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The Effectiveness of Diabetic Retinopathy Screening by Primary Care Providers: A Systematic Review of Literature

Jena Shackelford, PA-S; David B. Day, EdS, MPAS, PA-CDepartment of Physician Assistant

College of Health Professions, Wichita, Kansas

INTRODUCTIONDiabetic retinopathy (DR), is the leading cause of preventable blindness in the United States and much of the industrialized world. This complication has the potential to affect all patients with diabetes, regardless of type. Many patients with diabetes are unaware of any vision loss and may not receive treatment before its too late. Primary care providers play an important role in screening for any retinal changes in between patients’ annual visits with an ophthalmologist. Many health care providers feel inadequate in their ability to accurately screen for DR using the conventional ophthalmoscope, (CO).1 There has recently been a new ophthalmoscope, the PanOptic, (PO), which claims to be just as accurate. There is also an emerging form of screening by way of telemedicine. Telemedicine, (TM), occurs when digital images are obtained and evaluated off site by an ophthalmologist. The purpose of this paper was to perform a systematic review of the literature and examine the effectiveness of screening for DR by primary care providers by comparing the CO and PO with TM.

CONCLUSIONS Screening for DR in the primary care setting will not replace the vital role that eye care specialists play. Early detection will not only decrease the amount of unnecessary referrals, but also allow specialists the time needed to properly diagnose and treat DR. The CO is still an effective piece of equipment but TM holds much promise for protecting vision loss in diabetic patients. It takes the guess work out of the screening process and allows the images to be assessed by an eye professional. It will also allow DR screening for rural areas or patient populations that would not necessarily have access to an evaluation by an ophthalmologist or retinal specialist.

RESULTSBased on the inclusion material, (Figure 1) twenty-nine articles were selected. Twelve articles consisted of background information regarding DR, which included: epidemiology, signs and symptoms, diagnosis, treatment options, and inadequacies of screening by primary care providers. Two studies found PCP’s were effective using the CO after small workshops; one study found CO not effective. Only two studies discussed the PO. One found PO not as accurate as CO and gave a less clear image. The other compared physicians’ referrals using PO against an ophthalmologist’s referral based on standardized criteria. Twelve articles found TM to be effective. Forty-two percent of articles compared TM against an ophthalmologist’s use of the gold standard. Half of the articles chose to dilate the patients’ eyes with mydriatic drops prior to obtaining the images. The studies varied on the number of images obtained per patient eye, ranging from 1-15 images.

DISCUSSIONSeveral professional groups require a minimum sensitivity of 80% and specificity of 95% to be effective in DR screening. Two-thirds of the articles discussing the CO found it is still an effective piece of equipment in screening for DR, after receiving a training session. PCP’s using the PO were not very effective. It gave a duller image and less clear image than the CO.2 It also had an unacceptable specificity.

Although the studies regarding TM differed on the number of digital images obtained, they were all successful in diagnosing DR. The grading scales used in the studies varied from whether or not DR was present to grading levels of severity of DR. The majority of the studies discussing TM had at least 85% of the obtained images deemed gradable. If the image was not gradable, the patient was always sent for referral. An example of TM, the DigiScope, is a camera specifically designed to function in a primary care setting.3 The DigiScope is a low cost camera that had the highest sensitivity and specificity of all TM studies.METHODOLOGY

This project was conducted using Medline, FirstSearch and Infotrac Web Databases. Journal articles were only selected if they were peer-reviewed and dated from 1999 to the present, with the exception of two foundational articles. This time frame was selected to cover changes in technology and equipment in detecting DR. The search utilized the following keywords: DM, TM, primary health care, PanOptic, DigiScope, and eye exam.

Figure 1: Literature Review Flow SheetEffectiveness of Diabetic Retinopathy Screening by Primary Care Providers

Search Terms: Diabetic Retinopathy Primary Health Care PanOptic® Telemedicine Eye Exam DigiScope®

Total Articlesn = 29

PanOptic® effectiveness

n = 2

Conventional ophthalmoscope

effectivenessn = 3

Telemedicine effectiveness

n = 12

Backgroundn = 12

Retrospectiven = 3

Retrospectiven = 2

Random Controln = 3

Case Seriesn = 1

Retrospectiven = 8

Outcome: Telemedicine is effective for diabetic retinopathy screening by

primary care providers.