1. Audit of suspected DMR case screening by GOPD in RAMP (Risk Assessment and Management Program) Dr. Amy ML Sze MRCS Hong Kong Eye Hospital

2. Background

3. Risk factor Assessment & Management Program All DM patient FU in GOPD Ophthalmologist FU Otherwise No / Mild NPDMR Refer to ophthalmologist Follow Up in GOPD

4. Objectives Audit of screening quality in terms of Correlation of diagnosis of referred case between GOPD and ophthalmologist The true negativity of those not being referred to ophthalmologist Possible implications to eye clinic Generation of cases need intervention s (e.g. laser, surgery) Generation of extra case load Route to download stable cases for FU in GOPD

5. Methods Case review of patients referred from KCC GOPD through RAMP from April - December 2010 Random audit of fundus photos from patients not being referred to ophthalmologist Audit of referral and download statistic Statistical Method: Weighted Kappa by SPSS

6. Demographics of seen RAMP cases (April – Dec 2010)

7. 265 patients [ 530 eyes ] Average age 65 yo M/F : 1.2/1 Average HbA1C: 7.6 (< 7 good control) One patient on insulin, other on OHA Nephropathy: 22 patients (9.8%) Neuropathy: 3 patients (1.3%)

8. Diagnosis from GOPD and HKEH

9. Results - Correlation of diagnosis

10. Visual Acuity (Snellen)

11. Correlation of diagnosis (April – Dec 2010) R0M0R1M0R1M1R2M0R2M1R2M2R3M0R3M1R3M2R4UO Subtotal R0M0119211510000000147 R1M01100000000002 R1M1116210000000019 R2M01922160000000048 R2M11301000000005 R2M20000000000000 R3M021021300020011 R3M10102110001006 R3M20000100100002 R40200012004009 U121130100000100136 O902901348000000145 Subtotal 36499431813210800530 132 / 530 = 25% GOPD HKEH

12. Statistical Correlation Weighted Cohen Kappa Value Measure percentage of data values and adjusts these values for the amount of agreement that could be expected due to chance alone 0.053 p < 0.001 95% CI 0.026 – 0.08 < 0.2 Poor 0.2 - 0.4 Fair 0.4 - 0.6 Moderate 0.6 - 0.8 Good 0.8 - 1.0 Very Good

13. Audit of Photos not being referred to ophthalmologist 144 fundus photos screened One with poor photo quality not being referred 143 eyes were all normal Negative Predictive value: 99.3%

14. Referral & Discharge Statistic

15. Referral Statistic (from GOPD) Feedback

16. HKEH Discharge Statistic ** Guidelines for download: No/Mild NPDR without other significant eye diseases

17. SRC Statistic – Feb 2011

18. Possible Implications

19. Intervention X Six eyes (1.1%) X Eleven eyes (2.1%)

20. Extra case load generated 318 eyes with cataract, 18 listed (5.7%) for cataract OT 49 eyes with dry ARMD (age-related macular degeneration) for observation 12 eyes with ERM (epiretinal membrane) for observation

21. Summary

22. Poor Diagnostic correlation between GOPD and ophthalmologist High negative predictive values of fundus photo screening under RAMP Generation of case load with stable disease (e.g. mild cataract with good VA) to specialty clinic Route to download stable cases for GOPD FU

23. Conclusions

24. Fundus photo screening under RAMP is a major move to facilitate DM patient to have regular eye check up Good platform for communication between general practitioners and ophthalmologists Better communication - better allocation of cases - better patient care

25. Acknowledgements Dr. PP Yip Dr. Dexter Leung Dr. CW Tsang Dr. NM Lam Dr. CC Chi Nursing Staff MRO staff All ECAs Appointment Staff

26. Thanks