Diabetic Retinopathy Screening Health Equity Audit for Coventry PCT for 2008/9 and 2009/10

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1 Diabetic Retinopathy Screening Health Equity Audit for Coventry PCT for 2008/9 and 2009/10 Introduction to screening for diabetic retinopathy Diabetic retinopathy (DR) is the leading cause of blindness in adults under the age of 65 in the United Kingdom. 1 Diabetic retinopathy can be identified and treated to prevent loss of sight and for this reason a national screening programme was set up in 2005, using digital retinal photography. The Diabetes National Service Framework (NSF) in England set a target that by 2006, 80% of people with diabetes were to be offered retinal screening, rising to 100% by the end of The target for uptake of screening has been set at 80% by the National Screening Committee. Diabetic retinopathy is a microangiopathy which affects the microvasculature of the retina, namely the retinal precapillary arterioles, the capillaries and the venules. Diabetic retinopathy has features of both microvascular occlusion and leakage. Retinopathy can be classified into background retinopathy, preproliferative retinopathy, proliferative retinopathy and maculopathy. Any damage in the area of the macula is considered to be serious, as this area of the eye is most responsible for vision. It has been shown that whilst these changes are very common in patients with diabetes, good diabetic control, amongst other factors, can significantly slow the development of retinopathy. Further information about the pathophysiology of the condition can be found in Appendix 1. The English National Screening Programme for Diabetic Retinopathy aims to reduce the risk of sight loss amongst people with diabetes by the prompt identification and effective treatment if necessary of sight-threatening diabetic retinopathy, at the appropriate stage during the disease process. 2 The programme offers all people over the age of 12 years with diabetes annual eye examinations looking for signs of retinopathy, with treatment being offered to those patients who are deemed to require it. The national target for uptake of screening is 80%, however, we cannot be sure why some patients choose not to take up the opportunity of retinal screening. It has been found that a 1

2 number of patient features are associated with poor uptake of retinal screening, including young age, poor glycaemic and blood pressure control, smoking and long duration of diabetes. These patient features have also been found to be strong risk factors for the development of retinal disease in diabetes. 3 Diabetic retinopathy and social deprivation has been studied in Gloucestershire, and it was reported that with each increasing quintile of deprivation (i.e. more deprivation), diabetes prevalence increased, and the probability of having been screened for diabetic retinopathy decreased. 4 The prevalence of sight threatening diabetic retinopathy amongst screened patients in this study also increased with increasing quintiles of deprivation, however, there was no difference in non sight-threatening retinopathy. The reason for this is likely to be poorer diabetic control, which may be due to barriers such as lack of knowledge which may be found in areas of social deprivation and should be considered when trialling strategies to promote screening uptake. 4 The local picture The Coventry and Warwickshire Retinal Screening Programme has been based at the Hospital of St Cross, Rugby, since The programme offers screening to all people with diabetes who are registered with a GP within the geographical boundaries of Coventry and the whole of Warwickshire. Retinal screening clinics are located within GP surgeries or hospital clinics at University Hospital Coventry, St Cross Rugby and Coventry & Warwickshire Hospital. In addition, there are mobile screening centres that are able to screen at a number of different locations, including community centres. There are currently 147 screening locations throughout the target area. On arrival for screening the patient s level of vision is recorded and pupildilating drops are instilled. The drops can cause temporary blurring of vision so patients are advised not to drive after screening. Retinal screening is subsequently performed using digital retinal cameras which take images of the retina of each eye. Usually 2 images are taken of each eye although more may be taken if needed. The camera system is returned to the Retinal Screening Unit at St Cross each evening and patient data and images are 2

3 downloaded. The level of diabetic retinopathy in each eye is graded according to strict national criteria and quality assurance processes. Patients that are identified as having sight-threatening diabetic retinopathy will be referred to the Hospital Eye Service for further assessment and possible treatment. Those without sight threatening retinopathy or with no retinopathy will be informed of the result of their treatment and recalled annually. All GPs are informed of screening results in order that they may appropriately manage their patients diabetes care. 5 The annual report of the Director of Public Health in Coventry 2009/10 states that in 2008/9, 12,218 patients with diabetes were offered retinal screening (92%) and a total of 9,985 (82%) attended for screening. It was also shown that in this time period around 4,000 patients had some degree of retinal damage. In Coventry, the screening programme does not include patients who are already under the care of the Hospital Eye Service. 6 Whilst this level of screening uptake is acceptable under current guidelines, research (as mentioned above) has shown that there can be significant differences in attendance between different ethnic and socio-economic groups. In general, those who are less likely to attend screening are often those who are most at risk of developing sight threatening retinopathy. A health equity audit was needed in Coventry in order to assess and understand variation in uptake across the population, so that these areas may be targeted with interventions to increase uptake and result in a more equitable service across the area. What is Health Equity Audit? Health Equity audit is a process whereby there is systematic review of inequities in the causes of ill health, and in access to effective services and their outcomes, for a defined population. Further action is then agreed and incorporated into policy, plans and practice. Finally, actions taken are reviewed to assess whether inequities have been reduced. 7 3

