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Shumye AF, Tegegne MM, Eticha BL, Bekele MM, Woredekal AT, Asmare L. Prevalence and associated factors of proliferative diabetic retinopathy among adult diabetic patients in Northwest Ethiopia, 2023: A cross-sectional multicenter study. PLoS One 2024; 19:e0303267. [PMID: 38728350 PMCID: PMC11086827 DOI: 10.1371/journal.pone.0303267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 04/22/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Proliferative diabetic retinopathy is one of the advanced complications of diabetic retinopathy. If left untreated, almost all eyes could lose a significant portion of their vision within four months. There is limited evidence regarding the magnitude of proliferative diabetic retinopathy and associated factors in the study setting and also in Ethiopia. PURPOSE To determine the magnitude and associated factors of proliferative diabetic retinopathy among adult diabetic patients attending Specialized Comprehensive Hospital-Diabetic Care Clinics in Northwest Ethiopia, 2023. METHODS A multicenter, hospital-based, cross-sectional study was conducted on 1219 adult diabetic patients selected by systematic random sampling technique. Data were collected through an in-person interview and physical examination. The Statistical Package for Social Science Version 20 was used to analyze the data. Logistic regression methods were used to test the association between predisposing factors and proliferative diabetic retinopathy. The adjusted odds ratio with a 95% confidence interval was used to determine the strength of association. RESULTS The prevalence of proliferative diabetic retinopathy was 3.1% (95% CI: 2.10%-4.10%). Hypertension (AOR = 4.35 (95% CI: 1.87-10.12)), peripheral neuropathy (AOR = 3.87 (95% CI: 1.57-9.54)), nephropathy (AOR = 2.58 (95% CI: 1.13-5.87)), ≥10 years duration of diabetes mellitus (AOR = 5.30 (95% CI: 2.32-12.14)), insulin use (AOR = 3.07 (95% CI: 1.08-8.68)), and poor adherence to diabetes mellitus medications (AOR = 3.77 (95% CI: 1.64-8.64)) were confirmed to have statistically significant association with proliferative diabetic retinopathy. CONCLUSION The prevalence of proliferative diabetic retinopathy among adult diabetic patients in the diabetes clinic was higher than the global study. Hypertension, peripheral neuropathy, nephropathy, ≥10 year's duration of diabetic mellitus, insulin use and poor adherence to diabetes mellitus medications were among the factors significantly associated with proliferative diabetic retinopathy.
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Affiliation(s)
- Abebech Fikade Shumye
- Department of Optometry, College of Medicine and Health Sciences, Comprehensive Specialized Hospital, University of Gondar, Gondar, Ethiopia
| | - Mebratu Mulusew Tegegne
- Department of Optometry, College of Medicine and Health Sciences, Comprehensive Specialized Hospital, University of Gondar, Gondar, Ethiopia
| | - Biruk Lelisa Eticha
- Department of Optometry, College of Medicine and Health Sciences, Comprehensive Specialized Hospital, University of Gondar, Gondar, Ethiopia
| | - Matiyas Mamo Bekele
- Department of Optometry, College of Medicine and Health Sciences, Comprehensive Specialized Hospital, University of Gondar, Gondar, Ethiopia
| | - Asamere Tsegaw Woredekal
- Department of Ophthalmology, College of Medicine and Health Sciences, Comprehensive Specialized Hospital, University of Gondar, Gondar, Ethiopia
| | - Lakew Asmare
- Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
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Pereira AP, Macedo J, Afonso A, Laureano RMS, de Lima Neto FB. The use of social simulation modelling to understand adherence to diabetic retinopathy screening programs. Sci Rep 2024; 14:4963. [PMID: 38424187 PMCID: PMC10904866 DOI: 10.1038/s41598-024-55517-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 02/24/2024] [Indexed: 03/02/2024] Open
Abstract
The success of screening programs depends to a large extent on the adherence of the target population, so it is therefore of fundamental importance to develop computer simulation models that make it possible to understand the factors that correlate with this adherence, as well as to identify population groups with low adherence to define public health strategies that promote behavioral change. Our aim is to demonstrate that it is possible to simulate screening adherence behavior using computer simulations. Three versions of an agent-based model are presented using different methods to determine the agent's individual decision to adhere to screening: (a) logistic regression; (b) fuzzy logic components and (c) a combination of the previous. All versions were based on real data from 271,867 calls for diabetic retinopathy screening. The results obtained are statistically very close to the real ones, which allows us to conclude that despite having a high degree of abstraction from the real data, the simulations are very valid and useful as a tool to support decisions in health planning, while evaluating multiple scenarios and accounting for emergent behavior.
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Affiliation(s)
- Andreia Penso Pereira
- Information Sciences, Technologies and Architecture Research Center (ISTAR-IUL), Instituto Universitário de Lisboa (ISCTE-IUL), Av. das Forças Armadas, 1649-026, Lisboa, Portugal.
| | - João Macedo
- Escola Politécnica, Computer Engineering, (POLI/EComp), Universidade de Pernambuco (UPE), Recife, 50720-001, Brazil
| | - Ana Afonso
- Global Health and Tropical Medicine, GHTM, Associate Laboratory in Translation and Innovation Towards Global Health, LA-REAL, Instituto de Higiene e Medicina Tropical, IHMT, Universidade NOVA de Lisboa, UNL, Rua da Junqueira 100, 1349-008, Lisboa, Portugal
| | - Raul M S Laureano
- Information Sciences, Technologies and Architecture Research Center (ISTAR-IUL), Instituto Universitário de Lisboa (ISCTE-IUL), Av. das Forças Armadas, 1649-026, Lisboa, Portugal.
- Business Research Unit (BRU-IUL), Instituto Universitário de Lisboa (ISCTE-IUL), Av. das Forças Armadas, 1649-026, Lisboa, Portugal.
| | - Fernando Buarque de Lima Neto
- Escola Politécnica, Computer Engineering (POLI/PPG-EC), Universidade de Pernambuco (UPE), Rua Benfica, 455-Bloco 'C', Recife, 50720-001, Brazil
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3
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Jacoba CMP, Cavallerano JD, Tolston AM, Silva PS. Effect of Accessible Nonmydriatic Retinal Imaging on Diabetic Retinopathy Surveillance Rates. Telemed J E Health 2023; 29:1667-1672. [PMID: 36912812 DOI: 10.1089/tmj.2022.0313] [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] [Indexed: 03/14/2023] Open
Abstract
Purpose: To evaluate the impact on surveillance rates for diabetic retinopathy (DR) by providing nonmydriatic retinal imaging as part of comprehensive diabetes care at no cost to patients or insurers. Methods: A retrospective comparative cohort study was designed. Patients were imaged from April 1, 2016 to March 31, 2017 at a tertiary diabetes-specific academic medical center. Retinal imaging was provided without additional cost beginning October 16, 2016. Images were evaluated for DR and diabetic macular edema using standard protocol at a centralized reading center. Diabetes surveillance rates before and after no-cost imaging were compared. Results: A total of 759 and 2,080 patients respectively were imaged before and after offering no-cost retinal imaging. The difference represents a 274% increase in the number of patients screened. Furthermore, there was a 292% and 261% increase in the number of eyes with mild DR and referable DR, respectively. In the comparative 6-month period, 92 additional cases of proliferative DR were identified, estimated to prevent 6.7 cases of severe visual loss with annual cost savings of $180,230 (estimated yearly cost of severe vision loss per person: $26,900). In patients with referable DR, self-awareness was low, with no significant difference in the before and after groups (39.4% vs. 43.8%, p = 0.3725). Conclusions: Providing retinal imaging as part of comprehensive diabetes care substantially increased the number of patients identified by nearly threefold. The data suggest that the removal of out-of-pocket costs substantially increased patient surveillance rates, which may translate to improved long-term patient outcomes.
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Affiliation(s)
- Cris Martin P Jacoba
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Jerry D Cavallerano
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Ann M Tolston
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA
| | - Paolo S Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
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4
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Liu H, Li R, Zhang Y, Zhang K, Yusufu M, Liu Y, Mou D, Chen X, Tian J, Li H, Fan S, Tang J, Wang N. Economic evaluation of combined population-based screening for multiple blindness-causing eye diseases in China: a cost-effectiveness analysis. Lancet Glob Health 2023; 11:e456-e465. [PMID: 36702141 DOI: 10.1016/s2214-109x(22)00554-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 11/24/2022] [Accepted: 12/14/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND More than 90% of vision impairment is avoidable. However, in China, a routine screening programme is currently unavailable in primary health care. With the dearth of economic evidence on screening programmes for multiple blindness-causing eye diseases, delivery options, and screening frequencies, we aimed to evaluate the costs and benefits of a population-based screening programme for multiple eye diseases in China. METHODS We developed a decision-analytic Markov model for a cohort of individuals aged 50 years and older with a total of 30 1-year cycles. We calculated the cost-effectiveness and cost-utility of screening programmes for multiple major blindness-causing eye diseases in China, including age-related macular degeneration, glaucoma, diabetic retinopathy, cataracts, and pathological myopia, from a societal perspective (including direct and indirect costs). We analysed rural and urban settings separately by different screening delivery options (non-telemedicine [ie, face-to-face] screening, artificial intelligence [AI] telemedicine screening, and non-AI telemedicine screening) and frequencies. We calculated incremental cost-utility ratios (ICURs) using quality-adjusted life-years and incremental cost-effectiveness ratios (ICERs) in terms of the cost per blindness year avoided. One-way deterministic and simulated probabilistic sensitivity analyses were used to assess the robustness of the main outcomes. FINDINGS Compared with no screening, non-telemedicine combined screening of multiple eye diseases satisfied the criterion for a highly cost-effective health intervention, with an ICUR of US$2494 (95% CI 1130 to 2716) and an ICER of $12 487 (8773 to 18 791) in rural settings. In urban areas, the ICUR was $624 (395 to 907), and the ICER was $7251 (4238 to 13 501). Non-AI telemedicine screening could result in fewer costs and greater gains in health benefits (ICUR $2326 [1064 to 2538] and ICER $11 766 [8200 to 18 000] in rural settings; ICUR $581 [368 to 864] and ICER $6920 [3926 to 13 231] in urban settings). AI telemedicine screening dominated no screening in rural settings, and in urban settings the ICUR was $244 (-315 to 1073) and the ICER was $2567 (-4111 to 15 389). Sensitivity analyses showed all results to be robust. By further comparison, annual AI telemedicine screening was the most cost-effective strategy in both rural and urban areas. INTERPRETATION Combined screening of multiple eye diseases is cost-effective in both rural and urban China. AI coupled with teleophthalmology presents an opportunity to promote equity in eye health. FUNDING National Natural Science Foundation of China.
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Affiliation(s)
- Hanruo Liu
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China; School of Medical Technology, Beijing Institute of Technology, Beijing, China; National Institutes of Health Data Science at Peking University, Beijing, China.
| | - Ruyue Li
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yue Zhang
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Kaiwen Zhang
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Mayinuer Yusufu
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Department of Surgery (Ophthalmology), The University of Melbourne, Melbourne, VIC, Australia
| | - Yanting Liu
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mou
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Xiaoniao Chen
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Jiaxin Tian
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Huiqi Li
- School of Medical Technology, Beijing Institute of Technology, Beijing, China
| | - Sujie Fan
- Handan City Eye Hospital, Handan, China
| | - Jianjun Tang
- School of Agricultural Economics and Rural Development, Renmin University of China, Beijing, China.
| | - Ningli Wang
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China; School of Medical Technology, Beijing Institute of Technology, Beijing, China; National Institutes of Health Data Science at Peking University, Beijing, China.
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Curran DM, Kim BY, Withers N, Shepard DS, Brady CJ. Telehealth Screening for Diabetic Retinopathy: Economic Modeling Reveals Cost Savings. Telemed J E Health 2022; 28:1300-1308. [PMID: 35073213 PMCID: PMC9508450 DOI: 10.1089/tmj.2021.0352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 12/10/2021] [Accepted: 12/13/2021] [Indexed: 11/12/2022] Open
Abstract
Introduction: The use of telehealth screening (TS) for diabetic retinopathy (DR) consists of fundus photography in a primary care setting with remote interpretation of images. TS for DR is known to increase screening utilization and reduce vision loss compared with standard in-person conventional diabetic retinal exam (CDRE). Anti-vascular endothelial growth factor intravitreal injections have become standard of care for the treatment of DR, but they are expensive. We investigated whether TS for DR is cost-effective when DR management includes intravitreal injections using national data. Materials and Methods: We compared cost and effectiveness of TS and CDRE using decision-tree analysis and probabilistic sensitivity analysis with Monte Carlo simulation. We considered the disability weight (DW) of vision impairment and 1-year direct medical costs of managing patients based on Medicare allowable rates and clinical trial data. Primary outcomes include incremental costs and incremental effectiveness. Results: The average annual direct cost of eye care was $196 per person for TS and $275 for CDRE. On average, TS saves $78 (28%) compared with CDRE and was cost saving in 88.9% of simulations. The average DW outcome was equivalent in both groups. Discussion: Although this study was limited by a 1-year time horizon, it provides support that TS for DR can reduce costs of DR management despite expensive treatment with anti-VEGF agents. TS for DR is equally effective as CDRE at preserving vision. Conclusions: Annual TS for DR is cost saving and equally effective compared with CDRE given a 1-year time horizon.
