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      Andalusian program for early detection of diabetic retinopathy: implementation and 15-year follow-up of a population-based screening program in Andalusia, Southern Spain

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          Abstract

          Introduction

          Diabetic retinopathy (DR) is a preventable cause of vision loss and blindness worldwide. We aim at analyzing the impact of a population-based screening program of DR using retinal photography with remote reading in terms of population coverage, diagnosis of asymptomatic DR and impact on visual disability, in the region of Andalusia, Spain, in the period 2005–2019.

          Research design and methods

          Descriptive study. Sociodemographic and clinical features included in the Andalusian program for early detection of diabetic retinopathy (APDR) were analyzed. Population coverage, annual incidence of DR, and DR severity gradation were analyzed. Estimated data on prevalence and incidence of legal blindness due to DR were included.

          Results

          407 762 patients with at least one successful DR examination during the study period were included. Most of the performed retinographies (784 584, 84.3%) were ‘non-pathological.’ Asymptomatic DR was detected in 52 748 (5.9%) retinographies, most of them (94.2%) being classified as ‘mild to moderate non-proliferative DR.’ DR was detected in 44 815 patients, while sight-threatening DR (STDR) in 6256 patients; cumulative incidence of DR was 11.0% and STDR was 1.5%, as DR and STDR was detected in 44 815 and 6256 patients, respectively. Annual incidence risk per patient recruitment year progressively decreased from 22.0% by January 2005 to 3.2% by June 2019.

          Conclusions

          Implementation of a long-term population-based screening program for early detection of DR is technically feasible and clinically viable. Thus, after 15 years of existence, the program has enabled the screening of the vast majority of the target population allowing the optimization of healthcare resources and the identification of asymptomatic DR.

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          Most cited references19

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          The English National Screening Programme for diabetic retinopathy 2003–2016

          The aim of the English NHS Diabetic Eye Screening Programme is to reduce the risk of sight loss amongst people with diabetes by the prompt identification and effective treatment if necessary of sight-threatening diabetic retinopathy, at the appropriate stage during the disease process. In order to achieve the delivery of evidence-based, population-based screening programmes, it was recognised that certain key components were required. It is necessary to identify the eligible population in order to deliver the programme to the maximum number of people with diabetes. The programme is delivered and supported by suitably trained, competent, and qualified, clinical and non-clinical staff who participate in recognised ongoing Continuous Professional Development and Quality Assurance schemes. There is an appropriate referral route for those with screen-positive disease for ophthalmology treatment and for assessment of the retinal status in those with poor-quality images. Appropriate assessment of control of their diabetes is also important in those who are screen positive. Audit and internal and external quality assurance schemes are embedded in the service. In England, two-field mydriatic digital photographic screening is offered annually to all people with diabetes aged 12 years and over. The programme commenced in 2003 and reached population coverage across the whole of England by 2008. Increasing uptake has been achieved and the current annual uptake of the programme in 2015–16 is 82.8% when 2.59 million people with diabetes were offered screening and 2.14 million were screened. The benefit of the programme is that, in England, diabetic retinopathy/maculopathy is no longer the leading cause of certifiable blindness in the working age group.
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            Screening for diabetic retinopathy: new perspectives and challenges

            Although the prevalence of all stages of diabetic retinopathy has been declining since 1980 in populations with improved diabetes control, the crude prevalence of visual impairment and blindness caused by diabetic retinopathy worldwide increased between 1990 and 2015, largely because of the increasing prevalence of type 2 diabetes, particularly in low-income and middle-income countries. Screening for diabetic retinopathy is essential to detect referable cases that need timely full ophthalmic examination and treatment to avoid permanent visual loss. In the past few years, personalised screening intervals that take into account several risk factors have been proposed, with good cost-effectiveness ratios. However, resources for nationwide screening programmes are scarce in many countries. New technologies, such as scanning confocal ophthalmology with ultrawide field imaging and handheld mobile devices, teleophthalmology for remote grading, and artificial intelligence for automated detection and classification of diabetic retinopathy, are changing screening strategies and improving cost-effectiveness. Additionally, emerging evidence suggests that retinal imaging could be useful for identifying individuals at risk of cardiovascular disease or cognitive impairment, which could expand the role of diabetic retinopathy screening beyond the prevention of sight-threatening disease.
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              Incidence and progression of diabetic retinopathy: a systematic review

              Diabetic retinopathy is a leading cause of vision impairment and blindness. We systematically reviewed studies published from Jan 1, 1980, to Jan 7, 2018, assessed the methodological quality, and described variations in incidence of diabetic retinopathy by region with a focus on population-based studies that were conducted after 2000 (n=8, including two unpublished studies). Of these eight studies, five were from Asia, and one each from the North America, Caribbean, and sub-Saharan Africa. The annual incidence of diabetic retinopathy ranged from 2·2% to 12·7% and progression from 3·4% to 12·3%. Progression to proliferative diabetic retinopathy was higher in individuals with mild disease compared with those with no disease at baseline. Our Review suggests that more high-quality population-based studies capturing data on the incidence and progression of diabetic retinopathy with stratification by age and sex are needed to consolidate the evidence base. Our data is useful for conceptualisation and development of major public health strategies such as screening programmes for diabetic retinopathy.
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                Author and article information

                Journal
                BMJ Open Diabetes Res Care
                BMJ Open Diabetes Res Care
                bmjdrc
                bmjdrc
                BMJ Open Diabetes Research & Care
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2052-4897
                2020
                5 October 2020
                : 8
                : 1
                : e001622
                Affiliations
                [1 ]Andalusian Public Foundation Progress and Health , Seville, Spain
                [2 ]Comprehensive Healthcare Plan for Diabetes, Regional Ministry of Health and Families of Andalusia, Government of Andalusia , Seville, Spain
                [3 ]departmentEndocrinology and Nutrition , Hospital Puerta del Mar , Cadiz, Spain
                [4 ]Biomedical Research and Innovation Institute of Cadiz (INiBICA) , Cadiz, Spain
                [5 ]departmentEndocrinology and Nutrition , Virgen Macarena University Hospital , Seville, Spain
                [6 ]ONCE , Madrid, Spain
                [7 ]Regional Ministry of Health and Families of Andalusia, Government of Andalusia , Seville, Spain
                Author notes
                [Correspondence to ] Dr Maria Asuncion Martinez-Brocca; masuncion.martinez.sspa@ 123456juntadeandalucia.es
                Author information
                http://orcid.org/0000-0001-9657-5949
                http://orcid.org/0000-0001-9740-122X
                Article
                bmjdrc-2020-001622
                10.1136/bmjdrc-2020-001622
                7536837
                33020135
                358132c5-2717-404a-8491-db1979bfb3e8
                © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/.

                History
                : 29 May 2020
                : 13 July 2020
                : 23 July 2020
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100004587, Instituto de Salud Carlos III;
                Award ID: PI11/02924
                Award ID: PI17/01674
                Categories
                Epidemiology/Health services research
                1506
                1867
                Custom metadata
                unlocked

                diabetic retinopathy,blindness
                diabetic retinopathy, blindness

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