Diagnostic Accuracy of Tele-ophthalmology for Diabetic Retinopathy Assessment: A Meta-analysis and Economic Analysis

Tele-ophthalmology is a screening alternative that facilitates compliance to eye care guidelines regardless of geographic constraints, promoting adequate delivery of health services to underserved communities. We conducted a systematic review and meta-analysis to assess the diagnostic performance of tele-ophthalmology (TO) programs for the detection of diabetic retinopathy (DR), and used decision-tree modeling to explore its cost-effectiveness compared to in-person examination in a semi-urban scenario. From the 1,060 articles initially identified, 23 met inclusion criteria for data extraction. The diagnostic performance of TO for the detection of any DR and referable DR met the minimum diagnostic criteria by the Canadian Ophthalmological Society (sensitivity \u3e80%, specificity \u3e90%). Interpretation of clinical significance is limited due to significant heterogeneity. Considering a semi-urban scenario, the incremental cost per additional case of any DR detected after the introduction of pharmacy-based TO was $314.1, being more costly and more effective than in-person examination

Psychiatric Case Record

Bipolar Disorder-Mania: Patient was apparently normal one-month back, Then all of a sudden he developed sleep disturbances –mainly difficult in initiation of sleep. He also started abusing his family members for unwanted things. Subsequently, he started talking excessively and irritable. Sometimes he sings film songs and dances. He used to say that God Supreme exists in himself and so he has all the powers of Almighty. With that superior power he says that he can solve all the problems in this world. He also says that he has invented herbs to keep people young. For the past one week, he talks excessively without having an hour of sleep & wanders here and there & found excessively smoking. He becomes excessively spiritual and goes to near by villages for offering prayers to God. He takes only a little food everyday and he is very much keen in personal cleanliness. Paranoid Schizophrenia: She was apparently normal 8 months back, then she developed sleep disturbances in the form of difficult in falling asleep. She was found talking & smiling to herself at night & day with mirror gazing. She started saying that her neighbour & relatives are planning to kill herself by poisoning. In this context she had frequent quarrels with them and she refused to take food prepared by her mother in law. She left the home at night without informing any one and started wandering in the road side near her home. She was complaining that she hears voices as if her neighbour & relatives were talking about her among themselves She was not doing house hold activities for past 6 months and she was not taking care of her child. Her personal hygiene was very much deteriorated slowly as she used to take bath & brush, only if she was asked to do so. She started abusing & assaulting the strangers and family members. Generalised Anxiety Disorder: Six months back he was apparently normal. He is working as a system analyst in a private bank . He had once, made a mistake in his bank work for which he was given charges by his employer, followed this event he becomes very tense and afraid whenever his boss called him. He is very cautious that he should not commit any mistakes. Even though he is not doing so, he fears that he may commit some mistake in his work. At that moment he develops palpitation, giddiness, breathlessness, excessive sweating over palms and soles. Slowly these symptoms present through out the day even when he was not in his office, and he could not control his fearfulness. For the past 6 months he didn’t sleep well. His sleep is disturbed by bad dreams. Recurrent Depressive Disorder: Patient was apparently alright 2 months back. Then she developed sleep disturbances particularly early morning awakening, she use to wake up by 3.00 am and use to brood about herself and started crying. She was not doing her domestic work as before, as she felt excess tiredness and use to take frequent rests. She developed poor communication. She had lost her interest in pleasurable activities and was not interested in watching TV, and attending family gatherings. She stayed aloof most of the time & calm, quiet and withdrawn. She was expressing her helplessness and hopelessness about the future. She started to have decline in maintaining self care. 15 days back, she frequently expressed suicidal ideas and she had attempted suicide by hanging herself and was rescued by neighbours. 5 days back, she started talking in an irrelevant manner. She was smiling to self. She was assaulting her family members. She was suspicious that her neighbour had done black magic on her and also saying that people are talking about her. She reported hearing the voice of her neighbour scolding and threatening her. Organic Brain Syndrome – Dementia: Ten months back he was apparently alright. Then his relatives noticed himself frequently misplaces things inside his home. Then he started behaving aggressively. He was beating his wife without reason. He was roaming here and there, running out of home and wandering aimlessly. He was not able to come back home when he goes out. He was brought back to home by his relatives. Slowly he developed fearfulness and tremulousness while he was staying alone. He also started saying that his family members & neighbours were talking about himself, in this context he would make frequent quarrels with them. He also started hearing voices of known male voices abusing himself in third person. He sleeps for few hour only. He is passing urine and motion inside the house. He is asking about his brother and mother-in-law who were expired long back. He behaves abnormally such as pouring water in the plate while eating. And his relatives found the symptoms were worsened by evening. All these symptoms started insidiously, increased in severity through time and attained the present state. No history of loss of appetite / crying spells / suicidal tendencies / convulsions / fever / head injury

Diabetes eye screening in urban settings serving minority populations: detection of diabetic retinopathy and other ocular findings using telemedicine.

