Clinical indicators for diabetic eyecare delivered by optometrists in Australia: a Delphi study

ABSTRACT Clinical relevance Valid and updated clinical indicators can serve as important tools in assessing and improving eyecare delivery. Background Indicators for diabetic eyecare in Australia were previously developed from guidelines published before 2013 and then used to assess the appropriateness of care delivery through a nationwide patient record card audit (the iCareTrack study). To reflect emerging evidence and contemporary practice, this study aimed to update clinical indicators for optometric care for people with type 2 diabetes in Australia. Methods Forty-five candidate indicators, including existing iCareTrack and new indicators derived from nine high-quality evidence-based guidelines, were generated. A two-round modified Delphi process where expert panel members rated the impact, acceptability, and feasibility of the indicators on a 9-point scale and voted for inclusion or exclusion of the candidate indicators was used. Consensus on inclusion was reached when the median scores for impact, acceptability, and feasibility were ≥7 and >75% of experts voted for inclusion. Results Thirty-two clinical indicators with high acceptability, impact and feasibility ratings (all median scores: 9) were developed. The final indicators were related to history taking (n = 12), physical examination (n = 8), recall period (n = 5), referral (n = 5), and patient education/communication (n = 2). Most (14 of 15) iCareTrack indicators were retained either in the original format or with modifications. New indicators included documenting the type of diabetes, serum lipid level, pregnancy, systemic medications, nephropathy, Indigenous status, general practitioner details, pupil examination, intraocular pressure, optical coherence tomography, diabetic retinopathy grading, recall period for high-risk diabetic patients without retinopathy, referral of high-risk proliferative retinopathy, communication with the general practitioner, and patient education. Conclusion A set of 32 updated diabetic eyecare clinical indicators was developed based on contemporary evidence and expert consensus. These updated indicators inform the development of programs to assess and enhance the eyecare delivery for people with diabetes in Australia.


Introduction
Evidence-based clinical care (or appropriate care) results in improved healthcare quality, better health outcomes, minimised variation in care and reduced cost. 1,2However, studies have consistently shown large gaps in the uptake of evidence-based practice, with only about half to two-thirds of patients receiving appropriate care across a wide range of healthcare conditions and settings. 3,4Such gaps between the best available evidence and its translation into routine clinical practice (known as the evidence-to-practice gap) result in sub-optimal outcomes for patients and an increase in the burden on society. 5Such impact is especially pronounced for chronic conditions like diabetic retinopathy, a complication of diabetes and a leading cause of preventable vision loss. 6n up-to-date and robust assessment of primary diabetic eyecare delivery in Australia is lacking, however, the limited evidence available suggests that the care may not always be consistent with current evidence. 7,8For example, the iCareTrack study, a nationwide retrospective audit of Australian optometry practices, reported that diabetic eyecare delivered by optometrists aligned with evidencebased clinical indicators in 69% of patient encounters in 2013/14, with major gaps in history taking and physical examination. 9As primary eyecare providers in Australia, optometrists play a crucial role in early detection, management (including regular follow-up), referral for treatment and patient education for people with diabetes. 10,11herefore, improving the uptake of evidence-based eyecare by optometrists may help reduce the risk of vision loss among people with diabetes and thus have a significant public health impact.
Clinical indicators such as those used in the iCareTrack study are measurable components of standards or guidelines and assess clinician and healthcare system performance. 3,12,13These indicators measure whether a recommendation in patient care is being met (indicating appropriate care) and thus inform quality improvement initiatives. 3,14To achieve the intended goals, the indicators need to be relevant, applicable and valid (updated and evidence-supported). 13,15 The original iCareTrack indicators reflected the standards of care before 2013 as these were based on clinical guidelines published before 2014. 16Since then, the management of diabetic eye disease has evolved considerably with the new or updated guidelines and availability of new diagnostic and therapeutic technologies. 17,18Such developments in contemporary practice warrant a review of the existing indicators.Thus, this study aimed to utilise a systematic approach combining high-quality evidence and expert consensus to establish updated clinical indicators for primary diabetic eyecare by optometrists in Australia.

