title: Interobserver agreement in the interpretation of single-field digital fundus images for diabetic retinopathy screening.
abstract: OBJECTIVE
  To assess agreement among a group of ophthalmic care providers, including ophthalmologists and trained nonphysician personnel, in the interpretation of single-field digital fundus images for diabetic retinopathy screening.
  
  
  METHODS
  Interobserver reliability study.
  
  
  METHODS
  Twelve ophthalmic care personnel, including 3 retina specialists, 3 general ophthalmologists, 3 ophthalmic nurses, and 3 ophthalmic photographers.
  
  
  METHODS
  All participants were to read 400 good single-field digital fundus images of diabetic patients from a community hospital. The nonphysician personnel group read the images 1 month after attending a 2-day intensive instruction course regarding diabetic retinopathy screening. The ophthalmologists read the images without additional training. The 3 retina specialists read the images again together 2 months later to form a consensus regarding retinopathy severity and macular edema for each case. All readers used the Early Treatment Diabetic Retinopathy Study standard photographs as guidelines.
  
  
  METHODS
  The kappa statistic was used for the reliability assessment of the diabetic retinopathy severity and macular edema, and for the identification of cases that needed referral to ophthalmologists.
  
  
  RESULTS
  There is only fair agreement among all readers. The multirater kappa coefficient for retinopathy severity is 0.34; for macular edema, 0.27; and for referral cases, 0.28. Retina specialists have the best agreement among all groups (kappa = 0.58 for retinopathy severity or macular edema, kappa = 0.63 for referrals). There is also fair agreement when all readers are compared with the consensus of retina specialists (kappas = 0.35, 0.28, and 0.29 for retinopathy severity, macular edema, and referrals, respectively), and the retina specialist group also has the best agreement (kappas = 0.63, 0.65, and 0.67 for retinopathy severity, macular edema, and referrals).
  
  
  CONCLUSIONS
  Without additional training, retina specialists may be the most reliable personnel to interpret single-field digital fundus images for diabetic retinopathy screening. For other ophthalmic care personnel to achieve comparable reliability, a comprehensive instruction course with specific continuing education is essential. Authorized nonphysician interpreters should be experts, and new standard photographs for single-field digital fundus image interpretation may also be required to improve interobserver reliability.
authors.affiliation: Department of Ophthalmology, Rajavithi Hospital, Bangkok, Thailand. paisan_ru@rcopt.org
authors.forename: Paisan
authors.initials: P
authors.lastname: Ruamviboonsuk
authors.forename: Khemawan
authors.initials: K
authors.lastname: Teerasuwanajak
authors.forename: Montip
authors.initials: M
authors.lastname: Tiensuwan
authors.forename: Kanokwan
authors.initials: K
authors.lastname: Yuttitham
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003627:Data Interpretation, Statistical; D003930:Diabetic Retinopathy / Q000175:diagnosis*; D005260:Female; D005654:Fundus Oculi; D006282:Health Personnel / Q000592:standards; D006801:Humans; D008269:Macular Edema / Q000175:diagnosis; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D010781:Photography / Q000379:methods*; D012017:Referral and Consultation; D015203:Reproducibility of Results; D012160:Retina / Q000473:pathology*; D012680:Sensitivity and Specificity