1
|
Aravindhan A, Fenwick EK, Chan AWD, Man REK, Tan NC, Wong WT, Soo WF, Lim SW, Wee SYM, Sabanayagam C, Finkelstein E, Tan G, Hamzah H, Chakraborty B, Acharyya S, Shyong TE, Scanlon P, Wong TY, Lamoureux EL. Extending the diabetic retinopathy screening intervals in Singapore: methodology and preliminary findings of a cohort study. BMC Public Health 2024; 24:786. [PMID: 38481239 PMCID: PMC10935797 DOI: 10.1186/s12889-024-18287-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 03/05/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND The Diabetic Retinopathy Extended Screening Study (DRESS) aims to develop and validate a new DR/diabetic macular edema (DME) risk stratification model in patients with Type 2 diabetes (DM) to identify low-risk groups who can be safely assigned to biennial or triennial screening intervals. We describe the study methodology, participants' baseline characteristics, and preliminary DR progression rates at the first annual follow-up. METHODS DRESS is a 3-year ongoing longitudinal study of patients with T2DM and no or mild non-proliferative DR (NPDR, non-referable) who underwent teleophthalmic screening under the Singapore integrated Diabetic Retinopathy Programme (SiDRP) at four SingHealth Polyclinics. Patients with referable DR/DME (> mild NPDR) or ungradable fundus images were excluded. Sociodemographic, lifestyle, medical and clinical information was obtained from medical records and interviewer-administered questionnaires at baseline. These data are extracted from medical records at 12, 24 and 36 months post-enrollment. Baseline descriptive characteristics stratified by DR severity at baseline and rates of progression to referable DR at 12-month follow-up were calculated. RESULTS Of 5,840 eligible patients, 78.3% (n = 4,570, median [interquartile range [IQR] age 61.0 [55-67] years; 54.7% male; 68.0% Chinese) completed the baseline assessment. At baseline, 97.4% and 2.6% had none and mild NPDR (worse eye), respectively. Most participants had hypertension (79.2%) and dyslipidemia (92.8%); and almost half were obese (43.4%, BMI ≥ 27.5 kg/m2). Participants without DR (vs mild DR) reported shorter DM duration, and had lower haemoglobin A1c, triglycerides and urine albumin/creatinine ratio (all p < 0.05). To date, we have extracted 41.8% (n = 1909) of the 12-month follow-up data. Of these, 99.7% (n = 1,904) did not progress to referable DR. Those who progressed to referable DR status (0.3%) had no DR at baseline. CONCLUSIONS In our prospective study of patients with T2DM and non-referable DR attending polyclinics, we found extremely low annual DR progression rates. These preliminary results suggest that extending screening intervals beyond 12 months may be viable and safe for most participants, although our 3-year follow up data are needed to substantiate this claim and develop the risk stratification model to identify low-risk patients with T2DM who can be assigned biennial or triennial screening intervals.
Collapse
Affiliation(s)
- Amudha Aravindhan
- Singapore Eye Research Institute and Singapore National Eye Centre, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Eva K Fenwick
- Singapore Eye Research Institute and Singapore National Eye Centre, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Aurora Wing Dan Chan
- Singapore Eye Research Institute and Singapore National Eye Centre, Singapore, Singapore
| | - Ryan Eyn Kidd Man
- Singapore Eye Research Institute and Singapore National Eye Centre, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | | | | | | | | | | | - Charumathi Sabanayagam
- Singapore Eye Research Institute and Singapore National Eye Centre, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | | | - Gavin Tan
- Singapore Eye Research Institute and Singapore National Eye Centre, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Haslina Hamzah
- Singapore Eye Research Institute and Singapore National Eye Centre, Singapore, Singapore
| | | | | | - Tai E Shyong
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Peter Scanlon
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | | | - Ecosse L Lamoureux
- Singapore Eye Research Institute and Singapore National Eye Centre, Singapore, Singapore.
- Duke-NUS Medical School, Singapore, Singapore.
- The University of Melbourne, Melbourne, Australia.
| |
Collapse
|
2
|
Brennan IG, Kelly SR, McBride E, Garrahy D, Acheson R, Harmon J, McMahon S, Keegan DJ, Kavanagh H, O’Toole L. Addressing Technical Failures in a Diabetic Retinopathy Screening Program. Clin Ophthalmol 2024; 18:431-440. [PMID: 38356695 PMCID: PMC10864767 DOI: 10.2147/opth.s442414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 01/18/2024] [Indexed: 02/16/2024] Open
Abstract
Purpose Diabetic retinopathy (DR) is a preventable cause of blindness detectable through screening using retinal digital photography. The Irish National Diabetic Retina Screening (DRS) programme, Diabetic RetinaScreen, provides free screening services to patients with diabetes from aged 12 years and older. A technical failure (TF) occurs when digital retinal imaging is ungradable, resulting in delays in the diagnosis and treatment of sight-threatening disease. Despite their impact, the causes of TFs, and indeed the utility of interventions to prevent them, have not been extensively examined. Aim Primary analysis aimed to identify factors associated with TF. Secondary analysis examined a subset of cases, assessing patient data from five time points between 2019 and 2021 to identify photographer/patient factors associated with TF. Methods Patient data from the DRS database for one provider were extracted for analysis between 2018 and 2022. Information on patient demographics, screening results, and other factors previously associated with TF were analyzed. Primary analysis involved using mixed-effects logistic regression models with nested patient-eye random effects. Secondary analysis reviewed a subset of cases in detail, checking for causes of TF. Results The primary analysis included a total of 366,528 appointments from 104,407 patients over 5 years. Most patients had Type 2 diabetes (89.2%), and the overall TF rate was 4.9%. Diabetes type and duration, dilate pupil status, and the presence of lens artefacts on the camera were significantly associated with TF. The Secondary analysis identified the primary cause of TF was found to be optically dense cataracts, accounting for over half of the TFs. Conclusion This study provides insight into the causes of TF within the Irish DRS program, highlighting cataracts as the primary contributing factor. The identification of patient-level factors associated with TF facilitates appropriate interventions that can be put in place to improve patient outcomes and minimize delays in treatment and diagnosis.
Collapse
Affiliation(s)
- Ian Gerard Brennan
- Diabetic RetinaScreen, National Screening Service, Health Service Executive, Dublin, Ireland
| | - Stephen R Kelly
- Diabetic RetinaScreen, National Screening Service, Health Service Executive, Dublin, Ireland
| | - Edel McBride
- Diabetic Retinal Screening Service, NEC Care, Cork City, Co. Cork, Ireland
| | - Darragh Garrahy
- Diabetic RetinaScreen, National Screening Service, Health Service Executive, Dublin, Ireland
| | - Robert Acheson
- Diabetic Retinal Screening Service, NEC Care, Cork City, Co. Cork, Ireland
| | - Joanne Harmon
- Diabetic Retinal Screening Service, NEC Care, Cork City, Co. Cork, Ireland
| | - Shane McMahon
- Diabetic Retinal Screening Service, NEC Care, Cork City, Co. Cork, Ireland
| | - David J Keegan
- Diabetic RetinaScreen, National Screening Service, Health Service Executive, Dublin, Ireland
| | - Helen Kavanagh
- Diabetic RetinaScreen, National Screening Service, Health Service Executive, Dublin, Ireland
| | - Louise O’Toole
- Diabetic Retinal Screening Service, NEC Care, Cork City, Co. Cork, Ireland
| |
Collapse
|
3
|
Brodie J, Misra A, Jones CD, Jenkins C, Bachmann MO. Is diabetic retinopathy screening worthwhile among people first diagnosed with diabetes at older ages? A cohort study of Norfolk diabetic retinopathy screening programme. Diabet Med 2024; 41:e15164. [PMID: 37303287 DOI: 10.1111/dme.15164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 05/23/2023] [Accepted: 05/31/2023] [Indexed: 06/13/2023]
Abstract
AIMS England's Diabetic Eye Disease Screening Programme offers screening to every resident over age 12 with diabetes, starting as soon as possible after diagnosis and repeated annually. People first diagnosed with diabetes at older ages have shorter life expectancy and therefore may be less likely to benefit from screening and treatment. To inform decisions about whether diabetic eye screening policy should be stratified by age, we investigated the probability of receiving treatment according to age at first screening episode. METHODS This was a cohort study of participants in the Norfolk Diabetic Retinopathy Screening Programme from 2006 to 2017, with individuals' programme data linked to hospital treatment and death data recorded up to 2021. We estimated and compared the probability, annual incidence and screening costs of receiving retinal laser photocoagulation or intravitreal injection and of death, in age groups defined by age at first screening episode. RESULTS The probability of death increased with increasing age at diagnosis, while the probability of receiving either treatment decreased with increasing age. The estimated cost of screening per person who received either or both treatments was £18,608 among all participants, increasing with age up to £21,721 in those aged 70-79 and £26,214 in those aged 80-89. CONCLUSIONS Diabetic retinopathy screening is less effective and less cost-effective with increasing age at diagnosis of diabetes, because of the increasing probability of death before participants develop sight-threatening diabetic retinopathy and can benefit from treatment. Upper age limits on entry into screening programmes or risk stratification in older age groups may, therefore, be justifiable.
Collapse
Affiliation(s)
- James Brodie
- Department of Ophthalmology, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
| | - Aseema Misra
- Department of Ophthalmology, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
| | - Colin D Jones
- Department of Ophthalmology, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
| | - Christel Jenkins
- Department of Ophthalmology, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
| | - Max O Bachmann
- Norwich Medical School, University of East Anglia, Norwich, UK
| |
Collapse
|
4
|
Clarke K, Webster L, Althauser S, Anderson J, Stratton I, Brackenridge A, Mann SS. The risk of development and progression of diabetic retinopathy in a group of ethnically diverse pregnant women with diabetes attending three regional Diabetic Eye Screening Programs in the UK. Eye (Lond) 2024; 38:179-184. [PMID: 37419960 PMCID: PMC10764873 DOI: 10.1038/s41433-023-02655-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND/OBJECTIVES Currently, all pregnant women with diabetes are asked to attend screening at least twice during pregnancy, even if no retinopathy is detected in early pregnancy. We hypothesise that for women with no diabetic retinopathy in early pregnancy, the frequency of retinal screening may be safely reduced. SUBJECTS/METHODS In this retrospective cohort study, data for 4718 pregnant women attending one of three UK Diabetic Eye Screening (DES) Programmes between July 2011 and October 2019 was extracted. The women's UK DES grades at 13 weeks gestation (early pregnancy) and 28 weeks gestation (late pregnancy) were recorded. Descriptive statistics were used to report baseline data. Ordered logistic regression was used to control for covariates, such as age, ethnicity, diabetes duration, and diabetes type. RESULTS Of the women with grades recorded for both early and late pregnancy, a total of 3085 (65.39%) women had no retinopathy in early pregnancy, and 2306 (74.7%) of these women did not develop any retinopathy by 28 weeks. The number of women without retinopathy in early pregnancy who developed referable retinopathy was 14 (0.45%), none of whom required treatment. Diabetic Retinopathy in early pregnancy remained a significant predictor of DES grade in late pregnancy when covariates of Age, Ethnicity, and Diabetes Type were controlled for (P < 0.001). CONCLUSIONS In summary, this study has demonstrated that the burden of managing diabetes for pregnant mothers may be safely reduced by limiting the number of diabetic eye screening appointments in women who have no retinal changes in early pregnancy. Screening of women with retinopathy in early pregnancy should continue in line with current UK guidance.
Collapse
Affiliation(s)
- Kirsty Clarke
- Guy's and St Thomas' Hospital NHS Trust, London, England.
- Imperial College London, London, England.
| | - Laura Webster
- South East London Diabetic Eye Screening Programme, London, England
| | - Susanne Althauser
- North Central London Diabetic Eye Screening Programme, London, England
| | - John Anderson
- North East London Diabetic Eye Screening Service, Ilford, England
| | - Irene Stratton
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, England
| | | | - Samantha S Mann
- Guy's and St Thomas' Hospital NHS Trust, London, England
- South East London Diabetic Eye Screening Programme, London, England
| |
Collapse
|
5
|
Blonde L, Umpierrez GE, Reddy SS, McGill JB, Berga SL, Bush M, Chandrasekaran S, DeFronzo RA, Einhorn D, Galindo RJ, Gardner TW, Garg R, Garvey WT, Hirsch IB, Hurley DL, Izuora K, Kosiborod M, Olson D, Patel SB, Pop-Busui R, Sadhu AR, Samson SL, Stec C, Tamborlane WV, Tuttle KR, Twining C, Vella A, Vellanki P, Weber SL. American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update. Endocr Pract 2022; 28:923-1049. [PMID: 35963508 PMCID: PMC10200071 DOI: 10.1016/j.eprac.2022.08.002] [Citation(s) in RCA: 132] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers. METHODS The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development. RESULTS This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes. CONCLUSIONS This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.
Collapse
Affiliation(s)
| | | | - S Sethu Reddy
- Central Michigan University, Mount Pleasant, Michigan
| | | | | | | | | | | | - Daniel Einhorn
- Scripps Whittier Diabetes Institute, La Jolla, California
| | | | | | - Rajesh Garg
- Lundquist Institute/Harbor-UCLA Medical Center, Torrance, California
| | | | | | | | | | | | - Darin Olson
- Colorado Mountain Medical, LLC, Avon, Colorado
| | | | | | - Archana R Sadhu
- Houston Methodist; Weill Cornell Medicine; Texas A&M College of Medicine; Houston, Texas
| | | | - Carla Stec
- American Association of Clinical Endocrinology, Jacksonville, Florida
| | | | - Katherine R Tuttle
- University of Washington and Providence Health Care, Seattle and Spokane, Washington
| | | | | | | | - Sandra L Weber
- University of South Carolina School of Medicine-Greenville, Prisma Health System, Greenville, South Carolina
| |
Collapse
|
6
|
Grauslund J. Diabetic retinopathy screening in the emerging era of artificial intelligence. Diabetologia 2022; 65:1415-1423. [PMID: 35639120 DOI: 10.1007/s00125-022-05727-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/05/2022] [Indexed: 12/29/2022]
Abstract
Diabetic retinopathy is a frequent complication in diabetes and a leading cause of visual impairment. Regular eye screening is imperative to detect sight-threatening stages of diabetic retinopathy such as proliferative diabetic retinopathy and diabetic macular oedema in order to treat these before irreversible visual loss occurs. Screening is cost-effective and has been implemented in various countries in Europe and elsewhere. Along with optimised diabetes care, this has substantially reduced the risk of visual loss. Nevertheless, the growing number of patients with diabetes poses an increasing burden on healthcare systems and automated solutions are needed to alleviate the task of screening and improve diagnostic accuracy. Deep learning by convolutional neural networks is an optimised branch of artificial intelligence that is particularly well suited to automated image analysis. Pivotal studies have demonstrated high sensitivity and specificity for classifying advanced stages of diabetic retinopathy and identifying diabetic macular oedema in optical coherence tomography scans. Based on this, different algorithms have obtained regulatory approval for clinical use and have recently been implemented to some extent in a few countries. Handheld mobile devices are another promising option for self-monitoring, but so far they have not demonstrated comparable image quality to that of fundus photography using non-portable retinal cameras, which is the gold standard for diabetic retinopathy screening. Such technology has the potential to be integrated in telemedicine-based screening programmes, enabling self-captured retinal images to be transferred virtually to reading centres for analysis and planning of further steps. While emerging technologies have shown a lot of promise, clinical implementation has been sparse. Legal obstacles and difficulties in software integration may partly explain this, but it may also indicate that existing algorithms may not necessarily integrate well with national screening initiatives, which often differ substantially between countries.
