Compliance with recommendations from a screening programme for diabetic retinopathy

Willingness to pay for diabetic retinopathy screening in Qujiang District, rural Guangdong, southern China: a cross-sectional study

OBJECTIVE

To determine willingness to pay for a diabetic retinopathy screening, and its determinants, among people with diabetes mellitus in Qujiang District of Shaoguan City, rural Guangdong, southern China.

DESIGN

This cross-sectional study was conducted through a large-scale screening programme in 2019. We randomly selected 575 (21.5%) among 2677 people over 18 years old with known diabetes who attended the screening. Participants elected to pay nothing or RMB10-RMB120 (US$1.6-US$18.8), in RMB10 intervals, displayed on printed cards. One trained interviewer collected all the data.

SETTING

Ten primary health centres in Qujiang District of Shaoguan City, Guangdong.

PARTICIPANTS

545 from the 575 randomly selected people (94.8%) agreed to participate in the study.

OUTCOME MEASURES

Proportion of participants willing to pay anything for screening, mean amount they were willing to pay and determinants of these figures.

RESULTS

Among 545 participants (mean age 64.6 years (SD±10.4), 40.7% men), 327 (60.0%) were willing to pay something for screening, of whom 273 (83.5%) would pay RMB10-RMB30 (US$1.6-US$4.7). People living in rural areas and those from lower-income families were more likely to be willing to pay anything, while men, urban residents and those covered by employer-linked insurance were willing to pay larger sums (p<0.05 for all).

CONCLUSION

Nearly two-thirds of participants were willing to pay for screening in this screening programme organised at the primary care level in rural China. This finding offers the potential that such activities can be sustained and scaled up through user fees.

Rates and Predictors of Nonadherence to Postophthalmic Screening Tertiary Referrals in Patients with Type 2 Diabetes

Purpose

To determine the rates and develop an initial risk prediction model for nonadherence to post screening ophthalmic referral (PSOR) in type 2 diabetes mellitus (T2DM) patients attending a national diabetic retinopathy screening program in Singapore.

Methods

Data from 2387 patients with T2DM (mean [standard deviation] age: 66.5 [11] years; 52.5% female patients) who underwent teleophthalmic screening between 2010 and 2014 under the Singapore Integrated Diabetic Retinopathy Program were extracted from electronic medical records. All were referred for tertiary ophthalmic management at the Singapore National Eye Centre (SNEC). Nonadherence was defined as not attending the SNEC appointment within 6 months of the assigned appointment date. Regression analysis using traditional modified Poisson and conditional inference models was used to construct and evaluate the discriminative ability of the preliminary risk prediction model to identify nonadherent individuals.

Results

Nonadherence rates to PSOR was 12.7% (95% confidence interval, 11.4%–14.1%). In traditional multivariable models adjusted for sociodemographic, lifestyle, and ocular factors, nonadherent individuals had higher triglyceride levels and were less likely to have a referable eye condition (P < 0.05). This model was able to identify nonadherent individuals with an accuracy (area under the curve) of 84%. In contrast, the conditional inference model was able to achieve similar discriminative ability using only participants’ ocular health characteristics.

Conclusions

The rates of nonadherence to PSOR in Singaporean individuals with T2DM is low, with better ocular health being strongly predictive of nonadherence in our Asian population.

Translational Relevance

Our results may inform interventions to decrease nonadherence to PSOR.

Teleophthalmic Approach for Detection of Corneal Diseases: Accuracy and Reliability

PURPOSE

Corneal and anterior segment diseases cause most of the urgent visits to eye care professionals. We evaluated the diagnostic accuracy of detecting corneal diseases using external photographs from 2 portable cameras for telemedicine purposes.

