Population base eye screening in Scotland. Challenges of equity and coverage. Graham Leese University of Dundee

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1 Population base eye screening in Scotland. Challenges of equity and coverage Graham Leese University of Dundee Edinburgh July 16 th 2018

2 NUMBER OF PATIENTS RECEIVING LASER IN TAYSIDE Number of patients receiving laser 62% reduction Number of patients with diabetes (x100) 60% increase Vallance et al Diab Care 2008

3 PERCENTAGE OF PATIENTS RECEIVING LASER % of patients receiving laser fold reduction for both % of patients receiving incident laser Vallance et al Diab Care 2008

4 Prevalence of Blindness in Scotland due to Diabetes Rate per 10, Scottish Diabetes Survey Figures

5 A comparison of the causes of blindness certifications in England and Wales in working age adults (16 64 years), with Liew et al. BMJ Open. 2014; 4(2):

6 Visual Outcomes One episode of missing eye screening: 3.1x increased risk of laser Leese et al Diab Care 2008 From /17 Diabetes related blindness was due to poor attendance Rhatigan et al Eye 1999 From the majority of blindness due to diabetes related to poor attendance Cormack et al BJO 2001

7 Factors associated with nonattendance at retinal screening BACKGROUND Tayside: community screening from 1990 (digital 2000) and comprehensive from 2002 Study years ,150 patients, 32,621 screening episodes Average age 63 years Mean diabetes duration 7.3yrs 54% male 12% DNA rate at screening Leese et al Diab Care 2008

8 Clinical Risk Factors Associated with Nonattendance Young age Long diabetes duration High HbA1c High BP Smoker

9 Geography and Non Attendance GIS: looking at distance and time Average distance to screening 3.3 miles Average time 11.7 min (0-87.2min) Distance or Time NOT associated with attendance

10 Deprivation as a risk of Non-Attendance 2.5 * * p< Relative Risk * SIMD Deprivation Category Leese et al 2008

11 Reducing DNA in General Practice Patients given code to record, made to make verbal or written reminders. Poster with frequency of attendees (not DNAs) Code Verbal Written Verbal, Written, Poster Change in rate of DNA Martin et al JRSoc Med 2012

12 Are we looking in the right direction for solutions?...

13 Summary: What might help? Telephone and Text reminders Integrate with other diabetes appointments Patient to give verbal or written confirmation Evening appointments Opportunistic (IP/ OP/ Transition) Local Provision (Mobile unit/community Hall) Help with Language barriers

14 Prevalence of diabetes in Scotland 000s % 5.4%

15 Are there low risk patients who could be screened less often without harm?

16 % Annual Progression to Referable Retinopathy TYPE-2 DIABETES No baseline retinopathy UKPDS newly diagnosed (n=2316), LES all comers (n=9890) Other studies all: No retinopathy at baseline (Sweden HbA1c 46mmol/mol) Sweden n=1322. Wales n=57,199. England n=16,444. Scotland n=101,539

17 Progression to Referable Retinopathy TYPE-1 DIABETES LES all comers (n=501). Scotland no baseline retinopathy (n=7869)

18 Risk Groups Risk level First screen Second screen 1 R1 both eyes R1 both eyes 2 R1 one eye R1 both eyes 3 R0 both eyes R1 both eyes 4 R1 both eyes R1 one eye 5 R1 one eye R1 one eye 6 R0 both eyes R1 one eye 7 R1 both eyes R0 both eyes 8 R1 one eye R0 both eyes 9 R0 both eyes R0 both eyes Stratton et al

19 Time to STDR from background or no DR e.g. Programme 1 Incidence of STDR yield 5 % 1 highest risk group Note: step rises reflects annual screening 2.5 % 9 lowest risk group 1 % Stratton et al

20 DRS National Scotland Data Type-2 diabetes 2y 2y 1y 1y Looker et al 2014

21 DRS National Scotland Data Type-1 diabetes 2y 2y 1y 1y Looker et al 2014

22 UK Four Nations Retinal Screening Research Group Rates of Progression (%) in 354,549 patients from 7 UK centres No Baseline retinopathy BR in one eye REFERABLE RETINOPATHY PROLIFERATIVE RETINOPATHY Leese GP, Stratton IM et al Diab Care 2015

23 2015 ADA: March 2017 (Solomon et al Diab Care 2017)

24 Screening Interval Determined by Risk Two baselines with no retinopathy - exclude people with previous background reverting to normal - exclude people who do not attend regularly ie absence of baseline May be possible to further refine risk: - Type of diabetes (T2?) - Duration of diabetes - HbA1c - Blood Pressure - Proteomics and Genetics??