Collapse
Affiliation(s)
- Jakob Grauslund
- Department of Ophthalmology, Odense University Hospital, Odense, Denmark.
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark.
- Vestfold Hospital Trust, Tønsberg, Norway.
| |
Collapse
|
7
|
Fernandes AG, Ferraz AN, Brant R, Malerbi FK. Diabetic retinopathy screening and treatment through the Brazilian National Health Insurance. Sci Rep 2022; 12:13941. [PMID: 35977971 PMCID: PMC9385734 DOI: 10.1038/s41598-022-18054-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 08/04/2022] [Indexed: 11/09/2022] Open
Abstract
The current study aimed to investigate diabetic retinopathy (DR) screening and treatment coverages among diabetic patients evaluated through the Brazilian National Health Insurance from 2014 to 2019. The Brazilian Public Health System Information Database was used as the primary data source. DR screening coverage was calculated as the rate of procedures of clinical dilated fundus exam and color fundus photograph over the number of diabetic patients. DR treatment coverage was calculated as the rate of procedures of intravitreal injection, photocoagulation, and panretinal photocoagulation over the number of diabetic patients presumably in need of DR treatment. The overall screening coverage increased from 12.1% in 2014 to 21.2% in 2019 (p < 0.001) with substantial regional discrepancies so that North region was the only one with no changes along the period. The overall treatment coverage increased from 27.7% in 2014 to 44.1% in 2019, with Southeast and Midwest absorbing the demand for service from the North, Northeast and South. Despite an improvement along the past years, both screening and treatment coverages for DR in diabetes patients are ineffective in Brazil. Public health policies should address resources disparities throughout the country aiming to offer same healthcare conditions to patients regardless their geographic location.
Collapse
Affiliation(s)
- Arthur Gustavo Fernandes
- Department of Ophthalmology and Visual Sciences, Paulista Medical School, Federal University of Sao Paulo, Rua Botucatu, 816, São Paulo, SP, 04023-062, Brazil. .,Department of Anthropology and Archaeology, University of Calgary, Calgary, AB, Canada.
| | - Aline Nunes Ferraz
- Department of Ophthalmology and Visual Sciences, Paulista Medical School, Federal University of Sao Paulo, Rua Botucatu, 816, São Paulo, SP, 04023-062, Brazil
| | - Rodrigo Brant
- Department of Ophthalmology and Visual Sciences, Paulista Medical School, Federal University of Sao Paulo, Rua Botucatu, 816, São Paulo, SP, 04023-062, Brazil
| | - Fernando Korn Malerbi
- Department of Ophthalmology and Visual Sciences, Paulista Medical School, Federal University of Sao Paulo, Rua Botucatu, 816, São Paulo, SP, 04023-062, Brazil
| |
Collapse
|
8
|
Zafar S, Mahjoub H, Mehta N, Domalpally A, Channa R. Artificial Intelligence Algorithms in Diabetic Retinopathy Screening. Curr Diab Rep 2022; 22:267-274. [PMID: 35438458 DOI: 10.1007/s11892-022-01467-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW In this review, we focus on artificial intelligence (AI) algorithms for diabetic retinopathy (DR) screening and risk stratification and factors to consider when implementing AI algorithms in the clinic. RECENT FINDINGS AI algorithms have been adopted, and have received regulatory approval, for automated detection of referable DR with clinically acceptable diagnostic performance. While these metrics are an important first step, performance metrics that go beyond measures of technical accuracy are needed to fully evaluate the impact of AI algorithm on patient outcomes. Recent advances in AI present an exciting opportunity to improve patient care. Using DR as an example, we have reviewed factors to consider in the implementation of AI algorithms in real-world clinical practice. These include real-world evaluation of safety, efficacy, and equity (bias); impact on patient outcomes; ethical, logistical, and regulatory factors.
Collapse
Affiliation(s)
- Sidra Zafar
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Heba Mahjoub
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Nitish Mehta
- Department of Ophthalmology, New York University School of Medicine, New York, NY, USA
| | - Amitha Domalpally
- Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, WI, USA
| | - Roomasa Channa
- Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, WI, USA.
| |
Collapse
|
9
|
Ikesu R, Taguchi A, Hara K, Kawana K, Tsuruga T, Tomio J, Osuga Y. Prognosis of high-risk human papillomavirus-related cervical lesions: A hidden Markov model analysis of a single-center cohort in Japan. Cancer Med 2021; 11:664-675. [PMID: 34921517 PMCID: PMC8817087 DOI: 10.1002/cam4.4470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 10/14/2021] [Accepted: 11/16/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction Previous studies have shown that individuals with human papillomavirus (HPV)‐related cervical lesions have different prognoses according to the HPV genotype. However, these studies failed to account for possible diagnostic misclassification. In this retrospective cohort study, we aimed to clarify the natural course of cervical lesions according to HPV genotype to account for any diagnostic misclassification. Materials and Methods Our cohort included 729 patients classified as having cervical intraepithelial neoplasia (CIN). HPV was genotyped in all patients, who were followed up or treated for cervical lesions at the University of Tokyo Hospital from October 1, 2008 to March 31, 2015. Hidden Markov models were applied to estimate the diagnostic misclassification probabilities of the current diagnostic practice (histology and cytology) and the transitions between true states. We then simulated two‐year transition probabilities between true cervical states according to HPV genotype. Results Compared with lesions in patients with other HPV genotypes, lesions in HPV 16‐positive patients were estimated to be more likely to increase in severity (i.e., CIN3/cancer); over 2 years, 17.7% (95% confidence interval [CI], 9.3%–29.3%) and 27.8% (95% CI, 16.6%–43.5%) of those with HPV 16 progressed to CIN3/cancer from the true states of CIN1 and CIN2, respectively, whereas 55%–70% of CIN1/2 patients infected with HPV 52/58 remained in the CIN1/2 category. Misclassification was estimated to occur at a rate of 3%–38% in the current diagnostic practice. Conclusion This study contributes robust evidence to current literature on cervical lesion prognosis according to HPV genotype and quantifies the diagnostic misclassification of true cervical lesions.
Collapse
Affiliation(s)
- Ryo Ikesu
- Department of Public Health, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Ayumi Taguchi
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Konan Hara
- Department of Public Health, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan.,Department of Economics, University of Arizona, Tucson, Arizona, USA.,Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Kei Kawana
- Department of Obstetrics and Gynecology, School of Medicine, Nihon University, Itabashi-ku, Tokyo, Japan
| | - Tetsushi Tsuruga
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Jun Tomio
- Department of Public Health, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Yutaka Osuga
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| |
Collapse
|
10
|
Yang C, Liu Q, Guo H, Zhang M, Zhang L, Zhang G, Zeng J, Huang Z, Meng Q, Cui Y. Usefulness of Machine Learning for Identification of Referable Diabetic Retinopathy in a Large-Scale Population-Based Study. Front Med (Lausanne) 2021; 8:773881. [PMID: 34977075 PMCID: PMC8717406 DOI: 10.3389/fmed.2021.773881] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/11/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: To development and validation of machine learning-based classifiers based on simple non-ocular metrics for detecting referable diabetic retinopathy (RDR) in a large-scale Chinese population–based survey.Methods: The 1,418 patients with diabetes mellitus from 8,952 rural residents screened in the population-based Dongguan Eye Study were used for model development and validation. Eight algorithms [extreme gradient boosting (XGBoost), random forest, naïve Bayes, k-nearest neighbor (KNN), AdaBoost, Light GBM, artificial neural network (ANN), and logistic regression] were used for modeling to detect RDR in individuals with diabetes. The area under the receiver operating characteristic curve (AUC) and their 95% confidential interval (95% CI) were estimated using five-fold cross-validation as well as an 80:20 ratio of training and validation.Results: The 10 most important features in machine learning models were duration of diabetes, HbA1c, systolic blood pressure, triglyceride, body mass index, serum creatine, age, educational level, duration of hypertension, and income level. Based on these top 10 variables, the XGBoost model achieved the best discriminative performance, with an AUC of 0.816 (95%CI: 0.812, 0.820). The AUCs for logistic regression, AdaBoost, naïve Bayes, and Random forest were 0.766 (95%CI: 0.756, 0.776), 0.754 (95%CI: 0.744, 0.764), 0.753 (95%CI: 0.743, 0.763), and 0.705 (95%CI: 0.697, 0.713), respectively.Conclusions: A machine learning–based classifier that used 10 easily obtained non-ocular variables was able to effectively detect RDR patients. The importance scores of the variables provide insight to prevent the occurrence of RDR. Screening RDR with machine learning provides a useful complementary tool for clinical practice in resource-poor areas with limited ophthalmic infrastructure.
Collapse
Affiliation(s)
- Cheng Yang
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Eye Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Qingyang Liu
- Department of Ophthalmology, Dongguan People's Hospital, Dongguan, China
| | - Haike Guo
- Shanghai Peace Eye Hospital, Shanghai, China
- Xiamen Eye Center, Xiamen University, Xiamen, China
| | - Min Zhang
- Department of Ophthalmology, Dongguan People's Hospital, Dongguan, China
| | - Lixin Zhang
- Department of Ophthalmology, Hengli Hospital, Dongguan, China
| | - Guanrong Zhang
- Information and Statistical Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jin Zeng
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Eye Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zhongning Huang
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Eye Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Qianli Meng
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Eye Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
- *Correspondence: Qianli Meng
| | - Ying Cui
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Eye Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
- Ying Cui
| |
Collapse
|
11
|
Cheyne CP, Burgess PI, Broadbent DM, García-Fiñana M, Stratton IM, Criddle T, Wang A, Alshukri A, Rahni MM, Vazquez-Arango P, Vora JP, Harding SP. Incidence of sight-threatening diabetic retinopathy in an established urban screening programme: An 11-year cohort study. Diabet Med 2021; 38:e14583. [PMID: 33830513 DOI: 10.1111/dme.14583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 03/10/2021] [Accepted: 03/22/2021] [Indexed: 12/22/2022]
Abstract
AIMS Systematic annual screening to detect sight-threatening diabetic retinopathy (STDR) is established in the United Kingdom. We designed an observational cohort study to provide up-to-date data for policy makers and clinical researchers on incidence of key screening endpoints in people with diabetes attending one screening programme running for over 30 years. METHODS All people with diabetes aged ≥12 years registered with general practices in the Liverpool health district were offered inclusion. Data sources comprised: primary care (demographics, systemic risk factors), Liverpool Diabetes Eye Screening Programme (retinopathy grading), Hospital Eye Services (slit lamp biomicroscopy assessment of screen positives). RESULTS 133,366 screening episodes occurred in 28,384 people over 11 years. Overall incidences were: screen positive 6.7% (95% CI 6.5-6.8), screen positive for retinopathy 3.1% (3.0-3.1), unassessable images 2.6% (2.5-2.7), other significant eye diseases 1.0% (1.0-1.1). 1.6% (1.6-1.7) had sight-threatening retinopathy confirmed by slit lamp biomicroscopy. The annual incidence of screen positive and screen positive for retinopathy showed consistent declines from 8.8%-10.6% and 4.4%-4.6% in 2007/09 to 4.4%-6.8% and 2.3%-2.9% in 2013/17, respectively. Rates of STDR (true positive) were consistently below 2% after 2008/09. Screen positive rates were higher in first time attenders (9.9% [9.4-10.2] vs. 6.1% [6.0-6.2]) in part due to ungradeable images (4.1% vs. 2.3%) and other eye disease (2.4% vs. 0.8%). 4.5% (3.9-5.2) of previous non-attenders had sight-threatening retinopathy. Compared with people with type 2 diabetes, those with type 1 disease demonstrated higher rates of screen positive (11.9% vs. 6.0%) and STDR (6.4% vs. 1.2%). Overall prevalence of any retinopathy was 27.2% (27.0-27.4). CONCLUSIONS In an established screening programme with a stable population screen, positive rates show a consistent fall over time to a low level. Of those who are screen positive, fewer than 50% are screen positive for diabetic retinopathy. Most are due to sight threatening maculopathy. The annual incidence of STDR is under 2% suggesting future work on redefining screen positive and supporting extended intervals for people at low risk. Higher rates of screen positive and STDR are seen in first time attenders. Those who have never attended for screening should be specifically targeted.
Collapse
Affiliation(s)
- Christopher P Cheyne
- Department of Health Data Science, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
| | - Philip I Burgess
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
- St Paul's Eye Unit, Liverpool University Hospitals NHS Foundation Trust, Member of Liverpool Health Partners, Liverpool, UK
| | - Deborah M Broadbent
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
- St Paul's Eye Unit, Liverpool University Hospitals NHS Foundation Trust, Member of Liverpool Health Partners, Liverpool, UK
| | - Marta García-Fiñana
- Department of Health Data Science, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
| | - Irene M Stratton
- Gloucestershire Retinal Research Group, Cheltenham General Hospital, Cheltenham, UK
| | - Ticiana Criddle
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
| | - Amu Wang
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
| | - Ayesh Alshukri
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
| | - Mehrdad M Rahni
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
| | - Pilar Vazquez-Arango
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
| | - Jiten P Vora
- Department of Diabetes and Endocrinology, Royal Liverpool University Hospital, Liverpool, UK
| | - Simon P Harding
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
- St Paul's Eye Unit, Liverpool University Hospitals NHS Foundation Trust, Member of Liverpool Health Partners, Liverpool, UK
| |
Collapse
|
12
|
Byberg S, Vistisen D, Jørgensen ME, Diaz LJ, Valerius M, Hajari JN, Lund‐Andersen H. Quality assessment of a screening algorithm for diabetic retinopathy: prolongation of screening intervals with minimal effect of HbA 1c and arterial hypertension on the length of intervals. Acta Ophthalmol 2021; 99:e360-e367. [PMID: 32930495 DOI: 10.1111/aos.14590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 07/13/2020] [Accepted: 07/21/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE At Steno Diabetes Center Copenhagen (SDCC), diabetic retinopathy (DR) screening intervals are based on quantification of retinal lesions. Screening intervals are, for the milder forms of DR, prolonged to 2-3 years. The purpose of the present study was to evaluate the effect of the prolongation on developing unexpected events and to evaluate the effect of HbA1c and arterial hypertension. METHODS We assessed 18 972 screening intervals from 6000 patients from 1/1-2003 to 1/5-2017 for occurrence of unexpected events, defined as: (1) DR progression requiring treatment, at the following screening date, and (2) DR-related hospital contact within the planned interval. We modelled the effect of several risk factors for developing unexpected events in a Cox regression. Furthermore, we assessed the risk of unexpected events in a logistic regression analysis using cubic splines to model the effect of HbA1c , stratified by arterial hypertension status. RESULTS 16 283 (86%) intervals followed the planned interval and among those, only 86 (0.5%) experienced unexpected events. Intervals of dysregulated patients (86% of all intervals) did not experience more unexpected events, compared with well-regulated patient intervals (Hazard Ratio: 1.12, 95% CI: 0.55-2.27). We found a nonlinear effect of HbA1c on the risk of unexpected events which peaked around HbA1c levels of 80 mmol/mol. Having arterial hypertension slightly increased the risk of unexpected events. CONCLUSIONS The present study supports the validity of the current algorithm. We found no increased risk of unexpected events among dysregulated intervals but a nonlinear effect of HbA1c . Age, diabetes duration and diabetes type were significantly associated with unexpected events.
