We are testing a new beta website for gov.scot go to new site

Diabetic Retinopathy Screening Services in Scotland: Recommendations for Implementation

Listen

DIABETIC RETINOPATHY SCREENING SERVICES IN SCOTLAND: RECOMMENDATIONS FOR IMPLEMENTATION

Diabetic Retinopathy Screening: Annex F

Health Technology Assessment Advice 1: Organisation of services for diabetic retinopathy screening

Screening attendance

DRSIG Recommendation

People diagnosed with either type 1 or type 2 diabetes mellitus and aged over 12 years, or post puberty, should be included in the national screening programme unless they are unlikely to benefit from screening.

HTA Report 1,
Sections 6.5
Advice 2.2

Exclusion criteria to be included in DRS Manual and will be built into patient management and recall software. [Paragraph 87].

No upper age limit is suggested, but the following people are unlikely to benefit from screening:
• those who are already undergoing regular reviews by an ophthalmologist
• those who are medically unfit to receive laser treatment (as determined by their GP), or
• those who are irreversibly blind

Advice 2.3

Exclusion criteria to be included in DRS Manual and will be built into patient management and recall software. [Paragraph 87].

Appointment cards should be available in large print and information should be prepared in accessible formats (large print, disk, audio).

HTA Report 1,
Section 7
Advice 2.4

Examples and templates of patient information will be included in the DRS Manual. [Paragraphs 87 & 93].

Up to two written reminders are recommended to encourage attendance. Additional reminders have been shown to be ineffective. Instead, health professionals should discuss any barriers to screening attendance with people with diabetes.

HTA Report 1,
Section 7
Advice 2.5

Examples and templates of patient information will be included in the DRS Manual [Paragraphs 87 & 93].

Special attention should be given to targeting those who have never attended screening or who have not attended recently

HTA Report 1,
Section 7
Advice 2.6

Examples and templates of patient information will be included in the DRS Manual. [Paragraphs 87 & 93].

To encourage uptake of screening, a choice of venues and appointment times should be made available, to be facilitated in order and welcoming, and those attending should be treated as individuals.

HTA Report 1,
Section 7
Advice 2.7

Patient satisfaction with the DRS service should be monitored. [Paragraph 19].
Collaboration and communication surroundings should be pleasant between areas to share good practice. [Paragraph 84].


Screening process

DRSIG Recommendation

The national screening programme must be fully quality assured with systematic call/recall, failsafe (see paragraphs 2.12 and 2.14) and follow-up

HTA Report 1,
Section 6.14
Advice 2.8

Quality standards will be defined by NHS Quality Improvement Scotland. [Paragraph 65].
Development of software to support DRS to be funded by Scottish Executive. [Paragraph 105].

To be effective, the national screening programme must be integrated with routine diabetic care. Clinicians responsible for the ongoing care of people with diabetes must be informed of results, not only for sight-threatening retinopathy requiring referral to an ophthalmologist, but also for any retinopathy.

HTA Report 1,
Section 6
Advice 2.9

Software for DRS will be fully integrated with diabetes clinical management systems (SCI-DC). [Paragraph 54].

Digital photography, with or without mydriasis (dilation of the pupils with eye drops), is of sufficient sensitivity and specificity to be used in a population based, systematic diabetic retinopathy screening programme. Furthermore, it produces a permanent record of the retinal image that is useful for quality assurance purposes.

HTA Report 1,
Section 5
Advice 2.10

Scotland should be moving towards a fully camera based system. The DRSIG report establishes a timetable for the delivery of the key stages.[Paragraph 6].

Some people with diabetes are deterred from attending screening visits by the need for eye drops. Furthermore, as digital photography without mydriasis has been shown to be cost effective for screening purposes, it is recommended as the first stage in the screening programme, unless the individual is known to need mydriasis.

HTA Report 1,
Section 7.3.3.6
Advice 2.11

DRSIG endorses the three-stage process recommended by HTBS. [Paragraph 5].

