Diabetic Retinopathy Screening in Scotland Roderick Harvey DRS Lead Clinician.
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Transcript of Diabetic Retinopathy Screening in Scotland Roderick Harvey DRS Lead Clinician.
Diabetic Retinopathy Screening in Scotland
Roderick Harvey
DRS Lead Clinician
Population 5,144,200
The national programme
White paper 2000
Commitment to develop a Scottish Diabetes Framework
“The framework will include plans to establish a national screening strategy for diabetic retinopathy”
HTBS Report 2002
Aim – detection of sight threatening diabetic retinopathy
Screening modalities Primary - digital retinal
photography Secondary - slit lamp
biomicroscopy
Benefits of photographic screening
High sensitivity and specificity for sight threatening disease
Ease of image acquisition, storage and transmission
The opportunity for quality assurance through double reading
Cost effectiveness
Publications
NHS QIS DRS Standards
Screening delivered to a defined specification
80% of eligible people screened per year
100% of eligible people invited per year
Call & recall in place using national software
Arrangements for hard to reach groups
Staff trained and qualified (or under supervision)
Quality assurance is in place
Special features
Single field macular centred image
Mydriasis only if initial image of inadequate quality
Grading
Feature based
Software calculates final grade according to grading algorithm
Outcome determined automatically
All graders perform full grading Level 1 final grade normals only Level 2 final grade non referrable Level 3 final grade all referrable
Outcomes
Re screen 12 months R0 or R1
M0
Re screen 6 months R2 or M1
Refer ophthalmology R3 or above, or M2
Non diabetic lesions
Technical failure R6 – inadequate image
Quality assurance
All L1 & L2 graders have 500 image pairs per year regraded randomly by L3 grader
External QA of images under development 1st round of pilot completed 2008
External QA of programmes Standardised annual report template National Key Performance Indicators
Training & Accreditation
City & guilds Level 3 Certificate in Diabetic Retinopathy Screening
140 people in Scotland registered
110 modules passed
Slit lamp examiner standards and accreditation process defined
The Scottish National DRS Programme
Responsibility for screening lies with the fourteen individual Health Boards
Within each Board the programme is delivered to common standards defined by
NHS QIS standards on DRS Policies developed by the DRS Collaborative Constraints embedded in the national DRS software
National software for photography, administration and grading
SGHD
SDG
NSD
ExecutiveGroup
DRS IT BoardPFIG
ClinicalGroup
ServiceManagement
As required
BoardCo-ordinators
IT UsersGroup
Short-life groups
SCI-DC
NSD IT Board
The Board Programmes are all members of a formal DRS Collaborative
Implications of franchise model
Adherence to national standards
Sharing of a national database of eligible patients
Ability to tailor the details of the delivery of the screening programme to suit local needs Fixed site photography Mobile units Image capture through optometrists
Eligible population
All people resident in Scotland with confirmed diabetes
Aged 12 years or older
Not under the care of an ophthalmologist for treatment of diabetic retinopathy
Not suspended for a valid clinical or organisational reason (excludes temporarily unavailable)
SuspensionsSuspension Reason Suspension
TypeWho suspends and can unsuspend
Informed choice to opt out Temporary GP
Under Age Temporary System
Total Loss of Vision Permanent GP as advised by Ophthalmologist
Terminal Illness Temporary GP
Disabilities:Learning, Mental or Physical
Temporary orPermanent
GP
Under the care of an Ophthalmologist Temporary Retinal Screening Administrator as advised by Ophthalmologist
Temporarily Unavailable Temporary GP or Retinal Screening Administrator
Deceased TemporaryPermanent
GPSystem
Not Diabetic Permanent GP or other HCP
Not Permanently Resident in Scotland Permanent System
How is it all put together
Maintenace of the eligible population
Recording of diabetes in a primary care system automatically registers the patient for DRS
Dynamic link with SCI-DC and the CHI ensures that the population is accurately maintained
Registration can also be done directly through SCI-DC or Soarian
Suspensions are managed through SCI-DC and Soarian
Consortia server
CHI
SCI-DCGPASSVision
EMISXML Messages
Staging Server
Soarian
Mobile Admin Fixed
SCI-DC
Soarian
*********
*********
*********
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************
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*******
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How are we doing
DRS Population Scotland Over 12 years
0
10000
20000
30000
40000
50000
60000
70000
12 to 14 15 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 to 84 85 plus
Age
Nu
mb
er TS
PS
EP
Total living diabetic population 239,495
Eligible population 204,817
Annual DRS Screening Uptake Scotland
0
20
40
60
80
100
12 to 14 15 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 to 84 85 plus
Age
Pe
rce
nt Invited %
Attended %
Screened %
Invitation rate 93.2%
Attendance rate 77.0%
Successful screening rate 73.7%
Overall Referable 3.5%
Observable 1.9%
Tech failure 7.6%
DRS Scotland Screening Outcome
0
5
10
15
20
25
30
12 to 14 15 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 to 84 85 plus
Age
Pe
rce
nt % Referrable
% Observable
% Tech failure
Challenges
Slit lamp examination
About 8% of patients require slit lamp examination
Training & accreditation requirements defined
Difficulty for small and dispersed boards in meeting the requirements
Optometry
Most optometrists now have digital retinal cameras
Photography is part of GOS contract for over 60s
Opportunities for synergy and image capture by optometrists
Challenges of integration with board wide screening programmes without compromise of quality standards on grading
Framework for optometry image capture is being piloted in two health board regions
Ophthalmlogy
Closing the loop
Capturing outcome of ophthalmology consultations
Ensuring appropriate suspension of patients under the care of ophthalmology
Failsafe to track ophthalmology referrals
Capacity
Quality assurance
Need for more robust analysis of internal QA performance across all health boards
Need to establish regular external QA image sets and define reporting formats
FutureAutomated Grading
Start
Image of adequate quality?
Microaneurysms present?
Final Grade R0 M0
Refer to Level 2 Manual Grader
Yes
Yes
No
No
Automated Grading
6732 patients using gold standard grading for actionable retinopathy Automated grading 97.9% Routine manual 99.1%
33,535 patients from the Scottish DRS service the performance of automated grading for actionable retinopathy was Sensitivity 99.1% Specificity 59%
Automated grading DRS Collaborative commissioned an
independent review of the performance of automated lesion detection software
Four patients from 33535 (0.012%) may have missed clinically relevant maculopathy
Cost to detect these patients in Scotland £275,000 pa
Conclusion that it should be used for DRS programme in Scotland
Thank you for you attention