Sharing risk management: an implementation model for cardiovascular absolute risk assessment and management in Australian general practice

Purpose: Despite considerable work in developing and validating cardiovascular absolute risk (CVAR) algorithms, there has been less work on models for their implementation in assessment and management. The aim of our study was to develop a model for a joint approach to its implementation based on an exploration of views of patients, general practitioners (GPs) and key informants (KIs). Methods: We conducted six focus group (three with GPs and three with patients) and nine KI interviews in Sydney. Thematic analysis was used with comparison to highlight the similarities and differences in perspectives of participants. Results: Conducting CVAR was seen as more acceptable for regular patients rather than new patients for whom GPs had to attract their interest and build rapport before doing so at the next visit. GPs' interest and patients' positive attitude in managing risk were important in implementing CVAR. Long consultations, good communication skills and having a trusting relationship helped overcome the barriers during the process. All the participants supported engaging patients to self-assess their risk before the consultation and sharing decision making with GPs during consultation. Involving practice staff to help with the patient self-assessment, follow-up and referral would be helpful in implementing CVAR assessment and management, but GPs, patients and practices may need more support for this to occur. Conclusions: Multiple strategies are required to promote the better use of CVAR in the extremely busy working environment of Australian general practice. An implementation model has been developed based on our findings and the Chronic Care Model. Further research needs to investigate the effectiveness of the proposed model

The ChromaTest, a digital color contrast sensitivity analyzer, for diabetic maculopathy: a pilot study

Background: To assess the ability of the Chromatest in investigating diabetic maculopathy. Method: Patients with Type 2 diabetes and no concurrent ocular pathology or previous laser photocoagulation were recruited. Visual acuities were assessed followed by colour contrast sensitivity testing of each eye using Chromatest. Dilated fundoscopy with slit lamp biomicroscopy with 78 D lens was then performed to confirm the stage of diabetic retinopathy according to the Early Treatment Diabetic Retinopathy Study. Results: 150 eyes in 150 patients were recruited into this study. 35 eyes with no previous laser photocoagulation were shown to have clinically significant macular oedema (CSMO) and 115 eyes with untreated non-proliferative diabetic retinopathy (NPDR) on fundus biomicroscopy. Statistical significant difference was found between CSMO and NPDR eyes for protan colour contrast threshold (p = 0.01). Statistical significance was found between CSMO and NPDR eyes for tritan colour contrast threshold (p = 0.0002). Sensitivity and specificity for screening of CSMO using pass-fail criterion for age matched TCCT results achieved 71% (95% confidence interval: 53–85%) and 70% (95% confidence interval: 60–78%), respectively. However, threshold levels were derived using the same data set for both training and testing the effectiveness since this was the first study of NPDR using the Chromatest Conclusion: The ChromaTest is a simple, cheap, easy to use, and quick test for colour contrast sensitivity. This study did not achieve results to justify use of the Chromatest for screening, but it reinforced the changes seen in tritan colour vision in diabetic retinopathy

An observational study to assess if automated diabetic retinopathy image assessment software can replace one or more steps of manual imaging grading and to determine their cost-effectiveness.

BACKGROUND: Diabetic retinopathy screening in England involves labour-intensive manual grading of retinal images. Automated retinal image analysis systems (ARIASs) may offer an alternative to manual grading. OBJECTIVES: To determine the screening performance and cost-effectiveness of ARIASs to replace level 1 human graders or pre-screen with ARIASs in the NHS diabetic eye screening programme (DESP). To examine technical issues associated with implementation. DESIGN: Observational retrospective measurement comparison study with a real-time evaluation of technical issues and a decision-analytic model to evaluate cost-effectiveness. SETTING: A NHS DESP. PARTICIPANTS: Consecutive diabetic patients who attended a routine annual NHS DESP visit. INTERVENTIONS: Retinal images were manually graded and processed by three ARIASs: iGradingM (version 1.1; originally Medalytix Group Ltd, Manchester, UK, but purchased by Digital Healthcare, Cambridge, UK, at the initiation of the study, purchased in turn by EMIS Health, Leeds, UK, after conclusion of the study), Retmarker (version 0.8.2, Retmarker Ltd, Coimbra, Portugal) and EyeArt (Eyenuk Inc., Woodland Hills, CA, USA). The final manual grade was used as the reference standard. Arbitration on a subset of discrepancies between manual grading and the use of an ARIAS by a reading centre masked to all grading was used to create a reference standard manual grade modified by arbitration. MAIN OUTCOME MEASURES: Screening performance (sensitivity, specificity, false-positive rate and likelihood ratios) and diagnostic accuracy [95% confidence intervals (CIs)] of ARIASs. A secondary analysis explored the influence of camera type and patients' ethnicity, age and sex on screening performance. Economic analysis estimated the cost per appropriate screening outcome identified. RESULTS: A total of 20,258 patients with 102,856 images were entered into the study. The sensitivity point estimates of the ARIASs were as follows: EyeArt 94.7% (95% CI 94.2% to 95.2%) for any retinopathy, 93.8% (95% CI 92.9% to 94.6%) for referable retinopathy and 99.6% (95% CI 97.0% to 99.9%) for proliferative retinopathy; and Retmarker 73.0% (95% CI 72.0% to 74.0%) for any retinopathy, 85.0% (95% CI 83.6% to 86.2%) for referable retinopathy and 97.9% (95% CI 94.9 to 99.1%) for proliferative retinopathy. iGradingM classified all images as either 'disease' or 'ungradable', limiting further iGradingM analysis. The sensitivity and false-positive rates for EyeArt were not affected by ethnicity, sex or camera type but sensitivity declined marginally with increasing patient age. The screening performance of Retmarker appeared to vary with patient's age, ethnicity and camera type. Both EyeArt and Retmarker were cost saving relative to manual grading either as a replacement for level 1 human grading or used prior to level 1 human grading, although the latter was less cost-effective. A threshold analysis testing the highest ARIAS cost per patient before which ARIASs became more expensive per appropriate outcome than human grading, when used to replace level 1 grader, was Retmarker £3.82 and EyeArt £2.71 per patient. LIMITATIONS: The non-randomised study design limited the health economic analysis but the same retinal images were processed by all ARIASs in this measurement comparison study. CONCLUSIONS: Retmarker and EyeArt achieved acceptable sensitivity for referable retinopathy and false-positive rates (compared with human graders as reference standard) and appear to be cost-effective alternatives to a purely manual grading approach. Future work is required to develop technical specifications to optimise deployment and address potential governance issues. FUNDING: The National Institute for Health Research (NIHR) Health Technology Assessment programme, a Fight for Sight Grant (Hirsch grant award) and the Department of Health's NIHR Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital and the University College London Institute of Ophthalmology