METHODS

This is a prospective study of adults with a clinical diagnosis of corneal pathology including corneal abrasions, ulcers, scars, and pterygia. A cornea specialist provided the gold standard diagnosis by slit-lamp examination. Images of both eyes were obtained using iTouch 5S and Nidek VersaCam cameras in multiple gazes and interpreted by 3 cornea specialists for the presence of pathology. Accuracy to detect disease was compared with gold standard diagnosis, stratified by the camera and grader. Reliability was evaluated with weighted kappa statistics. Graders assessed image quality on a Likert scale from 1 (poor) to 9 (optimal).

RESULTS

A total of 198 eyes (110 subjects) were photographed. By gold standard diagnosis, 59 eyes (30%) had corneal scars, 34 (17%) had ulcers, 13 (7%) had abrasions, 10 (5%) had pterygia, and 82 (41%) were normal. Sensitivity to detect AS pathology ranged from 54% to 71% for the iTouch and 66% to 75% for the Nidek, across graders; specificity ranged from 82% to 96% for the iTouch and 91% to 98% for the Nidek. The intergrader reliability was moderate to strong (kappa ranges: 0.54-0.71 for the iTouch; 0.75-0.76 for the Nidek). Quality ratings were variable between graders.

CONCLUSIONS

External photographs taken by standard, nonenhanced portable cameras and interpreted remotely by ophthalmologist graders yielded sensitivity values that are not yet suitable for telemedicine applications. Additional work is needed to improve the ability to detect AS pathology remotely.

What do patients with diabetes and providers think of an innovative Australian model of remote diabetic retinopathy screening? A qualitative study

BACKGROUND

Diabetic retinopathy (DR) is the commonest cause of preventable blindness in working age populations, but up to 98% of visual loss secondary to DR can be prevented with early detection and treatment. In 2012, an innovative outreach DR screening model was implemented in remote communities in a state of Australia. The aim of this study was to explore the acceptability of this unique DR screening model to patients, health professionals and other key stakeholders.

METHODS

This descriptive qualitative study used semi-structured interviews with patients opportunistically recruited whilst attending DR screening, and purposefully selected health care professionals either working within or impacted by the programme. Interviews were audiotaped, transcribed and analysed using NVIVO. An iterative process of thematic analysis was used following the principles of grounded theory.

RESULTS

Interviews were conducted with fourteen patients with diabetes living in three remote communities and nine health professionals or key stakeholders. Nine key themes emerged during interviews with health professionals, key stakeholders and patients: i) improved patient access to DR screening; ii) efficiency, financial implications and sustainability; iii) quality and safety; iv) multi-disciplinary diabetes care; v) training and education; vi) operational elements of service delivery; vii) communication, information sharing and linkages; viii) coordination and integration of the service and ix) suggested improvements to service delivery.

CONCLUSIONS

The Remote Outreach DR Screening Service is highly acceptable to patients and health professionals. Challenges have primarily been encountered in communication and coordination of the service and further development in these areas could improve the programme's impact and sustainability in remote communities. The service is applicable to other remote communities nationally and potentially internationally.

An Innovative Australian Outreach Model of Diabetic Retinopathy Screening in Remote Communities

Background. Up to 98% of visual loss secondary to diabetic retinopathy (DR) can be prevented with early detection and treatment. Despite this, less than 50% of Australian and American diabetics receive appropriate screening. Diabetic patients living in rural and remote communities are further disadvantaged by limited access to ophthalmology services. Research Design and Methods. DR screening using a nonmydriatic fundal camera was performed as part of a multidisciplinary diabetes service already visiting remote communities. Images were onforwarded to a distant general practitioner who identified and graded retinopathy, with screen-positive patients referred to ophthalmology. This retrospective, descriptive study aims to compare the proportion of remote diabetic patients receiving appropriate DR screening prior to and following implementation of the service. Results. Of the 141 patients in 11 communities who underwent DR screening, 16.3% had received appropriate DR screening prior to the implementation of the service. In addition, 36.2% of patients had never been screened. Following the introduction of the service, 66.3% of patients underwent appropriate DR screening (p = 0.00025). Conclusion. This innovative model has greatly improved accessibility to DR screening in remote communities, thereby reducing preventable blindness. It provides a holistic, locally appropriate diabetes service and utilises existing infrastructure and health workforce more efficiently.

