{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,5,14]],"date-time":"2025-05-14T10:20:13Z","timestamp":1747218013781,"version":"3.40.5"},"reference-count":68,"publisher":"National Institute for Health and Care Research","issue":"32","license":[{"start":{"date-parts":[[2021,5,1]],"date-time":"2021-05-01T00:00:00Z","timestamp":1619827200000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/www.nationalarchives.gov.uk\/doc\/non-commercial-government-licence\/non-commercial-government-licence.htm"}],"funder":[{"DOI":"10.13039\/501100000664","name":"Health Technology Assessment programme","doi-asserted-by":"publisher","award":["15\/42\/08"],"award-info":[{"award-number":["15\/42\/08"]}],"id":[{"id":"10.13039\/501100000664","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["journalslibrary.nihr.ac.uk"],"crossmark-restriction":false},"short-container-title":["Health Technol Assess"],"abstract":"\n Background<\/jats:title>\n Owing to the increasing prevalence of diabetes, the workload related to diabetic macular oedema and proliferative diabetic retinopathy is rising, making it difficult for hospital eye services to meet demands.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n The objective was to evaluate the diagnostic performance, cost-effectiveness and acceptability of a new pathway using multimodal imaging interpreted by ophthalmic graders to detect reactivation of diabetic macular oedema\/proliferative diabetic retinopathy in previously treated patients.<\/jats:p>\n <\/jats:sec>\n \n Design<\/jats:title>\n This was a prospective, case-referent, cross-sectional diagnostic study.<\/jats:p>\n <\/jats:sec>\n \n Setting<\/jats:title>\n The setting was ophthalmic clinics in 13 NHS hospitals.<\/jats:p>\n <\/jats:sec>\n \n Participants<\/jats:title>\n Adults with type 1 or type 2 diabetes with previously successfully treated diabetic macular oedema\/proliferative diabetic retinopathy in one\/both eyes in whom, at the time of enrolment, diabetic macular oedema\/proliferative diabetic retinopathy could be active or inactive.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n For the ophthalmic grader pathway, review of the spectral domain optical coherence tomography scans to detect diabetic macular oedema, and seven-field Early Treatment Diabetic Retinopathy Study\/ultra-wide field fundus images to detect proliferative diabetic retinopathy, by trained ophthalmic graders. For the current standard care pathway (reference standard), ophthalmologists examined patients face to face by slit-lamp biomicroscopy for proliferative diabetic retinopathy and, in addition, spectral domain optical coherence tomography imaging for diabetic macular oedema.<\/jats:p>\n <\/jats:sec>\n \n Outcome measures<\/jats:title>\n The primary outcome measure was sensitivity of the ophthalmic grader pathway to detect active diabetic macular oedema\/proliferative diabetic retinopathy. The secondary outcomes were specificity, agreement between pathways, cost\u2013consequences, acceptability and the proportion of patients requiring subsequent ophthalmologist assessment, unable to undergo imaging and with inadequate quality images\/indeterminate findings. It was assumed for the main analysis that all patients in whom graders diagnosed active disease or were \u2018unsure\u2019 or images were \u2018ungradable\u2019 required examination by an ophthalmologist.