Joslin Vision Network Diabetes Eye Care ProgramElliott P. Joslin in 1898 • Largest center in the...
Transcript of Joslin Vision Network Diabetes Eye Care ProgramElliott P. Joslin in 1898 • Largest center in the...
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Joslin Vision Network Joslin Vision Network Diabetes Eye Care ProgramDiabetes Eye Care Program
Rajni Aneja MD,MBA,CPE
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2
Research Clinic Strategic Initiatives
• Sections are basic and clinical
• $310 million over past 20 years
• 60% of NIH grant applications approved, 20% is usual
• 140 MDs/PhDs in training: 1/3 MD, 1/3 PhD, 1/3 both degrees
• Founded by Dr. Elliott P. Joslin in 1898
• Largest center in the world for treatment and education of patients with diabetes
• Over 87,000 patient visits a year to experts in adult and pediatric diabetes, kidney disease, eye care, mental health and pregnancy
• Extends Joslin products, services and assets to the global marketplace
• Healthcare Services, Professional Education, Affiliated Programs, International Programs
Joslin Diabetes CenterJoslin Diabetes Center
Joslin Ventures
• Provides an active framework that will seed new ideas
• Partner technologies for co-development with other companies
• Brings selected Joslin technologies to a commercially ready stage for spin-out opportunities and joint ventures
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The World Relies on JoslinThe World Relies on JoslinMore than 40,000 patients cared for by the Joslin Vision Network
More than 100,000 patients seen each year at 41 Affiliated Centers
World’s largest team of board-certified physicians treating diabetes
Largest institution in the world devoted exclusively to diabetes research, care and education
Affiliated with Harvard Medical School
Highest patient population on insulin pumps in the world
Sets the standard of care and education with 250,000+ patients treated
Highest concentration of diabetes educators in the world
Database of medical data stretching back decades
Best record for saving kidneys, legs and eyesight potentially lost to diabetes
JoslinDiabetesCenter
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How Severe is the Problem?How Severe is the Problem?
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37.7 M51.2 M↑36%
25.1 M39.9 M↑59%
52.8 M64.2 M↑22% 187.9 M
112.8 M↑60%
14.7 M28.0 M↑90%
71.4 M121 M↑69%
M = million, AFR = Africa, NAC = North America and Caribbean, EUR = Europe, SACA = South and Central America, MENA = Middle East and North Africa, SEA = South-East Asia, WP = Western PacificDiabetes Atlas Committee. Diabetes Atlas 5th Edition: IDF 2011.
Global Projections for the Diabetes Global Projections for the Diabetes Epidemic: 2011Epidemic: 2011--20302030
AFR
NAC
SACA
EUR
SEAWP
32.6 M59.7 M↑83%
MENA
20112030
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Diabetes WorldwideDiabetes Worldwide
Persons with Diabetes 2011:366 million (8.3% of world’s adult population)
Persons with Diabetes 2030:552 million (51% increase)
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Prevalence of Diabetic ComplicationsPrevalence of Diabetic Complications%
of D
iab e
tes
Pat ie
nts
With
Dia
betic
Com
plic
atio
ns
0
10
20
30
40
50
60
Retinopathy Neuropathy Nephropathy CardiovascularDisease
49%
40%35%
43%
Centers for Disease Control and Prevention, 2008
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Global Retinopathy Evaluation NeedGlobal Retinopathy Evaluation Need
Based on current estimates
3 million eyes per day
at least will need to be
evaluated by 2030
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Why Focus on DiabeticWhy Focus on Diabetic Eye Disease?Eye Disease?
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SEVERITY
LPA 10LPA 10 Early Treatment Diabetic Retinopathy Study Research Group. Ophthalmology. 1991;98:823-833.
STAGE S BDR PPDR
PDR
(Background) (Preproliferative)
No DiabeticRetinopathy
Proliferative Diabetic
Retinopathy
NPDR Nonproliferative Diabetic
RetinopathyPre-Clinical Changes
Mild to Moderate Moderate to Severe NeovascularizationNone
MACULAR EDEMA more commonless common
Clinical Stages of Diabetic RetinopathyClinical Stages of Diabetic Retinopathy
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Retinal Vascular Proliferation
(Proliferative Diabetic Retinopathy - PDR)
Vision Loss from Diabetic RetinopathyVision Loss from Diabetic Retinopathy
Normal Retina PDR
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Retinal Vascular Proliferation
Traction Retinal Detachment - TRD
Vision Loss from Diabetic RetinopathyVision Loss from Diabetic Retinopathy
Normal Retina TRD
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Vitreous Hemorrhage
Vitreous Hemorrhage
Vision Loss from Diabetic RetinopathyVision Loss from Diabetic Retinopathy
Normal Retina
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Macular Edema
Vision Loss from Diabetic RetinopathyVision Loss from Diabetic Retinopathy
Normal RetinaMacular Edema
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Diabetic RetinopathyDiabetic Retinopathy
A Leading Cause Of:
Severe visual loss
Moderate visual loss
New onset blindness
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How Well Can We Treat Diabetic Eye How Well Can We Treat Diabetic Eye Disease?Disease?
