|Year : 2019 | Volume
| Issue : 2 | Page : 121-125
Integrating diabetic retinopathy detection with noncommunicable disease clinics at government hospitals in Kerala through teleophthalmology
Thomas Cherian, Sanitha Sathyan, KR Reesha
Department of Ophthalmology, Little Flower Hospital, Angamaly, Kerala, India
|Date of Web Publication||27-Aug-2019|
Dr. Thomas Cherian
Department of Ophthalmology, Little Flower Hospital, Angamaly, Kerala
Source of Support: None, Conflict of Interest: None
Purpose: The purpose of this study is to analyze the effect of integration of the existing noncommunicable disease clinics (NCDC) in government hospitals for early detection and treatment of diabetic retinopathy (DR) using teleophthalmology. Methods: Population-based screening was done in selected clusters of Thrissur district of Kerala, covering the population attending the NCDCs. Trained optometrists screened all the patients with diabetes mellitus (DM), using handheld nonmydriatic fundus camera (Bosch Eye Care Solutions, Finland). Those who required treatment were referred to higher centers. The data were statistically analyzed. Results: Out of the 11,298 patients screened, DR was present among 914 (8.09%) patients. Nonproliferative DR was detected in 727 (80%) and proliferative DR (PDR) in 187 (20%). There was significant association between >10-year duration of DM and occurrence of PDR (P < 0.00001, Chi-square test, odds ratio = 2.76) and between >5-year duration of DM and the occurrence of PDR (P < 0.001, Chi-square test, odds ratio = 2.56). There was significant association between irregular follow-up status for DM at the NCDCs and the occurrence of PDR (P < 0.0001, Chi-square test, odds ratio = 3.4). There was no significant association between age (P = 0.57) and gender (P = 0.08) with follow-up status at NCDCs. Conclusion: Prevalence of DR among DM patients attending NCD clinics of Kerala is 8.09%. There is a significant association between duration of DM, irregular follow-up at NCDCs for DM with the occurrence of PDR. Although DM is routinely treated at the NCDCs of Kerala, DR detection has not received the needed attention. This missing link has to be strengthened.
Keywords: Diabetic retinopathy screening, fundus photographs, India, Kerala, noncommunicable disease clinics
|How to cite this article:|
Cherian T, Sathyan S, Reesha K R. Integrating diabetic retinopathy detection with noncommunicable disease clinics at government hospitals in Kerala through teleophthalmology. Kerala J Ophthalmol 2019;31:121-5
|How to cite this URL:|
Cherian T, Sathyan S, Reesha K R. Integrating diabetic retinopathy detection with noncommunicable disease clinics at government hospitals in Kerala through teleophthalmology. Kerala J Ophthalmol [serial online] 2019 [cited 2019 Sep 20];31:121-5. Available from: http://www.kjophthal.com/text.asp?2019/31/2/121/265494
| Introduction|| |
The global prevalence of diabetes mellitus type 2 (DM) is 422 million. The incidence of DM is rising in low- and middle-income countries, including India. Diabetic retinopathy (DR) being a serious vision-threatening complication of DM, has a huge impact on human productivity and quality of life. Global data indicate that around 30% of those with DM have developed DR.
Kerala, with the dubious distinction of being the “diabetic capital” of India, has a prevalence of DM at 17%, against the national average of 8%. Epidemiological studies indicate a prevalence of 16% and 20% in the districts of Ernakulam and Thiruvananthapuram, respectively.
Kerala shows certain unique trends as far as the pattern of DM is concerned, first being the higher prevalence among the rural population than the urban population. The national data indicates more prevalence among the urban dwellers. Likewise, the prevalence of DM is higher among females than males of Kerala, while national data suggest male predominance. Even with the highest human development index and literacy rates in the country, the health literacy standards of Keralites remain poor. It is observed that even with the highest prevalence, the detection rates of DM remains poor among Keralites.
