always occur in a timely manner after the imaging procedure. While the reasons for this delay have not been specifically reviewed, at least some patients reported they were not able to receive a more timely appointment from an ophthalmologist or that other medical problems took precedence over an eye examination. Other possible reasons for the delay may include a lag in the time the primary care physician received the report and the time the patient was informed about the recommendations. Poor patient understanding of the urgent nature of the eye disease in particular may have been a factor, especially if the patient was asymptomatic. These study results provide an opportunity to implement actions that may reduce the length of time between imaging and ophthalmic evaluation of patients with an urgent referral recommendation.

11.7.3 Challenges

In spite of significant progress made toward delivery of highly effective telemedicine solutions to expand diabetic retinopathy assessment to the point of care in the primary care setting, major challenges remain. The primary issues that have prevented more widespread adoption of these technologies include the cost of the fundus camera, financial return, physician acceptance, and practice integration. The present reimbursement landscape creates both real and perceived difficulties for primary care physicians to deploy and utilize a diabetic retinopathy assessment service in their offices. While the majority of patients with insurance have coverage for this service in the primary care setting, the reimbursement rate is low when factoring in equipment costs, technician and staff time, and potential disruption of the office patient flow. Additionally, reimbursement rates have been reduced substantially in the past 5 years. Political pressures may also have a negative influence. Many ophthalmologists in the United States will not embrace or endorse diabetic retinopathy assessment outside of the conventional ophthalmology setting as they have the misconception that they may lose patients with a negative economic impact on their practice as a

result of these programs. Despite its potential, these hurdles have limited the use of ocular telehealth to only a small fraction of patients who are not receiving any diabetic retinopathy eye care and who could benefit significantly from its use.

11.7.4 Summary

A validated digital retinal imaging platform in the primary health-care environment can be used to reliably identify diabetic eye disease in patients not currently following recommended guidelines for regular retinal examinations. The advantages of the DigiScope® imaging system are ease of use (minimal training required), convenience (located in PCP’s office), and the ability to detect diabetic retinopathy at a level requiring referral to an ophthalmologist. The DigiScope® has been successfully integrated into numerous primary care sites as a means to increase compliance with recommendations for diabetic retinopathy assessment, and a large number of patients have been evaluated. With this system, referral is recommended for any patient identified as having more than mild nonproliferative diabetic retinopathy. The DigiScope® is not a substitute for a comprehensive eye examination. However, the system does allow detection of non-diabetic eye disease and may prove to be useful in identifying other ocular pathology requiring referral. Implementation of these remote telemedicine systems increases overall rates of diabetic retinopathy assessment. Compliance with recommendations for referral and evaluation in patients identified as having more advanced diabetic eye disease tends to be very good. Further assessment of the implementation of these technologies in the primary care setting is necessary to determine its full public health impact and utility in contributing to the reduction of vision loss in patients with diabetes.

References

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2. Zeimer R, Zou S, Meeder T et al (2002) A fundus camera dedicated to the screening of diabetic retinopathy in the primary care physician’s office. Invest Ophthalmol Vis Sci 43:1581–1587

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12.1Screening

The deÞnition of screening that was adapted by the WHO [15] in 1968 was Ôthe presumptive identiÞcation of unrecognised disease or defect by the application of tests, examinations or other procedures which can be applied rapidly. Screening tests sort out apparently well persons who probably have a disease from those who probably do not. A screening test is not intended to be diagnostic. Persons with positive or suspicious Þndings must be referred to their physicians for diagnosis and necessary treatment.Õ

The principles for screening for human disease that were derived from the public health papers produced by the WHO [15] in 1968 were:

1.The condition sought should be an important problem.

2.There should be an accepted treatment for patients with recognised disease.

3.Facilities for diagnosis and treatment should be available.

4.There should be a recognisable latent or early symptomatic stage.

5. There should be a suitable test or examination. 6. The test should be acceptable to the population.

P.H. Scanlon, M.D., FRCO, MRCOphth

English National Screening Programme for Diabetic Retinopathy, Cheltenham General Hospital, Sandford Rd., Cheltenham, Gloucestershire,

GL53 7AN, UK

e-mail: peter.scanlon@glos.nhs.uk

7.The natural history of the condition, including development from latent to declared disease, should be adequately understood.

8.There should be an agreed policy on whom to treat as patients.

9.The cost of the case-Þnding programme (including early diagnosis and treatment of patients diagnosed) should be economically balanced in relation to possible expenditure on medical care as a whole.

10.Case-Þnding should be a continuing process and not a Ôone-timeÕ project.

12.2Background

In 1990, the St. Vincent Declaration [10] recognised diabetes and diabetic retinopathy to be a major and growing European health problem, a problem at all ages and in all countries. The Þrst of the 5-year targets that were unanimously agreed by Government Health Departments and patientsÕ organisations from all European countries was to reduce new blindness due to diabetes by one-third or more.

In 1995, Kristinsson [7] reported the low prevalence of blindness in people with Type 1 and Type 2 diabetes in Iceland, which he attributed to a screening programme that had been established in 1980.

In1997,Backlund[1]reportedthatnewblindness in diabetes had reduced by more than one-third in Stockholm County, following the introduction of a community-wide mobile fundus photographic screening programme using 35-mm Þlm.