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Original Investigation
January 05, 2017

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

Jaclyn Gurwin, MD1,2; Lauren A. Tomlinson, BS1; Graham E. Quinn, MD, MSCE1,2; et al Gui-shuang Ying, PhD2; Agnieshka Baumritter, MS1; Gil Binenbaum, MD, MSCE1,2; 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
Author Affiliations
  • 1Division of Ophthalmology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
  • 2Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia
JAMA Ophthalmol. Published online January 5, 2017. doi:10.1001/jamaophthalmol.2016.5203
Key Points

Question  Does a tiered approach to retinopathy of prematurity screening (TARP), combining a postnatal weight gain model with telemedicine fundus image grading, provide advantages compared with either approach alone?

Findings  In this post hoc analysis of 242 infants from the Telemedicine Approaches to Evaluating Acute-Phase Retinopathy of Prematurity (e-ROP) Study and the Postnatal Growth and Retinopathy of Prematurity (G-ROP) Study, all screening approaches had 100% sensitivity for severe retinopathy of prematurity. However, the tiered approach was associated with a reduction in the number of retinal imaging sessions and examinations.

Meaning  These results suggest that applying a postnatal growth model and telemedicine system in a synergistic tiered approach can reduce the number of clinical retinopathy of prematurity interventions more than either approach alone.

Abstract

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.

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