4 Health equity audits can therefore: Inform the commissioning of services Contribute to local performance management of public services Support partnership working and the allocation of resources Encourage community involvement in the NHS Whilst health inequality describes the differences in health experiences and outcomes between those in different socioeconomic groups, health inequity describes differences in opportunity for different groups, which result in unequal life chances, access to health services, nutritious food, adequate housing and so on. Health equity audits assess how fairly resources are distributed in relation to the health needs of different groups, with the aim not to distribute resources equally, but in relation to need. Health inequalities can therefore be reduced by equitable provision of services. The health equity audit cycle is as follows: 7 Diagram taken from Hamer L, Jacobson B, Flowers J, Johnstone F. Health Equity Audit Made Simple.Helath Development Agency (2003). 7 Coventry Health Equity Audit The aims of this audit are to assess the uptake of screening for diabetic retinopathy across Coventry by year of attendance, and within this by age, gender, deprivation, ward of residence, GP practice and ethnicity. 4

5 Methods Data was collected from the Coventry and Warwickshire Diabetic Retinal Screening Unit in Rugby, which provides Diabetic Retinopathy Screening for all people within the Coventry area. Data was collected from April 2008 to March 2010 for the Coventry responsible population. Data obtained were date patients entered the diabetic retinopathy screening (DRS) service, NHS number, gender, date of birth, postcode, GP practice, whether invited for screening, whether screened, an archive reason and an archive date. Data was entered into an MS EXCEL spreadsheet, and patient identifiable data extracted. The data was then analysed by using filters and pivot tables options from MS EXCEL. The following analyses were made:- 1. Uptake of screening by gender for both and Uptake of screening by age (in 5 year age bands) for both and Uptake of screening by Ethnicity for both and Uptake of screening by IMD Quintile for both and Uptake of screening by Ward for both and Uptake of screening by GP Practice for both and Uptake of screening by ethnicity and deprivation quintile for both and Uptake of screening by age and deprivation quintile for both and Reasons for exclusion from the DRS programme for both and a) Ethnicity The NHS number was linked to the Nam Pechan database in order to identify ethnicity using surname. The Nam Pechan database seeks to associate names from South Asia with particular ethnic, linguistic and religious minorities from the sub-continent 8. b) Deprivation Postcode was initially liked to super-output area, and then to the index of multiple deprivation (IMD) quintiles and electoral wards. A super-output area 5

6 is a unit of geography used for the collection and publication of small area statistics and gives an good basis for comparison throughout the country 9. c) Exclusions In line with guidance from the Retinal Screening Unit, individuals in the following categories were counted as excluded: Patient under medical retina consultant Patient no longer registered with local GP Patient temporarily excluded awaiting confirmation of medical status from GP Patient medically unfit for screening d) Data Cleansing Initially, the data received had a number of people who were marked down as NOT invited, but who had been screened. Reasons for this may be that patients could have been invited before the cut off date for our data collection (generally invitations are sent 3 months in advance), which was the 1 st April 2008, some patients may have been screened at their GP surgeries ad hoc before an invitation could be sent, and some patients can be directly referred for screening by their GP (especially in the case where screening has already taken place at the practice) without an invitation letter being generated. In response to this, those who were originally marked as NOT invited but screened, were then changed to be invited and screened. Analyses were made on this corrected data. 6

7 Results 1. Uptake of screening by gender In 2008/9, the number of males who attended for DRS was 3786, with 816 non attendees. These figures for females are 3255 and 649 patients respectively. Graph 1 below shows the percentage of uptake by gender. Graph 1: Percentage uptake of DRS by gender 2008/9 Percentage uptake of DRS by Gender 2008/9 Uptake (%) Males Gender Females Attended Did not attend Source: Diabetic Retinopathy Screening Service (DRSS) Graph 2: Percentage uptake of DRS by gender 2009/10 Uptake (%) Percentage uptake of DRS by Gender 2009/10 Males Females Gender Attended Did t attend 7

8 Graph 2 shows the percentage uptake for males and females for 2009/10. The absolute numbers of attendees and non attendees in this year are 5,673 and 1,320 for males and 4,810 and 1,101 for females respectively. Pie charts 3-6 show the differences in uptake between males and females in 2008/9 and 2009/10. Graph 3: Uptake of Males attending DRS in 2008/9 Uptake of Males attending DRS in 2008/ % Graph 4: Uptake of Females attending DRS in 2008/9 Uptake of Females attending DRS in 2008/ % 82.27% Males invited and screened Males invited and NOT screened 83.38% Females invited and screened Females invited and NOT screened Graph 5: Uptake of Males attending DRS in 2009/10 Uptake of Males attending DRS in 2009/ % Graph 6: Uptake of Females attending DRS in 2009/10 Uptake of Females attending DRS in 2009/ % 81.12% Males invited and screened Males invited and NOT screened 81.37% Females invited and screened Females invited and NOT screened 8

9 2. Uptake of screening by age (in 5 year age bands) Graph 7: Number of patients in screening programme by age band 2008/9 Number of patients in screening programme by age band 2008/ < Number of patients 90+ Age band Graph 8: Number of patients in screening programme by age band 2009/10 Number of patients Number of patients in screening programme by age band 2009/ < Age Band Graphs 7 and 8 show the number of patients included in the screening programme in Coventry by five year age bands for 2008/9 and 2009/10. 9

10 Graph 9: Percentage Uptake of Diabetic Retinal Screening by age band 2008/ Percentage uptake of Diabetic Retinal Screening by age band 2008/9 < Uptake (%) Age band Uptake Target Graph 9 shows the percentage uptake of DRS by age band for 2008/9, with the national target of 80% screened marked in blue. Graph 10: Percentage Uptake of Diabetic Retinal Screening by age band 2009/10 Uptake (%) Percentage Uptake of Diabetic Retinal Screening by age band 2009/ < Age Bands Uptake Target Uptake Graph 10 shows the percentage uptake of DRS by age band for 2009/10, with the national target of 80% screened marked in blue. 10