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Affiliation(s)
- Delaney M. Curran
- Division of Ophthalmology, Department of Surgery, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Brian Y. Kim
- Division of Ophthalmology, Department of Surgery, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
- Division of Ophthalmology, Department of Surgery, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Natasha Withers
- Ambulatory Care, Porter Medical Center, University of Vermont Health Network, Middlebury, Vermont, USA
| | - Donald S. Shepard
- Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA
| | - Christopher J. Brady
- Division of Ophthalmology, Department of Surgery, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
- Division of Ophthalmology, Department of Surgery, University of Vermont Medical Center, Burlington, Vermont, USA
- Vermont Center on Behavior and Health, Larner College of Medicine, Burlington, Vermont, USA
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Ben-Assuli O. Measuring the cost-effectiveness of using telehealth for diabetes management: A narrative review of methods and findings. Int J Med Inform 2022; 163:104764. [DOI: 10.1016/j.ijmedinf.2022.104764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/07/2022] [Accepted: 04/10/2022] [Indexed: 10/18/2022]
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7
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Fuller SD, Hu J, Liu JC, Gibson E, Gregory M, Kuo J, Rajagopal R. Five-Year Cost-Effectiveness Modeling of Primary Care-Based, Nonmydriatic Automated Retinal Image Analysis Screening Among Low-Income Patients With Diabetes. J Diabetes Sci Technol 2022; 16:415-427. [PMID: 33124449 PMCID: PMC8861785 DOI: 10.1177/1932296820967011] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Artificial intelligence-based technology systems offer an alternative solution for diabetic retinopathy (DR) screening compared with standard, in-office dilated eye examinations. We performed a cost-effectiveness analysis of Automated Retinal Image Analysis System (ARIAS)-based DR screening in a primary care medicine clinic that serves a low-income patient population. METHODS A model-based, cost-effectiveness analysis of two DR screening systems was created utilizing data from a recent study comparing adherence rates to follow-up eye care among adults ages 18 or older with a clinical diagnosis of diabetes. In the study, the patients were prescreened with an ARIAS-based, nonmydriatic (undilated), point-of-care tool in the primary care setting and were compared with patients with diabetes who were referred for dilated retinal screening without prescreening, as is the current standard of care. Using a Markov model with microsimulation resulting in a total of 600 000 simulated patient experiences, we calculated the incremental cost-utility ratio (ICUR) of the two screening approaches, with regard to five-year cost-effectiveness of DR screening and treatment of vision-threatening DR. RESULTS At five years, ARIAS-based screening showed similar utility as the standard of care screening systems. However, ARIAS reduced costs by 23.3%, with an ICUR of $258 721.81 comparing the current practice to ARIAS. CONCLUSIONS Primary care-based ARIAS DR screening is cost-effective when compared with standard of care screening methods.
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Affiliation(s)
- Spencer D. Fuller
- John F. Hardesty Department of
Ophthalmology and Visual Sciences, Washington University School of Medicine, Saint
Louis, MO, USA
- Spencer D. Fuller, MD, MPH, John F. Hardesty
Department of Ophthalmology and Visual Sciences, Washington University School of
Medicine, 660 South Euclid Avenue, Campus Box 8096, Saint Louis, MO 63110, USA.
| | - Jenny Hu
- Shiley Eye Institute, University of
California San Diego School of Medicine, La Jolla, CA, USA
| | - James C. Liu
- John F. Hardesty Department of
Ophthalmology and Visual Sciences, Washington University School of Medicine, Saint
Louis, MO, USA
| | - Ella Gibson
- John F. Hardesty Department of
Ophthalmology and Visual Sciences, Washington University School of Medicine, Saint
Louis, MO, USA
| | - Martin Gregory
- John T. Milliken Department of Medicine,
Division of Gastroenterology, Washington University School of Medicine, St. Louis,
MO, USA
| | - Jessica Kuo
- John F. Hardesty Department of
Ophthalmology and Visual Sciences, Washington University School of Medicine, Saint
Louis, MO, USA
| | - Rithwick Rajagopal
- John F. Hardesty Department of
Ophthalmology and Visual Sciences, Washington University School of Medicine, Saint
Louis, MO, USA
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Ramasamy K, Mishra C, Kannan NB, Namperumalsamy P, Sen S. Telemedicine in diabetic retinopathy screening in India. Indian J Ophthalmol 2021; 69:2977-2986. [PMID: 34708732 PMCID: PMC8725153 DOI: 10.4103/ijo.ijo_1442_21] [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] [Indexed: 11/18/2022] Open
Abstract
With ever-growing prevalence of diabetes mellitus and its most common microvascular complication diabetic retinopathy (DR) in Indian population, screening for DR early for prevention of development of vision-threatening stages of the disease is becoming increasingly important. Most of the programs in India for DR screening are opportunistic and a universal screening program does not exist. Globally, telemedicine programs have demonstrated accuracy in classification of DR into referable disease, as well as into stages, with accuracies reaching that of human graders, in a cost-effective manner and with sufficient patient satisfaction. In this major review, we have summarized the global experience of telemedicine in DR screening and the way ahead toward planning a national integrated DR screening program based on telemedicine.
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Affiliation(s)
- Kim Ramasamy
- Department of Retina and Vitreous Services, Aravind Eye Hospital, Madurai, Tamil Nadu, India
| | - Chitaranjan Mishra
- Department of Retina and Vitreous Services, Aravind Eye Hospital, Madurai, Tamil Nadu, India
| | - Naresh B Kannan
- Department of Retina and Vitreous Services, Aravind Eye Hospital, Madurai, Tamil Nadu, India
| | - P Namperumalsamy
- Department of Retina and Vitreous Services, Aravind Eye Hospital, Madurai, Tamil Nadu, India
| | - Sagnik Sen
- Department of Retina and Vitreous Services, Aravind Eye Hospital, Madurai, Tamil Nadu, India
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9
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Walsh L, Hong SC, Chalakkal RJ, Ogbuehi KC. A Systematic Review of Current Teleophthalmology Services in New Zealand Compared to the Four Comparable Countries of the United Kingdom, Australia, United States of America (USA) and Canada. Clin Ophthalmol 2021; 15:4015-4027. [PMID: 34675470 PMCID: PMC8500493 DOI: 10.2147/opth.s294428] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 08/18/2021] [Indexed: 12/20/2022] Open
Abstract
Background Over 700,000 New Zealanders (NZ), particularly elderly and Māori, live without timely access to specialist ophthalmology services. Teleophthalmology is a widely recognised tool that can assist in overcoming resource and distance barriers. Teleophthalmology gained unprecedented traction in NZ during the COVID-19 pandemic and subsequent lockdown. However, its provision is still limited and there are equity issues. The aim of this study was to conduct a systematic review identifying, describing and contrasting teleophthalmology services in NZ with the comparable countries of Australia, USA, Canada and the United Kingdom. Methods The electronic databases Embase, PubMed, Web of Science, Google Scholar and Google were systemically searched using the keywords: telemedicine, ophthalmology, tele-ophthalmology/teleophthalmology. The searches were filtered to the countries above, with no time constraints. An integrative approach was used to synthesise findings. Results One hundred and thirty-two studies were identified describing 90 discrete teleophthalmology services. Articles spanned from 1997 to 2020. Models were categorised into general eye care (n=21; 16%); emergency/trauma (n=6; 4.5%); school screening (n=25; 19%); artificial intelligence (AI) (n=23; 18%); and disease-specific models of care (MOC) (n=57; 43%). The most common diseases addressed were diabetic retinopathy (n=23; 17%); retinopathy of prematurity (n=9; 7%); and glaucoma (n=8; 6%). Programs were mainly centred in the US (n=72; 54.5%), followed by the UK (n=29; 22%), then Canada (n=16; 12%), Australia (n=13; 10%), with the fewest identified in NZ (n=3; 2%). Models generally involved an ophthalmologist consultative service, remote supervision and triaging. Most models involved local clinicians transmitting fed-forward or live images. Conclusion Teleophthalmology will likely play a crucial role in the future of eye care. COVID-19 has offered a unique opportunity to observe the use of teleophthalmology services globally. Feed-forward and, increasingly, live-based teleophthalmology services have demonstrated feasibility and cost-effectiveness in similar countries internationally. New Zealand’s teleophthalmology services, however, are currently limited. Investing in strategic partnerships and technology at a national level can advance health equities in ophthalmic care.
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Affiliation(s)
- Liam Walsh
- Department of Ophthalmology, Southern District Health Board, Dunedin, Otago, New Zealand
| | - Sheng Chiong Hong
- Department of Ophthalmology, Southern District Health Board, Dunedin, Otago, New Zealand
| | - Renoh Johnson Chalakkal
- Research and Development, oDocs Eye Care, Dunedin, Otago, New Zealand.,Electrical and Computer Engineering, University of Auckland, Auckland, New Zealand
| | - Kelechi C Ogbuehi
- Department of Medicine, University of Otago, Dunedin, Otago, New Zealand
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10
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Wolf RM, Channa R, Abramoff MD, Lehmann HP. Cost-effectiveness of Autonomous Point-of-Care Diabetic Retinopathy Screening for Pediatric Patients With Diabetes. JAMA Ophthalmol 2021; 138:1063-1069. [PMID: 32880616 DOI: 10.1001/jamaophthalmol.2020.3190] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Screening for diabetic retinopathy is recommended for children with type 1 diabetes (T1D) and type 2 diabetes (T2D), yet screening rates remain low. Point-of-care diabetic retinopathy screening using autonomous artificial intelligence (AI) has become available, providing immediate results in the clinic setting, but the cost-effectiveness of this strategy compared with standard examination is unknown. Objective To assess the cost-effectiveness of detecting and treating diabetic retinopathy and its sequelae among children with T1D and T2D using AI diabetic retinopathy screening vs standard screening by an eye care professional (ECP). Design, Setting, and Participants In this economic evaluation, parameter estimates were obtained from the literature from 1994 to 2019 and assessed from March 2019 to January 2020. Parameters included out-of-pocket cost for autonomous AI screening, ophthalmology visits, and treating diabetic retinopathy; probability of undergoing standard retinal examination; relative odds of undergoing screening; and sensitivity, specificity, and diagnosability of the ECP screening examination and autonomous AI screening. Main Outcomes and Measures Costs or savings to the patient based on mean patient payment for diabetic retinopathy screening examination and cost-effectiveness based on costs or savings associated with the number of true-positive results identified by diabetic retinopathy screening. Results In this study, the expected true-positive proportions for standard ophthalmologic screening by an ECP were 0.006 for T1D and 0.01 for T2D, and the expected true-positive proportions for autonomous AI were 0.03 for T1D and 0.04 for T2D. The base case scenario of 20% adherence estimated that use of autonomous AI would result in a higher mean patient payment ($8.52 for T1D and $10.85 for T2D) than conventional ECP screening ($7.91 for T1D and $8.20 for T2D). However, autonomous AI screening was the preferred strategy when at least 23% of patients adhered to diabetic retinopathy screening. Conclusions and Relevance These results suggest that point-of-care diabetic retinopathy screening using autonomous AI systems is effective and cost saving for children with diabetes and their caregivers at recommended adherence rates.
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Affiliation(s)
- Risa M Wolf
- Department of Pediatrics, Division of Pediatric Endocrinology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Roomasa Channa
- Department of Ophthalmology, Baylor College of Medicine, Houston, Texas
| | - Michael D Abramoff
- Department of Ophthalmology and Visual Sciences, The University of Iowa, Iowa City.,Digital Diagnostics, Coralville, Iowa.,Iowa City Veterans Affairs Medical Center, Iowa City, Iowa.,Department of Biomedical Engineering, The University of Iowa, Iowa City.,Department of Electrical and Computer Engineering, The University of Iowa, Iowa City
| | - Harold P Lehmann
- Division of Health Sciences Informatics, Johns Hopkins School of Medicine, Baltimore, Maryland
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Fonda SJ, Bursell SE, Lewis DG, Clary D, Shahon D, Horton MB. The Indian Health Service Primary Care-Based Teleophthalmology Program for Diabetic Eye Disease Surveillance and Management. Telemed J E Health 2020; 26:1466-1474. [PMID: 32004436 PMCID: PMC7757525 DOI: 10.1089/tmj.2019.0281] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 12/27/2022] Open
Abstract
Background: Historically, fewer than half of American Indians and Alaska Natives (AI/AN) with diabetes received the annual diabetic retinopathy (DR) examination that is considered the minimum standard of care; this rate is similar to that of the general United States (U.S.) population with diabetes. Solution: The Indian Health Service-Joslin Vision Network (IHS-JVN) Teleophthalmology Program in 2000 to increase compliance with DR standards of care among AI/AN through validated, primary care-based telemedicine. The IHS-JVN provides remote diagnosis of DR severity, with a report including management recommendations that is returned to the patient's primary care provider. The program conforms with the American Telemedicine Association (ATA) Practice Guidelines for Ocular Telehealth-Diabetic Retinopathy. Outcomes: The IHS-JVN has been expanding incrementally since the first patients were recruited in 2000; this expansion coincides with large improvements in the annual DR examination rates reported as part of local, regional, and national regulatory compliance under the Government Performance and Results Act (GPRA). Currently, with 99 clinical implementations in 23 states, IHS-JVN is the largest primary care-based ATA validation category three telemedicine program in the U.S. Summary: This article describes the program's workflow, imaging and reading technologies, diagnostic protocols, reports to providers, training, quality assurance processes, and geographical distribution. In addition to its clinical use, the program has been utilized in research on utilization of diabetic eye care, cost-effectiveness, technology development, and DR epidemiology of the AI/AN population. Potential next steps for this program are discussed.
