SITUATION ANALYSIS FOR MANAGING DIABETIC RETINOPATHY IN TAKEO PROVINCE,

Dec 2012 Caritas Takeo Regional Eye Hospital

ACKNOWLEDGEMENTS

The evaluation team expresses their sincere appreciation to the National Eye Health Program team, Professor Ngy Meng, Director of NPEH; Professor Do Seiha, Vice Director and Coordinator for NPEH; and Professor Kong Piseth, a member of NPEH, Deputy Director and Chairman of the Department of Ophthalmology, Preah Ang Duong Hospital, , Cambodia. Additionally, Dr Hem Saret, Director Takeo Provincial Health Department; and Dr.Kheav Samros, Deputy Director of Provincial Health Department in charge of Dunkeo Referral Hospital (General Hospital) who also participated in the evaluation. Special thanks is also expressed toward the Caritas Takeo Eye Hospital management team and staff, for helping to make the necessary arrangements for appointments and visits to the Kiri Vong Referral Hospital Vision Centre. Particular acknowledgement to Dr Neang Mao, Mr Te Serey Bonn, Mr El Nimeth, Sr Myrna Porto, Sr Evangeline Dunton. The evaluation team also would like to thank the team at the Kiri Vong Referral Hospital and Kiri Vong Referral Hospital Vision Centre, and Dr Sambo (Director of the Kiri Vong Operational District). Funding for this program was provided by the Australia Agency for International Development (AusAID), Avoidable Blindness Initiative to CBM Australia / Caritas Takeo Eye Hospital.

EVALUATION TEAM

Rahul Chakrabarti1, Gail M Ormsby1, Mufarriq Shah1, Manfred Mörchen2, Jill E Keeffe3

1 PhD candidate, Population Health Unit, Centre for Eye Research Australia, The University of Melbourne, Royal Victorian Eye and Ear Hospital

2 Caritas Takeo Eye Hospital, Takeo, Cambodia; CBM

3 Head of Population Health Unit, Centre for Eye Research Australia, The University of Melbourne, Royal Victorian Eye and Ear Hospital

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TABLE OF CONTENTS Background ...... 5 Aim ...... 7 Objectives ...... 7 Methods ...... 8 Results ...... 10 The Need: Current Estimates of Diabetic Retinopathy ...... 10 Health Service Delivery ...... 11 Linkages and Networks ...... 13 Health Workforce and Strengthening Capacity ...... 15 Health Technologies and Infrastructure ...... 17 Health Information Systems and Management ...... 20 Health Financing and Sustainability ...... 20 Governance and Leadership ...... 21 Key Outcomes ...... 22 References...... 24

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ACRONYMS

AusAID Australian Agency for International Development

ABI Avoidable Blindness Initiative

CBMA CBM Australia

CBR Community Based Rehabilitation

CDMD Cambodian Development Mission for Disability

CERA Centre for Eye Research Australia

CTEH Caritas Takeo Eye Hospital

DM Diabetes Mellitus

DR Diabetic Retinopathy

HIMS Health Information Management System

KAP Knowledge, Attitude and Practice

KVRHVC Kiri Vong Referral Hospital Vision Centre

MoH Ministry of Health

MOU Memorandum of Understanding

NGO Non-Government Organisation

NPEH National Program for Eye Health

RAAB Rapid Assessment of Avoidable Blindness

URE Uncorrected Refractive Error

VA Visual Acuity

WHO World Health Organization

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EXECUTIVE SUMMARY

Background and context

Diabetic retinopathy (DR) is a microvascular complication of diabetes. Worldwide, the global burden of diabetes is estimated at 346 million.1 This is projected to increase to 438 million by the year 2030 (4.4% of the estimated world population). In Cambodia, it is estimated that the prevalence of any DR amongst people with diabetes is 30.3%.2 This is consistent with global meta- analyses data that showed one-third of patients with diabetes will have evidence of any DR, and one-third of those with DR will have vision threatening retinopathy (VTDR).3 Research has clearly demonstrated that blindness from diabetes is almost entirely preventable with early diagnosis, optimisation of risk factors, and timely photocoagulation where appropriate.4-6 Presently, 70 per cent of diabetes occurs in lower and middle income countries, where systematic screening for retinopathy is rare.7 The growth of diabetes and diabetic retinopathy is a concern for developing countries. According to the World Health Organization (WHO) in 2012, the age-standardised estimate of prevalence of diagnosed diabetes amongst adults (age 20-79) in Cambodia was 5.1%.8 King et al in 2005 estimated the prevalence of diabetes in a community-based survey of 5% in the Siem Riep province, and 11% in the , of which two-thirds of all cases of diabetes were undiagnosed prior to the survey.9 The WHO estimates the population with diabetes in Cambodia will increase to 317,000 by the year 2030.10 This will therefore impact upon the burden of vision impairment secondary to diabetes. Presently in Cambodia there is no systematic screening for DR. However, there is interest in using an evidence-based approach to guide future planning. This report will assess the existing infrastructure and the potential for the Kiri Vong Referral Hospital Vision Centre and Takeo Eye Hospital to screen, refer and manage patients with diabetes and diabetic retinopathy. At present, the Cambodian Government has expressed interest in addressing the issue of how to approach management of diabetic retinopathy. The NPEH committee has requested AusAID to fund the establishment of twelve diabetes clinics in 2013. It is intended that this preliminary report will provide insight into the current strengths and limitations of the health system to manage DR. This work will contribute to future research for the development of an evidence-based framework to guide the management of diabetic retinopathy as part of systemic approach to care for the patient with diabetes.