Collapse
Affiliation(s)
- Stine Byberg
- Steno Diabetes Center Copenhagen Gentofte Denmark
| | | | - Marit Eika Jørgensen
- Steno Diabetes Center Copenhagen Gentofte Denmark
- National Institute of Public Health University of Southern Denmark Copenhagen Denmark
| | | | - Marianne Valerius
- Steno Diabetes Center Copenhagen Gentofte Denmark
- University Hospital Glostrup Glostrup Denmark
| | - Javad Nouri Hajari
- Steno Diabetes Center Copenhagen Gentofte Denmark
- University Hospital Glostrup Glostrup Denmark
| | - Henrik Lund‐Andersen
- Steno Diabetes Center Copenhagen Gentofte Denmark
- University Hospital Glostrup Glostrup Denmark
| |
Collapse
|
13
|
Broadbent DM, Wang A, Cheyne CP, James M, Lathe J, Stratton IM, Roberts J, Moitt T, Vora JP, Gabbay M, García-Fiñana M, Harding SP. Safety and cost-effectiveness of individualised screening for diabetic retinopathy: the ISDR open-label, equivalence RCT. Diabetologia 2021; 64:56-69. [PMID: 33146763 PMCID: PMC7716929 DOI: 10.1007/s00125-020-05313-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/08/2020] [Indexed: 12/12/2022]
Abstract
AIMS/HYPOTHESIS Using variable diabetic retinopathy screening intervals, informed by personal risk levels, offers improved engagement of people with diabetes and reallocation of resources to high-risk groups, while addressing the increasing prevalence of diabetes. However, safety data on extending screening intervals are minimal. The aim of this study was to evaluate the safety and cost-effectiveness of individualised, variable-interval, risk-based population screening compared with usual care, with wide-ranging input from individuals with diabetes. METHODS This was a two-arm, parallel-assignment, equivalence RCT (minimum 2 year follow-up) in individuals with diabetes aged 12 years or older registered with a single English screening programme. Participants were randomly allocated 1:1 at baseline to individualised screening at 6, 12 or 24 months for those at high, medium and low risk, respectively, as determined at each screening episode by a risk-calculation engine using local demographic, screening and clinical data, or to annual screening (control group). Screening staff and investigators were observer-masked to allocation and interval. Data were collected within the screening programme. The primary outcome was attendance (safety). A secondary safety outcome was the development of sight-threatening diabetic retinopathy. Cost-effectiveness was evaluated within a 2 year time horizon from National Health Service and societal perspectives. RESULTS A total of 4534 participants were randomised. After withdrawals, there were 2097 participants in the individualised screening arm and 2224 in the control arm. Attendance rates at first follow-up were equivalent between the two arms (individualised screening 83.6%; control arm 84.7%; difference -1.0 [95% CI -3.2, 1.2]), while sight-threatening diabetic retinopathy detection rates were non-inferior in the individualised screening arm (individualised screening 1.4%, control arm 1.7%; difference -0.3 [95% CI -1.1, 0.5]). Sensitivity analyses confirmed these findings. No important adverse events were observed. Mean differences in complete case quality-adjusted life-years (EuroQol Five-Dimension Questionnaire, Health Utilities Index Mark 3) did not significantly differ from zero; multiple imputation supported the dominance of individualised screening. Incremental cost savings per person with individualised screening were £17.34 (95% CI 17.02, 17.67) from the National Health Service perspective and £23.11 (95% CI 22.73, 23.53) from the societal perspective, representing a 21% reduction in overall programme costs. Overall, 43.2% fewer screening appointments were required in the individualised arm. CONCLUSIONS/INTERPRETATION Stakeholders involved in diabetes care can be reassured by this study, which is the largest ophthalmic RCT in diabetic retinopathy screening to date, that extended and individualised, variable-interval, risk-based screening is feasible and can be safely and cost-effectively introduced in established systematic programmes. Because of the 2 year time horizon of the trial and the long time frame of the disease, robust monitoring of attendance and retinopathy rates should be included in any future implementation. TRIAL REGISTRATION ISRCTN 87561257 FUNDING: The study was funded by the UK National Institute for Health Research. Graphical abstract.
Collapse
Affiliation(s)
- Deborah M Broadbent
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK.
- St Paul's Eye Unit, Liverpool University Hospitals Foundation Trust, Member of Liverpool Health Partners, Liverpool, UK.
| | - Amu Wang
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
- St Paul's Eye Unit, Liverpool University Hospitals Foundation Trust, Member of Liverpool Health Partners, Liverpool, UK
| | - Christopher P Cheyne
- Department of Biostatistics, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
- Clinical Trials Research Centre, Liverpool, UK
| | - Marilyn James
- Division of Rehabilitation, Ageing and Wellbeing, School of Medicine, University of Nottingham, Nottingham, UK
| | - James Lathe
- Division of Rehabilitation, Ageing and Wellbeing, School of Medicine, University of Nottingham, Nottingham, UK
| | - Irene M Stratton
- Gloucestershire Retinal Research Group, Cheltenham General Hospital, Cheltenham, UK
| | | | - Tracy Moitt
- Clinical Trials Research Centre, Liverpool, UK
| | - Jiten P Vora
- Department of Diabetes and Endocrinology, Royal Liverpool University Hospital, Liverpool, UK
| | - Mark Gabbay
- Department of Health Services Research, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
- Brownlow Health Centre, Member of Liverpool Health Partners, Liverpool, UK
| | - Marta García-Fiñana
- Department of Biostatistics, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
- Clinical Trials Research Centre, Liverpool, UK
| | - Simon P Harding
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
- St Paul's Eye Unit, Liverpool University Hospitals Foundation Trust, Member of Liverpool Health Partners, Liverpool, UK
| | | |
Collapse
|
14
|
Debele GR, Kanfe SG, Weldesenbet AB, Ayana GM, Jifar WW, Raru TB. Incidence of Diabetic Retinopathy and Its Predictors Among Newly Diagnosed Type 1 and Type 2 Diabetic Patients: A Retrospective Follow-up Study at Tertiary Health-care Setting of Ethiopia. Diabetes Metab Syndr Obes 2021; 14:1305-1313. [PMID: 33790598 PMCID: PMC7997545 DOI: 10.2147/dmso.s300373] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/09/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND With an increasing number of diabetes patients in developing countries, the burden of diabetes-related blindness is undoubtedly posing a massive challenge to the sustainable health care system due to the cost of care. Despite this fact, to date, most of the epidemiological research on diabetic retinopathy (DR) in eastern Africa, including Ethiopia, has been limited to survey studies. Thus, we determined the incidence of retinopathy and its predictors among diabetic patients in Jimma University Medical Center, Southwest Ethiopia. METHODS A retrospective follow-up study was conducted on 402 randomly selected diabetic patients of aged ≥15 years. A preliminary reviewed checklist was used to obtain information on the demographics, clinical and physiological attributes. Data were entered using EpiData version 4.6 and analyzed using Stata version 14. All variables at P-values less than 0.2 in bivariable analysis were exported to multivariable analysis. Multivariable accelerated failure time (AFT) regression analyses using Weibull distribution were used to examine the predictors of DR at a 5% level of significance. RESULTS Throughout a median follow-up period of 5.9 years, the cumulative incidence of DR was 20.15% (95%CI: 16.50-24.37) and the incidence rate was 36.9 per 1000 person years (PY) (95%CI: 29.7-45.9). Multivariable Weibull AFT regression analyses showed that type two diabetes mellitus (T2DM) (adjusted time ratio (ATR) 0.4095%CI: 0.20-0.78), hypertension (HTN) (ATR 0.54; 95%CI: [0.35, 0.82]), low high density lipoprotein cholesterol (HDL-C) (ATR 0.51; 95%CI: 0.36-0.73), and borderline high total cholesterol (TC) (ATR 0.63; 95%CI: 0.42-0.94) were a predictor of time to DR. CONCLUSION The overall incidence of DR among patients with diabetes mellitus was estimated to be 20.15% and is becoming a public health burden in Ethiopia. Our results indicate that T2DM, HTN, low HDL-C and borderline high TC independently predicts an increased incidence/decreased survival time of retinopathy among diabetes patients. The low HDL-C, HTN, and high TC are modifiable risk factors that should be managed along with diabetes.
Collapse
Affiliation(s)
- Gebiso Roba Debele
- Department of Public Health, College of Health Sciences, Mettu University, Mettu, Ethiopia
- Correspondence: Gebiso Roba Debele Tel +251922042777 Email
| | - Shuma Gosha Kanfe
- Department of Health Informatics, College of Health Sciences, Mettu University, Mettu, Ethiopia
| | - Adisu Birhanu Weldesenbet
- Department of Epidemiology and Biostatistics, Collage of Health and Medical Sciences, Haramaya University, Haramaya, Ethiopia
| | - Galana Mamo Ayana
- Department of Epidemiology and Biostatistics, Collage of Health and Medical Sciences, Haramaya University, Haramaya, Ethiopia
| | - Wakuma Wakene Jifar
- Department of Pharmacy, College of Health Sciences, Mettu University, Mettu, Ethiopia
| | - Temam Beshir Raru
- Department of Epidemiology and Biostatistics, Collage of Health and Medical Sciences, Haramaya University, Haramaya, Ethiopia
| |
Collapse
|
15
|
Kunst N, Alarid-Escudero F, Aas E, Coupé VMH, Schrag D, Kuntz KM. Estimating Population-Based Recurrence Rates of Colorectal Cancer over Time in the United States. Cancer Epidemiol Biomarkers Prev 2020; 29:2710-2718. [PMID: 32998946 PMCID: PMC7747688 DOI: 10.1158/1055-9965.epi-20-0490] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/01/2020] [Accepted: 09/26/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Population-based metastatic recurrence rates for patients diagnosed with nonmetastatic colorectal cancer cannot be estimated directly from population-based cancer registries because recurrence information is not reported. We derived population-based colorectal cancer recurrence rates using disease-specific survival data based on our understanding of the colorectal cancer recurrence-death process. METHODS We used a statistical continuous-time multistate survival model to derive population-based annual colorectal cancer recurrence rates from 6 months to 10 years after colorectal cancer diagnosis using relative survival data from the Surveillance, Epidemiology, and End Results Program. The model was based on the assumption that, after 6 months of diagnosis, all colorectal cancer-related deaths occur only in patients who experience a metastatic recurrence first, and that the annual colorectal cancer-specific death rate among patients with recurrence was the same as in those diagnosed with de novo metastatic disease. We allowed recurrence rates to vary by post-diagnosis time, age, stage, and location for two diagnostic time periods. RESULTS In patients diagnosed in 1975-1984, annual recurrence rates 6 months to 5 years after diagnosis ranged from 0.054 to 0.060 in stage II colon cancer, 0.094 to 0.105 in stage II rectal cancer, and 0.146 to 0.177 in stage III colorectal cancer, depending on age. We found a statistically significant decrease in colorectal cancer recurrence among patients diagnosed in 1994-2003 compared with those diagnosed in 1975-1984 for 6 months to 5 years after diagnosis (hazard ratios between 0.43 and 0.70). CONCLUSIONS We derived population-based annual recurrence rates for up to 10 years after diagnosis using relative survival data. IMPACT Our estimates can be used in decision-analytic models to facilitate analyses of colorectal cancer interventions that are more generalizable.
Collapse
Affiliation(s)
- Natalia Kunst
- Department of Health Management and Health Economics, Faculty of Medicine, University of Oslo, Oslo, Norway.
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale University School of Medicine and Yale Cancer Center, New Haven, Connecticut
- Department of Epidemiology and Data Science, Amsterdam University Medical Centers, Amsterdam, the Netherlands
- LINK Medical Research, Oslo, Norway
| | - Fernando Alarid-Escudero
- Division of Public Administration, Center for Research and Teaching in Economics (CIDE), Aguascalientes, Aguascalientes, Mexico
| | - Eline Aas
- Department of Health Management and Health Economics, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Veerle M H Coupé
- Department of Epidemiology and Data Science, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Deborah Schrag
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Karen M Kuntz
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota
| |
Collapse
|
16
|
Rudland VL, Price SAL, Hughes R, Barrett HL, Lagstrom J, Porter C, Britten FL, Glastras S, Fulcher I, Wein P, Simmons D, McIntyre HD, Callaway L. ADIPS 2020 guideline for pre-existing diabetes and pregnancy. Aust N Z J Obstet Gynaecol 2020; 60:E18-E52. [PMID: 33200400 DOI: 10.1111/ajo.13265] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 09/14/2020] [Indexed: 02/07/2023]
Abstract
This is the full version of the Australasian Diabetes in Pregnancy Society (ADIPS) 2020 guideline for pre-existing diabetes and pregnancy. The guideline encompasses the management of women with pre-existing type 1 diabetes and type 2 diabetes in relation to pregnancy, including preconception, antepartum, intrapartum and postpartum care. The management of women with monogenic diabetes or cystic fibrosis-related diabetes in relation to pregnancy is also discussed.
