunphy RW, Fisch BM, Conlin PR. Detection of glaucoma-like optic discs in a diabetes teleretinal program. Optometry. 2007;78:657-63. 12. Devarajan N, Williams GS, Hopes M, O’Sullivan D, Jones D. The Carmarthenshire Glaucoma Referral Refinement Scheme, a safe and efficient screening service. Eye (Lond). 2011;25:43-9. 13. Secure Diagnostic Imaging Ltd. www.teleophthalmology.com/SDIR esearch.html. 14. Canadian Ophthalmological Society Glaucoma Clinical Practice Guideline Expert Committee; Canadian Ophthalmological Society. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol. 2009;44(Suppl 1):S7-93. 15. Ng M, Nathoo N, Rudnisky CJ, Tennant MT. Improving access to eye care: teleophthalmology in Alberta, Canada. J Diabetes Sci Technol. 2009;3:289-96. 16. Khouri AS, Szirth BC, Salti HI, Fechtner RD. DICOM transmission of simultaneous stereoscopic images of the optic nerve in patients with glaucoma. J Telemed Telecare. 2007;13:337-40. 17. Khouri AS, Szirth B, Realini T, Fechtner RD. Comparison of digital and film stereo photography of the optic nerve in the evaluation of patients with glaucoma. Telemed J e-health. 2006;12:632-8. 18. Kassam F, Sogbesan E, Boucher S, et al. Collaborative care and teleglaucoma: a novel approach to delivering glaucoma services in Northern Alberta, Canada.Clin Exp Optom.13 Jun 13 2013. [Epub ahead of print]
Northern Alberta remote teleglaucoma program: clinical outcomes and patient disposition Sanam Verma, BSc.,* Sourabh Arora, MD,* Faazil Kassam, MD,† Marianne C. Edwards, MD,* Karim F. Damji, MD, MBA, FRCSC* ABSTRACT ● RÉSUMÉ Objective: To review the diagnostic outcomes and clinical referral pathways of patients assessed and managed through a collaborative care patient-centred teleglaucoma program. Study design: Retrospective cohort study. Methods: Eligible patients were those assessed by the referring optometrist or ophthalmologist to be open-angle glaucoma suspects or to have definite early open-angle glaucoma. A glaucoma specialist graded each case through virtual consultation. Clinical referral pathways were noted: in-person consultation with glaucoma specialist, repeat teleconsultation, collaborative glaucoma management with optometrist, or referral for nonglaucomatous ophthalmic pathology. Results: A total of 247 patients were referred to the program from 2008 to 2012. Of all teleconsults, 31.1% were diagnosed with glaucoma, 42.1% were suspects, and 26.7% were unaffected. Of all patients, 27% were referred for in-person glaucoma evaluation; 69% of patients could be managed by their referring optometrist, with 48% of patients requiring repeat teleconsultation. Treatment was initiated before being seen for 87% of patients with definite glaucoma and 28% of glaucoma suspects. Conclusions: Of all patients seen through the remote teleglaucoma program, most did not require an in-person consultation with an ophthalmologist and could be managed through distance collaboration. For the approximately one third who were diagnosed with glaucoma based on virtual assessment, medication was started in the majority of cases and in-person consultation was arranged. Further studies to validate and consider cost-effectiveness of this system are under way. Objet : Revue des résultats de diagnostic et des voies de référence clinique des patients évalués et orientés par un programme de Téléglaucome de collaboration des soins centré sur les patients. Nature : Étude rétrospective de cohorte. Méthodes : Les patients éligibles sont ceux que l’optométriste ou l’ophtalmologiste a désignés comme sujets au glaucome à angle ouvert ou qui ont définitivement un glaucome à angle ouvert précoce. Un spécialiste du glaucome a évalué chaque cas par consultation virtuelle. Les voies de référence clinique étaient notées ainsi : consultation personnelle d’un spécialiste du glaucome, téléconsultation répétée, gestion du glaucome en collaboration avec un optométriste ou référence pour pathologie ophtalmique non glaucomateuse. Résultats : En tout, 247 patients ont été référés au programme entre 2008 et 2012. Parmi toutes les téléconsultations, 31,1 % des patients reçurent un diagnostic de glaucome, 42,1 % une suspicion et 26,7 % une indemnité. 27 % des patients ont été orientés vers une évaluation du glaucome en personne. 69 % pouvaient être gérés par leur optométriste de référence, avec 49 % des patients ayant besoin de répéter la téléconsultation. Le traitement a été initié avant l’examen pour 87 % des patients définitivement atteints de glaucome et 28 % soupçonnés de glaucome. Conclusion : Parmi tous les patients du programme de téléglaucome à distance, la plupart n’ont pas eu besoin de consultation en personne chez un ophtalmologiste et purent être suivis par collaboration à distance. Pour environ le tiers, qui ont eu un diagnostic de glaucome par évaluation virtuelle, la médication a été commencée dans la majorité des cas et la consultation en personne organisée. D’autres études sur la validation et l’examen de l’efficacité des coûts de ce système se poursuivent.
