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Br J Ophthalmol. 2018 Nov;102(11):1471-1476. doi: 10.1136/bjophthalmol-2018-312440. Epub 2018 Jul 4.

Accuracy of trained rural ophthalmologists versus non-medical image graders in the diagnosis of diabetic retinopathy in rural China.

Author information

1
State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China.
2
Centre for Public Health, Queen's University Belfast, Belfast, UK.
3
Ophthalmology Department, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
4
Northern Ireland Methodology Hub, Centre for Public Health, Queen's University Belfast, Belfast, UK.
5
Retina and Vitreous Department, Instituto Mexicano de Oftalmologia, Queretaro, Mexico.
6
Centre for Eye Research Australia, University of Melbourne, Royal Victorian Eye and Ear Hospital, Melbourne, Victoria, Australia.
7
State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China ncongdon1@gmail.com.
8
Orbis International, New York City, New York , USA.

Abstract

BACKGROUND/AIMS:

To determine the diagnostic accuracy of trained rural ophthalmologists and non-medical image graders in the assessment of diabetic retinopathy (DR) in rural China.

METHODS:

Consecutive patients with diabetes mellitus were examined from January 2014 to December 2015 at 10 county-level facilities in rural Southern China. Trained rural ophthalmologists performed a complete eye examination, recording diagnoses using the UK National Diabetic Eye Screening Programme (NDESP) classification system. Two field, mydriatic, 45° digital photographs were made by nurses using NDESP protocols and graded by trained graders with no medical background using the NDESP system. A fellowship-trained retina specialist graded all images in masked fashion and served as reference standard.

RESULTS:

Altogether, 375 participants (mean age 60±10 years, 48% men) were examined and 1277 images were graded. Grader sensitivity (0.82-0.94 (median 0.88)) and specificity (0.91-0.99 (median 0.98)), reached or exceeded NDESP standards (sensitivity 80%, specificity 95%) in all domains except specificity detecting any DR. Rural ophthalmologists' sensitivity was 0.65-0.95 (median 0.66) and specificity 0.59-0.95 (median 0.91). There was strong agreement between graders and the reference standard (kappa=0.84-0.87, p<0.001) and weak to moderate agreement between rural doctors and the reference (kappa=0.48-0.64, p<0.001).

CONCLUSION:

This is the first study of diagnostic accuracy in DR grading among non-medical graders or ophthalmologists in low-income and middle-income countries. Non-medical graders can achieve high levels of accuracy, whereas accuracy of trained rural ophthalmologists is not optimal.

KEYWORDS:

epidemiology; retina; telemedicine; vision

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