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n Eligible participants with active and inactive diabetic macular oedema (152 and 120 participants, respectively) and active and inactive proliferative diabetic retinopathy (111 and 170 participants, respectively) were recruited. Under the main analysis, graders had a sensitivity of 97% (142\/147) (95% confidence interval 92% to 99%) and specificity of 31% (35\/113) (95% confidence interval 23% to 40%) to detect diabetic macular oedema. For proliferative diabetic retinopathy, graders had a similar sensitivity and specificity using seven-field Early Treatment Diabetic Retinopathy Study [sensitivity 85% (87\/102), 95% confidence interval 77% to 91%; specificity 48% (77\/160), 95% confidence interval 41% to 56%] or ultra-wide field imaging [sensitivity 83% (87\/105), 95% confidence interval 75% to 89%; specificity 54% (86\/160), 95% confidence interval 46% to 61%]. Participants attending focus groups expressed preference for face-to-face evaluations by ophthalmologists. In the ophthalmologists\u2019 absence, patients voiced the need for immediate feedback following grader\u2019s assessments, maintaining periodic evaluations by ophthalmologists. Graders and ophthalmologists were supportive of the new pathway. When compared with the reference standard (current standard pathway), the new grader pathway could save \u00a31390 per 100 patients in the review of people with diabetic macular oedema and, depending on the imaging modality used, between \u00a3461 and \u00a31189 per 100 patients in the review of people with proliferative diabetic retinopathy.<\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n For people with diabetic macular oedema, the ophthalmic grader pathway appears safe and cost saving. The sensitivity of the new pathway to detect active proliferative diabetic retinopathy was lower, but may still be considered acceptable for patients with proliferative diabetic retinopathy previously treated with laser. Suggestions from focus group discussions should be taken into consideration if the new pathway is introduced to ensure its acceptability to users.<\/jats:p>\n <\/jats:sec>\n \n Limitations<\/jats:title>\n Lack of fundus fluorescein angiography to confirm diagnosis of active proliferative diabetic retinopathy.<\/jats:p>\n <\/jats:sec>\n \n Future work<\/jats:title>\n Could refinement of the new pathway increase its sensitivity to detect proliferative diabetic retinopathy? Could artificial intelligence be used for automated reading of images in this previously treated population?<\/jats:p>\n <\/jats:sec>\n \n Trial registration<\/jats:title>\n Current Controlled Trials ISRCTN10856638 and ClinicalTrials.gov NCT03490318.<\/jats:p>\n <\/jats:sec>\n \n Funding<\/jats:title>\n This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment <\/jats:italic>Vol. 25, No. 32. See the NIHR Journals Library website for further project information.<\/jats:p>\n <\/jats:sec>","DOI":"10.3310\/hta25320","type":"journal-article","created":{"date-parts":[[2021,6,1]],"date-time":"2021-06-01T09:26:45Z","timestamp":1622539605000},"page":"1-104","update-policy":"https:\/\/doi.org\/10.3310\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":2,"title":["Multimodal imaging interpreted by graders to detect re-activation of diabetic eye disease in previously treated patients: the EMERALD diagnostic accuracy study"],"prefix":"10.3310","volume":"25","clinical-trial-number":[{"clinical-trial-number":"isrctn10856638","registry":"10.18810\/isrctn","type":"results"},{"clinical-trial-number":"nct03490318","registry":"10.18810\/clinical-trials-gov","type":"results"}],"author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2666-2937","authenticated-orcid":true,"given":"Noemi","family":"Lois","sequence":"first","affiliation":[{"name":"The Wellcome-Wolfson Institute for Experimental Medicine, Queen\u2019s University Belfast, Belfast, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4156-6989","authenticated-orcid":true,"given":"Jonathan","family":"Cook","sequence":"additional","affiliation":[{"name":"Centre for Statistics in Medicine, University of Oxford, Oxford, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5360-9993","authenticated-orcid":true,"given":"Ariel","family":"Wang","sequence":"additional","affiliation":[{"name":"Centre for Statistics in Medicine, University of Oxford, Oxford, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1808-3580","authenticated-orcid":true,"given":"Stephen","family":"Aldington","sequence":"additional","affiliation":[{"name":"Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5023-1160","authenticated-orcid":true,"given":"Hema","family":"Mistry","sequence":"additional","affiliation":[{"name":"Warwick