11 3. Uptake of screening by Ethnicity Graph 11 shows the number of patients eligible for screening by ethnic group for 2008/9. Graph 11: Number of patients in screening programme by Ethnic group 2008/9 Number of patients Number of patients in screening programme by Ethnic group 2008/ Hindu Gujurati Hindu other 723 Muslim non Asian Ethnic group 791 Sikh 33 South Asian other 553 t matched Graph 12 shows the number of patients eligible for screening by ethnic group for 2009/10. Graph 12: Number of patients in screening programme by Ethnic group 2009/10 Population Numbers Number of patients in screening programe by Ethnic group 2009/ Hindu Gujurati Hindu other 1029 Muslim non Asian Ethnic Group 867 not matched 1119 Sikh 44 South Asian other 11

12 Graph 13: Percentage Uptake of DRS by ethnic group 2008/9 Uptake (%) Percentage Uptake of DRS by ethnic group 2008/9 Hindu Gujurati Hindu other Muslim non Sikh Asian Ethnic group South Asian other t matched % Uptake Target Graph 13 shows the percentage uptake of DRS by ethnic group for 2008/9, with the national target of 80% being shown in blue. Graph 14: Percentage Uptake of DRS by ethnic group 2009/10 Percentage Uptake Percentage Uptake of DRS by ethnicity group 2009/10 Hindu Gujurati Hindu other Muslim non Asian Ethnic Group Percentage Uptake not matched Target Uptake Sikh South Asian other Graph 14 shows the percentage uptake of DRS by ethnic group in 2009/10, with the national target of 80% being shown in blue. 12

13 4. Uptake of screening by IMD Quintile Graph 15: Numbers of patients who did and did not attend screening by IMD Quintile of Deprivation 2008/ Number of patients who did and did not attend screening by IMD Quintile of Deprivation 2008/9 Number of patients Most deprived Next most Middle category Next least Least deprived t known IMD Quintile Did not attend Attended Graph 15 shows numbers of patients who did and did not attend screening by IMD Quintile of Deprivation in 2008/9. Graph 16: Numbers of patients who did and did not attend screening by IMD Quintile of Deprivation 2009/ Numbers of patients who did and did not attend screening by IMD Quintile of Deprivation 2009/10 Number of patients Most deprived Next most Middle category Next least Least deprived t Known IMD Quintile Attended Did t Attend Graph 16 shows numbers of patients who did and did not attend screening by IMD Quintile of Deprivation in 2009/10. 13

14 Graph 17: Percentage Uptake of DRS by IMD Quintile of Deprivation 2008/9 Percentage uptake by IMD Quintile of Deprivation 2008/9 100 Uptake (%) Most deprived Next most Middle category Next least Least deprived t known Quintile of deprivation Uptake (%) Target uptake Graph 17 shows that the percentage uptake of DRS in IMD quintiles, with the 80% target shown as a line across the chart. Graph 18: Percentage Uptake of DRS by IMD Quintile of Deprivation 2009/ Percentage Uptake of DRS by IMD Quintile of Deprivation 2009/10 80 Uptake (%) Most deprived Next most Percentage Uptake Middle Next least category IMD Quintile Least deprived Target Uptake t Known Graph 18 shows the percentage uptake of DRS in 2009/10 for IMD quintiles of deprivation, with the 80% target shown as a line across the chart. 14

15 Graph 19: Scatter plot to show percentage of attendees by deprivation of SOA 2008/9 Scatter plot to show percentage of attendees by deprivation of SOA 2008/9 Uptake (%) IMD score (highest score = more deprivation) Graph 19, above, shows a scatter plot of the percentage of attendees by deprivation of SOA from 2008/9. IMD scores which are higher represent more deprivation. Graph 20, below, shows the same for 2009/10. It can be seen that SOAs with higher levels of deprivation have lower uptake of screening. Graph 20: Scatter plot to show percentage of attendees by deprivation of SOA 2009/10 Uptake (%) Scatter plot to show percentage of attendees by deprivation of SOA 2009/ IMD Score by SOA (higher score means more deprivation) Percentage Uptake Linear (Percentage Uptake) 15

16 5. Uptake of screening by electoral ward Graph 21: Total number of patients eligible for screening by electoral ward 2008/9 Total number of patients eligible for screening by electoral ward 2008/ Bablake Binley and Cheylesmore Earlsdon Foleshill Henley Holbrook Longford Lower Stoke Radford St Michael's Sherbourne Upper Stoke Wainbody Westwood Whoberley Woodlands Wyken t known Number of patients Ward Graph 21 shows the number of eligible patients for the screening programme within each electoral ward in Coventry for 2008/9. Graph 22 shows the same for 2009/10. Graph 22: Total number of patients eligible for screening by electoral ward 2009/10 Total number of patients eligible for screening by electoral ward 2009/ Number of patients Bablake Binley and Cheylesmore Earlsdon Foleshill Henley Holbrook Longford Lower Stoke Radford St Michael's Ward Sherbourne Upper Stoke Wainbody Westwood Whoberley Woodlands Wyken t Matched 16