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Affiliation(s)
| | - Sven-Erik Bursell
- Telehealth Research Institute, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Drew G. Lewis
- Estenda Solutions, Inc., Conshohocken, Pennsylvania, USA
| | - Dawn Clary
- Indian Health Service-Joslin Vision Network, Phoenix Indian Medical Center, Phoenix, Arizona, USA
| | - Dara Shahon
- Indian Health Service-Joslin Vision Network, Phoenix Indian Medical Center, Phoenix, Arizona, USA
- Department of Ophthalmology, Phoenix Indian Medical Center, Phoenix, Arizona, USA
| | - Mark B. Horton
- Indian Health Service, Phoenix Indian Medical Center, Phoenix, Arizona, USA
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Ullah W, Pathan SK, Panchal A, Anandan S, Saleem K, Sattar Y, Ahmad E, Mukhtar M, Nawaz H. Cost-effectiveness and diagnostic accuracy of telemedicine in macular disease and diabetic retinopathy: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e20306. [PMID: 32569163 PMCID: PMC7310976 DOI: 10.1097/md.0000000000020306] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To determine cost-effectiveness and the diagnostic accuracy of teleophthalmology (TO) in the detection of macular edema (ME) and various grades of diabetic retinopathy (DR). METHODS MEDLINE, EMBASE, and Cochrane databases were searched for TO, ME, and DR on May 25, 2016. The search was updated on April 2, 2019. Pooled sensitivity and specificity for ME and various grades of DR were determined using Meta-Disc software. A systematic review of the articles discussing the cost-effectiveness of TO screening was also performed. RESULTS Thirty-three articles on the diagnostic accuracy and 28 articles on the cost-effectiveness were selected. CONCLUSIONS Telescreening is moderately sensitive but very specific for the diagnosis of diabetic retinopathy. Non-mydriatic Teleretinal screening services are cost-effective, decrease clinics workload, and increase patient compliance if provided free of cost in remote low socioeconomic regions.
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Affiliation(s)
- Waqas Ullah
- Internal Medicine, Abington – Jefferson Health, Abington, PA, USA
| | | | | | | | | | - Yasar Sattar
- Internal Medicine, Icahn School of Medicine Mount Sinai-Elmhurst Hospital, NY, USA
| | - Ejaz Ahmad
- Internal Medicine, Nishtar Hospital Center, Multan
| | | | - Haq Nawaz
- Internal Medicine, Griffin Hospital, CT, USA
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Hacisoftaoglu RE, Karakaya M, Sallam AB. Deep Learning Frameworks for Diabetic Retinopathy Detection with Smartphone-based Retinal Imaging Systems. Pattern Recognit Lett 2020; 135:409-417. [PMID: 32704196 DOI: 10.1016/j.patrec.2020.04.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Diabetic Retinopathy (DR) may result in various degrees of vision loss and even blindness if not diagnosed in a timely manner. Therefore, having an annual eye exam helps early detection to prevent vision loss in earlier stages, especially for diabetic patients. Recent technological advances made smartphone-based retinal imaging systems available on the market to perform small-sized, low-powered, and affordable DR screening in diverse environments. However, the accuracy of DR detection depends on the field of view and image quality. Since smartphone-based retinal imaging systems have much more compact designs than a traditional fundus camera, captured images are likely to be the low quality with a smaller field of view. Our motivation in this paper is to develop an automatic DR detection model for smartphone-based retinal images using the deep learning approach with the ResNet50 network. This study first utilized the well-known AlexNet, GoogLeNet, and ResNet50 architectures, using the transfer learning approach. Second, these frameworks were retrained with retina images from several datasets including EyePACS, Messidor, IDRiD, and Messidor-2 to investigate the effect of using images from the single, cross, and multiple datasets. Third, the proposed ResNet50 model is applied to smartphone-based synthetic images to explore the DR detection accuracy of smartphone-based retinal imaging systems. Based on the vision-threatening diabetic retinopathy detection results, the proposed approach achieved a high classification accuracy of 98.6%, with a 98.2% sensitivity and a 99.1% specificity while its AUC was 0.9978 on the independent test dataset. As the main contributions, DR detection accuracy was improved using the deep transfer learning approach for the ResNet50 network with publicly available datasets and the effect of the field of view in smartphone-based retinal imaging was studied. Although a smaller number of images were used in the training set compared with the existing studies, considerably acceptable high accuracies for validation and testing data were obtained.
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Affiliation(s)
| | - Mahmut Karakaya
- Dept. of Computer Science, University of Central Arkansas, Conway, AR, 72035, USA
| | - Ahmed B Sallam
- Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
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14
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Xie Y, Nguyen QD, Hamzah H, Lim G, Bellemo V, Gunasekeran DV, Yip MYT, Qi Lee X, Hsu W, Li Lee M, Tan CS, Tym Wong H, Lamoureux EL, Tan GSW, Wong TY, Finkelstein EA, Ting DSW. Artificial intelligence for teleophthalmology-based diabetic retinopathy screening in a national programme: an economic analysis modelling study. LANCET DIGITAL HEALTH 2020; 2:e240-e249. [PMID: 33328056 DOI: 10.1016/s2589-7500(20)30060-1] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/18/2020] [Accepted: 02/21/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Deep learning is a novel machine learning technique that has been shown to be as effective as human graders in detecting diabetic retinopathy from fundus photographs. We used a cost-minimisation analysis to evaluate the potential savings of two deep learning approaches as compared with the current human assessment: a semi-automated deep learning model as a triage filter before secondary human assessment; and a fully automated deep learning model without human assessment. METHODS In this economic analysis modelling study, using 39 006 consecutive patients with diabetes in a national diabetic retinopathy screening programme in Singapore in 2015, we used a decision tree model and TreeAge Pro to compare the actual cost of screening this cohort with human graders against the simulated cost for semi-automated and fully automated screening models. Model parameters included diabetic retinopathy prevalence rates, diabetic retinopathy screening costs under each screening model, cost of medical consultation, and diagnostic performance (ie, sensitivity and specificity). The primary outcome was total cost for each screening model. Deterministic sensitivity analyses were done to gauge the sensitivity of the results to key model assumptions. FINDINGS From the health system perspective, the semi-automated screening model was the least expensive of the three models, at US$62 per patient per year. The fully automated model was $66 per patient per year, and the human assessment model was $77 per patient per year. The savings to the Singapore health system associated with switching to the semi-automated model are estimated to be $489 000, which is roughly 20% of the current annual screening cost. By 2050, Singapore is projected to have 1 million people with diabetes; at this time, the estimated annual savings would be $15 million. INTERPRETATION This study provides a strong economic rationale for using deep learning systems as an assistive tool to screen for diabetic retinopathy. FUNDING Ministry of Health, Singapore.
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Affiliation(s)
- Yuchen Xie
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
| | - Quang D Nguyen
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
| | - Haslina Hamzah
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
| | - Gilbert Lim
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore; School of Computing, National University of Singapore, Singapore
| | - Valentina Bellemo
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
| | | | | | - Xin Qi Lee
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
| | - Wynne Hsu
- School of Computing, National University of Singapore, Singapore
| | - Mong Li Lee
- School of Computing, National University of Singapore, Singapore
| | - Colin S Tan
- Tan Tock Seng Hospital, National Healthcare Group, Singapore
| | - Hon Tym Wong
- Tan Tock Seng Hospital, National Healthcare Group, Singapore
| | - Ecosse L Lamoureux
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore; Tan Tock Seng Hospital, National Healthcare Group, Singapore
| | - Gavin S W Tan
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore; Tan Tock Seng Hospital, National Healthcare Group, Singapore
| | - Tien Y Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore; Tan Tock Seng Hospital, National Healthcare Group, Singapore
| | | | - Daniel S W Ting
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore; Tan Tock Seng Hospital, National Healthcare Group, Singapore; State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yet-Sen University, Guangzhou, China.
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15
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Xie Y, Gunasekeran DV, Balaskas K, Keane PA, Sim DA, Bachmann LM, Macrae C, Ting DSW. Health Economic and Safety Considerations for Artificial Intelligence Applications in Diabetic Retinopathy Screening. Transl Vis Sci Technol 2020; 9:22. [PMID: 32818083 PMCID: PMC7396187 DOI: 10.1167/tvst.9.2.22] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 01/23/2020] [Indexed: 02/06/2023] Open
Abstract
Systematic screening for diabetic retinopathy (DR) has been widely recommended for early detection in patients with diabetes to address preventable vision loss. However, substantial manpower and financial resources are required to deploy opportunistic screening and transition to systematic DR screening programs. The advent of artificial intelligence (AI) technologies may improve access and reduce the financial burden for DR screening while maintaining comparable or enhanced clinical effectiveness. To deploy an AI-based DR screening program in a real-world setting, it is imperative that health economic assessment (HEA) and patient safety analyses are conducted to guide appropriate allocation of resources and design safe, reliable systems. Few studies published to date include these considerations when integrating AI-based solutions into DR screening programs. In this article, we provide an overview of the current state-of-the-art of AI technology (focusing on deep learning systems), followed by an appraisal of existing literature on the applications of AI in ophthalmology. We also discuss practical considerations that drive the development of a successful DR screening program, such as the implications of false-positive or false-negative results and image gradeability. Finally, we examine different plausible methods for HEA and safety analyses that can be used to assess concerns regarding AI-based screening.
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Affiliation(s)
- Yuchen Xie
- Singapore National Eye Center, Singapore Eye Research Institute, Singapore
| | - Dinesh V Gunasekeran
- Singapore National Eye Center, Singapore Eye Research Institute, Singapore
- School of Medicine, National University of Singapore, Singapore
| | | | - Pearse A Keane
- Moorfields Eye Hospital, National Health Service, London, UK
| | - Dawn A Sim
- Moorfields Eye Hospital, National Health Service, London, UK
| | - Lucas M Bachmann
- Clinical Epidemiology, University of Zurich, Zurich, Switzerland
| | - Carl Macrae
- Business School, Nottingham University, Nottingham, UK
| | - Daniel S W Ting
- Singapore National Eye Center, Singapore Eye Research Institute, Singapore
- School of Medicine, Duke-National University of Singapore, Singapore
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, Guangdong, China
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16
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Horton MB, Brady CJ, Cavallerano J, Abramoff M, Barker G, Chiang MF, Crockett CH, Garg S, Karth P, Liu Y, Newman CD, Rathi S, Sheth V, Silva P, Stebbins K, Zimmer-Galler I. Practice Guidelines for Ocular Telehealth-Diabetic Retinopathy, Third Edition. Telemed J E Health 2020; 26:495-543. [PMID: 32209018 PMCID: PMC7187969 DOI: 10.1089/tmj.2020.0006] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 01/11/2020] [Accepted: 01/11/2020] [Indexed: 12/24/2022] Open
Abstract
Contributors The following document and appendices represent the third edition of the Practice Guidelines for Ocular Telehealth-Diabetic Retinopathy. These guidelines were developed by the Diabetic Retinopathy Telehealth Practice Guidelines Working Group. This working group consisted of a large number of subject matter experts in clinical applications for telehealth in ophthalmology. The editorial committee consisted of Mark B. Horton, OD, MD, who served as working group chair and Christopher J. Brady, MD, MHS, and Jerry Cavallerano, OD, PhD, who served as cochairs. The writing committees were separated into seven different categories. They are as follows: 1.Clinical/operational: Jerry Cavallerano, OD, PhD (Chair), Gail Barker, PhD, MBA, Christopher J. Brady, MD, MHS, Yao Liu, MD, MS, Siddarth Rathi, MD, MBA, Veeral Sheth, MD, MBA, Paolo Silva, MD, and Ingrid Zimmer-Galler, MD. 2.Equipment: Veeral Sheth, MD (Chair), Mark B. Horton, OD, MD, Siddarth Rathi, MD, MBA, Paolo Silva, MD, and Kristen Stebbins, MSPH. 3.Quality assurance: Mark B. Horton, OD, MD (Chair), Seema Garg, MD, PhD, Yao Liu, MD, MS, and Ingrid Zimmer-Galler, MD. 4.Glaucoma: Yao Liu, MD, MS (Chair) and Siddarth Rathi, MD, MBA. 5.Retinopathy of prematurity: Christopher J. Brady, MD, MHS (Chair) and Ingrid Zimmer-Galler, MD. 6.Age-related macular degeneration: Christopher J. Brady, MD, MHS (Chair) and Ingrid Zimmer-Galler, MD. 7.Autonomous and computer assisted detection, classification and diagnosis of diabetic retinopathy: Michael Abramoff, MD, PhD (Chair), Michael F. Chiang, MD, and Paolo Silva, MD.
