The patient pathway through screening and referral

Once a person with diabetes is identified, it is important to guide them through the local screening and referral pathway. The flow chart on this step highlights the main activities that people with diabetes must take as they follow the pathway across the various health services.

Once a person is diagnosed with diabetes, by a medical or antenatal health service, they need to be directed to regular eye screening and grading services and then, for some patients, to eye care services for treatment and further management. Each service must carefully manage how it communicates about every patient across all stages and to ensure successful follow up.

Monitoring the screening and referral pathway

Managing screening includes tracking the rates of acceptance and attendance along the different connections. High rates of acceptance and attendance for a high coverage of 90% of the target population are essential for early detection of diabetic retinopathy and prevention of vision loss.

Managing the quality of the screening and grading will ensure that a screening programme and its patients are not overburdened by false positives – results which wrongly indicate that diabetic retinopathy is present.

As you examine the flow chart below, consider how can you ensure that all health providers in your setting are able to support persons with diabetes under their care to navigate the screening and referral pathway?

Flow chart: The DR screening and referral pathway

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Stage 1. Key steps in the medical services pathway

• Person with diabetes identified as eligible for screening
• Invitation to attend screening is sent
• If there is a history of pre-gestational diabetes (pre-existing diabetes before pregnancy), they are sent for screening as soon as possible

Stage 2. Key steps in the screening pathway

• Screening event held
• Retinal image set graded. Routine recall (based on agreed intervals) for a non-referral grade and slit lamp biomicroscopy for ungradeable image sets or those with a referral retinopathy grade
• Monitoring data collected on: Percentage of eligible people who do not attend screening and percentage of images sets correctly graded.

Key steps in the pre-gestational diabetes screening pathway:

• Screen as soon as possible, in the first trimester.
• If background retinopathy seen at first screening, undertake screening review at 20 weeks and then again at 28 weeks gestation.
• If no retinopathy is seen at first visit then review at 28 weeks gestation.
• Retinal image sets graded. Routine recall for a non-referral grade and referral for slit lamp biomicroscopy for ungradeable image sets or those with a referral grade.
• Follow up screening at six months after birth.

Stage 3. Key steps in the ophthalmic services referral pathway

• Slit lamp biomicroscopy is carried out
• If retinopathy or other eye pathology is found they are referred for further investigations and treatment
• Patients are given counselling, frequent monitoring, follow up and returned to routine screening as appropriate
• Monitoring data collected on: Percentage of referred people who do not attend slitlamp biomicroscopy and percentage who do not attend for treatment.