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

OBJECTIVE: 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. SUBJECTS AND METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Breast magnetic resonance imaging (MRI) surveillance in breast cancer survivors.

PURPOSE: As the breast cancer survivor population increases, the topic of screening these women for recurrences is increasingly relevant. In our institution, we use both breast MRI and mammography in the surveillance of breast cancer survivors, although little data exists on the use of MRI in this setting. We present a retrospective analysis of our experience and compare the sensitivity and specificity of MRI vs. mammography in this setting. METHODS: We identified women under 65 with a history of breast cancer and at least one follow-up MRI performed along with a mammogram done within 6 months of the MRI. We compared the outcomes of MRI and mammography in terms of biopsies performed as well as in detection of new cancers. RESULTS: Of 617 charts reviewed, 249 patients met inclusion criteria, with 571 paired MRI/mammogram results. There were 27 biopsies performed due to MRI findings alone, 10 done due to mammographic findings alone, and 15 done based on abnormalities seen on both imaging modalities. There were 8 malignancies identified based on an abnormal MRI, 3 detected on both MRI and mammography, and none identified via mammography alone. Overall, MRI had a sensitivity of 84.6% (the 95% CI 54.6-98.1) and a specificity of 95.3% (the 95% CI 93.3-96.9); mammography a sensitivity of 23.1% (the 95% CI 5.0-53.8), and a specificity of 96.4% (the 95% CI 94.5-97.8). CONCLUSIONS: Breast MRI is a useful surveillance modality in breast cancer survivors and may be more sensitive at detecting recurrences than mammography alone in this population.

Long-term Comparative Effectiveness of Telemedicine in Providing Diabetic Retinopathy Screening Examinations: A Randomized Clinical Trial.

IMPORTANCE: Minimal information exists regarding the long-term comparative effectiveness of telemedicine to provide diabetic retinopathy screening examinations. OBJECTIVE: To compare telemedicine to traditional eye examinations in their ability to provide diabetic retinopathy screening examinations. DESIGN, SETTING, AND PARTICIPANTS: From 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 MEASURES: Percentage 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. RESULTS: The 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 RELEVANCE: Telemedicine 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 REGISTRATION: clinicaltrials.gov Identifier: NCT01364129.

The impact of eyeglasses on vision-related quality of life in American Indian/Alaska Natives.

PURPOSE: To determine the change in vision-related quality-of-life scores after providing eyeglasses to American Indian/Alaska Natives with undercorrected refractive error. STUDY DESIGN: Prospective, comparative (nonrandomized) interventional study. METHODS: We compared a group with undercorrected refractive error to a control group who did not need a change in eyeglasses. Undercorrected refractive error was defined as distance visual acuity 20/40 or worse in the better-seeing eye that could be improved by at least 2 lines in Snellen visual acuity. Intervention was the provision of new glasses to the undercorrected refractive error group members, based on results of manifest refraction. The main outcome measures were the differences in the 25-Item National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25) scores from baseline (Time 1) to the time after providing eyeglasses (Time 2). RESULTS: The NEI VFQ-25 median Composite score at Time 1 was significantly lower in those with undercorrected refractive error when compared to the control group (75 vs 92, P = .001). The median Composite score for the undercorrected refractive error group improved to 96 (P < .001) at Time 2 when compared to Time 1, while the control group remained stable at 93 (P = .417). The undercorrected refractive error group showed significantly greater improvement than the control group in 8 of 12 subscale scores and in the overall Composite score (all P values ≤ .05). A multivariate linear regression analysis, which controlled for differences in age, percent self-identified American Indian/Alaskan Native, and best-corrected visual acuity between the undercorrected refractive error and control group, showed eyeglasses to be significantly associated with improvement in NEI VFQ-25 composite score. CONCLUSION: Visual impairment from undercorrected refractive error is common in American Indian/Alaskan Natives. Providing eyeglasses results in a large, significant increase in vision-related quality of life.