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Comparing the effectiveness of telemedicine and traditional surveillance in providing diabetic retinopathy screening examinations: a randomized controlled trial.

ABSTRACT: To determine the effectiveness of telemedicine for providing diabetic retinopathy screening examinations compared with the effectiveness of traditional surveillance in community health clinics with a high proportion of minorities, including American Indian/Alaska Natives.We conducted a multicenter, randomized controlled trial and assigned diabetic participants to one of two groups: (1) telemedicine with a nonmydriatic camera or (2) traditional surveillance with an eye care provider. For those receiving telemedicine, the criteria for requiring follow-up with an eye care provider were (1) moderate nonproliferative diabetic retinopathy or higher, (2) presence of clinically significant macular edema, or (3) "unable to grade" result for diabetic retinopathy or macular edema.The telemedicine group (n=296) was more likely to receive a diabetic retinopathy screening examination within the first year of enrollment compared with the traditional surveillance group (n=271) (94% versus 56%, p<0.001). The overall prevalence of diabetic retinopathy at baseline was 21.4%, and macular edema was present in 1.4% of participants. In the telemedicine group, 20.5% would require further evaluation with an eye care provider, and 86% of these referrals were because of poor-quality digital images.Telemedicine using nonmydriatic cameras increased the proportion of participants who obtained diabetic retinopathy screening examinations, and most did not require follow-up with an eye care provider. Telemedicine may be a more effective way to screen patients for diabetic retinopathy and to triage further evaluation with an eye care provider. Methods to decrease poor quality imaging would improve the effectiveness of telemedicine for diabetic retinopathy screening examinations.

SUBMITTER: Mansberger SL

PROVIDER: S-EPMC3850428 | biostudies-literature | 2013 Dec

REPOSITORIES: biostudies-literature

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Comparing the effectiveness of telemedicine and traditional surveillance in providing diabetic retinopathy screening examinations: a randomized controlled trial.

Mansberger Steven L SL Gleitsmann Ken K Gardiner Stuart S Sheppler Christina C Demirel Shaban S Wooten Kathleen K Becker Thomas M TM

Telemedicine journal and e-health : the official journal of the American Telemedicine Association 20131008 12

<h4>Objective</h4>To determine the effectiveness of telemedicine for providing diabetic retinopathy screening examinations compared with the effectiveness of traditional surveillance in community health clinics with a high proportion of minorities, including American Indian/Alaska Natives.<h4>Subjects and methods</h4>We conducted a multicenter, randomized controlled trial and assigned diabetic participants to one of two groups: (1) telemedicine with a nonmydriatic camera or (2) traditional surve ...[more]

PMID: 24102102

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Project description:ImportanceMinimal information exists regarding the long-term comparative effectiveness of telemedicine to provide diabetic retinopathy screening examinations.ObjectiveTo compare telemedicine to traditional eye examinations in their ability to provide diabetic retinopathy screening examinations.Design, setting, and participantsFrom August 1, 2006, through September 31, 2009, 567 participants with diabetes were randomized and followed up to 5 years of follow-up (last date of patient follow-up occurred on August 6, 2012) as part of a multicenter randomized clinical trial with an intent to treat analysis. We assigned participants to telemedicine with a nonmydriatic camera in a primary care medical clinic (n = 296) or traditional surveillance with an eye care professional (n = 271). Two years after enrollment, we offered telemedicine to all participants.Main outcomes and measuresPercentage of participants receiving annual diabetic retinopathy screening examinations, percentage of eyes with worsening diabetic retinopathy during the follow-up period using a validated scale from stage 0 (none) to stage 4 (proliferative diabetic retinopathy), and percentage of telemedicine participants who would require referral to an eye care professional for follow-up care using a cutoff of moderate diabetic retinopathy or worse, the presence of macular edema, or an unable-to-determine result for retinopathy or macular edema.ResultsThe telemedicine group was more likely to receive a diabetic retinopathy screening examination when compared with the traditional surveillance group during the 6-month or less (94.6% [280/296] vs 43.9% [119/271]; 95% CI, 46.6%-54.8%; P < .001) and greater than 6-month through 18-month (53.0% [157/296] vs 33.2% [90/271]; 95% CI, 16.5%-23.1%; P < .001) time bins. After we offered telemedicine to both groups, we could not identify a difference between the groups in the percentage of diabetic retinopathy screening examinations. Diabetic retinopathy worsened by 2 stages or more in 35 (8.6%) of 409 participants (95% CI, 5.8%-11.2%) and improved by 2 stages or more in 5 (1.2%) of 409 participants (95% CI, 0.1%-2.3%) during the 4-year period. The percent of telemedicine participants requiring referral ranged from 19.2% (52/271) to 27.9% (58/208).Conclusions and relevanceTelemedicine increased the percentage of diabetic retinopathy screening examinations, most participants did not require referral to an eye care professional, and diabetic retinopathy levels were generally stable during the study period. This finding suggests that primary care clinics can use telemedicine to screen for diabetic retinopathy and monitor for disease worsening over a long period.Trial registrationclinicaltrials.gov Identifier: NCT01364129.

