"An Incentive to Work Together": Student-Led Research Improves Eye Care

April 27, 2021 by Erin Post

UVM Assistant Professor of Surgery Christopher Brady, M.D., considers Vermont the “perfect living laboratory” for experimenting with telehealth. Even before the COVID-19 pandemic prompted a massive shift in healthcare delivery, he’s been researching how to efficiently provide preventive care to the patients who need it the most.

Delaney Curran ’22 (left) and Nicole Delgado ’22 (right)

UVM Assistant Professor of Surgery Christopher Brady, M.D., considers Vermont the “perfect living laboratory” for experimenting with telehealth. Even before the COVID-19 pandemic prompted a massive shift in healthcare delivery, he’s been researching how to efficiently provide preventive care to the patients who need it the most.

“It boils down to increasing access to eye care to everyone, but specifically as it relates to underserved and rural patients,” he says.

Vermont’s rural but relatively compact scale – along with the state’s all-payer accountable care organization model - create an environment ripe for innovation. As the state moves the healthcare system from volume-based to value-based payment, there’s the potential to leverage this new system for the common good.

“If we're all in it together, and it's a partnership between the providers, and the hospitals, and the payers, then we all have an incentive to work together,” he says. “We can all decide on making investments that will benefit people's health.”

This past year, Brady, who is an ophthalmologist, enlisted the help of two Larner College of Medicine medical students to further ongoing research into the prevention and treatment of diabetic retinopathy, the leading cause of vision loss in the U.S.   

A Deep Dive into Health Economics

Roughly 20 to 30 percent of patients with diabetes develop diabetic retinopathy, a serious condition that if caught early can be successfully treated. Delaney Curran ’22 focused her research on the usefulness of telehealth for this patient population: Could it be deployed to screen patients, prevent disease, and save money?

Curran took a deep dive into health economics to answer these questions.

“We designed an economic model, which is basically software that does dichotomous trees to demonstrate what a patient would go through in order to get screened for diabetic retinopathy,” says Curran. “It allows us to do some comparisons between treatment groups.”

She looked at patients screened via telehealth at a primary care office to the standard of care - an in-person visit to an eye doctor – and found cost savings. Since a higher percentage of patients are likely to screen negative for diabetic retinopathy than positive, the bulk of those screened are less prone to need follow-up, saving patients time and the healthcare system dollars.

The goal is to funnel the screening process through primary care offices equipped with retinal imaging technology.
“If somebody is in Vergennes and gets their picture taken by their primary care doctor there, it might get sent to Dr. Brady here at UVM,” she says. “And he would read it and then let the primary care doctor know if this patient needs follow-up at an optometrist or an ophthalmologist office or not.”
Vermont’s accountable care organization model supports this type of intervention. Curran’s research stands to help make the case for funding retinal imaging at primary care locations, especially when physicians are compensated per capita.
“It’s based on the idea that doctors work together, and they're given a certain amount of money per patient to share,” she says. “You could argue that in this setting, it's not just the ophthalmologist who is gaining a benefit and the primary care doctor isn't seeing any of that benefit. You [collaborate] as a network.”
A grant through the OneCare Innovation Fund has allowed Brady and team to implement a telemedicine screening project in partnership with UVM Health Network Porter Medical Center. Primary care offices in Vergennes and Middlebury are now equipped with cameras for retinal photographs, with a goal to better serve the community and study effectiveness and cost-savings. 
For Brady, the focus is on bringing the “programs and technologies that we know work in a laboratory…into the real world.” 
Curran, who presented her research virtually at the 2020 Association for Research in Vision and Ophthalmology annual meeting, is also preparing a manuscript for journal submission. Her project has led to many insights as she looks ahead to residency.
“This was the first research project that I did as more of an active participant,” she says. “The biggest takeaway is that there are a lot of smart people all around the world looking at very specific problems. I read hundreds of articles on this topic. It’s incredible to see how much work goes into answering a small question.” 
Improving Adherence to Follow-Up Care
Why do some patients with diabetic retinopathy regularly attend follow-up appointments while others neglect the screenings necessary for prevention? Nicole Delgado ’22 designed a study to help home in on interventions to improve follow-up adherence.
She conducted a semi-structured survey with 20 patients in Vermont – 10 of whom regularly made their appointments and 10 of whom often missed them. She found that 85 percent of patients in both groups reported at least one barrier to follow up.
The surprise was that no one factor emerged as the most likely to cause problems. This means that a single intervention – like offering a parking voucher or free childcare – is not likely to be effective.
“All patients face challenges getting to their appointments,” she says. “We need figure out how we can encourage them, maybe by providing some incentive that will help them to overcome [challenges].”
Education may also be key, as those who attended follow-up appointments seemed to have a better understanding of why regular screening was important. 
The study points towards using financial incentives as an effective method to improve follow up, a strategy that has been gaining traction in different fields including treatment of substance use disorder and smoking cessation. UVM has decades of leadership in this field through the Vermont Center on Behavior and Health, where Brady is a researcher and collaborator. The goal is to motivate patients to adhere to a health behavior that will make them healthier in the long run.
“Let’s help people do the right thing,” says Brady. “Let's help people do the thing they know they need to be doing anyway.”
Further research may help to narrow down an incentive plan that would work for the bulk of patients, says Delgado.
“The goal would be to figure out how much value can be placed on all of these factors that are a barrier - child care or the cost of travel or things like that - and then try to figure out what sort of financial incentive could potentially be offered to reach the majority of patients, and get them to come back,” she says.
For Delgado, delving into qualitative research – talking with patients about their experiences - has helped her to learn new skills. 
“It’s been interesting to figure out a new way of analyzing responses that can't necessarily be quantified, but that are just as valuable and provide so much information,” she says. 
She plans to present her research in May at the 2021 Association for Research in Vision and Ophthalmology annual meeting.