The use of non-physician health care professional examiners for detecting diabetic retinopathy has been coupled with use of photographic systems in the United Kingdom (84,85). The performance of trained photographic readers using a Polaroid camera system has matched or exceeded that of physicians and optometrcs. An accuracy of more than 90% in staging retinopathy has been reported with a modified Early Treatment Diabetic Retinopathy Study system that is similar to the International Clinical Diabetic Retinopathy system used by the Amercan Academy of Ophthalmology and the International Council of Ophthalmology
5.1.4 Use of reference photographs to standardize direct observation
Use by ancillary health care workers (and physicians) of a reference card or set of photographs in grading the severity of disease has been validated in the care of trachoma and other eye diseases, such as with the WHO trachoma grading card and prmary eye care chart. The pirnciple has also been used in numerous randomized controlled trals to achieve consistency in grading the presence and severity of other ocular features, such as lens opacities, corneal and conjunctival findings and optic disc damage (86-88). Use of such reference systems, however, requires careful training and regular monitorng, as performance reliability can vary (86).
5.2 Locations for detection and treatment of diabetic retinopathy
Diabetes mellitus and diabetic retinopathy are usually detected and treated at a health care facility, where one or more eye care professionals are available, in developed countries. Ophthalmologists and optometrists (in certain countries) provide most eye care services and can at least diagnose (ophthalmologists and optometrists) and treat (ophthalmologists) diabetic retinopathy, in private offices, pubic outpatient clinics and hospital facilities.
Eye care can be given in the offices of primary health care providers or general practitioners, but eye care services for diabetic retinopathy are rarely provided in these settings. A research group at the University of Melbourne, Australia, showed that most of the Australian general practitioners surveyed examined none or less than half of their patients with diabetes mellitus; of those who did examine these patients, two-thirds did not use pupil-dilating drops (89). The level of examination had not changed appreciably after the release of national guidelines for diabetes care by the National Health and Medical Research Council of Australia (90). Information on self-reported referral patterns showed, however, that most patents were regularly referred for an examination. For example, of those general practitioners who referred patients to an ophthalmologist, 98% referred them for an examination at least every other year. In contrast, in the United States durng a similar period, less than hal of the prmary care provders in Indiana referred all patients with type 1 diabetes mellitus to an eye care specialist annually (91). In the United Kingdom, examination of the fundus appeared to be common in some studies. In a survey of general practitioner practices in Oxfordshire, 83% conducted fundoscopy, but 63% referred patients for screening for diabetic retinopathy, indicating that about one-third were confident in performing their own screening (92).
The detection and treatment of diabetic retinopathy in developed countries is thus done manly by trained eye care provders and, therefore, in dedicated facilities. This is not surprising, as health care systems in developed countries concentrate their resources in specific locations, to which patents must go. This practice does, however, create a barrier to patent use because of transport, time and convenience factors.
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