17 Graph 23: Uptake by electoral ward 2008/9 Uptake by Electoral Ward 2008/9 Uptake (%) Bablake Binley and Cheylesmore Earlsdon Foleshill Henley Holbrook Longford Lower Stoke Radford St Michael's Sherbourne Upper Stoke Wainbody Westwood Whoberley Woodlands Wyken t known Electoral ward Uptake (%) Target Graph 23 shows the uptake of DRS by patients within each electoral ward in 2008/9, with the national target of 80% being shown as a blue line across the graph. Graph 24 shows the same data for 2009/10. Graph 24: Percentage Uptake by electoral ward 2009/10 Uptake (%) Percentage Uptake by electoral ward 2009/10 Bablake Binley and Cheylesmore Earlsdon Foleshill Henley Holbrook Longford Lower Stoke Radford St Michael's Sherbourne Upper Stoke Wainbody Westwood Whoberley Woodlands Wyken t Matched Ward Percentage Uptake Target 17

18 6. Uptake of screening by GP Practice Graph 27: Percentage Uptake by GP Practice 2008/9 100 Percentage Uptake by GP Surgery 2008/ Uptake (%) M86603 M86045 M86026 M86003 M86017 M86018 M86005 M86627 M86028 Y00996 M86012 M86008 M86638 M86009 M86032 M86035 M86013 M86046 M86621 M86010 M86034 M86634 M86048 M86029 M86605 M86617 M86607 M86037 M86021 M86629 M86604 M86043 M86613 M86033 M86041 M86610 M86022 Y00140 M86044 M86038 M86612 Y00060 Y02857 Y02613 M86039 M84012 M86001 M86002 M86004 M86006 M86007 M86011 M86014 M86015 M86016 M86019 M86020 M86023 M86027 M86030 M86040 M86622 M86624 M86630 M86633 Y02612 Y02784 GP Surgery % Uptake per GP Practice Target Uptake Graph 27 shows the uptake of DRS by patients within each Coventry GP Practice in 2008/9, with the national target of 80% being shown as a blue line across the graph. Graph 28 shows the same data for 2009/10. Graph 28: Percentage Uptake by GP Practice 2009/ Percentage Uptake by GP surgery 2009/ Uptake (%) M86603 M86045 M86026 M86003 M86017 M86018 M86005 M86627 M86028 Y00996 M86012 M86008 M86638 M86009 M86032 M86035 M86013 M86046 M86621 M86010 M86034 M86634 M86048 M86029 M86605 M86617 M86607 M86037 M86021 M86629 M86604 M86043 M86613 M86033 M86041 M86610 M86022 Y00140 M86044 M86038 M86612 Y00060 Y02857 Y02613 M86039 M84012 M86001 M86002 M86004 M86006 M86007 M86011 M86014 M86015 M86016 M86019 M86020 M86023 M86027 M86030 M86040 M86622 M86624 M86630 M86633 Y02784 GP Surgery % Uptake per GP Practice Target Uptake 18

19 7. Uptake of screening by ethnicity and deprivation quintile Graph 29: Percentage uptake of DRS by ethnicity and deprivation quintile 2008/9 Percentage uptake for DRS by ethnicity and deprivation quintile 2008/9 Uptake (%) Hindu Gujurati Hindu other Muslim Sikh n Asian Ethnic group Most deprived Next most Middle category Next least Least deprived Graph 29 shows the uptake of DRS in 2008/9 as analysed by ethnicity and IMD Quintile of Deprivation. Graph 30 shows the same for 2009/10. Graph 30: Percentage uptake of DRS by ethnicity and deprivation quintile 2009/ Percentage Uptake of DRS by ethnicity and deprivation Quintile 2009/ Uptake (%) Hindu Gujurati Hindu other Muslim non Asian Sikh Ethnicity Most deprived Next most Middle category Next least Least deprived 19

20 8. Uptake of screening by age and deprivation quintile Graph 31: Percentage uptake of DRS by age and deprivation quintile 2008/9 Uptake (%) Percentage uptake of DRS by age and deprivation quintile 2008/9 < Age Most deprived Next most Middle category Next least Least deprived Unmatched Graph 31 shows the uptake of DRS in 2008/9 as analysed by age and IMD Quintile of Deprivation. Graph 32 shows the same for 2009/10. Graph 32: Percentage uptake of DRS by age and deprivation quintile 2009/10 Uptake (%) Percentage Uptake of DRS by age and deprivation Quintile 2009/ < Age Most deprived Next most Middle Category Next least Least deprived Unmatched 20

21 9. Reasons for exclusion from the DRS programme Graph 33: Reasons for exclusion from the DRS programme 2008/9 Reasons for exclusion from the DRS programme 2008/ % 5.33% Patient medically unfit for screening 80.01% Patient under medical retina consultant Patient no longer registered w ith local GP Graphs 33 and 34 show reasons for exclusion from the DRS programme for 2008/9 and 2009/10 respectively. Graph 34: Reasons for exclusion from the DRS programme 2009/10 Reasons for exclusion from the DRS programme 2009/ % 2.19% 1.68% 90.57% Patient under medical retina consultant Patient no longer registered with local GP Medically unfit for screening Patient temporarily excluded - awaiting confirmaiton of medical status from GP 21