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Summary of Findings The situational analysis was conducted using themes adapted from the WHO Health System ‘Building Blocks’ that together constitute a complete system. 1. Health Service Delivery and Performance 2. Linkages and Networks 3. Health Workforce and Strengthening Capacity 4. Health information Systems and Management 5. Health Financing and Sustainability 6. Governance and Leadership

The situation analysis showed that the CTEH is the only facility in the Takeo Province with the capacity to examine and provide laser treatment of patients with diabetes for DR. Preliminary data suggests that DR accounts for 12% of all retinal pathology diagnosed at the CTEH. Eight of thirteen patients diagnosed with DR had mild non-proliferative retinopathy. People with diabetes access multiple sources of health care in the Takeo Province including health centres, general hospitals, community vision screening, and private medical practitioners. However, the CTEH is the only health care facility in the province with the capacity to perform retinal examination. Patients with diabetes can be referred for eye examinations from the KVRHVC, community outreach screening and the local NGO, Mo Po Tsyo to the CTEH. However, there is no referral of patients with diabetes from general hospitals, and currently it is estimated that only a small proportion patients are referred from KVRHVC or community outreach. Most patients with diabetes present to the CTEH as “walk-ins”. The health information management system for recording details of patients with diabetes can be improved. The CTEH health information system has recently started to record pertinent clinical information related to the eye examination for the patient with diabetes. However, the data entered at the KVRHVC is non-specific, and there is no established procedure for recording outcomes of patient follow-up. The cost recovery methods of the CTEH and KVRHVC involve sales of spectacles and nominal fees for cost-recovery. At the CTEH, approximately 30% of retinal examination fees are out-of-pocket for the patient. The KVRHVC continues to receive technical advice as required from the CTEH. There are no current national guidelines for diabetic retinopathy in Cambodia. There is no routine referral system for eye examination amongst patients with diabetes.

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AIM The aim is to perform a situation analysis of existing infrastructure at the Kiri Vong Referral Hospital Vision Centre (KVRHVC) and the Caritas Takeo Eye Hospital (CTEH) to examine and manage patients with diabetes mellitus for diabetic retinopathy.

OBJECTIVES The objectives of this research were guided by the National Strategic Plan for Blindness Prevention and Control, 2008-2015 (Cambodian Ministry for Health). The situation analysis assessed the possible role of the KVRHVC, CTEH and linkages with district hospitals in the care of patients with diabetes, and assessment and timely referral of people with diabetic retinopathy. The World Health Organization framework for health systems evaluation has guided the development of specific research themes to be used in this study. The objectives were: 1. Service Delivery and Performance in managing DR a. Describe and quantify the spectrum of functions performed by the CTEH to manage DR including: I. Diagnosis, treatment, referral, follow-up, and rehabilitation. II. Role of the CTEH and other health facilities in providing health promotion (information, education and communication) about diabetes and DR.

2. Linkages and Networks a. Describe linkages and referral pathways for patients with diabetes and DR between Vision Centres and primary health centres, CDMD, outreach services, public hospitals and the Caritas Takeo Eye Hospital. b. Identify service-related barriers to the delivery and utilisation of linkages and referral pathways. c. Describe what and how information is provided to patients with diabetes regarding DR, referral, the follow-up process, and reminders for screening.

3. Health Workforce and Strengthening Capacity a. Define the current roles and tasks performed by the workforce. b. Identify the capacity for training of the workforce and continuing medical education specifically for management of DR.

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4. Health Information Systems and Management a. Examine the content of health records, as to how diabetes and diabetic retinopathy and recorded. b. Describe the health information systems for patient record collection, storage, follow-up, and to show compliance with services.

5. Health Technologies and Infrastructure a. List the equipment at KVRHVC and CTEH to perform eye examinations for patients with diabetes and treatment of patients with retinopathy.

6. Health Financing and Sustainability a. For eye care services provided to the patients with diabetes, describe and quantify who pays (patient, government, NGO, private health insurance)

7. Governance and Leadership a. Describe the role and involvement of key stakeholders in the operation and overseeing diabetic retinopathy management at the CTEH and the KVRHVC. b. Describe the presence and rationale for clinical preferred practice statements or national guidelines.

METHODS Setting The situation analysis assessed the existing system for eye care management at the KVRHVC and Caritas Takeo Eye Hospital and their referral sources. Participants Key stakeholders consulted in the data collection phase included: (a) Policy level personnel (NPEH, Country directors for NGOs, Ministry of Health, Director of Takeo Operational District), (b) Workers at the Vision Centres and hospitals (Medical director, ophthalmologists, refractionists, ophthalmic nurse manager and educator, medical records personnel). Time frame of the Evaluation Data were collected over a two week period in mid December, 2012.

