Global partnerships and capacity building for DR screening programmes

This article is adapted from: Zondervan, M. et al. Diabetes and diabetic retinopathy: Changes in understanding of the disease over the last 25 years and how the UK is helping low-income countries tackle the challenges. Eye News Vol. 25 No. 1 2018.

As we learned in week 1, the recent Diabetic Retinopathy Barometer Study found fundamental deficiencies in delivering DR services across many countries. Until they are addressed, these issues will critically slow down progress in preventing vision loss from diabetes:

• Over 50% of respondents did not have access to educational materials for patients
• More than 50% had no written protocol for the detection and management of DR
• One in four eye specialists reported that they had received no training in the management of DR
• 40% reported that there was poor integration of diabetes and eye care services.

The DR-NET: International collaboration to develop DR services

The Queen Elizabeth Diamond Jubilee Trust (QEDJT), through the Commonwealth Eye Health Consortium, has enabled the formation of the Diabetic Retinopathy Network (DR-NET) which is building on existing partnerships between eye departments in 13 Commonwealth countries to share learning and promote training on DR screening and treatment.

The main activities of the DR-NET are:

• Use of international training programmes for screening and grading
• Establishing national frameworks and guidelines for development of DR services
• Use of databases and diabetic registers
• Acquiring and maintaining essential equipment – lasers and cameras
• Exchange of knowledge between countries addressing similar issues.

International training programmes for screening and grading

The DR-NET promotes training in screening and grading through distance learning courses run by the Gloucestershire Retinal Education Group (GREG). Different qualifications (accredited by the University of Gloucestershire) are available, depending on the competencies required by the DR programme member. The courses require one day a week study plus supervised and assessed application of the learning in clinical practice.

There is great value in having screener/graders in countries without a local DR training programme who have passed one of the GREG courses as they can use their expertise to help develop local DR screening services, ensure the quality assurance of the new services, and train others.

GREG also produces Test & Training (TAT) and the international version iTAT. This is an internet based monthly quality assurance and training-support system for graders who work in systematic DR screening programmes. It is equally useful to new or experienced screening staff and to staff wishing to improve their skills in the detection of diabetic retinopathy from ophthalmic images.

To enrol or find out more about GREG training programmes or the TAT/iTAT system visit the GREG website.

Additionally, the University of Melbourne has produced the Online Self-Directed Diabetic Retinopathy Grading Course. A free, internet based and self-directed training resource, it has a final competency based exam and is now available in seven languages.

National frameworks and guidelines for DR services

The DR-NET institutions are working to develop locally appropriate frameworks and guidelines for DR services. At the initial DR-NET Workshop in 2015, as well as the local target to increase DR services in their catchment areas, each participating eye care centre was also charged with developing a national framework for DR services for their country.

Databases and diabetes registers

Information management systems built on robust databases and diabetes registers support the close links between diabetes and eye care services needed to manage the diabetic eye care pathway. Experiences from the DR-NET in this area have highlighted some key learning points:

• Build close links between eye care teams and teams in diabetes departments
• Strengthen awareness amongst persons with diabetes about eye complications. To foster this, diabetologists and Ministry of Health officials representing eye care and non-communicable diseases (NCDs) participate in DR-NET workshops alongside ophthalmologists and nurses.
• Access an existing pool of patients already attending a diabetes clinic to achieve a ‘quick win’ when establishing a DR service. In some centres, a retinal camera has been installed in the diabetes clinic so that patients can be screened there and then, without needing to find their way to the eye department.
• Prioritise the development of a register of patients with diabetes. As well as using it to record the findings of the screening and any treatment carried out, it also facilitates recall of patients.
• Monitor the programme throughout by collecting data on the numbers of patients screened and treated on a monthly basis by all the partners. Better data collection provides the evidence needed for advocacy to acquire more resources at a local level. It is critical to share information and build up a picture of current and future need.

In summary

We know that the number of people in low- and middle-income countries who need regular screening for DR will grow over the next 25 years and this will place an increasing burden on health services. The DR-NET partners are benefiting from sharing learning and expertise as they plan and develop national and regional DR services.

Global partnerships and shared learning can be used to begin to address the inequity across health systems.

Reflection

Have you, or your institution, participated in an international DR partnership through the DR-NET or a similar collaboration? Share your thoughts on the benefits and challenges of taking part. How important is standardised training in screening and grading for your local setting?