Glaucoma is a progressive optic neuropathy that is associated with significant visual impairment, reduction in quality of life, falls, motor vehicle accidents, and depression.1 Patients with glaucoma and glaucoma suspects constitute up to 5% of the global population older than 40 years, and glaucoma is the world’s second leading cause of blindness.2,3 Teleophthalmology is a branch of telemedicine that uses technology to aid in distance management of ophthalmic disease. This care model has been validated in patients with diabetic retinopathy, for example, at the University of Alberta using stereoscopic digital imaging.4,5 Teleconsults
provide a different modality for diagnosis, management, and navigating referral pathways in the medical system. This approach was demonstrated to be a useful tool in delivering care and screening patients for glaucoma.6,7 In 2008, a patient-centred teleglaucoma program was launched at the University of Alberta with the aim of improving access to specialist care, enhance clinical teaching and research in telemedicine, and promote early diagnosis to prevent glaucoma-related sequelae. As opposed to teleophthalmology as a method of screening for eye disease, this teleglaucoma program would provide
From the *Department of Ophthalmology, University of Alberta, Edmonton, AB; and †Division of Ophthalmology, Department of Surgery, University of Calgary, Calgary, AB
Correspondence to Karim Damji, Royal Alexandria Hospital, 2317, 10240 Kingsway Avenue, Edmonton AB T5H 3V9; [email protected]
S.V. and S.A. provided equal intellectual contribution as co-first authors. Originally received Aug. 2, 2013. Final revision Nov. 7, 2013. Accepted Nov. 7, 2013
Can J Ophthalmol 2014;49:135–140 0008-4182/14/$-see front matter & 2014 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2013.11.005
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Remote teleglaucoma patient outcomes—Verma et al. comprehensive management directly from a glaucoma specialist, continuity of care, and in-person examinations as needed to ensure high quality of care. Thirteen optometrists, a family physician with an interest in eye disease, and a comprehensive ophthalmologist have participated in the program. Each of the 15 sites has a core set of equipment that includes an intraocular pressure (IOP) measuring device, pachymetry equipment (for ultrasonic measurement of central corneal thickness), a visual field machine, and a retinal camera. The teleglaucoma assessment, completed by a fellowship-trained glaucoma specialist, involves integrating information from a standardized history, examination, digital stereoscopic optic nerve images, and other diagnostic tests such as visual fields and optic nerve imaging devices.8 The grading specialist recommends medical management and follow-up care for the patient. Studies to date have examined the applicability of technology in remote management of patients with glaucoma.9–11 However, few have looked at outcome measures and referral pathways in teleglaucoma usage.7,12
This study aims to examine the referral pathways/disposition of patients managed by collaborative care via teleconsultation. We anticipate that detailed patient eligibility criteria and current comanagement capabilities of eye care providers will permit the majority of patients to be cared for in their remote communities.
METHODS This is a retrospective study of all patients assessed through the “remote” teleglaucoma program from September 2008 to May 2012. Details of this “remote teleglaucoma” model have been previously described.8 The flow pathway for patients is described in Fig. 1. All patients were being managed by a local optometrist or medical doctor and were referred for a teleconsultation if they met the inclusion and exclusion criteria (Table 1). The model was designed to primarily assess glaucoma suspects and those with early-stage glaucoma; however, some cases of advanced disease were also referred. Participating referring
Fig. 1 — University of Alberta Remote Teleglaucoma Model
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Remote teleglaucoma patient outcomes—Verma et al. Table 1—Participants: glaucoma suspects or those with early stages of glaucoma as determined by referring practitioner Inclusion Criteria
Exclusion Criteria ● Patient extremely anxious about diagnosis and/or prognosis ● Advanced glaucoma (VCDR 4 0.85 and/or VF defect within 10 degrees of fixation) ● Extremely high IOP (Z35 mm Hg) ● Features suggestive of angle closure (closed or occludable angles and IOP elevation) ● Features suggestive of secondary open- and/or closed-angle glaucoma ● Cultural or language barrier ● Mental health issues (e.g., dementia) ● Discretion of referring or reporting centre
Open-angle glaucoma suspect: ● Age 4 50 y (with Z1 of the following) ● Black, Latino ● Myopia ● Family history of glaucoma ● Systemic risk factors such as migraine, steroids, thyroid disease, sleep apnea ● Suspicious features of optic disc and/or visual field test
VCDR, vertical cup/disk ratio; VF, visual field; IOP, intraocular pressure.