Methods
The indicator development and updating process followed previously established methods. 14,19An overview of the process is shown on Figure 1, highlighting the initial generation of candidate indicators from high-quality evidence sources (Phase I) followed by an expert consensus process (Phase II).The study scope was limited to type 2 diabetes, the most common type, and other less prevalent types such as type 1, and gestational diabetes were not considered for this indicator development process at this stage.was described in full elsewhere. 14In brief, 15 clinical indicators (Supplementary material 1) were developed for diabetic eyecare assessment based on recommendations extracted from clinical guidelines published before 2013 and assessed by experts using the Delphi method.One original iCareTrack indicator (I-15, Supplementary material 1) was related to eyecare in people with type 1 diabetes and was thus excluded from the updating process.

Phase I: generation of the candidate clinical indicators
The second source included new indicators derived from the recommendations contained in nine highquality clinical guidelines (Table 1) for diabetic eyecare.These guidelines were identified in a recent systematic review and quality appraisal (using the Appraisal of Guidelines for Research and Evaluation: AGREE-II instrument, a tool to assess the methodological and reporting quality in clinical practice guidelines) 20 conducted by the research team. 17Clinical recommendations from these guidelines were extracted and assessed against published eligibility criteria for indicator formulation (Table 1). 21ndicators were formulated by a single investigator (RG) and written such that each indicator contained a qualifier (defining the condition, demographic characteristics such as age and sex) and compliance action (the recommended appropriate care).Two researchers (RG and MT) conducted an iterative review of these indicators for adherence to eligibility criteria, structure, and appropriateness in the Australian primary eyecare context.Any pertinent revisions were made through consensus, and a list of guidelines-derived potential indicators was developed.
The original iCareTrack indicators and new guidelinesderived indicators were combined to generate an initial list of candidate indicators.Duplicate indicators were removed, and similar or overlapping indicators were merged.Where some indicators conflicted, all conflicting indicators were retained in the final list of candidate indicators to be presented in the modified Delphi process.Indicators were grouped into five 'domains' of care: history taking, physical examination, recall period, referral and patient education/ communication.

Phase II: modified Delphi expert panel
A two-round modified Delphi technique was used to achieve consensus on the candidate indicators.A Delphi expert panel was convened involving clinical and health service research experts purposefully chosen to include clinical practitioners, professional leaders and academics/researchers with expertise in diabetic eyecare and healthcare delivery in Australia.Potential expert panellists were identified from the professional network of the research team or based on publicly available professional profiles.

Round 1 Delphi survey
In the first round, candidate indicators were sent to the experts as an online survey developed on the Qualtrics platform (Qualtrics, Provo, UT, USA).The experts were asked to rate each indicator on a 9-point Likert scale for impact on patient care, feasibility of measurement in clinical practice and acceptability as an essential component of diabetic eyecare in Australia in 2019/2020. 21As an overall assessment, experts also voted on whether to include or exclude each indicator on the final indicator list.An optional free-text box was also available for experts to provide additional comments or modification suggestions for each indicator.
The experts received an instruction manual and summary evidence from included guidelines and contextual information from the Optometry Australia guidance on diabetic eyecare for optometrists. 11The summary evidence documents outlined the source of the candidate clinical indicators, supporting evidence and evidence strength for each clinical indicator.

Defining consensus
Detailed criteria for consensus on indicator inclusion and exclusion are presented in Table 2. Consensus on inclusion (or exclusion) was defined when the majority (≥75%) of experts voted for inclusion (or exclusion) of an indicator, the median scores for impact, acceptability and feasibility were ≥7 (or ≤3 for exclusion), and the qualitative comments supported inclusion (or exclusion).Indicators with consensus for exclusion were eliminated and those with consensus for inclusion in the current format were retained for the final indicator list.The remaining indicators were re-presented in the round 2 Delphi survey as described below.

