1. DODIA 1 Screening for diabetic retinopathy: the first telemedical approach in a primary care setting in France (DODIA study). EPGRN, Nijmegen, May 11th, 2007 J.P. Aubert, P Massin, S. Bouée, G. Audran, A. Ben Mehidi, B Bernit, M Bouhassira, JC Bourovitch, I Cahitte, E.Eschwege, F. Fagnani, M. Marre, M Nougairède,AM Simonpoli

2. BACKGROUND main cause for blindness in the working population easily preventable :screening+laser In France, screening for DR is recommended once a year for all diabetic people

3. BACKGROUND 2.000.000 diabetics inFrance, increasing 5% every year 30 to 40% of french diabetics are expected to have a DR 41,5 % of diabetics had been examined by an ophtalmologist within the last year 5000 ophtalmologists in France in 2005, 2500 will remain in 2015 DR screening has to be optimized

4. SCREENING METHODS Conventionnal screening: eye fundus examination after pupillary dilatation Colour fundus photography obtained without pharmacological dilatation of the pupil storage and electronic transmission of photographs is easy

5. Eye fundus photography 3 photographs: papilla, macula, and temporal area. Sensitivity 85%, specificity 95%

6. Study design Observationnal study with control group experimental group: GPs from the Réseau de Santé Paris-Nord (North Paris Health network). control group : GPs from ARES-92 (another health network of the Paris suburb) All investigators were volunteer control group close geographic location to the experimental group, similar density of private ophthalmologists in the area, similar social and demographic characteristics of the living population.

7. Management of the experimental group non-mydriatic camera was set up in a community screening center, Patients referred by GPs to the screening center for photography of eye fundus Electronic transmission to Hospital Lariboisiere, Paris Postponed interpretation of photographs by ophtamologists (15 to 20 patients an hour) Results sent by snailmail to GP and patient

8. Management of the control group Usual procedure: Patients referred to their ophtalmologist Usual eye fond examination performed

9. Primary endpoint To assess the rate of actual DR screening among diabetic patients (type 1 and 2) from the two investigators groups

10. Secondary endpoints Improvement of the GPs knowledge of retinian condition of their patients satisfaction and compliance of patients regarding the photographic screening method rate of patients that accept the photographic screening method NB: no assessment of the efficiency of screening

11. What do we call « screening »? A screening for DR is an examination of eye fundus perfomed within six months after prescription by the GP, testified by the presence of a written report in the patients file.

12. Inclusion/exclusion criteria All type 1 and 2 diabetic patients attending one of the investigators during the inclusion period (7 months 1.4.2002-1.11.2002) Were excluded: Patients with known DR Patients who had had screening for DR within last year Patients from the experimental group who asked to consult their usual ophtalmologist People who refused the study

13. Participation of investigators

14. Patients Experimental group: 667 screened patients, 519 (78%) met inclusion criteria, of which 456 (87,9%) accepted the study Control group: 707 screened patients, 469( 67%) met inclusion criteria, of which 426 (90,8%) accepted the study

15. Baseline characteristics of patients No stastistical difference regarding Gender: 2/3 male Mean age: 60 Haemoglobin A1c (when available): 7,7% Mean blood pressure Treatment for diabetes (77,2% oral treatment alone) History of eye fundus examination (more than one year): 85% diabetes discovered more recently in the experimental group (6.4 ± 6.6 years vs 8.1 ± 8.0, p = 0.0011) apatients more frequently treated with diet alone in the experimental group (12.6% vs 7,9%, P = 0.002).

16. Primary outcome

17. Screening results

18. The delay before appointment is…(p<0,001)

19. I experienced visual impairment due to screening (p<0,001)

20. The place for screening is easy to reach (p<0,001)

21. I had to wait in the screening place (p<0,001)

22. The duration of the test (p<0,001)

23. Conclusion digital retinal images taken in a screening center and transferred electronically to an ophthalmologic detects and grades DR in primary care patients, filters eye-threatening cases requiring complete eye analysis by an ophthalmologist. The screening procedure is effective, increasing GPsawareness about their patient eye status. Most patients who received non dilated eye fundus photographs are satisfied need to extend this screening program to a larger number of different French sites.

24. 2006: toujours plus loin Fort de létude DODIA, le Réseau de santé Paris Nord a poursuivi son travail: Les OPH achètent massivement des rétinographes, dont le prix a baissé considérablement Lexamen au rétinographe est devenu le gold standard de la rétinopathie diabétique Le réseau a fabriqué la première banque de données photographiques européenne de dépistage de la rétinopathie diabétique Le réseau a mis au point un outil de formation des OPH, mis en ligne et qui va être annexé aux recommandations françaises de dépistage de la RD

29. Sources utilisées dans cette présentation [1] Klein R, Klein BEK, Moss SE, Davis MD, DeMets DL. The Wisconsin Epidemiologic Study of Diabetic Retinopathy : II. Prevalence and risk of diabetic retinopathy when age at diagnosis is less than 30 years. Arch Ophthalmol 1984 ; 102 : 520-526. [2] Klein R, Klein BEK, Moss SE, Davis MD, Demets DL. The Wisconsin Epidemiologic Study of Diabetic Retinopathy : III. Prevalence and risk of diabetic retinopathy when age at diagnosis is 30 years or more. Arch Ophthalmol 1984 ; 102 : 527-532. [3] Early Treatment Diabetic Retinopathy Study Research Group. Early photocoagulation for diabetic retinopathy. ETDRS report number 9. Ophthalmology 1991 ; 98 : 766-785. [4] Massin P, Angioi-Duprez K, Bacin F, et al. Recommandations de l'ALFEDIAM pour le dépistage et la surveillance de la rétinopathie diabétique. Diabète et Métabolisme 1996 ; 22 : 203-209. [5] Recommandations de l'ANAES. Suivi du patient diabétique de type 2 à l'exclusion du suivi des complications. Complications oculaires. Doiabète Metab 1999 ; 2( suppl) : 35-38. [6] Detournay B, Vauzelle-Kervroedan F, Charles MA, Forhan A, Fagnani F, Fender P, Eschwege E. Epidémiologie, prise en charge et coût du diabète de type 2 en France en 1998. Diabetes Metab 1999; 25(4) : 356-65. [7] Massin P, Erginay A, Ben Mehidi A, Vicaut E, Quentel G, Victor Z, Marre M, Guillausseau PJ, Gaudric A Evaluation of a new non-mydriatic digital camera for detection of diabetic retinopathy. Diabet Med. 2003 Aug;20(8):635-41.