Community Management of Retinopathy of Prematurity

Alex R. Kemper, MD, MPH, MSSheri Carroll, MD

David K. Wallace, MD, MPHNovember 13, 2007

CM-ROP

Overview

• ROP is common– 4% of all at-risk infants, increases with the degree of

prematurity– 1,100-1,500 require laser treatment

• ROP is serious– 400-600 cases of blindness annually– High physician liability

• ROP is preventable– Limiting excess oxygen exposure– Screening for early treatment

Challenges

1. The number of premature infants is increasing

2. The criteria for screening has expanded3. Some require treatment earlier than in

the past4. There are regional shortages in the

ophthalmology workforce5. It is difficult to assure eye care around

the time of transfer or discharge

Challenges

1. The number of premature infants is increasing

2. The criteria for screening has expanded3. Some require treatment earlier than in

the past4. There are regional shortages in the

ophthalmology workforce5. It is difficult to assure eye care around

the time of transfer or discharge

Screening Criteria

• Indirect ophthalmoscopy to screen for ROP is recommended for infants with– Birth weight ≤ 1,500 grams– Gestational age ≤ 30 weeks– Birth weight between 1,500 and 2,000 grams or

gestational age of >30 weeks and an unstable clinical course

– This is a change from the previous cutoff of 28 weeks

• Infants may require from 2 to 9 exams

Eye Care Workforce

• Total workforce is small– Screen: < 2,000 ophthalmologists– Treat: < 1,000 ophthalmologists

• For screening:– about equal numbers of general ophthalmologists and

pediatric ophthalmologists– However, pediatric ophthalmologists do more exams

• For treating:– More retina specialists than pediatric

ophthalmologists• Main reasons for not providing these services –

perceived lack of demand, liability risk, lack of training or experience

Transfer / Discharge

• No good data

• Data suggest– ROP follow-up missed in transfer from high

acuity to lower acuity NICUs– Parents do not follow-up after discharge

More infants at risk! Fewer resources!

No tolerance for missed cases!

New “High-Tech” Solutions

• Cameras with or without telemedicine

Wide Angle

Narrow Angle

New “High-Tech” Solutions

Decrease the amount of hay without losing the needle.

New “High-Tech” Solutions

• Telemedicine will likely play an important role – there are important questions about:– Relative accuracy of different strategies– Costs and effectiveness– Where and how to implement – it is unlikely

that there is “one way” to do things– Lots of very interesting and important

opportunities

Next Steps

• Prior to developing any intervention to improve the quality of ROP services delivered, data are needed to identify modifiable factors

• Such work will also help define the long-term goals for improving care, including involvement in telemedicine initiatives

Objectives

1. Describe the criteria and methods used to identify children that need ROP care

2. Quantify the frequency and outcomes of eye exams

3. Evaluate the coordination of ROP care around the time of discharge or transfer

CM-ROP

Design

• Short (2-page) survey of NICU director to provide an overview of ROP care within the NICU

• Chart audit to collect information related to ROP care before admission, during the NICU stay, and ROP care arrangements upon discharge or transfer

– Each participating NICU will identify all children with a birth weight ≤1,500 grams or a gestational age ≤ 30 weeks admitted beginning February 1, 2007. Charts audits will be completed sequentially based on date of admission until 50 neonates have been identified for chart abstraction or June 30, 2007 (i.e., 6 months later) is reached.

– $250 for participation

CM-ROP

Outcomes

• Identify opportunities for quality improvement

• Tailor activities to NICU characteristics• Be able to quantitatively evaluate change• Share knowledge, including peer-

reviewed publications• Seek extramural funding for future ROP

projects, focusing on care delivery in the “real world”

CM-ROP

Questions?

CM-ROP

Rates of Prematurity

Pediatrics 119:345-360, 2007

ROP: ClassificationAberrant development of immature retinal vessels in premature babies. Classification by ICROP based on 4 parameters:

1. Severity by stage

2. Location in the anterior-posterior dimension (3 zones)

3. Circumferential extent at the junction between the vascularized and avascular retina

4. Presence of abnormal vascular dilation and tortuosity of the posterior pole vessels (plus disease)