Objective To study and analyze the possible benefits on performance of community health workers using point-of-care clinical guidelines implemented a

Remote patient management (RPM) offers renal health care providers and patients with end-stage kidney disease opportunities to embrace home dialysis therapies with greater confidence and the potential to obtain better clinical outcomes. Barriers and evidence required to increase adoption of RPM by the nephrology community need to be clearly defined. Ten health care providers from specialties including nephrology, cardiology, pediatrics, epidemiology, nursing, and health informatics with experience in home dialysis and the use of RPM systems gathered in Vienna, Austria to discuss opportunities for, barriers to, and system requirements of RPM as it applies to the home dialysis patient. Although improved outcomes and cost-effectiveness of RPM have been demonstrated in patients with diabetes mellitus and heart disease, only observational data on RPM have been gathered in patients on dialysis. The current review focused on RPM systems currently in use, on how RPM should be integrated into future care, and on the evidence needed for optimized implementation to improve clinical and economic outcomes. Randomized controlled trials and/or large observational studies could inform the most effective and economical use of RPM in home dialysis. These studies are needed to establish the value of existing and/or future RPM models among patients, policy makers, and health care providers.

Purpose. To assess agreement between digital and film photography for research classification of diabetic retinopathy severity. Methods. Digital and film photographs from a 152-eye cohort with a full spectrum of Early Treatment Diabetic Retinopathy Study (ETDRS) severity levels were assessed for repeatability of grading within each image medium and for agreement on ETDRS discrete severity levels, ascending severity thresholds, and presence or absence of diabetic retinopathy index lesions, between digital and 35-mm slides (film). Digital photographs were color balanced to match film. Results. There was substantial agreement (κ = 0.61, κ_w [linear weighted] = 0.87) in classification of ETDRS diabetic retinopathy severity levels between digital images and film. Marginal homogeneity analyses found no significant difference in frequency distributions on the severity scale (P = 0.21, Bhapkar test). The κ results ranged from 0.72 to 0.95 for presence or absence of eight ascending diabetic retinopathy severity thresholds. Repeatability of grading between readers viewing digital images was equal to or better than that obtained with film (pair-wise interreader κ for digital images ranged from 0.47 to 0.57 and for film from 0.43 to 0.57. The κ results for identifying diabetic retinopathy lesions ranged from moderate to almost perfect. Moderate agreement of intraretinal microvascular abnormalities and venous beading between digital images and film accounted for slightly lower concordance for severity thresholds ≥47 and for slightly lower interreader agreement within digital and film images at severity thresholds ≥43 and ≥47. Conclusions. Under controlled circumstances, digital photography can equal the reliability of 35-mm slides for research classification of ETDRS severity level.

Purpose. To assess agreement between monoscopic and stereoscopic photography for research classification of the severity of diabetic retinopathy (DR). Methods. Monoscopic digital (MD) images were compared with stereo digital (SD) and film (SF) photographs from a 152-eye cohort with full-spectrum Early Treatment Diabetic Retinopathy Study (ETDRS) severity levels for agreement on severity level, DR presence with ascending severity threshold, presence of DR index lesions, and repeatability of grading. Results. There was substantial agreement classifying ETDRS DR severity levels between MD and SF (κ = 0.65, κ_w [linear weighted] = 0.87), MD and SD (κ = 0.66, κ_w = 0.87), and SD and SF (κ = 0.62, κ_w = 0.86) images. Marginal homogeneity analyses found no significant difference between MD and SF images (P = 0.53, Bhapkar test). The κ agreement between MD and SF ranged from 0.80 to 0.94 for the presence or absence of eight ascending DR severity thresholds. Repeatability between the readers of the MD images was equal to or better than that of the readers of SD or SF images. Severity threshold grading repeatability between readers was similar with the MD and SF images. The κ agreement between MD and SF for identifying diabetic retinopathy lesions ranged from moderate to almost perfect. The κ comparisons showed that performance of grading new vessels on the disc in MD images was slightly lower than that with the SF images. Conclusions. Monoscopic photography can equal the reliability of stereo photography for full ETDRS DR severity scale grading.

Purpose.: To evaluate digital photography parameters affecting comparability with the Early Treatment Diabetic Retinopathy Study (ETDRS) film protocol for diabetic retinopathy (DR) severity grading. Methods.: ETDRS protocol photographs and four variations of digital images (uncompressed stereoscopic, compressed stereoscopic, uncompressed monoscopic, and uncompressed monoscopic wide-angle mosaic) of 152 eyes were independently evaluated by using ETDRS classifications. Digital formats were compared to film and each other for agreement on severity level, DR presence at ascending threshold, presence of the DR index lesion, and repeatability of grading. Study parameters included image resolution sufficient to distinguish small lesions, color balancing of digital images to film, documenting essential ETDRS classification retinal regions, similar magnification, and supplementary green-channel viewing. Results.: The κ statistic was substantial or near substantial between all digital formats and film for classifying severity levels (κ = 0.59–0.62; κ_w [linear weighted] = 0.83–0.87). The distribution of DR levels in all digital formats was not significantly different from that of the film (Bhapkar test, P = 0.09–0.44). The κ among digital formats for severity level was also substantial or near substantial (κ = 0.58–0.76, κ_w = 0.82–0.92). Differences between digital formats and film for grading severity level, severity threshold, or index lesions were not significant. The repeatability of grading between readers using film and all digital formats was also similar. Conclusions.: Digital format variations compared favorably with film for DR classification. Translating film characteristics (resolution, color/contrast) and protocol (magnification, retinal regions) to digital equivalents and augmentation of full color with green-channel viewing most likely contributed to the results.

Currently, in developing countries, there is considerable interest in using mobile phones as job-aids for community health workers (CHWs) to improve the care they provide. However, acceptance of new technologies can be inhibited if the workload imposed is perceived as excessive compared to existing methods. To compare perceived workload of CHWs using clinical care guidelines presented on mobile phones versus using conventional paper-based guidelines. Validated clinical practice guidelines were developed as Interactive Structured Rich-Medical guidelines (ISRMGs) on Windows Mobile 6.5 mobile phones. A prospective randomized controlled study was performed in Colombia in which 50 CHWs used the ISRMGs, and paper-based materials with the same information, in a cross-over design to diagnose and treat 15 matched pairs of medical cases presented on Human Patient simulators. The NASA Task Load Index, a validated measure of perceived workload, was administered and results compared by means of a mixed model analysis. When using the ISRMGs on mobile phones the health workers reported statistically significant decreases in mental demand, frustration, and overall workload as compared to using paper-based job-aids. Use of ISRMGs on mobile phones by community health workers in developing countries has the potential to decrease their perceived workload, fatigue, and enhance their ability to provide better care for more patients.