Medical School, University of Warwick, Coventry, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2030-3338","authenticated-orcid":true,"given":"Mandy","family":"Maredza","sequence":"additional","affiliation":[{"name":"Warwick Medical School, University of Warwick, Coventry, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3283-1947","authenticated-orcid":true,"given":"Danny","family":"McAuley","sequence":"additional","affiliation":[{"name":"The Wellcome-Wolfson Institute for Experimental Medicine, Queen\u2019s University Belfast, Belfast, UK"},{"name":"The Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9739-7280","authenticated-orcid":true,"given":"Tariq","family":"Aslam","sequence":"additional","affiliation":[{"name":"The Manchester Academic Health Science Centre, Manchester Royal Eye Hospital and Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2141-4512","authenticated-orcid":true,"given":"Clare","family":"Bailey","sequence":"additional","affiliation":[{"name":"Bristol Eye Hospital, Bristol, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7693-522X","authenticated-orcid":true,"given":"Victor","family":"Chong","sequence":"additional","affiliation":[{"name":"Royal Free Hospital NHS Foundation Trust, London, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4448-8162","authenticated-orcid":true,"given":"Faruque","family":"Ghanchi","sequence":"additional","affiliation":[{"name":"Bradford Teaching Hospitals NHS Foundation Trust, Bradford Royal Infirmary, Bradford, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8513-710X","authenticated-orcid":true,"given":"Peter","family":"Scanlon","sequence":"additional","affiliation":[{"name":"Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8952-0659","authenticated-orcid":true,"given":"Sobha","family":"Sivaprasad","sequence":"additional","affiliation":[{"name":"National Institute for Health Research Moorfields Biomedical Research Centre, London, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8734-3089","authenticated-orcid":true,"given":"David","family":"Steel","sequence":"additional","affiliation":[{"name":"Sunderland Eye Infirmary, Sunderland, UK"},{"name":"Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6515-1032","authenticated-orcid":true,"given":"Caroline","family":"Styles","sequence":"additional","affiliation":[{"name":"Queen Margaret Hospital, Dunfermline, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4805-9322","authenticated-orcid":true,"given":"Augusto","family":"Azuara-Blanco","sequence":"additional","affiliation":[{"name":"Centre for Public Health, Queen\u2019s University Belfast, Belfast, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9903-5841","authenticated-orcid":true,"given":"Lindsay","family":"Prior","sequence":"additional","affiliation":[{"name":"Centre for Public Health, Queen\u2019s University Belfast, Belfast, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0934-4961","authenticated-orcid":true,"given":"Norman","family":"Waugh","sequence":"additional","affiliation":[{"name":"Warwick Medical School, University of Warwick, Coventry, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"6221","published-online":{"date-parts":[[2021,5]]},"reference":[{"key":"key2021052815021588_ref1-bib1","doi-asserted-by":"publisher","first-page":"e027795","DOI":"10.1136\/bmjopen-2018-027795","article-title":"Effectiveness of Multimodal imaging for the Evaluation of Retinal oedema And new vesseLs in Diabetic retinopathy (EMERALD)","volume":"9","author":"Lois","year":"2019","journal-title":"BMJ Open"},{"key":"key2021052815021588_ref1-bib2","doi-asserted-by":"publisher","first-page":"56173","DOI":"10.1016\/j.ophtha.2020.10.030","article-title":"Evaluation of a new model of care for people with complications of diabetic retinopathy: the EMERALD