practitioner offices completed an orientation training session to clarify patient eligibility and features that would raise suspicion for glaucoma diagnosis. Consultations were uploaded onto the Secure Diagnostic Imaging (SDI)13 system, and the glaucoma specialist reviewing the cases created a report indicating a diagnosis of “definite” (including stage of disease, i.e., early, moderate, or advanced), “suspect” (including risk stratification, i.e., low, moderate, or high risk for progression), or “normal” for glaucoma, and a management plan was provided.3,14 Individual teleglaucoma patient reports were reviewed, and a database was established for all patients from 2008 to 2012, which included demographic data (such as age, sex, and postal code) and clinical information (such as medical history, IOP, interpretation of visual field tests and fundus photos, diagnosis, and management plan). The primary outcome evaluated was the disposition of the patients who fell into 1 of 4 categories: discharge and follow up as needed, repeat teleconsultation, in-person glaucoma evaluation, and referral for care unrelated to glaucoma. Simple summary statistics were computed. Secondary outcomes included diagnosis, treatment recommendations, and follow-up interval times. Information regarding diagnosis was extracted from reports, and for cases of definite glaucoma, there was further detail to classify cases as “mild,” “moderate,” or “advanced” stage. If the glaucoma specialist described a classification of “moderate-to-advanced” disease, we included it in the advanced group. Treatment goals were extracted from each report made by the glaucoma specialist. In some cases, treatment by topical glaucoma medications was recommended by the ophthalmologist and started by the optometrist, without the patient ever seeing the ophthalmologist in person. For recommended treatments more advanced than topical
medications, it was advised that the patient be referred to an ophthalmologist, or to the grading glaucoma specialist depending on complexity of the case and convenience of the patient. The time to follow-up and type of specialist being referred to were noted. All clinical information about patients pertaining to their repeat or follow-up visit with the teleprogram was included in a separate database; the same primary and secondary outcomes were extracted but analyzed separately.
RESULTS A total of 273 patients assessed through the remote teleglaucoma program from 2008 to 2012. Five patient records were removed because of reports that were repeated in the SDI database, and 1 patient was excluded from teleglaucoma because the patient was seen in person. From the remaining 267 cases, 20 teleglaucoma consultations were repeat visits, and there were 247 new patient consultations. The average age of these 247 patients was 59.5 ⫾ 17.2 years (range 6–94). There were 132 females and 114 males evaluated (Table 2). The percentage of all patients seen through teleglaucoma who were referred for in-person evaluation was 31% (76/247), and additional details regarding disposition were analyzed (Table 3). The percentage of all patients whose in-person evaluation was for assessment of glaucoma was 27% (66/247). The remaining 10 (4%) patients were referred to an ophthalmologist for in-person evaluation of another diagnosis that was detected through teleglaucoma, most frequently cataract, disk drusen, and age-related macular degeneration. Nine of these patients were believed to be without glaucoma
Table 2—Baseline demographic factors
Mean age, y Male/Female, n Mean IOP, mm Hg
Total
Definite Glaucoma
Glaucoma Suspect
Normal
59.5 ⫾ 17.2 114/132 17.86 ⫾ 4.6 OD 17.95 ⫾ 5.2 OS
67.3 ⫾ 13.7 35/42 18.8 ⫾ 5.4 OD 19.5 ⫾ 6.8 OS
60.6 ⫾ 13.7 51/53 17.7 ⫾ 4.3 OD 17.8 ⫾ 4.5 OS
48.8 ⫾ 20.3 29/37 17.0 ⫾ 3.9 OD 16.4 ⫾ 3.4 OS
Mean age +/ SD; mean IOP +/ SD.