Collapse
Affiliation(s)
- Victoria L Rudland
- Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Sarah A L Price
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Diabetes, Royal Women's Hospital, Melbourne, Victoria, Australia.,Mercy Hospital for Women, Melbourne, Victoria, Australia.,Faculty of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Ruth Hughes
- Department of Obstetrics and Gynaecology, University of Otago, Christchurch, New Zealand
| | - Helen L Barrett
- Department of Endocrinology, Mater Health, Brisbane, Queensland, Australia.,Mater Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Janet Lagstrom
- Green St Specialists Wangaratta, Wangaratta, Victoria, Australia.,Denis Medical Yarrawonga, Yarrawonga, Victoria, Australia.,Corowa Medical Clinic, Corowa, New South Wales, Australia.,NCN Health, Numurkah, Victoria, Australia
| | - Cynthia Porter
- Geraldton Diabetes Clinic, Geraldton, Western Australia, Australia
| | - Fiona L Britten
- Department of Obstetric Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Mater Private Hospital and Mater Mother's Private Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Sarah Glastras
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Department of Diabetes, Endocrinology and Metabolism, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Ian Fulcher
- Liverpool Hospital, Sydney, New South Wales, Australia
| | - Peter Wein
- Mercy Hospital for Women, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - David Simmons
- Western Sydney University, Sydney, New South Wales, Australia.,Campbelltown Hospital, Sydney, New South Wales, Australia
| | - H David McIntyre
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Mater Health, Brisbane, Queensland, Australia
| | - Leonie Callaway
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Women's and Children's Services, Metro North Hospital and Health Service District, Brisbane, Queensland, Australia.,Women's and Newborn Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| |
Collapse
|
17
|
Emamipour S, van der Heijden AAWA, Nijpels G, Elders P, Beulens JWJ, Postma MJ, van Boven JFM, Feenstra TL. A personalised screening strategy for diabetic retinopathy: a cost-effectiveness perspective. Diabetologia 2020; 63:2452-2461. [PMID: 32734441 PMCID: PMC7527375 DOI: 10.1007/s00125-020-05239-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 06/10/2020] [Indexed: 01/06/2023]
Abstract
AIMS/HYPOTHESIS In this study we examined the cost-effectiveness of three different screening strategies for diabetic retinopathy: using a personalised adaptive model, annual screening (fixed intervals), and the current Dutch guideline (stratified based on previous retinopathy grade). METHODS For each individual, optimal diabetic retinopathy screening intervals were determined, using a validated risk prediction model. Observational data (1998-2017) from the Hoorn Diabetes Care System cohort of people with type 2 diabetes were used (n = 5514). The missing values of retinopathy grades were imputed using two scenarios of slow and fast sight-threatening retinopathy (STR) progression. By comparing the model-based screening intervals to observed time to develop STR, the number of delayed STR diagnoses was determined. Costs were calculated using the healthcare perspective and the societal perspective. Finally, outcomes and costs were compared for the different screening strategies. RESULTS For the fast STR progression scenario, personalised screening resulted in 11.6% more delayed STR diagnoses and €11.4 less costs per patient compared to annual screening from a healthcare perspective. The personalised screening model performed better in terms of timely diagnosis of STR (8.8% less delayed STR diagnosis) but it was slightly more expensive (€1.8 per patient from a healthcare perspective) than the Dutch guideline strategy. CONCLUSIONS/INTERPRETATION The personalised diabetic retinopathy screening model is more cost-effective than the Dutch guideline screening strategy. Although the personalised screening strategy was less effective, in terms of timely diagnosis of STR patients, than annual screening, the number of delayed STR diagnoses is low and the cost saving is considerable. With around one million people with type 2 diabetes in the Netherlands, implementing this personalised model could save €11.4 million per year compared with annual screening, at the cost of 658 delayed STR diagnoses with a maximum delayed time to diagnosis of 48 months.
Collapse
Affiliation(s)
- Sajad Emamipour
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, 9700 RB, Groningen, the Netherlands.
| | - Amber A W A van der Heijden
- Department of General Practice and Elderly Care Medicine, Amsterdam University Medical Center, location VU, Amsterdam, the Netherlands
| | - Giel Nijpels
- Department of General Practice and Elderly Care Medicine, Amsterdam University Medical Center, location VU, Amsterdam, the Netherlands
| | - Petra Elders
- Department of General Practice and Elderly Care Medicine, Amsterdam University Medical Center, location VU, Amsterdam, the Netherlands
| | - Joline W J Beulens
- Department of General Practice and Elderly Care Medicine, Amsterdam University Medical Center, location VU, Amsterdam, the Netherlands
| | - Maarten J Postma
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Faculty of Science and Engineering, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, the Netherlands
- Department of Economics, Econometrics & Finance, Faculty of Economics & Business, University of Groningen, Groningen, the Netherlands
| | - Job F M van Boven
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, 9700 RB, Groningen, the Netherlands
| | - Talitha L Feenstra
- Faculty of Science and Engineering, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, the Netherlands
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| |
Collapse
|
18
|
Rodriguez-Acuña R, Mayoral E, Aguilar-Diosdado M, Rave R, Oyarzabal B, Lama C, Carriazo A, Martinez-Brocca MA. Andalusian program for early detection of diabetic retinopathy: implementation and 15-year follow-up of a population-based screening program in Andalusia, Southern Spain. BMJ Open Diabetes Res Care 2020; 8:8/1/e001622. [PMID: 33020135 PMCID: PMC7536837 DOI: 10.1136/bmjdrc-2020-001622] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/13/2020] [Accepted: 07/23/2020] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Diabetic retinopathy (DR) is a preventable cause of vision loss and blindness worldwide. We aim at analyzing the impact of a population-based screening program of DR using retinal photography with remote reading in terms of population coverage, diagnosis of asymptomatic DR and impact on visual disability, in the region of Andalusia, Spain, in the period 2005-2019. RESEARCH DESIGN AND METHODS Descriptive study. Sociodemographic and clinical features included in the Andalusian program for early detection of diabetic retinopathy (APDR) were analyzed. Population coverage, annual incidence of DR, and DR severity gradation were analyzed. Estimated data on prevalence and incidence of legal blindness due to DR were included. RESULTS 407 762 patients with at least one successful DR examination during the study period were included. Most of the performed retinographies (784 584, 84.3%) were 'non-pathological.' Asymptomatic DR was detected in 52 748 (5.9%) retinographies, most of them (94.2%) being classified as 'mild to moderate non-proliferative DR.' DR was detected in 44 815 patients, while sight-threatening DR (STDR) in 6256 patients; cumulative incidence of DR was 11.0% and STDR was 1.5%, as DR and STDR was detected in 44 815 and 6256 patients, respectively. Annual incidence risk per patient recruitment year progressively decreased from 22.0% by January 2005 to 3.2% by June 2019. CONCLUSIONS Implementation of a long-term population-based screening program for early detection of DR is technically feasible and clinically viable. Thus, after 15 years of existence, the program has enabled the screening of the vast majority of the target population allowing the optimization of healthcare resources and the identification of asymptomatic DR.
Collapse
Affiliation(s)
| | - Eduardo Mayoral
- Comprehensive Healthcare Plan for Diabetes, Regional Ministry of Health and Families of Andalusia, Government of Andalusia, Seville, Spain
| | - Manuel Aguilar-Diosdado
- Endocrinology and Nutrition, Hospital Puerta del Mar, Cadiz, Spain
- Biomedical Research and Innovation Institute of Cadiz (INiBICA), Cadiz, Spain
| | - Reyes Rave
- Endocrinology and Nutrition, Virgen Macarena University Hospital, Seville, Spain
| | | | - Carmen Lama
- Regional Ministry of Health and Families of Andalusia, Government of Andalusia, Seville, Spain
| | - Ana Carriazo
- Regional Ministry of Health and Families of Andalusia, Government of Andalusia, Seville, Spain
| | - Maria Asuncion Martinez-Brocca
- Comprehensive Healthcare Plan for Diabetes, Regional Ministry of Health and Families of Andalusia, Government of Andalusia, Seville, Spain
- Endocrinology and Nutrition, Virgen Macarena University Hospital, Seville, Spain
| |
Collapse
|
19
|
Thomas RL, Winfield TG, Prettyjohns M, Dunstan FD, Cheung WY, Anderson PM, Peter R, Luzio SD, Owens DR. Cost-effectiveness of biennial screening for diabetes related retinopathy in people with type 1 and type 2 diabetes compared to annual screening. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2020; 21:993-1002. [PMID: 32385543 PMCID: PMC7423794 DOI: 10.1007/s10198-020-01191-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 04/21/2020] [Indexed: 05/05/2023]
Abstract
OBJECTIVE Examine the health and economic impact of extending screening intervals in people with Type 2 diabetes (T2DM) and Type 1 diabetes (T1DM) without diabetes-related retinopathy (DR). SETTING Diabetic Eye Screening Wales (DESW). STUDY DESIGN Retrospective observational study with cost-utility analysis (CUA) and Decremental Cost-Effectiveness Ratios (DCER) study. INTERVENTION Biennial screening versus usual care (annual screening). INPUTS Anonymised data from DESW were linked to primary care data for people with two prior screening events with no DR. Transition probabilities for progression to DR were estimated based on a subset of 26,812 and 1232 people with T2DM and T1DM, respectively. DCER above £20,000 per QALY was considered cost-effective. RESULTS The base case analysis DCER results of £71,243 and £23,446 per QALY for T2DM and T1DM respectively at a 3.5% discount rate and £56,822 and £14,221 respectively when discounted at 1.5%. Diabetes management represented by the mean HbA1c was 7.5% for those with T2DM and 8.7% for T1DM. SENSITIVITY ANALYSIS Extending screening to biennial based on HbA1c, being the strongest predictor of progression of DR, at three levels of HbA1c 6.5%, 8.0% and 9.5% lost one QALY saving the NHS £106,075; £58,653 and £31,626 respectively for T2DM and £94,696, £37,646 and £11,089 respectively for T1DM. In addition, extending screening to biennial based on the duration of diabetes > 6 years for T2DM per QALY lost, saving the NHS £54,106 and for 6-12 and > 12 years for T1DM saving £83,856, £23,446 and £13,340 respectively. CONCLUSIONS Base case and sensitivity analyses indicate biennial screening to be cost-effective for T2DM irrespective of HbA1c and duration of diabetes. However, the uncertainty around the DCER indicates that annual screening should be maintained for those with T1DM especially when the HbA1c exceeds 80 mmol/mol (9.5%) and duration of diabetes is greater than 12 years.
Collapse
Affiliation(s)
- Rebecca L Thomas
- Diabetes Research Unit Cymru, Swansea University Medical School, Singleton Park, Swansea, SA2 8PP, UK.
| | | | | | - Frank D Dunstan
- Institute of Primary Care and Public Health, Cardiff University, Heath Park, Cardiff, CF14 4XN, UK
| | - Wai-Yee Cheung
- Diabetes Research Unit Cymru, Swansea University Medical School, Singleton Park, Swansea, SA2 8PP, UK
| | - Philippa M Anderson
- Swansea Centre for Health Economics, College of Human and Health Sciences, Swansea University, Singleton Park, Swansea, SA2 8PP, UK
| | - Rajesh Peter
- Swansea Bay University Health Board, Neath Port Talbot Hospital, Baglan Way, Port Talbot, West Glamorgan, SA12 7BX, UK
| | - Stephen D Luzio
- Diabetes Research Unit Cymru, Swansea University Medical School, Singleton Park, Swansea, SA2 8PP, UK
| | - David R Owens
- Diabetes Research Unit Cymru, Swansea University Medical School, Singleton Park, Swansea, SA2 8PP, UK
| |
Collapse
|
20
|
Byrne P, Thetford C, Gabbay M, Clarke P, Doncaster E, Harding SP. Personalising screening of sight-threatening diabetic retinopathy - qualitative evidence to inform effective implementation. BMC Public Health 2020; 20:881. [PMID: 32513143 PMCID: PMC7278114 DOI: 10.1186/s12889-020-08974-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 05/24/2020] [Indexed: 12/29/2022] Open
Abstract
Background Internationally, systematic screening for sight-threatening diabetic retinopathy (STDR) usually includes annual recall. Researchers and policy-makers support extending screening intervals, citing evidence from observational studies with low incidence rates. However, there is little research around the acceptability to people with diabetes (PWD) and health care professionals (HCP) about changing eye screening intervals. Methods We conducted a qualitative study to explore issues surrounding acceptability and the barriers and enablers for changing from annual screening, using in-depth, semistructured interviews analysed using the constant comparative method. PWD were recruited from general practices and HCP from eye screening networks and related specialties in North West England using purposive sampling. Interviews were conducted prior to the commencement of and during a randomised controlled trial (RCT) comparing fixed annual with variable (6, 12 or 24 month) interval risk-based screening. Results Thirty PWD and 21 HCP participants were interviewed prior to and 30 PWD during the parallel RCT. The data suggests that a move to variable screening intervals was generally acceptable in principle, though highlighted significant concerns and challenges to successful implementation. The current annual interval was recognised as unsustainable against a backdrop of increasing diabetes prevalence. There were important caveats attached to acceptability and a need for clear safeguards around: the safety and reliability of calculating screening intervals, capturing all PWD, referral into screening of PWD with diabetic changes regardless of planned interval. For PWD the 6-month interval was perceived positively as medical reassurance, and the 12-month seen as usual treatment. Concerns were expressed by many HCP and PWD that a 2-year interval was too lengthy and was risky for detecting STDR. There were also concerns about a negative effect upon PWD care and increasing non-attendance rates. Amongst PWD, there was considerable conflation and misunderstanding about different eye-related appointments within the health care system. Conclusions Implementing variable-interval screening into clinical practice is generally acceptable to PWD and HCP with important caveats, and misconceptions must be addressed. Clear safeguards against increasing non-attendance, loss of diabetes control and alternative referral pathways are required. For risk calculation systems to be safe, reliable monitoring and clear communication is required.
Collapse
Affiliation(s)
- P Byrne
- Institute of Population Health, University of Liverpool, Liverpool, UK.
| | - C Thetford
- Faculty of Health and Wellbeing, University of Central Lancashire, Liverpool, UK
| | - M Gabbay
- Institute of Population Health, University of Liverpool, Liverpool, UK
| | - P Clarke
- Institute of Population Health, University of Liverpool, Liverpool, UK
| | - E Doncaster
- ISDR Public Involvement Group, University of Liverpool, Liverpool, UK
| | - S P Harding
- Eye and Vision Science, University of Liverpool and St. Paul's Eye Unit, Royal Liverpool University Hospital, Preston, UK
| | | |
Collapse
|
21
|
Vujosevic S, Aldington SJ, Silva P, Hernández C, Scanlon P, Peto T, Simó R. Screening for diabetic retinopathy: new perspectives and challenges. Lancet Diabetes Endocrinol 2020; 8:337-347. [PMID: 32113513 DOI: 10.1016/s2213-8587(19)30411-5] [Citation(s) in RCA: 226] [Impact Index Per Article: 56.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/18/2019] [Accepted: 11/18/2019] [Indexed: 12/15/2022]
Abstract
Although the prevalence of all stages of diabetic retinopathy has been declining since 1980 in populations with improved diabetes control, the crude prevalence of visual impairment and blindness caused by diabetic retinopathy worldwide increased between 1990 and 2015, largely because of the increasing prevalence of type 2 diabetes, particularly in low-income and middle-income countries. Screening for diabetic retinopathy is essential to detect referable cases that need timely full ophthalmic examination and treatment to avoid permanent visual loss. In the past few years, personalised screening intervals that take into account several risk factors have been proposed, with good cost-effectiveness ratios. However, resources for nationwide screening programmes are scarce in many countries. New technologies, such as scanning confocal ophthalmology with ultrawide field imaging and handheld mobile devices, teleophthalmology for remote grading, and artificial intelligence for automated detection and classification of diabetic retinopathy, are changing screening strategies and improving cost-effectiveness. Additionally, emerging evidence suggests that retinal imaging could be useful for identifying individuals at risk of cardiovascular disease or cognitive impairment, which could expand the role of diabetic retinopathy screening beyond the prevention of sight-threatening disease.