Indian studies indicate a prevalence of 7.3%–26.2% of DR among patients with DM.,,,,,,, Despite the heavy burden of DM and hence the potential for higher number of patients with DR, data from Kerala regarding DR and its implications remain meager. There are no population-based studies from Kerala on the prevalence of DR, done in this decade, and there exists a paucity of literature regarding the prevalence and patterns of DR. The existing lacunae in literature in the understanding of this rampant disease demands community screening strategies and epidemiological studies to identify and manage its impact on public health.
Any community-based screening requires a reliable screening tool for identification of the disease under investigation. In case of DR, fundus photographs obtained using handheld nonmydriatic fundus camera has been found to be a reliable and sensitive tool for community screening. With teleophthalmology integration, this strategy has the potential to cover large population cohorts cost-effectively.
Another factor facilitating efficient mass screening is the existence of a strong public health-care system at the primary level in Kerala. The model using noncommunicable disease clinics (NCDCs) at primary and secondary health-care tiers ensures effective communication networks of grass-root level workers (ASHA, Anganwadi, Village Health workers), which can be utilized for building up effective screening strategies.
Therefore, this study was proposed to explore the potential for active screening and early detection of DR in Kerala by making use of existing public health networks for access to the grass-root level.
The aim of this study was to analyze the effect of integration of the existing NCDC in government hospitals for early detection and treatment of DR using teleophthalmology.
| Methods|| |
A population-based screening was conducted in Thrissur district of Central Kerala. In the initial phase, health-care workers at primary, secondary, and tertiary levels of Kerala Health Service facilities were trained on DR by the base hospital team through a meeting convened at the respective Taluks. The second phase consisted of the visit to the NCDs by the ophthalmology team, consisting of an optometrist and counselor. Visual acuity testing and fundus photographs of all diabetic patients reporting to the NCDs were obtained using nonmydriatic fundus camera. The field visits were linked to the base hospital through teleophthalmology and doubtful images are verified by an ophthalmologist at the base hospital. Onsite decisions regarding referral were taken based upon this.
During the second phase of field visit, a series of five fundus photographs were introduced to the diabetics to improve their awareness about DR and its complications. This was done by the ophthalmic team with the aim of convincing the patients about the need for proper diabetic control and management of DR. The awareness tools consisted of the following photographs [Figure 1].
- Photograph 1: Normal fundus
- Photograph 2: Patient's fundus photograph, which will be inserted to the right-hand side and compared with the other four fundus photographs
- Photograph 3: Proliferative DR (PDR) with tractional retinal detachment
- Photograph 4: PDR with vitreous hemorrhage
- Photograph 5: Diabetic macular edema.
The patient was explained about the state of his/her fundus in relation to that of the normal fundus. The message that without proper intervention, likely progression to the stages depicted in the 2nd, 3rd, and 4th stages was conveyed to the patient.
Quality control of the program was ensured by periodic random checks. Those requiring further evaluation were referred to higher facilities in the government sector/base hospital. In the third phase, the evaluations at higher centers were done by vitreoretinal specialists at the respective centers.
Demographic variables were depicted using bar charts. Association between age and gender with NCD clinic follow-ups was compared using Chi-square test and odds ratio. Association between duration of DM and severity of DR (PDR) was also compared using Chi-square test and odds ratio.
| Results|| |
A total of 11,298 patients with DM were screened at the NCDCs for the presence of DR. Mean age was 57.80 ± 8.7 years. There were 408 (44.64%) males and 506 (55.36%) females. Mean duration of DM was 14.27 ± 7.49 years. Out of the total, 414 (45.30%) had regular follow-up at NCDCs and 500 (54.70%) had irregular follow-up [Table 1].
Out of the total patients screened, 914 (8.09%) were detected to have DR, whereas 10,384 (91.91%) did not have DR. Out of those detected with DR, NPDR was detected in 727 (80%) and PDR in 187 (20%).