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Data collection Data were acquired from two main sources. 1. Existing information available in medical records and databases at Caritas Takeo Eye Hospital and the Kiri Vong Referral Hospital Vision Centre. 2. Semi-structured interviews and observational data from site visits and consultation with relevant stakeholders. Evaluation study questionnaires The evaluation study questionnaires were developed by the Population Health Unit at the Centre for Eye Research Australia (CERA). The questionnaires were designed to assess the specific objectives listed. Each questionnaire included items relevant to the particular health care setting and stakeholders (KVRHVC, CTEH, and NPEH). The 15 page questionnaire is obtainable from CERA on request. The questionnaires were divided into the nine themes as listed in the objectives. Informed consent was obtained from all participants in the evaluation.

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RESULTS

THE NEED: CURRENT ESTIMATES OF DIABETIC RETINOPATHY

Whilst there is a deficiency of absolute data regarding diabetes and DR in the Takeo province, several sources of information (in addition to RAAB estimates) have provided insight into the burden of the disease. Contemporary meta-analysis by Yau et al has showed the age-standardised prevalence of any DR amongst people with known diabetes at 35.4%, proliferative DR (PDR) at 7.2%, diabetic macular oedema (DME) at 7.5%, and vision threatening DR (VTDR) at 11.7%. Using the World Bank population estimate of for Cambodia (14.3 million) and the IDF estimated prevalence (3.0%) of known diabetes we estimated the distribution of the severity of DR. (Figure 1)

Estimated number of patients with diabetic retinopathy in Cambodia. 500000 429,155 450000 400000 350000 300000 250000 200000 148,488 150000 100000 31,071 32,101 50000 0 Population with Any DR Proliferative DR Diabetic Macular Diabetes Oedema

FIGURE 1. NUMBER OF PATIENTS WITH DIABETES AND SEVERITY OF DIABETIC RETINOPATHY IN CAMBODIA. IT IS IMPORTANT TO NOTE THAT THE PROPORTION WITH ANY DR INCLUDES PDR AND DME. THE PROPORTION WITH VTDR INCLUDES DME AND PDR. POPULATION OF CAMBODIA SOURCED FROM WORLD BANK STATISTICS (2011).11 PREVALENCE STATISTICS OF DR FROM YAU ET AL (2012).3

The Caritas Takeo Eye Hospital has a retinal service through its outpatient department that provides medical management of retinal pathology. We examined data from the CTEH as it was the only data currently available for patients with diabetes, albeit with a small sample of patients. Within the most recent time period of available data between January 2011 to September 2012, 102 patients with retinal pathology (n=13 with diabetic retinopathy) were assessed at the CTEH outpatient clinic.12 (Figure 2) The median duration of diabetes amongst the sample was 4.7 years. Amongst the patients with DR (n=13), 8 had mild non-proliferative DR (NPDR), 2 with moderate

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NPDR, 1 with severe NPDR, and 2 with clinically significant macular oedema. There were no patients with proliferative DR (PDR).

Types of retinal pathology diagnosed at the CTEH retinal clinic

2% 1% 1%

Retinal Detachment 6% Diabetic Retinopathy 8% Retinal Degeneration Retinal Dystrophy 8% Retinal Scar Retinal Vein Occlusion 12% 62% Retinal Artery Occlusion Retinal Hole

FIGURE 2. DISTRIBUTION OF RETINAL PATHOLOGY (N=102) DIAGNOSED AND RECORDED AT THE CARITAS TAKEO EYE HOSPITAL RETINAL UNIT. DATA SOURCED FROM CTEH RECORDS (2011-2012).

HEALTH SERVICE DELIVERY

CARITAS TAKEO EYE HOSPITAL: OVERVIEW

The Caritas Takeo Eye Hospital is a major tertiary ophthalmic facility, performing multiple roles in the provision of eye care in Cambodia. According to the 2011 NPEH annual report, 191,741 outpatient department examinations were performed in Cambodia, of those, 15% (n=28,964) were conducted at CTEH. Additionally, of the 22,762 cataract surgeries nationally, 10.5% (n=2,400) were performed at CTEH.13 Since 2009, the CTEH has provided the following services: Outpatient clinics: 105,178 outpatient department consultations were performed, of which 55% (n=57,807) were new consultations, and 45% (n=47,371) were existing patients. Overall, 14% (n=14,375) of all outpatient department consultations were for cataract, 11% were for refractive error, and 75% for other conditions which were not specified in the records. Surgery: 14,030 ophthalmic operations were performed at the CTEH, of which 61% (n=8,580) were for cataract extraction.

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Vision screening in the Takeo province: 8,828 people were screened for vision loss. 11% of the screened population had “normal” eyes. Amongst the population with ophthalmic pathology, 44% were diagnosed with cataract, of which 67% (n=2,198) were referred for surgery at the CTEH. Refractive Services and Optical workshop: Since 2009, the CTEH has performed 11,802 refractions and dispensed 6419 spectacles. Training: In 2011, the CTEH provided training of 9 resident doctors in the national ophthalmology training program, an additional 3 doctors in the diploma of ophthalmology program, 18 nurses in diploma of ophthalmic nursing, and training of one paediatric nurse and one orthoptic nurse. The diploma of ophthalmology program has since ceased. Diploma qualified and Basic Eye Doctors are now receiving training to be upgraded to ophthalmologists.

