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Setting up screening: Practical issues

The key management steps within a DR screening service and the practical concerns to consider and address within the system.
Diabetic retinopathy screening programmes can be broken down
into 8 linked stages: 1. Invitation 2. Screening 3. Grading 4. Slit lamp biomicroscopy 5. Results 6. Referral and treatment 7. Monitor outcomes 8. Recall standards For a screening service to be effective, people with diabetes must flow easily along this pipeline across all the stages. Blocks in the pipeline, such as appointment delays, excessive grader workload or long waiting lists for treatment can result in adverse outcomes. Lets consider ways to maximise the flow of people with diabetes through this pipeline and minimise the blocks at each stage. Each programme does this before screening is established and during implementation. We’ll start with stage 1. Invitation to screening.
There are two key practical issues to consider here: programme location and information management.
Firstly, where will the programme be located? We can use evidence to establish the number of people with diabetes the programme will serve. Screening needs to be accessible and It should be carried out as close as possible to the population or the diabetes clinics they attend. These could be static or mobile tele-screening clinics. The screening venue also needs to be accessible, for example some people with diabetes may be in wheelchairs or have poor mobility.
If we plan to use optometry practices, its important to remember that optometrists are running a business and will need
to fit screening and grading into their model: - Is there is a suitable room to grade in? - Will they have sufficient time to grade images adequately? The benefits of optometry practices include the staffs knowledge of the eye and the accessible locations. Visiting all proposed screening venues will ensure they are fit for purpose.
Secondly - Information management. How will we know about our population? Screening programmes must maintain up to date records of each patients contact and address details. They also need to manage information about new cases, deceased patients, referrals, suspensions and excluded cases. This may require establishing links with doctors and diabetology clinics. Ideally, a failsafe officer will be responsible for managing the information using a database. Specific attention must be paid to managing information about pregnant patients who need more frequent screening. Making links with the maternity service can be very beneficial. Its important to know if a patient has miscarried as it can be extremely upsetting for these patients to be called for trimester screening.
Screening services must also inform and empower people with diabetes by promoting awareness of the service and the importance of regular checks. For example, by running eye health education events at diabetes clinics. Or by distributing posters and videos explaining screening and why it is so important. Stage 2 is the screening stage. Before any screening programme starts, its important to test the selected screening method. Ideally, a few test patients are put through the whole screening process to highlight any unexpected issues with the patient pathway. Support staff are key to screening. Cameras must be regularly tested and maintained. And information technology staff can be invaluable for resolving issues with equipment and software.
Programmes must provide screeners with training on how to use screening cameras and perform basic maintenance. The screening team must also be supported
to address the day to day issues which are likely to arise: - Keep a note book at each screening venue where screeners can record when they’ve had a problem. - Hold regular meetings to discuss issues with equipment and venues. - Produce a trouble shooting guide of the issues encountered and how they were resolved. Stage 3 is grading We must have an adequate number of graders for the grading pathway to work. To maintain high quality and stop bottle necks, a grader should only review each set of images once and pass on for any further arbitration as needed. Plans for graders workloads must also allow for holidays, maternity leave and sickness.
Workload queues should not be too large as this can delay referral of cases and lead to sight loss. Long grading queues can also cause stress to the graders who may try to grade too quickly and not pay enough attention to subtle changes. Stage 4. Slit lamp biomicroscopy The ophthalmologist for the screening service must assess ungradeable images and review patients in a timely way. And unnecessary referrals can cause delays. The slit lamp biomicroscopy report must be followed up for each patient, to establish their treatment pathway or recall them back to screening as needed. Stage 5 is the results stage. It is useful to have standard templates to communicate screening results to patients.
Clear explanations to go with the results can also be helpful, so that the patient is not unduly worried or is able to contact the programme for further support. Stage 6. Referral and treatment. Before screening starts, programmes must liaise closely with the local eye health service which will need to be reinforced to manage a huge increase in patient numbers once screening is implemented. Once screening is established, programmes must closely manage the referral links between screening and ophthalmic services. Even in highly resourced settings, eye health services do not always inform screening programmes of a patients status. Having a failsafe officer to monitor treatment timeframes and appointments will help to support and complete the patient pathway loop from treatment back to screening.
Patients do not always understand why it’s important to attend screening and treatment appointments. Phoning them to inform them of the referral as well as sending a letter or message will increase the attendance rate. Stage 7. Monitor outcomes. Much of the efficient running of a screening programme depends on the regular collection and review of data on activities and using this to make informed decisions. Its essential to establish a practical monitoring system that is relevant for the local health system. For example, do not install an electronic records system without training both the screening and treatment teams to use it. Stage 8. Recall standards.
Each programme must have clear clinical and administrative protocols on the screening process for the team to follow and, in particular, to monitor screening intervals. Any timeline breaches of agreed recall intervals may be due to capacity or demand within the programme. Quality assurance is vital for the efficient running of screening programmes. Many issues for example whether a screening venue is fully accessible - do not come to light until a programme is up and running. Frequent, regular meetings with staff during the first 6 months can help to identify and resolve issues as they emerge. In summary. The practical challenges of setting up a screening service are unique to each health system but taking an informed
and evidence driven team approach will: minimise delays, enable timely decision making, manage workload and ultimately reduce the incidence of blindness from diabetic retinopathy.

Implementing screening and treatment for diabetic retinopathy has been shown to be effective, and cost-effective, with much of the evidence from resource-rich settings.

From a public health perspective, screening for diabetic eye disease is one of the most cost effective health procedures available. Diabetic eye disease can be prevented using existing technology and the cost will be many times less than the economic and human cost of managing blindness from diabetes. Because of this, and despite the many challenges involved in screening, it can be argued that it is crucial to channel available resources to develop innovative strategies to increase awareness of and access to screening services and treatment for DR across all countries and settings.

To prevent blindness the connections between screening and the referral pathways have to be actively managed. The English national diabetic eye screening programme (Scanlon, 2003) uses three key performance indicators to ensure the process remains on track:

  1. Proportion of people with diabetes offered routine digital screening who attend a screening where images are captured: Acceptable target >75%
  2. Time between routine digital screening event or digital surveillance event or slitlamp biomicroscopy event and printing of results letters to the person with diabetes, GP and relevant health professionals: Acceptable target: 85% within 3 weeks and 99% within 6 weeks
  3. Time between screening event and first attended consultation at hospital eye services or digital surveillance. Acceptable time for urgent referrals: 80% within 6 weeks. Acceptable time for routine referrals: 70% within 13 weeks.

This video covers the key steps and practical concerns of managing a DR screening service. As you watch, consider the key practical challenges that need to be prioritised to realistically implement systematic early detection and management of DR in your setting. If systematic screening is already in place, what are its main challenges in your experience?

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Diabetic Eye Disease: Building Capacity To Prevent Blindness

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