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Steven Mansberger, Stuart Gardiner, Shaban Demirel, Thomas Becker; Long-term comparative effectiveness of telemedicine to detect diabetic retinopathy. Invest. Ophthalmol. Vis. Sci. 2013;54(15):1549.
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To determine the long-term comparative effectiveness of telemedicine for providing diabetic retinopathy screening exams in community health clinics with a high proportion of minorities including American Indian/Alaska Natives.
We enrolled 567 participants with diabetes into a multicenter, randomized controlled trial with a staged intervention. We assigned diabetic participants to one of two groups: 1) telemedicine with a non-mydriatic camera in a primary medical clinic; or 2) traditional surveillance with an eye care provider. After two years, the trial offered telemedicine to all participants. We determined the proportion of diabetic retinopathy screening exams during each year after enrollment using an intention-to-treat analysis. We graded diabetic retinopathy using a validated scale from Stage 0 (none) to Stage 4 (proliferative diabetic retinopathy).
The Telemedicine group (n=296) was more likely to receive a diabetic screening exam when compared to the Traditional Surveillance group (n=271) during Year 1 (91.9 vs. 43.9%, P<.001), and Year 2 (53.0 vs. 33.2%, P<.001). However, after the trial offered telemedicine to both groups, the proportion of diabetic screening exams was similar between groups for the subsequent years (Year 3, 44.3 vs. 39.5%, P=.25; Year 4, 45.9 vs. 46.1%, P=.96; Year 5, 47.6 vs. 51.3%, P=.38). Using a cut-off of ‘moderate diabetic retinopathy or worse’ as requiring referral to an ophthalmologist, only 8.3%, 6.2%, 3.9%, 6.4%, and 5.2% of participant would require referral during Year 1, 2, 3, 4, and 5, respectively.
Telemedicine in the primary medical clinic using non-mydriatic cameras increased the proportion of participants who obtained diabetic screening exams when compared to traditional surveillance, and most patients did not have levels of diabetic retinopathy requiring a referral to an ophthalmologist. Telemedicine may be a more effective way to screen patients for diabetic retinopathy, and to triage further evaluation with an eye care provider when compared to traditional surveillance by an eye care provider. The staged intervention suggests that telemedicine would increase the proportion of diabetic screening exams over the long-term, but the decrease in the proportion of diabetic screening exam in both groups suggests that other barriers to diabetic screening exist even when telemedicine is available.
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