Andalusian Programme for Diabetes

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Susan Short
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1 Andalusian Programme for Diabetes

2 Diabetic Retinopathy Screening Programme in Andalusia Francisco José Sánchez Laguna MSc Health Informatics

3 Diabetic Retinopathy High prevalence. Socioeconomic impact. Cause of blindness.

4 Prevalence Depending on disease evolution. Less than 5 years 15-30% From 6 to 10 years 39-43% More than 15 years 70% Depending on diabetes type. 2-3 times higher in type 1.

5 Cause of Blindness Second in developed countries. First in working life. ONCE: 3 rd reason for membership. O.N.C.E. Spanish National Organisation for the Blind (

6 Justifying an Early Diagnosis Important cause of morbidity. Asymptomatic stage. Early diagnosis improves prognosis. Effective treatment.

7 Effective treatment Laser photocoagulation Up to 60% blindness reduction

8 Justifying an early diagnosis Important morbidity cause. Asymptomatic stage. Early diagnosis improves prognosis. Effective treatment. Screening test available. Sensitive, specific and cost-effective.

9 Examining the Retina Ophthalmoscopy.

10 Examining the Retina Ophthalmoscopy. Slit-lamp eye examination.

11 Examining the Retina Ophthalmoscopy. Slit-lamp eye examination. Digital retinography.

14 Is it Cost-effective? (our sources) 1996 BC Technology Evaluation Agency. Sensitivity 91.9% Specificity 89.7%. 33% cost reduction (about 30 saving) Hernáez-Ortega et al. Similar sensitivity and specificity. 35.7% cost reduction.

15 Recent studies 2004 Cabrera López, F et al. Cost per true positive test ( 80 vs 140) % cost reduction Lee, LJ et al. (diabetic employees annual costs) PDR/non-PDR: $30,135/$13,445. DR w/wo photocoag: $34,539/$16,041.

16 Investment System Development. Three years. More than 220,000. Screening Programme Total Investment. About 2.2 million. Andalusian Government Website News 14/4/2008

17 Advantages Early diagnosis and treatment. Reduces patients waiting time. Avoids unnecessary Ophthalmologist consultation. Reduces patients inconvenience.

18 Advantages Provides long lasting picture files: Uploaded to a centralized database. Attached to the patient s unique electronic health record. Allows comparison with previous images. Encourages primary and hospital care collaboration.

19 Target Population Population: 8,177,805 (17.82% of Spain). Area: 87,268 Km 2 (17.2 % of Spain). 20 municipalities with more than 50,000 inhabitants. Undiagnosed diabetic retinopathy patients: 250,000

20 Patients Selection Criteria Patients with diabetes type 2: When diagnosed. Once every two years. Unless coexisting risk factors or bad metabolic control: once a year.

21 Implementation Process Professional training. Software development Supported on our corporative intranet and DPC Technical resources providing Health Centres Hospitals

22 106 Retinal Cameras in Health Centres

23 Endocrinology Day Care Units: 10

24 13 Reference Ophthalmology Centres Angiography Laser therapy

25 Screenshots (Family Nurse)

26 Screenshots (Family Doctor)

27 Screenshots (Ophthalmologist)

Patient Recruitment Consent Clinical Information Work Flow New appointment as appropriate Healthy Retina Appointment Family Doctor Diagnosis

29 Patient Recruitment Consent Clinical Information Work Flow New appointment as appropriate Healthy Retina Appointment Family Doctor Diagnosis Diabetic Retinopathy or doubtful image Digital Retinography IDP Ophthalmologist Diagnosis Ophthalmologist Appointment Confirms Diabetic Retinopathy

30 Retinography Diagnosis-based Work-flow Ophthalmologist Appointment Family Doctor Ophthalmologist Diabetic retinopathy No retinopathy Non diabetic retinopathy Diagnostic doubt Other diagnosis Need further tests No retinopathy Diabetic retinopathy Unassessable image Unassessable image Patient s report

31 Quality Control Preventing False Positives. Reference Ophthalmologist Review. Preventing False Negatives. Auditor Ophthalmologist Review. Random Sample from Negative Images. From Family Doctors and Reference Ophthalmologist.

32 Figures Recruited Patients 81,425 (32.57%)

33 Figures Family doctor diagnosis

34 Figures Final results (over finished cycles)

35 Figures Diagnosed retinopathy stages

36 Thank you very much for your kind attention. Any questions? Special thanks to: Víctor Regife García (Andalusian Health Service). Management Staff from Hospital Reina Sofía (Córdoba). Management and Support Staff from Córdoba Health Districts. Main references: Andalusian Programme for Diabetes Economical analysis of non-midriatic retinal cameras in diabetic retinopathy screening. Osteba Berriak Report 1996; 12. Hernáez-Ortega MC et al. Efficiency assessment of non-midriatic retinal cameras in diabetic retinopathy diagnosis. Revista Clínica Española 1998; 198: Cabrera López F et al. Assessment of effectiveness and cost-effectiveness of the digital image in the diabetic retinopathy diagnosis. Archivos de la Sociedad Canaria de Oftalmología 2004; 15: Lee LJ et al. Direct and indirect costs among employees with diabetic retinopathy in the United States. Current Medical Research and Opinion 2008; vol 24 issue 5:

Diabetic Retinopathy Screening Programme

Diabetic Retinopathy Screening Programme Information for patients As you have diabetes, your GP has arranged for you to attend the Diabetic Retinopathy Screening Service. This service is free and is provided