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Essay: Effective and qualitative teleophthalmology examination

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  • Published: 24 October 2015*
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The objective of the current study was to contribute to effective and qualitative teleophthalmology examination in order to increase telemedicine activities by determining the inter-rater reliability of the diagnosis and management plan between optometrists and ophthalmologists in evaluating eye diseases, and by reporting on performance indicators for efficiency and quality. Therefore, the present study answered three important questions about the optometrists abilities, efficiency and quality of the screening process of teleophthalmology. The optometrists abilities have been assessed by diagnosis and management plan.
The Kappa analysis pointed out that there was a moderate diagnostic reliability between optometrists and ophthalmologists for all eye diseases. However, there was a fair diagnostic agreement for glaucoma, and a slight agreement for macular degeneration. Although, these results differ from some published studies (Mul et al., 2004; Banes et al., 2000), they are consistent with those of Batterbury (2001). The poor reliability in identifying glaucoma may be due to inexperienced optometrists, who may fail to differentiate glaucoma from other eye diseases (Batterbury, 2001). This can be explained by the fact that optometrist fail to apply diagnostic criteria for glaucoma when examining the optic nerve (Ieong, 2003). Interestingly, our results showed that experienced optometrists had a substantial agreement with the ‘gold standard’ of ophthalmologist for all eye diseases. In contrast, the Kappa analysis of the management plan showed that there was moderate (glaucoma) and substantial (macular degeneration and all eye diseases) reliability between optometrists and ophthalmologists. These results are consistent with those of Azuara’Blanco et al. (2007) who also found a substantial agreement of management reliability (88%, ?? 0.72) in a study of glaucoma screening between optometrists and ophthalmologists.
Furthermore, the management plan accuracy for glaucoma showed a high specificity. This will reduce the false positive referrals to a minimum, and therefore reduce unnecessary workload to ophthalmologists. The sensitivity was lower for the management plan of glaucoma. These results of management plan accuracy for glaucoma are in agreement with those obtained by Azuara’Blanco et al. (2007). They also found a higher specificity compared to the sensitivity. In the case of all eye diseases and macular degeneration, this study found a high sensitivity and specificity. However, literature reporting the management accuracy of optometrists for all eye diseases and macular degeneration are not available, despite a systematic literature search.
The research has also shown that optometrist would have physically referred 44,8 % of the patients if teleophthalmology were not available. Teleophthalmology led ultimately to a 28 % reduction in the number of physical referrals of all eye diseases. However, Mul et al. (2004) reported that in the case of glaucoma screening 70% of the 1729 patient did not require physical referrals. A possible explanation for this might be that the setting of Mul et al. was different from our study, because in this study it was not known whether the patients would have been physically referred without teleophthalmology. On the question ‘When a teleconsult was not compulsory, would you still have done a teleconsult for this patient’?, 57.6 % of the optometrists indicated that they would not have done a teleconsultation with an ophthalmologist. This result may partly be explained by the fact that optometrists in a large proportion of the cases already knows how they should act.
Another important finding was that in 55 % of the cases a teleconsult was performed for second opinion. Seven percent of these patients who would normally not have been physically referred by an optometrist, now were physically referred after teleconsultation on advice of the ophthalmologist. As a consequence, the quality of care for these patients is likely improved. The average of providing a diagnosis and management plan by the ophthalmologist to the optometrist was within 6.5 hours. On the question of the optometrists experienced an educational effect, this study found that 65,7% of the optometrists learned from the ophthalmologists response. Accordingly, future patients will benefit from this learning, and should lead to improved patient healthcare (Johnston et al., 2004). Interestingly, there was a significant decrease between 2012 and 2015 of the learning effect from the ophthalmologist by teleconsultation. This result may be explained by the fact that optometrists have learned over the past few years.
A number of restrictions of our study and areas for future research should be mentioned. First of all, little was found in the literature on the concept of quality (e.g. the number of teleophthalmology consultation performed for second opinion) in the field of teleophthalmology. Therefore, this is an important concept for future research. Secondly, optometrists were able to select several eye diseases for every patient. This made it unclear whether different diseases were present or they could not make a specific diagnosis. In addition, a lot of patients were diagnosed as other eye diseases. The KSYOS teleconsultation system need to be updated with more common eye diseases, to prevent the number of other eye diseases. More specifically, only in the case of glaucoma it was possible to choose for ‘no glaucoma’, ‘suspect glaucoma’, and ‘glaucoma’. This also have to be taken into account. A further study with more focus on inter-rater reliability on diagnosis is therefore suggested. Thirdly, no follow-up data on patients were collected. It is therefore not known whether patient for whom optometrists indicated they were not physically referred to an ophthalmologist, did indeed not visit an ophthalmologist. Finally, a quantitative research method is especially suitable to gain an overall picture. As a consequence, no in-depth analysis of the problem could be made. For example, to develop a full picture of the educational effect, additional qualitative and quantitative studies will be needed that explore the educational effect by teleconsultation. However, the strength of the study is that the used conceptual model has already been applied for other telemedicine services (e.g. teledermatology). Therefore, the model was ideally suited for this study. Another strength is that teleophthalmology was implemented in real life daily general practice, not in a simulated research setting.
The findings of this study have a number of important implications for future practice of teleophthalmology at KSYOS TeleMedical Centre. Even though the high Kappa for the management plan of optometrists, the low Kappa for detecting eye diseases requires a coordinated program to increase the agreement. As already mentioned by Batterbury (2001), additional training and accreditation for optometrists in glaucoma screening and other eye diseases is needed in order to ensure that participating optometrists reach particular standards for detecting eye diseases. The current teleophthalmology screening process has already been developed to ensure the quality of the screening by 100 percent control through ophthalmologists. However, KSYOS have already a large network with ophthalmologists, and they could play a very important role in this training process. Face-to-face training, for example, could be beneficial to improve the diagnostic assessment.
7. Conclusion
This study shows that teleophthalmology examination for certain eye diseases is useful in a daily healthcare setting in the Netherlands. Teleophthalmology reduces the number of physical referrals, and contributes to the educational effect by ophthalmologist. In addition, the average response time of a teleconsult by the ophthalmologist was within 6.5 hours. Conversely, the inter-rater reliability of detecting eye diseases by optometrists does not reach agreed ‘gold standards’ of ophthalmologists. Additional training for community optometrists in detecting certain eye disease, like glaucoma, is needed to be at least as accurate as junior ophthalmologists. However, to satisfy the demand for eye care between 2010 and 2020 in the Netherlands, teleophthalmology together with community optometrists should be considered as a possible solution for the detection and management of certain eye diseases.

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