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Call and recall: Who does what and when on the screening pathway

An effective DR screening programme screens all eligible people in a timely manner to enable early detection and management of retinopathy.
An effective diabetic retinopathy screening programme screens all eligible people in a timely manner to enable early detection and management of retinal disease and prevent blindness. To achieve this ambitious objective, programmes need locally appropriate screening protocols which balance available capacity against the cost of screening in the health system. Screening protocols set out when to first invite people with diabetes for their first eye examination (call) and then how often to re-invite them for re-examination (recall). There are international guidelines for use or adaptation in a local setting. These are based on the known evidence for the incidence and progression of diabetic retinopathy and diabetic macular oedema. At the first screening visit, the recall decision
is based on the level (or grade) of retinal disease identified: Patients with mild non-proliferative or no diabetic retinopathy can be safely screened at 1 to 2 year intervals. They do not need referral to an ophthalmologist. Patients with moderate to severe non-proliferative diabetic retinopathy should be seen earlier. Moderate at 6-12 months, severe at less than 3-4 months. Patients with proliferative diabetic retinopathy should be seen by an ophthalmologist within 1 month as they are at very high risk of sight loss. Patient with non-central involved diabetic macula oedema do not require a referral to ophthalmology but should be re-screened in 3 months and advised on blood sugar, blood pressure and cholesterol management.
Patients with central involvement of diabetic macular oedema are also at high risk of sight loss and, where possible, should be referred and seen within one month by an ophthalmologist. Pregnant patients are at risk of their diabetic retinopathy increasing and should be screened regularly during pregnancy. Trained graders follow referral protocols to minimise any extra burden to the programme from false positives. Using a referral protocol is viable only if eye care clinicians are available to assess and treat the referred patients. Establishing and administering a robust call and recall system can ensure that no one is missed out and no one is screened more often than necessary.
This involves: - Creating and managing a regular list of people with diabetes from doctors surgeries or pharmacy lists, ideally as an electronic database. - Calling newly diagnosed people with diabetes for their first screening within 3 months of diagnosis. - Capturing a detailed record of each screening event. - Ensuring that the recall booking system invites each patient to attend their next screening at the correct interval. An important practical consideration for managing a diabetic retinopathy screening programme database is that some people may need to be excluded or suspended from the database.
People who are excluded from the database are: - Those who cannot be treated for sight threatening diabetic retinopathy. For example, someone with advanced dementia is not able to co-operate with instructions when undergoing laser treatment. - People with no light perception in both eyes.
Reasons for suspension from the database include: - Children with diabetes under the age of 12 are at extremely low risk and don’t require screening. - People already under the active ophthalmic treatment. They are returned back to the screening once treatment is completed. - People who choose to opt out of screening. For example, medical treatment for another condition can mean someone doesnt feel able to attend screening. A time limit, of up to 3 years, should be set for the opt out.
Recall systems run over the long term and need to be managed by: - Maintaining up to date records of all screening locations (including their accessibility) and screening dates and times. - And providing each person with diabetes with appropriate and timely information about their screening appointment and the reason for it. Because the early progression of diabetic retinopathy is often symptomless, people with diabetes may not appreciate why they need to attend regular screening. The recall system must not be too frequent or unnecessary and it must gain the co-operation of people with diabetes. Appropriately informing people with diabetes
about screening includes: - Providing them with all the information they need to make an informed choice to attend. - Providing relevant information in a language and method they can understand. - Giving them the option to opt out of screening for a limited time after providing all relevant information. Even in highly resourced setting, managing the acceptance and attendance of screening by people with diabetes can be challenging.
Failsafe mechanisms to reduce loss to follow up include: - Employing a dedicated failsafe officer. - Using software to manage the database which flags up people who have missed appointments. - Following up with people who have missed screening either by choice or who have slipped through any gaps in the system. - And, ensuring good links between screening and referral centres to monitor people with diabetes being discharged back to the care of the screening programme.
Call and recall systems should monitor: - Coverage and uptake of the screening service: How many people with diabetes were invited and how many accepted. - And the number of people with diabetes lost to follow up.
In summary, - People with diabetes must be called into a diabetic retinolathy screening programme in a timely way. - The call and recall system must be co-ordinated through a nationally agreed protocol. - Systematic call and recall through a dedicated administrative system can ensure good coverage and uptake of screening services and prevent blindness from DR.

Good screening programmes track the quality of care provided and maintain key standards. After each screening and grading event, failsafe processes ensure that the required next steps on the pathway take place by:

  • Communicating the results of screening with the person with diabetes and their medical doctor
  • Ensuring timely referral for further investigations for those who need it
  • Tracking all referrals for treatment
  • Ensuring timely treatment appointments
  • Maintaining timely (e.g. annual) screening intervals for recall
  • Regularly collecting data on people who are blind from diabetic retinopathy (DR) for low vision services.

Below are short extracts from the recent Diabetic Retinopathy Barometer Report which highlighted the key challenges faced in implementing and managing screening services:

  • The lack of guidelines, standards of care and protocols
  • Gaps and barriers to referral.

The lack of locally appropriate guidelines and protocols

“The gap in access to, or application of, protocols and guidelines across all types of providers was serious and significant. Of particular concern was the finding that less than half of the providers either did not have access to protocols or, for some, the protocols available were not used.”
“The lack of written protocols and important guidelines relating to the diagnosis and treatment of diabetic eye disease must be of primary concern, particularly amongst providers who may not have the required training and experience.”

Gaps and barriers to eye care and referral

“The study also revealed barriers that were related to provider capacity such as: long waiting times to schedule an appointment with a specialist, the length of waiting time required in the clinic on the day of the visit, limited availability of necessary health services, and the distances to available services.”
“We are trying to draw their attention to the need of periodic ophthalmologic examinations. But unfortunately, we do not succeed 100% every time. A lot of our patients do not understand why they should come, even if they do not have anything with their eyes. “Why should I come?” they ask us. “Nothing upsets me,” they say.”
Ophthalmologist, Romania

In this video we introduce the call and recall system used to manage DR screening. As you watch, reflect on your own setting. Is there a guideline on call and recall intervals available or a system in place already? If not, how could one be set up? What are the main challenges that are, or are likely to be, encountered in managing a call and recall system in your setting?

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Diabetic Eye Disease: Building Capacity To Prevent Blindness

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