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Affiliation(s)
- Mark B. Horton
- Indian Health Service-Joslin Vision Network (IHS-JVN) Teleophthalmology Program, Phoenix Indian Medical Center, Phoenix, Arizona
| | - Christopher J. Brady
- Division of Ophthalmology, Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Jerry Cavallerano
- Beetham Eye Institute, Joslin Diabetes Center, Massachusetts
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Michael Abramoff
- Department of Ophthalmology and Visual Sciences, The University of Iowa, Iowa City, Iowa
- Department of Biomedical Engineering, and The University of Iowa, Iowa City, Iowa
- Department of Electrical and Computer Engineering, The University of Iowa, Iowa City, Iowa
- Department of Ophthalmology, Stephen A. Wynn Institute for Vision Research, The University of Iowa, Iowa City, Iowa
- Iowa City VA Health Care System, Iowa City, Iowa
- IDx, Coralville, Iowa
| | - Gail Barker
- Arizona Telemedicine Program, The University of Arizona, Phoenix, Arizona
| | - Michael F. Chiang
- Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland, Oregon
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon
| | | | - Seema Garg
- Department of Ophthalmology, University of North Carolina, Chapel Hill, North Carolina
| | | | - Yao Liu
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, Wisconsin
| | | | - Siddarth Rathi
- Department of Ophthalmology, NYU Langone Health, New York, New York
| | - Veeral Sheth
- University Retina and Macula Associates, University of Illinois at Chicago, Chicago, Illinois
| | - Paolo Silva
- Beetham Eye Institute, Joslin Diabetes Center, Massachusetts
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Kristen Stebbins
- Vision Care Department, Hillrom, Skaneateles Falls, New York, New York
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18
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Sasongko MB, Wardhana FS, Febryanto GA, Agni AN, Supanji S, Indrayanti SR, Widayanti TW, Widyaputri F, Widhasari IA, Lestari YD, Adriono GA, Sovani I, Kartasasmita AS. The estimated healthcare cost of diabetic retinopathy in Indonesia and its projection for 2025. Br J Ophthalmol 2019; 104:487-492. [PMID: 31285276 DOI: 10.1136/bjophthalmol-2019-313997] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 05/10/2019] [Accepted: 06/10/2019] [Indexed: 01/24/2023]
Abstract
PURPOSE To estimate the total healthcare cost associated with diabetic retinopathy (DR) in type 2 diabetes in Indonesia and its projection for 2025. METHODS A prevalence-based cost-of-illness model was constructed from previous population-based DR study. Projection for 2025 was derived from estimated diabetes population in 2025. Direct treatment costs of DR were estimated from the perspective of healthcare. Patient perspective costs were obtained from thorough interview including only transportation cost and lost of working days related to treatment. We developed four cost-of-illness models according to DR severity level, DR without necessary treatment, needing laser treatment, laser +intravitreal (IVT) injection and laser + IVT +vitrectomy. All costs were estimated in 2017 US$. RESULTS The healthcare costs of DR in Indonesia were estimated to be $2.4 billion in 2017 and $8.9 billion in 2025. The total cost in 2017 consisted of the cost for no DR and mild-moderate non-proliferative DR (NPDR) requiring eye screening ($25.9 million), severe NPDR or proliferative DR (PDR) requiring laser treatment ($0.25 billion), severe NPDR or PDR requiring both laser and IVT injection ($1.75 billion) and advance level of PDR requiring vitrectomy ($0.44 billion). CONCLUSIONS The estimated healthcare cost of DR in Indonesia in 2017 was considerably high, nearly 2% of the 2017 national state budget, and projected to increase significantly to more than threefold in 2025. The highest cost may incur for DR requiring both laser and IVT injection. Therefore, public health intervention to delay or prevent severe DR may substantially reduce the healthcare cost of DR in Indonesia.
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Affiliation(s)
- Muhammad Bayu Sasongko
- Department of Ophthalmology, Faculty of Medicine Public Health and Nursing, Universitas Gadjah Mada-Dr Sardjito General Hospital, Yogyakarta, Indonesia
| | - Firman Setya Wardhana
- Department of Ophthalmology, Faculty of Medicine Public Health and Nursing, Universitas Gadjah Mada-Dr Sardjito General Hospital, Yogyakarta, Indonesia
| | - Gandhi Anandika Febryanto
- Department of Ophthalmology, Faculty of Medicine Public Health and Nursing, Universitas Gadjah Mada-Dr Sardjito General Hospital, Yogyakarta, Indonesia
| | - Angela Nurini Agni
- Department of Ophthalmology, Faculty of Medicine Public Health and Nursing, Universitas Gadjah Mada-Dr Sardjito General Hospital, Yogyakarta, Indonesia
| | - Supanji Supanji
- Department of Ophthalmology, Faculty of Medicine Public Health and Nursing, Universitas Gadjah Mada-Dr Sardjito General Hospital, Yogyakarta, Indonesia
| | - Sarah Rizqia Indrayanti
- Department of Ophthalmology, Faculty of Medicine Public Health and Nursing, Universitas Gadjah Mada-Dr Sardjito General Hospital, Yogyakarta, Indonesia
| | - Tri Wahyu Widayanti
- Department of Ophthalmology, Faculty of Medicine Public Health and Nursing, Universitas Gadjah Mada-Dr Sardjito General Hospital, Yogyakarta, Indonesia
| | - Felicia Widyaputri
- Department of Ophthalmology, Faculty of Medicine Public Health and Nursing, Universitas Gadjah Mada-Dr Sardjito General Hospital, Yogyakarta, Indonesia
| | - Idhayu Anggit Widhasari
- Department of Ophthalmology, Faculty of Medicine Public Health and Nursing, Universitas Gadjah Mada-Dr Sardjito General Hospital, Yogyakarta, Indonesia
| | - Yeni Dwi Lestari
- Department of Ophthalmology, Faculty of Medicine, Universitas Indonesia-Dr Ciptomangunkusumo National Hospital, Jakarta, Indonesia
| | - Gitalisa Andayani Adriono
- Department of Ophthalmology, Faculty of Medicine, Universitas Indonesia-Dr Ciptomangunkusumo National Hospital, Jakarta, Indonesia
| | - Iwan Sovani
- Department of Ophthalmology, Faculty of Medicine, Universitas Padjajaran-Cicendo National Eye Hospital, Bandung, Indonesia
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Liu Y, Zupan NJ, Swearingen R, Jacobson N, Carlson JN, Mahoney JE, Klein R, Bjelland TD, Smith MA. Identification of barriers, facilitators and system-based implementation strategies to increase teleophthalmology use for diabetic eye screening in a rural US primary care clinic: a qualitative study. BMJ Open 2019; 9:e022594. [PMID: 30782868 PMCID: PMC6398662 DOI: 10.1136/bmjopen-2018-022594] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE Teleophthalmology for diabetic eye screening is an evidence-based intervention substantially underused in US multipayer primary care clinics, even when equipment and trained personnel are readily available. We sought to identify patient and primary care provider (PCP) barriers, facilitators, as well as strategies to increase teleophthalmology use. DESIGN We conducted standardised open-ended, individual interviews and analysed the transcripts using both inductive and directed content analysis to identify barriers and facilitators to teleophthalmology use. The Chronic Care Model was used as a framework for the development of the interview guide and for categorising implementation strategies to increase teleophthalmology use. SETTING A rural, US multipayer primary care clinic with an established teleophthalmology programme for diabetic eye screening. PARTICIPANTS We conducted interviews with 29 participants (20 patients with diabetes and 9 PCPs). RESULTS Major patient barriers to teleophthalmology use included being unfamiliar with teleophthalmology, misconceptions about diabetic eye screening and logistical challenges. Major patient facilitators included a recommendation from the patient's PCP and factors related to convenience. Major PCP barriers to referring patients for teleophthalmology included difficulty identifying when patients are due for diabetic eye screening and being unfamiliar with teleophthalmology. Major PCP facilitators included the ease of the referral process and the communication of screening results. Based on our results, we developed a model that maps where these key patient and PCP barriers occur in the teleophthalmology referral process. Patients and PCPs also identified implementation strategies to directly address barriers and facilitators to teleophthalmology use. CONCLUSIONS Patients and PCPs have limited familiarity with teleophthalmology for diabetic eye screening. PCPs were expected to initiate teleophthalmology referrals, but reported significant difficulty identifying when patients are due for diabetic eye screening. System-based implementation strategies primarily targeting PCP barriers in conjunction with improved patient and provider education may increase teleophthalmology use in rural, US multipayer primary care clinics.
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Affiliation(s)
- Yao Liu
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
- Health Innovation Program, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Nicholas J Zupan
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Rebecca Swearingen
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
- Health Innovation Program, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Nora Jacobson
- Institute for Clinical and Translational Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Julia N Carlson
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Jane E Mahoney
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Ronald Klein
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | | | - Maureen A Smith
- Health Innovation Program, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
- Departments of Population Health Sciences, Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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De Fauw J, Ledsam JR, Romera-Paredes B, Nikolov S, Tomasev N, Blackwell S, Askham H, Glorot X, O'Donoghue B, Visentin D, van den Driessche G, Lakshminarayanan B, Meyer C, Mackinder F, Bouton S, Ayoub K, Chopra R, King D, Karthikesalingam A, Hughes CO, Raine R, Hughes J, Sim DA, Egan C, Tufail A, Montgomery H, Hassabis D, Rees G, Back T, Khaw PT, Suleyman M, Cornebise J, Keane PA, Ronneberger O. Clinically applicable deep learning for diagnosis and referral in retinal disease. Nat Med 2018; 24:1342-1350. [PMID: 30104768 DOI: 10.1038/s41591-018-0107-6] [Citation(s) in RCA: 1053] [Impact Index Per Article: 175.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 06/01/2018] [Indexed: 12/12/2022]
Abstract
The volume and complexity of diagnostic imaging is increasing at a pace faster than the availability of human expertise to interpret it. Artificial intelligence has shown great promise in classifying two-dimensional photographs of some common diseases and typically relies on databases of millions of annotated images. Until now, the challenge of reaching the performance of expert clinicians in a real-world clinical pathway with three-dimensional diagnostic scans has remained unsolved. Here, we apply a novel deep learning architecture to a clinically heterogeneous set of three-dimensional optical coherence tomography scans from patients referred to a major eye hospital. We demonstrate performance in making a referral recommendation that reaches or exceeds that of experts on a range of sight-threatening retinal diseases after training on only 14,884 scans. Moreover, we demonstrate that the tissue segmentations produced by our architecture act as a device-independent representation; referral accuracy is maintained when using tissue segmentations from a different type of device. Our work removes previous barriers to wider clinical use without prohibitive training data requirements across multiple pathologies in a real-world setting.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Reena Chopra
- NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK
| | | | | | - Cían O Hughes
- DeepMind, London, UK
- University College London, London, UK
| | | | - Julian Hughes
- NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK
| | - Dawn A Sim
- NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK
| | - Catherine Egan
- NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK
| | - Adnan Tufail
- NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK
| | | | | | | | | | - Peng T Khaw
- NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK
| | | | | | - Pearse A Keane
- NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK.
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Garoon RB, Lin WV, Young AK, Yeh AG, Chu YI, Weng CY. Cost Savings Analysis for a Diabetic Retinopathy Teleretinal Screening Program Using an Activity-Based Costing Approach. ACTA ACUST UNITED AC 2018; 2:906-913. [DOI: 10.1016/j.oret.2018.01.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 01/30/2018] [Accepted: 01/31/2018] [Indexed: 12/21/2022]
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22
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Abstract
BACKGROUND Telemedicine has been utilized increasingly worldwide for diabetes management, due to its potential to improve healthcare access and clinical outcomes. Few studies have assessed the economic benefits of telemedicine, which may contribute to underfunding in potentially important programs. We aim to systematically review the literature on economic evaluations of telemedicine in diabetes care, assess the quality, and summarize the evidence on driver of cost-effectiveness. MATERIALS AND METHODS A literature search was performed in 10 databases from inception until February 2018. All economic evaluations assessing the economic evaluation of telemedicine in diabetes were eligible for inclusion. We subsequently evaluated the study quality in terms of effectiveness measures, cost measure, economic model, as well as time horizon. RESULTS Of the 1877 studies identified, 14 articles were included in our final review. The healthcare providers' fees are a major predictor for total cost. In particular, the use of telemedicine for retinal screening was beneficial and cost-effective for diabetes management, with an incremental cost-effectiveness ratio between $113.48/quality-adjusted life year (QALY) and $3,328.46/QALY (adjusted to 2017 inflation rate). Similarly, the use of telemonitoring and telephone reminders was cost-effective in diabetes management. CONCLUSIONS Among all telemedicine strategies examined, teleophthalmology was the most cost-effective intervention. Future research is needed to provide evidence on the long-term experience of telemedicine and facilitate resource allocation.