Out of the administrative blocks studied, Chavakkad (10.58%) had the highest prevalence of DR among the DM patients screened, followed by Thrissur block (10.45%), Kodungalloor (9.93%), Chalakkudy (9.55%), and Kunnamkulam (8.41%). Block-wise detection of DR is shown in [Figure 2].
|Figure 2: Blockwise detection of diabetic retinopathy among patients with diabetes mellitus attending NCDC|
Click here to view
Association between duration of DM and chance of having PDR was analyzed using odds ratio. When analyzed for the association between 10-year duration of DM and the presence of DR, odds ratio was 2.76 (P < 0.00001, Chi-square test). This indicates that a patient with >10-year duration of DM has 2.76 times chance of having PDR than that with <10-year duration.
When analyzed for the association between 5-year duration of DM and the presence of DR, odds ratio was 2.56 (P < 0.001, Chi-square test). A patient with >5-year duration of DM has 2.56 times chance of having PDR than that with <5-year duration [Figure 3].
|Figure 3: Bar chart showing the association between >10-year duration of diabetes mellitus and chance of having proliferative diabetic retinopathy|
Click here to view
Association between regularity of follow-up for DM at NCDCs and the presence of DR was analyzed among DR-detected patients and odd's Ratio was found to be 0.3, which indicates that a patient with regular follow-up for DM at NCDCs has 0.3 times chance of having PDR than those with irregular follow-up. In similar lines, a patient with irregular follow-up for DM at NCDCs has 3.41 times more chance of having PDR than those with regular follow-up (odds ratio = 3.41).
Gender (P = 0.08) and age (P = 0.57) were not significant factors affecting regularity of follow-ups of patients with DM at the NCDCs. Association between follow-up status and development of PDR is shown in [Figure 4]. Association between gender and follow-up status of patients with DM is shown in [Figure 5].
|Figure 4: Association between follow-up status and development of proliferative diabetic retinopathy|
Click here to view
|Figure 5: Association between gender and follow-up status of patients with diabetes mellitus|
Click here to view
| Discussion|| |
Our study indicates that the prevalence of DR among DM patients attending NCD clinics of Kerala is high (8.09%). We observed a significant association between duration of DM and chance of having PDR. A patient with >5-year duration of DM has 2.56 times chance of having PDR than one with <5-year duration of DM (odds ratio = 2.56; P < 0.001). Similarly, a patient with >10-year duration of DM has 2.76 times chance of having PDR than that with <10-year duration (odds ratio = 2.76; P < 0.00001). This is in line with the published studies.,,,
An important aspect observed in our study is the association between regularity of follow-up at NCDCs and the chance of developing PDR. Our result indicates that there is a significant association between irregular follow-up at NCDs and the chance of developing PDR (P = 0.0001). On the assumption that those attending NCDCs regularly are likely to have better control of DM, this is indirect evidence to the fact that the primary purpose of NCDCs at the government sector, i.e. glycemic control among those with DM, is well served. Therefore, it is clear that the poor attendance at NCDCs, which is again associated with poor control of DM, is more likely due to patient factors like poor compliance or low awareness, rather than the lack of provisions for service delivery in the health system.
We also analyzed the factors responsible for defaults in follow-up status in our population. However, age (P = 0.08) and gender (P = 0.57) were not significant factors associated with follow-up status for DM at the NCDCs. Although we did not analyze other social factors responsible for trend, we assume that the lack of awareness about the need for tight control of blood sugar and the importance of follow-up visits needs to be stressed more in the population. Furthermore, there was almost similar proportion of DR (8.41% in Kunnamkulam block to 10.58% in Chavakkad block) detected patients among DM patients in all the administrative blocks studied.
Out of those detected with DR, 20% had PDR and 80% had NPDR. This is a matter of grave concern as these patients were registered and under treatment from the NCDCs. The fact that sight-threatening DR was not appropriately detected points to the need for modifying the priorities and protocols in the NCDCs in Kerala.
| Conclusion|| |
Our study indicates that DR among diabetic patients registered in NCDCs in Kerala is high. Even after attending NCD clinics, DR is largely undetected. Longer duration of DM was significantly associated with PDR. Patients with regular follow-up at NCDCs were found to have lesser chance of having PDR; implying better glycemic control.
