Griffith S P, Freeman W L, Shaw C J, Mitchell W H, Olden C R, Figgs L D, Kinyoun J L, Underwood D L, Will J C
Office of Health Program Research and Development, Indian Health Service, Tucson, AZ 85746.
J Fam Pract. 1993 Jul;37(1):49-56.
Type II diabetes mellitus is a major health problem among Native Americans, and diabetic retinopathy is a frequent complication of this disease. Screening for retinopathy can identify early disease and prevent major vision loss, but the most cost-effective screening method has not yet been determined.
In a rural clinic that served more than 400 Native Americans with diabetes, we compared the accuracy of referrals made based on two screening methods: ophthalmoscopy by trained primary care physicians and seven-view nonstereoscopic, mydriatic fundal photography read by two general ophthalmologists and a retinal specialist. Patients in whom abnormal findings were detected by either screening method were then referred to a general ophthalmologist for further evaluation.
Two hundred forty-three examinations were performed and 83 referrals made. Both screening methods had high sensitivity for referring patients with retinopathy that required treatment or follow-up sooner than 1 year (100% for direct ophthalmoscopy by primary care physicians, 94% for the general ophthalmologist photography readers, and 100% for the retinal specialist reader). The calculated costs of screening by direct ophthalmoscopy and by retinal photography were 64% less and 44% to 35% less, respectively, than the cost of yearly ophthalmological examinations by ophthalmologists.
Careful screening for treatable diabetic eye disease by trained primary care physicians proved to be a clinically acceptable, cost-effective strategy. Screening methods for diabetic retinopathy should be evaluated based on the absolute sensitivity, specificity, and predictive values of their ability to correctly refer patients rather than their diagnostic accuracy.
2型糖尿病是美国原住民中的一个主要健康问题，糖尿病视网膜病变是该疾病常见的并发症。视网膜病变筛查能够识别早期疾病并预防严重视力丧失，但最具成本效益的筛查方法尚未确定。
在一家为400多名患有糖尿病的美国原住民提供服务的乡村诊所，我们比较了基于两种筛查方法进行转诊的准确性：由经过培训的初级保健医生进行的检眼镜检查，以及由两名普通眼科医生和一名视网膜专科医生阅读的七视图非立体散瞳眼底摄影。通过任何一种筛查方法检测到异常结果的患者随后被转诊至普通眼科医生处进行进一步评估。
共进行了243次检查，转诊83例。两种筛查方法对于转诊需要在1年内进行治疗或随访的视网膜病变患者均具有较高的敏感性（初级保健医生直接检眼镜检查为100%，普通眼科医生摄影阅片者为94%，视网膜专科医生阅片者为100%）。直接检眼镜检查和视网膜摄影筛查的计算成本分别比眼科医生每年进行眼科检查的成本低64%和44%至35%。
事实证明，由经过培训的初级保健医生仔细筛查可治疗的糖尿病眼病是一种临床上可接受的、具有成本效益的策略。糖尿病视网膜病变的筛查方法应根据其正确转诊患者的绝对敏感性、特异性和预测值进行评估，而非其诊断准确性。
