title: Interobserver agreement between primary graders and an expert grader in the Bristol and Weston diabetic retinopathy screening programme: a quality assurance audit.
abstract: OBJECTIVE
  To assess the quality and accuracy of primary grading in the Bristol and Weston diabetic retinopathy screening programme and to set standards for future interobserver agreement reports.
  
  
  METHODS
  A prospective audit of 213 image sets from six fully trained primary graders in the Bristol and Weston diabetic retinopathy screening programme was carried out over a 4-week period. All the images graded by the primary graders were regraded by an expert grader blinded to the primary grading results and the identity of the primary grader. The interobserver agreement between primary graders and the blinded expert grader and the corresponding Kappa coefficient was determined for overall grading, referable, non-referable and ungradable disease. The audit standard was set at 80% for interobserver agreement with a Kappa coefficient of 0.7.
  
  
  RESULTS
  The interobserver agreement bettered the audit standard of 80% in all the categories. The Kappa coefficient was substantial (0.7) for the overall grading results and ranged from moderate to substantial (0.59-0.65) for referable, non-referable and ungradable disease categories. The main recommendation of the audit was to provide refresher training for the primary graders with focus on ungradable disease.
  
  
  CONCLUSIONS
  The audit demonstrated an acceptable level of quality and accuracy of primary grading in the Bristol and Weston diabetic retinopathy screening programme and provided a standard against which future interobserver agreement can be measured for quality assurance within a screening programme. Diabet. Med. 26, 820-823 (2009).
authors.affiliation: Bristol Eye Hospital, Bristol, UK. eshnac@yahoo.co.uk
authors.forename: S
authors.initials: S
authors.lastname: Patra
authors.forename: E M W
authors.initials: EM
authors.lastname: Gomm
authors.forename: M
authors.initials: M
authors.lastname: Macipe
authors.forename: C
authors.initials: C
authors.lastname: Bailey
mesh_terms: D003930:Diabetic Retinopathy / Q000175:diagnosis*; D004739:England; D006801:Humans; D007089:Image Enhancement / Q000379:methods; D008403:Mass Screening / Q000379:methods*; D015588:Observer Variation; D010781:Photography / Q000379:methods; D011786:Quality Control; D015203:Reproducibility of Results; D012720:Severity of Illness Index