HTBS recommends that people with diabetes should be screened annually using the following three-stage process.
(1) Macular single field digital retinal photography, without mydriasis, for each eye.
(2) If there is a technical failure, macular single field digital retinal photography, with mydriasis for each eye.
(3) If there is a technical failure with mydriatic digital photography, biomicroscopy with a slit lamp.
Visual acuity, with refractive correction if required, should be recorded for each eye immediately prior to the screening examination.

HTA Report 1,
Section 9.2
Advice 2.12

DRSIG endorses the three-stage process recommended by HTBS. [Paragraph 5].

If mydriasis is used, tropicamide is the recommended agent. It must be administered by a professional complying with the Patient Group Directions and the possible adverse effects of the mydriatic agent should be clearly explained to patients. Mydriatic agents can cause blurred vision and sensitivity to light for up to six hours, or longer in isolated cases. Other rare side effects may include glaucoma and allergic reactions

HTA Report 1,
Section 3.5.3
Advice 2.13

The question of Patient Group Directions needs to be resolved. [Paragraph 26].

Retinal images should be graded according to the Scottish Diabetic Retinopathy Grading System. A three-level grading process is recommended, with images referred up to the next level if the grader identifies any potential sign of retinopathy.

HTA Report 1,
Section 6.10
Advice 2.14

DRSIG endorses a modification of the grading system recommended by HTBS. [Paragraph 43].

All graders must be specially trained, accredited and competent, with the more experienced professionals involved in the second (optometrist/ senior grader) and third (ophthalmologist) levels of grading.

HTA Report 1,
Section 6.13.5.1
Advice 2.15

A training manual for graders will be published and appropriate training courses will be established. [Paragraph 41/42].

Accredited optometrists are well suited to be part of the national screening programme, for the first and second level grading and screening with digital retinal cameras, or for slit lamp screening of those not amenable to digital cameras. Their value for money will depend on the fee charged and the cost of local alternatives.

HTA Report 1,
Section 6.13.3
Advice 2.16

DRSIG report includes recommendations regarding. optometrist fees. [Paragraph 107].

Results of screening should be communicated to people with diabetes and GPs in a timeous manner. The timeframe for this should be agreed at the outset of the national programme as part of the quality standards.

HTA Report 1,
Section 7
Advice 2.17

This will be included in the standards to be published by NHSQIS. [Paragraph 65].

Direct ophthalmoscopes should only be used opportunistically for persistent non-attenders who would not otherwise receive a retinal examination.

HTA Report 1,
Section 5
Advice 2.18

DRSIG endorses this view.

Further research should be undertaken as the screening programme is rolled out to enable optimal service provision.

HTA Report 1,
Section 9.3.7
Advice 2.19

The DRSIG supports the need for research. [Paragraph 98/99].


Technical requirements

DRSIG Recommendation

In the short-term, simple standardised call/recall systems should be established locally or regionally, which can be integrated into the national system being developed under the Scottish Care Information - Diabetes Collaboration (SCI-DC). This will require the inclusion of optometrists on the NHSnet to facilitate the appropriate flow of data between health professionals.

HTA Report 1,
Section 6.8
Advice 2.20

Work to define and develop a national call/recall system is ongoing[Paragraph 52].

The screening programme should use digital retinal cameras for all individuals amenable to photography. Higher resolution digital cameras(of at least 1365 x 1000 pixels) are recommended. Image transfer should use a direct digital route to avoid degradation of quality. The image should be graded on a computer or terminal with a cathode ray tube(CRT) monitor of at least 19 or 21". Images should be graded at capture resolution until further evidence on the acceptability of compressed JPEG images becomes available.

HTA Report 1,
Section 6.11
Advice 2.21

Guidance about cameras and image transmission is included in this report. [Paragraph 45-49].


