Use of personalised risk-based screening schedules to optimise workload and sojourn time in screening programmes for diabetic retinopathy: A retrospective cohort study

Autoři: Andreas Ochs aff001;  Stuart McGurnaghan aff001;  Mike W. Black aff002;  Graham P. Leese aff003;  Sam Philip aff004;  Naveed Sattar aff005;  Caroline Styles aff006;  Sarah H. Wild aff007;  Paul M. McKeigue aff007;  Helen M. Colhoun aff001
Působiště autorů: Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, United Kingdom aff001;  Diabetic Retinopathy Screening Collaborative, NHS Highland, Inverness, United Kingdom aff002;  Ninewells Hospital, Dundee, United Kingdom aff003;  Grampian Diabetes Research Unit, Diabetes Centre, Aberdeen Royal Infirmary, Aberdeen, United Kingdom aff004;  British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom aff005;  Queen Margaret Hospital, Dunfermline, United Kingdom aff006;  Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom aff007
Vyšlo v časopise: Use of personalised risk-based screening schedules to optimise workload and sojourn time in screening programmes for diabetic retinopathy: A retrospective cohort study. PLoS Med 16(10): e32767. doi:10.1371/journal.pmed.1002945
Kategorie: Research Article
doi: 10.1371/journal.pmed.1002945



National guidelines in most countries set screening intervals for diabetic retinopathy (DR) that are insufficiently informed by contemporary incidence rates. This has unspecified implications for interval disease risks (IDs) of referable DR, disparities in ID between groups or individuals, time spent in referable state before screening (sojourn time), and workload. We explored the effect of various screening schedules on these outcomes and developed an open-access interactive policy tool informed by contemporary DR incidence rates.

Methods and findings

Scottish Diabetic Retinopathy Screening Programme data from 1 January 2007 to 31 December 2016 were linked to diabetes registry data. This yielded 128,606 screening examinations in people with type 1 diabetes (T1D) and 1,384,360 examinations in people with type 2 diabetes (T2D). Among those with T1D, 47% of those without and 44% of those with referable DR were female, mean diabetes duration was 21 and 23 years, respectively, and mean age was 26 and 24 years, respectively. Among those with T2D, 44% of those without and 42% of those with referable DR were female, mean diabetes duration was 9 and 14 years, respectively, and mean age was 58 and 52 years, respectively. Individual probability of developing referable DR was estimated using a generalised linear model and was used to calculate the intervals needed to achieve various IDs across prior grade strata, or at the individual level, and the resultant workload and sojourn time. The current policy in Scotland—screening people with no or mild disease annually and moderate disease every 6 months—yielded large differences in ID by prior grade (13.2%, 3.6%, and 0.6% annually for moderate, mild, and no prior DR strata, respectively, in T1D) and diabetes type (2.4% in T1D and 0.6% in T2D overall). Maintaining these overall risks but equalising risk across prior grade strata would require extremely short intervals in those with moderate DR (1–2 months) and very long intervals in those with no prior DR (35–47 months), with little change in workload or average sojourn time. Changing to intervals of 12, 9, and 3 months in T1D and to 24, 9, and 3 months in T2D for no, mild, and moderate DR strata, respectively, would substantially reduce disparity in ID across strata and between diabetes types whilst reducing workload by 26% and increasing sojourn time by 2.3 months. Including clinical risk factor data gave a small but significant increment in prediction of referable DR beyond grade (increase in C-statistic of 0.013 in T1D and 0.016 in T2D, both p < 0.001). However, using this model to derive personalised intervals did not have substantial workload or sojourn time benefits over stratum-specific intervals. The main limitation is that the results are pertinent only to countries that share broadly similar rates of retinal disease and risk factor distributions to Scotland.


Changing current policies could reduce disparities in ID and achieve substantial reductions in workload within the range of IDs likely to be deemed acceptable. Our tool should facilitate more rational policy setting for screening.

Klíčová slova:

Diabetic retinopathy – Medical risk factors – Retinopathy – Scotland – Screening guidelines


1. Jones S, Edwards RT. Diabetic retinopathy screening: a systematic review of the economic evidence. Diabet Med. 2010;27(3):249–56. doi: 10.1111/j.1464-5491.2009.02870.x 20536486

2. Olafsdottir E, Stefánsson E. Biennial eye screening in patients with diabetes without retinopathy: 10-year experience. Br J Ophthalmol. 2007;91(12):1599–601. doi: 10.1136/bjo.2007.123810 17627978

3. Scanlon PH. The English National Screening Programme for diabetic retinopathy 2003–2016. Acta Diabetol. 2017;54(6):515–25. doi: 10.1007/s00592-017-0974-1 28224275