Collapse
Affiliation(s)
- Stela Vujosevic
- Eye Unit, University Hospital Maggiore della Carità, Novara, Italy
| | - Stephen J Aldington
- Department of Ophthalmology, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
| | - Paolo Silva
- Beetham Eye Institute, Joslin Diabetes Centre, Harvard Medical School, Boston, MA, USA; Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
| | - Cristina Hernández
- Diabetes and Metabolism Research Unit, Vall d'Hebron Research Institute, Barcelona, Spain; Department of Medicine and Endocrinology, Autonomous University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, Madrid, Spain
| | - Peter Scanlon
- Department of Ophthalmology, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
| | - Tunde Peto
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Rafael Simó
- Diabetes and Metabolism Research Unit, Vall d'Hebron Research Institute, Barcelona, Spain; Department of Medicine and Endocrinology, Autonomous University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, Madrid, Spain.
| |
Collapse
|
22
|
Limwattanayingyong J, Nganthavee V, Seresirikachorn K, Singalavanija T, Soonthornworasiri N, Ruamviboonsuk V, Rao C, Raman R, Grzybowski A, Schaekermann M, Peng LH, Webster DR, Semturs C, Krause J, Sayres R, Hersch F, Tiwari R, Liu Y, Ruamviboonsuk P. Longitudinal Screening for Diabetic Retinopathy in a Nationwide Screening Program: Comparing Deep Learning and Human Graders. J Diabetes Res 2020; 2020:8839376. [PMID: 33381600 PMCID: PMC7758133 DOI: 10.1155/2020/8839376] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/06/2020] [Accepted: 11/30/2020] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE To evaluate diabetic retinopathy (DR) screening via deep learning (DL) and trained human graders (HG) in a longitudinal cohort, as case spectrum shifts based on treatment referral and new-onset DR. METHODS We randomly selected patients with diabetes screened twice, two years apart within a nationwide screening program. The reference standard was established via adjudication by retina specialists. Each patient's color fundus photographs were graded, and a patient was considered as having sight-threatening DR (STDR) if the worse eye had severe nonproliferative DR, proliferative DR, or diabetic macular edema. We compared DR screening via two modalities: DL and HG. For each modality, we simulated treatment referral by excluding patients with detected STDR from the second screening using that modality. RESULTS There were 5,738 patients (12.3% STDR) in the first screening. DL and HG captured different numbers of STDR cases, and after simulated referral and excluding ungradable cases, 4,148 and 4,263 patients remained in the second screening, respectively. The STDR prevalence at the second screening was 5.1% and 6.8% for DL- and HG-based screening, respectively. Along with the prevalence decrease, the sensitivity for both modalities decreased from the first to the second screening (DL: from 95% to 90%, p = 0.008; HG: from 74% to 57%, p < 0.001). At both the first and second screenings, the rate of false negatives for the DL was a fifth that of HG (0.5-0.6% vs. 2.9-3.2%). CONCLUSION On 2-year longitudinal follow-up of a DR screening cohort, STDR prevalence decreased for both DL- and HG-based screening. Follow-up screenings in longitudinal DR screening can be more difficult and induce lower sensitivity for both DL and HG, though the false negative rate was substantially lower for DL. Our data may be useful for health-economics analyses of longitudinal screening settings.
Collapse
Affiliation(s)
- Jirawut Limwattanayingyong
- Department of Ophthalmology, College of Medicine, Rangsit University, Rajavithi Hospital, Bangkok, Thailand
| | - Variya Nganthavee
- Department of Ophthalmology, College of Medicine, Rangsit University, Rajavithi Hospital, Bangkok, Thailand
| | - Kasem Seresirikachorn
- Department of Ophthalmology, College of Medicine, Rangsit University, Rajavithi Hospital, Bangkok, Thailand
| | - Tassapol Singalavanija
- Department of Ophthalmology, Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand
| | | | - Varis Ruamviboonsuk
- Department of Biochemistry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Chetan Rao
- Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Rajiv Raman
- Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Andrzej Grzybowski
- Department of Ophthalmology, University of Warmia and Mazury, Olsztyn, Poland
- Institute for Research in Ophthalmology, Foundation for Ophthalmology Development, Poznan, Poland
| | | | | | | | | | | | | | | | - Richa Tiwari
- Work done at Google via Optimum Solutions Pte Ltd, Singapore
| | - Yun Liu
- Google Health, Palo Alto, CA, USA
| | - Paisan Ruamviboonsuk
- Department of Ophthalmology, College of Medicine, Rangsit University, Rajavithi Hospital, Bangkok, Thailand
| |
Collapse
|
23
|
Zarranz-Ventura J, Barraso M, Alé-Chilet A, Hernandez T, Oliva C, Gascón J, Sala-Puigdollers A, Figueras-Roca M, Vinagre I, Ortega E, Esmatjes E, Adan A. Evaluation of microvascular changes in the perifoveal vascular network using optical coherence tomography angiography (OCTA) in type I diabetes mellitus: a large scale prospective trial. BMC Med Imaging 2019; 19:91. [PMID: 31752726 PMCID: PMC6873669 DOI: 10.1186/s12880-019-0391-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 10/25/2019] [Indexed: 02/01/2023] Open
Abstract
Background Diabetic retinopathy (DR) is the leading cause of blindness in type 1 Diabetes Mellitus (DM) patients, as a consequence of impaired blood flow in the retina. Optical coherence tomography angiography (OCTA) is a newly developed, non-invasive, retinal imaging technique that permits adequate delineation of the perifoveal vascular network. It allows the detection of paramacular areas of capillary non perfusion and/or enlargement of the foveal avascular zone (FAZ), representing an excellent tool for assessment of DR. The relationship of these microvascular changes with systemic factors such as metabolic control or duration of the disease still needs to be elucidated. Methods Prospective, consecutive, large-scale OCTA study. A complete ocular examination including a comprehensive series of OCTA images of different scan sizes captured with 2 OCT devices (Cirrus HD-OCT, Carl Zeiss Meditec, Dublin, CA, USA, and Triton Deep Range Imaging OCT, Topcon Corp, Topcon, Japan) will be obtained as part of the yearly routine follow up visits in type 1 DM patients seen in the Diabetes Unit of the Endocrinology department which give written informed consent to participate in the project. The aim of this study is to investigate the relationship between OCTA-derived parameters and systemic factors, as metabolic control (Hb1Ac, lipid profile, cholesterol, etc), and other relevant clinical factors as demographics or duration of the disease. Discussion This study is directed to investigate the relationship between the status of the perifoveal vascular network and systemic markers of the disease, and in particular to study whether these changes reflect those occurring elsewhere in the body affected by diabetic microvascular disease, as the kidneys or the brain. If these relationships were demonstrated, early detection of these microvascular changes by OCTA could lead to modifications in the pharmacological management of type 1 diabetic patients, as a way to reduce the risk of future complications in both the eye and other organs. Trial registration ClinicalTrials.gov, trial number NCT03422965.
Collapse
Affiliation(s)
- Javier Zarranz-Ventura
- Institut Clínic d'Oftalmología (ICOF), Hospital Clinic de Barcelona, C/ Sabino Arana 1, 08028, Barcelona, Spain. .,Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
| | - Marina Barraso
- Institut Clínic d'Oftalmología (ICOF), Hospital Clinic de Barcelona, C/ Sabino Arana 1, 08028, Barcelona, Spain
| | - Anibal Alé-Chilet
- Institut Clínic d'Oftalmología (ICOF), Hospital Clinic de Barcelona, C/ Sabino Arana 1, 08028, Barcelona, Spain
| | - Teresa Hernandez
- Institut Clínic d'Oftalmología (ICOF), Hospital Clinic de Barcelona, C/ Sabino Arana 1, 08028, Barcelona, Spain
| | - Cristian Oliva
- Institut Clínic d'Oftalmología (ICOF), Hospital Clinic de Barcelona, C/ Sabino Arana 1, 08028, Barcelona, Spain
| | - Jesus Gascón
- Institut Clínic d'Oftalmología (ICOF), Hospital Clinic de Barcelona, C/ Sabino Arana 1, 08028, Barcelona, Spain
| | - Anna Sala-Puigdollers
- Institut Clínic d'Oftalmología (ICOF), Hospital Clinic de Barcelona, C/ Sabino Arana 1, 08028, Barcelona, Spain.,Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Marc Figueras-Roca
- Institut Clínic d'Oftalmología (ICOF), Hospital Clinic de Barcelona, C/ Sabino Arana 1, 08028, Barcelona, Spain.,Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Irene Vinagre
- Diabetes Unit, Institut Clínic de Malalties Digestives i Metaboliques (ICMDM), Hospital Clinic de Barcelona, Barcelona, Spain
| | - Emilio Ortega
- Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Diabetes Unit, Institut Clínic de Malalties Digestives i Metaboliques (ICMDM), Hospital Clinic de Barcelona, Barcelona, Spain
| | - Enric Esmatjes
- Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Diabetes Unit, Institut Clínic de Malalties Digestives i Metaboliques (ICMDM), Hospital Clinic de Barcelona, Barcelona, Spain
| | - Alfredo Adan
- Institut Clínic d'Oftalmología (ICOF), Hospital Clinic de Barcelona, C/ Sabino Arana 1, 08028, Barcelona, Spain.,Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| |
Collapse
|
24
|
Groeneveld Y, Tavenier D, Blom J, Polak B. Incidence of sight-threatening diabetic retinopathy in people with Type 2 diabetes mellitus and numbers needed to screen: a systematic review. Diabet Med 2019; 36:1199-1208. [PMID: 30677170 PMCID: PMC6767411 DOI: 10.1111/dme.13908] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/22/2019] [Indexed: 12/20/2022]
Abstract
AIM To investigate the incidence of sight-threatening diabetic retinopathy in Type 2 diabetes mellitus. BACKGROUND In most countries, yearly or biennial screening intervals for diabetic retinopathy in people with Type 2 diabetes are recommended. Fewer screening sessions reduce the effort required of people with Type 2 diabetes and reduce healthcare costs. METHODS We conducted a search of PubMed, Embase, Web of Science and the COCHRANE Library for studies published betweeen 1 January 2000 and 1 January 2017. Eligible studies were those that included general populations of >100 people with Type 2 diabetes mellitus. Additional study population criteria were absence of moderate diabetic retinopathy or more severe diabetic retinopathy at last screening session and at least two gradable retinal screening sessions. Outcomes of interest in the included studies were moderate and severe non-proliferative diabetic retinopathy (R2), proliferative diabetic retinopathy (R3) or maculopathy (M1), collectively known as sight-threatening or referable diabetic retinopathy. RESULTS A total of 17 studies were included. In people with Type 2 diabetes without or with only mild diabetic retinopathy at baseline, the average incidence rates of sight-threatening diabetic retinopathy were ~1 per 100 person-years and ~8 per 100 person-years, respectively. The average numbers needed to screen to detect one case of sight-threatening diabetic retinopathy were 175 and 19 in people without and with mild retinopathy at last screening, respectively. CONCLUSION In people with Type 2 diabetes without retinopathy at last screening, the incidence of severe sight-threatening retinopathy at the subsequent screening session was low. In people with mild retinopathy, progression to sight-threatening diabetic retinopathy was nearly 10-fold higher. This review supports lengthening of the screening interval of patients with Type 2 diabetes without retinopathy at last screening session.
Collapse
Affiliation(s)
- Y. Groeneveld
- Department of Public Health and Primary CareLeiden University Medical CentreLeidenThe Netherlands
| | - D. Tavenier
- Group Practice AsklepiosEMGO Institute for Health and Care ResearchVU University Medical CentreBarneveldThe Netherlands
| | - J.W. Blom
- Department of Public Health and Primary CareLeiden University Medical CentreLeidenThe Netherlands
| | - B.C.P. Polak
- Department of OphthalmologyEMGO Institute for Health and Care ResearchUniversitair Medische Centra AmsterdamAmsterdamThe Netherlands
| |
Collapse
|
25
|
García‐Fiñana M, Hughes DM, Cheyne CP, Broadbent DM, Wang A, Komárek A, Stratton IM, Mobayen‐Rahni M, Alshukri A, Vora JP, Harding SP. Personalized risk-based screening for diabetic retinopathy: A multivariate approach versus the use of stratification rules. Diabetes Obes Metab 2019; 21:560-568. [PMID: 30284381 PMCID: PMC6492102 DOI: 10.1111/dom.13552] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 09/21/2018] [Accepted: 09/30/2018] [Indexed: 12/23/2022]
Abstract
AIMS To evaluate our proposed multivariate approach to identify patients who will develop sight-threatening diabetic retinopathy (STDR) within a 1-year screen interval, and explore the impact of simple stratification rules on prediction. MATERIALS AND METHODS A 7-year dataset (2009-2016) from people with diabetes (PWD) was analysed using a novel multivariate longitudinal discriminant approach. Level of diabetic retinopathy, assessed from routine digital screening photographs of both eyes, was jointly modelled using clinical data collected over time. Simple stratification rules based on retinopathy level were also applied and compared with the multivariate discriminant approach. RESULTS Data from 13 103 PWD (49 520 screening episodes) were analysed. The multivariate approach accurately predicted whether patients developed STDR or not within 1 year from the time of prediction in 84.0% of patients (95% confidence interval [CI] 80.4-89.7), compared with 56.7% (95% CI 55.5-58.0) and 79.7% (95% CI 78.8-80.6) achieved by the two stratification rules. While the stratification rules detected up to 95.2% (95% CI 92.2-97.6) of the STDR cases (sensitivity) only 55.6% (95% CI 54.5-56.7) of patients who did not develop STDR were correctly identified (specificity), compared with 85.4% (95% CI 80.4-89.7%) and 84.0% (95% CI 80.7-87.6%), respectively, achieved by the multivariate risk model. CONCLUSIONS Accurate prediction of progression to STDR in PWD can be achieved using a multivariate risk model whilst also maintaining desirable specificity. While simple stratification rules can achieve good levels of sensitivity, the present study indicates that their lower specificity (high false-positive rate) would therefore necessitate a greater frequency of eye examinations.
