Where will retinal screening go?

Graham Leese

Ninewells Hospital Dundee

Lead Clinician for DRS in Tayside

Exciting times

• Screening Intervals

• OCT in screening

• Anti-VEGF treatment

• Automated grading

• Reaching the unreachable

Why do we screen annually?

Always Been so

Easy to organise

Fits in with Annual visits to Doctor

PRACTICAL REASONS

Not EVIDENCE BASED REASONS

Retinal Photography Screening

IT call/recall systems

Chance to change Annual Routine

Wisconsin: Incidence at 4 year from Diagnosis

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Young Older

Prolif

Macul

Treatable

Wisconsin II, III, IV (1984)

%

N=<996 N=<1370

“Reclaim Democracy”

Prevalence of Proliferative Retinopathy (%)

0

5

10

15

20

25

30

35

40

0-4y 5-9y 10-14y 15-19y 20-24y 25+

Kristinsson et al 1997Diabetes Duration

Pale blue: Type-1 diabetes

Dark blue: Type-2 diabetes

1994: National Retinal Screening Scheme

Slit Lamp every 2 years if no baseline retinopathy

10yr review in 2007 of 296 patients:

23 pre-proliferative, 4 proliferative

4 Macular oedema- all in eye clinic before treatment req’d

Olafsdottir et al BJO 2007

Progression of Retinopathy:T2 Diabetes: Newly Diagnosed: No baseline retinopathy

0

1

2

3

4

3yr 6yr 9yr

Kohner et al UKPDS 52Diab Med 2001

UKPDS: n=2316

% needing laser

0.2%

1.1%

Progression of RetinopathyAny Type-2 diabetes: No baseline retinopathy

0

1

2

3

4

1yr 2yr 3yr 4yr

Younis et al Lancet 2003

Liverpool Eye Study: n=9890, 20570 screening events

% with ST eye disease

0.5%*

1.4%

0.3% ST-retinopathy

Screening Interval: Type-1 Diabetes

Incidence of ST eye disease (%) from baseline “no retinopathy”

0

1

2

3

4

5

6

7

8

9

1 2 3 4 5 6

Younis et al 2003, Diab Med

0.6%*

1.6%

N=501: 2742 screening events

0.3% ST retinopathy

2.6%

Progression at 3 yearsType-2 Diabetes: No baseline retinopathy

0

5

10

15

20

25

30

Mild/Mod Sev/Prolif Mac Edema

Agardh et al Diab Care 2011

% progressed

N=1322

0.2%*

*Only ONE eye required laser

Nb: HbA1c = 46 mmol/mol / 6.4%

Incidence of RetinopathyNo baseline Retinopathy: T2 diabetes

0

2

4

6

8

10

12

14

1 year 4 year

Any

Refer

Ins & 10yr subgrp

Annual Incidence per 100 patients

N=57,199 (87% follow-up)

0.2 0.35

Thomas et al BMJ 2012

Incidence of RetinopathyNo baseline Retinopathy: T2 diabetes

Outcome at 5 YEARS

0

1

2

3

4

5

6

7

No Basal Ret Basal BR

PreProlif

Prolif

Macul

Incidence per 100 patients

N=16,444

Jones et al Diab Care 2012

0.68

Norfolk

Progression in Type 1 diabetes from no baseline retinopathy:

DRS Scotland

0

0.5

1

1.5

2

2.5

3

1y 2y

Overall

Mac

Prolif

N=7869

%

0.50.7

Progression in Type 2 diabetes from no baseline retinopathy:

DRS Scotland

0

0.5

1

1.5

2

2.5

3

1y 2y

Overall

Mac

Prolif

N=101,539

%

0.13 0.22

Cost-effectiveness of retinal screening: 1 vs 3 years

AGE 45 yr 65yr

HbA1c 11%

(97mmol/mol)

7%

(53 mmol/mol)

Days of sight saved (1 vs 3yr)

21 3

Cost per QALY

(1 vs 2 yr)

£27,000 £141,000

Vijan et al JAMA 2000

Use of Optical Coherence Tomography (OCT)

Macular Disease

• 80% of referrals are for maculopathy

• 80%+ of these do not require treatment (at time of referral)

• At least 65% of referrals unnecessary

• Eye Clinics overloaded

• ISMO trial – looking at the use of OCT in screening

M2 result

Retinal Screening

Eye Clinic

Retinal Screening

M2 Result

OCT screening

Eye Clinic

100%

20%

Incorporation of OCT step within screening programme

Double Benefit

a) Fewer referrals

b) Can discharge more from Eye Clinic

Intra-vitreal VEGF therapy

Ranibizumab (Lucentis): Licenced

Bevacizumab (Avastin): Cheap

Diabetic Macular Oedema

• Proven benefit in clinical trials

• NICE reviewing use of Lucentis (31/10/12)- 400μm central thickness- company discount - ? For 6/18 vision

• New Treatment option

• 5 maculopathy referrals for 1 proliferative

• More important to look for maculopathy? - more treatable

• Less important to look for maculopathy? - becomes a symptomatic condition

BACKGROUND

QUESTIONS

AUTOMATED GRADING

Automated Grading

EQA results

Q3 2012

Centres Autograder

Sensitivity 88.6-95.5% 95.5%

Specificity 87.0-97.8% 34.8%

What are we trying identify?

What are we expected to identify?

Non-diabetic pathology?

Who does what?

ANNUAL ANNUAL

……….and its getting better all the time!