25 Hazards Ratio for Risk Factors - HTA SBP 1.03 DBP 0.95 Sight threatening Retinopathy Maculopathy T2 vs T1* 0.45 ( ) Smoking 0.99 Female 1.10 HbA1c (per 10mmol) 1.31 ( ) Diabetes Duration 1.2 ( ) BMI 0.99 Creatinine 1.02 Cholesterol 1.14 ( ) Urine albumin 1.01 (1-1.02) *T1 vs T2 (Duration 17 vs 2 yr; HbA1c 64 vs 50 mmol/mol) Pre-/Proliferative disease

26 Cox-proportional Hazards - HTA Criterion Sight threatening Retinopathy Background retinopathy (Both eyes) 7.1 ( ) Background retinopathy (One eye) 2.6 (2-3.2) HbA1c (per 10mmol/mol) 1.28 ( ) Diabetes Duration (per 5years) 1.20 ( ) Cholesterol (per 1mmol/l) 1.12 ( ) Creatinine (per 10umol/l) 1.04 ( )

27 Individualized Clinical Risk Score Baseline Retinopathy Glycaemic control Duration of diabetes Type of Diabetes Renal function Cholesterol Blood pressure Age?

28 Risk of transition to Referable retinopathy from second year of screening, using the variables: DR grades age Sex diabetes duration BMI HbA1c Blood pressure Blood lipids egfr visual acuity smoking status statin drug use hypertensive drug use CVD status SDRN epi group 2018

29 T2D Predictive Models Model AUROC and log likelihood on the test data Model AUROC LogLikelihood (1) Grade only ) Grade + Age + Sex + Duration (3) Full Model (4) Backward Selection (5) Grade + Age + Sex + Duration + HbA1c + Tchol (6) Grade + Duration + HbA1c + systolic blood pressure (replication of Aspelund et al) (7) Grade + HbA1c (replication of DCCT/EDIC)

30 T2D Screening Policy Number of patients screened per year Current Policy Observed Risk of transition to referable DR in the current system(%) Number of Screenings per year required in the current system Prior DR grade Current Screening Intervals None Mild Moderate Overall Personalised Interval Prior DR grade Accepted Risk Threshold for transition to referable DR Number of Screening Ratio Screenings required Current:Personalised per year policy None :1 Mild :1 Moderate :1 Overall :1 Prior DR grade Stratum specific/averaged Interval Accepted Risk Threshold for Number of transition to Screenings required referable DR per year Screening Ratio Current:Stratum specific policy None :1 Mild :1 Moderate :1 Overall :1

31 Impact of Increased Screening Intervals on Attendance One episode of missing eye screening: 3.1x increased risk of laser Leese et al 2008

32 AUTOMATED GRADING

33 Automated Grading EQA results Q Centres Autograder Sensitivity % 95.5% Specificity % 34.8% Supports data from Philip S et al. Br J Ophthalmology 2007;91:

34 Autograder Grading Level 1 grader No abnormality Level 2 Mild to moderate retinopathy Rescreen 6 or 12 months Level 3 Refer ophthalmology Internal quality assurance

35 External Quality Assurance Source: Scottish DRS EQA System, Dr K.A. Goatman, University of Aberdeen

36 Maculopathy and Macular Oedema

38 Intra-vitreal VEGF therapy Ranibizumab (Lucentis): Licenced Aflibercet (Eylea): Licenced Bevacizumab (Avastin): Cheap

39 Use of Optical Coherence Tomography (OCT)

40 Macular Disease 80% of referrals to Ophthalmology are for maculopathy 80%+ of these do not require treatment (at time of referral) Therefore at least 65% of referrals unnecessary Eye Clinics overloaded

41 Retinal Screening Retinal Screening M2 result M2 Result 100% OCT screening 20% Eye Clinic Eye Clinic Incorporation of OCT step within screening programme

42 Double Benefit a) Fewer referrals b) Can discharge more from Eye Clinic

43 The Retina a Source of Imaging Biomarkers for Global Vascular Health

44 Vascular Assessment and Measurement Platform for Images of the Retina Tom McGillivray Dundee Prof Trucco Dundee Machine learning supported measurement of retinal microvascular parameters CRAE CRVE AVR Arterial Tortuosity Venular Tortuosity Optic Disc Radius Fractal Dimensions etc Calibre Tortuosity Fractal

45 Retinal Risk Score = Increased Venular Tortuosity Plus Reduced Venular Fractal Dimension

46 Improved Technology and Screening Automated Grading Efficiency Integrated OCT screening 2 yearly screening for low risk patients - individualised screening intervals

47 Improved Patient Factors Text reminders More convenient and novel screening opportunities Reaching out to socially disadvantaged Greater attention (rather than less) to those who do not attend

48 V&A Dundee THANK YOU FOR LISTENING

50 Use of dilating drops % not requiring dilating drops % not requiring dilating drops

Diabetic retinopathy is a SPOTLIGHT ON RETINAL SCREENING MEDICINE DIGEST

Diabetic retinopathy is a SPOTLIGHT ON RETINAL SCREENING MEDICINE DIGEST SPOTLIGHT ON PHOTO: NCL DESP AT NMUH NHS TRUST Diabetic retinopathy is no longer the leading cause of blindness among people of working age thanks, at least in part, to retinal screening. But there are