Collapse
Affiliation(s)
- Marta García‐Fiñana
- Department of BiostatisticsInstitute of Translational Medicine, University of LiverpoolLiverpoolUK
| | - David M. Hughes
- Department of BiostatisticsInstitute of Translational Medicine, University of LiverpoolLiverpoolUK
| | - Christopher P. Cheyne
- Department of BiostatisticsInstitute of Translational Medicine, University of LiverpoolLiverpoolUK
| | - Deborah M. Broadbent
- Department of Eye and Vision ScienceInstitute of Ageing and Chronic Disease, University of LiverpoolLiverpoolUK
- St Paul's Eye UnitRoyal Liverpool University HospitalLiverpoolUK
| | - Amu Wang
- Department of Eye and Vision ScienceInstitute of Ageing and Chronic Disease, University of LiverpoolLiverpoolUK
| | - Arnošt Komárek
- Department of Probability and Mathematical StatisticsFaculty of Mathematics and Physics, Charles UniversityPragueCzech Republic
| | - Irene M. Stratton
- Gloucestershire Retinal Research GroupGloucestershire Hospitals NHS Foundation Trust, Cheltenham General HospitalCheltenhamUK
| | - Mehrdad Mobayen‐Rahni
- Department of Eye and Vision ScienceInstitute of Ageing and Chronic Disease, University of LiverpoolLiverpoolUK
- Department of Medical Physics and Clinical EngineeringRoyal Liverpool University HospitalLiverpoolUK
| | - Ayesh Alshukri
- Department of Eye and Vision ScienceInstitute of Ageing and Chronic Disease, University of LiverpoolLiverpoolUK
| | - Jiten P. Vora
- Diabetes and EndocrinologyRoyal Liverpool University HospitalLiverpoolUK
| | - Simon P. Harding
- Department of Eye and Vision ScienceInstitute of Ageing and Chronic Disease, University of LiverpoolLiverpoolUK
- St Paul's Eye UnitRoyal Liverpool University HospitalLiverpoolUK
| |
Collapse
|
26
|
Iglicki M, Zur D, Busch C, Okada M, Loewenstein A. Progression of diabetic retinopathy severity after treatment with dexamethasone implant: a 24-month cohort study the 'DR-Pro-DEX Study'. Acta Diabetol 2018; 55:541-547. [PMID: 29497837 DOI: 10.1007/s00592-018-1117-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 02/09/2018] [Indexed: 01/21/2023]
Abstract
PURPOSE Intravitreal anti-vascular endothelial growth factor agents have been shown to reduce diabetic retinopathy (DR) progression; data on the effects of intravitreal corticosteroids on modifying disease severity are limited. This study evaluates the long-term effect of intravitreal dexamethasone implant (DEX) on the severity and progression of non-proliferative DR (NPDR). METHODS This was a retrospective cohort study. Sixty eyes from 60 consecutive patients with NPDR and diabetic macular edema (DME) treated with dexamethasone implant (DEX group) and 49 eyes from consecutive 49 patients without DME requiring observation only. Fundus angiography images from baseline and after 24 months were graded by two masked assessors into mild, moderate and severe NPDR and PDR, according to the ETDRS classification. Patients were followed up 1-3 and 4-6 months after each DEX implant. Re-treatment with DEX implant was on a pro re nata basis. Records were reviewed for performance of panretinal photocoagulation. Main outcome was as follows: change of DR ≥ 1 grade and progression to proliferative diabetic retinopathy (PDR). RESULTS Three eyes (5%) in the DEX group and 43 (87.8%) eyes in the control group progressed to PDR (P < 0.0001). Twenty-five eyes (41.7%) in the DEX group but none in the control group demonstrated an improvement in DR severity (P < 0.0001). CONCLUSION This study provides the first long-term evidence that DEX implant has the potential to not only delay progression of DR and PDR development, but may also improve DR severity over 24 months. Better understanding of the effects of corticosteroids will help guide its use in the treatment pathway of DR.
Collapse
Affiliation(s)
- Matias Iglicki
- Retina Private Office, University of Buenos Aires, 525 Aguirre St., 3rd floor, Apt. A, Zip code 1414, Buenos Aires, Argentina.
| | - Dinah Zur
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Catharina Busch
- Department of Ophthalmology, University of Leipzig, Leipzig, Germany
| | - Mali Okada
- Royal Victorian Eye and Ear Hospital, Melbourne, VIC, Australia
| | - Anat Loewenstein
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Incumbent, Sydney A. Fox Chair in Ophthalmology, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
27
|
Wang S, Zuo Y, Wang N, Tong B. Fundus fluorescence Angiography in diagnosing diabetic retinopathy. Pak J Med Sci 2017; 33:1328-1332. [PMID: 29492053 PMCID: PMC5768819 DOI: 10.12669/pjms.336.13405] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To investigate the manifestation characteristics of fundus fluorescence angiography (FFA) and its values in diagnosing diabetic retinopathy through comparing direct ophthalmoscopy. Methods: Two hundred fifty patients (500 eyes) who were suspected as diabetic retinopathy and admitted to the hospital between February 2015 and December 2016 were selected. They underwent direct ophthalmoscopy and FFA. The manifestation characteristics of FFA in the diagnosis of diabetic retinopathy were summarized. The two examination methods were compared. Results: In the diagnosis with direct ophthalmoscopy, 375 eyes out of 500 eyes were diagnosed as diabetic retinopathy (75%); there were 74 eyes at stage I, 88 eyes at stage II, 92 eyes at stage III, 83 eyes of stage IV, 28 eyes of stage V and 10 eyes of stage VI. In the diagnosis with FFA, 465 eyes out of 500 eyes were diagnosed as diabetic retinopathy (93%); there were 94 eyes at stage I, 110 eyes at stage II, 112 at stage III, 92 eyes at stage IV, 41 eyes at stage V and 16 eyes at stage VI. The detection rate of diabetic retinopathy using FFA was significantly higher than that using direct ophthalmoscopy (P<0.05). FFA found that 316 eyes had non-proliferative retinopathy (67.96%), 75 eyes had pre-proliferative lesions (16.13%), 149 eyes had proliferative lesions (32.04%), 135 eyes had diabetic maculopathy (29.03%) and 31 eyes had diabetic optic disc lesions (6.67%). Conclusion: The detection rate of diabetic retinopathy using FFA is higher than that using direct ophthalmoscopy. FFA could accurately determine clinical stage. Therefore, it is an important approach in treatment efficacy evaluation and treatment guidance, suggesting a significant application value.
Collapse
Affiliation(s)
- Shuhui Wang
- Shuhui Wang, Department of Ophthalmology, Binzhou People's Hospital, Shandong, 256600, China
| | - Yuqin Zuo
- Yuqin Zuo, Department of GI Medicine, Binzhou People's Hospital, Shandong, 256600, China
| | - Ning Wang
- Ning Wang, Department of Psychiatry, Binzhou People's Hospital, Shandong, 256600, China
| | - Bin Tong
- Bin Tong, Department of Ophthalmology, Binzhou People's Hospital, Shandong, 256600, China
| |
Collapse
|
28
|
Eleuteri A, Fisher AC, Broadbent DM, García-Fiñana M, Cheyne CP, Wang A, Stratton IM, Gabbay M, Seddon D, Harding SP. Individualised variable-interval risk-based screening for sight-threatening diabetic retinopathy: the Liverpool Risk Calculation Engine. Diabetologia 2017; 60:2174-2182. [PMID: 28840258 PMCID: PMC6448900 DOI: 10.1007/s00125-017-4386-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 06/12/2017] [Indexed: 12/22/2022]
Abstract
AIMS/HYPOTHESIS Individualised variable-interval risk-based screening offers better targeting and improved cost-effectiveness in screening for diabetic retinopathy. We developed a generalisable risk calculation engine (RCE) to assign personalised intervals linked to local population characteristics, and explored differences in assignment compared with current practice. METHODS Data from 5 years of photographic screening and primary care for people with diabetes, screen negative at the first of > 1 episode, were combined in a purpose-built near-real-time warehouse. Covariates were selected from a dataset created using mixed qualitative/quantitative methods. Markov modelling predicted progression to screen-positive (referable diabetic retinopathy) against the local cohort history. Retinopathy grade informed baseline risk and multiple imputation dealt with missing data. Acceptable intervals (6, 12, 24 months) and risk threshold (2.5%) were established with patients and professional end users. RESULTS Data were from 11,806 people with diabetes (46,525 episodes, 388 screen-positive). Covariates with sufficient predictive value were: duration of known disease, HbA1c, age, systolic BP and total cholesterol. Corrected AUC (95% CIs) were: 6 months 0.88 (0.83, 0.93), 12 months 0.90 (0.87, 0.93) and 24 months 0.91 (0.87, 0.94). Sensitivities/specificities for a 2.5% risk were: 6 months 0.61, 0.93, 12 months 0.67, 0.90 and 24 months 0.82, 0.81. Implementing individualised RCE-based intervals would reduce the proportion of people becoming screen-positive before the allocated screening date by > 50% and the number of episodes by 30%. CONCLUSIONS/INTERPRETATION The Liverpool RCE shows sufficient performance for a local introduction into practice before wider implementation, subject to external validation. This approach offers potential enhancements of screening in improved local applicability, targeting and cost-effectiveness.
Collapse
Affiliation(s)
- Antonio Eleuteri
- Department of Medical Physics and Clinical Engineering, Royal Liverpool University Hospital, Liverpool, UK
| | - Anthony C Fisher
- Department of Medical Physics and Clinical Engineering, Royal Liverpool University Hospital, Liverpool, UK
| | - Deborah M Broadbent
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, William Henry Duncan Building, 6, West Derby Street, Liverpool, L7 8TX, UK
- St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Marta García-Fiñana
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Christopher P Cheyne
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Amu Wang
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, William Henry Duncan Building, 6, West Derby Street, Liverpool, L7 8TX, UK
| | - Irene M Stratton
- Gloucestershire Retinal Research Group, Cheltenham General Hospital, Cheltenham, UK
| | - Mark Gabbay
- Department of Health Services Research, University of Liverpool, Liverpool, UK
| | - Daniel Seddon
- Public Health England, Cheshire and Merseyside Screening and Immunisation Team, Liverpool, UK
| | - Simon P Harding
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, William Henry Duncan Building, 6, West Derby Street, Liverpool, L7 8TX, UK.
- St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK.
| | | |
Collapse
|
29
|
Abstract
PURPOSE OF REVIEW The purpose of this study is to review the evidence that lower risk groups who could safely be screened less frequently for sight-threatening diabetic retinopathy (DR) than annually. RECENT FINDINGS Data have demonstrated that people with no DR in either eye are at a low risk of progression to sight-threatening DR over a 2-year period (event rate 4.8 per 1000 person years), irrespective of whether the screening method is one-field non-mydriatic or two-field mydriatic digital photography. Low risk has been defined as no retinopathy on two consecutive screening episodes or no retinopathy on one screening episode combined with risk factor data. The risk of an extension to 2 years is less than 5 per 1000 person years in a population with a national screening programme, and the general standard of diabetes care is relatively good, whether low risk is defined as no retinopathy on two consecutive screening episodes or no retinopathy on one screening episode combined with other risk factor data. The definition used in different populations is likely to depend on the availability of data.
Collapse
Affiliation(s)
- Peter H Scanlon
- Gloucestershire Retinal Research Group, Gloucestershire Hospitals NHS Foundation Trust, Office above Oakley Ward, Cheltenham General Hospital, Sandford Road, Cheltenham, GL53 7AN, UK.
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, UK.
| |
Collapse
|
30
|
Identifying risk factors for bone mass transition states for postmenopausal osteoporosis. Eur J Integr Med 2017. [DOI: 10.1016/j.eujim.2017.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
31
|
Abstract
PURPOSE OF REVIEW Diabetic retinopathy remains the leading cause of blindness among working-age US adults even though timely screening and treatment prevent 90% of blindness. We summarize current knowledge and perspectives to better understand why diabetic eye screening rates remain low and future directions towards preventing blindness from diabetes. RECENT FINDINGS Significant advancements in the past 10 years include primary care and patient-oriented interventions as well as the use of teleophthalmology. In England, diabetic eye disease is no longer the leading cause of certifiable blindness following the implementation of a national teleophthalmology program for diabetic retinopathy. Multiple workflow and systems-level barriers affect providers. Patient barriers include a limited understanding of screening and lack of access to care. Interventions have been developed, but new barriers exist towards sustaining their impact. More research is needed to identify and implement the best practices to increase diabetic eye screening rates long-term.
Collapse
Affiliation(s)
- Yao Liu
- Dept. of Ophthalmology and Visual Sciences, University of
Wisconsin School of Medicine and Public Health, 2870 University Ave, Ste 206,
Madison, WI 53705,
| | - Rebecca Swearingen
- Dept. of Ophthalmology and Visual Sciences, University of
Wisconsin School of Medicine and Public Health, 2870 University Ave, Ste 206,
Madison, WI 53705,
| |
Collapse
|
32
|
Vujosevic S, Pucci P, Casciano M, Daniele A, Bini S, Berton M, Cavarzeran F, Avogaro A, Lapolla A, Midena E. A decade-long telemedicine screening program for diabetic retinopathy in the north-east of Italy. J Diabetes Complications 2017; 31:1348-1353. [PMID: 28551296 DOI: 10.1016/j.jdiacomp.2017.04.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 03/22/2017] [Accepted: 04/10/2017] [Indexed: 12/21/2022]
Abstract
AIM To describe a decade long telemedicine screening for diabetic retinopathy (DR) in the metropolitan area of Padova (North-East Italy) and to report about prevalence/incidence of DR and maculopathy, rate of progression to STDR and optimal screening interval in patients with no DR at first examination. METHODS Observational, longitudinal, cohort study; 9347 patients with Type 1 and Type 2 diabetes mellitus (DM) underwent 17,344 fundus exams (three-45° color photos per eye) in two diabetes clinics and were graded in the Reading Centre, by certified personnel. The incidence of STDR, progression of maculopathy and risk factors were evaluated by log Rank test (Kaplan-Meier method). A receiver operating curve was used to determine the optimal screening interval in patients who at the first examination had no DR. RESULTS The overall prevalence of DR was 27.6%:12.5% mild non proliferative (NPDR), 11.3% moderate NPDR, 2.9% severe NPDR and 0.9% proliferative (PDR). The overall prevalence of maculopathy was 5.7%: 2.8% mild, 2.2% moderate, and 0.7% severe maculopathy. The 10-year incidence of STDR was: 0.6% in no DR, 5.5% in mild NPDR and 21.1% in moderate NPDR at first examination. The 10-year incidence of maculopathy was: 2.1% mild, 1.7% moderate and 0.2% severe. The incidence of STDR in patients with type 1 and type 2 DM and duration>10years was 8.21% and 8.15%;in type 1 DM with duration <10years was 5.5% and in type 2 DM and duration <10years was 1.91%.In patients with no DR at first screening, the best (sensitivity-specificity) follow-up interval is 2.5years. CONCLUSIONS Screening every 2.5-year in patients without DR at the first examination seems to be adequate. Duration of disease is a relevant risk factor for progression to STDR, however patients with type 1 DM and duration <10years have greater incidence of STDR than patients with type 2 DM and similar disease duration. Epidemiologic data from this decade-long screening program in the North East of Italy may serve for implementing a national screening program.
Collapse
Affiliation(s)
| | - Porzia Pucci
- Department of Ophthalmology, University of Padova, Italy
| | | | | | - Silvia Bini
- Department of Ophthalmology, University of Padova, Italy
| | | | | | - Angelo Avogaro
- Department of Medicine, Metabolic Disease Division, University of Padova, Italy
| | - Annunziata Lapolla
- Department of Medicine, Center for Diabetes and Dietetics, ULSS 16, Padova, Italy
| | - Edoardo Midena
- Department of Ophthalmology, University of Padova, Italy; Fondazione G. B. Bietti, IRCCS, Roma, Italy.
| |
Collapse
|
33
|
Nathan DM, Bebu I, Hainsworth D, Klein R, Tamborlane W, Lorenzi G, Gubitosi-Klug R, Lachin JM. Frequency of Evidence-Based Screening for Retinopathy in Type 1 Diabetes. N Engl J Med 2017; 376:1507-1516. [PMID: 28423305 PMCID: PMC5557280 DOI: 10.1056/nejmoa1612836] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND In patients who have had type 1 diabetes for 5 years, current recommendations regarding screening for diabetic retinopathy include annual dilated retinal examinations to detect proliferative retinopathy or clinically significant macular edema, both of which require timely intervention to preserve vision. During 30 years of the Diabetes Control and Complications Trial (DCCT) and its longitudinal follow-up Epidemiology of Diabetes Interventions and Complications (EDIC) study, retinal photography was performed at intervals of 6 months to 4 years. METHODS We used retinal photographs from the DCCT/EDIC study to develop a rational screening frequency for retinopathy. Markov modeling was used to determine the likelihood of progression to proliferative diabetic retinopathy or clinically significant macular edema in patients with various initial retinopathy levels (no retinopathy or mild, moderate, or severe nonproliferative diabetic retinopathy). The models included recognized risk factors for progression of retinopathy. RESULTS Overall, the probability of progression to proliferative diabetic retinopathy or clinically significant macular edema was limited to approximately 5% between retinal screening examinations at 4 years among patients who had no retinopathy, 3 years among those with mild retinopathy, 6 months among those with moderate retinopathy, and 3 months among those with severe nonproliferative diabetic retinopathy. The risk of progression was also closely related to mean glycated hemoglobin levels. The risk of progression from no retinopathy to proliferative diabetic retinopathy or clinically significant macular edema was 1.0% over 5 years among patients with a glycated hemoglobin level of 6%, as compared with 4.3% over 3 years among patients with a glycated hemoglobin level of 10%. Over a 20-year period, the frequency of eye examinations was 58% lower with our practical, evidence-based schedule than with routine annual examinations, which resulted in substantial cost savings. CONCLUSIONS Our model for establishing an individualized schedule for retinopathy screening on the basis of the patient's current state of retinopathy and glycated hemoglobin level reduced the frequency of eye examinations without delaying the diagnosis of clinically significant disease. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others; DCCT/EDIC ClinicalTrials.gov numbers, NCT00360893 and NCT00360815 .).