CARITAS TAKEO EYE HOSPITAL AND DIABETIC RETINOPATHY

Screening patients with diabetes for diabetic retinopathy has been a recent addition to the services of the outpatient department at the CTEH. The screening examination involves assessment of the patient’s visual acuity, measurement of intraocular pressure (IOP), and dilated fundoscopy which is performed by ophthalmologists. Patients with suspected refractive error are assessed by ophthalmic nurses trained in refraction; and those requiring spectacles are referred to the optical workshop. The CTEH currently does not provide pathology services for patients with diabetes as such services are located nearby in Provincial Regional Hospital (general hospital). The typical examination interval for patients with varying severity of DR attending the CTEH outpatient clinic is shown in the table below. Interestingly, for patients with nil to mild NPDR the current practised examination interval is 12 months. However, it was shown in the small cohort from CTEH that patients with diabetes had short duration from the diabetes diagnosis (median 4.7 years), and had mild DR. Further longitudinal data will provide insight into the true distribution of DR severity at CTEH. However, evidence has shown that extending the screening interval to two years for the majority of patients with diabetes who have nil-mild NPDR is a safe and practical approach to meet the demands of screening.14

TABLE 1. EXAMINATION INTERVAL FOR PATIENTS AT VARYING SEVERITY OF DR. SOURCED FROM CORRESPONDENCE WITH OPHTHALMOLOGIST AT THE CTEH, 2012.

Severity of DR Examination interval

Nil-Mild Non Proliferative DR 12 months

Moderate Non Proliferative DR 6 months

Severe Non Proliferative DR 3 months

Clinically significant Macular Oedema 1 month

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The CTEH also has the capacity for non-surgical treatment of retinopathy. It is estimated that two patients with diabetes referred to the CTEH outpatient department have been treated with retinal laser. The CTEH does not have vitreoretinal surgical expertise or equipment. Those requiring surgery for vitreous haemorrhage or vitreoretinal traction related issues are referred to the National Eye Hospital in Phnom Penh; the number of patients referred was not available. Beyond screening, the retinal unit is also involved in health promotion for patients with diabetes. Through the CTEH vision screening program, health education is provided during the screening days. Additionally, most patients referred for surgical assessment at the outpatient department are routinely asked of their diabetes status, but are not usually asked whether they have had a previous examination to the back of their eye. For all patients with diabetes, the CTEH provides general advice on diabetes control, and education about blindness from diabetes and treatment. Specifically, patients are educated on the complications of diabetes and the importance of regular eye examination. At present, there are no data regarding the quality of these services provided, and the impact of their effect on change in knowledge, attitudes and practice.

LINKAGES AND NETWORKS

The CTEH is the only facility in the province that has the capacity to perform dilated retinal examinations for patients with diabetes. People with diabetes are referred the CTEH outpatient department for examination and management from several sources including the Kiri Vong Referral Hospital Vision Centre (KVRHVC), outreach vision screening clinics, general medical hospitals, private clinics, and from Mo Po Tsyo (a local NGO involved in screening for diabetes in the community). Kiri Vong Referral Hospital Vision Centre The KVRHVC has been in operation since April 2010. The primary functions of the KVRHVC are provision of primary eye care, refraction, provision of ready-made spectacles and sunglasses, and participation in community eye screening. The staff at the KVRHVC cannot perform dilated retinal examinations so patients with diabetes are referred for eye examination at the CTEH. Review of the KVRHVC records between April 2010 and November 2012 documented 7,858 consultations of which 1,774 patients were referred to the CTEH. Amongst the patients referred from the KVRHVC to the CTEH, 47% (n=826) were for management of cataract, 44% (n=788) for “other” conditions, 8% (n=153) refractive error, and <1% (n=7) for glaucoma. However, there were no records to estimate the proportion of patients with diabetes seen at the KVRHVC or the proportion of those that were referred to the CTEH. Outreach vision screening The community outreach vision screening programs conducted by the KVRHVC and the CTEH are important sources of referral of patients to the CTEH outpatient department. Between January 2010 to October 2012, 8,828 patients were screened through the CTEH outreach program, of which 3,534 people were referred for examination at the CTEH. From the proportion of patients referred to the CTEH, 62% (n=2,198) were for cataract, and the remainder were for “other” Page 13 of 26 conditions. As patients with diabetes were not identified specifically at screening, it was reported that few patients with DR were referred from outreach screening for eye examination. Vision screening is conducted by the Kiri Vong Referral Hospital Vision Centre outreach program in the Kiri Vong District. From data obtained of referrals made from screening in the Kiri Vong District (2010-2011, n=2,997), it was estimated that cataract accounted for 39% (n=1158), refractive error 15% (n=439), and 46% (n=1,396) were recorded as “other” conditions. Analysis of the sources for patient referral to the KVRHVC showed that 82% of consultations were from “walk-in” patients. This opens the opportunity to enquire about the known diagnosis of diabetes or previous eye examination amongst patients with diabetes during the consultation as a simple method to facilitate early identification of people needing follow-up eye examination for diabetes related ocular complications. General Medical Hospital (Chronic Disease Clinic of Dunkeo Referral Hospital) General hospitals are a potential source of referral of patients with diabetes for an eye examination. The Dunkeo Referral Hospital is a general hospital in close proximity to the CTEH was staffed by three medical officers (doctors), and six nurses. Typically, patients with diabetes are asked by attending clinicians about their diabetes type, duration since diagnosis, and current treatment (oral medication, insulin). General hospitals have the facilities to perform and record a basic examination (weight and blood pressure measurement), and simple pathology tests for patients with diabetes. Patients with diabetes are provided general advice on diabetes control and informed about the complications of diabetes (including vision threatening disease). However, patients are not routinely asked if they have ever had an eye examination. Data on the proportion of patients with diabetes attending general hospital and those referred to CTEH were not available. There is no eye care provided at general hospitals, or referral protocol for patients with diabetes attending a general hospital to have an eye examination. Consequently, very few patients are referred to CTEH for eye examination. If required, patients with diabetes reporting or found to have deterioration in their vision are provided a verbal referral to attend the CTEH. Local Non-Government Organisation – Mo Po Tsyo The close network between CTEH and the local NGO, Mo Po Tsyo, offers an insight into how DR can be approached in low-resource settings. The Mo Po Tsyo program performs a screening for diabetes amongst the population at high risk across five . In their referral pathway, a research assistant visits households and those with evidence of an abnormal urinalysis (urine dipstick test for glucose, protein) are requested to have further blood tests and are advised to visit a referral hospital in their district on a particular date. That particular hospital is visited by a diabetologist (who is employed by Mo Po Tsyo) who performs the examination and investigation of these patients. Whilst this method may only capture the proportion of patients with diabetes with renal impairment, through interview with Mo Po Tsyo staff it was explained that this is a relatively inexpensive tool in a setting where glucometers (and their random blood sugar sampling

