Fundoscopy not a sensitive method for screening diabetic retinopathy in primary care practices: JAMA

USA: Fundoscopic examination is rarely performed and is not sensitive for detecting diabetic retinopathy (DR) in clinical practice, states a study report published in The JAMA Network Open. 

Diabetic retinopathy (DR) is a complication of diabetes that affects the eyes. It may lead to loss of vision if left undiagnosed and untreated. DR is diagnosed clinically by fundoscopy, a visual examination of the retina using an ophthalmoscope. Previous studies showed fundoscopy as an effective DR screening tool in primary care. Primary care professionals (PCPs) have a central role in screening for DR, especially in settings with limited access to specialty eye care. Data on DR screening practice patterns in primary care are needed to inform screening strategies.

Song A, Duke University School of Medicine, USA, and her team conducted a retrospective cohort study to assess the practice patterns of fundoscopic examination for DR screening in a large primary care network and to evaluate the sensitivity and accuracy of PCP fundoscopy for detecting DR.

Investigators collected data from 2001 encounters from the electronic health record for a random sample of 767 patients. 7449 adult patients with diabetes seen at least once in the primary care network were included in the study from a primary care network of 28 clinics. The frequency of PCPs performing fundoscopy at least once in the calendar year for patients with diabetes was set as the main outcome. The PCP examination results were compared with diagnoses made by eye care professionals to assess the sensitivity and accuracy of the findings from PCP examinations.

Key findings of the study,

• PCPs performed a documented fundoscopic examination for 12.1% of patients.

• Using eye care professional examination results as the reference standard, the accuracy of PCP fundoscopic examination was 62.7% and sensitivity for detecting disease was 0.0%.

• No patient demographic or clinical characteristics were associated with PCPs performing fundoscopy.

• In multivariable logistic regression the number of PCP years in practice with a greater odds of patients receiving fundoscopy at least once in the year. 

• Nurse practitioner credentials were also linked to a lower odds of receiving fundoscopy (compared with having physician credentials).

The authors concluded that fundoscopic examination was rarely performed and was not sensitive for detecting DR in primary care practice. The findings complement the existing literature reporting low rates of DR screening, thus suggesting that current primary care systems are insufficient to fill gaps in eye care for patients with diabetes.

Further research to explore and break down barriers to the implementation of effective primary care-based DR screening strategies, such as teleretinal imaging, is needed to prevent vision loss from undiagnosed DR, the authors suggested.

Reference:

Song A, Lusk JB, Roh K, et al. Practice Patterns of Fundoscopic Examination for Diabetic Retinopathy Screening in Primary Care. JAMA Netw Open. 2022;5(6):e2218753. doi:10.1001/jamanetworkopen.2022.18753