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.

..\..\Operational Issues\DVD\Retinopathy-part1_WMV 480p (16x9).wmv

Educational DVD

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 weeksDES generates invitation letters

- 3 weeks to - 2 weeksPatient phones for an appointmentBDESP Office open from 9am to 8pm Monday to Friday

- 3 daysText messages sent or reminder telephone call made

- 1 weekBDESP 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 ScreeningVisit takes place

+ 1 week to + 3 weeksImages graded and assessed

+ 3 weeksReminder letters sent

+ 4 weeks to + 5 weeksBDESP office issues results and makes referralBDESP 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)

Grading Pathway Primary Grader Review

90% of Normal patient image-sets input by

primary grader

Annual Rescreen

10% of Normal patient image-sets input by

primary grader AND/OR R1,

R2, M1 and P1

Secondary Grader Review

Agree R0, R1, M0 and P1

(stable treated DR)

Annual Rescreen

Agree R2, M1 and P1

(unstable treated DR)

TriageReferral to HES

- Soon

Disagree

Arbitration Grader Review

(Secondary Grader to input)

R0, R1 and M0

Annual Rescreen

Arbitration Review (Clinical Lead / Fellow to

input)

R2, R3 , M1 and P1

Direct Referral to HES

– Soon (R3 Urgent)

R3

Direct Referral to HES

- Urgent

 Retinopathy (R) Level 0 None Level 1 Background Level 2 Pre-proliferative Level 3s Proliferative – stable treatedLevel 3a Proliferative - active Maculopathy (M) Level 0 NoneLevel 1 Features presentPhotocoagulation (P) Level 0 None evidenceLevel 1 Focal / grid to macula or peripheral scatterUnclassifiable (U) An image set that cannot be graded

 

NSC Retinopathy Grading Standard  

 

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 Home1. Blood Glucose (caution with

rapid improvement)– HBA1C < 58 mmol/mol

2. Blood Fats i. Total Chol <4mmol/lii. LDL Chol < 2mmol/liii. HDL Chol >1.2mmol/liv. Triglycerides <1.7mmol/l

3. Blood pressure– BP < 130/80

At Hospital1. Laser2. Intravitreal Injections - Steroids - VEGF inhibitors3. 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?