Page 14 of 26 strips) are not readily affordable. After consultation with the endocrinologist, patients with high risk factors (duration since diagnosis of diabetes, hypertension, poor glycaemic control) are referred for a retinal examination at CTEH and the Kien Khleang National Rehabilitation Centre Ophthalmology Service (Phnom Penh). The Kien Khleang ophthalmology service has the capacity to measure visual acuity, slit-lamp examination and retinal photography. Findings are recorded in a computerised health information system, and reported back to Mo Po Tsyo. (Appendix) The strength of collaboration between the Mo Po Tsyo clinic and the CTEH is evidenced by the increased numbers of referrals of patients with diabetes to the retina clinic from 44 patients in 2011, to 136 patients in 2012.

HEALTH WORKFORCE AND STRENGTHENING CAPACITY

CARITAS TAKEO EYE HOSPITAL

The CTEH has 3 ophthalmologists, 2 refractionists, 4 ophthalmic nurses (2 who are trained to perform refraction, and 2 who are also trained in low-vision and orthoptics), 2 nurse assistants, and 4 administrative staff. (Table 2)

TABLE 2. HUMAN RESOURCES AT THE CARITAS TAKEO EYE HOSPITAL, AND THEIR CURRENT TASKS PERFORMED, AND ADDITIONAL TASKS THAT COULD BE REALISTICALLY PERFORMED.

Cadre Number Current Tasks performed relating to the Additional tasks that could be assessment and management of diabetic performed with additional retinopathy training and resources Ophthalmic 5 History taking Fundus photography Nurse Examine visual acuity 2 trained in performing refraction 2 trained in low-vision and orthoptics Measure intraocular pressure Administer mydriatic drops Conduct patient counseling Provide medicine according to the prescription of doctor Instruct patients on how to use medication. Ophthalmologist 3 History taking Grading retinal photographs Dilated fundus examination Diagnosis Treatment (Laser)

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Intra-vitreal triamcinolone (corticosteroid for severe CSME) Nurse assistants 2 Examine visual acuity Fundus photography Complete health information records and forms Administrative 4 Patient registration staff Record keeping Retrieve patient records Enter patient data into the hospital health information system Facilitate patient after examination for other services

Optical 2 Make spectacle technician Provide advice to the patient on how to use or to care for their spectacle or sunglass. Refer patient to refraction department for re-check with their spectacle.

Screening for DR at the CTEH involves a vision technician, ophthalmologist, and an ophthalmic nurse. Patients referred to the outpatient clinic have visual acuity measured by a vision technician. The patient is then referred to the ophthalmologist. The ophthalmologist, after performing a primary examination then refers the patient directly for pupil dilatation. Once dilated, the patients are examined using dilated fundoscopy by the ophthalmologist. The ophthalmologist recommends further management (treatment with retinal laser or further observation). Patients who require refraction are provided another appointment specifically for refraction assessment at the CTEH. The CTEH is an important centre for clinical education of its staff. Whilst continuing medical education and training is provided to all staff at the CTEH, there is limited training specific to DR provided on-site. Currently, an ophthalmic nurse has received training to perform fundus photography at the Aravind Eye Hospital in Madurai, India. Additionally, in early 2013, a senior local ophthalmologist is scheduled to attend a two month training course in laser treatment methods for DR. Training for junior medical and nursing staff is provided at regular intervals, but also through informal updates and once-off workshops. Amongst other components, the retinal curriculum emphasises enabling doctors to distinguish between a normal fundus from that with DR.