Taking these facts to consideration, we propose that NCDCs at government level need integration with ophthalmologists at NCDCs for early detection and management of DR. Steps for increasing the awareness among health workers and the general public have a long way to go in the fight for eliminating this cause of blindness among those with DM.
We acknowledge the Government of Kerala, Queen Elizabeth Diamond Jubilee Trust, the United Kingdom and Public Health Foundation of India, New Delhi, for the financial and infrastructural support provided to the Diabetic Retinopathy Screening project conducted by Little Flower Hospital, Angamaly, Kerala.
Financial support and sponsorship
This study was financially supported by the Government of Kerala, Public Health Foundation of India, New Delhi and Queen Elizabeth Diamond Jubilee Trust, the United Kingdom.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006;3:e442.
World Health Organization. World Health Statistics 2016: Monitoring Health for the SDGs Sustainable Development Goals. World Health Organization; 2016.
Menon VU, Kumar KV, Gilchrist A, Sugathan TN, Sundaram KR, Nair V, et al.
Prevalence of known and undetected diabetes and associated risk factors in central Kerala – ADEPS. Diabetes Res Clin Pract 2006;74:289-94.
Kaveeshwar SA, Cornwall J. The current state of diabetes mellitus in India. Australas Med J 2014;7:45-8.
Thankappan KR, Shah B, Mathur P, Sarma PS, Srinivas G, Mini GK, et al.
Risk factor profile for chronic non-communicable diseases: Results of a community-based study in Kerala, India. Indian J Med Res 2010;131:53-63.
] [Full text]
Shah B, Mathur P. Surveillance of cardiovascular disease risk factors in India: The need and scope. Indian J Med Res 2010;132:634-42.
] [Full text]
Rema M, Ponnaiya M, Mohan V. Prevalence of retinopathy in non insulin dependent diabetes mellitus at a diabetes centre in Southern India. Diabetes Res Clin Pract 1996;34:29-36.
Dandona L, Dandona R, Naduvilath TJ, McCarty CA, Rao GN. Population based assessment of diabetic retinopathy in an urban population in Southern India. Br J Ophthalmol 1999;83:937-40.
Rema M, Deepa R, Mohan V. Prevalence of retinopathy at diagnosis among type 2 diabetic patients attending a diabetic centre in South India. Br J Ophthalmol 2000;84:1058-60.
Narendran V, John RK, Raghuram A, Ravindran RD, Nirmalan PK, Thulasiraj RD. Diabetic retinopathy among self reported diabetics in Southern India: A population based assessment. Br J Ophthalmol 2002;86:1014-8.
Rema M, Premkumar S, Anitha B, Deepa R, Pradeepa R, Mohan V. Prevalence of diabetic retinopathy in urban India: The Chennai urban rural epidemiology study (CURES) eye study, I. Invest Ophthalmol Vis Sci 2005;46:2328-33.
Namperumalsamy P, Kim R, Vignesh TP, Nithya N, Royes J, Gijo T, et al.
Prevalence and risk factors for diabetic retinopathy: A population-based assessment from Theni district, South India. Br J Ophthalmol 2009;93:429-34.
Gulshan V, Peng L, Coram M, Stumpe MC, Wu D, Narayanaswamy A, et al.
Development and validation of a deep learning algorithm for detection of diabetic retinopathy in retinal fundus photographs. JAMA 2016;316:2402-10.
Gadkari SS, Maskati QB, Nayak BK. Prevalence of diabetic retinopathy in India: The all India ophthalmological society diabetic retinopathy eye screening study 2014. Indian J Ophthalmol 2016;64:38-44.
] [Full text]
Scarpa G, Urban F, Vujosevic S, Tessarin M, Gallo G, Visentin A. The nonmydriatic fundus camera in diabetic retinopathy screening: A cost-effective study with evaluation for future large-scale application. J Ophthalmol 2016;2016:4625096.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]