The Utility of Routine Fundus Photography Screening for Posterior Segment Disease: A Stepped-wedge, Cluster-randomized Trial in South India.
The Utility of Routine Fundus Photography Screening for Posterior Segment Disease: A Stepped-wedge, Cluster-randomized Trial in South India.
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DOI：
10.1016/j.ophtha.2020.11.025
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发表时间：
2021-07
期刊：
影响因子：
13.7
通讯作者：
Venkatesh R
中科院分区：
文献类型：
--
作者：
Shekhawat NS;Niziol LM;Sharma SS;Joseph S;Robin AL;Gillespie BW;Musch DC;Woodward MA;Venkatesh R
旨在评估印度南部社区眼科诊所用于筛查眼后段疾病的常规眼底照相 (RFP) 是否会增加转诊至城市医院接受眼科护理的数量。阶梯楔形、整群随机试验。 40-75 岁和 20-40 岁已知高血压或糖尿病病史的患者就诊于印度本地治里 Aravind 眼科医院相关的四个技术人员运营的社区眼保健中心（视力中心）。视觉中心（集群）在五个为期两周的研究期（步骤）中被随机分配到标准护理或 RFP。每个集群中的患者在第一步中都接受了标准护理。在每个后续步骤开始时，随机选择的集群会交叉为符合条件的患者提供 RFP。所有集群中的患者都在最后一步中参与了 RFP。标准护理包括技术人员眼科检查、可选的眼底摄影以及眼科医生的远程咨询。 RFP 包括技术人员眼科检查、强制散瞳和 40 度眼底摄影以及眼科医生的远程会诊。根据因眼底照相结果转诊至眼科医生现场评估的患者比例以及转诊的紧急程度（≤2 周内紧急与 > 2 周内非紧急），对标准护理和 RFP 集群进行比较。与标准护理相比，使用调整集群和步骤的广义线性混合模型来估计由于眼底摄影结果而转诊的可能性。各视力中心共招募了 1447 名患者，其中标准护理组 737 名，RFP 组 710 名。与标准护理相比，RFP 组因眼底照相结果转诊的比例较高（11.3% 对 4.4%），因眼底照相转诊的非紧急转诊比例较高（9.3% 对 3.3%），因眼底照相转诊的紧急转诊比例较高（1.8% 对 1.1%）。与标准护理相比，RFP 干预与因摄影结果而被转诊的几率增加两倍相关（比值比 = 2.07，95% 置信区间 = 0.98–4.40，p = 0.058）。与标准护理相比，将 RFP 添加到社区眼科诊所会增加转诊几率。转诊人数的增加主要归因于非紧急后段疾病。在这项以社区为基础的大型随机试验中，在常规眼科检查中加入强制性眼底照相，使青光眼和糖尿病性视网膜病变等需要转诊的眼后段疾病的检出率增加了一倍，这主要是由于早期病理的检测。
To assess whether routine fundus photography (RFP) to screen for posterior segment disease at community eye clinics in South India increases referral to the urban hospital for ophthalmology care. Stepped-wedge, cluster-randomized trial. Patients aged 40–75 and those aged 20–40 with a known history of hypertension or diabetes mellitus presenting to four technician-run, community eye care centers (vision centers) associated with the Aravind Eye Hospital, Pondicherry, India. Vision centers (clusters) were randomized to standard care or RFP across five 2-week study periods (steps). Patients in each cluster received standard care in the first step. At the start of each subsequent step, a randomly chosen cluster crossed over to providing RFP to eligible patients. Patients in all clusters took part in RFP during the last step. Standard care involved technician eye exams, optional fundus photography, and teleconsultation with an ophthalmologist. RFP involved technician eye exams, mandatory dilation and 40-degree fundus photography, and teleconsultation with an ophthalmologist. Standard care and RFP clusters were compared by the proportion of patients referred for in-person evaluation by an ophthalmologist due to fundus photography findings as well as urgency of referral (urgently in ≤2 weeks vs. non-urgently in >2 weeks). Generalized linear mixed models adjusting for cluster and step were used to estimate the odds of referral due to fundus photography findings compared to standard care. 1447 patients were enrolled across the vision centers, including 737 in the standard care group and 710 in the RFP group. Compared to standard care, the RFP group had a higher proportion of referrals due to fundus photography findings (11.3% vs. 4.4%), non-urgent referrals due to fundus photography (9.3% vs. 3.3%), and urgent referrals due to fundus photography (1.8% vs. 1.1%). The RFP intervention was associated with a two-fold increased odds of being referred due to photography findings compared to standard care (odds ratio=2.07, 95% confidence interval=0.98–4.40, p=0.058). Adding RFP to community eye clinics was associated with an increased odds of referral compared to standard care. This increase in referral was mostly attributed to non-urgent posterior segment disease. In this large community-based randomized trial, adding mandatory fundus photography to routine eye examinations doubled detection of referral-warranted posterior segment diseases such as glaucoma and diabetic retinopathy, primarily due to detection of early stage pathology.
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