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Affiliation(s)
- Jun Yang Lee
- 1 School of Pharmacy, Monash University Malaysia , Bandar Sunway, Malaysia
| | - Shaun Wen Huey Lee
- 1 School of Pharmacy, Monash University Malaysia , Bandar Sunway, Malaysia
- 2 Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes (PICO), Health and Well-being Cluster, Global Asia in the 21st Century (GA21) Platform, Monash University Malaysia , Bandar Sunway, Malaysia
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23
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Sharafeldin N, Kawaguchi A, Sundaram A, Campbell S, Rudnisky C, Weis E, Tennant MTS, Damji KF. Review of economic evaluations of teleophthalmology as a screening strategy for chronic eye disease in adults. Br J Ophthalmol 2018; 102:1485-1491. [PMID: 29680803 DOI: 10.1136/bjophthalmol-2017-311452] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 03/07/2018] [Accepted: 03/31/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND/AIMS Teleophthalmology is well positioned to play a key role in screening of major chronic eye diseases. Economic evaluation of cost-effectiveness of teleophthalmology, however, is lacking. This study provides a systematic review of economic studies of teleophthalmology screening for diabetic retinopathy (DR), glaucoma and macular degeneration. METHODS Structured search of electronic databases and full article review yielded 20 cost-related articles. Sixteen articles fulfilled the inclusion criteria and were retained for a narrative review: 12 on DR, 2 on glaucoma and 2 on chronic eye disease. RESULTS Teleophthalmology for DR yielded the most cost savings when compared with traditional clinic examination. The study settings varied among urban, rural and remote settings, community, hospital and health mobile units. The most important determinant of cost-effectiveness of teleophthalmology was the prevalence of DR among patients screened, indicating an increase of cost savings with the increase of screening rates. The required patient pool size to be screened varied from 110 to 3500 patients. Other factors potentially influencing cost-effectiveness of teleophthalmology were older patient age, regular screening and full utilisation of the equipment. Teleophthalmology for glaucoma was more cost-effective compared with in-person examination. Similarly, increasing number of glaucoma patients targeted for screening yielded more cost savings. CONCLUSIONS This economic review provides supportive evidence of cost-effectiveness of teleophthalmology for DR and glaucoma screening potentially increasing screening accessibility especially for rural and remote populations. Special selection of the targeted screening population will optimise the cost-effectiveness of teleophthalmology.
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Affiliation(s)
- Noha Sharafeldin
- School of Public Health, University of Alberta, Edmonton, Canada.,Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Atsushi Kawaguchi
- School of Public Health, University of Alberta, Edmonton, Canada.,Department of Pediatrics, Pediatric Critical Care Medicine, University of Alberta, Edmonton, Canada
| | - Aishwarya Sundaram
- Department of Ophthalmology and Visual Sciences, Dalhousie University, Halifax, Canada
| | - Sandy Campbell
- JW Scott Library, Health Sciences Library, University of Alberta, Edmonton, Canada
| | - Chris Rudnisky
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Canada
| | - Ezekiel Weis
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Canada
| | - Matthew T S Tennant
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Canada
| | - Karim F Damji
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Canada
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24
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Telemedicine: A systematic review of economic evaluations. Med J Islam Repub Iran 2017; 31:113. [PMID: 29951414 PMCID: PMC6014807 DOI: 10.14196/mjiri.31.113] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Indexed: 01/18/2023] Open
Abstract
Background: Telemedicine is an expanded term in health information technology that comprises procedures for transmitting medical
information electronically to improve patients’ health status. The objective of this research is to evaluate the cost-effectiveness of
telemedicine interventions in various specialty areas.
Methods: The Cochrane Library and Centre for Review and Dissemination were searched up to February 2013 using Mesh. Studies
that compared any kind of telemedicine with any other routine care technique and used cost per health utility unit’s outcomes were
included.
Results: Twenty-one articles were included. According to the included studies, it seems that using telemedicine in cardiology can be
effective and cost-effective enough but pre-hospital telemedicine diagnostics program are likely to have little impact on acute myocardial
infarction fatality. In pulmonary, telemedicine can be a cost-effective strategy for delivering outpatient pulmonary care to rural
populations which have limited access to specialized services, but telemedicine is not cost- effective in asthma and airways cancer. In
ophthalmology, especially in the diagnosis of diabetic retinopathy, the use of telemedicine is a cost-effective tool. In dermatology,
telemedicine is not cost-effective enough in comparison of conventional cares. In other fields such as physical activity and diet, eating
disorder, tele-ICU, psychotherapy for depression and telemedicine on ships, telemedicine can be used as a cost-effective tool for treatments
or cares.
Conclusion: Most of the included studies confirmed that telemedicine is cost-effective for applying in major medical fields such as
cardiology; but in dermatology, papers could not confirm the positive capability of telemedicine.
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25
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Mohammadpour M, Heidari Z, Mirghorbani M, Hashemi H. Smartphones, tele-ophthalmology, and VISION 2020. Int J Ophthalmol 2017; 10:1909-1918. [PMID: 29259912 PMCID: PMC5733521 DOI: 10.18240/ijo.2017.12.19] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 09/05/2017] [Indexed: 12/31/2022] Open
Abstract
Telemedicine is an emerging field in recent medical achievements with rapid development. The "smartphone" availability has increased in both developed and developing countries even among people in rural and remotes areas. Tele-based services can be used for screening ophthalmic diseases and also monitoring patients with known diseases. Electronic ophthalmologic records of the patients including captured images by smartphones from anterior and posterior segments of the eye will be evaluated by ophthalmologists, and if patients require further evaluations, they will be referred to experts in the relevant field. Eye diseases such as cataract, glaucoma, age-related macular degeneration, diabetic retinopathy, and retinopathy of prematurity are the most common causes of blindness in many countries and beneficial use of teleophthalmology with smartphones will be a good way to achieve the aim of VISION 2020 all over the world. Numerous studies have shown that teleophthalmology is similar to the conventional eye care system in clinical outcomes and even provides more patient satisfaction as it saves time and cost. This review explains how teleophthalmology helps to improve patient outcomes through smartphones.
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Affiliation(s)
- Mehrdad Mohammadpour
- Farabi Eye Hospital, Ophthalmology Department and Eye Research Center, Tehran University of Medical Sciences, Tehran 1336616351, Iran
- Noor Ophthalmology Research Center, Noor Eye Hospital, Tehran 1968653111, Iran
| | - Zahra Heidari
- Noor Ophthalmology Research Center, Noor Eye Hospital, Tehran 1968653111, Iran
- Department of Rehabilitation Science, Mazandaran University of Medical Sciences, Sari 4815733971, Iran
| | - Masoud Mirghorbani
- Farabi Eye Hospital, Ophthalmology Department and Eye Research Center, Tehran University of Medical Sciences, Tehran 1336616351, Iran
| | - Hassan Hashemi
- Noor Research Center for Ophthalmic Epidemiology, Noor Eye Hospital, Tehran 1968653111, Iran
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26
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Hooper P, Boucher MC, Cruess A, Dawson KG, Delpero W, Greve M, Kozousek V, Lam WC, Maberley DAL. Excerpt from the Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of diabetic retinopathy. Can J Ophthalmol 2017; 52 Suppl 1:S45-S74. [PMID: 29074014 DOI: 10.1016/j.jcjo.2017.09.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Philip Hooper
- Philip Hooper, London, ON (Chair) (retina and uveitis); Marie Carole Boucher, Montreal, QC (retina and teleophthalmology); Alan Cruess, Halifax, NS (retina); Keith G. Dawson, Vancouver, BC (endocrinology); Walter Delpero, Ottawa, ON (cataract and strabismus); Mark Greve, Edmonton, AB (retina and teleophthalmology); Vladimir Kozousek, Halifax, NS (medical retina); Wai-Ching Lam, Toronto, ON (retina and research); David A.L. Maberley, Vancouver, BC (retina)..
| | - Marie Carole Boucher
- Philip Hooper, London, ON (Chair) (retina and uveitis); Marie Carole Boucher, Montreal, QC (retina and teleophthalmology); Alan Cruess, Halifax, NS (retina); Keith G. Dawson, Vancouver, BC (endocrinology); Walter Delpero, Ottawa, ON (cataract and strabismus); Mark Greve, Edmonton, AB (retina and teleophthalmology); Vladimir Kozousek, Halifax, NS (medical retina); Wai-Ching Lam, Toronto, ON (retina and research); David A.L. Maberley, Vancouver, BC (retina)
| | - Alan Cruess
- Philip Hooper, London, ON (Chair) (retina and uveitis); Marie Carole Boucher, Montreal, QC (retina and teleophthalmology); Alan Cruess, Halifax, NS (retina); Keith G. Dawson, Vancouver, BC (endocrinology); Walter Delpero, Ottawa, ON (cataract and strabismus); Mark Greve, Edmonton, AB (retina and teleophthalmology); Vladimir Kozousek, Halifax, NS (medical retina); Wai-Ching Lam, Toronto, ON (retina and research); David A.L. Maberley, Vancouver, BC (retina)
| | - Keith G Dawson
- Philip Hooper, London, ON (Chair) (retina and uveitis); Marie Carole Boucher, Montreal, QC (retina and teleophthalmology); Alan Cruess, Halifax, NS (retina); Keith G. Dawson, Vancouver, BC (endocrinology); Walter Delpero, Ottawa, ON (cataract and strabismus); Mark Greve, Edmonton, AB (retina and teleophthalmology); Vladimir Kozousek, Halifax, NS (medical retina); Wai-Ching Lam, Toronto, ON (retina and research); David A.L. Maberley, Vancouver, BC (retina)
| | - Walter Delpero
- Philip Hooper, London, ON (Chair) (retina and uveitis); Marie Carole Boucher, Montreal, QC (retina and teleophthalmology); Alan Cruess, Halifax, NS (retina); Keith G. Dawson, Vancouver, BC (endocrinology); Walter Delpero, Ottawa, ON (cataract and strabismus); Mark Greve, Edmonton, AB (retina and teleophthalmology); Vladimir Kozousek, Halifax, NS (medical retina); Wai-Ching Lam, Toronto, ON (retina and research); David A.L. Maberley, Vancouver, BC (retina)
| | - Mark Greve
- Philip Hooper, London, ON (Chair) (retina and uveitis); Marie Carole Boucher, Montreal, QC (retina and teleophthalmology); Alan Cruess, Halifax, NS (retina); Keith G. Dawson, Vancouver, BC (endocrinology); Walter Delpero, Ottawa, ON (cataract and strabismus); Mark Greve, Edmonton, AB (retina and teleophthalmology); Vladimir Kozousek, Halifax, NS (medical retina); Wai-Ching Lam, Toronto, ON (retina and research); David A.L. Maberley, Vancouver, BC (retina)
| | - Vladimir Kozousek
- Philip Hooper, London, ON (Chair) (retina and uveitis); Marie Carole Boucher, Montreal, QC (retina and teleophthalmology); Alan Cruess, Halifax, NS (retina); Keith G. Dawson, Vancouver, BC (endocrinology); Walter Delpero, Ottawa, ON (cataract and strabismus); Mark Greve, Edmonton, AB (retina and teleophthalmology); Vladimir Kozousek, Halifax, NS (medical retina); Wai-Ching Lam, Toronto, ON (retina and research); David A.L. Maberley, Vancouver, BC (retina)
| | - Wai-Ching Lam
- Philip Hooper, London, ON (Chair) (retina and uveitis); Marie Carole Boucher, Montreal, QC (retina and teleophthalmology); Alan Cruess, Halifax, NS (retina); Keith G. Dawson, Vancouver, BC (endocrinology); Walter Delpero, Ottawa, ON (cataract and strabismus); Mark Greve, Edmonton, AB (retina and teleophthalmology); Vladimir Kozousek, Halifax, NS (medical retina); Wai-Ching Lam, Toronto, ON (retina and research); David A.L. Maberley, Vancouver, BC (retina)
| | - David A L Maberley
- Philip Hooper, London, ON (Chair) (retina and uveitis); Marie Carole Boucher, Montreal, QC (retina and teleophthalmology); Alan Cruess, Halifax, NS (retina); Keith G. Dawson, Vancouver, BC (endocrinology); Walter Delpero, Ottawa, ON (cataract and strabismus); Mark Greve, Edmonton, AB (retina and teleophthalmology); Vladimir Kozousek, Halifax, NS (medical retina); Wai-Ching Lam, Toronto, ON (retina and research); David A.L. Maberley, Vancouver, BC (retina)
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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.
