title: Screening for diabetic retinopathy in a clinical setting: a comparison of direct ophthalmoscopy by primary care physicians with fundus photography.
abstract: BACKGROUND
  Type II diabetes mellitus is a major health problem among Native Americans, and diabetic retinopathy is a frequent complication of this disease. Screening for retinopathy can identify early disease and prevent major vision loss, but the most cost-effective screening method has not yet been determined.
  
  
  METHODS
  In a rural clinic that served more than 400 Native Americans with diabetes, we compared the accuracy of referrals made based on two screening methods: ophthalmoscopy by trained primary care physicians and seven-view nonstereoscopic, mydriatic fundal photography read by two general ophthalmologists and a retinal specialist. Patients in whom abnormal findings were detected by either screening method were then referred to a general ophthalmologist for further evaluation.
  
  
  RESULTS
  Two hundred forty-three examinations were performed and 83 referrals made. Both screening methods had high sensitivity for referring patients with retinopathy that required treatment or follow-up sooner than 1 year (100% for direct ophthalmoscopy by primary care physicians, 94% for the general ophthalmologist photography readers, and 100% for the retinal specialist reader). The calculated costs of screening by direct ophthalmoscopy and by retinal photography were 64% less and 44% to 35% less, respectively, than the cost of yearly ophthalmological examinations by ophthalmologists.
  
  
  CONCLUSIONS
  Careful screening for treatable diabetic eye disease by trained primary care physicians proved to be a clinically acceptable, cost-effective strategy. Screening methods for diabetic retinopathy should be evaluated based on the absolute sensitivity, specificity, and predictive values of their ability to correctly refer patients rather than their diagnostic accuracy.
authors.affiliation: Office of Health Program Research and Development, Indian Health Service, Tucson, AZ 85746.
authors.forename: S P
authors.initials: SP
authors.lastname: Griffith
authors.forename: W L
authors.initials: WL
authors.lastname: Freeman
authors.forename: C J
authors.initials: CJ
authors.lastname: Shaw
authors.forename: W H
authors.initials: WH
authors.lastname: Mitchell
authors.forename: C R
authors.initials: CR
authors.lastname: Olden
authors.forename: L D
authors.initials: LD
authors.lastname: Figgs
authors.forename: J L
authors.initials: JL
authors.lastname: Kinyoun
authors.forename: D L
authors.initials: DL
authors.lastname: Underwood
authors.forename: J C
authors.initials: JC
authors.lastname: Will
mesh_terms: D003362:Cost-Benefit Analysis; D003924:Diabetes Mellitus, Type 2 / Q000150:complications*; D003930:Diabetic Retinopathy / Q000517:prevention & control*; D005194:Family Practice; D005654:Fundus Oculi; D006801:Humans; D007198:Indians, North American; D008403:Mass Screening / Q000191:economics / Q000379:methods*; D009184:Mydriatics / Q000494:pharmacology; D009885:Ophthalmology; D009887:Ophthalmoscopy / Q000191:economics / Q000706:statistics & numerical data*; D010781:Photography / Q000191:economics / Q000706:statistics & numerical data*; D011680:Pupil / Q000187:drug effects; D012017:Referral and Consultation; D012189:Retrospective Studies; D012423:Rural Health; D012680:Sensitivity and Specificity; D014861:Washington
chemical_list: D009184:Mydriatics