22 Discussion Overall the uptake of diabetic retinopathy screening for Coventry PCT was 82.78% in 2008/9 and 81.25% in 2009/10. These figures meet current national targets for DRS uptake. However, the results show that there are significant differences in uptake between different age groups, ethnic groups and socio-economic groups. Gender Graphs 1-6 (pages 7-8) focus on attendance and uptake by gender, with no significant differences between either sex in either year analysed. This implies that males and females place similar importance on DR screening, and that any interventions designed to increase uptake of retinal screening in Coventry could be targeted at both sexes equally. Uptake for males in 2008/9 was 82.27%, and 81.12% in 2009/ % of females attended screening in 2008/9, which dropped to 81.37% in 2009/10. While the percentage uptake is slightly lower in 2009/10 for both sexes, the national target of 80% has still been reached. It appears in both years that there are more males than females included in the DR screening programme, with 4602 males and 3993 females in 2008/9, and 6993 males and 5911 females invited in 2009/10. Age Graphs 7-10 (pages 9-10) represent attendance and uptake by 5 year age bands. In both 2008/9 and 2009/10 the age bands which contain the largest amount of people are 60-64, and The age bands with the least amount of people eligible for screening are the oldest (90+) and the youngest (<20). In 2008/9 the age bands with the highest percentage uptake are followed by In 2009/10 the age band with the highest percentage uptake is again years, followed by and In 2008/9, patients aged between 50 and 84 years all exceed the 80% national target for uptake of retinal screening. The group of under 20 s also reach the national target of 80%, with their percentage uptake being 80.52%. The groups which have the lowest percentage uptake are people between 20-24, and 30-34, with uptakes of 60.27%, 60.71% and 63.95% 22

23 respectively. The percentage uptake for these age bands is significantly lower than that for people between the ages of 45 and 89, and also significantly lower than the national target of 80%. In 2009/10 patients aged 55 and 84 years exceed the 80% national target for uptake of retinal screening. The age bands of have a percentage uptake of 79.23%, therefore are very close to the national average. Unlike 2008/9, the group of patients eligible for screening who are under the age of 20 do not reach the national target of 80% in 2009/10. The percentage uptake in this group was 76.86% for 2009/10 compared to 80.52% in 2008/9. However, this difference is not significant due to the low numbers of patients in this group. The groups which again have the lowest percentage uptake are patients aged between 20-24, followed by the and year olds. The percentage uptake for these age bands is significantly lower than that of patients between the ages of 50 and 89, and significantly lower than the national target of 80%. In both years analysed, it appears that uptake in patients aged over 90 years is lower than the national target of 80%. In 2009/10 the difference is significantly lower than the target. However, numbers of eligible patients in this group are lower than in many other age bands, and it is likely that other co-morbidities and general immobility may prevent optimum attendance in these patients. It has been found that in both years analysed, uptake tails off significantly once patients eligible for retinal screening reach the age of 20, with poor uptake between the ages of 20 and 44, of at least 10% below the national target. Interestingly, in both 2008/9 and 2009/10, the highest proportion of non-attendees was seen within the age bands This proportion of nonattendees slowly decreases as the age increases, with still nearly one third (32.4%) of patients within the age group not attending screening in 2009/10. It is possible that those patients who are under the age of 20 still have some parental influence in attending their screening appointments, hence the better levels of uptake. Once patients become more independent, it could be that the importance of retinal screening becomes less, until they 23

24 reach an age whereby health may become more of an issue. This finding may be useful when planning interventions to increase the uptake across Coventry by specifically targeting the younger eligible population. Ethnic Group Graphs (pages 11-12) focus on attendance and uptake of patients eligible for screening by ethnic group. In both 2008/9 and 2009/10 it can be seen that non-asian patients are by far the largest group eligible for screening in Coventry. This group is followed by Sikh and Muslim patients, although in much smaller numbers. These groups, as would be expected, also have the highest number of attendees for both years. The smallest group for both years is South Asian other, with only 33 patients eligible for screening in 2008/9 and 44 in 2009/10. Some patients who were eligible for screening could not be matched to an ethnic group using the Nam Pechan data, and have not been included in some of the later analyses. It can be seen from the 2009/10 data, that 30% of Muslim patients, and 34% of patients from the South Asian-other group did not attend screening. These are the groups with the largest proportion of non-attendees, with the Hindu Gujurati group having the smallest proportion of non-attendees (14%). In both 2008/9 and 2009/10, the groups who reach the national target for uptake of DRS are the Hindu Gujurati, the non-asian and the not matched group. In 2008/9, Muslim patients appear to have the lowest percentage uptake, which is also significantly lower than the national average. In 2009/10 the group that appears to have the lowest percentage uptake is the South Asian other group, and both the Hindu-other group and the Muslim group have percentage uptakes significantly lower than the national average. From this data, it can be assumed that the group who may benefit from additional input to increase screening participation is the Muslim population. This group not only has a higher number of eligible people within it, it also has one of the highest numbers of non-attendees (30%) and has one of the lowest uptake rates over the two years, being significantly lower than the national average. 24

25 This information will be of use when deciding where to target screening programmes within Coventry. Targeting specific communities with low uptake of DRS such as the Muslim community may therefore be helpful in increasing the overall uptake of the population. Patients of South Asian origin have been shown in previous studies to consistently have poor uptake of screening, whether this is diabetic retinopathy screening or cancer screening. 10 It seems that barriers to attending screening programmes may exist in these groups of patients that do not exist for other groups of patients. These barriers may be both general, and specific to the type of screening programme. Whether there is a general lack of knowledge regarding the importance and effectiveness of screening programmes, or other reasons, it would seem important that these barriers are identified and tackled when trying to achieve equitable uptake of retinal screening within Coventry. Deprivation Graphs (pages 13 15) show data analysis by level of deprivation. In both 2008/9 and 2009/10 it can be seen that the greatest number of eligible patients are in IMD Quintile 1 (most deprived) and that this group also has the greatest percentage of non-attendees. In 2008/9, the uptake of DRS in Quintiles 2-5 is shown to be significantly above the national target of 80%. This is also depicted in table 1. Table 1: Table to show percentage uptake of DRS for IMD Quintiles 2008/9 Uptake (%) IMD quintile 2008/9 95% CI LL 95% CI UL t known

