Evaluación del manejo y seguimiento de los pacientes diabéticos en la prevención de la retinopatía diabética / Evaluation of the management and follow-up of diabetic patients in the prevention of diabetic retinopathy

Fundamentos: La diabetes mellitus es una enfermedad crónica con alta morbimortalidad que afecta a 537 millones de adultos en el mundo. España es el segundo país europeo en prevalencia, con un 14,8% en población de veinte-setenta y nueve años, con 11,6 casos por cada 1.000 personas/año. La retinopatía diabética (RD) es la quinta causa de pérdida de visión a nivel mundial y la séptima causa de ceguera/discapacidad visual entre afiliados a la Organización Nacional de Ciegos de España (ONCE). La detección precoz de RD previene la ceguera en diabéticos y está condicionada por la hemoglobina glicosilada. El objetivo de este trabajo fue analizar el manejo de los pacientes diabéticos en la comarca del Aljarafe (Sevilla) e identificar oportunidades de mejora en la coordinación de su seguimiento entre el médico de Atención Primaria y el médico oftalmólogo. Métodos: Se realizó un estudio observacional retrospectivo (2016-2019) con los pacientes registrados en el censo de diabéticos de los veintiocho municipios del Aljarafe. Se consultó la historia de salud de Atención Primaria y Hospital, así como el programa de Telemedicina. En cuanto al análisis estadístico, para variables cualitativas se calcularon totales y porcentajes; para variables cuantitativas, media y distribución estándar (si distribución normal), y la mediana y cuartiles (distribución no normal). Resultados: Se registraron 17.175 diabéticos en el Aljarafe (5,7% de población); 14.440 pacientes (84,1%) tenían alguna determinación de hemoglobina durante el periodo, 9.228 (63,9%) las tenían todas en rango adecuado. Tenían control fundoscópico 12.040 diabéticos (70,1%), y de los que no, 346 (10,6%) tenían todas fuera de rango. Hubo 1.878 (10,9%) pacientes sin control fundoscópico ni metabólico, 1.019 (54,3%) eran mujeres, 1.219 (64,9%) menores de sesenta y cinco años, 1.019 (54,3%) con comorbilidad grave...(AU)

Background: Diabetes mellitus is a chronic disease with high morbidity and mortality, affecting 537 million adults worldwide. Spain is the second European country in prevalence, with 14.8% in the population aged twenty/seventy-nine years; with 11.6 cases per 1,000 people/year. Diabetic retinopathy (DR) is the fifth cause of vision loss worldwide and the seventh cause of blindness/visual impairment among members of the National Organization of the Blind in Spain (ONCE). Early detection of DR prevents blindness in diabetics and is conditioned by glycosylated hemoglobin. The aim of this paper was to analyze the management of diabetic patients in Aljarafe region (Seville) and identify opportunities for improvement in the coordination of their follow-up between the Primary Care physician and the ophthalmologist. Methods: A retrospective observational study (2016-2019) was carried out, with patients registered in the diabetic census of the twenty-eight municipalities of Aljarafe. The primary care and hospital health history, and telemedicine program were consulted. About statistical analysis, for qualitative variables, totals and percentages were calculated; for quantitative variables, mean and standard devia-tion (if normally distributed) and median and quartiles (if non-normally distributed). RESULTS // There were 17,175 diabetics registered in Aljarafe (5.7% of the population); 14,440 patients (84.1%) had some determi-nation of hemoglobin during the period, 9,228 (63.9%) had all of them in the appropriate range. Fundoscopic control was performed on 12,040 diabetics (70.1%), and of those who did not, 346 (10.6%) had all of them out of range. There were 1,878 (10.9%) patients without fundoscopic or metabolic control, 1,019 (54.3%) were women, 1,219 (64.9%) were under sixty-five years of age, 1,019 (54.3%) had severe comorbidity...(AU)

Cribado de la retinopatía diabética mediante teleoftalmología en una zona básica de salud rural / Teleophthalmology-based diabetic retinopathy screening in a rural health basic area