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KIRI VONG REFERRAL HOSPITAL AND VISION CENTRE

The Kiri Vong Referral Hospital Vision Centre is staffed by two ophthalmic nurses, who are employees of the Kiri Vong Referral Hospital. The nurses are both ophthalmic trained, and one has additional training in refraction. (Table 3) Ophthalmic training for both nurses was provided as a one year course at the Caritas Takeo Eye Hospital. For refraction, a 3 month training program was facilitated at the national level Eye Hospital in Phnom Penh coordinated through the Brien Holden Vision Institute.

TABLE 3. HUMAN RESOURCES AT THE KIRI VONG REFERRAL HOSPITAL VISION CENTRE, THEIR CURRENT TASKS PERFORMED, AND ADDITIONAL TASKS THAT COULD BE REALISTICALLY PERFORMED.

Cadre Number Current Tasks performed relating to the assessment Additional tasks that and management of diabetic retinopathy could be performed with additional training and resources Ophthalmic 2 History taking Fundus photography Nurse Examine visual acuity Low vision assessment 1 trained in performing refraction Measure intraocular pressure Primary eye care tasks (eye swabbing, removal of corneal foreign bodies, removal of sutures) Diagnosis and referral to CTEH for surgical and emergent conditions (penetrating trauma, corneal ulcer, sudden loss of vision, cataract, posterior segment disease, suspected uveitis, trichiasis) Administrative – register and record all patient details, retrieve data for patient follow-up

HEALTH TECHNOLOGIES AND INFRASTRUCTURE

Overall, the CTEH has the basic infrastructure for retinal screening and non-surgical management of diabetic retinopathy. The current equipment available for dilated retinal examination includes a direct ophthalmoscope, slit-lamp with indirect lens, and binocular indirect ophthalmoscope. The CTEH has recently placed order for its first retinal camera (mydriatic camera, Carl Zeiss Inc.) which is estimated to be functioning in early 2013. The CTEH has capacity to perform retinal laser. (Table 4)

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TABLE 4. LIST OF EQUIPMENT AVAILABLE AND FUNCTIONAL AT THE CTEH THAT ARE RELEVANT TO THE ASSESSMENT AND MANAGEMENT OF DIABETIC RETINOPATHY.

Item Available and Functional

Direct ophthalmoscope

Slit lamp with indirect lens

Binocular indirect ophthalmoscope

Non-mydriatic retinal camera

Mydriatic retinal camera *Estimated to arrive in early 2013

Argon Laser

Yag Laser

Fundus fluorescein angiography *Estimated to arrive in 2013

Ultrasonography (A scan)

Ultrasonography (B Scan)

Vitrectomy console

Vitreoretinal surgical equipment

Surgical operating microscope

Optical coherence tomography (OCT)

Telemedicine equipment

Telemedicine infrastructure (internet)

Generator

Surgical standard clean running water

Autoclave (steam steriliser)

Steriliser (other)

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The KVRHVC have a good inventory of ‘Essential’, and ‘desirable’ equipment (based on the Vision 2020 suggestions for Vision Centres).15 The equipment that is pertinent to the identification of those requiring referral for formal diagnosis of DR is highlighted in the table. (Table 5)

TABLE 5. TABLE OF OPHTHALMIC EQUIPMENT FOR KIRI VONG REFERRAL HOSPITAL VISION CENTRES. DATA SOURCED FROM THE KIRI VONG REFERRAL HOSPITAL VISION CENTRE. GROUP STRATIFICATION DERIVED FROM VISION 2020 MANUAL (2011)15

Essential Available Desirable Available Ideal equipment Available equipment and Equipment and and functional functional functional

Flash light Tonometer Lea symbols Distance Vision Slit lamp with Low vision testing charts applanation kit tonometer

Near vision charts Auto refractor Glucometer Trial set Colour vision Standardised chart medical records software

Trial frames Blood pressure Non-mydriatic instrument retinal camera

Paediatric trial Thermometer frames

Slit lamp Telephone/ Mobile phone

Streak Computer retinoscope

Direct ophthalmoscope

Hand washing solutions

Generator Lensometer Occluder Near vision light Big mirror Optical rule Cross cylinder Medical Record books

