Author: Sejal Bhatt (United Kingdom)
Co-authors: Francis Halliday, Kevin Gallagher
Purpose
The prevalence of diabetic retinopathy is increasing with a consequent increase in demand for the diabetic retinopathy (DR) clinic. The majority of patients seen in the DR clinics are referred from Diabetic Eye Screening Wales (DESW). Face-to-face (F2F) appointment capacity remains a significant challenge, particularly so during the COVID pandemic due to the need to reduce clinic capacity to allow for adequate social distancing. To address the need for capacity to meet the ever increasing demand, a virtual DR clinic was set-up.
Setting/Venue
A UK district general hospital in South Wales.
Methods
20 patients per week were booked to the virtual DR clinic. At the virtual appointment, a visual acuity, intraocular pressure, ocular and medical history were recorded. Patients subsequently had bilateral dilated fundal photographs (including colour fundus, red-free and blue autofluoresence photographs) and an OCT of the macula. Patients deemed unsuitable for the virtual clinic were those with visual acuity of 6/18 or worse, ungradable images, vulnerable adults, or those with suspected active proliferative disease. 1 clinic per week was designated as the virtual DR review clinic to review the notes of the previous weeks’ 20 patients. All patients were allocated retinopathy and maculopathy grades and were provided with follow-up outcomes including F2F medical retina follow-up, repeat virtual clinic follow-up or discharge to the DESW. Every alternate week, there was a F2F clinic to accommodate any urgent patients generated from the virtual DR clinic. Data regarding waiting time, referral grade, referral source, retinopathy grade and clinic outcome were recorded prospectively.
Results
Between 08/11/19 and 25/3/21, 691 patients were booked in the virtual DR clinic. Virtual clinics were suspended during the peak of the COVID-19 pandemic from 04/03/20 and restarted with limited capacity on 21/08/20. 534 patients in total attended their appointment which included 215 new patients, 316 follow-up patients and 3 unknown. Of all the new referrals - 100% of R1M0, 74% of R1M1, 80% of R2M0 and 28% of R2M1 referrals were not seen in face-to-face clinics and were safely discharged back into the community screening service or monitored in the virtual clinic. In contrast all new R3AM0/1 and ungradable patients were seen in face-to-face clinics. Of all the follow-up patients - 60% of R0, 73% of R1, 83% of R2 and 33% of R3S were discharged back into the community screening service or monitored in the virtual clinic. While 100% of follow-up R3A and ungradable patients were seen in face-to-face clinics. Of those that required a face-to-face appointment, reasons included the need for urgent or routine treatment, close observation (e.g. severe NPDR), further investigations or examinations, patient unsuitable for virtual clinic, booking error, patient request, poor image quality or other diagnosis requiring urgent or routine review.
Conlusions
The virtual DR clinic is an efficient way of seeing patients and reducing delays in new and follow-up appointments. Looking at all patients combined, 52% (n=278) could be kept under virtual review or be discharged to DESW. 43% (n=232) required a F2F appointment. If we look specifically at the R1M1 new referrals, this cohort made up 61% of new referrals seen in the virtual clinic (n=123). Of this 61%, 74% (n=92) had an outcome of either discharge to DESW or remain in the virtual clinic. This cohort did not need treatment for macular oedema. There is the possibility of intervening in the referral pathway for these R1M1 patients to reduce the need for a review in the hospital eye service. In London, they have introduced OCT scanning within the screening service for patients graded as R1M1. A referral algorithm based on the presence of absence of fluid, visual acuity and whether or not the ILM/foveal contour was disturbed was used by the graders and allowed those patients who did not require treatment (i.e. n=92 in our case) to remain under the screening service thereby reserving hospital appointments for patients most likely to require treatment.
Financial Disclosure
Nil
Comments
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