Doc­tor’s vi­sion helps save di­a­bet­ics’ sight

Pro­gram cuts wait time for vi­tal eye test af­ter di­ag­no­sis

Los Angeles Times - - CALIFORNIA - By Soumya Kar­la­mangla

Af­ter years with­out an eye exam, pa­tients would show up at Dr. Lau­ren Dask­ivich’s clinic sud­denly un­able to see. They were di­a­bet­ics who had bled into their eye, mar­ring their vi­sion.

“It’s like a tick­ing time bomb and pa­tients have no idea, but when the bomb goes off they def­i­nitely do,” said Dask­ivich, an oph­thal­mol­o­gist. “We were just see­ing pa­tients far too late.”

The con­di­tion, called di­a­betic retinopa­thy, is the lead­ing cause of blind­ness among work­ing-age adults na­tion­wide. A sim­ple test can de­tect and help treat the prob­lem, but four years ago most di­a­bet­ics in Los An­ge­les County’s mas­sive health­care sys­tem weren’t get­ting screened.

It was a months-long wait to see an eye doc­tor in the county sys­tem. Some-

times peo­ple didn’t even know they had di­a­betes. “You’d get these pa­tients and they’d ask you for their di­a­betes meds,” said Dask­ivich, who over­sees all eye care ser­vices for the county.

A few years ago, Dask­ivich be­gan test­ing as a way to help ease the back­log and im­prove pa­tient care. Med­i­cal as­sis­tants in pri­mary care clin­ics can now take pho­tographs of di­a­bet­ics’ eyes and send those images to oph­thal­mol­o­gists who an­a­lyze them. If the pho­tos re­veal dam­age, the pa­tients are sent to eye doc­tors.

Pa­tients might still wait months for that ap­point­ment, but the wait time for the ini­tial screen­ing for those us­ing the new sys­tem dropped by 89%, ac­cord­ing to data Dask­ivich pub­lished this year.

The project is one of many novel ways health­care providers are try­ing to im­prove ac­cess to spe­cial­ists since the ex­pan­sion of health in­sur­ance un­der the Af­ford­able Care Act, said Melissa Buck­ley, who stud­ies tech­nol­ogy in­no­va­tions at the Cal­i­for­nia Health Care Foun­da­tion.

The law known as Oba­macare as­sured health­care cov­er­age for mil­lions of pre­vi­ously unin­sured peo­ple, but did not guar­an­tee there would be enough doc­tors to see them.

So some health­care sys­tems have of­fered pa­tients or their pri­mary care physi­cians the chance to use video chat, text or email to get ad­vice from a spe­cial­ist sooner.

“That’s a huge, huge area that we’re all fo­cused on, pri­mar­ily be­cause ac­cess to spe­cialty care is a huge chal­lenge,” Buck­ley said. “[These ini­tia­tives] are get­ting lots of trac­tion be­cause there’s such a need.”

Such in­no­va­tions, how­ever, of­ten il­lus­trate not only the pos­si­bil­i­ties but also the lim­i­ta­tions of us­ing tech­nol­ogy to solve physi­cian short­ages.

Rosa Guzman, 46, was di­ag­nosed with di­a­betes on a re­cent Mon­day morn­ing at a pri­mary care clinic at Los An­ge­les County-USC Med­i­cal Cen­ter in Boyle Heights. Later that morn­ing, she was read­ing an eye chart as med­i­cal as­sis­tant Sil­via Fletes pointed to smaller and smaller let­ters.

Fletes then took pho­tos of Guzman’s eyes. A ma­chine flashed in the dark­ness, and images of cloudy pink cir­cles in­ter­sected by red lines ap­peared on a com­puter screen. Guzman left a few min­utes later.

When Dask­ivich and Dr. Bar­bara Ru­bino, an in­ternist, learned that Guzman had been screened only hours af­ter be­ing di­ag­nosed with di­a­betes, they high­fived. Get­ting an eye test on de­mand was es­sen­tially im­pos­si­ble a few years ago.

“That was the ul­ti­mate, ul­ti­mate goal,” Ru­bino said.

The high blood sugar lev­els as­so­ci­ated with di­a­betes can dam­age the blood ves­sels in the retina, which makes them leak fluid or bleed and dis­tort vi­sion. But di­a­betic retinopa­thy doesn’t usu­ally have symp­toms un­til peo­ple be­gin bleed­ing into their eye.

