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Lessons from the UK National DR Screening Program for Areas with Limited Resources

Lessons from the UK National DR Screening Program for Areas with Limited Resources. Prof. Peter Scanlon MD FRCOphth FRCP DCH Programme Director English National Programme. UK Population. Scotland -population 5.2 million. Northern Ireland - population 1.8 million.

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Lessons from the UK National DR Screening Program for Areas with Limited Resources

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  1. Lessons from the UK National DR Screening Program for Areas with Limited Resources Prof. Peter Scanlon MD FRCOphth FRCP DCH Programme Director English National Programme

  2. UK Population Scotland -population 5.2 million Northern Ireland - population 1.8 million England - population 51.9 million 2.6 million with diabetes Wales- population 3.0 million

  3. English National DR Screening Programme Large Telemedicine Programme 2011-12 81 centres 2.6 million with diabetes 2.4 million offered 1.9 million actually screened Increase 121,000 in 12 months Cost approx 80 million US dollars

  4. Screening What are the risks? Are the risks changing?

  5. Basis of the ENSPDR Grading Criteria Key points – refer at 11.3% risk of developing proliferative in 12 months R1 = background = mild NPDR = do not refer R2 = pre-proliferative = moderate to severe NPDR = refer R3 = proliferative = refer Fundus photographic risk factors for progression of diabetic retinopathy. ETDRS report number 12. Early Treatment Diabetic Retinopathy Study Research Group. Ophthalmology 1991; 98:823-33.

  6. Better glycaemic control and to a lesser extent BP control may be beneficial in reducing incidence of PDR and increasing odds of improvement of DR Reduction in prevalence of PDR in more recently diagnosed cohorts possible benefit of recent changes in management of diabetes WESDR: Twenty-Five Year Progression Of Retinopathy In Patients With T1DM Year of diagnosis of diabetes 1922–59 1960–69 1970–74 1975–80 70 60 50 40 30 20 10 0 PDR Prevalence (%) • 0–4 5–9 10–14 15–19 20–24 25–29 30–34 35+ Duration of Diabetes (years) Klein, R et al. Ophthalmol. 2008; 115:1859–1868 WESDR; Wisconsin Epidemiologic Study of Diabetic Retinopathy

  7. Maculopathy Key points – M0 = No maculopathy M1 = Maculopathy What are the risks of developing Clinically Significant Macular Oedema from 2D photographic markers?

  8. OCT photographic clinics for screen test positive maculopathy

  9. Standardising the grading of retinopathy • In 2009/10, English DESP introduced: • Monthly QA test sets for all (1500+) graders in 86 local screening sites • Sets of 30 (Yr 1) or 20 (Yr 2) cases / month, weighted to DR+ cases • Year 1: Up to 12 blocks in numerical order • Year 2: Up to 12 ‘monthly’ sets Accessed via the internet

  10. Accessed via the internet at their own place of work or from home Exact: 235/300 (79%) Not referred: 11/157 (7.0%)

  11. Exact agreement with R + M grade: Yr 1 Number of Users completing all cumulative blocks - 1301 1278 1235 1112 1003 948 901 827 731 664 564 461 Mean proportion (%) agreement with system grade Block number Yr 1 (2009-10) Trend: p<0.001

  12. Exact agreement with R + M grade: Yr 2 Number of Users completing set in month - 780 886 957 865 940 882 (0) 1016 896 1011 931 952 Mean proportion (%) agreement with system grade Mean (SD) Monthly sets Yr 2 (2011-12) Trend: p<0.01 N.B. No test was presented in October 2011

  13. Agreement against system & peers April, Screen no.7 ‘System’ grade Grader 23 -

  14. Agreement against system & peers April, Screen no.8 ‘System’ grade Grader 23 -

  15. Screening Programme – why does it matter?

  16. Generic QA Themes & Objectives

  17. Diabetic Retinopathy Screening How to Start Buy a Fundus Camera?

  18. Step 1. Manoeuvring around the politics of funding • Many different levels • Who is going to provided funding to support • Is this going to be run by Public Health Physicians or by Specialists – Diabetologist? Or Ophthalmologist? • A Champion is needed who has some skills in diplomacy • Budgets need to be ring fenced • Politics change from when a service is getting off the ground to when it is up and running

