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A Tiered Approach to Retinopathy of Prematurity Screening (TARP) Using a Weight Gain Predictive Model and a
Jaclyn Gurwin1, Lauren A Tomlinson2, Graham E Quinn1
1Division of Ophthalmology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania2Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
Insights
A new tiered approach to ROP screening (TARP) effectively identifies severe retinopathy of prematurity (ROP) while reducing clinical encounters. This method combines telemedicine and predictive modeling for improved ROP screening efficiency.
Area of Science:
- Ophthalmology
- Neonatology
- Medical Informatics
Background:
- Current screening for retinopathy of prematurity (ROP) has limited specificity for severe ROP.
- Telemedicine Approaches to Evaluating Acute-Phase Retinopathy of Prematurity (e-ROP) and Children's Hospital of Philadelphia Retinopathy of Prematurity (CHOP-ROP) models offer potential improvements in ROP screening efficiency.
Purpose of the Study:
- To evaluate a tiered approach to ROP screening (TARP) for identifying infants with severe ROP.
- To assess the synergistic use of telemedicine and a predictive model for ROP screening.
Main Methods:
- Post hoc analysis of cohorts from the e-ROP and G-ROP studies.
- Evaluation of four screening approaches: ROUTINE, CHOP-ROP, e-ROP IMAGING, and TARP.
- Comparison of sensitivity for type 1 ROP and reduction in imaging sessions, examinations, and total clinical encounters.
Main Results:
- All approaches achieved 100% sensitivity for detecting type 1 ROP.
- TARP resulted in the fewest patient encounters (734) compared to ROUTINE (877), CHOP-ROP (730), and e-ROP IMAGING (877).
- TARP involved 182 infants with 412 imaging sessions and 322 examinations.
Conclusions:
- The tiered approach to ROP screening (TARP) significantly reduced the number of examinations and imaging sessions.
- Combining a postnatal growth model with telemedicine in a tiered approach may decrease clinical ROP interventions more effectively than individual methods.
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 Measures:
The 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 Relevance:
The tiered approach to ROP screening was associated with a reduced number of examinations and imaging sessions compared with the other approaches. Applying a postnatal growth model and telemedicine system in a tiered approach may reduce the number of clinical ROP interventions more than either approach alone.