Di­a­bet­ics should be screened an­nu­ally, but only about 60% na­tion­ally get their eyes checked ev­ery year.

Four years ago, the sit­u­a­tion was even worse in L.A. County’s pub­lic health sys­tem, the na­tion’s largest, serv­ing more than 800,000 pa­tients per year. Thou­sands of di­a­betic pa­tients from hun­dreds of pri­mary care clin­ics were re­ferred to 10 eye clin­ics, where waits for screen­ings could be more than eight months, Dask­ivich said.

When med­i­cal as­sis­tants be­gan tak­ing pho­tos of di­a­betic pa­tients’ eyes, screen­ing rates in­creased from 41% to 57%, ac­cord­ing to a pa­per Dask­ivich pub­lished in March in the jour­nal JAMA In­ter­nal Medicine.

For those whose eyes were checked, the me­dian wait time for screen­ing dropped from five months to 2½ weeks, the pa­per found. They even found eye prob­lems that weren’t di­a­betes­re­lated, like glau­coma or cataracts, in about 1 of ev­ery 10 pa­tients.

The screen­ing rates have con­tin­ued to im­prove and now are about 65%, but they still are far from per­fect, Dask­ivich said. Pa­tients who do end up need­ing an eye ap­point­ment can move to the front of the line if it’s ur­gent, but there are typ­i­cally 3,000 peo­ple wait­ing for eye care at any given time.

“In the safety net you’re al­ways go­ing to have limited re­sources .... We’d love to see a per­son to­mor­row,” Dask­ivich said. “We cer­tainly do have some work to do to get there, but I think we’re mov­ing in that di­rec­tion.”

Though pub­lic health sys­tems might not be flush with cash, they ac­tu­ally have a nat­u­ral ad­van­tage when it comes to im­prov­ing care co­or­di­na­tion, Buck­ley said.

Doc­tors are usu­ally paid ev­ery time they see a pa­tient, so they wouldn’t get paid to an­a­lyze a pho­to­graph for an­other doc­tor — even if that might be the most ef­fi­cient way to di­vide the work. In Los An­ge­les County’s pub­lic med­i­cal sys­tem, in which doc­tors are typ­i­cally salaried, it’s eas­ier to make these sorts of changes.

“It’s easy to make that hap­pen in L.A. be­cause it’s a closed sys­tem.… They are just cre­at­ing a com­mu­ni­ca­tion bridge,” Buck­ley said. “Out­side of L.A., it’s harder to make that spread.”

For in­stance, the county has been able to im­ple­ment a sys­tem called eCon­sult that al­lows doc­tors to mes­sage each other about pa­tients, re­duc­ing un­nec­es­sary ap­point­ments and wait times to see spe­cial­ists. That sys­tem would be harder to im­ple­ment else­where be­cause each doc­tor needs to fig­ure out a way to get paid. The Af­ford­able Care Act aimed to move away from the tra­di­tional “fee-for-ser­vice” model to al­le­vi­ate some of these prob­lems, but it’s been a slow shift.

For a doc­tor who has just di­ag­nosed a pa­tient with di­a­betes, the new sys­tems of­fer peace of mind. Now they can send them next door to get their eye photo, and they can track the re­fer­ral through eCon­sult. Not that long ago, they didn’t have any way of mak­ing sure pa­tients’ eyes were ac­tu­ally checked.

“You’d cross your fin­gers and hope they would get their eyes screened,” Ru­bino said. “They usu­ally wouldn’t.”

Pho­tographs by David McNew For The Times

BEA TOMAYO, stand­ing, ap­plies drops to di­late Juana Lorez’s eyes be­fore a di­a­betic retinopa­thy screen­ing. A pro­gram led by Dr. Lau­ren Dask­ivich helps ease the back­log of the tests for di­a­bet­ics in L.A. County.

ROSA GUZMAN leans into a ma­chine that pho­tographs her retina. Four years ago, most di­a­bet­ics in L.A. County’s health­care sys­tem didn’t get screened.

Pho­tographs by David McNew For The Times

MED­I­CAL as­sis­tant Sil­via Fletes pre­pares Rosa Guzman for a reti­nal test at a clinic in Boyle Heights within hours of her di­a­betes di­ag­no­sis. Her doc­tors can track her re­fer­rals through the county’s eCon­sult por­tal.

READ­ING an eye chart pre­cedes the test, which used to be dif­fi­cult to get on de­mand, doc­tors say.

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