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HEALTH INFORMATION SYSTEMS AND MANAGEMENT

Health records of patients attending the CTEH are hand-written and then entered into a computer database. The basic parameters that are routinely documented in the clinical notes for a patient with diabetes are demographics (age, gender, address), type of diabetes, presence of hypertension and hyperlipidaemia, presence and severity of retinopathy, current treatment regimen for diabetes, previous treatment of DR (laser, vitreoretinal surgery), and the management plan. For patients referred to the CTEH from Mo Po Tsyo, clinical parameters including duration of diabetes, presence and severity of DR, additional health co-morbidities and follow-up schedule are entered as a separate entity in the computer database. For ongoing follow up patients are provided with a card which states the date of their next appointment. The KVRHVC uses a similar combination to the CTEH of hand-written and computerised database methods for recording patient details. For all patients, standard recorded information includes: demographics (name, address, age, gender, socio-economic status, presence of self-reported disability), relevant brief general medical history, relevant family history, probable diagnosis, visual acuity, and a management plan. However, when clinical notes are entered into the database, there is omission of ophthalmic-relevant patient co-morbidities (such as diabetes). The referral system from KVRHVC to CTEH typically involves a referral note or letter. However, the KVRHVC does not receive notification if the patient has attended their appointment unless they are referred back from CTEH for follow-up. The KVRHVC does not have a system to enable accurate recording from periodic assessments of the same patient. In this context, it is foreseeable that the introduction of the non-mydriatic camera will be beneficial for diagnostic accuracy, teaching, and to facilitate monitoring the quality of services and follow-up for patients with diabetes.

HEALTH FINANCING AND SUSTAINABILITY

There were limited data regarding out-of-pocket expenditure for patients with diabetes attending outpatient department at the CTEH for management of DR. The cost recovery strategy at the CTEH has set the platform for its expansion of services. The hospital estimates that approximately 30% of costs for retinal examinations are paid for by patients and 70% from NGO funding. According to the CTEH Annual Report in 2011, the hospital has three private rooms designated for full-fee paying patients. The optical workshop based at the CTEH estimates 49% of spectacles dispensed are paid the full price (ranging from US$2 to $6).16 Furthermore, according to the memorandum of understanding between Mo Po Tsyo and CTEH, patients referred from Mo Po Tsyo to CTEH are required to pay a registration fee of 4,000 Riel (US$1), which includes the fee for the first consultation. The fee for follow-up consultations is 2,000 Riel (US$0.5). For patients referred from Mo Po Tsyo, transport costs are incurred by the CTEH, and any laser treatment for DR is provided free of charge.

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In the case at the KVRHVC, records specific to the out-of-pocket expenditure for patients with diabetes were not available. Previously, the KVRHVC had an ‘Equity fund’ for patients from lower socioeconomic backgrounds with limited resources to obtain their spectacles. This funding now comes from the Government. The KVRHVC also accepts a nominal user fee from patients who can afford a certain percentage but not the full cost of their care. The KVRHVC has generated cost recovery from the sale of glasses. This has made a positive contribution to the income of the Kiri Vong Referral Hospital. It currently supports the cost of salaries and provides a sustainable supply of glasses. Within the region is it stated that approximately 30% of the population is below the poverty line. There are some patients who cannot afford the total cost of eye care and glasses. Some patients have been subsidised by the hospital.

GOVERNANCE AND LEADERSHIP

The CTEH and the KVRHVC are the only providers of public eye care services in the Takeo Province. The sustained performance of the CTEH and the KVRHVC can largely be attributed to the strength of governance and stakeholder (Government and Non-Government Organisation) contributions. Both these facilities have established themselves as trusted points of eye care within the public health system. In addition to community outreach screening, the CTEH and KVRHVC have engaged with local stakeholders (general hospitals, CDMD, health centres) to conduct eye health promotion as an important component of the holistic approach to healthcare, and to facilitate early referral of people with vision impairment. In the context of DR, progression to blindness can almost always be prevented through early detection of diabetes and timely referral for eye examination. Opportunistic referral of patients with diabetes for eye examination occurs from KVRHVC and Mo Po Tsyo to the CTEH. However, at present, the presence and use of clinical practice guidelines for screening and treatment of DR do not exist in Cambodia. There is no process of routine referral of patients with diabetes who attend other medical facilities. Emphasis must also be placed upon data collection and reporting of diabetes and its complications. This may be enhanced by the presence of guidelines for health management information systems across all levels of health care. Accurate collection and reporting of data pertaining to diabetes and DR will also enable essential key performance indicators to be monitored for future planning of service delivery.17 (Table 6)

TABLE 6 KEY PERFORMANCE INDICATORS AT A NATIONAL LEVEL RELEVANT TO DIABETIC RETINOPATHY. SOURCED FROM THE GLOBAL INDICATORS TO MONITOR ELIMINATION OF AVOIDABLE BLINDNESS REPORT, 2012.18

Prevalence of blindness and vision impairment due to diabetic retinopathy Coverage of screening services: Percentage of patients with diabetes that undergo eye examination Coverage of treatment services: Percentage of patients with diabetes that are treated with retinal laser

