1. Diabetic Retinopathy Screening in Scotland Roderick Harvey DRS Lead Clinician

2. Population 5,144,200

3. The national programme White paper 2000 Commitment to develop a Scottish Diabetes Framework The framework will include plans to establish a national screening strategy for diabetic retinopathy

4. HTBS Report 2002 Aim – detection of sight threatening diabetic retinopathy Screening modalities Primary - digital retinal photography Secondary - slit lamp biomicroscopy

5. Benefits of photographic screening High sensitivity and specificity for sight threatening disease Ease of image acquisition, storage and transmission The opportunity for quality assurance through double reading Cost effectiveness

6. Publications

7. NHS QIS DRS Standards Screening delivered to a defined specification 80% of eligible people screened per year 100% of eligible people invited per year Call & recall in place using national software Arrangements for hard to reach groups Staff trained and qualified (or under supervision) Quality assurance is in place

8. Special features Single field macular centred image Mydriasis only if initial image of inadequate quality

9. Grading Feature based Software calculates final grade according to grading algorithm Outcome determined automatically All graders perform full grading Level 1 final grade normals only Level 2 final grade non referrable Level 3 final grade all referrable

12. Outcomes Re screen 12 monthsR0 or R1 M0 Re screen 6 monthsR2 or M1 Refer ophthalmologyR3 or above, or M2 Non diabetic lesions Technical failureR6 – inadequate image

14. Quality assurance All L1 & L2 graders have 500 image pairs per year regraded randomly by L3 grader External QA of images under development 1 st round of pilot completed 2008 External QA of programmes Standardised annual report template National Key Performance Indicators

15. Training & Accreditation City & guilds Level 3 Certificate in Diabetic Retinopathy Screening 140 people in Scotland registered 110 modules passed Slit lamp examiner standards and accreditation process defined

16. The Scottish National DRS Programme Responsibility for screening lies with the fourteen individual Health Boards Within each Board the programme is delivered to common standards defined by NHS QIS standards on DRS Policies developed by the DRS Collaborative Constraints embedded in the national DRS software National software for photography, administration and grading

20. SGHD SDG NSD Executive Group DRS IT Board PFIG Clinical Group Service Management As required Board Co-ordinators IT Users Group Short-life groups SCI-DC NSD IT Board The Board Programmes are all members of a formal DRS Collaborative

21. Implications of franchise model Adherence to national standards Sharing of a national database of eligible patients Ability to tailor the details of the delivery of the screening programme to suit local needs Fixed site photography Mobile units Image capture through optometrists

22. Eligible population All people resident in Scotland with confirmed diabetes Aged 12 years or older Not under the care of an ophthalmologist for treatment of diabetic retinopathy Not suspended for a valid clinical or organisational reason (excludes temporarily unavailable)

23. Suspensions Suspension ReasonSuspension Type Who suspends and can unsuspend Informed choice to opt outTemporaryGP Under AgeTemporarySystem Total Loss of VisionPermanentGP as advised by Ophthalmologist Terminal IllnessTemporaryGP Disabilities: Learning, Mental or Physical Temporary or Permanent GP Under the care of an OphthalmologistTemporaryRetinal Screening Administrator as advised by Ophthalmologist Temporarily UnavailableTemporaryGP or Retinal Screening Administrator DeceasedTemporary Permanent GP System Not DiabeticPermanentGP or other HCP Not Permanently Resident in ScotlandPermanentSystem

24. How is it all put together

25. Maintenace of the eligible population Recording of diabetes in a primary care system automatically registers the patient for DRS Dynamic link with SCI-DC and the CHI ensures that the population is accurately maintained Registration can also be done directly through SCI-DC or Soarian Suspensions are managed through SCI-DC and Soarian

26. Consortia server CHI SCI-DC GPASS Vision EMIS XML Messages Staging Server Soarian MobileAdminFixed SCI-DC Soarian

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32. How are we doing

33. Total living diabetic population 239,495 Eligible population 204,817

34. Invitation rate93.2% Attendance rate77.0% Successful screening rate73.7%

35. Overall Referable3.5% Observable1.9% Tech failure7.6%

36. Challenges

37. Slit lamp examination About 8% of patients require slit lamp examination Training & accreditation requirements defined Difficulty for small and dispersed boards in meeting the requirements

38. Optometry Most optometrists now have digital retinal cameras Photography is part of GOS contract for over 60s Opportunities for synergy and image capture by optometrists Challenges of integration with board wide screening programmes without compromise of quality standards on grading Framework for optometry image capture is being piloted in two health board regions

39. Ophthalmlogy Closing the loop Capturing outcome of ophthalmology consultations Ensuring appropriate suspension of patients under the care of ophthalmology Failsafe to track ophthalmology referrals Capacity

40. Quality assurance Need for more robust analysis of internal QA performance across all health boards Need to establish regular external QA image sets and define reporting formats

41. Future Automated Grading

42. Start Image of adequate quality? Microaneurysms present? Final Grade R0 M0 Refer to Level 2 Manual Grader Yes No

43. Automated Grading 6732 patients using gold standard grading for actionable retinopathy Automated grading 97.9% Routine manual 99.1% 33,535 patients from the Scottish DRS service the performance of automated grading for actionable retinopathy was Sensitivity 99.1% Specificity 59%

44. Automated grading DRS Collaborative commissioned an independent review of the performance of automated lesion detection software Four patients from 33535 (0.012%) may have missed clinically relevant maculopathy Cost to detect these patients in Scotland £275,000 pa Conclusion that it should be used for DRS programme in Scotland

45. Thank you for you attention