26 However, the percentage uptake in quintile 1 is significantly below both the national target, and the other quintiles of deprivation including the not known group at 78.20% (CI 76.68%-79.71%). In 2009/10, Quintiles 3-5 have been shown to be significantly above the national target of 80%. Table 2: Table to show percentage uptake of DRS for IMD Quintiles 2009/10 Uptake (%) IMD Quintile 2009/10 95% CI LL 95% CI UL t Known The percentage uptake in quintile 2 (next most deprived) is slightly above the national target at 80.56%, and the percentage uptake in quintile 1 (most deprived) is significantly lower than the national target at 76.0%, and significantly lower than all other quintiles, including the not known group. Both scatter plots for 2008/9 and 2009/10 (page 15) show a downward trend signifying that people with the highest IMD score of deprivation, which equates to a higher level of deprivation, have a lower percentage uptake for DRS. This result is not unexpected, as it has already been shown in one area of the UK that deprivation has a significant impact on attendance at DRS. 4 In both years, the percentage uptake within quintile 1, i.e. those who are most deprived, is significantly below the national target of 80%, and significantly lower than the rest of the eligible population in Coventry. Once again, this implies that interventions to benefit and increase uptake may be usefully targeted at the more deprived areas (IMD Quintile 1) in order to equitably increase the uptake of DRS across Coventry. Electoral Ward Graphs (pages 16 17) show data analysis by electoral ward for both 2008/9 and 2009/10. In both 2008/9 and 2009/10 the areas with the greatest number of patients eligible to attend the programme are the Foleshill area, 26

27 followed by Longford and Henley. The areas with the least number of people eligible are Earsldon and Woodlands for both years. The wards with the highest percentages of non-attendees are St Michael s in 2008/9 and Foleshill in 2009/10, with 27% of eligible people in Foleshill not attending. In 2008, all Coventry wards except Foleshill, St Michael s and Upper Stoke attained the national target of 80% attendance. Both Foleshill and St Michael s have significantly lower uptake than that national target and the majority of other areas within Coventry. Areas that were significantly above the national average were Bablake, Binley and Willenhall, Hoolbrook, Sherbourne, Wainbody, Whoberley, Woodlands, Wyken and the not known group. In 2009/10, more wards did not meet the national target, including Foleshill, Henley, Holbrook, Longford and St Michael s. Foleshill, Longford and St Michael s all were significantly below the national average of 80% uptake, and significantly below the uptake rates of the majority of other areas. Areas where uptake was significantly higher than the national target were Cheylesmore, Earlsdon, Wainbody, Woodlands and Wyken. There appears to be more areas that reach or exceed the national target, and in 2008/9 when compared to 2009/10. The reason for this shift in poorer performance from 2008/9 to 2009/10 is unknown at present. However the data highlights that there are certain areas within Coventry, namely Foleshill, Longford and St Michael s, where either interventions to increase screening may need to be introduced, or opportunities for providing screening need to be increased. GP Practices Graphs (pages 18 19) show data analysis by GP Practice for both 2008/9 and 2009/10. From the graphs it can be seen that there are huge variations in numbers of eligible people for DRS within each GP Practice. Appendix 4 shows the name of the GP practice in relation to the GP Code in addition to a table of absolute numbers for each GP practice, and percentage uptake per practice for both years. 27

28 The GP practice with the highest numbers of eligible patients in 2008/9 and 2009/10 was led by Dr Chandra-Mohan at the Green Lane Medical Centre. The GP practices with the lowest numbers of eligible patients in 2008/9 were Aldermoor, and in 2009/10. In 2008/9, 46 GP practices out of a total 67 reached and exceeded the national target of 80% uptake, leaving 31% (21 practices) below the national target. The GP Practice with the highest uptake in 2008/9 was Dr Cooper at Woodside Medical Centre with 94.5% uptake, and the practice with the lowest uptake was Malling@Foleshill, with 50% uptake. The Malling@Foleshill GP practice has only a small amount of eligible patients for DRS within the practice, however still have a poor uptake of 50%. In 2009/10, 42 GP practices out of a total 66 reached and exceeded the national target of 80% uptake, leaving 36.4% (24 practices) below the national target. This percentage of practices not achieving the target rose by 5.4% between 2008/9 and 2009/10, hence showing that more practices in 2009/10 did not achieve the target in the subsequent year. The GP Practice with the highest uptake was led by Dr Dadhania with 97.4% uptake (which had risen considerably from 81.25% uptake in 2008/9), and the practice with the lowest uptake was the Anchor Centre, with 41.7% uptake (which had dropped noticeably from 80% uptake in 2008/9). In total, between 2008/9 and 2009/10, thirty practices increased their percentage uptake, with the highest rise seen by Dr Jayarathnam at Swanswell Medial Centre with uptakes increasing from 52.63% in 2008/9 to 83.05% in 2009/10. The next highest increase was seen with Dr Dosanj at Daventry Road Surgery with an increase from 74.55% in 2008/9 to 87.16% in 2009/10. Thirty six practices saw a reduction in percentage uptake from 2008/9 to 2009/10, with the biggest drop seen in the Anchor Centre as mentioned above. The next largest decrease was seen with Dr Lyall at Bell Green Health Centre with uptake dropping from 85.87% in 2008/9 to 70.77% in 2009/10. 28