Collapse
Affiliation(s)
- David M Nathan
- Massachusetts General Hospital and Harvard Medical School, Boston
| | - Ionut Bebu
- Biostatistics Center, George Washington University, Rockville, MD
| | - Dean Hainsworth
- Department of Ophthalmology, University of Missouri, Columbia
| | - Ronald Klein
- University of Wisconsin School of Medicine, Madison
| | | | | | | | - John M Lachin
- Biostatistics Center, George Washington University, Rockville, MD
| |
Collapse
|
34
|
Vujosevic S, Midena E. Diabetic Retinopathy in Italy: Epidemiology Data and Telemedicine Screening Programs. J Diabetes Res 2016; 2016:3627465. [PMID: 27990441 PMCID: PMC5136623 DOI: 10.1155/2016/3627465] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 10/26/2016] [Accepted: 10/30/2016] [Indexed: 11/18/2022] Open
Abstract
In Italy, the number of people living with diabetes is about 3.5 million (5.5% of the population), with an increase by about 60% in the last 20 years and with 1 person out of 3 older than 65 years. The Italian Health Service system estimates that 10 billion euros is spent annually on caring for patients with diabetes, a figure that increases yearly. No national data on prevalence and incidence of legal blindness in patients with diabetes and no national registry of patients with diabetic retinopathy (DR) are currently available. However, the available epidemiological data (in several locations throughout the country) are consistent with those reported in other European countries. The use of telemedicine for the screening of DR in Italy is confined to geographically limited locations. The available data in the literature on implementation and use of telematic screening proved to be successful from patient, caregiver, and authorities point of view. This review addresses the available epidemiological data on DR and telematic screening realities in Italy and thus may help in establishing a national screening program.
Collapse
Affiliation(s)
- Stela Vujosevic
- Department of Ophthalmology, University of Padova, Padova, Italy
| | - Edoardo Midena
- Department of Ophthalmology, University of Padova, Padova, Italy
- Fondazione G. B. Bietti, IRCCS, Roma, Italy
| |
Collapse
|
35
|
Hughes D, Nair S, Harvey JN. Determining diabetic retinopathy screening interval based on time from no retinopathy to laser therapy. J Med Screen 2016; 24:170-175. [PMID: 27810985 DOI: 10.1177/0969141316672687] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives To determine the necessary screening interval for retinopathy in diabetic patients with no retinopathy based on time to laser therapy and to assess long-term visual outcome following screening. Methods In a population-based community screening programme in North Wales, 2917 patients were followed until death or for approximately 12 years. At screening, 2493 had no retinopathy; 424 had mostly minor degrees of non-proliferative retinopathy. Data on timing of first laser therapy and visual outcome following screening were obtained from local hospitals and ophthalmology units. Results Survival analysis showed that very few of the no retinopathy at screening group required laser therapy in the early years compared with the non-proliferative retinopathy group ( p < 0.001). After two years, <0.1% of the no retinopathy at screening group required laser therapy, and at three years 0.2% (cumulative), lower rates of treatment than have been suggested by analyses of sight-threatening retinopathy determined photographically. At follow-up (mean 7.8 ± 4.6 years), mild to moderate visual impairment in one or both eyes due to diabetic retinopathy was more common in those with retinopathy at screening (26% vs. 5%, p < 0.001), but blindness due to diabetes occurred in only 1 in 1000. Conclusions Optimum screening intervals should be determined from time to active treatment. Based on requirement for laser therapy, the screening interval for diabetic patients with no retinopathy can be extended to two to three years. Patients who attend for retinal screening and treatment who have no or non-proliferative retinopathy now have a very low risk of eventual blindness from diabetes.
Collapse
Affiliation(s)
- Daniel Hughes
- 1 Diabetes Research Group, School of Medical Sciences, Bangor University, Bangor, UK
| | - Sunil Nair
- 2 Department of Diabetes & Endocrinology, Countess of Chester Hospital, Chester, UK
| | - John N Harvey
- 1 Diabetes Research Group, School of Medical Sciences, Bangor University, Bangor, UK
| |
Collapse
|
36
|
Roy R, Lobo A, Lob A, Pal BP, Oliveira CM, Raman R, Sharma T. Automated diabetic retinopathy imaging in Indian eyes: a pilot study. Indian J Ophthalmol 2016; 62:1121-4. [PMID: 25579354 PMCID: PMC4313490 DOI: 10.4103/0301-4738.149129] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Aim: To evaluate the efficacy of an automated retinal image grading system in diabetic retinopathy (DR) screening. Materials and Methods: Color fundus images of patients of a DR screening project were analyzed for the purpose of the study. For each eye two set of images were acquired, one centerd on the disk and the other centerd on the macula. All images were processed by automated DR screening software (Retmarker). The results were compared to ophthalmologist grading of the same set of photographs. Results: 5780 images of 1445 patients were analyzed. Patients were screened into two categories DR or no DR. Image quality was high, medium and low in 71 (4.91%), 1117 (77.30%) and 257 (17.78%) patients respectively. Specificity and sensitivity for detecting DR in the high, medium and low group were (0.59, 0.91); (0.11, 0.95) and (0.93, 0.14). Conclusion: Automated retinal image screening system for DR had a high sensitivity in high and medium quality images. Automated DR grading software's hold promise in future screening programs.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Tarun Sharma
- Department Vitreo Retina, Shri Bhagwan Mahavir Vitreoretinal, Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
| |
Collapse
|
37
|
Scotland G, Bryan S. Why Do Health Economists Promote Technology Adoption Rather Than the Search for Efficiency? A Proposal for a Change in Our Approach to Economic Evaluation in Health Care. Med Decis Making 2016; 37:139-147. [DOI: 10.1177/0272989x16653397] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
At a time of intense pressure on health care budgets, the technology management challenge is for disinvestment in low-value technologies and reinvestment in higher value alternatives. The aim of this article is to explore ways in which health economists might begin to redress the observed imbalance between the evaluation of new and existing in-use technologies. The argument is not against evaluating new technologies but in favor of the “search for efficiency,” where the ultimate objective is to identify reallocations that improve population health in the face of resource scarcity. We explore why in-use technologies may be of low value and consider how economic evaluation analysts might embrace a broader efficiency lens, first through “technology management” (a process of analysis and evidence-informed decision making throughout a technology’s life cycle) and progressing through “pathway management” (the search for efficiency gains across entire clinical care pathways). A number of model-based examples are used to illustrate the approaches.
Collapse
Affiliation(s)
- Graham Scotland
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK (GS, SB)
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK (GS)
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada (SB)
- School of Population & Public Health, University of British Columbia, Vancouver, BC, Canada (SB)
| | - Stirling Bryan
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK (GS, SB)
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK (GS)
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada (SB)
- School of Population & Public Health, University of British Columbia, Vancouver, BC, Canada (SB)
| |
Collapse
|
38
|
Scotland G, McKeigue P, Philip S, Leese GP, Olson JA, Looker HC, Colhoun HM, Javanbakht M. Modelling the cost-effectiveness of adopting risk-stratified approaches to extended screening intervals in the national diabetic retinopathy screening programme in Scotland. Diabet Med 2016; 33:886-95. [PMID: 27040994 DOI: 10.1111/dme.13129] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2016] [Indexed: 01/04/2023]
Abstract
AIMS To assess the cost-effectiveness of adopting risk-stratified approaches to extended screening intervals in the national diabetic retinopathy screening programme in Scotland. METHODS A continuous-time hidden Markov model was fitted to national longitudinal screening data to derive transition probabilities between observed non-referable and referable retinopathy states. These were incorporated in a decision model simulating progression, costs and visual acuity outcomes for a synthetic cohort with a covariate distribution matching that of the Scottish diabetic screening population. The cost-effectiveness of adopting extended (2-year) screening for groups with no observed retinopathy was then assessed over a 30-year time horizon. RESULTS Individuals with a current grade of no retinopathy on two consecutive screening episodes face the lowest risk of progressing to referable disease. For the cohort as a whole, the incremental cost per quality-adjusted life year gained for annual vs. biennial screening ranged from approximately £74 000 (for those with no retinopathy and a prior observed grade of mild or observable background retinopathy) to approximately £232 000 per quality-adjusted life year gained (for those with no retinopathy on two consecutive screening episodes). The corresponding incremental cost-effectiveness ratios in the subgroup with Type 1 diabetes were substantially lower; approximately £22 000 to £85 000 per quality-adjusted life year gained, respectively. CONCLUSIONS Biennial screening for individuals with diabetes who have no retinopathy is likely to deliver significant savings for a very small increase in the risk of adverse visual acuity and quality of life outcomes. There is greater uncertainty regarding the long-term cost-effectiveness of adopting biennial screening in younger people with Type 1 diabetes.
Collapse
Affiliation(s)
- G Scotland
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - P McKeigue
- Centre for Population Health Sciences, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - S Philip
- Grampian Diabetes Research Unit, NHS Grampian, Aberdeen, UK
| | - G P Leese
- Diabetes and Endocrinology, NHS Tayside, Dundee, UK
| | - J A Olson
- Diabetes Retinal Screening, NHS Grampian, Aberdeen, UK
| | - H C Looker
- Division for Clinical & Population Sciences and Education (CPSE), University of Dundee, Dundee, UK
| | - H M Colhoun
- Division for Clinical & Population Sciences and Education (CPSE), University of Dundee, Dundee, UK
| | - M Javanbakht
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| |
Collapse
|
39
|
Oke JL, Stratton IM, Aldington SJ, Stevens RJ, Scanlon PH. The use of statistical methodology to determine the accuracy of grading within a diabetic retinopathy screening programme. Diabet Med 2016; 33:896-903. [PMID: 26666463 PMCID: PMC5019246 DOI: 10.1111/dme.13053] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2015] [Indexed: 01/06/2023]
Abstract
AIMS We aimed to use longitudinal data from an established screening programme with good quality assurance and quality control procedures and a stable well-trained workforce to determine the accuracy of grading in diabetic retinopathy screening. METHODS We used a continuous time-hidden Markov model with five states to estimate the probability of true progression or regression of retinopathy and the conditional probability of an observed grade given the true grade (misclassification). The true stage of retinopathy was modelled as a function of the duration of diabetes and HbA1c . RESULTS The modelling dataset consisted of 65 839 grades from 14 187 people. The median number [interquartile range (IQR)] of examinations was 5 (3, 6) and the median (IQR) interval between examinations was 1.04 (0.99, 1.17) years. In total, 14 227 grades (21.6%) were estimated as being misclassified, 10 592 (16.1%) represented over-grading and 3635 (5.5%) represented under-grading. There were 1935 (2.9%) misclassified referrals, 1305 were false-positive results (2.2%) and 630 were false-negative results (1.0%). Misclassification of background diabetic retinopathy as no detectable retinopathy was common (3.4% of all grades) but rarely preceded referable maculopathy or retinopathy. CONCLUSION Misclassification between lower grades of retinopathy is not uncommon but is unlikely to lead to significant delays in referring people for sight-threatening retinopathy.
Collapse
Affiliation(s)
- J L Oke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - I M Stratton
- Gloucestershire Retinal Research Group, Gloucester, UK
| | - S J Aldington
- Gloucestershire Retinal Research Group, Gloucester, UK
| | - R J Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - P H Scanlon
- Gloucestershire Retinal Research Group, Gloucester, UK
| |
Collapse
|
40
|
Gregg EW, Sattar N, Ali MK. The changing face of diabetes complications. Lancet Diabetes Endocrinol 2016; 4:537-47. [PMID: 27156051 DOI: 10.1016/s2213-8587(16)30010-9] [Citation(s) in RCA: 322] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 03/22/2016] [Accepted: 03/23/2016] [Indexed: 12/16/2022]
Abstract
The global increase in type 2 diabetes prevalence is well documented, but international trends in complications of type 2 diabetes are less clear. The available data suggest large reductions in classic complications of type 2 diabetes in high-income countries over the past 20 years, predominantly reductions in myocardial infarction, stroke, amputations, and mortality. These trends might be accompanied by less obvious, but still important, changes in the character of morbidity in people with diabetes. In the USA, for example, substantial reductions in macrovascular complications in adults aged 65 years or older mean that a large proportion of total complications now occur among adults aged 45-64 years instead, rates of renal disease could persist more than other complications, and obesity-related type 2 diabetes could have increasing effect in youth and adults under 45 years of age. Additionally, the combination of decreasing mortality and increasing diabetes prevalence has increased the overall mean years lived with diabetes and could lead to a diversification of diabetes morbidity, including continued high rates of renal disease, ageing-related disability, and cancers. Unfortunately, data on trends in diabetes-related complications are limited to only about a dozen countries, most of which are high income, leaving the changing character for countries of low and middle income ambiguous.
Collapse
Affiliation(s)
- Edward W Gregg
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Mohammed K Ali
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA; Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| |
Collapse
|
41
|
Sullivan F. Atomic data: James Mackenzie Lecture 2015. Br J Gen Pract 2016; 66:e368-70. [PMID: 27127292 PMCID: PMC4838451 DOI: 10.3399/bjgp16x685153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Affiliation(s)
- Frank Sullivan
- Gordon F Cheesbrough Research Chair and Director of UTOPIAN, Toronto, Canada; FMTU, North York General Hospital, Toronto, Canada; Professor, Department of Family & Community Medicine and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Adjunct Scientist Institute for Clinical Evaluative Sciences (ICES), Toronto, Canada; Honorary Professor, University of Dundee, Dundee, UK
| |
Collapse
|
42
|
Results of a diabetic retinopathy screening. Risk markers analysis. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2016; 91:15-9. [PMID: 26614736 DOI: 10.1016/j.oftal.2015.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 08/16/2015] [Accepted: 09/15/2015] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To identify risk markers for retinopathy in patients from our geographic area, and to compare them with those published in other studies. To design a screening interval strategy, taking into account these results, and compare it with intervals suggested in published studies. MATERIAL AND METHODS Cross-sectional observational study on 383 diabetic patients with no previous retinopathy diagnosis, who were screened for diabetic retinopathy. An analysis was made on the possible association between patient factors and presence of retinopathy. RESULTS A greater probability for finding retinopathy in diabetic patients was associated to insulin treatment in our study, with a statistical significance level of 95%. In patients with less than 10year onset of their diabetes, only mild retinopathy without macular oedema was found. CONCLUSIONS Insulin treatment and time of onset of diabetes should be taken into account when designing efficient screening strategies for diabetic retinopathy.