Project description:BackgroundDiabetic retinopathy (DR) is a significant global public health and economic burden. DR accounts for approximately 15-17% of all cases of total blindness in the USA and Europe. Telemedicine is a new intervention for DR screening, however, there is not enough evidence to support its cost-effectiveness. The aim of this study is to review the most recent published literature on economic evaluations of telemedicine in DR screening and summarize the evidence on the cost-effectiveness of this technology.MethodsA systematic search of PubMed, Embase and Google Scholar for relevant articles published between January 2010 and January 2020. Studies were included if they met the following criteria: (1) recruited subjects with either type 1, type 2 diabetes (2) evaluated telemedicine technology (3) patients underwent primary screening for DR (4) compared a telemedicine-based intervention with standard care (5) performed an economic evaluation or provided sufficient data for evaluating the cost-effectiveness of the technology used.ResultsOf 2238 articles screened, seven studies were included. Four of the studies were conducted in developed countries: The United States, Singapore and two studies in Canada. Three studies were conducted in developing countries: India, Brazil and South Africa. The patient populations in all studies were diabetic patients over the age of 18, previously not screened for DR. All seven studies used a telemedicine program which included capturing a retinal image and subsequently transmitting it to an ocular imaging center to assess the severity of DR. All studies compared telemedicine to a standard screening method for DR, including the option of no screening as standard of care. Although telemedicine requires initial and maintenance costs, it has the potential to provide significant cost savings by increasing patients' working ability, increasing independent living ability, increasing quality of life and reducing travel costs.ConclusionsDiabetic retinopathy telemedicine technology has the potential to provide significant cost savings, especially in low-income populations and rural patients with high transportation costs.

Project description:BackgroundDiabetic retinopathy (DR) is the leading cause of vision loss among adults in the USA. Vision loss associated with diabetic retinopathy can be prevented with timely ophthalmologic care, and therefore, it is recommended that individuals with diabetes have annual retinal examinations. There is limited evidence on whether using telemedicine to screen for DR in primary care clinics in the USA effectively leads to increased DR screening rates. The objective of this systematic review is to collate evidence from existing studies to investigate the effectiveness of telemedicine DR screening (TDRS) in primary care clinics on DR screening rates.MethodsRelevant studies will be identified through searching MEDLINE/PubMed interface, Scopus, and Web of Science from their inception until November 2021, as well as searching reference lists of included studies and previous related review articles or systematic reviews. There will be no restrictions on study design. Eligible studies will include subjects with either type 1 or type 2 diabetes, will evaluate telemedicine technology for screening of DR, will have been conducted in the USA, and will report DR screening rates or data necessary for calculating such rates. Two reviewers will screen search results independently. Risk-of-bias assessment and data extraction will be carried out by two reviewers. The version 2 of the Cochrane risk-of-bias tool (RoB 2) and the Newcastle-Ottawa scale (NOS) tool will be used to assess the quality and validity of individual studies. If feasible, we will conduct random-effects meta-analysis where appropriate. If possible, we will conduct subgroup analyses to explore potential heterogeneity sources (setting, socio-economic status, age, ethnicity, study design, outcomes). We will disseminate the findings through publications and relevant networks.DiscussionThis protocol outlines the methods for systematic review and synthesis of evidence of TDRS and its effect on DR screening rates. The results will be of interest to policy makers and program managers tasked with designing and implementing evidence-based services to prevent and manage diabetes and its complications in similar settings.Systematic review registrationPROSPERO CRD42021231067.

