DIABETIC RETINOPATHY

Irish ophthalmology saw its long-awaited national diabetic screening programme, known as Diabetic Retina Screen, finally began its phased roll-out this year. The programme encountered many issues along the way including the cost of anti-VEGF injections, convincing treatment centres to sign up to a new funding model, and a healthcare staff recruitment embargo.

Diarmuid Smith MD, FRCPI, Ireland’s Health Service Executive (HSE) National Clinical Lead for Diabetes, gave a detailed presentation on the development of the programme during the Irish College of Ophthalmologists annual conference. Attempts to set up a national diabetic screening programme in Ireland have been ongoing for more than 20 years, he told delegates.

Previous attempts to start a national screening programme in the early 2000s had been turned down by the Department of Health but despite this a number of local screening initiatives started. The success of these local screening initiatives have helped advocate for a national screening programme, Dr Smith told the conference. The programme was finally granted funding to launch in 2011 but its roll-out has proved more difficult than anticipated, largely due to the Irish health service’s recruitment embargo, so the necessary staff could not be recruited, Dr Smith explained.

The National Cancer Screening Service (NCSS) is to implement the national retinopathy screening programme. As part of this implementation a procurement process was undertaken and two external providers have been identified to deliver the retinopathy screening programme nationally. In addition, given the costs of the programme in a time of recession and the likely increase in retinopathy treatment demands, it was felt that a phased roll-out would be the best option.

There have been significant difficulties in accurately costing the new programme, partly due to the lack of Irish data on the number of people with diabetes, as well as the increasing use of anti-VEGF injections for some retinopathy patients when compared to laser injections, Dr Smith acknowledged. He said current calculations estimate that the programme should cost approximately €14m per year for screening and treatment when it is fully up and running.

Some ophthalmologists, speaking during the Q&A session, noted the use of anti-VEGF injections varies across Irish facilities. Dr Smith said a new clinical group involving ophthalmologists and vitreoretinal surgeons would be established to define clinical pathways for the use of anti- VEGF injections in patients with diabetic maculopathy and this work will help define in a more robust fashion the cost of treatment of diabetic eye disease for 2014 and in the future.

Dr Smith said the new programme offers free, regular diabetic retinopathy screening to all persons with diabetes aged 12 years and older, taken from a newly set-up national diabetes register. The programme calculates that about 18 per cent of screened patients will have a diabetes-related pathology; an estimated five per cent will have sight-threatening retinopathy (three per cent macular oedema and two per cent proliferative retinopathy), while a further seven per cent will have a non-diabetes-related eye problem.

Dr Smith said he hopes 30 per cent of eligible Irish diabetic patients will be screened in 2013, with the remaining 70 per cent in 2014, and that 100 per cent coverage can be achieved in 2015. The programme expects a 20 per cent ‘do not attend’ rate. About 250 patients were screened earlier this year on a pilot basis with the programme due to ramp up screening numbers to 500-1,000 patients a week shortly, if all goes to plan.

In addition, best practice standards for the operation of the programme have been created by a multidisciplinary quality assurance committee, which will be launched later this year. Significant challenges remain to be overcome to ensure the programme is fully rolled out. These include more accurate costings and ensuring those who are screened have immediate access to any necessary treatment. Dr Smith admitted there have been difficulties in convincing all seven treatment centres earmarked under the programme to sign-up, with three centres yet to do so.

A Limerick-based ophthalmologist told the conference that the funding stream for the programme, based on Ireland’s new ‘money follows the patient’ funding model, is more difficult to access and is not ring-fenced like cancer screening funds, which is why her centre has not yet signed-up. However, Dr Smith urged the remaining centres to “take a leap of faith” and sign-up so screening can commence in all parts of the country. Dr Smith stressed that Diabetic Retina Screen is the only new project the Irish health service has approved funding for in recent times and has been well supported by health management and policymakers, concluding that it is “fantastic” that the programme has finally been set-up.