  19. European Experience - barriers • Public awareness • Patient compliance • Lack of funding for equipment, training, education • Collaboration between ophthalmologists and diabetologists • Lack of engagement of private providers of eye care • Lack of systematic process, competency, registers, data • Political instability • Access to laser treatment remained poor in a few countries. Some perverse financial incentives were reported causing for example intravitreal bevacizumab or triamcinolone being given even when laser is available.

  20. Step 2: Are Assessment and Treatment facilities available? • Adequate number of lasers and ophthalmologists to treat • If not - Contract with an organisation that can provide treatment

  21. Step 3. Identify cohort for invitation and call - recall • Diabetes Register • How do you record patient details? • If literacy levels are low the patient surname may be spelled differently at each visit • Is there a National ID number? • Are births and deaths recorded in the population?

  22. Step 4. How are you going to invite them? In those who want screening, to facilitate uptake in eligible population • Letter? • Word of mouth? • Etc………..

  23. Step 5. How are you going to inform the patients and maximise uptake? • To maximise informed choice throughout the screening programme • Educating the population - this is not a diagnostic test – some patients with sight threatening diabetic retinopathy will be missed. • Patient education, engagement with patient organisations, 3. Appropriate exclusion criteria e.g. those already under ophthalmology, terminally ill etc..

  24. Step 6. Establish an IT infrastructure • Preferably as simple as possible • Need reliable power supply • An inexpensive joined up solution for administration of call recall, screening, grading and audit is an urgent requirement. • Make sure images attached to patient details Who is going to support that IT iinfrastructure? How is it going to be backed up? How are you going to ensure confidentiality of patient data?

  25. Step 7 - Purchase a Camera Minimum camera specification Most of the modern non-mydriatic digital cameras meet a good quality specification What relationship is there with the camera manufacturer for technical support in your area?

  26. Image sizes of cameras and recommend compression at source

  27. Step 8 - The test and grading images – Choices for programmes • Mydriasis or non-mydriasis? • The number of fields • The grading referral criteria • Viewing the images for grading

  28. The test – mydriasis, selective mydriasis or not? Clear protocols need to be in place

  29. The test – number of fields and positioning

  30. The Grading Referral Criteria Retinopathy progresses with increasing ischaemia R grade Leaks occur in the macular area M grade The treated patient is more difficult to grade Recommend R0M0, R1M0, R1M1 etc…. So that every eye has at least an R and M grade This makes it much easier to compare between programmes

  31. Recommendations on Viewing Images • Screen resolution • Display 60% of the image at once on the grading screen

  32. Management of patients with ungradable images Clear protocols need to be in place

  33. Step 9.Employ and train a competent workforce • To ensure that whole screening programme is provided by a trained and competent workforce • Staff accreditation • Evidence of ongoing CPD and EQA test sets

  34. Step 10. introduce some Quality Assurance • Reduce the probability of error and risk • Ensure that errors are dealt with competently and sensitively • Help professionals and organisations improve year on year • Set and keep under review national standards; • Manage these processes.

  35. 1. What would I do with 150k USD recurring? • Start with a pilot project • Check that assessment and laser treatment facilities in place • Liaise with local patient groups, ophthalmologists and diabetologists • Write protocols and decide on patient pathways for screen positive and ungradable images • Make sure adequate power supply to screening and grading locations • Employ someone with IT skills • Choose software, hardware and back up facilities

  36. 2. What would I do with 150k USD recurring? • Decide on grading form that refers at the agreed level of risk • Train non medical graders • Buy a camera • Provide patients with appropriate education • Invite cohort for screening • Photograph eyes • Send image to central grading where possible.

  37. It is worth doing despite all the obstacles and organisational difficulties! Thank you for listening

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