study","volume":"128","author":"Lois","year":"2021","journal-title":"Ophthalmology"},{"key":"key2021052815021588_ref1-bib3","doi-asserted-by":"publisher","first-page":"e004015","DOI":"10.1136\/bmjopen-2013-004015","article-title":"A comparison of the causes of blindness certifications in England and Wales in working age adults (16\u201364 years), 1999\u20132000 with 2009\u20132010","volume":"4","author":"Liew","year":"2014","journal-title":"BMJ Open"},{"key":"key2021052815021588_ref1-bib4","doi-asserted-by":"publisher","first-page":"345","DOI":"10.1136\/bjo.2011.204040","article-title":"Prevalence of diabetic macular oedema and related health and social care resource use in England","volume":"96","author":"Minassian","year":"2012","journal-title":"Br J Ophthalmol"},{"key":"key2021052815021588_ref1-bib5","doi-asserted-by":"publisher","first-page":"556","DOI":"10.2337\/dc11-1909","article-title":"Global prevalence and major risk factors of diabetic retinopathy","volume":"35","author":"Yau","year":"2012","journal-title":"Diabetes Care"},{"volume-title":"Diabetes UK","year":"2020","author":"Diabetes UK","key":"key2021052815021588_ref1-bib6"},{"key":"key2021052815021588_ref1-bib7","unstructured":"National Institute for Health and Care Excellence (NICE). Ranibizumab for Treating Diabetic Macular Oedema. London: NICE; 2013."},{"key":"key2021052815021588_ref1-bib8","unstructured":"National Institute for Health and Care Excellence (NICE). Aflibercept for Treating Diabetic Macular Oedema. London: NICE; 2015."},{"key":"key2021052815021588_ref1-bib9","unstructured":"National Institute for Health and Care Excellence (NICE). Fluocinolone Acetonide Intravitreal Implant for Treating Chronic Diabetic Macular Oedema after an Inadequate Response to Prior Therapy. London: NICE; 2013."},{"key":"key2021052815021588_ref1-bib10","unstructured":"The Royal College of Ophthalmologists. Diabetic Retinopathy Guidelines. London: The Royal College of Ophthalmologists; 2012."},{"key":"key2021052815021588_ref1-bib11","doi-asserted-by":"publisher","first-page":"1064","DOI":"10.1016\/j.ophtha.2010.02.031","article-title":"Randomized trial evaluating ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema","volume":"117","author":"Elman","year":"2010","journal-title":"Ophthalmology"},{"key":"key2021052815021588_ref1-bib12","doi-asserted-by":"publisher","first-page":"615","DOI":"10.1016\/j.ophtha.2011.01.031","article-title":"The RESTORE study: ranibizumab monotherapy or combined with laser versus laser monotherapy for diabetic macular edema","volume":"118","author":"Mitchell","year":"2011","journal-title":"Ophthalmology"},{"key":"key2021052815021588_ref1-bib13","doi-asserted-by":"publisher","first-page":"789","DOI":"10.1016\/j.ophtha.2011.12.039","article-title":"Ranibizumab for diabetic macular edema: results from 2 phase III randomized trials: RISE and RIDE","volume":"119","author":"Nguyen","year":"2012","journal-title":"Ophthalmology"},{"key":"key2021052815021588_ref1-bib14","doi-asserted-by":"publisher","first-page":"2247","DOI":"10.1016\/j.ophtha.2014.05.006","article-title":"Intravitreal aflibercept for diabetic macular edema","volume":"121","author":"Korobelnik","year":"2014","journal-title":"Ophthalmology"},{"key":"key2021052815021588_ref1-bib15","doi-asserted-by":"publisher","first-page":"1193","DOI":"10.1056\/NEJMoa1414264","article-title":"Aflibercept, bevacizumab, or ranibizumab for diabetic macular edema","volume":"372","author":"Diabetic Retinopathy Clinical Research Network","year":"2015","journal-title":"N Eng J Med"},{"key":"key2021052815021588_ref1-bib16","doi-asserted-by":"publisher","DOI":"10.1002\/14651858.CD008081.pub3","article-title":"Optical coherence tomography (OCT) for detection of macular oedema in patients with diabetic retinopathy","volume":"1","author":"Virgili","year":"2015","journal-title":"Cochrane Database Syst Rev"},{"key":"key2021052815021588_ref1-bib17","doi-asserted-by":"publisher","first-page":"766","DOI":"10.1016\/S0161-6420(13)38011-7","article-title":"Early