Collapse
|
43
|
Cichosz SL, Johansen MD, Hejlesen O. Toward Big Data Analytics: Review of Predictive Models in Management of Diabetes and Its Complications. J Diabetes Sci Technol 2015; 10:27-34. [PMID: 26468133 PMCID: PMC4738225 DOI: 10.1177/1932296815611680] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Diabetes is one of the top priorities in medical science and health care management, and an abundance of data and information is available on these patients. Whether data stem from statistical models or complex pattern recognition models, they may be fused into predictive models that combine patient information and prognostic outcome results. Such knowledge could be used in clinical decision support, disease surveillance, and public health management to improve patient care. Our aim was to review the literature and give an introduction to predictive models in screening for and the management of prevalent short- and long-term complications in diabetes. Predictive models have been developed for management of diabetes and its complications, and the number of publications on such models has been growing over the past decade. Often multiple logistic or a similar linear regression is used for prediction model development, possibly owing to its transparent functionality. Ultimately, for prediction models to prove useful, they must demonstrate impact, namely, their use must generate better patient outcomes. Although extensive effort has been put in to building these predictive models, there is a remarkable scarcity of impact studies.
Collapse
Affiliation(s)
- Simon Lebech Cichosz
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | | | - Ole Hejlesen
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| |
Collapse
|
44
|
The progress in understanding and treatment of diabetic retinopathy. Prog Retin Eye Res 2015; 51:156-86. [PMID: 26297071 DOI: 10.1016/j.preteyeres.2015.08.001] [Citation(s) in RCA: 601] [Impact Index Per Article: 66.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 08/12/2015] [Accepted: 08/13/2015] [Indexed: 12/15/2022]
Abstract
Diabetic retinopathy is the most frequently occurring complication of diabetes mellitus and remains a leading cause of vision loss globally. Its aetiology and pathology have been extensively studied for half a century, yet there are disappointingly few therapeutic options. Although some new treatments have been introduced for diabetic macular oedema (DMO) (e.g. intravitreal vascular endothelial growth factor inhibitors ('anti-VEGFs') and new steroids), up to 50% of patients fail to respond. Furthermore, for people with proliferative diabetic retinopathy (PDR), laser photocoagulation remains a mainstay therapy, even though it is an inherently destructive procedure. This review summarises the clinical features of diabetic retinopathy and its risk factors. It describes details of retinal pathology and how advances in our understanding of pathogenesis have led to identification of new therapeutic targets. We emphasise that although there have been significant advances, there is still a pressing need for a better understanding basic mechanisms enable development of reliable and robust means to identify patients at highest risk, and to intervene effectively before vision loss occurs.
Collapse
|
45
|
Jenkins AJ, Joglekar MV, Hardikar AA, Keech AC, O'Neal DN, Januszewski AS. Biomarkers in Diabetic Retinopathy. Rev Diabet Stud 2015; 12:159-95. [PMID: 26676667 DOI: 10.1900/rds.2015.12.159] [Citation(s) in RCA: 164] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
There is a global diabetes epidemic correlating with an increase in obesity. This coincidence may lead to a rise in the prevalence of type 2 diabetes. There is also an as yet unexplained increase in the incidence of type 1 diabetes, which is not related to adiposity. Whilst improved diabetes care has substantially improved diabetes outcomes, the disease remains a common cause of working age adult-onset blindness. Diabetic retinopathy is the most frequently occurring complication of diabetes; it is greatly feared by many diabetes patients. There are multiple risk factors and markers for the onset and progression of diabetic retinopathy, yet residual risk remains. Screening for diabetic retinopathy is recommended to facilitate early detection and treatment. Common biomarkers of diabetic retinopathy and its risk in clinical practice today relate to the visualization of the retinal vasculature and measures of glycemia, lipids, blood pressure, body weight, smoking, and pregnancy status. Greater knowledge of novel biomarkers and mediators of diabetic retinopathy, such as those related to inflammation and angiogenesis, has contributed to the development of additional therapeutics, in particular for late-stage retinopathy, including intra-ocular corticosteroids and intravitreal vascular endothelial growth factor inhibitors ('anti-VEGFs') agents. Unfortunately, in spite of a range of treatments (including laser photocoagulation, intraocular steroids, and anti-VEGF agents, and more recently oral fenofibrate, a PPAR-alpha agonist lipid-lowering drug), many patients with diabetic retinopathy do not respond well to current therapeutics. Therefore, more effective treatments for diabetic retinopathy are necessary. New analytical techniques, in particular those related to molecular markers, are accelerating progress in diabetic retinopathy research. Given the increasing incidence and prevalence of diabetes, and the limited capacity of healthcare systems to screen and treat diabetic retinopathy, there is need to reliably identify and triage people with diabetes. Biomarkers may facilitate a better understanding of diabetic retinopathy, and contribute to the development of novel treatments and new clinical strategies to prevent vision loss in people with diabetes. This article reviews key aspects related to biomarker research, and focuses on some specific biomarkers relevant to diabetic retinopathy.
Collapse
Affiliation(s)
- Alicia J Jenkins
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, Sydney, Australia
| | - Mugdha V Joglekar
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, Sydney, Australia
| | | | - Anthony C Keech
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, Sydney, Australia
| | - David N O'Neal
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, Sydney, Australia
| | | |
Collapse
|
46
|
Soto-Pedre E, Pinies JA, Hernaez-Ortega MC. External validation of a risk assessment model to adjust the frequency of eye-screening visits in patients with diabetes mellitus. J Diabetes Complications 2015; 29:508-11. [PMID: 25725582 DOI: 10.1016/j.jdiacomp.2014.12.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 12/15/2014] [Accepted: 12/29/2014] [Indexed: 11/22/2022]
Abstract
AIMS To validate a sight-threatening diabetic retinopathy (STDR) risk assessment model to adjust the frequency of eye-screening visits in patients with diabetes mellitus. METHODS Retrospective follow-up study of patients with diabetes mellitus attending a diabetes center. Anonimyzed data on gender, type and duration of diabetes, HbA1c, blood pressure and the presence and grade of diabetic retinopathy were gathered to estimate risk for STDR for each individual's worse eye over time by means of a prediction model. Receiver operating characteristics (ROC) analysis was performed to determine the diagnostic ability of the model, and a calibration graph was done to see the model fit. RESULTS 508 screening intervals were analyzed, median diabetes duration was 10years, 87% were type 2 diabetes mellitus, and 3.1% developed STDR before the next screening visit. The area under the ROC curve was 0.74, and the calibration graph showed that model had a good fit. The reduction in screening frequency was 40% compared with fixed annual screening. CONCLUSIONS Current prediction model used to estimate the risk of developing STDR in patients with diabetes performed well. A personalized screening frequency for diabetic retinopathy could be implemented in practice.
Collapse
Affiliation(s)
- Enrique Soto-Pedre
- European Innovative Biomedicine Institute (EIBI), C/ Jardines #2, Apt. 1-G, 39700 Castro Urdiales, Cantabria, Spain.
| | - Jose A Pinies
- Pinies Diabetes Centre (PDC), C/ Gran Via 40 Bis, 2°, 48009 Bilbao, Vizcaya, Spain
| | - Maria C Hernaez-Ortega
- European Innovative Biomedicine Institute (EIBI), C/ Jardines #2, Apt. 1-G, 39700 Castro Urdiales, Cantabria, Spain
| |
Collapse
|
47
|
Nentwich MM, Ulbig MW. Diabetic retinopathy - ocular complications of diabetes mellitus. World J Diabetes 2015; 6:489-499. [PMID: 25897358 PMCID: PMC4398904 DOI: 10.4239/wjd.v6.i3.489] [Citation(s) in RCA: 263] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 01/03/2015] [Accepted: 01/20/2015] [Indexed: 02/05/2023] Open
Abstract
In industrialized nations diabetic retinopathy is the most frequent microvascular complication of diabetes mellitus and the most common cause of blindness in the working-age population. In the next 15 years, the number of patients suffering from diabetes mellitus is expected to increase significantly. By the year 2030, about 440 million people in the age-group 20-79 years are estimated to be suffering from diabetes mellitus worldwide (prevalence 7.7%), while in 2010 there were 285 million people with diabetes mellitus (prevalence 6.4%). This accounts for an increase in patients with diabetes in industrialized nations by 20% and in developing countries by 69% until the year 2030. Due to the expected rise in diabetic patients, the need for ophthalmic care of patients (i.e., exams and treatments) will also increase and represents a challenge for eye-care providers. Development of optimized screening programs, which respect available resources of the ophthalmic infrastructure, will become even more important. Main reasons for loss of vision in patients with diabetes mellitus are diabetic macular edema and proliferative diabetic retinopathy. Incidence or progression of these potentially blinding complications can be greatly reduced by adequate control of blood glucose and blood pressure levels. Additionally, regular ophthalmic exams are mandatory for detecting ocular complications and initiating treatments such as laser photocoagulation in case of clinical significant diabetic macular edema or early proliferative diabetic retinopathy. In this way, the risk of blindness can considerably be reduced. In advanced stages of diabetic retinopathy, pars-plana vitrectomy is performed to treat vitreous hemorrhage and tractional retinal detachment. In recent years, the advent of intravitreal medication has improved therapeutic options for patients with advanced diabetic macular edema.
Collapse
|
48
|
Leese GP, Stratton IM, Land M, Bachmann MO, Jones C, Scanlon P, Looker HC, Ferguson B. Progression of diabetes retinal status within community screening programs and potential implications for screening intervals. Diabetes Care 2015; 38:488-94. [PMID: 25524948 DOI: 10.2337/dc14-1778] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study aimed to follow the natural progression of retinal changes in patients with diabetes. Such information should inform decisions with regard to the screening intervals for such patients. RESEARCH DESIGN AND METHODS An observational study was undertaken linking the data from seven diabetes retinal screening programs across the U.K. for retinal grading results between 2005 and 2012. Patients with absent or background retinopathy were followed up for progression to the end points referable retinopathy and treatable retinopathy (proliferative retinopathy). RESULTS In total, 354,549 patients were observed for up to 4 years during which 16,196 patients progressed to referable retinopathy. Of patients with no retinopathy in either eye for two successive screening episodes at least 12 months apart, the conditions of between 0.3% (95% CI 0.3-0.8%) and 1.3% (1.0-1.6%) of patients progressed to referable retinopathy, and rates of treatable eye disease were <0.3% at 2 years. The corresponding progression rates for patients with bilateral background retinopathy in successive screening episodes were 13-29% and up to 4%, respectively, in the different programs. CONCLUSIONS It may be possible to stratify patients for risk, according to baseline retinal criteria, into groups with low and high risk of their conditions progressing to proliferative retinopathy. Screening intervals for such diverse groups of patients could safely be modified according to their risk.
Collapse
Affiliation(s)
| | | | | | | | - Colin Jones
- Norwich and Norfolk University Hospital, Norwich, U.K
| | | | | | | | | |
Collapse
|
49
|
Taylor-Phillips S, Mistry H, Leslie R, Todkill D, Tsertsvadze A, Connock M, Clarke A. Extending the diabetic retinopathy screening interval beyond 1 year: systematic review. Br J Ophthalmol 2015; 100:105-14. [PMID: 25586713 PMCID: PMC4717369 DOI: 10.1136/bjophthalmol-2014-305938] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Accepted: 12/14/2014] [Indexed: 01/09/2023]
Abstract
To determine whether the recommended screening interval for diabetic retinopathy (DR) in the UK can safely be extended beyond 1 year. Systematic review of clinical and cost-effectiveness studies. Nine databases were searched with no date restrictions. Randomised controlled trials (RCTs), cohort studies, prognostic or economic modelling studies which described the incidence and progression of DR in populations with type 1 diabetes mellitus or type 2 diabetes mellitus of either sex and of any age reporting incidence and progression of DR in relation to screening interval (vs annual screening interval) and/or prognostic factors were included. Narrative synthesis was undertaken. 14 013 papers were identified, of which 11 observational studies, 5 risk stratification modelling studies and 9 economic studies were included. Data were available for 262 541 patients of whom at least 228 649 (87%) had type 2 diabetes. There were no RCTs. Studies concluded that there is little difference between clinical outcomes from screening 1 yearly or 2 yearly in low-risk patients. However there was high loss to follow-up (13–31%), heterogeneity in definitions of low risk and variation in screening and grading protocols for prior retinopathy results. Observational and economic modelling studies in low-risk patients show little difference in clinical outcomes between 1-year and 2-year screening intervals. The lack of experimental research designs and heterogeneity in definition of low risk considerably limits the reliability and validity of this conclusion. Cost-effectiveness findings were mixed. There is insufficient evidence to recommend a move to extend the screening interval beyond 1 year.
Collapse
Affiliation(s)
| | - Hema Mistry
- Warwick Medical School, The University of Warwick, Coventry, UK
| | - Rachael Leslie
- Warwick Medical School, The University of Warwick, Coventry, UK
| | - Dan Todkill
- Warwick Medical School, The University of Warwick, Coventry, UK
| | | | - Martin Connock
- Warwick Medical School, The University of Warwick, Coventry, UK
| | - Aileen Clarke
- Warwick Medical School, The University of Warwick, Coventry, UK
| |
Collapse
|
50
|
Creuzot-Garcher C, Martin-Phipps T, Beynat J, Astruc K, Brassac K, Bron AM. Effectiveness of a mobile diabetic retinopathy screening campaign to encourage diabetics to undergo regular ophthalmic follow-up. Ophthalmic Res 2014; 52:206-11. [PMID: 25402747 DOI: 10.1159/000363326] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 04/26/2014] [Indexed: 11/19/2022]
Abstract
AIM To evaluate the effectiveness of a mobile diabetic retinopathy (DR) screening campaign with a non-mydriatic camera to encourage diabetics to undergo a subsequent ophthalmic follow-up. METHODS Diabetic patients who underwent free DR screening with a non-mydriatic fundus camera were given the recommendation to have an ophthalmic visit, in a time frame suited to the DR stage or in case abnormalities in the macula, the optic nerve or intra-ocular pressure were detected. The photographs were performed by a trained orthoptist. The date of the visit to their ophthalmologist and the report of this consultation were recorded. RESULTS During 5 annual campaigns, 4,699 diabetics were screened. Of the 1,573 ophthalmic examinations recommended at the screening, 1,241 (79%) were actually conducted. A total of 623 new cases of DR were found in the course of this screening campaign, with a fair concordance between the diagnosis suggested at screening and the examination by the ophthalmologist (κ = 0.48). CONCLUSION Information and recommendations given during DR screening helped to reintroduce patients to a regular ophthalmic follow-up, at least in the short term.
Collapse
|