Project description:BackgroundCommunity-based telemedicine screening for diabetic retinopathy (DR) has been highly recommended worldwide. However, evidence from low- and middle-income countries (LMICs) on the choice between artificial intelligence (AI)-based and manual grading-based telemedicine screening is inadequate for policy making.ObjectiveThe aim of this study was to test whether the AI model is more worthwhile than manual grading in community-based telemedicine screening for DR in the context of labor costs in urban China.MethodsWe conducted cost-effectiveness and cost-utility analyses by using decision-analytic Markov models with 30 one-year cycles from a societal perspective to compare the cost, effectiveness, and utility of 2 scenarios in telemedicine screening for DR: manual grading and an AI model. Sensitivity analyses were performed. Real-world data were obtained mainly from the Shanghai Digital Eye Disease Screening Program. The main outcomes were the incremental cost-effectiveness ratio (ICER) and the incremental cost-utility ratio (ICUR). The ICUR thresholds were set as 1 and 3 times the local gross domestic product per capita.ResultsThe total expected costs for a 65-year-old resident were US $3182.50 and US $3265.40, while the total expected years without blindness were 9.80 years and 9.83 years, and the utilities were 6.748 quality-adjusted life years (QALYs) and 6.753 QALYs in the AI model and manual grading, respectively. The ICER for the AI-assisted model was US $2553.39 per year without blindness, and the ICUR was US $15,216.96 per QALY, which indicated that AI-assisted model was not cost-effective. The sensitivity analysis suggested that if there is an increase in compliance with referrals after the adoption of AI by 7.5%, an increase in on-site screening costs in manual grading by 50%, or a decrease in on-site screening costs in the AI model by 50%, then the AI model could be the dominant strategy.ConclusionsOur study may provide a reference for policy making in planning community-based telemedicine screening for DR in LMICs. Our findings indicate that unless the referral compliance of patients with suspected DR increases, the adoption of the AI model may not improve the value of telemedicine screening compared to that of manual grading in LMICs. The main reason is that in the context of the low labor costs in LMICs, the direct health care costs saved by replacing manual grading with AI are less, and the screening effectiveness (QALYs and years without blindness) decreases. Our study suggests that the magnitude of the value generated by this technology replacement depends primarily on 2 aspects. The first is the extent of direct health care costs reduced by AI, and the second is the change in health care service utilization caused by AI. Therefore, our research can also provide analytical ideas for other health care sectors in their decision to use AI.

Project description:Aims/hypothesisIn this study we examined the cost-effectiveness of three different screening strategies for diabetic retinopathy: using a personalised adaptive model, annual screening (fixed intervals), and the current Dutch guideline (stratified based on previous retinopathy grade).MethodsFor each individual, optimal diabetic retinopathy screening intervals were determined, using a validated risk prediction model. Observational data (1998-2017) from the Hoorn Diabetes Care System cohort of people with type 2 diabetes were used (n = 5514). The missing values of retinopathy grades were imputed using two scenarios of slow and fast sight-threatening retinopathy (STR) progression. By comparing the model-based screening intervals to observed time to develop STR, the number of delayed STR diagnoses was determined. Costs were calculated using the healthcare perspective and the societal perspective. Finally, outcomes and costs were compared for the different screening strategies.ResultsFor the fast STR progression scenario, personalised screening resulted in 11.6% more delayed STR diagnoses and €11.4 less costs per patient compared to annual screening from a healthcare perspective. The personalised screening model performed better in terms of timely diagnosis of STR (8.8% less delayed STR diagnosis) but it was slightly more expensive (€1.8 per patient from a healthcare perspective) than the Dutch guideline strategy.Conclusions/interpretationThe personalised diabetic retinopathy screening model is more cost-effective than the Dutch guideline screening strategy. Although the personalised screening strategy was less effective, in terms of timely diagnosis of STR patients, than annual screening, the number of delayed STR diagnoses is low and the cost saving is considerable. With around one million people with type 2 diabetes in the Netherlands, implementing this personalised model could save €11.4 million per year compared with annual screening, at the cost of 658 delayed STR diagnoses with a maximum delayed time to diagnosis of 48 months.

