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 Wisconsin II, III, IV (1984) % N=<996N=<1370

“Reclaim Democracy”

Prevalence of Proliferative Retinopathy (%) Kristinsson et al 1997 Diabetes 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 Kohner et al UKPDS 52 Diab Med 2001 UKPDS: n=2316 % needing laser 0.2% 1.1%

Progression of Retinopathy Any Type-2 diabetes: No baseline retinopathy Younis et al Lancet 2003 Liverpool Eye Study: n=9890, 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 ” Younis et al 2003, Diab Med 0.6%* 1.6% N=501: 2742 screening events 0.3% ST retinopathy 2.6%

Progression at 3 years Type-2 Diabetes: No baseline retinopathy Agardh et al Diab Care 2011 % progressed N= %* *Only ONE eye required laser Nb: HbA1c = 46 mmol/mol / 6.4%

Incidence of Retinopathy No baseline Retinopathy: T2 diabetes Annual Incidence per 100 patients N=57,199 (87% follow-up) Thomas et al BMJ 2012

Incidence of Retinopathy No baseline Retinopathy: T2 diabetes Outcome at 5 YEARS Incidence per 100 patients N=16,444 Jones et al Diab Care Norfolk

Progression in Type 1 diabetes from no baseline retinopathy: DRS Scotland N=7869 %

Progression in Type 2 diabetes from no baseline retinopathy: DRS Scotland N=101,539 %

Progression to STR from no baseline retinopathy % 2 years3 years UKPDS (laser)0.2 Wales –T Liverpool –T Liverpool – T Sweden – T20.2 Scotland –T21.4 (0.22)

Cost-effectiveness of retinal screening: 1 vs 3 years AGE45 yr65yr HbA1c11% (97mmol/mol) 7% (53 mmol/mol) Days of sight saved (1 vs 3yr) 213 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 Q CentresAutograder Sensitivity %95.5% Specificity %34.8%

What are we trying identify? What are we expected to identify? Non-diabetic pathology? Who does what?

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 2.9%1.8%4.0%4.8% Numbers doubling every 9-10 years

Number of patients receiving laser Number of patients with diabetes (x100) NUMBER OF PATIENTS RECEIVING LASER IN TAYSIDE Vallance et al Diab Care % reduction 60% increase

PERCENTAGE OF PATIENTS RECEIVING LASER % of patients receiving laser % of patients receiving incident laser Vallance et al Diab Care fold reduction for both

Prevalence of Blindness in Scotland due to Diabetes Scottish Diabetes Survey Figures Rate per 10,000

Prevalence of Blindness in Scotland due to Diabetes Scottish Diabetes Survey Figures Rate per 10,000 Fife

Visual Outcomes One episode of missing eye screening: 3.1x increased risk of laser From /17 Diabetes related blindness was due to poor attendance From 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 ~ % diabetes ,150 patients, 32,621 screening episodes Age 63 years 7.3yrs of diabetes 54% male 12% DNA rate Leese et al Diab Care 2008 BACKGROUNDSTUDY

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 ( min) Distance or Time NOT associated with attendance Appointments to mobile Unit: 2.9 ( ) x more likely not attend eye screening than Static Unit (p<0.01).

Deprivation as a risk of Non- Attendance SIMD Deprivation Category Relative Risk * * * p<0.01 Leese et al 2008

Lothian DRS Survey 2011 Interview of 20 DNAs Unaware of Importance5 Transport problems4 Other health problems4 Work3 Previous negative experience3 Lack of mobility2 Caring for others2 Bereavement1

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 prior 25.3% to 5.7% DNA rate Rheumatology clinic 72% wanted reminder 1-4d before 52% phone call most popular, Unless <28yr: text was most popular Four RCTs with 3547 participants Additional phone calls reduce DNA Text 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 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