Telemedicina en Atención Primaria: evaluación de la retinopatía diabética en una Zona Básica de Salud

[Diabetic retinopathy screening programme in primary health care. Diagnostic concordance between family and eye care practitioners]

AIM

To evaluate the diagnostic concordance in retinography interpretation between primary care and eye care practitioners and assess the soundness index of a diabetic retinography screening programme during its implementation stage.

MATERIAL AND METHODS

Descriptive, observational study was conducted on a sample of 243 patients with diabetes mellitus (type 1 and 2) over age 14, in 2 urban health care centers, gathered in an opportunistic manner between the dates of 21/07/2011 and 26/01/2012. A 45° digital bilateral retinography, intraocular pressure and visual acuity were obtained from each patient. The primary care practitioners prepared a report for each patient, which was telematically sent to the eye care doctor within the corresponding retinographies. A new diagnostic report was prepared then by the eye care doctor after revising the images. The lack of retinographies and/or reports were considered both as losses. The diagnostic concordance between the observers and the validity and reliability from the screening programme were estimated.

RESULTS

The kappa value obtained was 0.62 (95% CI 0.42-0.82) and 0.89 PABAK. The following validity indexes were obtained: Sensitivity 68.8%, specificity 96.5%, positive and negative predictive values: 61.1 and 97.5%, respectively. A percentage of 57.2 of the patients were not observed any pathology requiring referral to a eye care doctor.

CONCLUSIONS

The concordance value obtained varied between considerable and almost perfect, depending on the index used for the analysis (kappa/PABAK, respectively). It's worth highlighting that carrying out retinographies in the primary care centers enhances patient-treatment capacity of the primary care doctors and the patients accessibility to screening.

[Implementation of diabetic retinopathy screening using digital retinography in primary care]

OBJECTIVE

To improve early detection and monitoring of diabetic retinopathy (DR) in two primary care centers (PCC) using a non-mydriatic retinal camera (NMRC).

DESIGN

Prospective longitudinal descriptive study.

LOCATION

Area 11 Primary Care, Madrid.

PARTICIPANTS

Adult patients with diabetes (DM) without funduscopic examination in the last two years (FO).

INTERVENTIONS

Implementation process of screening for DR by NMRC in PCC. Digital photography of the retina made by nursing staff. Interpretation of retinal images by an ophthalmologist.

MEASUREMENTS

Number of DM with FO. Number of patients with DR. Metabolic control in the last two years (HbA1c).

STUDY PERIOD

September 2009-September 2011.

RESULTS

DM increased from 2850 to 3357. The proportion of patients with FO increased from 6.7% (95% CI: 5.7-7.6%) to 32.4% (95% CI: 30.8-34.0%) (P<.001). The prevalence of DR increased from 3.85% (95% CI: 3.14-4.58%) to 4.3% (95% CI: 3.59-4.99%). The percentage of patients with FO and DR decreased from 60% (95% CI: 52.77-67.23%) to 14% (95% CI: 11.87-16.09%) (P<.001). The proportion of DM with HbA1c increased from 21.9% (95% CI: 20.36-23.43%) to 52.4% (95% CI: 50.69-54.10%) (P<.001). The mean HbA1c in patients with DR and without DR was 7.8 (95% CI: 7.50-8.06) and 7.1 (IC95% CI: 7.08-7.22) (P<.001), respectively.

CONCLUSIONS

NMRC in PCC is accompanied by an increase in the number of diabetics with FO examination. The implementing of DR screening is possible if an NMRC is available, along with available resources, the motivation of the professionals involved and management commitment. A longer follow-up is required to determine its impact on referral rates to ophthalmology service, and to only refer those with dubious images.

[Retinography and tonometry in primary care: techniques incorporated into routine nursing practice]

OBJECTIVES

To determine the frequency of eye fundus examinations during the study period compared to the previous year. To find out the prevalence of diabetic retinopathy and the level of agreement between the primary care doctor and the ophthalmologist in the interpration of retinographies performed. To determine the relationship of the different variables with the prevalence of retinopathy. To describe the problems detected in the handling of the digital retinograph. And finally to determine the prevalence of increased intraocular pressure (IOP) in diabetic patients.

METHODS

In the wellness area S. Gormaz Esteban (Soria, Spain) we performed a descriptive observational study on patients with diabetes. The nurse conducted a visual screening that included retinography and tonometry.

RESULTS

There was moderate agreement in interpretation of retinographs. The coverage of diabetes who have undergone eye screening has increased to 50% (133). Some degree of retinopathy was seen in 38% (44) of the patients studied and the quality of images obtained in 67% (88) was good. The type of diabetes and treatment, the presence of dyslipidemia and nephropathy and years of evolution and elevated glycated haemoglobin are statistically significant variables. The mean IOP was 14.66 mmHg, and 5% (6) had levels >21 mmHg.

CONCLUSIONS

The implementation of comprehensive eye screening for diabetic patients should be consolidated as an intervention in primary care and referring only patients with specialized referral criteria, doubtful cases and technical failures.