Objetivo: Conocer la prevalencia de retinopatía diabética en una zona básica de salud rural, clasificándola según tipo y grado de severidad y conocer su relación con la presencia de otros factores de riesgo cardiovascular y con el sexo. Diseño: Estudio descriptivo transversal o de prevalencia. Emplazamiento: Zona básica de salud rural en España. Nivel de atención primaria. Participantes: Quinientos pacientes diabéticos mayores de 18 años. Mediciones principales: Estudio de la retina mediante retinografía bajo midriasis, según protocolo de la Joslin Vision Network, incorporando un centro de lectura para diagnóstico. Correlación de la existencia y gravedad de la retinopatía con los factores de riesgo cardiovascular –tabaquismo, hipertensión e hiperlipemia– y las características de la diabetes –tipo, tiempo de evolución, tratamiento, control metabólico y función renal–Resultados: Prevalencia encontrada del 16,4%, sin diferencias significativas entre sexos. Las variables tabaquismo e hipertensión estaban relacionadas con la existencia de retinopatía y la variable años de evolución de la diabetes con su existencia y su gravedad. El 9,6% de las personas afectadas fueron derivadas a oftalmología con carácter preferente, por retinopatía amenazante para la visión y el 6,8% de las personas estudiadas fueron derivadas por otras patologías oftalmológicas. Conclusiones: Es posible el seguimiento oftalmológico del 82% de la población diabética en atención primaria, implicando a sus profesionales y trabajando en equipo con el servicio de oftalmología. Es fundamental considerar esta enfermedad en el contexto global de la persona con diabetes, relacionándola con las otras complicaciones microvasculares y la enfermedad cardiovascular.(AU)

Objective: To investigate the prevalence of diabetic retinopathy in a rural health basic area, and to establish the type, the severity degree and the relationship with sex and with another cardiovascular risk factors. Design: Cross-sectional or prevalence descriptive study. Location: Rural health basic area in Spain. Primary health care level. Participants: 500 patients over 18 years old with diabetes. Main measurements: Study of the retina through retinography under mydriasis, according to the Joslin Vision Network protocol, with the incorporation of a diagnostic reading center. Correlation of the existence and severity of the retinopathy with the cardiovascular risk factors –smoking, hypertension and hyperlipidemia– and the characteristics of the diabetes –type, evolution time, treatment, metabolic control and renal function–.Results: The findings showed a 16.4% prevalence, with no significant differences between both sexes. The variables smoking and high blood pressure were related to the existence of retinopathy, and the variable years of diabetes evolution was correlated to both the existence and the severity of the retinopathy. In the study, 9.6% of the affected people were preferentially referred to the ophthalmologists because of sight-threatening retinopathy, and 6.8% of the people studied were referred due to other ophthalmological pathologies. Conclusions: It is possible to do the ophthalmological follow-up of 82% of the population with diabetes in primary health care, involving its professionals and team-working with the ophthalmologists. It is paramount to consider diabetic retinopathy within the global context of the person with diabetes, relating diabetic retinopathy with the other microvascular complications and cardiovascular diseases.(AU)

[Teleophthalmology-based diabetic retinopathy screening in a rural health basic area]. / Cribado de la retinopatía diabética mediante teleoftalmología en una zona básica de salud rural.

OBJECTIVE: To investigate the prevalence of diabetic retinopathy in a rural health basic area, and to establish the type, the severity degree and the relationship with sex and with another cardiovascular risk factors. DESIGN: Cross-sectional or prevalence descriptive study. LOCATION: Rural health basic area in Spain. Primary health care level. PARTICIPANTS: 500 patients over 18 years old with diabetes. MAIN MEASUREMENTS: Study of the retina through retinography under mydriasis, according to the Joslin Vision Network protocol, with the incorporation of a diagnostic reading center. Correlation of the existence and severity of the retinopathy with the cardiovascular risk factors -smoking, hypertension and hyperlipidemia- and the characteristics of the diabetes -type, evolution time, treatment, metabolic control and renal function-. RESULTS: The findings showed a 16.4% prevalence, with no significant differences between both sexes. The variables smoking and high blood pressure were related to the existence of retinopathy, and the variable years of diabetes evolution was correlated to both the existence and the severity of the retinopathy. In the study, 9.6% of the affected people were preferentially referred to the ophthalmologists because of sight-threatening retinopathy, and 6.8% of the people studied were referred due to other ophthalmological pathologies. CONCLUSIONS: It is possible to do the ophthalmological follow-up of 82% of the population with diabetes in primary health care, involving its professionals and team-working with the ophthalmologists. It is paramount to consider diabetic retinopathy within the global context of the person with diabetes, relating diabetic retinopathy with the other microvascular complications and cardiovascular diseases.