29 Ethnicity and Deprivation Graphs 29 and 30 (Page 20) show data analysis by ethnicity and level of deprivation. Data from 2008/9 shows that despite level of deprivation, the non- Asian group have a tendency to attend more. The ethnic groups of Hindu Gujurati, Hindu other, Muslim and Sikh have a level of uptake that is below that of the non-asian group, with a few exceptions. In addition, within ethnic groups, not including the non-asian group, the majority of deprivation quintiles show uptake levels that are below the national uptake of 80%. This data is however not statistically significant. Similar can be seen with the 2009/10 data with the non-asian group in general attending more than other ethnic groups across all deprivation quintiles. A difference seen in 2009/10 is a higher level of uptake throughout each deprivation quintile within the Hindu Gujurati population. Once again, the ethnic groups of Hindu other, Muslim and Sikh have a level of uptake that is below that of the non-asian group throughout all deprivation quintiles, with a few exceptions. Once again, the data is not statistically significant, due to the relatively small numbers of patients in these groups. Some patient details could not be matched to an IMD quintile of deprivation or an ethnic group using our methods. When analysing ethnic group with deprivation, these patients were not included in this analysis. As well as this, the group of patients matched as South Asian other were also excluded, due to small numbers present in the group. The majority of the patients that were not-matched for IMD quintiles had postcodes outside of the Coventry area, and therefore were not from Coventry (although registered with a Coventry GP). 7.15% of the database was excluded in this way when analysing data for ethnic group and deprivation from 2008/9 and 7.29% from 2009/10. Age and Deprivation Graphs 31 and 32 (Page 21) show data analysis both by deprivation quintile and age. Data from 2008/9 shows that in general, despite deprivation quintile, people under the age of 40 are less likely to attend for screening. Within the 29

30 age groups 40-59, and 80+, the lowest level of attendance is seen within quintile 1 (most deprived), with attendance generally increasing as the deprivation quintile also rises. Within all age ranges, the quintile which has the highest percentage uptake is either quintile 4 or 5 (next least and least deprived). The data however is not statistically significant. For 2009/10, the converse can be observed. From this data, it can be seen that younger people in general attend more than the older generation, with people under the age of 40 attending more and people aged over 60 attending less, when compared to data seen in 2008/9. Once again, within each age group, quintile 1 (most deprived) seems to have the lowest percentage uptake, with either quintile 4 or 5 (next least and least deprived) having the highest percentage uptake. The data is once again statistically not significant. For each deprivation quintile, the percentage uptake for people aged remains similar to that seen in 2008/9, with all deprivation quintiles above, or just meeting the national target. The reason for the increased uptake seen within each deprivation quintile in people under the age of 40 between 2008/9 and 2009/10 is not known at present. In addition, the reason for the decreased uptake seen within each deprivation quintile in people between 60-79, and /9 and 2009/10 also remains unknown. Exclusion from the screening programme Graphs 33 and 34 (Page 22) show exclusion criteria from the DRS programme for both years. From the 2008/9 data, the reason for most exclusions from the programme is that the patient is under the care of a medical retina consultant (80.01%). This is also the reason for the highest number of exclusions from the screening programme in 2009/10 (90.57% of patients excluded). The next largest group of patients excluded in both years analysed is due to the patient no longer being registered with a local GP (14.66% in 2008/9 and 5.56% in 2009/10). Further patients were excluded if they were either medically unfit for screening or excluded on a temporary basis until their medical status (diabetes or fit for screening) has been confirmed by their GP. 30

31 Conclusions This health equity audit reveals that despite current overall DRS uptake in Coventry being above the national target of 80%, there are significant differences in the equity of uptake of retinal screening across Coventry in age, socio-economic and ethnic groups. There are key underperforming areas or groups highlighted from all analyses made for which development and improvement in actual services, service acquisition and service provision may be made in order to increase uptake. Interventions targeted at these specific groups should be of use in optimising equitable uptake. The groups identified as not reaching the national target and requiring further interventions are people at the extremes of age, i.e. under 34 and older than 90 (however it is unlikely that interventions may increase this number in the older age-groups, as co-morbidities may prevent attendance), people of Muslim ethnicity, people living within more deprived areas (within IMD quintile 1) and people living within the electoral wards of Foleshill, Longford and St Michael s. Many GP practices in addition are not achieving the national target for DR screening, with having the lowest percentage uptake in 2008/9 and The Anchor Centre and again having the lowest percentage uptakes in 2009/10. The results of this audit imply that in Coventry, young people, people from areas of greater deprivation and minority ethnic backgrounds seem to place less importance on attending screening for ocular complications associated with diabetes. Within the context of diabetes, these groups may also maintain poorer diabetic control and so put themselves at a higher risk of developing complications like diabetic retinopathy. As these populations are also the ones who appear to accept the screening process less, resulting in lower levels of uptake, there is a greater chance of developing complications, and earlier than otherwise expected. It is therefore of importance to target these high risk groups mentioned above in order to increase screening uptake, and therefore prevent complications such as blindness. 31