IMPORTANCE: The use of a nonmydriatic camera for retinal imaging combined with the remote evaluation of images at a telemedicine reading center has been advanced as a strategy for diabetic retinopathy (DR) screening, particularly among patients with diabetes mellitus from ethnic/racial minority populations with low utilization of eye care. OBJECTIVE: To examine the rate and types of DR identified through a telemedicine screening program using a nonmydriatic camera, as well as the rate of other ocular findings. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study (Innovative Network for Sight [INSIGHT]) was conducted at 4 urban clinic or pharmacy settings in the United States serving predominantly ethnic/racial minority and uninsured persons with diabetes. Participants included persons aged 18 years or older who had type 1 or 2 diabetes mellitus and presented to the community-based settings. MAIN OUTCOMES AND MEASURES: The percentage of DR detection, including type of DR, and the percentage of detection of other ocular findings. RESULTS: A total of 1894 persons participated in the INSIGHT screening program across sites, with 21.7% having DR in at least 1 eye. The most common type of DR was background DR, which was present in 94.1% of all participants with DR. Almost half (44.2%) of the sample screened had ocular findings other than DR; 30.7% of the other ocular findings were cataract. CONCLUSIONS AND RELEVANCE: In a DR telemedicine screening program in urban clinic or pharmacy settings in the United States serving predominantly ethnic/racial minority populations, DR was identified on screening in approximately 1 in 5 persons with diabetes. The vast majority of DR was background, indicating high public health potential for intervention in the earliest phases of DR when treatment can prevent vision loss. Other ocular conditions were detected at a high rate, a collateral benefit of DR screening programs that may be underappreciated

JAMA Ophthalmol

ImportanceThe use of a non-mydriatic camera for retinal imaging combined with the remote evaluation of images at a telemedicine reading center has been advanced as a strategy for diabetic retinopathy (DR) screening, particularly among patients with diabetes from minority populations with low eye care utilization.ObjectiveTo examine the rate and types of DR identified through a telemedicine screening program using a non-mydriatic camera, as well as the rate of other ocular findings.DesignCross-sectional.SettingFour urban clinic or pharmacy settings in the United States serving predominantly minority and uninsured persons with diabetes.ParticipantsPersons age 65 18 years old who have type 1 or 2 diabetes and present to the community-based settings.Main Outcome MeasurePercentage of DR detection including type of DR, and percentage of detection of other ocular findings.ResultsA total of 1,894 persons participated in the screening program across sites, with 21.7% having DR in at least one eye. The most common type of DR by far was background DR, which was present in 94.1% of all participants with DR. Almost half of those screened had ocular findings other than DR with 30% of other findings being cataract.Conclusions and RelevanceIn a DR telemedicine screening program in urban clinic/pharmacy settings in the US serving predominantly minority populations, 1 in 5 persons with diabetes screened positive for DR. The vast majority of DR was background indicating high public health potential for intervention in DR\u2019s earliest phases when treatment can prevent vision loss. Other ocular conditions were detected at a high rate, a collateral benefit of DR screening programs that may be under appreciated.U58 DP002655/DP/NCCDPHP CDC HHS/United States5U58DP002652/DP/NCCDPHP CDC HHS/United States5U58DP002653/DP/NCCDPHP CDC HHS/United StatesU58 DP002653/DP/NCCDPHP CDC HHS/United StatesP30 DK079626/DK/NIDDK NIH HHS/United States5U58DP002655/DP/NCCDPHP CDC HHS/United StatesU58 DP002652/DP/NCCDPHP CDC HHS/United States5U58DP002651/DP/NCCDPHP CDC HHS/United StatesU58 DP002651/DP/NCCDPHP CDC HHS/United States2016-02-01T00:00:00Z25393129PMC4479273vault:266

Teleophthalmology-enabled and artificial intelligence-ready referral pathway for community optometry referrals of retinal disease (HERMES): a Cluster Randomised Superiority Trial with a linked Diagnostic Accuracy Study-HERMES study report 1-study protocol

INTRODUCTION: Recent years have witnessed an upsurge of demand in eye care services in the UK. With a large proportion of patients referred to Hospital Eye Services (HES) for diagnostics and disease management, the referral process results in unnecessary referrals from erroneous diagnoses and delays in access to appropriate treatment. A potential solution is a teleophthalmology digital referral pathway linking community optometry and HES. METHODS AND ANALYSIS: The HERMES study (Teleophthalmology-enabled and artificial intelligence-ready referral pathway for community optometry referrals of retinal disease: a cluster randomised superiority trial with a linked diagnostic accuracy study) is a cluster randomised clinical trial for evaluating the effectiveness of a teleophthalmology referral pathway between community optometry and HES for retinal diseases. Nested within HERMES is a diagnostic accuracy study, which assesses the accuracy of an artificial intelligence (AI) decision support system (DSS) for automated diagnosis and referral recommendation. A postimplementation, observational substudy, a within-trial economic evaluation and discrete choice experiment will assess the feasibility of implementation of both digital technologies within a real-life setting. Patients with a suspicion of retinal disease, undergoing eye examination and optical coherence tomography (OCT) scans, will be recruited across 24 optometry practices in the UK. Optometry practices will be randomised to standard care or teleophthalmology. The primary outcome is the proportion of false-positive referrals (unnecessary HES visits) in the current referral pathway compared with the teleophthalmology referral pathway. OCT scans will be interpreted by the AI DSS, which provides a diagnosis and referral decision and the primary outcome for the AI diagnostic study is diagnostic accuracy of the referral decision made by the Moorfields-DeepMind AI system. Secondary outcomes relate to inappropriate referral rate, cost-effectiveness analyses and human-computer interaction (HCI) analyses. ETHICS AND DISSEMINATION: Ethical approval was obtained from the London-Bromley Research Ethics Committee (REC 20/LO/1299). Findings will be reported through academic journals in ophthalmology, health services research and HCI. TRIAL REGISTRATION NUMBER: ISRCTN18106677 (protocol V.1.1)