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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,
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28
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Jani PD, Forbes L, Choudhury A, Preisser JS, Viera AJ, Garg S. Evaluation of Diabetic Retinal Screening and Factors for Ophthalmology Referral in a Telemedicine Network. JAMA Ophthalmol 2017; 135:706-714. [PMID: 28520833 DOI: 10.1001/jamaophthalmol.2017.1150] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Retinal telescreening for evaluation of diabetic retinopathy (DR) in the primary care setting may be useful in reaching rural and underserved patients. Objectives To evaluate telemedicine retinal screenings for patients with type 1 or 2 diabetes and identify factors for ophthalmology referral in the North Carolina Diabetic Retinopathy Telemedicine Network. Design, Setting, and Participants A preimplementation and postimplementation evaluation was conducted from January 6, 2014, to November 1, 2015, at 5 primary care clinics serving rural and underserved populations in North Carolina among 1787 adult patients with type 1 or 2 diabetes who received primary care at the clinics and obtained retinal telescreening to determine the presence and severity of DR. A total of 1661 patients with complete data were included in the statistical analysis. Intervention Nonmydriatic fundus photography with remote interpretation by an expert. Main Outcomes and Measures Number of patients recruited, level of detected DR, change in rates of screening, rate of ophthalmology referral, percentage of completed referrals, and patient characteristics associated with varying levels of DR. Results Of the 1661 patients (1041 women and 620 men; mean [SD] age, 55.4 [12.7] years), 1323 patients (79.7%) had no DR, 183 patients (11.0%) had DR without a need for an ophthalmology referral, and 155 patients (9.3%) had DR with a need for an ophthalmology referral. The mean rate of screening for DR before implementation of the program was 25.6% (1512 of 5905), which increased to 40.4% (1884 of 4664) after implementation. A total of 93 referred patients (60.0%) completed an ophthalmology referral visit within the study period. Older patients (odds ratio [OR], 1.28; 95% CI, 1.11-1.48) and African American patients (OR, 1.84; 95% CI, 1.24-2.73) or other racial/ethnic minorities (OR, 2.19; 95% CI, 1.16-4.11) had greater odds of requiring an ophthalmology referral compared with white and/or younger patients. Patients with higher hemoglobin A1c levels (OR, 1.19 per unit change; 95% CI, 1.13-1.25 per unit change) and longer duration of diabetes (OR, 1.76 per decade; 95% CI, 1.53-2.02 per decade) had greater odds of DR requiring an ophthalmology referral. History of stroke (OR, 1.65; 95% CI, 1.10-2.48) and kidney disease (OR, 1.59; 95% CI, 1.10-2.31) were strongly associated with DR and ophthalmology referral. Conclusions and Relevance When implemented in the primary care setting, retinal telescreening increased the rate of evaluation for DR for patients in rural and underserved settings. This strategy may also increase access to care for minorities and patients with DR requiring treatment.
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Affiliation(s)
- Pooja D Jani
- Department of Ophthalmology, University of North Carolina at Chapel Hill2Department of Family Medicine, University of North Carolina at Chapel Hill
| | - Lauren Forbes
- Department of Ophthalmology, University of North Carolina at Chapel Hill
| | - Arkopal Choudhury
- Department of Biostatistics, University of North Carolina at Chapel Hill
| | - John S Preisser
- Department of Biostatistics, University of North Carolina at Chapel Hill
| | - Anthony J Viera
- Department of Family Medicine, University of North Carolina at Chapel Hill
| | - Seema Garg
- Department of Ophthalmology, University of North Carolina at Chapel Hill
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29
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Murchison AP, Haller JA, Mayro E, Hark L, Gower E, Huisingh C, Rhodes L, Friedman DS, Lee DJ, Lam BL. Reaching the Unreachable: Novel Approaches to Telemedicine Screening of Underserved Populations for Vitreoretinal Disease. Curr Eye Res 2017; 42:963-970. [PMID: 28506091 DOI: 10.1080/02713683.2017.1297463] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Telemedicine involves electronic communication between a physician in one location and a patient in another location to provide remote medical care. Ophthalmologists are increasingly employing telemedicine, particularly in retinal disease screening and monitoring. Telemedicine has been utilized to decrease barriers to care and yield greater patient satisfaction and lower costs, while maintaining high sensitivity and specificity. This review discusses common patient barriers to eye care, innovative approaches to retinal disease screening and monitoring using telemedicine, and eye care policy initiatives needed to enact large-scale telemedicine eye disease screening programs.
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Affiliation(s)
- Ann P Murchison
- a Wills Eye Hospital , Thomas Jefferson University , Philadelphia , PA , USA
| | - Julia A Haller
- a Wills Eye Hospital , Thomas Jefferson University , Philadelphia , PA , USA
| | - Eileen Mayro
- a Wills Eye Hospital , Thomas Jefferson University , Philadelphia , PA , USA
| | - Lisa Hark
- a Wills Eye Hospital , Thomas Jefferson University , Philadelphia , PA , USA
| | - Emily Gower
- b Wilmer Eye Institute , Dana Center for Preventive Ophthalmology, The Johns Hopkins School of Medicine , Baltimore , MD , USA.,c Department of Epidemiology , Wake Forest School of Medicine , Winston-Salem , NC , USA.,d Department of Ophthalmology , Wake Forest School of Medicine , Winston-Salem , NC , USA
| | - Carrie Huisingh
- e Department of Ophthalmology , School of Medicine, University of Alabama at Birmingham , Birmingham , AL , USA
| | - Lindsay Rhodes
- e Department of Ophthalmology , School of Medicine, University of Alabama at Birmingham , Birmingham , AL , USA
| | - David S Friedman
- b Wilmer Eye Institute , Dana Center for Preventive Ophthalmology, The Johns Hopkins School of Medicine , Baltimore , MD , USA.,d Department of Ophthalmology , Wake Forest School of Medicine , Winston-Salem , NC , USA
| | - David J Lee
- f Departments of Public Health Sciences and Ophthalmology , Miller School of Medicine, University of Miami , Miami , FL , USA
| | - Byron L Lam
- f Departments of Public Health Sciences and Ophthalmology , Miller School of Medicine, University of Miami , Miami , FL , USA
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30
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Maa AY, Patel S, Chasan JE, Delaune W, Lynch MG. Retrospective Evaluation of a Teleretinal Screening Program in Detecting Multiple Nondiabetic Eye Diseases. Telemed J E Health 2017; 23:41-48. [DOI: 10.1089/tmj.2016.0039] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- April Y. Maa
- Ophthalmology Division, Atlanta VA Medical Center, Decatur, Georgia
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Shivangi Patel
- Ophthalmology Division, Atlanta VA Medical Center, Decatur, Georgia
| | - Joel E. Chasan
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - William Delaune
- Center for Visual and Neurocognitive Rehabilitation, Atlanta VA Medical Center, Decatur, Georgia
| | - Mary G. Lynch
- Ophthalmology Division, Atlanta VA Medical Center, Decatur, Georgia
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
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31
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Further Reading. J Telemed Telecare 2016. [DOI: 10.1258/135763307782213598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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32
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Abstract
Diabetic retinopathy is a leading cause of new-onset vision loss worldwide. Treatments supported by large clinical trials are effective in preserving vision, but many persons do not receive timely diagnosis and treatment of diabetic retinopathy, which is typically asymptomatic when most treatable. Telemedicine evaluation to identify diabetic retinopathy has the potential to improve access to care and improve outcomes, but incomplete implementation of published standards creates a risk to program utility and sustainability. In a prior article, we reviewed the literature regarding the impact of imaging device, number and size of retinal images, pupil dilation, type of image grader, and diagnostic accuracy on telemedicine assessment for diabetic retinopathy. This article reviews the literature regarding the impact of automated image grading, cost effectiveness, program standards, and quality assurance (QA) on telemedicine assessment of diabetic retinopathy. Telemedicine assessment of diabetic retinopathy has the potential to preserve vision, but greater attention to development and implementation of standards is needed to better realize its potential.
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Affiliation(s)
- Mark B Horton
- Joslin Vision Network-Indian Health Service Teleophthalmology Program, Phoenix, AZ, USA.
| | - Paolo S Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Jerry D Cavallerano
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Lloyd Paul Aiello
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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33
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Abstract
Diabetic retinopathy is a leading cause of new-onset vision loss worldwide. Treatments supported by large clinical trials are effective in preserving vision, but many persons do not receive timely diagnosis and treatment of diabetic retinopathy, which is typically asymptomatic when most treatable. Telemedicine evaluation to identify diabetic retinopathy has the potential to improve access to care, but there are no universal standards regarding camera choice or protocol for ocular telemedicine. We review the literature regarding the impact of imaging device, number and size of retinal images, pupil dilation, type of image grader, and diagnostic accuracy on telemedicine assessment for diabetic retinopathy. Telemedicine assessment of diabetic retinopathy has the potential to preserve vision, but further development of telemedicine specific technology and standardization of operations are needed to better realize its potential.
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Affiliation(s)
- Mark B Horton
- Joslin Vision Network - Indian Health Service Teleophthalmology Program, Phoenix, AZ, USA.
| | - Paolo S Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Jerry D Cavallerano
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Lloyd Paul Aiello
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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34
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Abstract
According to current projections, the number of Americans with diabetes mellitus will increase from 27.8 million in 2007 to 60.7 million in 2030. With the increasing gap between demand for eye care and supply of ophthalmologists and optometrists, and the non-uniform distribution of eye care providers in US counties, barriers to eye examinations will likely increase. Telemedicine assessment of diabetic retinal disease through remote retinal imaging and diagnosis has the potential to meet these growing demands. To establish evidence for a telemedicine program as an effective modality for diabetic retinopathy (DR) assessment, the interpretation of teleretinal images should compare favorably with Early Treatment Diabetic Retinopathy Study film or digital photographs. We review the current evidence on the critical features and characteristics of ocular telehealth programs for DR in the following categories: image gradability, mydriasis, sensitivity and specificity, cost-effectiveness, long-term effectiveness, patient comfort and satisfaction, and improvement of patient related outcomes.
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Affiliation(s)
- Aditi Gupta
- a Beetham Eye Institute, Joslin Diabetes Center , Boston , MA , USA
| | - Jerry Cavallerano
- a Beetham Eye Institute, Joslin Diabetes Center , Boston , MA , USA.,b Department of Ophthalmology , Harvard Medical School , Boston , MA , USA
| | - Jennifer K Sun
- a Beetham Eye Institute, Joslin Diabetes Center , Boston , MA , USA.,b Department of Ophthalmology , Harvard Medical School , Boston , MA , USA
| | - Paolo S Silva
- a Beetham Eye Institute, Joslin Diabetes Center , Boston , MA , USA.,b Department of Ophthalmology , Harvard Medical School , Boston , MA , USA
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35
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Pareja-Ríos A, Bonaque-González S, Serrano-García M, Cabrera-López F, Abreu-Reyes P, Marrero-Saavedra MD. Tele-ophthalmology for diabetic retinopathy screening: 8 years of experience. ACTA ACUST UNITED AC 2016; 92:63-70. [PMID: 27756515 DOI: 10.1016/j.oftal.2016.08.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 08/10/2016] [Accepted: 08/16/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe the results of a diabetic retinopathy screening program implemented in a primary care area. METHODS A retrospective study was conducted using data automatically collected since the program began on 1 January 2007 until 31 December 2015. RESULTS The number of screened diabetic patients has progressively increased, from 7,173 patients in 2007 to 42,339 diabetic patients in 2015. Furthermore, the ability of family doctors to correctly interpret retinographies has improved, with the proportion of retinal images classified as normal having increased from 55% in 2007 to 68% at the end of the study period. The proportion of non-evaluable retinographies decreased to 7% in 2015, having peaked at 15% during the program. This was partly due to a change in the screening program policy that allowed the use of tropicamide. The number of severe cases detected has declined, from 14% with severe non-proliferative and proliferativediabetic retinopathy in the initial phase of the program to 3% in 2015. CONCLUSIONS Diabetic eye disease screening by tele-ophthalmology has shown to be a valuable method in a growing population of diabetics. It leads to a regular medical examination of patients, helps ease the workload of specialised care services and favours the early detection of treatable cases. However, the results of implementing a program of this type are not immediate, achieving only modest results in the early years of the project that have improved over subsequent years.
