The IHS-Joslin Vision Network Teleophthalmology Program: Preventing Diabetes-Related Blindness in American Indians and Alaska Natives

Transcription

1 The IHS-Joslin Vision Network Teleophthalmology Program: Preenting Diabetes-Related Blindness in American Indians and Alaska Naties Department of Health and Human Serices Indian Health Serice Diision of Diabetes Treatment and Preention JUNE 2008

2 Diabetes is the leading cause of blindness among adults. American Indians and Alaska Naties with diabetes are particularly susceptible to diabetes-related blindness, largely because less than half of them get an annual diabetic eye exam. The Indian Health Serice-Joslin Vision Network (IHS-JVN) Teleophthalmology Program was established in 2000 to use telemedicine technology to proide accurate, cost-effectie annual eye exams to American Indians and Alaska Naties. After more than 21,000 eye exams across the nation, this program has proen its effectieness in decreasing diabetes-related blindness in American Indians and Alaska Naties. Blindness caused by diabetes can be preented. In fact, early diagnosis and treatment of diabetic retinopathy can reduce seere ision loss by more than 95%. The IHS-JVN Teleophthalmology Program is leading the way to improing early identification of American Indians and Alaska Naties at risk of losing their sight. 2

3 Diabetes-related blindness in American Indians and Alaska Naties American Indians and Alaska Naties hae the highest rates of diabetes in the United States, with a diabetes prealence rate that is more than twice that of the general population. Because American Indians and Alaska Naties hae higher rates of diabetes, they also suffer from higher rates of diabetes-related complications. Blindness is a particularly deastating yet preentable complication of diabetes. Oer time, diabetes causes damage to blood essels in the eyes in a condition called diabetic retinopathy. The damage to the blood essels can sometimes grow to dangerous leels, ultimately leading to blindness. People with diabetic retinopathy usually do not experience isual symptoms until it is too late and blindness has irreparably set in. The IHS-JVN Teleophthalmology Program: Increasing access to eye care Timely, annual eye exams of people with diabetes can help preent diabetes-related blindness. These exams identify people at high risk for losing their sight who need to be treated to preent further ision loss. Furthermore, eye exams and laser treatment of high-risk indiiduals is ery cost effectie, saing hundreds of millions of dollars each year by preenting diabetes-related ision loss. Unfortunately, only 50% of American Indians and Alaska Naties with diabetes obtain annual eye exams. To address this gap in health care, special Federal appropriations created the Indian Health Serice-Joslin Vision Network (IHS-JVN) Teleophthalmology Program in The program uses innoatie telemedicine technology deeloped at the Joslin Diabetes Center to proide accurate, cost-effectie annual eye exams to American Indians and Alaska Naties with diabetes. The IHS-JVN Teleophthalmology Program is currently aailable at 65 primary care clinics, which allows patients to obtain an eye exam during a regularly scheduled medical appointment. Without the use of dilating eye drops, clinic staff take a photograph of the patient s eye using a digital camera (Figure 1). Special computer software transmits the photograph to the National IHS-JVN Reading Center located in Phoenix. IHS eye doctors, specially trained by the Joslin Diabetes Center, interpret the images and send a report to the patient and primary care physician. The report includes the leel of diabetic retinopathy, presence of any non-diabetic eye disease, and recommended treatment. Figure 1. Patient receiing an eye exam through the IHS-JVN Teleophthalmology Program. 3

4 Results from the IHS-JVN Teleophthalmology Program Many American Indians and Alaska Naties with diabetes lie far from health care centers that can proide nationally accepted standards of eye care particularly eye exams that could identify those at high risk for diabetes-related blindness. Since 2000, the IHS-JVN Teleophthalmology Program has reduced this barrier by proiding eye exams to American Indians and Alaska Naties at 65 sites in 17 states (Table 1). Table 1. IHS-JVN Teleophthalomology Program sites. Fairbanks, AK Ft. Defiance, AZ Ft. Yuma, AZ Inscription House, AZ Kayenta, AZ Naajo Mountain, AZ Parker, AZ Peach Springs, AZ Phoenix, AZ Polacca, AZ Salt Rier, AZ San Carlos, AZ Sells, AZ Tuba City, AZ San Xaier, AZ Tucson, AZ Whiterier, AZ Fort Hall, ID Lapwai, ID Plummer, ID Lawrence, KS Mayetta, KS Cass Lake, MN Red Lake, MN Crow Agency, MT Ft. Belknap, MT Winnebago, NE Albuquerque, NM Crown Point, NM Jicarilla, NM Mescalero, NM Santa Fe, NM Shiprock, NM Elko, NV (4 sites) Fallon, NV McDermitt, NV Reno Sparks, NV Schurz, NV Washoe, NV Oneida, NY Clinton, OK Eufaula, OK Lawton, OK Oklahoma City, OK Okmulgee, OK Pawnee, OK Tahlequah, OK Wewoka, OK Salem, OR Warm Springs, OR Rock Hill, SC McLaughlin, SD Pine Ridge, SD Rosebud, SD Liingston, TX Blanding, UT Montezuma Creek, UT Monument Valley, UT Nespelem, WA Tacoma, WA Wellpinit, WA Yakima, WA 4