photocoagulation for diabetic retinopathy. ETDRS report number 9","volume":"98","author":"Early Treatment Diabetic Retinopathy Study Research Group","year":"1991","journal-title":"Ophthalmology"},{"issue":"51","key":"key2021052815021588_ref1-bib18","doi-asserted-by":"publisher","DOI":"10.3310\/hta19510","article-title":"Pan-retinal photocoagulation and other forms of laser treatment and drug therapies for non-proliferative diabetic retinopathy: systematic review and economic evaluation","volume":"19","author":"Royle","year":"2015","journal-title":"Health Technol Assess"},{"key":"key2021052815021588_ref1-bib19","doi-asserted-by":"publisher","DOI":"10.1002\/14651858.CD012314.pub2","article-title":"Different lasers and techniques for proliferative diabetic retinopathy","volume":"3","author":"Moutray","year":"2018","journal-title":"Cochrane Database Syst Rev"},{"key":"key2021052815021588_ref1-bib20","doi-asserted-by":"publisher","first-page":"431","DOI":"10.1016\/j.ophtha.2016.12.005","article-title":"Factors associated with worsening proliferative diabetic retinopathy in eyes treated with panretinal photocoagulation or ranibizumab","volume":"124","author":"Bressler","year":"2017","journal-title":"Ophthalmology"},{"key":"key2021052815021588_ref1-bib21","doi-asserted-by":"publisher","first-page":"1397","DOI":"10.1038\/eye.2013.196","article-title":"United Kingdom National Ophthalmology Database Study: diabetic retinopathy; report 1: prevalence of centre-involving diabetic macular oedema and other grades of maculopathy and retinopathy in hospital eye services","volume":"27","author":"Keenan","year":"2013","journal-title":"Eye"},{"key":"key2021052815021588_ref1-bib22","doi-asserted-by":"publisher","first-page":"949","DOI":"10.1016\/j.ophtha.2015.01.008","article-title":"Peripheral lesions identified on ultrawide field imaging predict increased risk of diabetic retinopathy progression over 4 years","volume":"122","author":"Silva","year":"2015","journal-title":"Ophthalmology"},{"key":"key2021052815021588_ref1-bib23","unstructured":"Royal College of Ophthalmologists. Eye Health Experts Call for Urgent Action on Hospital Eyecare to Reduce Delays and Improve Patient Safety. London: Royal College of Ophthalmologists; 2020. URL: www.rcophth.ac.uk\/2020\/02\/eye-health-experts-call-for-urgent-action-on-hospital-eyecare-to-reduce-delays-and-improve-patient-safety\/ (accessed 18 January 2020)."},{"key":"key2021052815021588_ref1-bib24","doi-asserted-by":"publisher","first-page":"1118","DOI":"10.1016\/S0895-4356(03)00206-3","article-title":"Assessment of the accuracy of diagnostic tests: the cross-sectional study","volume":"56","author":"Knottnerus","year":"2003","journal-title":"J Clin Epidemiol"},{"key":"key2021052815021588_ref1-bib25","doi-asserted-by":"publisher","first-page":"529","DOI":"10.7326\/0003-4819-155-8-201110180-00009","article-title":"QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies","volume":"155","author":"Whiting","year":"2011","journal-title":"Ann Intern Med"},{"key":"key2021052815021588_ref1-bib26","doi-asserted-by":"publisher","first-page":"65","DOI":"10.1080\/105294199277860","article-title":"The International Conference on Harmonization Good Clinical Practice guideline","volume":"6","author":"Dixon","year":"1998","journal-title":"Qual Assur"},{"key":"key2021052815021588_ref1-bib27","doi-asserted-by":"publisher","first-page":"371","DOI":"10.1177\/096228029800700405","article-title":"Sample size calculations in studies of test accuracy","volume":"7","author":"Obuchowski","year":"1998","journal-title":"Stat Methods Med Res"},{"key":"key2021052815021588_ref1-bib28","doi-asserted-by":"publisher","first-page":"1643","DOI":"10.2337\/dc15-0161","article-title":"Real-time ultrawide field image evaluation of retinopathy in a diabetes telemedicine program","volume":"38","author":"Silva","year":"2015","journal-title":"Diabetes