Exploring the Utility of a Tele-Retinal Referral System for Patients with Diabetic Macular Edema and Neovascular Age-Related Macular Degeneration. A Single Site Prospective Study

Authors: Matthew Fung, Jenny Qian, Joshua Barbosa, Varun Chaudhary. 
Author Disclosure Block: M. Fung: None. J. Qian: None. J. Barbosa: None. V. Chaudhary: Any direct financial payments including receipt of honoraria; Name of for-profit or not-for-profit organization(s); Novartis, Bayer. Any direct financial payments including receipt of honoraria; Description of relationship(s); Speaker fees. Membership on advisory boards or speakers’ bureaus; Name of for-profit or not-for-profit organization(s); Novartis, Bayer, Roche, Alcon Inc.. Membership on advisory boards or speakers’ bureaus; Description of relationship(s); Advisory Board. Funded grants or clinical trials; Name of for-profit or not-for-profit organization(s); Novartis, Bayer. Funded grants or clinical trials; Description of relationship(s); Grants and clinical trials.

Purpose: Early intervention for neovascular age-related macular degeneration (nAMD) and diabetic macula edema (DME) is an important factor for favorable long-term outcomes. This study assessed the time to treatment with anti-VEGF agents between a new tele-referral system compared to the standard of care at the Hamilton Regional Eye Institute (HREI) for patients with DME and nAMD. 

Study Design: This is a single center, single practitioner, prospective observational study. 

Methods: Referrals to HREI were sent via fax or tele-referral. Tele-referrals were sent by means of a secure email service and included preliminary fundus and/or optical coherence tomography (OCT) images. The main outcome of the study was to compare time to treatment defined as the time when the referral was reviewed to when the patient received treatment between groups. Additionally, patient demographic information such as referral date, diagnosis, and commuting distance was also captured. 

Results: Out of 151 participants (196 eyes) the average patient distance from the eye clinic was 17.7 ± 18.8 km for tele-referral, and 15.4 ± 11.5 km for fax referrals. The average age was 73.6 ± 11.7 years and 68.2 ± 14.1 years for tele- and fax referrals, respectively. Tele-referrals took 8.3 ± 9.2 days from the time of referral to be reviewed compared to 3.3 ± 3.6 days for fax referrals (p<0.0001). 45.5% of tele-referred patients required treatment compared to 43.7% from fax. Overall, the time to treatment was 46.2 ± 21.9 days in tele-referred patients and 68.0 ± 31.7 days for fax patients (p < 0.01). Additionally, time from optometry referral to treatment for tele-referrals was 52.8 ± 23.7 days compared to 70.6 ± 32.1 days for fax referrals (p < 0.05). Both groups had a similar number of visits (1.9 ± 0.7 for tele-referrals and 2.2 ± 0.6 for fax) but less tests were ordered for tele-referred patients (1.5 ± 0.8 tests versus 2.3 ± 0.7 for fax) (p<0.0001) prior to treatment. 

Conclusions: Although the time to review referrals was longer for the tele-referral group, the overall time to treatment was shorter. The tele-referral group and fax referral group had similar a proportion of patients requiring treatment. Patients referred via telemedicine also required fewer diagnostic tests before treatment compared to conventional fax referrals. Our study demonstrates that teleophthalmology referral systems can connect patients with nAMD and DME to appropriate management quicker and more efficiently utilize limited health care resources by reducing the number of investigations before treatment.