title: Accuracy of diabetic retinopathy screening by trained non-physician graders using non-mydriatic fundus camera.
abstract: BACKGROUND
  We compared the agreement of diabetic retinopathy (DR) assessment between trained non-physician graders (NPGs) and family physicians (FPs) in a primary healthcare setting.
  
  
  METHODS
  This was a cross-sectional study conducted retrospectively over a period of one month. The participants were diabetic patients from two primary healthcare clinics (polyclinics) in Singapore. Single-field digital retinal images were obtained using a non-mydriatic 45-degree fundus camera. Retinal images were graded for the presence or absence of DR by FPs at the polyclinics and by NPGs at a central ocular grading centre. The FPs' and NPGs' assessments of DR were compared with readings by a single retinal specialist (reference standard).
  
  
  RESULTS
  A total of 367 diabetic patients (706 eyes) were included in the study. The mean age of the patients was 63 years, and the majority were Chinese (83.8%). For DR assessment, the agreement between NPGs and the retinal specialist was substantial (ĸ = 0.66), while the agreement between FPs and the retinal specialist was only fair (ĸ = 0.40). NPGs' assessment showed higher sensitivity (70% vs. 45%) and comparable specificity (94% vs. 92%) as compared to FPs' assessment. The area under the receiver operating characteristic curve of NPGs' assessment of DR was greater than that of the FPs' (0.82 vs. 0.69, p < 0.001).
  
  
  CONCLUSIONS
  This study has demonstrated that trained NPGs are able to provide good detection of DR and maculopathy from fundus photographs. Our findings suggest that DR screening by trained NPGs may provide a costeffective alternative to FPs.
authors.affiliation: Singapore Eye Research Institute, Singapore National Eye Centre, Singapore.
authors.forename: Mayuri
authors.initials: M
authors.lastname: Bhargava
authors.forename: Carol Yim-Lui
authors.initials: CY
authors.lastname: Cheung
authors.forename: Charumathi
authors.initials: C
authors.lastname: Sabanayagam
authors.forename: Ryo
authors.initials: R
authors.lastname: Kawasaki
authors.forename: C Alex
authors.initials: CA
authors.lastname: Harper
authors.forename: Ecosse L
authors.initials: EL
authors.lastname: Lamoureux
authors.forename: Wai Leng
authors.initials: WL
authors.lastname: Chow
authors.forename: Adrian
authors.initials: A
authors.lastname: Ee
authors.forename: Haslina
authors.initials: H
authors.lastname: Hamzah
authors.forename: Maisie
authors.initials: M
authors.lastname: Ho
authors.forename: Wanling
authors.initials: W
authors.lastname: Wong
authors.forename: Tien Yin
authors.initials: TY
authors.lastname: Wong
mesh_terms: D000368:Aged; D003430:Cross-Sectional Studies; D003930:Diabetic Retinopathy / Q000175:diagnosis*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009184:Mydriatics; D009726:Nurses; D015588:Observer Variation; D009885:Ophthalmology; D010821:Physicians, Family; D011320:Primary Health Care / Q000379:methods*; D012372:ROC Curve; D012017:Referral and Consultation; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D012846:Singapore; D000078329:Workforce
chemical_list: D009184:Mydriatics