Care"},{"key":"key2021052815021588_ref1-bib29","doi-asserted-by":"publisher","first-page":"309","DOI":"10.1016\/j.csda.2003.10.002","article-title":"Sample sizes for improved binomial confidence intervals","volume":"46","author":"Piegorsch","year":"2004","journal-title":"Comput Stat Data Anal"},{"key":"key2021052815021588_ref1-bib30","doi-asserted-by":"publisher","first-page":"2635","DOI":"10.1002\/(SICI)1097-0258(19981130)17:22<2635::AID-SIM954>3.0.CO;2-C","article-title":"Improved confidence intervals for the difference between binomial proportions based on paired data","volume":"17","author":"Newcombe","year":"1998","journal-title":"Stat Med"},{"key":"key2021052815021588_ref1-bib31","doi-asserted-by":"publisher","first-page":"153","DOI":"10.1007\/BF02295996","article-title":"Note on the sampling error of the difference between correlated proportions or percentages","volume":"12","author":"McNemar","year":"1947","journal-title":"Psychometrika"},{"key":"key2021052815021588_ref1-bib32","doi-asserted-by":"crossref","DOI":"10.1017\/CBO9780511806452","volume-title":"Exploratory Social Network Analysis with Pajek","author":"de Nooy","year":"2005"},{"volume-title":"Unit Costs of Health and Social Care 2019","year":"2019","author":"Curtis","key":"key2021052815021588_ref1-bib33"},{"volume-title":"2019\/20 National Tariff Payment System: National Prices and Prices for Emergency Care Services","year":"2019","author":"NHS England and NHS Improvement joint pricing team","key":"key2021052815021588_ref1-bib34"},{"volume-title":"Reference Costs 2017\/2018: Highlights, Analysis and Introduction to the Data","year":"2018","author":"NHS Improvement","key":"key2021052815021588_ref1-bib35"},{"volume-title":"Eye Unit","year":"2019","author":"University Hospital Southampton NHS Foundation Trust","key":"key2021052815021588_ref1-bib36"},{"volume-title":"Equipment Price","author":"Topcon Ireland Medical","key":"key2021052815021588_ref1-bib37"},{"volume-title":"Equipment Price","author":"Optos Plc","key":"key2021052815021588_ref1-bib38"},{"volume-title":"Haag-Streit BM 900 Table LED Slit Lamp Equipment Price.","author":"Veatch Ophthalmic Instruments","key":"key2021052815021588_ref1-bib39"},{"key":"key2021052815021588_ref1-bib40","unstructured":"National Institute for Health and Care Excellence (NICE). Guide to the Methods of Technology Appraisal. London: NICE; 2013."},{"volume-title":"EQ-5D-5L","author":"EuroQol Group","key":"key2021052815021588_ref1-bib41"},{"key":"key2021052815021588_ref1-bib42","doi-asserted-by":"publisher","first-page":"708","DOI":"10.1016\/j.jval.2012.02.008","article-title":"Interim scoring for the EQ-5D-5L: mapping the EQ-5D-5L to EQ-5D-3L value sets","volume":"15","author":"van Hout","year":"2012","journal-title":"Value Health"},{"key":"key2021052815021588_ref1-bib43","doi-asserted-by":"publisher","first-page":"1050","DOI":"10.1001\/archopht.119.7.1050","article-title":"Development of the 25-item National Eye Institute Visual Function Questionnaire","volume":"119","author":"Mangione","year":"2001","journal-title":"Arch Ophthalmol"},{"key":"key2021052815021588_ref1-bib44","doi-asserted-by":"publisher","first-page":"218","DOI":"10.1080\/09286580801979417","article-title":"Vision and quality of life: development of methods for the VisQoL vision-related utility instrument","volume":"15","author":"Peacock","year":"2008","journal-title":"Ophthalmic Epidemiol"},{"key":"key2021052815021588_ref1-bib45","unstructured":"Centre for Economics. Scoring - Psychometric (unweighted) or Utility (weighted)? Australia: Monash University; 2020. URL: www.aqol.com.au\/index.php\/scoring-algorithms (accessed 13 February 2020)."