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Affiliation(s)
- A Pareja-Ríos
- Hospital Universitario de Canarias, La Laguna, Tenerife, España
| | - S Bonaque-González
- Departamento de Física, Universidad de La Laguna, La Laguna, Santa Cruz de Tenerife, España; Grupo de Ciencias de la Visión, Universidad de Murcia., Murcia, España
| | - M Serrano-García
- Hospital Universitario de Canarias, La Laguna, Tenerife, España.
| | - F Cabrera-López
- Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, España
| | - P Abreu-Reyes
- Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España
| | - M D Marrero-Saavedra
- Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, España
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Nguyen HV, Tan GSW, Tapp RJ, Mital S, Ting DSW, Wong HT, Tan CS, Laude A, Tai ES, Tan NC, Finkelstein EA, Wong TY, Lamoureux EL. Cost-effectiveness of a National Telemedicine Diabetic Retinopathy Screening Program in Singapore. Ophthalmology 2016; 123:2571-2580. [PMID: 27726962 DOI: 10.1016/j.ophtha.2016.08.021] [Citation(s) in RCA: 127] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 08/17/2016] [Accepted: 08/18/2016] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To determine the incremental cost-effectiveness of a new telemedicine technician-based assessment relative to an existing model of family physician (FP)-based assessment of diabetic retinopathy (DR) in Singapore from the health system and societal perspectives. DESIGN Model-based, cost-effectiveness analysis of the Singapore Integrated Diabetic Retinopathy Program (SiDRP). PARTICIPANTS A hypothetical cohort of patients aged 55 years with type 2 diabetes previously not screened for DR. METHODS The SiDRP is a new telemedicine-based DR screening program using trained technicians to assess retinal photographs. We compared the cost-effectiveness of SiDRP with the existing model in which FPs assess photographs. We developed a hybrid decision tree/Markov model to simulate the costs, effectiveness, and incremental cost-effectiveness ratio (ICER) of SiDRP relative to FP-based DR screening over a lifetime horizon. We estimated the costs from the health system and societal perspectives. Effectiveness was measured in terms of quality-adjusted life-years (QALYs). Result robustness was calculated using deterministic and probabilistic sensitivity analyses. MAIN OUTCOME MEASURES The ICER. RESULTS From the societal perspective that takes into account all costs and effects, the telemedicine-based DR screening model had significantly lower costs (total cost savings of S$173 per person) while generating similar QALYs compared with the physician-based model (i.e., 13.1 QALYs). From the health system perspective that includes only direct medical costs, the cost savings are S$144 per person. By extrapolating these data to approximately 170 000 patients with diabetes currently being screened yearly for DR in Singapore's primary care polyclinics, the present value of future cost savings associated with the telemedicine-based model is estimated to be S$29.4 million over a lifetime horizon. CONCLUSIONS While generating similar health outcomes, the telemedicine-based DR screening using technicians in the primary care setting saves costs for Singapore compared with the FP model. Our data provide a strong economic rationale to expand the telemedicine-based DR screening program in Singapore and elsewhere.
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Affiliation(s)
- Hai V Nguyen
- School of Pharmacy, Memorial University of Newfoundland, St. John's, Canada
| | - Gavin Siew Wei Tan
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
| | - Robyn Jennifer Tapp
- Department of Optometry and Vision Sciences, University of Melbourne, Melbourne, Australia; School of Clinical and Applied Sciences, Leeds Beckett University, Leeds, United Kingdom
| | - Shweta Mital
- Health Services and Systems Research, Duke NUS Medical School, Singapore
| | | | - Hon Tym Wong
- Department of Ophthalmology, Tan Tock Seng Hospital, Singapore
| | - Colin S Tan
- Department of Ophthalmology, Tan Tock Seng Hospital, Singapore
| | - Augustinus Laude
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore
| | - E Shyong Tai
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Eric A Finkelstein
- Health Services and Systems Research, Duke NUS Medical School, Singapore
| | - Tien Yin Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore; Academic Medicine Research Institute, Duke NUS Medical School, Singapore
| | - Ecosse L Lamoureux
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore; Academic Medicine Research Institute, Duke NUS Medical School, Singapore.
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Silva PS, Horton MB, Clary D, Lewis DG, Sun JK, Cavallerano JD, Aiello LP. Identification of Diabetic Retinopathy and Ungradable Image Rate with Ultrawide Field Imaging in a National Teleophthalmology Program. Ophthalmology 2016; 123:1360-7. [DOI: 10.1016/j.ophtha.2016.01.043] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 01/12/2016] [Accepted: 01/27/2016] [Indexed: 11/29/2022] Open
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Fathy C, Patel S, Sternberg P, Kohanim S. Disparities in Adherence to Screening Guidelines for Diabetic Retinopathy in the United States: A Comprehensive Review and Guide for Future Directions. Semin Ophthalmol 2016; 31:364-77. [PMID: 27116205 DOI: 10.3109/08820538.2016.1154170] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Diabetic retinopathy (DR) is the leading cause of new-onset blindness in American adults aged 20-74 years old. The number of diabetics living with diagnosed DR increased by 89%, from 4.06 million to 7.69 million, between 2000 and 2010. Projected numbers from the Vision Health Initiative by the CDC predict that the rate of DR will triple by 2050, from 5.5 million people living with DR to 16 million. Screening guidelines aim to detect cases early because the treatments for DR can reduce severe vision loss by up to 94%. However, adherence to these guidelines is quite low. It is estimated that more than half of patients with diabetes may fail to receive necessary screening. Risk factors for non-screening discussed in this study include low health literacy, lack of access to care, pregnancy, physician adherence to guidelines, unique factors present in different minority populations, gender and age disparities, and living in rural regions. This paper also aims to address potential interventions that may improve adherence rates.
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Affiliation(s)
- Cherie Fathy
- a Department of Ophthalmology and Visual Sciences , Vanderbilt University Medical Center , Nashville , TN , USA
| | - Shriji Patel
- a Department of Ophthalmology and Visual Sciences , Vanderbilt University Medical Center , Nashville , TN , USA
| | - Paul Sternberg
- a Department of Ophthalmology and Visual Sciences , Vanderbilt University Medical Center , Nashville , TN , USA
| | - Sahar Kohanim
- a Department of Ophthalmology and Visual Sciences , Vanderbilt University Medical Center , Nashville , TN , USA
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Should We Add Screening of Age-Related Macular Degeneration to Current Screening Programs for Diabetic Retinopathy? Ophthalmology 2016; 122:2155-6. [PMID: 26498078 DOI: 10.1016/j.ophtha.2015.08.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 08/04/2015] [Accepted: 08/04/2015] [Indexed: 11/20/2022] Open
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Sim DA, Mitry D, Alexander P, Mapani A, Goverdhan S, Aslam T, Tufail A, Egan CA, Keane PA. The Evolution of Teleophthalmology Programs in the United Kingdom: Beyond Diabetic Retinopathy Screening. J Diabetes Sci Technol 2016; 10:308-17. [PMID: 26830492 PMCID: PMC4773982 DOI: 10.1177/1932296816629983] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Modern ophthalmic practice in the United Kingdom is faced by the challenges of an aging population, increasing prevalence of systemic pathologies with ophthalmic manifestations, and emergent treatments that are revolutionary but dependent on timely monitoring and diagnosis. This represents a huge strain not only on diagnostic services but also outpatient management and surveillance capacity. There is an urgent need for newer means of managing this surge in demand and the socioeconomic burden it places on the health care system. Concurrently, there have been exponential increases in computing power, expansions in the strength and ubiquity of communications technologies, and developments in imaging capabilities. Advances in imaging have been not only in terms of resolution, but also in terms of anatomical coverage, allowing new inferences to be made. In spite of this, image analysis techniques are still currently superseded by expert ophthalmologist interpretation. Teleophthalmology is therefore currently perfectly placed to face this urgent and immediate challenge of provision of optimal and expert care to remote and multiple patients over widespread geographical areas. This article reviews teleophthalmology programs currently deployed in the United Kingdom, focusing on diabetic eye care but also discussing glaucoma, emergency eye care, and other retinal diseases. We examined current programs and levels of evidence for their utility, and explored the relationships between screening, teleophthalmology, disease detection, and monitoring before discussing aspects of health economics pertinent to diabetic eye care. The use of teleophthalmology presents an immense opportunity to manage the steadily increasing demand for eye care, but challenges remain in the delivery of practical, viable, and clinically proven solutions.
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Affiliation(s)
- Dawn A Sim
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, London, UK Moorfields South, Croydon University Hospital, London, UK Moorfields South, St George's Hospital, London, UK University College London, Institute of Ophthalmology, London, UK
| | - Danny Mitry
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Philip Alexander
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Adam Mapani
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Srini Goverdhan
- University of Southampton, Southampton Eye Unit, Southampton, UK
| | - Tariq Aslam
- Manchester University, Manchester Royal Eye Hospital, Manchester, UK
| | - Adnan Tufail
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, London, UK University College London, Institute of Ophthalmology, London, UK
| | - Catherine A Egan
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, London, UK Moorfields South, St George's Hospital, London, UK University College London, Institute of Ophthalmology, London, UK
| | - Pearse A Keane
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, London, UK University College London, Institute of Ophthalmology, London, UK
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Coronado AC, Zaric GS, Martin J, Malvankar-Mehta M, Si FF, Hodge WG. Diabetic retinopathy screening with pharmacy-based teleophthalmology in a semiurban setting: a cost-effectiveness analysis. CMAJ Open 2016; 4:E95-E102. [PMID: 27280120 PMCID: PMC4866927 DOI: 10.9778/cmajo.20150085] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Diabetic eye complications are the leading cause of visual loss among working-aged people. Pharmacy-based teleophthalmology has emerged as a possible alternative to in-person examination that may facilitate compliance with evidence-based recommendations and reduce barriers to specialized eye care. The objective of this study was to estimate the cost-effectiveness of mobile teleophthalmology screening compared with in-person examination (primary care) for the diabetic population residing in semiurban areas of southwestern Ontario. METHODS A decision tree was constructed to compare in-person examination (comparator program) versus pharmacy-based teleophthalmology (intervention program). The economic model was designed to identify patients with more than minimal diabetic retinopathy, manifested by at least 1 microaneurysm at examination (modified Airlie House classification grade of ≥ 20). Cost-effectiveness was assessed as cost per case detected (true-positive result) and cost per case correctly diagnosed (including true-positive and true-negative results). RESULTS The cost per case detected was $510 with in-person examination and $478 with teleophthalmology, and the cost per case correctly diagnosed was $107 and $102 respectively. The incremental cost-effectiveness ratio was $314 per additional case detected and $73 per additional case correctly diagnosed. Use of pharmacologic dilation and health care specialists' fees were the most important cost drivers. INTERPRETATION The study showed that a compound teleophthalmology program in a semiurban community would be more effective but more costly than in-person examination. The findings raise the question of whether the benefits of pharmacy-based teleophthalmology in semiurban areas, where in-person examination is still available, are equivalent to those observed in remote communities. Further study is needed to investigate the impact of this program on the prevention of severe vision loss and quality of life in a semiurban setting.
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Affiliation(s)
- Andrea C Coronado
- Department of Epidemiology & Biostatistics (Coronado, Martin, Malvankar-Mehta, Hodge), Western University; Richard Ivey School of Business (Zaric), Western University; Ivey Eye Institute (Malvankar-Mahta, Si, Hodge), Western University, London, Ont
| | - Gregory S Zaric
- Department of Epidemiology & Biostatistics (Coronado, Martin, Malvankar-Mehta, Hodge), Western University; Richard Ivey School of Business (Zaric), Western University; Ivey Eye Institute (Malvankar-Mahta, Si, Hodge), Western University, London, Ont
| | - Janet Martin
- Department of Epidemiology & Biostatistics (Coronado, Martin, Malvankar-Mehta, Hodge), Western University; Richard Ivey School of Business (Zaric), Western University; Ivey Eye Institute (Malvankar-Mahta, Si, Hodge), Western University, London, Ont
| | - Monali Malvankar-Mehta
- Department of Epidemiology & Biostatistics (Coronado, Martin, Malvankar-Mehta, Hodge), Western University; Richard Ivey School of Business (Zaric), Western University; Ivey Eye Institute (Malvankar-Mahta, Si, Hodge), Western University, London, Ont
| | - Francie F Si
- Department of Epidemiology & Biostatistics (Coronado, Martin, Malvankar-Mehta, Hodge), Western University; Richard Ivey School of Business (Zaric), Western University; Ivey Eye Institute (Malvankar-Mahta, Si, Hodge), Western University, London, Ont
| | - William G Hodge
- Department of Epidemiology & Biostatistics (Coronado, Martin, Malvankar-Mehta, Hodge), Western University; Richard Ivey School of Business (Zaric), Western University; Ivey Eye Institute (Malvankar-Mahta, Si, Hodge), Western University, London, Ont
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Pasquel FJ, Hendrick AM, Ryan M, Cason E, Ali MK, Narayan KMV. Cost-effectiveness of Different Diabetic Retinopathy Screening Modalities. J Diabetes Sci Technol 2015; 10:301-7. [PMID: 26719134 PMCID: PMC4773976 DOI: 10.1177/1932296815624109] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Current screening strategies aimed at detection of diabetic retinopathy (DR) historically have poor compliance, but advancements in technology can enable improved access to care. Nearly 80% of all persons with diabetes live in low- and middle-income countries (LMICs), highlighting the importance of a cost effective screening program. Establishing mechanisms to reach populations with geographic and financial barriers to access is essential to prevent visual disability. Teleretinal programs leverage technology to improve access and reduce cost. The quality of currently employed screening modalities depends on many variables including the instrument used, use of pupillary mydriasis, number of photographic fields, and the qualifications of the photographer and image interpreter. Recent telemedicine and newer technological approaches have been introduced, but data for these technologies is yet limited. We present results of a systematic review of studies evaluating cost-effectiveness of DR screening, and discuss potential relevance for LMICs.
