Retinal Screening, Seeing Sense! Dinesh Nagi MBBS, PhD, FRCP Clinical Director Division of Medicine Mid- Yorkshire NHS Trust, Wakefield

Transcription

1 Retinal Screening, Seeing Sense! Dinesh Nagi MBBS, PhD, FRCP Clinical Director Division of Medicine Mid- Yorkshire NHS Trust, Wakefield York Race Course 11 th Nov 2014

2 Presentation Importance of regular Screening How to engage with who do not attend? New grading system? Future direction?

3 Introduction The primary aim of retinal screening is to identify sight threatening retinopathy so that visual loss can be prevented However, eye screening provides an opportunity to improve metabolic control, to prevent progression of diabetic retinopathy Risk factor management for Cardiovascular disease is paramount Integrated approach to Diabetes Care

4 Prevention of Retinopathy progression and reducing visual impairment Diabetes Diagnosis Diabetic retinopathy Visual impairment Early Advanced Duration Primary Prevention Secondary Prevention Tertiary Prevention

5 Retinopathy is associated with Mortality and Cardiovascular disease incidence The EURODIAB Prospective Complications Study Manon V. Van Hecke et al. Diabetes Care 2005 (28) Retinopathy Status All Incident Cause mortality CVD Hazard Ratio 95 % CI NPR PR

6 Cumulative Survival in Patients with Type 1 DM EURODIAB Prospective study

7 Is Diabetic Retinopathy an Independent Risk Factor for Ischaemic stroke? Ning Cheung et al. Stroke 2007 (38) Retinopathy Status Hazard Ratio for Ischaemic Stroke 95 % CI Retinopathy

8 Associated co-morbidity in People with visual loss due to Diabetes Nephropathy 50% Neuropathy 22% Hypertension 75% Amputations 20% Myocardial Infarcts 21% Cerebro-vascular 51% 71% of subjects had died with in 10 years of registering blind

9 Key Message 1 People with retinopathy are at high risk patients These can only be identified through regular screening Metabolic and cardiovascular risk management remains key! while managing eye disease A holistic and personalised approach to diabetes care

10 National Programme for Retinopathy Screening Interesting Times!

11 The way we were! Pre National Programme Era Retinopathy Screening was an integral part of annual review The screening was neither systematic nor comprehensive (exceptions) Majority of complex diabetes care happened at the Diabetes Centres Diabetologist took a keen interest and did eye screening

12 Population to be Screened GP Surgeries Call & Recall Co-ordinating Centre for Diabetes Register and Eye Screening Data flow to & from Primary care Specialist Ophthalmic Services Primary Eye Care Sites Image Handling Reporting Diabetes Centres

13 The way we are! Post National Programme Era Annual automated Call and recall Eye Screening is separated from annual review of diabetes Care by design Diabetologist and other Clinicians do not do eye screening They are dis-engaged from the whole process Some may even feel disenchanted

14 Successes of National Programme! 2003 Identifying Resources Getting screening into the National Target and PCT must do list Explicit National Standards Standardisation of Camera software, methodology etc Comprehensive QA System (EQA visits) Training programme for screeners and Graders (City & Guilds) Software for managing pathways Helping GP s earn their QOF points!

15 Challenges! Poor Quality Commissioning remains so! Data on QA from within Ophthalmology? Failure to integrate screening into diabetes services Resources to meet Training and QA? Continuous Software issues? Total Annual Cost of the National programme! At present no effective monitoring of outcomes: i.e. visual loss -nationally

16 Grading of Images? Original Grading System Revised Feature based grading Training

17 New Revised Grading Old Grade New Grading Comments RO, R1 RO, R1 No Change R2 R2 Clearer Guidance R3 R3a, R3s New Grade M0, M1 M0, M1 Clearer Guidance P0, P1 P0, P1 Clearer Guidance ---- U New Grade Introduction of Feature Based Grading

18 New Revised Grading Definitions and guidance clearer Importance Cotton Wool spots IRMA- clarified Outcomes now clearer

19 New Surviellanace System OPDR - Pathway SLB - Pathway Both are out of Routine retinal screening but call and recall still run by RS Units

20 What role for Clinicians delivering Care? Leadership Management support Screening and Grading Education and support Management of screen positive? Contribution to MDT & Quality control Joint working with Ophthalmology

21 Management of Screen positives Making sure that there are fail safe systems are in place to treat STDR Models to sort Technical Failures Creating systems of care to optimise metabolic control To prevent further retinopathy progression To prevent development of Nephropathy Management of risk factors to reduce the risk of CVD

22 Joint working is the Key How can we minimise risk? MDT case conferences Clinical Incident reporting Availability of patient history of Diabetes management at the time of Ophthalmic review (including the eye Photographs)

23 MDT Case conferences Discuss all patients with STDR (R2, M1 and R3) Patients referred to Ophthalmology with STDR outside the screening programme Those who underwent angiograms Complicated Laser (e. g poor response) Pregnancy related retinopathy Good forum to discuss any other logistic issues related to either screening or screen + ve patients

24 The Final Act How do we engage non attenders

25 Risk Factors for Visual impairment in People with Diabetes Patient Specific Unmodifiable Age Duration Pregnancy Modifiable Treatment non-compliance Hyperglycaemia Hypertension Nephropathy Organisational No Diabetes services No Screening services No Joint up working

26 Risk Factors for Visual impairment in People with Diabetes Modifiable Patient Specific Treatment noncompliance Hyperglycaemia Hypertension Nephropathy Organisational No Joint up working

27 Retinal Screening: an opportunity lost? What is happening out there? How do we engage those who are not keen? Why are they disengaged?? Needs more Qualitative research

28 The Disengaged! Those who do not attend for eye screening Those who are found to have R3a and will default urgent appointment Those who have started laser treatment for R3a and then default WHY?

29 Why? No Clear explanation of disease (R3a) Risks/benefits of treatment not explained in a Jargon free language Myth that they will go blind- due to laser Rx Lost to the Hospital Follow up system (fail safe breakdown) Not treated appropriately (poor patient experience) Several Other Reasons

30 Conclusions National programme is a big success story Local retinopathy screening programmes are struggling Commissioining needs sorting Clinicians delivering diabetes care have a key role to play in the The challenge is to provide optimum risk factor management which clinicians should lead in their locality. The degree and depth of engagement from clinicians needs addressing Data on Impact of National programme on visual loss need to be available IT Automation and integration with primary Care systems