Advancing Integration of Tele-ophthalmology for Diabetic Retinopathy in Rural, Multi-payer Settings

 描述(申请人提供)：糖尿病视网膜病变仍然是美国工作年龄成年人失明的主要原因，尽管主要的NEI临床试验表明，早期发现和治疗可将严重视力丧失的风险降低90%。在美国，遵守每年一次的糖尿病视网膜病变筛查指南的比例停滞不前，为50%。眼部远程医疗(即远程眼科)可以非常有效地提高糖尿病视网膜病变筛查率，但这些计划在多付费医疗系统中的使用非常有限，这构成了美国医疗系统的大部分。远程眼科的成功应用存在重大障碍，但人们对这些障碍知之甚少。刘博士的K23研究计划旨在(1)确定初级保健提供者和患者层面的障碍和促进者，以便在农村、多方付费的医疗系统中进行糖尿病视网膜病变的远程眼科筛查；(2)开发一套实施方案，以在单一初级保健地点克服这些障碍；以及(3)中试测试该实施方案对多个初级保健诊所的糖尿病视网膜病变筛查率的影响。她假设，这一实施方案建立在完善的框架之上，以增加对糖尿病护理指南的遵守和医疗流程的改进，将成功地将远程眼科纳入现有的医疗系统，并将实现并保持更高的糖尿病视网膜病变筛查率。刘医生的长期职业目标是通过远程眼科医疗扩大眼部护理的覆盖面，以减少服务不足社区的视力损失。她拟议的有指导的研究和培训将提供成为眼科保健服务提供方面的独立调查员所需的进一步技能，并在新兴的传播和实施科学领域拥有更多的专门知识。她将通过威斯康星大学获得丰富的资源，包括NIH资助的远程医疗、流行病学、混合方法(即定性和定量)、传播和实施、工业/系统工程和卫生服务研究等多学科领域的杰出导师和合作者。这项K23提案直接回应了国家眼科研究所(NEI)的健康差距战略计划和国家眼科和视力研究计划(NPEVR)的多个要素。这些领域包括卫生服务研究的重点领域，糖尿病视网膜病变，以及扩大对农村、服务不足的人口的接触。NEI健康差异战略计划指出，远程医疗具有巨大的“减少获取差异的潜力”，NPEVR呼吁“扩大远程医疗的努力，以管理……农村和/或服务不足的人群的糖尿病视网膜病变。”通过了解如何在多付费医疗系统中有效地整合和利用眼部远程医疗，刘博士的研究将促进远程医疗技术的有效转化，从而提高社区的糖尿病视网膜病变筛查率。在这项工作的基础上，她计划开发未来的远程医疗筛查和治疗方案，用于其他导致视力残疾的主要原因，如未矫正的屈光不正、黄斑变性和青光眼。眼部远程医疗的进步有可能为数百万美国人提供无与伦比的眼部护理，这些技术的有效转化对于解决健康差距以及满足我们日益增长的需求将是至关重要的 人口老龄化。

 DESCRIPTION (provided by applicant): Diabetic retinopathy remains the leading cause of blindness among working-age U.S. adults despite the fact that major NEI clinical trials show that early detection and treatment reduce the risk of severe vision loss by 90%. Adherence with yearly diabetic retinopathy screening guidelines in the U.S has stagnated at 50%. Ocular telemedicine (i.e. tele-ophthalmology) can be highly effective for increasing diabetic retinopathy screening rates, but there is very limited utilization of these programs in multi-payer health systems, which constitute the majority of U.S. healthcare systems. Significant barriers exist to the successful application of tele-ophthalmology, but these barriers are poorly understood. Dr. Liu's K23 research plan aims to (1) identify primary care provider and patient-level barriers and facilitators to tele-ophthalmology screening for diabetic retinopathy in a rural, multi-payer healt system, (2) develop an implementation package to overcome those barriers at a single primary care site, and (3) pilot-test the impact of this implementation package on diabetic retinopathy screening rates at multiple primary care clinics. She hypothesizes that this implementation package, structured upon well-established frameworks for increasing adherence with diabetes care guidelines and healthcare process improvement, will successfully integrate tele-ophthalmology into the existing healthcare system, and will both achieve and maintain increased diabetic retinopathy screening rates. Dr. Liu's long-term career goal is to reduce vision loss in underserved communities by expanding access to eye care through ocular telemedicine. Her proposed mentored research and training would provide the further skills needed to become an independent investigator in ophthalmic health services delivery with additional expertise in the emerging field of dissemination and implementation science. She will access a wealth of resources through the University of Wisconsin, including accomplished NIH-funded mentors and collaborators in the multidisciplinary fields of telemedicine, epidemiology, mixed methods (i.e. qualitative and quantitative), dissemination and implementation, industrial/systems engineering, and health services research. This K23 proposal directly responds to multiple elements of the National Eye Institute's (NEI) Health Disparities Strategic Plan and National Plan for Eye and Vision Research (NPEVR). These include areas of emphasis in health services research, diabetic retinopathy, and expanding access to rural, underserved populations. The NEI Health Disparities Strategic Plan states that telemedicine has great "potential to reduce access disparities" and the NPEVR calls to "expand efforts in telemedicine to manage diabetic retinopathy...for rural and/or underserved populations." By understanding how to effectively integrate and utilize ocular telemedicine in multi-payer health systems, Dr. Liu's research will facilitate the effective translation of telemedicine technology ino improved diabetic retinopathy screening rates in the community. Building from this work, she plans to develop future telemedicine screening and management protocols for other major causes of visual disability such as uncorrected refractive error, macular degeneration, and glaucoma. Advancements in ocular telemedicine have the potential to provide unparalleled access to eye care for millions of Americans and the effective translation of these technologies will be critical both for addressing health disparities as well as to meet the growing needs of our aging population.