32 Recommendations There should be a sustained health promotion campaign targeted at deprived populations within Coventry. There should also be work with non-attenders in the younger age groups, for example years of age as uptake is very poor in these groups Health promotion work with those from South Asian ethnic backgrounds should also be considered. Discuss uptake results with GPs to make them aware of their current practice, especially targeting those GPs who are below the national target and/or have seen decreasing levels of uptake between the two years. Present this information and recommendations to those with an interest, for example all local GPs at weekly teaching meetings and to local diabetologists and ophthalmologists with an interest in diabetic eye disease. Re-audit in the future once agreed actions with stakeholders have been implemented, to monitor any change in uptake in the targeted ages, areas and ethnic groups identified in this audit. 32

33 References: 1. Bunce C, Wormald R. Leading causes of certification for blindness and partial sight in England and Wales. BMC Public Health 2006; 6: The English National Screening Programme for Diabetic Retinopathy website Last accessed September Scanlon PH, Carter SC, Foy C, Husband RF, Abbas J, Bachman MO. Diabetic retinopathy screening and socioeconomic deprivation in Gloucestershire. Journal of Medical Screening 2008; 15(3): Leese GP, Boyle P, Feng Z, Emslie-Smith A, Ellis JD. Screening uptake in a well-established diabetic retinopathy screening program: the role of geographical access and deprivation. Diabetes Care 2008; 31 (11): Karen Moss, Retinal Screening Grader at Rugby St Cross Hospital, Personal Communication 6. The Annual Report of the Director of Public Health for Coventry 2009/ Hamer L, Jacobson B, Flowers J, Johnstone F. Health Equity Audit Made Simple.Helath Development Agency (2003) Webber R. Names as predictors of ethnicity, language and culture. mes.doc 9. Super Output Areas: Introduction. Neighbourhood Statistics, Office for National Statistics. neighbourhood/geography/superoutputareas/soa-intro.htm 10. P O Hare, N.T. Raymond, K Bush, M Ford-Adams, S Kumar. Chapter 15: Diabetic Retinopathy Diabetes UK and South Asian Health Foundation recommendations on diabetes research priorities for British South Asians Diabetes UK

34 Appendix 1 Information on Diabetic Retinopathy adapted from Diabetes UK What is diabetic retinopathy? Diabetic retinopathy means changes to the retina (the seeing part at the back of the eye) and is a complication that can affect anyone who has diabetes. To see, light must be able to pass through to the retina without anything getting in its way. Retinopathy is caused when the blood vessels in the retina become blocked or leaky, or grow haphazardly, which can damage the retina and prevent it from working properly. Patients may not be aware of changes to the retina until vision has been impaired, and this is why it is recommended that the eyes of people with diabetes are screened every year. Retinal screening with a digital camera every year will pick up the earliest signs of retinopathy developing and is essential for everyone with diabetes. Retinopathy can permanently damage vision if left untreated. Early detection is the key to successful treatment. Who gets diabetic retinopathy? Patients with Type 1 diabetes who have had it for less that five years are unlikely to have retinopathy. However, the longer people have Type 1 diabetes, the more common retinopathy becomes. Nearly one in five people with Type 2 diabetes have a significant degree of retinopathy when they are diagnosed. This is because their diabetes may have been present for months or even years before diagnosis and blood glucose levels may have been higher than normal for some time. 34

35 More research is needed to understand the precise causes of retinopathy. It is known that the chances of retinopathy developing and progressing can be reduced by maintaining blood glucose, blood pressure and blood fat levels as near to normal as possible. Protecting eyes Retinopathy is a complication of diabetes. Therefore to reduce the risk of developing retinopathy or to stop it from getting worse, research has shown the following aspects of good diabetes control to be significant benefit: 10. Good blood glucose control aim for an HbA1c of less than 6.5 per cent 11. Good blood pressure control below 130/80 or less. 12. Total cholesterol less than 4 mmol/l 13. LDL cholesterol less than 2 mmol/l 14. HDL cholesterol above 1 mmol/l for men and above 1.2 mmol/l for women. 15. Triglycerides less than 1.7 mmol/l In addition, following a healthy balanced diet, losing weight if needed, and keeping active are central to good diabetes control. Children with diabetes should start having their eyes screened from the age of 12, or post puberty, whichever is sooner. Types of retinopathy Background retinopathy The earliest visible change to the retina is known as background retinopathy. This is when some of the capillaries (small blood vessels) in the retina become blocked, reducing the supply of nutrients, like oxygen, to the retina. To make up for this the blocked blood vessels then become bigger allowing more blood to flow through them. These enlarged blood vessels are usually leaky and unwanted fluids get through them into the retina. They then become fragile and tend to haemorrhage (bleed). Neither these small haemorrhages, nor the leakage will initially affect eyesight, unless it occurs at the macula. The macula is the centre of the retina, which is the part of the eye used for close, detailed work. However, the background retinopathy may progress to the more serious forms of retinopathy. Background retinopathy needs to be carefully monitored by a GP, diabetologist or eye specialist. Pre-proliferative and proliferative (spreading) retinopathy Large areas of the retina will not be getting a proper blood supply because of blocked and damaged blood vessels, and this actually stimulates the growth of new blood vessels to replace blocked ones. Unfortunately, these do not grow into the areas where they are needed, but proliferate (spread) 35