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Remote teleglaucoma patient outcomes—Verma et al. Table 3—Disposition pathway Glaucoma-Related In-Person Follow-up with Ophthalmologist
Referred for Nonglaucoma Concern
66 (26.7%)
10 (4%)
All patients (N ¼ 247), n (%)
based on virtual examination. One of those patients was diagnosed virtually as a glaucoma suspect but was seen in person for assessment of a concomitant diagnosis of disk drusen. Most patients being assessed for glaucoma in person were recommended to follow-up with a glaucoma specialist (52/66, 79%), whereas 14 (21%) were referred to a comprehensive ophthalmologist. Among patients diagnosed with glaucoma, 51% required in-person examination, and a higher proportion of patients with advanced disease required in-person examination (Table 4). Thirty-one percent of patients were diagnosed with glaucoma, 42% as suspects, and 27% were thought to be normal or have a diagnosis other than glaucoma (Table 4). Of patients with glaucoma, 87% had treatment initiated remotely (Table 5). Diagnoses other than glaucoma were made in 26 patients (11% of all cases), the most frequent ones being disk drusen (15%) and cataracts (11.5%). Two patients were referred to comprehensive ophthalmology and 4 were referred to neuro-ophthalmology for nonglaucoma diagnosis. The mean time from patients’ visit with optometrist to a completed grading was 16.2 ⫾ 18.4 (range 0–121) days, whereas the time taken for the physician to complete the report once received was 6.5 ⫾ 6 (range 0–35) days. The number of patients who were seen for a second virtual visit through teleglaucoma was 20 of 267 (7.5 %). These patients were initially assessed through teleglaucoma, and after this initial consult, their mean follow-up interval until their second virtual consult was 8.25 ⫾ 3.8 months. At the time of this study, which was after these patients had their second teleconsultation, 5 patients (25%) were recommended to undergo in-person follow-up with a glaucoma specialist, whereas 13 (65%) could continue being managed through collaborative care and were recommended to have a third teleconsultation in the future. Two patients were discharged back to their optometrist to allow for reconsultation as needed because it was believed they did not need to be followed by an ophthalmologist.
Table 4—Patients requiring in-person examination by diagnosis Diagnosis No glaucoma Glaucoma suspect Definite glaucoma Early Moderate Advanced
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Patients, n 66 104 77 48 13 16
Requiring In-Person Examination, n (% of patients with given diagnosis) 9 28 39 25 4 10
(14%) (27%) (51%) (52%) (31%) (63%)
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Followed Only by Their Optometrist 171 (69%) (48% of patients had repeat teleconsultation, whereas 21% were discharged to referring primary eye care provider)
During this second virtual visit, medical management or laser therapy was suggested in 13 (65%) cases. There were 13 patients diagnosed with glaucoma, 5 glaucoma suspects, and 2 thought to have normal results.
DISCUSSION Patients assessed through the “remote teleglaucoma” program were managed through collaborative care with optometrists, and most did not require an in-person examination with an ophthalmologist. Twenty-seven percent of patients were seen in person for glaucoma evaluation, and this was more likely for those of more advanced disease. Sixty-two percent of patients were found to be glaucoma suspects or normal for glaucoma, and a small percentage of these patients were recommended for an in-person examination (22%; Table 4). Almost half of all patients seen through teleglaucoma could be comanaged through continued teleconsultation (Table 3). This is especially relevant because in Alberta, optometrists can prescribe glaucoma medications with consultation from an ophthalmologist. Teleglaucoma is a platform that enables for this to happen efficiently. Devarajan et al.12 described their model of teleglaucoma, and it was noted that the benefit to their Hospital Eye Service was a 53% decrease in the absolute number of patients referred with suspected glaucoma; the cost saving was £117 per patient. They found that 47% of their patients’ required in-person evaluation. Our smaller percentage requiring evaluation (31%) may be attributable to the lower burden of disease in the patients selected for teleconsultation and stringent inclusion and exclusion criteria. The mean IOP among patients in our study with definite glaucoma was approximately 19 mm Hg, which is less than those with typical glaucoma diagnosis, reflecting some patients with normal tension glaucoma and some patients who were already being treated and required a second opinion, such as a change in medication. Patients who presented to the optometrist and were deemed urgent, with extremely elevated IOP, were referred directly to the ophthalmology service and not to the teleglaucoma program. When comparing teleglaucoma with other teleophthalmology projects, such as teleretina for diabetic retinopathy, similar referral patterns are apparent. A study of 5500 teleretina patients had 17% seen in person for additional testing or treatment and an additional 2% because of inability to image. Teleretina decreased the time to treatment, allowed treated patients to be followed
Remote teleglaucoma patient outcomes—Verma et al. Table 5—Management recommendations and referral intervals
Treatment initiated Time to in-person referral Time to repeat tele-examination
All Patients