Project description:BackgroundRetinopathy is a common complication of diabetes mellitus that if detected early by regular retinal examinations can be treated; thus, blindness can be delayed or prevented. Providing high-quality retinal screening is difficult, especially in rural and remote areas. Canada's First Nations population has a higher prevalence of diabetes and is, in general, more geographically isolated than the broader Canadian population. We modelled the cost-effectiveness of retinopathy screening by travelling retina specialists versus retinal photography with a portable digital camera in an isolated First Nations cohort with diabetes.MethodsThe 2 screening programs were modelled to run concurrently for 5 years, with outcomes evaluated over 10 years. To construct economic models for the population of Cree individuals living in the western James Bay area of northern Ontario, we used available data on the prevalence of diabetes in the area and estimates of the incidence of retinopathy derived from the published literature. We compared the screening models and calculated total costs, visual outcome, costs per sight-year saved and costs per quality-adjusted life year (QALY). We also estimated the costs of implementing a screening program for all First Nations individuals in Ontario with diabetes and no access to an ophthalmologist.ResultsFrom the perspective of the health care system the camera program was preferable to the specialist-based program. Over 10 years, 67 v. 56 sight years were saved, compared with no screening, at costs of 3900 Canadian dollars v. 9800 Canadian dollars per sight year and 15,000 Canadian dollars v. 37,000 Canadian dollars per QALY. Generalizing these results to the province of Ontario, the camera system could allow most isolated First Nations people with diabetes to be screened for 5 years for approximately 1.2 million Canadian dollars.InterpretationA portable retinal camera is a cost-effective means of screening for diabetic retinopathy in isolated communities of at-risk individuals.

Project description:ContextDiabetic retinopathy (DR) is the leading cause of incident blindness among working-age adults in the United States. Federally designated safety-net clinics (FDSC) often serve as point-of-contact for patients least likely to receive recommended DR screenings, creating opportunity for targeted interventions to increase screening access and compliance.Study design and methodsWith such a goal, we implemented and assessed the longitudinal performance of an FDSC-based telemedicine DR screening (TDRS) network of 22 clinical sites providing nonmydriatic fundus photography with remote interpretation and reporting. Retrospective analysis of patient encounters between February 2014 and January 2019 was performed to assess rates of pathology and referral. A generalized estimating equation logistic regression model was used for subset analysis from audits of pre- and post-implementation screening rates. Finally, patient surveys were conducted and assessed as a measure of intervention acceptability.ResultsOf the 13,923 individual telescreening encounters (4327 female, 4220 male, and 5376 unspecified; mean [SD] age, 54.9 [12.5] years) studied, 10,540 were of adequate quality to identify 3532 (33.5%) patients with ocular pathology: 2319 (22.0%) patients had some level of DR with 1604 (15.2%) requiring specialist referral, and 808 (7.7%) patients required referral for other ocular pathologies. The mean screening rate for audited clinics in the year prior to program implementation was 29.9% (641/2147), which increased to 47.7% (1012/2124) in the program's first year, doubling patients' odds of being screened (OR 2.2; 95% CI: 1.3-3.7; P = .003). These gains were sustained over four years following implementation (OR 1.9; 95% CI: 1.1-3.1; P = .018) despite varied clinic screening performance (4-year averaged range, 22.9-55.1%). Odds of early detection likewise doubled for patients with consecutive screenings (OR 2.2, 95% CI: 2.0-2.4; P < .001). Finally, surveyed patients preferred TDRS to specialist exams (82.5%; 776/941) and would recommend the service to friends (92.7%; 868/936).Conclusion and relevanceA statewide, FDSC-centered TDRS network was successfully established and sustained in a medically underserved region of the United States. Our results suggest that large TDRS networks in FDSCs can increase screening access and compliance for otherwise unscreened populations, but outcomes can vary greatly among clinics. Further work to optimize program implementation is needed to maximize this model's impact.

Dataset Information

Comparing the effectiveness of telemedicine and traditional surveillance in providing diabetic retinopathy screening examinations: a randomized controlled trial.

Publications

Comparing the effectiveness of telemedicine and traditional surveillance in providing diabetic retinopathy screening examinations: a randomized controlled trial.

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