The North Carolina Diabetic Retinopathy Telemedicine Network: Final Program Evaluation

Importance: Retinal tele-screening with remote expert interpretation is an emerging strategy for providing diabetic retinopathy (DR) evaluations in the primary care setting and is especially useful in reaching patients living in rural and underserved areas. Objective: To evaluate the effectiveness of telemedicine in providing retinal screenings to patients with diabetes who participated in the North Carolina Diabetic Retinopathy Telemedicine Network (NCDRTN). Design: Cross-sectional study conducted from January 2014 to November 2015. Setting: 5 Area Health Education Center (AHEC) primary care clinics which serve rural and underserved populations in North Carolina. Participants: 1787 patients with diabetes received retinal screening photographs with remote expert interpretation to determine the presence and severity of DR. Participants included patients aged 18 years or older with Type I or Type II diabetes mellitus who presented to these 5 clinics for their routine diabetes care. Of these patients, 1661 with complete data were included in the statistical analysis. Main Outcomes and Measures: Identification of patient characteristics associated with DR and ophthalmologist referral as well as percentage increase in DR screening rates at the 5 clinics. Results: 1661 patients with complete data were included in the analysis. 1323 (79.7%) had no DR, 183 (11.0%) had DR without referral, and 155 (9.3%) had DR with referral. Age and race were not associated with DR, but were associated with referral. Older patients (OR = 1.28) and African American patients (OR = 1.84) or another minority (OR = 2.19) had greater odds of referral when compared to those who were Caucasian and/or younger by 10 year increments. Patients with higher HgA1c levels (OR = 1.19) and longer duration of diabetes (OR = 1.76) had increased odds of having DR that required referral. Stroke (OR = 1.65) and kidney disease (OR = 1.59) were the comorbid conditions most associated with DR and referral in our study population. The mean reported pre-implementation DR screening rate among the 5 clinics was 25.6% and the post-implementation DR screening rate in active patients was 40.4%. Conclusions and Relevance: When implemented in the primary care setting, telemedicine is an effective intervention for increasing the reach of DR screening in patients with diabetes who otherwise face access barriers to proper and timely eye care.Master of Public Healt

Diabetes eye screening in urban settings serving minority populations: Detection of diabetic retinopathy and other ocular findings using telemedicine

IMPORTANCE The use of a nonmydriatic camera for retinal imaging combined with the remote evaluation of images at a telemedicine reading center has been advanced as a strategy for diabetic retinopathy (DR) screening, particularly among patients with diabetes mellitus from ethnic/racial minority populations with low utilization of eye care. OBJECTIVE To examine the rate and types of DR identified through a telemedicine screening program using a nonmydriatic camera, as well as the rate of other ocular findings. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional study (Innovative Network for Sight [INSIGHT]) was conducted at 4 urban clinic or pharmacy settings in the United States serving predominantly ethnic/racial minority and uninsured persons with diabetes. Participants included persons aged 18 years or older who had type 1 or 2 diabetes mellitus and presented to the community-based settings. MAIN OUTCOMES AND MEASURES The percentage of DR detection, including type of DR, and the percentage of detection of other ocular findings. RESULTS A total of 1894 persons participated in the INSIGHT screening program across sites, with 21.7%having DR in at least 1 eye. The most common type of DR was background DR, which was present in 94.1%of all participants with DR. Almost half (44.2%) of the sample screened had ocular findings other than DR; 30.7%of the other ocular findings were cataract. CONCLUSIONS AND RELEVANCE In a DR telemedicine screening program in urban clinic or pharmacy settings in the United States serving predominantly ethnic/racial minority populations, DR was identified on screening in approximately 1 in 5 persons with diabetes. The vast majority of DR was background, indicating high public health potential for intervention in the earliest phases of DR when treatment can prevent vision loss. Other ocular conditions were detected at a high rate, a collateral benefit of DR screening programs that may be underappreciated

Telemedicine

Telemedicine is a rapidly evolving field as new technologies are implemented for example for the development of wireless sensors, quality data transmission. Using the Internet applications such as counseling, clinical consultation support and home care monitoring and management are more and more realized, which improves access to high level medical care in underserved areas. The 23 chapters of this book present manifold examples of telemedicine treating both theoretical and practical foundations and application scenarios