Teleophthalmology screening for diabetic retinopathy through mobile imaging units within Canada

BACKGROUND

This study aimed to describe and measure the health results of a Category 3 teleophthalmology screening project for diabetic retinopathy (DR). Implemented through mobile screening imaging units located within pharmacies, the project had the goal of reaching unscreened diabetic patients in urban communities while lowering barriers to screening and saving medical resources.

METHODS

Image capture of both eyes of 3505 known diabetic individuals was performed in the provinces of Quebec, British Columbia, Alberta, Manitoba, and Saskatchewan. A photographer performed fundus imaging, and a nurse used mild pupil dilation only when necessary to secure image quality. Screening was provided free of cost in the context of DR health days for DR screening. Through teleophthalmology, ophthalmologists proceeded with data and image interpretation, and timely referral when indicated.

RESULTS

This project allowed the resumption of screening of over 38% of the cohort of known diabetics who reported never having undergone any eye examination with pupil dilation, and an additional 30% who reported not having been examined for over 2 years. All known diabetics were under the care of a general physician, and their mean diabetes duration, when known, was 8 years. DR pathology was found in 22.5% (20%-28%) of the cohort, 1.8% requiring urgent referral (within 30 days) as a result of the severity of the DR and 0.6% (0%-1.8%) requiring urgent referral for other reasons. An additional 8.7% (8.1%-19.5%) required ophthalmologic attention within 6 months because of DR and another 2.0% (0%-6.3%) between 6 months and 1 year. Incidental findings were found in 23%, the majority of which were related to cataract and dry macular degeneration. Urgent or significant incidental findings were found in 0.6% of the screened eyes. Pupil dilation with tropicamide 1% was deemed useful or necessary in 33.7% of the cohort. For 0.7% of the cohort, the images could not be interpreted because of poor image quality and for that reason had to be referred for a traditional dilated eye examination. Ophthalmologists were relieved of the examination of 85.6% of the screened diabetic individuals who benefited from screening without requiring a traditional ophthalmologic examination. On the other hand, ophthalmologists were required to provide urgent (within 30 days) services to 2% of the cohort, either because of threatening DR or because of incidental findings requiring rapid ophthalmologic attention.

INTERPRETATION

This screening strategy for DR through mobile teleophthalmology imaging units efficiently lowered barriers to screening and created new screening opportunities for a large number of known diabetic individuals who were lost to the traditional health system. It has the potential to provide better outreach to diabetic populations while identifying individuals truly in need of the services of an ophthalmologist; at the same time it maximizes the use of limited ophthalmologic resources while favouring multidisciplinary collaborations. The significant incidental findings associated with screening highlight the need for ophthalmologic competencies during DR screening within a teleophthalmology approach. Further involvement of government health authorities is pivotal in embracing the opportunities provided by emerging technologies such as teleophthalmology and translating them into better outreach services to diabetic populations and thus better visual health results.

Virtual community consultation? Using the literature and weblogs to link community perspectives and health technology assessment

BACKGROUND

Community views, expressed in social impact assessments and collected through community consultation, should play an important role in health technology assessment (HTA). Yet HTA methodologists have been slow to include outcomes of these forms of inquiry in analyses, in part because collecting community views is time-consuming and resource intensive.

OBJECTIVE

To explore how community views sourced from published studies, grey literature and informal internet web pages can inform HTA.

METHODS

A technology reviewed by Adelaide HTA in 2004 was selected: retinal photography for detection of diabetic retinopathy. Published literature, 'grey' literature and informal web pages were searched to examine the availability of evidence about service community and user community views with respect to this technology. Particular efforts were made to source evidence relating to rural, remote and Aboriginal populations.