5 The extensie implementation of the IHS-JVN Teleophthalmology Program has proided more than 21,000 eye exams to American Indians and Alaska Naties who might not otherwise receie this important standard of care (Figure 2). A four-year study of the program demonstrated its effectieness at increasing access to nationally accepted standards of eye care and treatment to preent blindness (Figure 3): 50% increase in annual eye exams. 51% increase in laser treatments to preent blindness. Lower cost with quality equal to or better than a normal eye exam. It is important to note that each of the additional laser treatments performed as a result of the IHS-JVN Teleophthalmology Program represent a patient who was saed from diabetes-related blindness. Figure 2. Increase in Annual Eye Exams Cumulatie Stduies Annual Stduies Program Year Figure 3. Annual Rates of Eye Exams and Laser Treatments, Laser Treatment Rate Eye Exam Rate Laser treatment per 1000 diabetic person - years Eye exams per 100 diabetic person - years Year 5

6 These outcomes underscore the importance of the program especially when one considers that American Indian and Alaska Natie communities without access to the program continue to experience a sustained downward trend in the rate of annual eye exams. Furthermore, the program has been able to achiee these results while decreasing the costs associated with adding new sites. Figure 4. Transporting the portable JVN deice by dog sled. In addition to the program s clinical success, the IHS-JVN Teleophthalmology Program has made seeral significant technical achieements notably the deelopment of a portable JVN deice. This potable deice allows the program to proide eye exams to American Indians and Alaska Naties liing in remote locations or particularly harsh enironments. In February 2006, the IHS and Joslin Diabetes Center tested the portable deice in Selawik, Alaska (Figures 4 and 5). Despite the site s considerable challenges a location north of the Arctic Circle, temperatures hoering below 20º F, transportation aailable only by small aircraft and dog sled, and data transmission ia satellite the portable deice performed successfully. These results offer encouragement that the portable deice can be used in other American Indian and Alaska Natie communities throughout Alaska, as well as remote and small communities in the continental United States. Figure 5. Using the portable JVN deice in Selawik, Alaska. 6

7 Spreading quality eye care throughout the Indian health system At existing appropriation leels, the Indian Health Serice and the Joslin Vision Network can continue to support the 65 sites that currently hae access to the IHS-JVN Teleophthalmology Program. Howeer, the public health successes achieed by the program hae increased demand for its serices and technology. As the number of sites sered by the program has increased, the program s budget has remained flat and clinical operational costs hae risen. Additional appropriations would allow the program to meet the increasing demand for its serices and technology as more American Indian and Alaska Natie communities seek improements in diabetes eye care. Additional appropriations would also ensure that the program can implement necessary upgrades to its serices and technology including: The ability to expand eye care serices to remote locations through the use of the portable JVN deice. The deelopment of a mobile JVN unit that would also house additional telemedicine technology (e.g., diabetes foot care equipment). Technical upgrades at the National IHS-JVN Reading Center to decrease staff costs and increase accuracy. Post-image processing and computer-assisted decision making tools to improe diagnostic efficiency, accuracy, and cost-effectieness. Streamlined incorporation of eye exam data into the IHS electronic health record in compliance with the President s Executie Order. Deelopment of a quality assurance system. Pursue opportunities for reimbursement from Medicare, Medicaid, and priate insurance companies. Continued support of the IHS-JVN Teleophthalmology Program is necessary to ensure that American Indian and Alaska Natie communities continue to hae access to nationally accepted standards of eye care through this program, which has been proen to reduce diabetes-related blindness in an efficient, cost-effectie manner. The IHS-JVN Teleophthalmology Program increased annual diabetic eye exams by 50% and laser treatment to preent blindness by 51% using methods that are more cost-effectie than conentional eye care. 7

8 Department of Health and Human Serices Indian Health Serice Diision of Diabetes Treatment and Preention