},{"key":"key2021052815021588_ref1-bib46","first-page":"473","article-title":"Vision and quality of life","volume":"97","author":"Brown","year":"1999","journal-title":"Trans Am Ophthalmol Soc"},{"key":"key2021052815021588_ref1-bib47","doi-asserted-by":"publisher","first-page":"481","DOI":"10.1001\/archopht.120.4.481","article-title":"Quality of life with visual acuity loss from diabetic retinopathy and age-related macular degeneration","volume":"120","author":"Brown","year":"2002","journal-title":"Arch Ophthalmol"},{"volume-title":"Pay and Conditions Circular (M&D) 2\/2019 R2","year":"2020","author":"Wallace","key":"key2021052815021588_ref1-bib48"},{"volume-title":"Pay Scales for Consultants in England","year":"2019","author":"British Medical Association","key":"key2021052815021588_ref1-bib49"},{"key":"key2021052815021588_ref1-bib50","doi-asserted-by":"publisher","first-page":"1042","DOI":"10.1136\/bjophthalmol-2013-304338","article-title":"Improving the cost-effectiveness of photographic screening for diabetic macular oedema: a prospective, multi-centre, UK study","volume":"98","author":"Prescott","year":"2014","journal-title":"Br J Ophthalmol"},{"volume-title":"Report Warns of Crisis in Eye Clinic Capacity as Cancelled Appointments Risks Patients\u2019 Sight","year":"2018","author":"Royal National Institute of Blind People","key":"key2021052815021588_ref1-bib51"},{"volume-title":"See the Light: Improving Capacity in NHS Eye Care in England","year":"2018","author":"Impairment A-PPGoEHaV","key":"key2021052815021588_ref1-bib52"},{"issue":"30","key":"key2021052815021588_ref1-bib53","doi-asserted-by":"publisher","DOI":"10.3310\/hta7300","article-title":"The value of digital imaging in diabetic retinopathy","volume":"7","author":"Sharp","year":"2003","journal-title":"Health Technol Assess"},{"issue":"51","key":"key2021052815021588_ref1-bib54","doi-asserted-by":"publisher","DOI":"10.3310\/hta17510","article-title":"Improving the economic value of photographic screening for optical coherence tomography-detectable macular oedema: a prospective, multicentre, UK study","volume":"17","author":"Olson","year":"2013","journal-title":"Health Technol Assess"},{"key":"key2021052815021588_ref1-bib55","doi-asserted-by":"publisher","first-page":"5200","DOI":"10.1167\/iovs.16-19964","article-title":"Improved automated detection of diabetic retinopathy on a publicly available dataset through integration of deep learning","volume":"57","author":"Abr\u00e0moff","year":"2016","journal-title":"Invest Ophthalmol Vis Sci"},{"key":"key2021052815021588_ref1-bib56","doi-asserted-by":"publisher","first-page":"39","DOI":"10.1038\/s41746-018-0040-6","article-title":"Pivotal trial of an autonomous AI-based diagnostic system for detection of diabetic retinopathy in primary care offices","volume":"1","author":"Abr\u00e0moff","year":"2018","journal-title":"NPJ Digit Med"},{"key":"key2021052815021588_ref1-bib57","doi-asserted-by":"publisher","first-page":"1606","DOI":"10.1136\/bjophthalmol-2015-306719","article-title":"New vessels detected on wide-field imaging compared to two-field and seven-field imaging: implications for diabetic retinopathy screening image analysis","volume":"99","author":"Talks","year":"2015","journal-title":"Br J Ophthalmol"},{"key":"key2021052815021588_ref1-bib58","doi-asserted-by":"publisher","first-page":"e353","DOI":"10.1111\/aos.12832","article-title":"The concept of virtual clinics in monitoring patients with age-related macular degeneration","volume":"94","author":"Tsaousis","year":"2016","journal-title":"Acta Ophthalmol"},{"key":"key2021052815021588_ref1-bib59","doi-asserted-by":"publisher","first-page":"2337","DOI":"10.2147\/OPTH.S181108","article-title":"Expanding the role of medical retina virtual clinics using multimodal ultra-widefield and optical coherence tomography imaging","volume":"12","author":"Lee","year":"2018","journal-title":"Clin Ophthalmol"},{"key":"key2021052815021588_ref1-bib60","doi-asserted-by":"publisher","first-page":"1391","DOI":"10.1136\/bjophthalmol-2017-311494","article-title":"Implementation of medical retina virtual clinics in a tertiary eye care referral centre","volume":"102","author":"Kortuem","year":"2018","journal-title":"Br J Ophthalmol"},{"key":"key2021052815021588_ref1-bib61","doi-asserted-by":"publisher","first-page":"207","DOI":"10.1016\/j.jcjo.2017.10.035","article-title":"Assessing