Round 2 Delphi survey
Round 2 consisted of three categories of indicators presented to the experts (Table 3).The first category included indicators that reached consensus on inclusion but had minor modifications suggested in round 1.These indicators were presented for approval of the minor modifications.The second category consisted of indicators that were re-presented for include or exclude voting as these indicators failed to reach a consensus in round 1 but had no major modifications.The final category included considerably modified versions of round 1 indicators that were presented for re-rating on acceptability, impact and feasibility and include/exclude voting.
Experts were presented with updated evidence summaries and de-identified group feedback from round 1 to assist their decision-making.The feedback for each indicator consisted of the individual expert scores, the panel summary scores (median scores for appropriateness, impact and feasibility and aggregate 'Yes, Include' vote percentage), de-identified comments, any modifications made to the original indicator and any clarification from the research team.

Phase I: candidate indicator generated
From the nine high-quality guidelines (Table 1), a total of 420 recommendations, action statements and key points/ good practice points were extracted.After excluding ineligible recommendations (n = 248), 172 recommendations were used to formulate 43 guidelines-derived indicators.These were combined with the 14 original iCareTrack clinical indicators.After an iterative internal review with the removal of duplicates and merging of overlapping indicators, a list of 45 candidate indicators (Supplementary material 2) was generated for the modified Delphi survey (Figure 2).

Phase II: modified Delphi consensus process
Of the 20 experts identified and invited, nine agreed and completed the modified Delphi process with no dropout after initial commitment (100% response rate).The final expert panel consisted of eight optometrists and one ophthalmologist, with clinical experience ranging between 11 and 48 years.While one expert (optometrist) was involved in full-time private practice, all other experts were affiliated with clinical educational facilities.Two experts involved in the original iCareTrack indicator development process were part of this expert panel, providing continuity between the two processes.The modified Delphi process took 184 days to complete, and experts took an average of 27 days (range: 14-70 days) and 7 days (range: 1-31 days) to complete round 1 and round 2 surveys, respectively.
The overview results from the Delphi survey are summarised in Figure 3.  3)

Round 1 Delphi survey
The complete indicators presented in the Delphi survey are available in Supplementary Material 2 and their ratings in each round are presented in Supplementary Material 3.
Of the 45 candidate indicators presented in the first round survey, a consensus was reached to include 18 and exclude three candidate indicators.The excluded indicators related to documenting learning disabilities (H.17, Supplementary material 2), performing gonioscopy before dilation (PE.9) and first-trimester examination in diabetic pregnant women (RP.6).For the remaining 24 candidate indicators, either consensus was not reached (n = 8) or modifications were requested (n = 16).
Five of the 24 indicators met the consensus criteria for inclusion; however, there were minor modifications suggested.As a result, these indicators were presented with modifications for approval in round 2. There were major modification suggestions for eight indicators, and their modified versions were presented for re-rating (as in round 1) in round 2. Eleven indicators had conflicting ratings in round 1 and were thus presented for final include or exclude voting in round 2 (Figure 3).

Round 2 Delphi survey
All minor modifications presented for approval in round 2 were approved; thus, these five indicators were included in the final list.Of the 11 uncertain indicators presented for include or exclude voting, a consensus was reached for the inclusion of three and exclusion of three indicators.There was no consensus on five indicators, and these were thus retired.Five of the eight indicators with the major modification that were re-rated reached consensus for inclusion, and two failed to reach consensus.The remaining one indicator with a major modification was related to the management of diabetic macular oedema (REF.5).While the experts did not reach any consensus on the modification of this indicator, there was an agreement on the inclusion of the original indicator.Thus, this indicator was retained in its original form.

Final list of clinical indicators
Altogether, by the end of round 2, 13 clinical indicators were excluded and 32 were included in the final list (Figure 3).The finalised indicators were rated highly and given the highest possible score by experts for their acceptability (median 9, Interquartile range (IQR) 0), impact (median 9, IQR 0) and feasibility (median 9, IQR 0.5).All finalised indicators had >75% 'Yes, Include' vote, with 17 (53.1%)finalised indicators voted to be included by all experts.
The indicators included in the final list are presented in their abbreviated form in Table 4 and in detailed form in Supplementary Material 4.There were 12 finalised indicators in history taking, eight in physical examination, five each in recall period and referral, and two in patient education/communication domain.One of the indicators presented in the