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KEY OUTCOMES

Health Services The CTEH is the only facility in the Takeo Province with the capacity to examine and provide laser treatment of patients with diabetes for diabetic retinopathy. People with diabetes access multiple sources of health care including health centres, general hospitals, community vision screening, and private medical practitioners. However, currently there is a paucity of information on the quality of services provided for patients with diabetes due to health information management systems. Health Workforce and Training Currently there is no capacity for posterior segment examination at the secondary (district hospital) level. This could possibly be achieved with non-mydriatic retinal imaging and training vision centre workers to use the technology. Health Management Information Systems Currently there is no accurate record of the number of people with diabetes who are presenting to health care facilities or the proportion who are being referred for eye examination at the CTEH. The CTEH health information system does record pertinent clinical information related to the eye examination for the patient with diabetes. However, the data entered at the KVRHVC is non- specific, thus not providing specific information on all important causes of vision impairment that is required to estimate the need, monitor key performance indicators, and plan service development. Additionally, there is no established procedure for recording of follow-up management of patients. Referral Pathways Patients with diabetes can be referred for eye examinations from the KVRHVC, community outreach screening and the local NGO, Mo Po Tsyo to the CTEH. However, there is no referral of patients with diabetes from general hospitals, and currently it is estimated that only a small proportion patients are referred from KVRHVC or community outreach. Most patients with diabetes present to the CTEH as “walk-ins”. Although it is at early stages, the collaboration between CTEH and Mo Po Tsyo has demonstrated that such a partnership can be a successful approach to conduct a DR screening program in Cambodia. The large proportion of “walk-in” patients attending the KVRHVC and community outreach presents the opportunity at these sites of primary care to increase community awareness of diabetes, identify patients at risk of DR, and facilitate early referral for eye examination.

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Sustainability The sustainability of the CTEH and KVRHVC has been demonstrated through their successful integration into the public health care system. Both facilities have used sales of spectacles and nominal fees for cost-recovery. At the CTEH, approximately 30% of retinal examination fees are out-of-pocket for the patient. The KVRHVC continues to receive technical advice as required from the CTEH. Governance There are no current national guidelines for diabetic retinopathy in Cambodia. There is no routine referral system for eye examination amongst patients with diabetes.

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APPENDIX APPENDIX A: RECORD OF AN EYE EXAMINATION OF A PATIENT WITH DIABETES REFERRED FROM MO PO TSYO TO THE KIEN KHLEAN NATIONAL REHABILITATION CENTRE OPHTHALMOLOGY SERVICE. SOURCED FROM MO PO TSYO (NOVEMBER, 2012)

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REFERENCES

1. WHO. Diabetes fact sheet. 2011; http://www.who.int/mediacentre/factsheets/fs312/en/index.html. Accessed 13/12/2011, 2011. 2. Ruamviboonsuk P, Wongcumchang N, Surawongsin P, Panyawatananukul E, Tiensuwan M. Screening for diabetic retinopathy in rural area using single-field, digital fundus images. J Med Assoc Thai. Feb 2005;88(2):176-180. 3. Yau JW, Rogers SL, Kawasaki R, et al. Global Prevalence and Major Risk Factors of Diabetic Retinopathy. Diabetes Care. Mar 2012;35(3):556-564. 4. Photocoagulation treatment of proliferative diabetic retinopathy. Clinical application of Diabetic Retinopathy Study (DRS) findings, DRS Report Number 8. The Diabetic Retinopathy Study Research Group. Ophthalmology. Jul 1981;88(7):583-600. 5. Early photocoagulation for diabetic retinopathy. ETDRS report number 9. Early Treatment Diabetic Retinopathy Study Research Group. Ophthalmology. May 1991;98(5 Suppl):766- 785. 6. Mohamed Q, Gillies MC, Wong TY. Management of diabetic retinopathy: a systematic review. JAMA. Aug 22 2007;298(8):902-916. 7. Friedman DS, Ali F, Kourgialis N. Diabetic retinopathy in the developing world: how to approach identifying and treating underserved populations. Am J Ophthalmol. Feb 2011;151(2):192-194 e191. 8. Global Health Observatory Data Repository: Blood glucose. In: WHO, ed. Geneva2012. 9. King H, Keuky L, Seng S, Khun T, Roglic G, Pinget M. Diabetes and associated disorders in Cambodia: two epidemiological surveys. Lancet. Nov 5 2005;366(9497):1633-1639. 10. WHO. Diabetes facts. 2010; http://www.who.int/diabetes/facts/world_figures/en/. Accessed 16/12/2012. 11. The World Bank Group: Total population of Cambodia. . 2012; http://data.worldbank.org/indicator/SP.POP.TOTL?cid=GPD_1. Accessed 20/12/2012. 12. Morchen M, Ang C, Mao N, Van Pelt M. Outcome of screening for diabetic retinopathy in collaboration with community based peer educators in Takeo province, Cambodia. Asia Pacific Ophthalmology Association (APAO), 2012. Busan, Korea.2012. 13. NPEH. Annual report of the National Committee for Prevention of Blindness, Cambodia. Phnom Penh2011. 14. Chakrabarti R, Harper C, Keeffe J. Diabetic retinopathy management guidelines. Expert Review of Ophthalmology. 2012;7(5):417-439. 15. Vision2020. Vision Centre Manual. New Delhi, India: VISION2020: The right to sight India;2011. 16. Annual Report: Caritas Takeo Eye Hospital 2011. http://www.caritascambodia.org/teh/tehdocs/annualreport/Annual%20Report%202011.p df. Takeo: Caritas Cambodia;2011.

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17. WHO. Global initiative for the elimination of avoidable blindness. Action Plan 2006-2011. Geneva: WHO;2007. 18. CERA. Global Indicators to Monitor Elimination of Avoidable Blindness. Melbourne: Centre for Eye Research Australia;2012.

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