This was a retrospective cohort study using deidentified medical record data obtained during routine clinical operations of the IHS teleophthalmology program at 75 primary care clinics distributed among 20 states. The IHS serves enrolled members of federally recognized tribes. The study was reviewed and approved by the IHS institutional review board at Phoenix Indian Medical Center under the exempt process. Written informed consent from participants was not required or obtained.
Details regarding the teleophthalmology program’s origins, protocols, distribution, and outcomes have been previously described.13 (link) Briefly, the program evaluates patients from participating primary care clinics. It is a validated American Telemedicine Association Category 3 program and its graders identify the Early Treatment Diabetic Retinopathy Study (ETDRS)–defined clinical levels of DR and diabetic macular edema (DME) severity.13 (link),14 (link),15 (link) Graders are certified and licensed optometrists who render a diagnosis using standardized protocols. The program currently recommends that patients receive annual DR examinations.
Before selecting the analytic cohort for this study, we defined a baseline period of January 1, 2015, to December 31, 2015, and a follow-up period of January 1, 2016, to December 31, 2019. Eligible patients had at least 1 IHS teleophthalmology examination with the program in both periods. Additionally, eligible patients were 20 years or older and had no evidence of DR or had mild nonproliferative DR (NPDR; ETDRS levels 10, 14, 15, 20) in the baseline period. Patients with severe/very severe NPDR (ETDRS levels 53 a-e), proliferative DR (PDR; ETDRS levels 61, 65, 71, 75, 81, 85), and/or any level of DME are referred out of the teleophthalmology program to specialty eye care; therefore, these patients were excluded. Referral recommendations of patients with moderate NPDR (ETDRS levels 35, 43, 47) are dependent on risk factors; therefore, these patients were also excluded. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE ) reporting guidelines.
Details regarding the teleophthalmology program’s origins, protocols, distribution, and outcomes have been previously described.13 (link) Briefly, the program evaluates patients from participating primary care clinics. It is a validated American Telemedicine Association Category 3 program and its graders identify the Early Treatment Diabetic Retinopathy Study (ETDRS)–defined clinical levels of DR and diabetic macular edema (DME) severity.13 (link),14 (link),15 (link) Graders are certified and licensed optometrists who render a diagnosis using standardized protocols. The program currently recommends that patients receive annual DR examinations.
Before selecting the analytic cohort for this study, we defined a baseline period of January 1, 2015, to December 31, 2015, and a follow-up period of January 1, 2016, to December 31, 2019. Eligible patients had at least 1 IHS teleophthalmology examination with the program in both periods. Additionally, eligible patients were 20 years or older and had no evidence of DR or had mild nonproliferative DR (NPDR; ETDRS levels 10, 14, 15, 20) in the baseline period. Patients with severe/very severe NPDR (ETDRS levels 53 a-e), proliferative DR (PDR; ETDRS levels 61, 65, 71, 75, 81, 85), and/or any level of DME are referred out of the teleophthalmology program to specialty eye care; therefore, these patients were excluded. Referral recommendations of patients with moderate NPDR (ETDRS levels 35, 43, 47) are dependent on risk factors; therefore, these patients were also excluded. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (
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