RESULTS

We found that journal articles, reports from the grey literature and informal internet web pages (including blogs and discussion forums) can provide valuable insight into community views. Although there was little empirical evidence relating to the experience of diabetes and diabetes management in rural, remote and Aboriginal communities, there were indications that some evidence may be transferable from other populations.

CONCLUSIONS

Community perspectives on selected health technologies can be gauged from available resources in published and grey literature and perspectives collected in this way can provide insight into whether the introduction of the technology would be acceptable to the community. The limitations of this approach are discussed.

Comparative study of the polaroid and digital non-mydriatic cameras in the detection of referrable diabetic retinopathy in Australia

AIM

To show that the non-mydriatic retinal camera (NMRC) using polaroid film is as effective as the NMRC using digital imaging in detecting referrable retinopathy.

METHODS

A series of patients with diabetes attending the eye out-patients department at the Royal Victorian Eye and Ear Hospital had single-field non-mydriatic fundus photographs taken using first a digital and then a polaroid camera. Dilated 30 degrees seven-field stereo fundus photographs were then taken of each eye as the gold standard. The photographs were graded in a masked fashion. Retinopathy levels were defined using the simplified Wisconsin Grading system. We used the kappa statistics for inter-reader and intrareader agreement and the generalized linear model to derive the odds ratio.

RESULTS

There were 196 participants giving 325 undilated retinal photographs. Of these participants 111 (57%) were males. The mean age of the patients was 68.8 years. There were 298 eyes with all three sets of photographs from 154 patients. The digital NMRC had a sensitivity of 86.2%[95% confidence interval (CI) 65.8, 95.3], whilst the polaroid NMRC had a sensitivity of 84.1% (95% CI 65.5, 93.7). The specificities of the two cameras were identical at 71.2% (95% CI 58.8, 81.1). There was no difference in the ability of the polaroid and digital camera to detect referrable retinopathy (odds ratio 1.06, 95% CI 0.80, 1.40, P = 0.68).

CONCLUSION

This study suggests that non-mydriatic retinal photography using polaroid film is as effective as digital imaging in the detection of referrable retinopathy in countries such as the USA and Australia or others that use the same criterion for referral.

Mass community screening for diabetic retinopathy using a nonmydriatic camera with telemedicine

BACKGROUND

Diabetic retinopathy is a leading cause of blindness. Studies have shown the value of screening and early, timely treatment. Our aim was to measure the effectiveness and degree of acceptance of community screening for diabetic retinopathy using telemedicine.

METHODS

In this prospective, population-based cross-sectional study, diabetics recruited through a regional multimedia campaign were surveyed and screened for retinopathy using a nonmydriatic camera and evaluated through telemedical imaging.

RESULTS

Of the 291 diabetics recruited over a 3-week period (37% by the regional diabetes association and 30% by the media), 49.4% reported having their most recent eye examination within 1 year, 30.7% between 1 to 2 years, 9.7% over 2 years, and 10.1% had never had an exam. 98.6% found our screening method acceptable, with 95.1% wanting to return for their next screening and 91.2% stating it would increase their compliance to annual screening.

INTERPRETATION

Telemedicine provided a reliable and highly acceptable method for diabetic retinopathy screening. It can attract a significant number of people with diabetes and potentially recruit patients who would otherwise be missed by the current methods of vision screening.

Single-field fundus photography for diabetic retinopathy screening: a report by the American Academy of Ophthalmology

OBJECTIVE

To evaluate whether single-field fundus photography can be used as a screening tool to identify diabetic retinopathy for referral for further ophthalmic care.

METHODS

A MEDLINE search of the peer-reviewed literature was conducted in June 2001 for the years 1968 to 2001 and updated in September 2003, yielding 145 articles. The search was limited to articles published in English. The Cochrane Library of clinical trials was also investigated. The authors reviewed the abstracts of these articles and selected 63 of possible clinical relevance for review by the panel. Of these 63 articles, the panel selected 32 for the panel methodologist to review and rate according to the strength of evidence.