Is it time to consider teleophthalmology as a game-changer in the management of diabetic retinopathy? / É hora de se considerar a teleoftalmologia como um agente de mudança no manejo da retinopatia diabética?

ABSTRACT Currently the "pandemic" of diabetes mellitus is noted. The incidence and prevalence of diabetes and diabetic retinopathy, the most common microvascular complications of diabetes, are exponentially growing due to increased life expectancy in many parts of the world. The increasing number of people suffering from diabetic retinopathy not only highlights medical issues, but also an economic burden, representing a medical and social challenge. It is extremely important to identify a disease as soon as possible and successfully treat it. Technological progress results in developing Artificial Intelligence systems capable of detecting diabetic retinopathy. Current screening will be cost effectively based on the use of advanced digital technologies, in particular teleretinal screening systems. At present, we may consider teleophthalmology and Artificial Intelligence with automatic analysis of fundus photos as a Millennium-minded impactful tool for increasing discoverability and manageability of diabetic retinopathy, especially in filling the gap of inaccessibility to hard-to-reach areas, which enforces highly professionally effective time- and cost-saving care everywhere to provide the best possible care for the patients.

RESUMO Atualmente, observa-se a "pandemia" do diabetes mellitus. A incidência e a prevalência do diabetes e da retinopatia diabética, as complicações microvasculares mais comuns do diabetes, estão crescendo exponencialmente devido ao aumento da expectativa de vida em muitas partes do mundo. O número cada vez maior de pessoas que sofrem de retinopatia diabética não apenas destaca problemas médicos, mas também um ônus econômico, representando um desafio médico e social. É extremamente importante identificar uma doença o mais rápido possível e tratá-la com sucesso. O progresso tecnológico resulta no desenvolvimento de sistemas de Inteligência Artificial capazes de detectar a retinopatia diabética. A triagem atual será econômica com base no uso de tecnologias digitais avançadas, em especial os sistemas de triagem telerretiniana. No momento, podemos considerar a teleoftalmologia e a Inteligência Artificial com análise automática de fotos de fundo de olho como uma ferramenta de impacto do milênio para aumentar a capacidade de descoberta e de manejo da retinopatia diabética, especialmente para preencher a lacuna da inacessibilidade a áreas de difícil acesso, o que impõe um atendimento altamente profissional e eficaz, com economia de tempo e de custos, em todos os lugares, para oferecer o melhor atendimento possível aos pacientes.

Impact of the COVID‒19 pandemic on ophthalmic outpatient care at the Ophthalmology Department of the New St. John's Hospital, Budapest / A COVID-19-pandémia hatása a szemészeti járóbeteg-szakellátásra az Új Szent János Kórházban, Budapesten.

