A Tiered Approach to Retinopathy of Prematurity Screening (TARP) Using a Weight Gain Predictive Model and a Telemedicine System

Abstract

for the Postnatal Growth and Retinopathy of Prematurity (G-ROP) Study Group and the Telemedicine Approaches to Evaluating Acute-Phase Retinopathy of Prematurity (e-ROP) Cooperative Group IMPORTANCE The Telemedicine Approaches to Evaluating Acute-Phase Retinopathy of Prematurity (e-ROP) Study telemedicine system of remote fundus image grading and The Children's Hospital of Philadelphia Retinopathy of Prematurity (CHOP-ROP) postnatal weight gain predictive model are 2 approaches for improving ROP screening efficiency. Current screening has low specificity for severe ROP. OBJECTIVE To describe a tiered approach to ROP screening (TARP) for identifying children who develop severe ROP using telemedicine and a predictive model synergistically. DESIGN, SETTING, AND PARTICIPANTS This investigation was a post hoc analysis of a cohort in the e-ROP Study (a multicenter prospective telemedicine study) and the Postnatal Growth and Retinopathy of Prematurity (G-ROP) Study (a multicenter retrospective cohort study). The setting was neonatal intensive care units at The Children's Hospital of Philadelphia and the Hospital of the University of Pennsylvania. Participants in the e-ROP Study were premature infants with a birth weight less than 1251 g and a known ROP outcome enrolled between May 25, 2011, and October 31, 2013. The G-ROP Study enrolled all infants undergoing ROP examinations with a known ROP outcome who were born between January 1, 2006, and December 31, 2011. MAIN OUTCOMES AND MEASURESThe mean outcomes were the sensitivity for type 1 ROP, reductions in infants requiring imaging or examinations, numbers of imaging sessions and examinations, and total clinical encounters (imaging sessions and examinations combined). The following 4 screening approaches were evaluated: ROUTINE (only diagnostic examinations by an ophthalmologist), CHOP-ROP (birth weight and gestational age, with weekly weight gain initiating examinations when the risk cut point is surpassed), e-ROP IMAGING (trained reader grading of type 1 or 2 ROP initiates diagnostic examinations), and TARP (CHOP-ROP alarm initiates imaging, and imaging finding of severe ROP initiates diagnostic examinations).RESULTS A total of 242 infants were included in the study, with a median birth weight of 858 g (range, 690-1035 g). The median gestational age was 27 weeks (range, 25-29 weeks). Fifty-one percent (124 of 242) were female, and 49% (118 of 242) were male. The race/ethnicity was 27.3% (66 of 242) white, 56.2% (136 of 242) black, 2.1% (5 of 242) Native American, 1.7% (4 of 242) Asian, and 12.8% (31 of 242) other. The sensitivity for detecting type 1 ROP (32 infants) was 100% (95% CI, 89.3%-100%) with each approach. With ROUTINE, 242 infants had 877 examinations; with CHOP-ROP, 184 infants had 730 examinations; with e-ROP IMAGING, 242 infants had 532 imaging sessions, and 94 infants had 345 examinations (877 patient encounters); and with TARP, 182 infants had 412 imaging sessions, and 87 infants had 322 examinations (734 patient encounters). CONCLUSIONS AND RELEVANCEThe ...

Pathophysiology, screening and treatment of ROP: A multi-disciplinary perspective

“…Since only a small proportion of infants at ROP risk warrants treatment and there is a general shortage of ROP skilled ophthalmologists, identifying those at highest risk using screening methods such as telemedicine (discussed above) or rate of weight gain algorithms (WINROP: (Hellstrom et al, 2009, Wu et al, 2012a; CHOPROP: (Binenbaum andTomlinson, 2017, Binenbaum et al, 2012)) alone or in combination (Gurwin et al, 2017) may offer solutions to the maldistribution of ophthalmologists (located mainly in high income countries) and premature infants (most of whom are born in middle and low income countries). However, the conclusion of Fierson and colleagues (Fierson et al, 2015) that telemedicine should be considered an adjunct to and not a replacement for indirect ophthalmoscopy has to be taken into consideration before widespread adoption of telemedicine in high income countries such as the US.…”

N-terminal B-type natriuretic peptide urinary concentrations and retinopathy of prematurity

“…NTproBNP and NTproBNP-based scores share the problem of limited generalizability with proportional weight gain (20,21) or risk factor-based models (22,24). In contrast to the expectations underlying this multinational endeavor, the results of this study do not allow for a change in current clinical practice in infants o30 weeks.…”

“…Although immaturity and oxygen exposure are pivotal for the development of ROP, the risk of severe ROP is further increased by poor postnatal growth. This link is thought to be mediated by low levels of insulin-like growth factor 1 and serves as a base for ROP prediction models such as WINROP (20) or CHOPROP (21). Furthermore, severe ROP is more common in infants with conditions that increase myocardial pressure or volume load, such as sepsis (22,23), blood transfusions (23,24), pulmonary hypertension treated with inhaled nitric oxide (25), patent ductus arteriosus (23), or inotrope use (22,(26)(27)(28)(29).…”

A novel telemedicine technique for evaluation of ocular exam findings via smartphone images

“…3,4 To date, the majority of tele-ophthalmology initiatives have focused on posterior segment eye pathology such as diabetic retinopathy and utilize technology unavailable to the average American. 1,[5][6][7][8][9] An improvement in telemedicine initiatives would utilize technology that most patients and clinicians already possess, such as smartphones, rather than rely on novel technology that could impose prohibitive expenses and prolonged learning curves.…”