title: Implementation and Evaluation of a Large-Scale Teleretinal Diabetic Retinopathy Screening Program in the Los Angeles County Department of Health Services.
abstract: Diabetic retinopathy (DR) is the leading cause of blindness in adults of working age in the United States. In the Los Angeles County safety net, a nonvertically integrated system serving underinsured and uninsured patients, the prevalence of DR is approximately 50%, and owing to limited specialty care resources, the average wait times for screening for DR have been 8 months or more.
  
  
  
  To determine whether a primary care-based teleretinal DR screening (TDRS) program reduces wait times for screening and improves timeliness of needed care in the Los Angeles County safety net.
  
  
  
  Quasi-experimental, pretest-posttest evaluation of exposure to primary care-based TDRS at 5 of 15 Los Angeles County Department of Health Services safety net clinics from September 1, 2013, to December 31, 2015, with a subgroup analysis of random samples of 600 patients before and after the intervention (1200 total).
  
  
  
  Primary care clinic-based teleretinal screening for DR.
  
  
  
  Annual rates of screening for DR before and after implementation of the TDRS program across the 5 clinics, time to screening for DR in a random sample of patients from these clinics, and a description of the larger framework of program implementation.
  
  
  
  Among the 21 222 patients who underwent the screening (12 790 female, 8084 male, and 348 other gender or not specified; mean [SD] age, 57.4 [9.6] years), the median time to screening for DR decreased from 158 days (interquartile range, 68-324 days) before the intervention to 17 days (interquartile range, 8-50 days) after initiation of the program (P < .001). Overall annual screening rates for DR increased from 5942 of 14 633 patients (40.6%) before implementation to 7470 of 13 133 patients (56.9%) after initiation of the program at all 15 targeted clinics (odds ratio, 1.9; 95% CI, 1.3-2.9; P = .002). Of the 21 222 patients who were screened, 14 595 (68.8%) did not require referral to an eye care professional, 4160 (19.6%) were referred for treatment or monitoring of DR, and 2461 (11.6%) were referred for other ophthalmologic conditions.
  
  
  
  A digital TDRS program was successfully implemented for the largest publicly operated county safety net population in the United States, resulting in the elimination of the need for more than 14 000 visits to specialty care professionals, a 16.3% increase in annual rates of screening for DR, and an 89.2% reduction in wait times for screening. Teleretinal DR screening programs have the potential to maximize access and efficiency in the safety net, where the need for such programs is most critical.
authors.affiliation: Ophthalmology and Eye Health Programs, Department of Health Services, Los Angeles County, Los Angeles, California.
authors.forename: Lauren P
authors.initials: LP
authors.lastname: Daskivich
authors.affiliation: Department of Medicine, David Geffen School of Medicine, UCLA (University of California, Los Angeles)3Department of Health Policy and Management, UCLA Fielding School of Public Health, University of California, Los Angeles.
authors.forename: Carolina
authors.initials: C
authors.lastname: Vasquez
authors.affiliation: Charles R. Drew University of Medicine and Science, Los Angeles, California.
authors.forename: Carlos
authors.initials: C
authors.lastname: Martinez
authors.affiliation: Department of Medicine, David Geffen School of Medicine, UCLA (University of California, Los Angeles)3Department of Health Policy and Management, UCLA Fielding School of Public Health, University of California, Los Angeles.
authors.forename: Chi-Hong
authors.initials: CH
authors.lastname: Tseng
authors.affiliation: Department of Medicine, David Geffen School of Medicine, UCLA (University of California, Los Angeles).
authors.forename: Carol M
authors.initials: CM
authors.lastname: Mangione
mesh_terms: D000368:Aged; D000553:Ambulatory Care; D003430:Cross-Sectional Studies; D003930:Diabetic Retinopathy / Q000175:diagnosis*; D005260:Female; D005654:Fundus Oculi; D006296:Health Services; D065386:Historically Controlled Study; D006801:Humans; D015141:Los Angeles; D008297:Male; D008403:Mass Screening; D008875:Middle Aged; D016017:Odds Ratio; D009885:Ophthalmology; D009907:Optometry; D010781:Photography; D011320:Primary Health Care; D012017:Referral and Consultation; D012189:Retrospective Studies; D017216:Telemedicine / Q000379:methods*