IMPROVING ANNUAL DIABETIC RETINAL SCAN SCREENING RATES IN A PRIMARY CARE CLINIC DURING THE COVID-19 PANDEMIC

STATEMENT OF PROBLEM/QUESTION: How can systems-based changes increase the rate of diabetic retinal scan (DRS) completion in a primary care clinic during the COVID pandemic with decreased in-person visits? DESCRIPTION OF PROGRAM/INTERVENTION: The intervention was based in a primary care clinic associated with a public county-based health system. During the COVID-19 pandemic, in-person clinic visits were drastically reduced to prevent transmission, leading to a significant decrease in DRS completion rates. Additional barriers to completion of DRS screening included the following: (1) patients needed a separate, scheduled visit in our electronic medical record system (EPIC) for the DRS exam, (2) DRS clinic had limited hours during the primary care visit day, (3) many of our underserved patients could not afford consecutive clinic visits within a short period of time, and (4) providers signed the orders for DRS at the end of the visit;thus, nursing staff could not start scheduling patients an appointment until the end of the primary care visit. The intervention included two Plan-Do-Study-Act (PDSA) cycles. The first PDSA cycle involved a physician manually screening all patients due for DRS on a weekly basis if they were scheduled for a clinic visit in the upcoming week. For those identified, our nursing staff scheduled and completed a separate DRS appointment for the same day as the patient's clinic visit to minimize multiple visits. The second PDSA cycle involved using an EPIC tool, SlicerDicer, to automatically identify patient charts with overdue DRS screenings and upcoming clinic visits. The list of identified patients were then sent over to our nursing staff in order to schedule patients for their DRS on the same day as their clinic visit. MEASURES OF SUCCESS: We recorded diabetic retinal scan completion rate each month for one year from September 2020 to August 2021 to assess if rates would improve after our interventions. Monthly completion rates were measured on a rolling basis and based on the completion of the annual DRS for all clinic patients within the last 12 months. FINDINGS TO DATE: The percent of completed annual diabetic retinal exams for all clinic patients increased from 32.4% in September 2020 to 70.9% in August 2021 after implementation of our interventions. KEY LESSONS FOR DISSEMINATION: We identified system-based barriers that were negatively impacting our patients' ability to complete an important health maintenance screening such as the DRS exam. After identifying these barriers, we utilized existing tools and technology within our electronic medical record system to help patients complete their annual DRS exams and drastically increased overall clinic DRS completion rates.

SYSTEMATIC REVIEW OF TELEHEALTH INTERVENTIONS IN PATIENTS WITH CHRONIC LIVER DISEASES

Background and aim Telehealth (TH) interventions may improve access to care, diseasespecific and general quality outcomes in chronic liver diseases (CLD). Given the current COVID-19 pandemic, TH interest has grown exponentially. We aimed to systematically evaluate outcomes of TH interventions in a variety of CLD. Methods We used key terms and searched PubMed/EMBASE from inception to 12/5/2020 for observational studies or clinical trials. Two authors independently screened s. We included any type of CLD, including post-transplant patients. Disagreements were solved by a third reviewer. We excluded s, case-reports, and reviews. We extracted the outcomes defined by the authors for each CLD (chronic hepatitis C or B, decompensated cirrhosis, hepatocellular carcinoma-HCC-, liver transplant referral and readmission/rejection after transplantation or weight loss in nonalcoholic fatty liver disease-NAFLD). No meta-analysis was planned due to the heterogeneity of the data. Results Of a total of 3567 studies screened, 29 met inclusion criteria (Table 1). Of these, 17 reported on HCV treatment outcomes [14 video telemedicine, 2 remote specialist consultation, and one texting based intervention]. All studies showed no statistically significant differences between sustained virological response (SVR) rates in telehealth intervention groups compared to control groups or historic general population. 4 retrospective studies examined decompensated cirrhosis/liver transplant referral, followup after transplant, and showed a reduction in time to transplant (138.8 days vs 249 day, P<0.01), mortality or readmission following transplant (28% vs 58%, P=0.004), and improved referral timing (0% immediate rejections of transplant referral vs 41%, P<0.001). Other important outcomes measured also demonstrated benefit in favor of telemedicine incorporation including autoimmune hepatitis remission (100% vs 77.3%, P=0.035). One study assessed chronic hepatitis B outcomes and had no difference in development of hepatocellular carcinoma, ALT fluctuation or cirrhosis over 2 years of follow-up. Finally, two studies assessed weight loss in nonalcoholic fatty liver disease: the prospective study showed no change in weight loss while the randomized clinical trial did. Conclusion TH interventions in patients with CLD shows consistent equivalent or improved clinical outcomes compared to traditional encounter. Similar SVR, decreased time to liver transplant referral and mortality outcomes were observed in the TH groups. In CHB, development of HCC, cirrhosis or biochemical remission was similar as well. In the NAFLD clinical trial, the TH group had 5%+ weight loss over 3 months compared to the control group. In the light of the ongoing COVID19 pandemic, TH in CLD should be the bridge to improve clinical outcomes when face-to-face encounters are not possible. (Table Presented) Abbreviations: DOC: Department of Corrections, TH: Telehealth, SVR: sustained virological response, SVR12: sustained virological response for 12 weeks, SVR24: sustained virological response for 24 weeks, GP: general practitioner, RCT: randomized controlled trial *Sterling et al, 2018 compared patients with private insurance in clinic vs indigent patients in clinic vs patients in the department of corrections using telemedicine. †Lepage et al, 2020 compared patients in outpatient clinic vs mixed delivery including clinic and telemedicine vs telemedicine only. ††These studies reported rates of SVR in their cohort and compared to historical rates of SVR in similar cohorts.