Berkshire Diabetic Eye Screening Service Stephanie Holland, Service Manager and Dr Philip Haynes, GP Brookside Practice Aims: To reduce the risk of sight loss amongst people with diabetes by a systematic screening programme for diabetic retinopathy that fully complies with the national standards set by the NHS Diabetic Eye Screening Programme (NHS DESP). To reduce new blindness due to retinopathy amongst people with diabetes, by the prompt identification and effective treatment of sight threatening retinopathy, at the appropriate stage during the disease process. Educational DVD ..\..\Operational Issues\DVD\Retinopathy-part1_WMV 480p (16x9).wmv Process - 7 weeks The scheduled visit to GP Surgery if confirmed. - 6 weeks A Patient List is sent to the GP Surgery - 5 weeks A Patient List is returned to the BDESP Office - 4 weeks DES generates invitation letters - 3 weeks to - 2 weeks Patient phones for an appointment BDESP Office open from 9am to 8pm Monday to Friday - 3 days Text messages sent or reminder telephone call made - 1 week BDESP office faxes completed appointment lists to GP Practices and prepares patient information. GP Practices to contact patient who have not made an appointment Week of Screening Visit takes place + 1 week to + 3 weeks Images graded and assessed + 3 weeks Reminder letters sent + 4 weeks to + 5 weeks BDESP office issues results and makes referral BDESP notify GP Practice of patients that did not respond to two invitations. GP Practice to follow up with patients + 5 weeks BDESP office monitors referrals to ensure that patients are seen within timescales and monitor discharges to ensure patients do not ‘slip through the net’ (Failsafe) Primary Grader Review Grading Pathway 90% of Normal patient imagesets input by primary grader 10% of Normal patient imagesets input by primary grader AND/OR R1, R2, M1 and P1 R3 Annual Rescreen Secondary Grader Review Direct Referral to HES - Urgent Agree R0, R1, M0 and P1 (stable treated DR) Agree R2, M1 and P1 (unstable treated DR) Annual Rescreen Triage Referral to HES - Soon Disagree Arbitration Grader Review (Secondary Grader to input) Arbitration Review (Clinical Lead / Fellow to input) R0, R1 and M0 R2, R3 , M1 and P1 Annual Rescreen Direct Referral to HES – Soon (R3 Urgent) NSC Retinopathy Grading Standard Retinopathy (R) Level 0 None Level 1 Background Level 2 Pre-proliferative Level 3s Proliferative – stable treated Level 3a Proliferative - active Maculopathy (M) Level 0 None Level 1 Features present Photocoagulation (P) Level 0 None evidence Level 1 Focal / grid to macula or peripheral scatter Unclassifiable (U) An image set that cannot be graded What is Failsafe? Failsafe is a back-up mechanism which ensures that when something goes wrong in a system, processes are in place to identify what is going wrong and action follows to ensure that there is a safe outcome. The NHS Screening Programme Lead, general practitioners, Clinical Lead, Office Manager, screeners taking photographs and graders all have failsafe responsibilities. Image of a Screening Session Other websites: www.youtube.com/watch?v=gi_77R21ZlE www.diabeticeye.screening.nhs.uk (NHS Diabetic Eye Screening Programme (NDESP)) Statistics (12 months ending March 2013) Berkshire No. of Patients as at March 2013 Population as at October 2012 c. 933700 Programme Size 38428 (4%) Invitations Made (Eligible population) 34732 Patients Screened 25713 (74%) Patients Referred 1452 (5.7%) Urgent Referrals 122 (8.4%) National Changes in 2013/14 • Why the change • What is different • Pathway • Commissioning • Exclusions & Suspensions Screening Principles • • • • • • Important Problem Accepted Treatment Recognisable Latent / Early Stage Suitable / Acceptable Test Cost Effective Continuing Process Diabetic Eye Disease • Retinopathy – Non-Proliferative - Proliferative • Maculopathy • Cataracts • Retinal Vein Occlusion • Retinal Detachment Treatment for Diabetic Eye Disease At Home 1. Blood Glucose (caution with rapid improvement) – HBA1C < 58 mmol/mol 2. Blood Fats i. Total Chol <4mmol/l ii. LDL Chol < 2mmol/l iii. HDL Chol >1.2mmol/l iv. Triglycerides <1.7mmol/l 3. Blood pressure – BP < 130/80 At Hospital 1. Laser 2. Intravitreal Injections - Steroids - VEGF inhibitors 3. Vitrectomy NDA READ Codes • • • • • • 3129. Eye fundus photography 68A7. Diabetic retinopathy screening 312F. Camera fundoscopy 58C1. Retinal photography 68A8. Digital retinal screening 9N2f. Seen by retinal screener Who isn’t being screened? • Screening rates higher in the Elderly, and those with lower HbA1C and BP • Screening rates lower in : – Type 1 diabetes – Longer history of diabetes – Younger People Eye Screening in Gloucester(Diabetes and Primary Care Vol 14 No 5 2012) Why not screened? • • • • • • • • • • 22% Thought attending optician /optometrist or even ophthalmologist was sufficient 18% Did not receive invitation 12% Health problems 8% too busy 8% transport problems 7% Cannot remember 6% On holiday 6% At work 4% concerned about procedure Remainder: Dementia, forgot to make appointment, language difficulty, thought vision was ok, family illness, forgot to go. Eye Screening in Gloucester(Diabetes and Primary Care Vol 14 No 5 2012) Top Tips • Flag Reminders on screen with BDES phone number (0118 949 5152) and office opening hours (2 – 8 pm) • Check Ophthalmology Letters for patients who have not been screened • Mobile phone numbers – text reminders Key Messages • Education – Asymptomatic • Organisation – Work together with BDES • READ Coding – 68A7. Diabetic Retinopathy Screening Questions?