Implementation and first-year screening results of an ocular telehealth system for diabetic retinopathy in China

<p>Abstract</p> <p>Background</p> <p>To describe implementation and first-year screening results of the first Chinese telehealth system for diabetic retinopathy (DR) - the Beixinjing Community Diabetic Retinopathy Telehealth system (BCDRT).</p> <p>Methods</p> <p>BCDRT implementation was based on the acquisition of adequate digital retinographs, secure digital transmission, storage and retrieval of participants' data and reader-generated medical reports. Local diabetic residents meeting inclusion criteria were enrolled into the BCDRT system beginning in 2009. Participants recommended for further in-person examination with ophthalmologists were followed, and the consistencies in diagnoses between BCDRT and ophthalmologists for DR or macular edema were calculated.</p> <p>Results</p> <p>A total of 471 diabetic residents participated in BCDRT screening in 2009. The proportions of total DR, proliferative DR, and diabetic macular edema were 24.42% (115 patients), 2.12% (10 patients) and 6.47% (24 patients), respectively: 56 patients consulted ophthalmologists for further in-person retinal examination with funduscopy after pupil dilation. High rates of consistency between BCDRT screening and ophthalmologists were observed for macular edema (Kappa = 0.81), moderate or severe non-proliferative DR grade (Kappa = 0.92), and other DR grades (Kappa = 1). A total of 456 (96.82%) patients were willing to participate in the next BCDRT screening.</p> <p>Conclusions</p> <p>BCDRT was a reliable and valid system for DR screening, and offers the potential to increase DR annual screening rates in local residents.</p

Threshold for detection of diabetic peripheral sensory neuropathy using a range of research grade monofilaments in persons with Type 2 diabetes mellitus

<p>Abstract</p> <p>Aims</p> <p>To identify the threshold of reduced sensory perception in Type 2 diabetes mellitus (Type 2 DM) using a range of research grade monofilaments.</p> <p>Methods</p> <p>Three groups of participants were recruited into a between subject, cross-sectional study. Group 1(NEW), persons with Type 2 DM diagnosed for less than 2 years (<it>n </it>= 80); Group 2 (EST) persons with Type 2 DM diagnosed for more than 2 years (<it>n </it>= 91), and Group 3, a Comparison group without Type 2 DM (<it>n </it>= 73), resulted in a total study population, <it>n </it>= 244. Research grade monofilaments (2, 4, 6, 8 and 10-gram) were employed using standardised protocol, at 6 sites on the plantar aspect of both feet. The demographic and anthropometric measures of gender, age, height, weight, body mass index (BMI), blood pressure and duration of Type 2 DM since diagnosis (if applicable) of the participants were analysed.</p> <p>Results</p> <p>Perception of the research grade monofilaments differed significantly between the 3 groups (p < 0.05). The 6-gram monofilament was found to be the threshold of normal perception, based on 90% of the Comparison group perceiving the 6-gram monofilament at all sites in contrast to 64% of NEW and 48% of EST groups.</p> <p>Conclusion</p> <p>The 6-gram monofilament was identified as the threshold of normal sensory perception. Inability to perceive the 6-gram monofilament indicates, when using the method described in this study, that diminution of sensory perception is evident. Employing a range of monofilaments, 6, 8 and 10-grams in Type 2 DM foot screening would allow the clinical detection of deteriorating sensory perception and enable implementation of foot protection strategies at an earlier stage than is currently practised.</p