Összefoglaló. Bevezetés: Az új típusú koronavírus-járvány (COVID-19) az egészségügyi ellátóhálózatot egy eddig ismeretlen helyzet elé állította. A nemzetközi adatok alapján a szemészeti járóbeteg-ellátásban jelentos változások alakultak ki. Célkituzés: Felmérni a COVID-19-járvány okozta kvantitatív és kvalitatív változásokat az Észak-Közép-budai Centrum, Új Szent János Kórház és Szakrendelo Szemészeti Osztályának járóbeteg-szakellátásában. Módszer: A pandémia elso hullámában (2020. április 1-30.) mért járóbeteg-forgalmi adatokat hasonlítottuk össze a megelozo év azonos periódusában rögzített adatokkal. A betegek demográfiai jellemzoi mellett megvizsgáltuk a sürgosségi besorolásukat, valamint a panaszokhoz kötheto fodiagnózis-csoportok eloszlását. Rögzítettük a telemedicina keretein belül történt ellátások számát. Eredmények: 2020 vizsgált idoszakában 916, míg az elozo év azonos hónapjában 2835 járóbeteg-eset került rögzítésre. A 2020-as idoszakban a törvényi szabályozás szerint sürgos panaszokkal jelentkezo betegek aránya nem változott (p = 0,38), azonban a szakorvosi megítélés szerint sürgos panaszokkal érkezo betegek aránya nott (p<0,001) az elozo évhez viszonyítva. A zöld hályog, kötohártya-gyulladás, árpa, sérülés és nedves típusú maculadegeneratio miatt ellátásra jelentkezo betegek aránya szignifikánsan nott (p<0,001 mind), míg a szürke hályog, a száraz típusú maculadegeneratio, egyéb, a szemhéj és a könnyutak betegségei, utóhályog miatt és a szemészeti betegség nélkül érkezok aránya csökkent (p<0,001 mind). A telemedicina keretei között ellátott betegek száma 2020-ban közel a tizenötszörösére emelkedett 2019-hez képest (p<0,001). Következtetés: A COVID-19-pandémia elso hulláma során markáns betegszámcsökkenést regisztráltunk a szemészeti járóbeteg-szakellátásban. Több fodiagnózis-csoport esetén számolhatunk jelentos terápiavesztéssel és halasztott ellátási igény jelentkezésével. Az adatok kiértékelése segítséget nyújthat az elkövetkezo években az ellátási folyamat proaktív átszervezésében, a humáneroforrás-szükségletek jobb tervezésében, valamint a teleoftalmológiai ellátás fejlesztésében. Orv Hetil. 2021; 162(6): 203-211. INTRODUCTION: The COVID-19 pandemic put the healthcare network in a hitherto unknown situation. The ophthalmic outpatient care changed internationally. OBJECTIVE: To assess the quantitative and qualitative changes of the outpatient specialty care at the Ophthalmology Department of the North-Central-Buda Center, New St. John's Hospital and Clinic, through the pandemic. METHOD: Outpatient service data during the first wave of the pandemic (April 2020) were compared with those in April 2019. Patient demographics, emergency classification, distribution of the main diagnostic groups (associated with complaints) and services provided via telemedicine were collected. RESULTS: There were 2835 patient visits in 2019 and 916 in 2020. For 2020, the proportion of patients with emergency classification according to legal regulations did not change (p = 0.38), however, using the ophthalmologist's classification increased (p<0.001) significantly. The proportion of patients with glaucoma, conjunctivitis, chalazeon, injury and wet macular degeneration increased (p<0.001 all), while the proportion of patients with cataract, dry macular degeneration, other diseases, other adnexal diseases, secondary cataract and without ophthalmic pathology decreased significantly (p<0.001 for all). Patient number using telemedicine treatment was about 15× of those treated in 2019 (p<0.001). CONCLUSION: During the first wave of the pandemic, a marked decrease in ophthalmic outpatient care volume was recorded. In the case of several main diagnosis groups, significant therapy loss and a delayed need for care could be expected. Evaluation of the data helps in the upcoming years in proactive reorganization of the care process, in better planning of human resource needs, and in improvement of teleophthalmology care. Orv Hetil. 2021; 162(6): 203-211.

Open-care telemedicine in ophthalmology during the COVID-19 pandemic: a pilot study. / Telemedicina en oftalmología durante la pandemia de COVID-19: una experiencia piloto.

BACKGROUND: To report a pilot experience of telemedicine in ophthalmology in open-care modality (i.e. direct video call), in a confinement period due to the COVID-19 pandemic. METHODS: Descriptive study of the demographic and clinical characteristics of patients attended in a 10-week confinement period. Reported satisfaction of the participating patients and doctors was evaluated through an online survey. RESULTS: In the 10-week period, 291 ophthalmologic telemedicine consultations were performed. The main reasons for consultation were inflammatory conditions of the ocular surface and eyelids (79.4%), followed by administrative requirements (6.5%), non-inflammatory conditions of the ocular surface (5.2%), strabismus suspicion (3.4%) and vitreo-retinal symptoms (3.1%). According to previously defined criteria, 22 patients (7.5%) were referred to immediate face-to-face consultation. The level of satisfaction was high, both in doctors (100%) and in patients (93.4%). CONCLUSIONS: Open-care modality of telemedicine in ophthalmology during the pandemic period is a useful instrument to filter potential face-to-face consultations, either elective or emergency, and potentially reduce the risk of COVID-19 infection.

