title: Rapid grading of fundus photographs for diabetic retinopathy using crowdsourcing.
abstract: BACKGROUND
  Screening for diabetic retinopathy is both effective and cost-effective, but rates of screening compliance remain suboptimal. As screening improves, new methods to deal with screening data may help reduce the human resource needs. Crowdsourcing has been used in many contexts to harness distributed human intelligence for the completion of small tasks including image categorization.
  
  
  OBJECTIVE
  Our goal was to develop and validate a novel method for fundus photograph grading.
  
  
  METHODS
  An interface for fundus photo classification was developed for the Amazon Mechanical Turk crowdsourcing platform. We posted 19 expert-graded images for grading by Turkers, with 10 repetitions per photo for an initial proof-of-concept (Phase I). Turkers were paid US $0.10 per image. In Phase II, one prototypical image from each of the four grading categories received 500 unique Turker interpretations. Fifty draws of 1-50 Turkers were then used to estimate the variance in accuracy derived from randomly drawn samples of increasing crowd size to determine the minimum number of Turkers needed to produce valid results. In Phase III, the interface was modified to attempt to improve Turker grading.
  
  
  RESULTS
  Across 230 grading instances in the normal versus abnormal arm of Phase I, 187 images (81.3%) were correctly classified by Turkers. Average time to grade each image was 25 seconds, including time to review training images. With the addition of grading categories, time to grade each image increased and percentage of images graded correctly decreased. In Phase II, area under the curve (AUC) of the receiver-operator characteristic (ROC) indicated that sensitivity and specificity were maximized after 7 graders for ratings of normal versus abnormal (AUC=0.98) but was significantly reduced (AUC=0.63) when Turkers were asked to specify the level of severity. With improvements to the interface in Phase III, correctly classified images by the mean Turker grade in four-category grading increased to a maximum of 52.6% (10/19 images) from 26.3% (5/19 images). Throughout all trials, 100% sensitivity for normal versus abnormal was maintained.
  
  
  CONCLUSIONS
  With minimal training, the Amazon Mechanical Turk workforce can rapidly and correctly categorize fundus photos of diabetic patients as normal or abnormal, though further refinement of the methodology is needed to improve Turker ratings of the degree of retinopathy. Images were interpreted for a total cost of US $1.10 per eye. Crowdsourcing may offer a novel and inexpensive means to reduce the skilled grader burden and increase screening for diabetic retinopathy.
authors.affiliation: Wills Eye Hospital, Retina Service: Mid Atlantic Retina, Philadelphia, PA, United States. brady@jhmi.edu.
authors.forename: Christopher J
authors.identifier: http://orcid.org/0000-0001-7847-3914
authors.initials: CJ
authors.lastname: Brady
authors.forename: Andrea C
authors.identifier: http://orcid.org/0000-0003-3104-966X
authors.initials: AC
authors.lastname: Villanti
authors.forename: Jennifer L
authors.identifier: http://orcid.org/0000-0002-1400-5932
authors.initials: JL
authors.lastname: Pearson
authors.forename: Thomas R
authors.identifier: http://orcid.org/0000-0001-5764-4980
authors.initials: TR
authors.lastname: Kirchner
authors.forename: Omesh P
authors.identifier: http://orcid.org/0000-0003-4845-0409
authors.initials: OP
authors.lastname: Gupta
authors.forename: Chirag P
authors.identifier: http://orcid.org/0000-0001-6369-4917
authors.initials: CP
authors.lastname: Shah
mesh_terms: D063045:Crowdsourcing / Q000191:economics / Q000379:methods*; D003930:Diabetic Retinopathy / Q000175:diagnosis / Q000473:pathology*; D003941:Diagnostic Techniques, Ophthalmological; D005654:Fundus Oculi; D006801:Humans; D020407:Internet; D010781:Photography / Q000379:methods; D015203:Reproducibility of Results; D017216:Telemedicine / Q000379:methods*
keywords: Amazon Mechanical Turk; crowdsourcing; diabetic retinopathy; fundus photography; telemedicine