English Programme update

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English Programme update a view of Scottish
Progress

• Dr Peter Scanlon
• DR Screening Programme Director, England
• Ophthalmologist, Gloucestershire Oxford

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1921 the Discovery of Insulin

• Banting and Best tied off the pancreatic ducts of
  several dogs for 7 weeks. Although the pancreas
  became shriveled, the islets of Langerhans
  remained intact, and a solution was extracted
  from them.
• Fourteen-year-old Leonard Thompson had been
  diabetic since 1919, weighed only 65 pounds (4
  stone) , and was about to slip into a coma and
  die.
• 1923 Nobel Prize

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Blindness in Scotland
The incidence of blindness due to diabetes was
0.64 (SD 24, 95 CI 49-79) per 100 000 diabetic
population/year. Cormack 2001 BJO Gloucestershire
0.025 Newcastle 0.035 Arun 2003 Potential
reduction 213,000 x 0.615 1,309 new people /
yr
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Evolution
2007 103 programmes
2002 8 reasonable quality services
5/8 shown
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The Future

• Moved from Planning and Implementation
• to
• Quality Assurance/Risk Reduction monitoring

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External Quality Assurance

• Analysis of data from annual reports European
  procurement.
• External on line QA sets of image grading
• 5 regional QA managers
• Grading review
• Full peer review visits on all programmes.

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QA Standards - Objectives
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Issues for the English Programme

• Accurate identification of patient lists
• Poor outcome data coming from Hospital
  Ophthalmology departments
• Is funding that is being given by PCTs for
  screening actually reaching the screening
  programme
• Variations in
• Retinopathy levels - referable and background
• Numbers excluded
• Ungradable image levels
• Results from slit lamp biomicroscopy for patients
  with ungradable images

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Main difference - Mydriatic 2-field
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Scottish Implementation
Predicted year end (08-09) eligible invited for
screening 96.65 Predicted screened
79.71 Referrals for retinopathy 3.5
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Scottish Successes

• DRS Registers fed automatically from GP systems
  to Community Health Index (CHI) to Soarian via a
  SCI-DC.
• Link to risk factor data Hb A1c, B/P etc..
• Internal QA of graders - randomly selects 12
  images on a weekly basis

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Scottish Successes

• Leadership and Collaboration

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Scottish Successes

• 6 monthly option for rephotographing.
• Keeping the slit-lamp biomicroscopy within the
  screening service
• Automated analysis software

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Scottish Key Performance Indicators
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Data to revisit

• Annual reports from Health Boards?
• Reported retinopathy levels and comparisons?
• Outcome data on Blindness / Visual loss
• 8.1 slit lamp biomicroscopy rate
• (with ? additional 3.5 referral to
  Ophthalmology)
• Temporarily suspended 10, permanent 4
• (the latter sounds high)

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Joint Working Scotland and England
Accreditation of The Workforce Certificate in
diabetic retinopathy screening
Competence frameworkNational Occupational
StandardsCertificate in Diabetic Retinopathy
ScreeningAccreditation by City Guilds

• 3 mandatory and 6 optional learning units
• Award includes 3 mandatory and a minimum further
  3 optional units

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Where now?

• Is this Screening Test or a Screening Programme?
• What happens after referral?
• Is the standard of treatment good?
• What are the treatment outcomes?
• What are the visual outcomes?

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1998 RCOphth audit of laser treatment - How well
are we as Ophthalmologists doing? - PRP

• DRS protocol, 800 1600 argon laser burns of 500
  micron spot size
• area of 157 to 314 mm2
• ETDRS protocol, 1200 1600 argon laser burns of
  500 micron spot size
• 236 mm2 to 314 mm2

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1998 - How well are we as Ophthalmologists doing?
- PRP

• Initial panretinal photocoagulation in one
  sitting in 41.2
• high risk characteristics (n65)
• the median was 104.6 mm2 (range 10.4 682.5
  mm2) if standard lens used or
• median 377.6 mm2 (range 37.6 2464 mm2) if
  quadraspheric lens was used
• DRS ETDRS protocol 157 to 314mm2

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1998 - How well are we as Ophthalmologists doing?
CSMO

• Range of burns in National DR laser audit
• Grid treatment mean 161.6 burns (range 14
  1226).
• Focal mean 69.3 (range 4 650).
• Treatment of CSMO before or on the first
  treatment session for PRP (n 86)
• 26.7 (n 23) had Rx before commencement of PRP
• 45.3 (n 39) had Rx at same session
• 22.1 (n 19) had maculopathy Rx after PRP
• 5.8 no specific intention to rx maculopathy

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Outcomes of treatment Screening Programme not
just a Screening Test

• How are we going to collect this information?
• VAs 6 weeks after first laser?
• Are patients being lost in the Hospital system
  proper tracking of patients?
• Long term visions of our patients?
• CVI data

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