AUTOGRADING

Sensitivity / Coverage

• Screening Intervals

• OCT in screening

• Anti-VEGF treatment

• Automated grading

• Reaching the unreachable

Number of people with Diabetes in Tayside

0

5000

10000

15000

20000

25000

1997 2002 2007 2012

2.9%1.8% 4.0% 4.8%

Numbers doubling every 9-10 years

0

50

100

150

200

250

300

2001 2002 2003 2004 2005 2006

Number of patients receiving laser

Number of patients with diabetes (x100)

NUMBER OF PATIENTS RECEIVING LASER IN TAYSIDE

Vallance et al Diab Care 2008

62% reduction

60% increase

0

0.5

1

1.5

2

2.5

2001 2002 2003 2004 2005 2006

PERCENTAGE OF PATIENTS RECEIVING LASER

% of patients receiving laser

% of patients receiving incident laser

Vallance et al Diab Care 2008

2.5 fold reduction for both

Prevalence of Blindness in Scotland due to Diabetes

0

10

20

30

40

50

60

70

80

2004 2005 2006 2008 2009 2010 2011

Scottish Diabetes Survey Figures

Rate per 10,000

Prevalence of Blindness in Scotland due to Diabetes

0

10

20

30

40

50

60

70

80

1999 2004 2005 2006 2008 2009 2010 2011

Scottish Diabetes Survey Figures

Rate per 10,000

Fife

Visual Outcomes

• One episode of missing eye screening:3.1x increased risk of laser

• From 1990-1995 16/17 Diabetes related blindness was due to poor attendance

• From 1990-1999 the majority of blindness due to diabetes related to poor attendance

Cormack et al BJO 2001

Rhatigan et al Eye 1999

Leese et al Diab Care 2008

RISK FACTORS FOR NON-ATTENDANCE

Geography & Screening Uptake

• Tayside, Scotland• Community retinal

photography from 1990

• Digital screening from 2000

• Comprehensive annual screening from ~ 2002

• 4.2% diabetes

• 2004-2006• 15,150 patients,

32,621 screening episodes

• Age 63 years• 7.3yrs of diabetes• 54% male• 12% DNA rate

Leese et al Diab Care 2008

BACKGROUND STUDY

Clinical Risk Factors Associated with Non-attendance

• Young age

• Long diabetes duration

• High HbA1c

• High BP

• Smoker

Geography and Non Attendance

• GIS: looking at distance and time

• Average distance to screening 3.3 miles

• Average time 11.7 min (0 - 87.2min)

• Distance or Time NOT associated with attendance

• Appointments to mobile Unit: 2.9 (2.5- 3.4) x more likely not attend eye screening than Static Unit (p<0.01).

Deprivation as a risk of Non-Attendance

0

0.5

1

1.5

2

2.5

1 2 3 4 5

SIMD Deprivation Category

Relative Risk *

** p<0.01

Leese et al 2008

Lothian DRS Survey 2011Interview of 20 DNAs

Unaware of Importance 5

Transport problems 4

Other health problems 4

Work 3

Previous negative experience 3

Lack of mobility 2

Caring for others 2

Bereavement 1

Barriers to accessing Eye Care Services: RNIB 2011 Focus Group

• Limited awareness of eye health

• Symptom led demand for eye examinations

• Worry and confusion about costs (what is free and what is not?)

• Services fragmented

• Poor interaction with clinicians

Bradford, Cwm Taf, Glasgow, Hackney, West Belfast

WHAT MIGHT HELP IMPROVE ATTENDANCE?

Telephone Reminders

• Gastroenterology clinic. Call 1wk prior25.3% to 5.7% DNA rate

• Rheumatology clinic72% wanted reminder 1-4d before52% phone call most popular,Unless <28yr: text was most popular

• Four RCTs with 3547 participantsAdditional phone calls reduce DNAText as good as phone call

Gauthier et al J Clin Rheu 2012

Scott et al JRSocMed 2009

Car et al Cochrane Rev 2012

Reducing DNA in General Practice

-35

-30

-25

-20

-15

-10

-5

0

5

Code Verbal Written Verbal,Written,Poster

Change inrate of DNA

Patients given code to record, made to make verbal or written reminders. Poster with frequency of attendees (not DNAs).

Martin et al JRSoc Med 2012

Patient suggestions to improve• Evening appointments

• Link with other appointments

• Telephone reminders

• Text reminders

• Short time scales

Patient comments•Confusion with Optician role

•Busy people

•Local provision valued Lothian DRS survey 2011

Solutions to accessing DRS in Glasgow: RNIB 2011 Focus Group• Screening liked

• Confusion about roles of Optometry/GPs/DRS/Eye Clinics

• Use local centres e.g. Community Hall

• Want general support for Diabetes Care (ie integrate care)

• Solutions should build on existing services

• Help with language barriers

Are we looking in the right direction for solutions?......

Summary: Who is High Risk of Non Attendance?

Summary: What might help?

• Telephone and Text reminders

• Integrate with other diabetes appointments

• Patient to give verbal or written confirmation

• Evening appointments

• Opportunistic (IP/ OP/ Transition)

• Local Provision (Mobile unit/Community Hall)

• Help with Language barriers

Optical Coherence Tomography (OCT)

IMPACT OF REDUCE UNNECESSARY REFERALS

Impact of Increased Screening Intervals on Attendance

THANK YOU FOR LISTENING

Tayside, Scotland