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Affiliation(s)
- Francisco J Pasquel
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Andrew M Hendrick
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA
| | - Martha Ryan
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA
| | - Emily Cason
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Mohammed K Ali
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - K M Venkat Narayan
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Tozer K, Woodward MA, Newman-Casey PA. Telemedicine and Diabetic Retinopathy: Review of Published Screening Programs. ACTA ACUST UNITED AC 2015; 2. [PMID: 27430019 DOI: 10.15226/2374-6890/2/4/00131] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Diabetic Retinopathy (DR) is a leading cause of blindness worldwide even though successful treatments exist. Improving screening and treatment could avoid many cases of vision loss. However, due to an increasing prevalence of diabetes, traditional in-person screening for DR for every diabetic patient is not feasible. Telemedicine is one viable solution to provide high-quality and efficient screening to large number of diabetic patients. PURPOSE To provide a narrative review of large DR telemedicine screening programs. METHODS Articles were identified through a comprehensive search of the English-language literature published between 2000 and 2014. Telemedicine screening programs were included for review if they had published data on at least 150 patients and had available validation studies supporting their model. Screening programs were then categorized according to their American Telemedicine Association Validation Level. RESULTS Seven programs from the US and abroad were identified and included in the review. Three programs were Category 1 programs (Ophdiat, EyePacs, and Digiscope), two were Category 2 programs (Eye Check, NHS Diabetic Eye Screening Program), and two were Category 3 programs (Joslin Vision Network, Alberta Screening Program). No program was identified that claimed category 4 status. Programs ranged from community or city level programs to large nationwide programs including millions of individuals. The programs demonstrated a high level of clinical accuracy in screening for DR. There was no consensus amongst the programs regarding the need for dilation, need for stereoscopic images, or the level of training for approved image graders. CONCLUSION Telemedicine programs have been clinically validated and successfully implemented across the globe. They can provide a high-level of clinical accuracy for screening for DR while improving patient access in a cost-effective and scalable manner.
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Affiliation(s)
- Kevin Tozer
- Department of Ophthalmology & Visual Sciences, University of Michigan Medical School, Ann Arbor, Michigan 48105, USA
| | - Maria A Woodward
- Department of Ophthalmology & Visual Sciences, University of Michigan Medical School, Ann Arbor, Michigan 48105, USA
| | - Paula A Newman-Casey
- Department of Ophthalmology & Visual Sciences, University of Michigan Medical School, Ann Arbor, Michigan 48105, USA
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Brady CJ, Villanti AC, Gupta OP, Graham MG, Sergott RC. Tele-ophthalmology screening for proliferative diabetic retinopathy in urban primary care offices: an economic analysis. Ophthalmic Surg Lasers Imaging Retina 2015; 45:556-61. [PMID: 25423636 DOI: 10.3928/23258160-20141118-11] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 08/13/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE To determine whether tele-ophthalmology screening for proliferative diabetic retinopathy (PDR) can be cost-saving. PATIENTS AND METHODS Adults with diabetes presenting for routine medical care underwent non-mydriatic fundus photography with remote grading. Direct medical costs were estimated using the Medicare fee schedule in the base case, with Medicaid and commercial insurance rates used for low and high values, respectively. One-way and probabilistic sensitivity analyses were performed. RESULTS Of 99 participants, at least mild retinopathy was found in 24 (24.2%). Urgent consultation was recommended for eight participants (8.1%) for possible vision-threatening diabetic retinopathy, including two participants (three eyes) with PDR. In the base case, screening saved $36 per patient. A Monte Carlo simulation indicated that screening saved a median of $48 per patient. CONCLUSION A substantial burden of diabetic retinopathy was identified, most of which was undiagnosed. In a closed system, tele-ophthalmology screening for PDR is likely to be cost-saving across the range of scenarios explored.
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Sim DA, Keane PA, Tufail A, Egan CA, Aiello LP, Silva PS. Automated retinal image analysis for diabetic retinopathy in telemedicine. Curr Diab Rep 2015; 15:14. [PMID: 25697773 DOI: 10.1007/s11892-015-0577-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
There will be an estimated 552 million persons with diabetes globally by the year 2030. Over half of these individuals will develop diabetic retinopathy, representing a nearly insurmountable burden for providing diabetes eye care. Telemedicine programmes have the capability to distribute quality eye care to virtually any location and address the lack of access to ophthalmic services. In most programmes, there is currently a heavy reliance on specially trained retinal image graders, a resource in short supply worldwide. These factors necessitate an image grading automation process to increase the speed of retinal image evaluation while maintaining accuracy and cost effectiveness. Several automatic retinal image analysis systems designed for use in telemedicine have recently become commercially available. Such systems have the potential to substantially improve the manner by which diabetes eye care is delivered by providing automated real-time evaluation to expedite diagnosis and referral if required. Furthermore, integration with electronic medical records may allow a more accurate prognostication for individual patients and may provide predictive modelling of medical risk factors based on broad population data.
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Affiliation(s)
- Dawn A Sim
- Department of Ophthalmology, Harvard Medical School and Beetham Eye Institute, Joslin Diabetes Center, One Joslin Place, Boston, MA, 02215, USA
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Darkins A. The Growth of Telehealth Services in the Veterans Health Administration Between 1994 and 2014: A Study in the Diffusion of Innovation. Telemed J E Health 2014; 20:761-8. [DOI: 10.1089/tmj.2014.0143] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Adam Darkins
- Office of Patient Care Services, Veterans Health Administration, Washington, D.C
- Opinions and views expressed in this paper are those of the author and do not represent those of the U.S. Department of Veterans Affairs
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Merrell RC, Doarn CR. Disease Management in Telemedicine and e-Health. Telemed J E Health 2014; 20:679-80. [DOI: 10.1089/tmj.2014.9984] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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MacLennan PA, McGwin G, Searcey K, Owsley C. A survey of Alabama eye care providers in 2010-2011. BMC Ophthalmol 2014; 14:44. [PMID: 24708636 PMCID: PMC4233655 DOI: 10.1186/1471-2415-14-44] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 03/26/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND State level information regarding eye care resources can provide policy makers with valuable information about availability of eye care services. The current study surveyed ophthalmologists, optometrists and vision rehabilitation providers practicing in Alabama. METHODS Three mutually exclusive provider groups were identified, i.e., all ophthalmologists, optometrists, and vision rehabilitation providers working in Alabama in 2010. Eligible providers were contacted in 2010 and 2011 and information was requested regarding provider demographics and training, practice type and service characteristics, and patient characteristics. Descriptive statistics (e.g., means, proportions) were used to characterize provider groups by their demographic and training characteristics, practice characteristics, services provided and patients or clients served. In addition, county level figures demonstrate the numbers and per capita ophthalmologists and optometrists. RESULTS Ophthalmologists were located in 24 of Alabama's 67 counties, optometrists in 56, and 10 counties had neither an ophthalmologist nor an optometrist. Overall, 1,033 vision care professionals were identified as eligible to participate in the survey: 217 ophthalmologists, 638 optometrists, and 178 visual rehabilitation providers. Of those, 111 (51.2%) ophthalmologists, 246 (38.6%) optometrists, and 81 (45.5%) rehabilitation providers participated. Most participating ophthalmologists, optometrists, and vision rehabilitation providers identified themselves as non-Hispanic White. Ophthalmologists and optometrists estimated that 27% and 22%, respectively, of their patients had diabetes but that the proportion that adhered to eye care guidelines was 61% among ophthalmology patients and 53% among optometry patients. CONCLUSIONS A large number of Alabama communities are isolated from eye care services. Increased future demand for eye care is anticipated nationally given the aging of the population and decreasing numbers of providers; however, Alabama also has a high and growing prevalence of diabetes which will result in greater numbers at risk for diabetic retinopathy, glaucoma, and cataracts.
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Affiliation(s)
- Paul A MacLennan
- Department of Surgery, School of Medicine, University of Alabama at Birmingham, 115 Kracke Building, 1530 3rd Ave South, Birmingham, AL 35294-0016, USA
| | - Gerald McGwin
- Department of Surgery, School of Medicine, University of Alabama at Birmingham, 115 Kracke Building, 1530 3rd Ave South, Birmingham, AL 35294-0016, USA
- Department of Ophthalmology, School of Medicine, University of Alabama at Birmingham, Suite 609, 700 South 18th Street, 35294-0009 Birmingham, AL, USA
| | - Karen Searcey
- Department of Ophthalmology, School of Medicine, University of Alabama at Birmingham, Suite 609, 700 South 18th Street, 35294-0009 Birmingham, AL, USA
| | - Cynthia Owsley
- Department of Ophthalmology, School of Medicine, University of Alabama at Birmingham, Suite 609, 700 South 18th Street, 35294-0009 Birmingham, AL, USA
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Askari A, Khodaie M, Bahaadinbeigy K. The 60 most highly cited articles published in the Journal of Telemedicine and Telecare and Telemedicine Journal and E-health. J Telemed Telecare 2014; 20:35-43. [DOI: 10.1177/1357633x13519899] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Summary We analysed the most highly cited articles in two specialist telemedicine journals, the Journal of Telemedicine and Telecare (JTT) and Telemedicine Journal and E-health (TJEH). Articles were extracted from the Science Citation Index Expanded in September 2012. A total of 1810 articles were listed for the JTT and 1550 for TJEH. In the JTT, the mean number of citations was 43 (SD 13); in TJEH the mean number of citations was 30 (SD 11). The average number of citations for the JTT was significantly higher than for TJEH ( P < 0.001). In each journal, the 60 articles which had the most citations were identified as highly cited publications (HCPs). The 60 HCPs in the JTT originated from 16 countries; the 60 HCPs in TJEH originated from 10 countries. Considering both journals together, the majority of HCPs came from the US, UK, Australia and Canada. In the JTT, the mean number of authors for each HCP was 4.6 (SD = 3.1); in TJEH, the mean number of authors for each HCP was 4.5 (SD = 2.3). There was no difference between the two journals ( P = 0.84) and the characteristics of the HCPs published in the JTT and TJEH were broadly similar. Although HCPs are not a direct method of measuring quality, they are an indicator of the scientific impact of the articles.
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Affiliation(s)
- Azam Askari
- Medical Informatics Research Centre, Institute of Futures Studies in Health, Kerman University of Medical Science, Kerman, Iran
| | - Mahdieh Khodaie
- Medical Informatics Research Centre, Institute of Futures Studies in Health, Kerman University of Medical Science, Kerman, Iran
| | - Kambiz Bahaadinbeigy
- Research Center for Modelling in Health, Institute of Future Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
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Liegl R, Liegl K, Ceklic L, Haritoglou C, Kampik A, Ulbig MW, Kernt M, Neubauer AS. Nonmydriatic ultra-wide-field scanning laser ophthalmoscopy (Optomap) versus two-field fundus photography in diabetic retinopathy. Ophthalmologica 2013; 231:31-6. [PMID: 24247157 DOI: 10.1159/000355092] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 08/02/2013] [Indexed: 12/18/2022]
Abstract
The purpose of this study was to investigate the diagnostic properties of a 2-laser wavelength nonmydriatic 200° ultra-wide-field scanning laser ophthalmoscope (SLO) versus mydriatic 2-field 45° color fundus photography (EURODIAB standard) for assessing diabetic retinopathy (DR). A total of 143 consecutive eyes of patients with different levels of DR were graded regarding DR level and macular edema based on 2-field color photographs or 1 Optomap Panoramic 200 SLO image. All SLO images were nonmydriatic and all photographs mydriatic. Grading was performed masked to patient and clinical data. Based on photography, 20 eyes had no DR, 44 had mild, 18 moderate and 42 severe nonproliferative DR, and 19 eyes had proliferative DR. Overall correlation for grading DR level compared to Optomap SLO was moderate with kappa 0.54 (p < 0.001), fair-to-moderate in macular edema grading with kappa 0.39 (p < 0.001), and substantial for grading clinically significant macular edema (kappa 0.77). The wide-field SLO offers a wider field of view and can potentially better differentiate lesions by applying the 2 laser wavelengths. However, these advantages over 2-field fundus photography need to be confirmed in further studies.
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Affiliation(s)
- Raffael Liegl
- Department of Ophthalmology, Ludwig-Maximilians University Munich, Munich, Germany
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