Discussion
A set of 32 updated clinical indicators for the assessment of eyecare delivered by optometrists for people with type 2 diabetes in Australia were developed.The systematic method included a modified Delphi process to reach a consensus on candidate indicators derived from original iCareTrack indicators and high-quality evidence-based clinical guidelines.The process resulted in the retention of most of the original iCareTrack indicators (either in original or modified form) and the addition of several new guideline-derived indicators that reflect a comprehensive and contemporary evidencebased primary eyecare for people with type 2 diabetes.
All original iCareTrack history taking indicators were retained, and nine new indicators were added.In addition to the duration of diabetes, blood glucose control and systemic hypertension, new indicators related to the type of diabetes, blood lipid control, pregnancy and renal disease provide a comprehensive profile of the risk factors associated with the development and progression of diabetic retinopathy. 22,23 key addition is the documentation of Indigenous (Aboriginal and Torres Strait Islander people) status.This is particularly important considering the higher risk of diabetes and diabetic retinopathy and lower access to care for Aboriginal and Torres Strait Islander people compared to the general population.10,22,24 Documenting ethnic background is often incomplete in optometry practices, and practitioners report a range of barriers when inquiring about and documenting such information.Pragmatic solutions such as a dedicated field in patient record cards (electronic or paperbased) and patient registration forms could facilitate the recording of this information important for the provision of appropriate clinical care to Aboriginal and Torres Strait Islander people in Australia.10,25 Documenting the details of the general (medical) practitioner managing diabetes for the patient is another new indicator.This highlights the importance of interprofessional communication to facilitate multidisciplinary care, especially because the general practitioner coordinates the management of people with diabetes through the annual diabetes cycle of care in Australia.Most of the candidate indicators related to physical examination (including original iCareTrack indicators) reached expert consensus on inclusion.One notable change is that experts suggested dilated fundus examination as the examination method for initial or subsequent comprehensive diabetic eye examination (rather than as an alternative to retinal photography).As experts suggested, retinal photography (along with the incorporation of machine learning and artificial intelligence) 26 could serve as an ancillary test (in addition to standard dilated fundus examination) to acquire digital retinal images to detect, document and compare the presence of any retinal changes at each diabetic eye examination.The current indicator aligns with the majority of highquality clinical guidelines, 17 as well as the existing Medicare Benefits Schedule (a list of health professional services that the Australian Government subsidises) items for optometric services in Australia.
Another new indicator was optical coherence tomography (OCT) imaging in the initial and/or subsequent examination of people with (or suspected of) diabetic macula oedema.OCT provides an objective and precise measurement of retinal thickness and has become a standard imaging modality in diabetic eye examination and monitoring. 27While some concerns were raised by experts about the feasibility of conducting this procedure in optometric practices, the majority agreed on including this indicator.While the feasibility of applying this (and for that matter, all other updated indicators) remains to be evaluated, it should be noted that over two-thirds of Australian optometrists had access to OCT imaging in 2019 (likely to have increased since), and those who have OCT devices at their practice have more self-reported confidence in the assessment of diabetic macula oedema. 28he indicator related to the management of diabetic macular oedema received conflicting opinions from experts.While most experts agreed on the referral of patients with diabetic macular oedema, two experts suggested that optometric monitoring of the patient with non-centre involving macular oedema and good vision could be recommended.These experts considered that the recent Diabetic Retinopathy Clinical Research Retina Network (DRCR.net)Protocol V study, 29 a multi-centre randomised clinical trial, and the OBTAIN retrospective, observational cohort study supported the monitoring of patients with diabetic macula oedema and good visual acuity. 30s the majority of the experts in both rounds voted for referring diabetic macula oedema patients for ophthalmological examination (the original iCareTrack indicator) as per the local guidelines, the indicator was retained in its original form.This debate highlights the emerging evidence and interest in an expanded scope of practice, especially considering the availability of OCT imaging for over two-thirds of optometrists in Australia. 28Optometrists should consider the current scope of practice, their skill levels and experience in managing early diabetic macula oedema while recognising the importance of collaborative care.
The new patient education and communication domain and indicators highlight the role of optometrists in the primary diabetic eyecare process.As primary eyecare providers who may often be the first clinicians detecting diabetic eye complications in a patient, optometrists are well positioned to educate the patient and communicate with their diabetes care provider (a general practitioner in the Australian context who coordinates diabetes care plan for a patient).