patient acceptance of virtual clinics for diabetic retinopathy: a large scale postal survey","volume":"53","author":"Ahnood","year":"2018","journal-title":"Can J Ophthalmol"},{"key":"key2021052815021588_ref1-bib62","doi-asserted-by":"publisher","first-page":"422","DOI":"10.1016\/j.oret.2019.01.011","article-title":"Clinical outcomes of a hospital-based teleophthalmology service: what happens to patients in a virtual clinic?","volume":"3","author":"Kern","year":"2019","journal-title":"Ophthalmol Retina"},{"key":"key2021052815021588_ref1-bib63","doi-asserted-by":"publisher","first-page":"1915","DOI":"10.2147\/OPTH.S92409","article-title":"Experiences with developing and implementing a virtual clinic for glaucoma care in an NHS setting","volume":"9","author":"Kotecha","year":"2015","journal-title":"Clin Ophthalmol"},{"key":"key2021052815021588_ref1-bib64","doi-asserted-by":"publisher","first-page":"e000127","DOI":"10.1136\/bmjophth-2017-000127","article-title":"Acceptability and use of glaucoma virtual clinics in the UK: a national survey of clinical leads","volume":"3","author":"Gunn","year":"2018","journal-title":"BMJ Open Ophthalmol"},{"key":"key2021052815021588_ref1-bib65","doi-asserted-by":"publisher","first-page":"115","DOI":"10.1080\/09581596.2015.1130250","article-title":"In praise of small N, and of N\u2009=\u20091 in particular","volume":"26","author":"Prior","year":"2016","journal-title":"Critical Public Health"},{"key":"key2021052815021588_ref1-bib66","doi-asserted-by":"publisher","first-page":"73","DOI":"10.1016\/j.socscimed.2014.05.015","article-title":"Exploring lay views on physical activity and their implications for public health policy. A case study from East Belfast","volume":"114","author":"Prior","year":"2014","journal-title":"Soc Sci Med"},{"key":"key2021052815021588_ref1-bib67","first-page":"352","article-title":"A qualitative study of lay beliefs about influenza immunisation in older people","volume":"57","author":"Evans","year":"2007","journal-title":"Br J Gen Pract"},{"key":"key2021052815021588_ref1-bib68","doi-asserted-by":"publisher","first-page":"30","DOI":"10.1186\/1471-2296-6-30","article-title":"Patients\u2019 views on outcome following head injury: a qualitative study","volume":"6","author":"Morris","year":"2005","journal-title":"BMC Fam Pract"}],"container-title":["Health Technology Assessment"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/njl-admin.nihr.ac.uk\/document\/download\/2036758","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.journalslibrary.nihr.ac.uk\/publications\/hta25320\/hta25320.xml","content-type":"text\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/njl-admin.nihr.ac.uk\/document\/download\/2036758","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,8,15]],"date-time":"2023-08-15T15:38:12Z","timestamp":1692113892000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.journalslibrary.nihr.ac.uk\/hta\/hta25320"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,5]]},"references-count":68,"journal-issue":{"issue":"32","published-online":{"date-parts":[[2021,5]]}},"alternative-id":["10.3310\/hta25320"],"URL":"https:\/\/doi.org\/10.3310\/hta25320","relation":{},"ISSN":["1366-5278","2046-4924"],"issn-type":[{"type":"print","value":"1366-5278"},{"type":"electronic","value":"2046-4924"}],"subject":[],"published":{"date-parts":[[2021,5]]},"assertion":[{"value":"This content has been made freely available to all.","name":"free","label":"Free to read"},{"value":"4-2017","name":"contractual_start_date","label":"Contractual start date","group":{"name":"article_history","label":"Article History"}},{"value":"3-2020","name":"editorial_review_begun","label":"Editorial review begun","group":{"name":"article_history","label":"Article History"}},{"value":"6-2020","name":"accepted_for_publication","label":"Accepted for publication","group":{"name":"article_history","label":"Article History"}}]}}