Accuracy of Detection and Grading of Diabetic Retinopathy and Diabetic Macular Edema Using Teleretinal Screening.

PURPOSE: To determine the accuracy of a county teleretinal screening program of detecting referable diabetic retinopathy (DR) and treatable diabetic macular edema (DME), as well as to evaluate patient compliance with clinic follow-up after referral from teleretinal screening. DESIGN: Retrospective observational study. PARTICIPANTS: Patients in the Harris Health System (HHS, Houston, TX) older than 18 years of age who underwent teleretinal screening between July 2014 and July 2016. METHODS: Teleretinal imaging (TRI) consisting of single-field 45-degree nonmydriatic color fundus photography with referral thresholds of severe nonproliferative DR, proliferative DR, and significant DME. Teleretinal imaging results for all referred subjects were obtained and cross-referenced with dilated fundus examination findings with regard to DR severity and the presence of DME. Follow-up status was also noted. Subjects underwent OCT if deemed necessary by the examining specialist. Agreement between TRI and dilated fundus examination (DFE) findings was determined by calculating the Cohen κ coefficient. MAIN OUTCOME MEASURES: The primary outcome measure is agreement between TRI results and DFE findings with regard to DR severity and the presence of DME. The secondary outcome measure is compliance with follow-up. RESULTS: Of 1767 patients who were screened and referred for clinical examination, 935 (52.9%) attended their clinic appointment. Overall agreement between DFE and TRI was moderate (weighted κ 0.45) in terms of DR severity. There was agreement within one DR severity level in 86.2% of patients. The positive predictive value for detecting referable disease was 71.3%. Of patients referred for DME, 30.4% were deemed to have treatable DME. CONCLUSIONS: The HHS teleretinal screening program demonstrates a high level of accuracy in the detection and classification of referable DR, but a lesser degree of accuracy in the detection of treatable DME. Only slightly more than half of participants were compliant with follow-up after a TRI referral. This large-scale study provides insight into the utility of teleretinal screening in a county health care system.

Cost Savings Analysis for a Diabetic Retinopathy Teleretinal Screening Program Using an Activity-Based Costing Approach.

PURPOSE: To examine the costs and cost savings associated with a large, urban teleretinal screening program for diabetic retinopathy (DR). DESIGN: Retrospective analysis. PARTICIPANTS: Eighteen thousand twenty-five patients (36 050 eyes) screened via the Harris Health System (HHS) DR teleretinal screening program between June 2013 and April 2014. METHODS: Activity-based costing applied to the operational screening pathway was implemented to determine the cost of screening. Actual costs were calculated based on retrospective chart review and figures obtained from the HHS and Centers for Medicare and Medicaid Services. Theoretical costs of in-clinic examinations and delayed intervention were compared with actual costs of screening and treatment to determine costs savings. MAIN OUTCOME MEASURES: Costs and cost savings in United States dollars were estimated. RESULTS: The per-patient cost of teleretinal screening itself was found to be $27.35, whereas the average total cost (factoring in treatment) per patient was determined to be $43.14. The physical examination-only and treatment-only models yielded cost savings estimates of $2 047 442.53 and $1 148 597.35, respectively. CONCLUSIONS: The cost savings yielded by the HHS DR teleretinal screening program compared with conventional screening are substantial and corroborate the findings of similar studies that have analyzed teleretinal screening. Additionally, it can be presumed that there are additional indirect economic benefits resulting from earlier detection and treatment of disease.

Evaluation of Automated Teleretinal Screening Program for Diabetic Retinopathy.

IMPORTANCE: Diabetic retinopathy is a leading cause of blindness, but its detrimental effects are preventable with early detection and treatment. Screening for diabetic retinopathy has the potential to increase the number of cases treated early, especially in populations with limited access to care. OBJECTIVE: To determine the efficacy of an automated algorithm in interpreting screening ophthalmoscopic photographs from patients with diabetes compared with a reading center interpretation. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort analysis of 15,015 patients with type 1 or 2 diabetes in the Harris Health System in Harris County, Texas, who had undergone a retinal screening examination and nonmydriatic fundus photography via the Intelligent Retinal Imaging System (IRIS) from June 2013 to April 2014 were included. The IRIS-based interpretations were compared with manual interpretation. The IRIS algorithm population statistics were calculated. MAIN OUTCOMES AND MEASURES: Sensitivity and false-negative rate of the IRIS computer-based algorithm compared with reading center interpretation of the same images. RESULTS: A total of 15 015 consecutive patients (aged 18-98 years); mean 54.3 years with known type 1 or 2 diabetes underwent nonmydriatic fundus photography for a diabetic retinopathy screening examination. The sensitivity of the IRIS algorithm in detecting sight-threatening diabetic eye disease compared with the reading center interpretation was 66.4% (95% CI, 62.8%-69.9%) with a false-negative rate of 2%. The specificity was 72.8% (95% CI, 72.0%-73.5%). In a population where 15.8% of people with diabetes have sight-threatening diabetic eye disease, the IRIS algorithm positive predictive value was 10.8% (95% CI, 9.6%-11.9%) and the negative predictive value was 97.8% (95% CI, 96.8%-98.6%). CONCLUSIONS AND RELEVANCE: In this large urban setting, the IRIS computer algorithm-based screening program had a high sensitivity and a low false-negative rate, suggesting that it may be an effective alternative to conventional reading center image interpretation. The IRIS algorithm shows promise as a screening program, but algorithm refinement is needed to achieve better performance. Further studies of patient safety, cost-effectiveness, and widespread applications of this type of algorithm should be pursued to better understand the role of teleretinal imaging and automated analysis in the global health care system.

The timing of antibiotic administration in the management of infant dacryocystitis.

PURPOSE: To report (1) the prevalence of bacteremia among infants with dacryocystitis and (2) the influence of timing of antibiotic administration on the need for repeat probing in the management of these patients. METHODS: A retrospective analysis of the hospital records of 25 infants < or =6 weeks of age treated for acute dacryocystitis was conducted, including analysis of laboratory data and outcomes. RESULTS: Of 22 infants who underwent blood cultures, 5 (22.7%) were bacteremic. Twenty-one of the 25 infants underwent nasolacrimal duct probing. Infants who received preoperative antibiotics were less likely to require a repeat probing than those who did not (6% vs. 80%), and this difference was statistically significant (p = 0.004). CONCLUSIONS: The high rate of bacteremia in this series of patients and the significantly lower incidence of repeat probing among infants who received preprocedural antibiotics suggests that blood cultures and subsequent administration of intravenous antibiotics should be considered prior to probing of infants with dacryocystitis.