Communication between eyecare and primary care providers (regardless of the diabetic retinopathy status) is important as it is likely to improve patient adherence to ongoing diabetic eye examination and management. 31While published evidence on the effectiveness of the education provided during diabetic eyecare consultations on patient outcomes is lacking, the importance of educating patients about the potential threat of vision loss, the asymptomatic nature in early stages of retinopathy, benefits of risk control and lifestyle modifications, need for regular follow-up eye examination and appropriate treatment is well recognised and included as consensus-based recommendations in many high-quality clinical practice guidelines. 16,32,33As expressed by the experts (for example, lower scores for REF 6 indicator), while optometrists may be aware of the impact of these care processes, how well these two indicators are documented in optometry clinical record cards remains to be evaluated.
The purpose of the clinical indicator development is not to create new clinical practice guidelines or update the existing ones, but rather to inform the development of a tool to assess the most essential components of care delivery. 14ptometrists may still need to consider several other factors which are not reflected in the final list of clinical indicators (for example, non-English-speaking background as a social determinant to access and adherence to care) while providing evidence-based care tailored to their patients with diabetes. 10,11he clinical indicators developed in this study provide a foundation for a routine collection of clinical care data to promote the appropriateness of diabetic eyecare as provided by Australian optometrists.Such routinely collected data could be used to calculate benchmarks for quality improvement. 9Effectively incorporating these clinical indicators into structured electronic patient record card systems (for example, as data entry forms, drop-down menus, or reminder prompts) in optometry practices could also serve as an educational reminder about the 'correct' process for the care of people with diabetes. 34In addition, the indicators also form the central part of a quality improvement tool called the i-ACT (iCareTrack -assessment of Appropriateness in Clinical pracTice) tool which provides optometrists with a platform for regular self-assessment, reflection and goal setting to improve the care they provide across the clinical indicators.The details of the i-ACT tool development and evaluation process have been published elsewhere. 35he process used in developing these indicators has strong methodological rigour and has been applied previously in a range of healthcare settings and contexts. 14,19,36,37The candidate indicators were sourced from the originally validated iCareTrack indicators and the high-quality clinical practice guidelines identified through a robust systematic review and quality appraisal process.The modified Delphi method provided a systematic process that combined evidence (which can be limited or, at times, methodologically weak) and expert opinion (which are sometimes conflicting on the interpretation of evidence) through a structured and facilitated consensus-building exercise. 13he advantage of using the modified Delphi process (as opposed to a face-to-face consensus meeting) is that the process allowed anonymity of expert responses, enabling a more accurate and equal account of beliefs irrespective of individual characteristics or seniority.It also provided an opportunity for experts to re-evaluate their ratings after receiving group feedback. 36he online survey method adopted for the modified Delphi process facilitated the capture of opinions from experts from different parts of Australia with 100% response rates throughout the process.The goal for the composition of the expert panel was a balanced representation of experts from academic, clinical and health service research backgrounds with a varying range of clinical experiences to obtain a broad but direct opinion on the topic. 38The inclusion of an ophthalmologist in the expert panel provided an opportunity to obtain the views of a topical expert responsible for secondary diabetic eyecare and, thus, a direct stakeholder in the primary diabetic eyecare process.Following the good practice recommendation for the Delphi process, we set an a priori criteria for consensus but also established additional criteria during the process due to the exploratory nature of the study. 38 limitation of the study is the homogeneity of the expert panel, with most of the experts serving in academic clinical roles.A more heterogeneous panel including other experts such as diabetes educators and medical experts (e.g., general practitioners and endocrinologists) may have been beneficial to this type of consensus exercise. 37ecause the study was focused on the clinical process (as opposed to other aspects of quality), patients were not involved in the expert panel.However, involving patients or patient representatives directly during the development process or providing an opportunity to contribute their views on the developed indicators could help make these indicators more patient-centred and reflective of patient views. 39he final set of indicators had face validity as they were derived from high-quality local and international evidencebased guidelines and had high expert consensus on acceptability, impact, and feasibility.However, there may be several challenges associated with capabilities (e.g., limited knowledge), motivation (e.g., perceived role in the care process and misdirected beliefs about consequences) and social and practice environment (e.g., peer or patient influences, limited time, and availability of supporting resources such as electronic patient record cards) that hinder optometrists in providing care in line with these indicators. 40,41Thus, the external validity and feasibility of the application of these indicators in clinical settings need further evaluation.In recognition of the need for valid and up-to-date indicators to reflect the emerging evidence and changing practice patterns (for example, the emergence of artificial intelligence and its use in retinal photography to detect retinopathy changes), 26 it is recommended that these indicators go through similar updating process in the next five years or sooner if new evidence or clinical practice guidelines are available that would warrant practice change.