National and local structure

DRSIG Recommendation

The National Services Division (NSD) will work with the Clinical Standards Board for Scotland (CSBS) and NHS Boards to ensure a consistent, coordinated approach to the national screening programme through the creation of national specifications and the sharing of good practice and audit results.

HTA Report 1,
Section 6.15
Advice 2.22

NHS Quality Improvement Scotland are leading on work to produce national standards. [Paragraph 65]. The DRS collaborative network will provide a mechanism to share good practice and audit results. [Paragraph 84].

CSBS will develop and publish national standards for the programme with NHS Boards, based on the work of the National Standards Screening Committee and will review the performance of NHS Boards against these standards

HTA Report 1,
Section 6.15
Advice 2.23

NHS Quality Improvement Scotland will publish draft national standards in May 2003. [Paragraph 65]. Reviews will be undertaken once DRS services are in operation[Paragraph 68].

NHS Boards should identify a 'named individual' who is empowered to take local responsibility for the diabetic retinopathy screening programme and work in close collaboration with NSD to plan the local rollout and implementation of the programme.

Advice 2.24

NHS Boards should appoint a lead clinician [Paragraph 31]. NSD will appoint a DRS network co-ordinator to foster collaboration and communication and support local implementation. [Paragraph 85].

A subgroup of the Local Diabetes Service Advisory Group should monitor and report on the local diabetic retinopathy screening programme.

HTA Report 1,
Section 3.2.3
Advice 2.25

No specific recommendation made. However, a subgroup of the LDSAG would ensure that retinopathy screening remains firmly integrated with other aspects of diabetes care.

NHS Boards should plan, establish and commission screening services to meet the needs of local populations according to the national specification, with local variation agreed where appropriate. Options based in health facilities, mobile units and optometric practices are compared in the report and this information should be considered in the local context. For efficiency, collaboration between neighbouring NHS Boards is recommended.

HTA Report 1,
Section 6.4 and Section 8
Advice 2.26

DRSIG looks to each NHS Board to undertake a needs assessment and define the best means of delivering DRS to their population. The network DRS collaborative will promote and encourage collaboration. [Paragraph 84]. The potential to share facilities should be explored. [Paragraph 103].

NHS Boards should promote screening uptake and provide information in keeping with national standards and in conjunction with the Health Education Board for Scotland (HEBS).

HTA Report 1,
Section 7
Advice 2.27

A patient information leaflet to inform people about the screening process and to promote uptake has been developed. [Paragraph 95].


Information needs

DRSIG Recommendation

NHS Boards should monitor local performance of the programme using CSBS standards and agree any action required, particularly in response to the regular CSBS peer reviews of performance against national standards.

HTA Report 1,
Section 6.14
Advice 2.28

Local systems for QA (in line with standards set by NHSQIS) must be put in place by NHS boards and monitored by local clinical governance arrangements. [Paragraph 65]. A framework for inter-board sharing and support will be facilitated by the 'DRS network Co-ordinator'. [Paragraph 84].

NHS Boards should record the local performance of the screening programme within their overall Diabetes Annual Report which, according to the Scottish Diabetes Framework, all NHS Boards will be expected to produce.

Advice 2.29

DRSIG endorses this recommendation. [Paragraph 90].

People with diabetes and all health professionals involved in the delivery of diabetic care should be informed about the screening programme, including the screening process, its limitations and possible outcomes. A variety of methods should be used to determine the most effective and efficient approaches for specific audiences.

HTA Report 1,
Section 7.3.1.3
Advice 2.30

Examples and templates of patient information will be included in DRS Manual. [Paragraph 87].

Before attending screening, people with diabetes should be informed of the possible need for mydriasis and its effects. They should be informed that if mydriasis is used:
• their eyes will be more sensitive to light
• driving is not recommended for at least two hours after mydriasis
• the effects may last longer in some individuals.

This information should be available in accessible formats (large print, disk, audio).

HTA Report 1,
Section 3.5.3
Advice 2.31

Examples and templates of patient information will be included in DRS Manual. [Paragraph 87].