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Q&A: Diabetic Retinopathy Screening Importance and Practice Pearls
A panel of experts in the management of diabetes answer questions relating to the importance of early screening and detection of diabetic retinopathy and provide practice pearls for how to facilitate in-office screenings.
Allen Dobson, Jr., MD, FAAFP: Let’s take some questions, and then we can circle back around to some of the key points we’ve come across this afternoon. The first question is, “If I’m thinking about incorporating retinopathy screening in our practice, what are some of the things I need to think about?” My takeaway is the technology and the time for in-office primary care screening is now. If I don’t do it, what do I need to know?
Wade Brosius, DO: If you don’t do it, I’d tell you you’re foolish. Because it meets every aspect of the Quadruple Aim. In regard to some of the things you need to think about, it’s important to have a tidy workflow. We have a previsit…tool, and one of the things on that is making sure the patients have already had their screening this calendar year. The second part of it is to make sure that you have good staff training. The third thing is to think about space, because you’re usually at a specific spot in a medical practice building, or some place, and you need to have a dark room where you can get this type of stuff done. But you’d be foolish not to incorporate this into your practice.
Shelton Hager, MD: My poor practice doesn’t run efficiently, I usually run behind. It’s one of those things with my chronic patients and everything. One other thing I would add is to do the right thing for the patient. You can do it timely if you have them at the point of care, and it gives them something to do while they’re waiting for you. If you’ve identified a gap where it hasn’t been done yet this year and they’re due for it, you can have the medical assistant get it done before you walk in the room. That would be one of the things that you’ve already done, and then they can continue their visit with you.
Steven Peskin, MD: Wait for care gap reports and then, more recently, a health information exchange that will have more real-time reporting to the practice and the previsit plan aspect to let the practice know where the care is necessary, like diabetic retina screening.
Wade Brosius, DO: I can tell you something similar to what Shelton said about looking at your final quarter. If you’re in that fourth quarter and you haven’t had people in, a way we’ve addressed that is by having screening weekends. Even the table top screening systems are portable, so we can grab a whole bunch, throw them into an office that’s relatively centrally located, and without pushing people into overtime, be able to push a fair amount of patients through on a Saturday morning. You can get caught up in a hurry doing it that way. I’ve found it to be really worthwhile.
Allen Dobson, Jr., MD, FAAFP: Great. I’ve got a question here. “If you’ve got somebody with diabetic retinopathy, what vision care professionals can do this? Ophthalmologists, optometrists, retina specialists?” Who can you refer to if you’ve got somebody who screens positive?
Wade Brosius, DO: We’re lucky that we have a glut of ophthalmologists in our region. We always use ophthalmology for someone who already has known retinopathy. It’s not something that we take lightly. Part of the reason we do that is that it’s very much worthwhile to have the person who can do the intervention be the person who’s following the patient. It’s important to have that continuity of care and a comfortable handoff, handing them to someone who you know is an expert in their field and does quality work. That’s why we do what we do.
Shelton Hager, MD: I definitely agree. If they’re moving toward retinopathy, proliferative, or moderate nonproliferative, they go to the ophthalmologists, or even to the retina specialists.
Allen Dobson, Jr., MD, FAAFP: Right. If you have a retinopathy clinic or a hospital, that’s great, but an ophthalmologist should be able to take those patients on referral.
Let me do a corollary. What if you aren’t doing screening in your office? Let’s say you aren’t able to for some reason. What alternatives do you suggest in terms of making sure patients are aware, and where they can get their screening? I’m going back to rural areas. In your small town, you may not have many choices. Is this something where the family doctor could set up something for an optometrist to do screenings? Or do you need to refer them to the big city to an ophthalmologist? What would you recommend if you aren’t able to do screenings in your office?
Wade Brosius, DO: From my perspective, I find it difficult that you couldn’t. The only reason you couldn’t is potentially because of space, because it’s cash flow positive. Shelton was good enough to buy his machine. We lease ours, and you just need 5 people a month to break even. With 5 people a month to break even, we’re still getting extra money on our HEDIS [Healthcare Effectiveness Data and Information Set] Stars measures, so it’s really positive. But the other thing is the value that you get to give to your patients. Sometimes you can think outside the box. In our local area, there’s a nationwide laboratory carrier that in certain spots has the retinal camera. Even when we send our patients for their blood work, if we send them to a specific location, they can get their retinal imaging done there.
Allen Dobson, Jr., MD, FAAFP: That’s interesting. That follows into this next question, “How does reimbursement work for diabetic retinopathy screening in primary care? How do I know I would recoup my investment if I purchased a screening tool?” You just answered that, 5 patients a month.
Wade Brosius, DO: Yes, and it’s less if you use the handheld system. But if you’re the average primary care provider who’s seeing about 20 patients a day—depending on which office you go to in our network, it’s a little more, and very few see a little less—if about 25% of your visits are diabetic visits, you’re getting the 5 in a day, let alone a month.
Shelton Hager, MD: As we talked about, the technical component can be paid to you by the payers. It’s also one of the gaps in the HEDIS criteria. Most of the Medicare Advantage plans would be very excited for you to do it.
Transcript Edited for Clarity
Man With Newly Diagnosed Type 2 Diabetes: What HbA1c Goal-And How to Get There?
May 8th 2013The patient, an active 49-year-old man, had an HbA1c of 8.6 after diabetes was first diagnosed. It’s now 7.6 with metformin and lifestyle measures. Is the current A1c goal adequate, or should you treat more aggressively?