4. Leese GP, Morris AD, Swaminathan K, Petrie JR, Sinharay R, Ellingford A, et al. Implementation of national diabetes retinal screening programme is associated with a lower proportion of patients referred to ophthalmology. Diabet Med. 2005;22(8):1112–5. doi: 10.1111/j.1464-5491.2005.01603.x 16026382

5. American Diabetes Association. Standards of medical care in diabetes 2019. Diabetes Care. 2019;42(Suppl 1):S1–193. doi: 10.2337/dc19-Sint01 30559224

6. Looker HC, Nyangoma SO, Cromie DT, Olson JA, Leese GP, Black MW, et al. Rates of referable eye disease in the Scottish National Diabetic Retinopathy Screening Programme. Br J Ophthalmol. 2014;98(6):790–5. doi: 10.1136/bjophthalmol-2013-303948 24599419

7. Wong TY, Mwamburi M, Klein R, Larsen M, Flynn H, Hernandez-Medina M, et al. Rates of progression in diabetic retinopathy during different time periods. Diabetes Care. 2009;32(12):2307–13. doi: 10.2337/dc09-0615 19940227

8. Aspelund T, Thornórisdóttir O, Olafsdottir E, Gudmundsdottir A, Einarsdóttir AB, Mehlsen J, et al. Individual risk assessment and information technology to optimise screening frequency for diabetic retinopathy. Diabetologia. 2011;54(10):2525–32. doi: 10.1007/s00125-011-2257-7 21792613

9. Eleuteri A, Fisher AC, Broadbent DM, García-Fiñana M, Cheyne CP, Wang A, et al. Individualised variable-interval risk-based screening for sight-threatening diabetic retinopathy: the Liverpool Risk Calculation Engine. Diabetologia. 2017;60(11):2174–82. doi: 10.1007/s00125-017-4386-0 28840258

10. DCCT/EDIC Research Group. Frequency of evidence-based screening for retinopathy in type 1 diabetes. N Engl J Med. 2017;376(16):1507–16. doi: 10.1056/NEJMoa1612836 28423305

11. Agardh E, Tababat-Khani P. Adopting 3-year screening intervals for sight-threatening retinal vascular lesions in type 2 diabetic subjects without retinopathy. Diabetes Care. 2011;34(6):1318–9. doi: 10.2337/dc10-2308 21562322

12. Livingstone SJ, Looker HC, Hothersall EJ, Wild SH, Lindsay RS, Chalmers J, et al. Risk of cardiovascular disease and total mortality in adults with type 1 diabetes: Scottish Registry Linkage Study. PLoS Med. 2012;9(10):e1001321. doi: 10.1371/journal.pmed.1001321 23055834

13. Early Treatment Diabetic Retinopathy Study Research Group. Early Treatment Diabetic Retinopathy Study design and baseline patient characteristics. Ophthalmology. 1991;98(5):741–56.

14. Scottish Diabetic Retinal Screening Collaborative. Scottish diabetic retinopathy grading scheme 2007 v1.1. Scottish Diabetic Retinal Screening Collaborative; 2007 [cited 2019 Sep 21]. Available from:

15. Prescott G, Sharp P, Goatman K, Scotland G, Fleming A, Philip S, et al. Improving the cost-effectiveness of photographic screening for diabetic macular oedema: a prospective, multi-centre, UK study. Br J Ophthalmol. 2014;98(8):1042–9. doi: 10.1136/bjophthalmol-2013-304338 24682180

16. Wong RL, Tsang CW, Wong DS, McGhee S, Lam CH, Lian J, et al. Are we making good use of our public resources? The false-positive rate of screening by fundus photography for diabetic macular oedema. Hong Kong Med J. 2017;23(4):356–64. doi: 10.12809/hkmj166078 28684650

17. Su Y-S, Gelman A, Hill J, Yajima M. Multiple imputation with diagnostics (mi) in R: opening windows into the black box. J Stat Softw. 2011;45(2):1–31. doi: 10.18637/jss.v045.i02

18. McKnight JA, Wild SH, Lamb MJE, Cooper MN, Jones TW, Davis EA, et al. Glycaemic control of type 1 diabetes in clinical practice early in the 21st century: an international comparison. Diabet Med. 2015;32(8):1036–50. doi: 10.1111/dme.12676 25510978

Interní lékařství

Článek vyšel v časopise

PLOS Medicine

2019 Číslo 10

Nejčtenější v tomto čísle

Tomuto tématu se dále věnují…

Kurzy Doporučená témata Časopisy
Zapomenuté heslo

Nemáte účet?  Registrujte se

Zapomenuté heslo

Zadejte e-mailovou adresu se kterou jste vytvářel(a) účet, budou Vám na ni zaslány informace k nastavení nového hesla.


Nemáte účet?  Registrujte se

VIRTUÁLNÍ ČEKÁRNA ČR Jste praktický lékař nebo pediatr? Zapojte se! Jste praktik nebo pediatr? Zapojte se!