Conclusion
The study described a systematic process of updating clinical indicators by combining high-quality evidence and expert consensus.As a result, 32 clinical indicators related to history taking, physical examination, recall period, referral and patient education and communication were developed to reflect the contemporary best practice in primary eyecare for people with diabetes.These updated indicators inform the development of a tool to assess and enhance primary diabetic eyecare delivery in Australia.

Figure 1 .
Figure 1.Overview of the process used to update clinical indicators for diabetic eyecare delivery (AGREE II: Appraisal of Guidelines for Research & Evaluation Instrument).

Figure 2 .
Figure 2. Results of phase I: generation of candidate clinical indicators (AGREE II: Appraisal of Guidelines for Research & Evaluation Instrument).*While the original iCareTrack study developed 15 clinical indicators, one was related to eyecare in people with type 1 diabetes and was thus excluded from this process.

Figure 3 .
Figure 3. Overview of the results from the two round Delphi survey.

Table 4 . 9 1 PE. 2 1 RP. 2 RP. 3 RP. 5 1 REF. 5 1 REF. 6 *
Finalised clinical indicators for primary diabetic eyecare delivered by optometrists in Australia.Final indicators stratified by domain of care (total 32) Patients with diabetes should have the following documented in their initial and/or subsequent visit (s): H.1 Duration (or year of diagnosis) of diabetes (O) 9.0 9.0 9.0 100 H.2 Most recent HbA1c result or self-reported level of blood glucose control (O) 9.0 9.0 9.0 100 H.3 Presence/history of high blood pressure or self-reported blood pressure control or current systolic blood pressure (O) (only for Female patients of childbearing age (15-44 years) with diabetes) Ocular history (e.g., trauma, other eye diseases, ocular injections, surgery including Laser) (N) 9.0 8.0 9.0 100 H.10 Visual Symptoms (e.g., distorted or blurred or double vision, flashes or spots before eyes) Details of the practitioners managing the patient's diabetes care (N) Patients with diabetes should have the following assessments performed and documented in their initial and subsequent visit(s): Visual acuity (O) Patients with diabetes should have the following assessments performed (or referral organised for assessment) and documented during initial and subsequent comprehensive eye examination visit(s): Dilated fundus exam (M) 9.0 9.0 9.0 100 Patients with diabetes should have the following assessments performed (or referral organised for assessment) and documented during initial and/or subsequent visit(s): PE.3 Slit lamp biomicroscope for anterior segment and iris examination (M) 9.0 9.0 9.0 89 PE.4 Intraocular Pressure measurement (N) 9.0 9.0 9.0 100 PE.5 Pupillary assessment (N) 9.0 7.0 8.0 78 PE.6 Patients with diabetes and suspected or established diabetic macular oedema should have the following assessments performed (or referral organised for assessment) and documented: Optical Coherence Tomography (N) 9.0 9.0 8.0 78 PE.7 Patients with diabetes should have the diabetic retinopathy graded and documented in their initial and/or subsequent visit(s).(M) 9.0 9.0 8.0 100 PE.8 Patients with diabetes who are pregnant should be dilated using standalone Tropicamide (not Tropicamide + Phenylephrine combination).Patients with diabetes with no high-risk factors and no DR should be advised to have their eyes examined at least every 2 years.