Definite Glaucoma
Suspect Glaucoma
Normal for Glaucoma
96/247 (39%) 8.6 ⫾ 3.4 weeks 8.8 ⫾ 3.4 mo
67/77 (87%) 7.9 ⫾ 3.2 weeks 8.01 ⫾ 3.6 mo
29/104 (28%) 10.2 ⫾ 2.8 weeks 8.6 ⫾ 3.3 mo
0/66 3.7 ⫾ 2.1 weeks 10.8 ⫾ 2.6 mo
remotely, and prevented unnecessary referrals.15 This teleglaucoma program mirrors teleretina in terms of allowing remote management; 87% of patients with glaucoma had treatment initiated remotely. The increased proportion of patients in teleglaucoma requiring in-person examination may be related to the fact that glaucoma may be difficult to diagnose over just 1 visit because of IOP fluctuation, variability in performance on visual field testing, and challenges in detecting structural changes of the optic nerve. Our secondary outcome revealed 31% and 42% of referrals were definite glaucoma and suspects, respectively. In comparison, de Mul et al.7 demonstrated 4% and 1% of their patient population were definite glaucoma and suspects, respectively. However, our study examined teleophthalmology in a higher clinical suspicion setting, whereas de Mul et al.7 examined teleophthalmology as a screening tool. To facilitate a smooth transition into the program, the optometrists involved underwent an orientation as to the program operation, and specific inclusion and exclusion criteria so that the patients being referred had some suspicion of glaucoma. Previous studies have examined the delivery of glaucoma care via telemedicine. Bergua et al.10 determined that visualization of 3-dimensional images can be easily performed and applied in hospitals or decentralized research institutions.7 Studies by Khouri et al.16,17 found that digital imaging of the optic nerve in glaucoma provides all of the advantages of digital photography with “no loss of quality” over film. Our data add to these previous studies by demonstrating that teleglaucoma can facilitate consultation for patients residing distant from our centre, and effectively triage which patients should travel for an in-person examination. Efficiency is another advantage of this model, and accordingly, the time taken for the specialist to complete a virtual consultation after being received was, on average, 6.5 ⫾ 6 days. From the time the patient was seen by their optometrist, they receive specialist consultation after a mean of 16.2 ⫾ 18.4 days. In addition to glaucoma, 11% of all patients had other ophthalmologic concerns that were identified, with disc drusen and cataracts being the most common. The potential of using stereoscopic imaging techniques for nonglaucoma-related diagnosis needs to be further explored. This teleglaucoma program differs from other teleophthalmology programs in that it is not just a model for case detection, but it enables specialists to provide serial evaluations of diagnosis, management, and patient disposition. By collaborating with optometrists to enforce
stringent screening criteria, the consultations viewed by a specialist are more likely to have ocular pathology that can be safely managed through virtual consultation. Nonetheless, a possible limitation of the model is that without inperson clinical interaction, patients may receive less education about the disease, and their compliance rates may be lower. It is our belief that these risks are mitigated because patients still interact with eye care professionals, typically optometrists. A limitation of our study was that we did not assess whether patients attended follow-up appointments or whether the optometrists carried out recommendations made by the grader. Given the retrospective nature of the study, we were also limited by incomplete data. A future prospective study assessing the efficacy of the ophthalmologists in grading consultations virtually as compared with in-person examination would provide additional support for accuracy of the model, and is currently under way at our centre. Assessing the long-term outcomes and costs of the patients being managed remotely would prove that teleglaucoma is a safe and cost-effective model of health care delivery. Teleglaucoma has the ability to reduce travel times for patients and provide ocular care by an ophthalmologist despite significant geographical barriers. This study demonstrates the clinical outcomes of teleglaucoma and how it can potentially streamline patients to be referred for additional care as needed and benefit from specialist advice well before it would be possible to see them in clinic. Based on the results of our study, we would recommend a collaborative approach,18 and a key factor for success is using stringent criteria for consultations sent by optometrists. As this model improves through continued communication and feedback among health care providers, it is possible that the number of patients requiring in-person examination will decrease. As technology improves, it is also possible that reliability of clinical testing will improve such that fewer in-person assessments are needed. We recommend teleglaucoma models to adopt a degree of fluidity in their design, with the opportunity to adapt as technology, patient preferences, and health care provider relationships continue to evolve.
Disclosure: The authors have no proprietary or commercial interest in any materials discussed in this article. Acknowledgements: The authors acknowledge Samreen Amin and Abshir Moalin, who have provided support for the operation of the teleglaucoma program and the data collection. CAN J OPHTHALMOL — VOL. 49, NO. 2, APRIL 2014
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