Avaliação Econômica de um Serviço de Telemedicina para ampliação da Atenção Primária à Saúde no Rio Grande do Sul: o microcusteio do Projeto TeleOftalmo / Economic Evaluation of a Telemedicine Service to expand Primary Health Care in Rio Grande do Sul: TeleOftalmo's microcosting analysis

Resumo Este estudo avaliou o custo de um serviço público de telediagnóstico em oftalmologia. O método de custeio baseado em atividades e tempo (TDABC) foi adotado para examinar os componentes de custos relacionados à teleoftalmologia. Com este método, também foi possível estabelecer o custo unitário padrão que o telediagnóstico deveria ter, dada a capacidade instalada e utilização de profissionais. Dados de um ano de telediagnósticos foram considerados, e avaliou-se a mudança do custo por telediagnóstico ao longo do período de adaptação da tecnologia no sistema. O custo padrão calculado por diagnóstico oftalmológico a distância foi de R$ 119, considerando a emissão de 1.080 laudos de telediagnóstico oftalmológico por mês. Foi identificado um desequilíbrio entre as atividades que sugere a capacidade do método TDABC orientar ações de gestão e melhoria na alocação dos recursos. Ao longo de um ano, o custo unitário real passou de R$ 783 para R$ 283, ainda havendo espaço para se aproximar do custo padrão estimado. Avaliações econômicas parciais possuem importante aporte para subsidiar a incorporação de novas tecnologias. O TDABC merece destaque nesse sentido, pois permite obter informações mais precisas sobre custo da tecnologia, melhorando a capacidade de dimensionamento e gerenciamento da organização de saúde.

Abstract This study evaluated the cost of public telediagnostic service in ophthalmology. The time-driven activity-based costing method (TDABC) was adopted to examine the cost components related to teleophthalmology. This method allowed us to establish the standard unit cost of telediagnosis, given the installed capacity and utilization of professionals. We considered data from one year of telediagnoses and evaluated the cost per telediagnosis change throughout technology adaptation in the system. The standard cost calculated by distance ophthalmic diagnosis was approximately R$ 119, considering the issuance of 1,080 monthly ophthalmic telediagnostic reports. We identified an imbalance between activities, which suggests the TDABC method's ability to guide management actions and improve resource allocation. The actual unit cost fell from R$ 783 to R$ 283 over one year - with room to approach the estimated standard cost. Partial economic evaluations contribute significantly to support the incorporation of new technologies. The TDABC method deserves prominence, as it enables us to retrieve more accurate information on the cost of technology, improving the scalability and management capacity of the healthcare system.

The role of tele-ophthalmology in diabetic retinopathy screening.

Diabetic retinopathy (DR) is the leading cause of legal blindness in the United States. Considering the increasing incidence of DR, it is extremely important to detect the most cost-effective tools for DR screening, so as to manage this surge in demand and the socioeconomic burden it places on the health care system. Despite the advances in retinal imaging, analysis techniques are still superseded by expert ophthalmologist interpretation. Teleophthalmology presents an immense opportunity, with high rates of sensitivity and specificity, to manage the steadily increasing demand for eye care of patients with diabetes, but challenges remain in the delivery of practical, viable, and clinically proven solutions.

Five-year experience of tele-ophthalmology for diabetic retinopathy screening in a rural population. / Análisis de un programa de teleoftalmología para el cribado de retinopatía diabética en área rural tras cinco años.

OBJECTIVE: To identify the prevalence and risk factors of diabetic retinopathy (DR) among rural inhabitants included in a tele-ophthalmology program. To analyse diagnostic accuracy among primary care physicians, concordance with ophthalmologists, and financial savings. MATERIAL AND METHODS: An observational randomised study was conducted on 394 patients included in a tele-ophthalmology program (from January 2010 to January 2015). An analysis was performed on the clinical characteristics, DR findings in retinography images, and correspondence between the request for a second interpretation by an ophthalmologist, and previously established criteria for it: presence of moderate to severe DR, vision loss, poor image quality and/or intraocular pressure >22mmHg. Statistical analysis was performed using the SPSS program (Student t and χ(2) tests). RESULTS: DR prevalence was 12.1%. Patients with glycosylated haemoglobin values >7.68% or those treated with a combination of insulin and oral antidiabetic drugs showed a higher risk of DR (P<.05). 43.3% of patients correctly referred to ophthalmologists showed moderate to severe DR. Unnecessary referrals to specialists were improved from 91.7% in 2010 to 98.6% in 2014. It is estimated that the program has made a total saving of €152,550.45. CONCLUSIONS: Tele-ophthalmology programs are a useful tool in DR screening. Primary care physicians are able to distinguish patients who need specialist care, avoiding unnecessary referrals to ophthalmologists, and saving costs.