(M) (High risk factors: longer duration of diabetes (>15 years) or poor glycaemic control (HbA1c>8%) or blood pressure (systolic >140 mmHg) or blood lipid control (LDL ≥3.5mmol/L and/or triglycerides ≥2.0 mml/L or HDL-c<1mmol/L (men) or <1.3mmol/L (women) or taking lipidmodifying medications) Patients with diabetes and Indigenous status or non-English speaking background and no DR should be advised to have their eyes examined at least every year (N) Patients with diabetes and no DR and with high-risk factors should be advised to have their eyes examined at least every year (N) 9.0 9.0 9.0 78 RP.4 Patients with diabetes and mild NPDR and no diabetic macular oedema should be advised to have their eyes examined at least every year.Patients with diabetes and moderate NPDR and no diabetic macular oedema should be advised to have their eyes examined every 3Patients with diabetes and severe NPDR and no Diabetic Macular Oedema should be referred to and be advised to be seen by an ophthalmologist within 4 weeks.(M) 9.0 9.0 9.0 89 REF.2 Patients with diabetes presenting with DR and any unexplained reduction in best-corrected visual acuity should be referred to and be advised to be seen by an ophthalmologist within 4 weeks.(O) 9.0 9.0 8.0 78 REF.3 Patients with diabetes presenting with non-high-risk PDR and/or Vitreous/pre-retinal Haemorrhage should be referred to and be advised to be seen by an ophthalmologist within 2 weeks.(M) (High-risk PDR (one or more of the following: new vessels on or near the disc (NVD)≥1/4 to 1/3 of disc area; NVD and vitreous haemorrhage/ pre-retinal haemorrhage; new vessels elsewhere (NVE)≥1/2 disc area and vitreous haemorrhage/pre-retinal haemorrhage).9.0 9.0 9.0 78 REF.4 Patients with diabetes presenting with high-risk PDR should be referred to and be advised to be seen by an ophthalmologist within 1 week.Patients with diabetes presenting with or suspected of diabetic macular oedema (possible/suspected thickening, hard exudates, oedema) should be referred to and be advised to be seen by an ophthalmologist within 4 weeks.Patients with diabetes with or without DR should be educated, with documentation, about the benefits of regular follow-up eye examinations and care.Patients with diabetes should have the results of their eye examination reported to their General Practitioner after initial and/or subsequent visit(s) .#(N) Final round means the round (either round 1 or 2) where the indicator reached consensus for inclusion.Ratings for acceptability, impact and feasibility indicate median scores (possible scores: 0 to 9).A: Acceptability, I: Impact, F: Feasibility, Inc%: proportion of experts with Include vote.O: reflects original iCareTrack indicator, M: significantly modified from the original iCareTrack indicator, N: new indicator.# This indicator was presented in the domain of referral in round 1 survey.The modifications finalised after round 2 warranted moving the revised indicator to the Education/communication domain.HbA1c: Haemoglobin A1C; LDL: Low-density lipoprotein, HDL: High-density lipoprotein; DR: Diabetic Retinopathy, NPDR: Non-Proliferative Diabetic Retinopathy; PDR: Proliferative Diabetic Retinopathy.

Table 1 .
17iteria for recommendation extraction for indicator formulation21and the source guidelines17.American Academy of Ophthalmology -Preferred Practice Pattern® Guidelines: Diabetic Retinopathy (2019) (5) American Optometric Association-Evidence-Based Clinical Practice Guideline: Eye Care of the Patients with Diabetes Mellitus (2019) (6) Scottish Intercollegiate Guidelines Network -Management of diabetes: A national clinical guideline-Prevention of visual impairment (2017) (7) Canadian Ophthalmological Society-Evidence-based clinical practice guidelines for the management of diabetic retinopathy (2012) (8) Malaysian Ministry of Health -Clinical Practice Guidelines: Screening of Diabetic Retinopathy (2017) (9) German Agency for Quality in Medicine -Clinical Practice Guideline: The Prevention and Treatment of Retinal Complications in Diabetes (2016)

Table 2 .
Criteria for consensus used in the modified Delphi survey.

Table 3 .
Categories of indicators and consensus criteria in round 2 Delphi survey.