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LPA 17LPA 17
Panretinal Laser PhotocoagulationPanretinal Laser Photocoagulation
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Effective Evidence Based Eye CareEffective Evidence Based Eye Care
60-96% reduction in moderate &
severe visual loss
We
Extensive evidence based data upon which to develop
evaluation & treatment approaches
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Visual Outcomes at the Joslin Diabetes Visual Outcomes at the Joslin Diabetes Center 2006 Center 2006 –– 2010 (N=14,597 patients)2010 (N=14,597 patients)
Best Corrected VA, median (Q1, Q3)*
20/20 (20/16,20/25)
Change in BCVA, mean (SD)† - 0.5 (± 7) letters
20/20 or better (N) 72% (10,535)
20/40 or better (N) 92% (13,414)
20/200 or worse (N) 1% (153)
61% with DR, 18% with PDR, 22% with DME, 6% with CSME*14,511 (99.4%) with measured BCVA, 12 patients with light perception or worse vision in the better-seeing eye† Mean follow-up of 1.9 years
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Effective Diabetes Eye CareEffective Diabetes Eye Care
• Identification of diabetes• Assessment of the eyes for retinopathy• Determination of retinopathy severity• Routine lifelong eye care• Coordinated medical care
o Blood glucose, hypertension, lipids• Patient education• Prompt treatment when indicated
Can be addressed using TelemedicineCan be addressed using Telemedicine
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How Well Are We Addressing Identification How Well Are We Addressing Identification and Care Delivery?and Care Delivery?
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% of Diagnosed Diabetes Patients Who Said% of Diagnosed Diabetes Patients Who Said They had a Dilated Eye Exam in the Past YearThey had a Dilated Eye Exam in the Past Year
74%
64% 63%55% 54%
43% 42%
0%10%20%30%40%50%60%70%80%
France Netherlands Italy SpainGermanyUnitedKingdom
UnitedStates
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Discrepancies in Access to Eye CareDiscrepancies in Access to Eye Care
285,000,000 individuals with diabetes160,000 ophthalmologists
54% increase in diabetes population< 2% growth in the number of ophthalmologists
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Telemedicine ApproachTelemedicine Approach• Brings exam to patient
• Within cultural context
• Flexible timing
• Avoid dilation
• Combined with education
• Apply disease management
• Facilitate clinical trials
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Telemedicine ApproachTelemedicine Approach
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Joslin Vision Network: Joslin Vision Network: Validated Telemedicine Program for DRValidated Telemedicine Program for DR
• Digital stereoscopic images• Undilated pupils• Image/data transfer & storage• Clinical Level of DR • Non DM retinal findings • EMR interface• Equivalent to retinal exam for
diabetic retinopathy but does not replace a comprehensive eye exam
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Primary Care PracticePrimary Care Practice Joslin Ocular Telehealth ProgramJoslin Ocular Telehealth Program
Provider requests spontaneous referral for
retinal imaging
Patient Care Coordinator pre-schedules patient
with DM for retinal imaging
Reports read immediately if certified imager identifies
findings that may be URGENT
All other reports read by certified graders within 1-2
business days
NON-URGENT or OVERDUE
Patient scheduled for appropriate eye exam
URGENT FINDINGS
Patient scheduled for
prompt Eye Exam
Patient Education
Reading Center
Primary provider receives final report
with diagnosisand eye care
recommendation
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JoslinJoslin Vision Network DeploymentVision Network DeploymentClinical Programs in point-of-care setting
• Indian Health Service• Approximately 78 sites in 22 states
• Veteran’s Administration• Approximately 15 sites - up to 2000
patients/month• Department of Defense
• Approximately 10 sites [Army & Air Force]• Academics: 4 Boston sites (BWH, MGH, BIDMC,
JDC)• Venezuela-JVN Pediatric Program• Frequent requests for additional clinical deployments
(Domestic and International)
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Can Can JoslinJoslin Vision Network Vision Network Make a Difference?Make a Difference?
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Overall IHS Diabetic Retinopathy Overall IHS Diabetic Retinopathy Examination Rate 1992Examination Rate 1992--20032003
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Diabetic Retinopathy Diabetic Retinopathy PIMC Telemedicine ImpactPIMC Telemedicine Impact
Annual rates of retinal screening and laser treatment
0
5
10
15
20
25
30
35
1999 2000 2001 2002 2003Year
Lase
r The
rapy
per
100
0 di
abet
ic
pers
on-y
ear
0
10
20
30
40
50
60
70
80
Ret
inal
exa
ms
per 1
00di
abet
ic
pers
on-y
ears
Laser treatment rate Retinal exam rate
JVN Telemedicine Program
+50%
+50%
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Impact on Telemedicine Programs for Impact on Telemedicine Programs for Retinopathy AssessmentRetinopathy Assessment
• Telemedicine diabetic retinopathy assessment is feasible and effective
• Telemedicine provides convenient, expanded management of diabetic patients in the primary care setting and may reduce risk of vision loss through early and routine surveillance for diabetic retinopathy
• Telemedicine systems may increase surveillance and timely treatment rates for diabetic retinopathy