RESULTS

Three of the 32 articles reviewed were classified as level I evidence, and 4 were classified as level II evidence. Evidence from level I studies demonstrates that as a tool to detect vision-threatening retinopathy, single-field fundus photography interpreted by trained readers has sensitivity ranging from 61% to 90% and specificity ranging from 85% to 97% when compared with the gold standard reference of stereophotographs of 7 standard fields. When compared with dilated ophthalmoscopy by an ophthalmologist, single-field fundus photography has sensitivity ranging from 38% to 100% and specificity ranging from 75% to 100%.

CONCLUSIONS

Single-field fundus photography is not a substitute for a comprehensive ophthalmic examination, but there is level I evidence that it can serve as a screening tool for diabetic retinopathy to identify patients with retinopathy for referral for ophthalmic evaluation and management. The advantages of single-field fundus photography interpreted by trained readers are ease of use (only one photograph is required), convenience, and ability to detect retinopathy. Further studies will be required to assess the implementation of single-field photography-based programs to confirm the clinical and cost-effectiveness of these techniques in improving population visual outcomes. Future research also should include establishing standardized protocols and satisfactory performance standards for diabetic retinopathy screening programs.

Management of diabetic retinopathy by general practitioners in Victoria

PURPOSE

To compare the self-reported management of diabetic retinopathy by general practitioners to the National Health and Medical Research Council of Australia (NHMRC) Guidelines for the Management of Diabetic Retinopathy.

METHODS

In 1994, a stratified (by urban/rural practice location) sample of 500 general practitioners in Victoria was surveyed in regard to their management of diabetic retinopathy. Following the release of the NHMRC Guidelines for the Management of Diabetic Retinopathy in 1997, these same general practitioners were sent a two-page questionnaire related to their management of diabetic retinopathy.

RESULTS

Completed questionnaires were received from 228 general practitioners (59% of original participants). Only 37% (79/216) of the general practitioners reported that they had received a copy of the guidelines. Of the general practitioners who had received the guidelines, 18% (14/79) said that they had not read them at all, while 65% (51/79) had read them partially and 18% (14/79) had read them in their entirety. At follow up, less than half (98/214) of general practitioners reported examining 50% or more of their patients for diabetic retinopathy, compared with 104/214 at baseline. General practitioners who had read the guidelines were more likely to report that not being sure what to do when changes were detected was a minor barrier or was not a barrier to them performing dilated ophthalmoscopy (93% vs 83%, chi2(1) = 3.67, P = 0.055). Nearly all of the general practitioners reported that they refer their patients with diabetes to an ophthalmologist or optometrist at least every 2 years as recommended. Seventy-six per cent (170/224) of the general practitioners felt that 70% or more of their patients complied with their instructions to visit an ophthalmologist or optometrist.

CONCLUSION

The NHMRC guidelines for diabetic retinopathy appear to have had a positive effect on some of the attitudes of general practitioners who have read them, but more effort is needed to disseminate the guidelines to all general practitioners and to increase their uptake.

Examination compliance and screening for diabetic retinopathy: a 2-year follow-up study

Early detection and timely treatment of diabetic retinopathy can preserve vision, yet many people with diabetes do not have their eyes examined regularly. The purpose of this study was to examine eye care practices of people with diabetes who had not previously accessed eye care services on a regular basis. Screening with non-mydriatic retinal photography for diabetic retinopathy was initiated in 1996, and targeted people with diabetes who did not access eye care services on a regular basis. Each test area was revisited 2 years after the initial screening. Patients that did not attend the biennial screening were followed up by mail survey. Although none of the participants in this study had been previously accessing eye care services on a regular basis, 87% did so after attending the screening. These results indicate that mobile screening with non-mydriatic photography, as an adjunct to current eye care services, has the potential to increase examination compliance for diabetic retinopathy and to achieve sustained behaviour change.