INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE

Contents

Acknowledgement 5 Evidence-based leaflet to promote uptake Acronyms 6 of retinal screening among young adults Why this report 7 in Australia 19 Introduction 9 Preventing Blindness from Diabetic Retinopathy and Other Diabetes-Related Integration –What do we mean Eye Diseases in Armenia 23 and what does it look like? 11 Comprehensive, integrated diabetes care 1. INTEGRATION OF EYE CARE INTO for children in Bangladesh 27 ROUTINE DIABETES CARE/PRIMARY CARE 12 A successful integration of DR into 2. INTEGRATION OF DIABETES INTO comprehensive, county-level eye care in COMPREHENSIVE/PRIMARY EYE CARE 12 rural China 31 3. HORIZONTAL AND VERTICAL Reduction in Blindness in the English INTEGRATION OF SERVICES 12 County of Gloucestershire 33 4. INTEGRATION OF DR POLICIES, Diabetes eye care awareness training GUIDELINES AND TRAINING INTO ALL for primary level clinicians in Fiji 37 RELEVANT NATIONAL HEALTH POLICIES, Integrated Models of Care for Diabetic AND GUIDELINES 12 Retinopathy in India 41 Guiding Principles for Integrated Addressing Diabetic Retinopathy in Indonesia 45 Diabetes and Eye Health Care 15 Modelling a Telemedicine Screening Program People-centred care 15 for Diabetic Retinopathy and Implementing Equity 15 a Pilot Project in Iran 49 Quality 15 Screening for Diabetic Retinopathy in México, Collaboration 16 Telemedicine: Pilot Project 53 Evidence Base 16 Integrated Approaches to Address Diabetic Cost Efficient 16 Retinopathy in three Districts of Pakistan 57 Recommendations 16 Comprehensive Model of Diabetic retinopathy Management in the Palestinian Territories 61 Recommendations for Primary Health Care Providers: Preventative Action, Implementing an Integrated Diabetic Improved Results 16 Retinopathy Health System Model in La Libertad, Peru 65 Recommendations for Secondary & Tertiary Care Providers: Working in Evidence-Based Shared Care Eye Model: Collaboration to Overcome Barriers 17 Right Siting Of Stable Diabetic Retinopathy Patients To Primary Eye Clinic In Singapore 69 Recommendations for Government: Driving Change, Exerting Influence 17 Upscaling of diabetic retinopathy screening in Tanzania 73 Recommendations for Donors, Funding and Investment Partners: Financing for Impact 18 Diabetic eye health care model of integration at the inter and intraprofessional levels at International Case Studies of Integrated a community health center in the US 77 Care for Diabetes and Eye Health 19 Diabetic retinopathy screening and treatment in Zambia 81 DR Screening event at the Standard Chartered Bank head office in Nairobi, Kenya

2 3 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018 Acknowledgement

‘Integrated care for diabetes and eye health: The Leadership Group of the initiative would Recommended A global compendium of good practice’ has like to thank the contributing authors of the Citation been developed by the partners of the Global case studies presented in the compendium Diabetic Retinopathy Advocacy Initiative. for their time spent developing this important Global Diabetic content and for their collaboration with the Retinopathy The initiative is a multi-agency advocacy compendium authors. Advocacy Initiative. project being undertaken by leading non- Integrated care for government agencies in the diabetes and eye The compendium was written and compiled diabetes and eye health sectors from 2017-2018. The current by The Fred Hollows Foundation. For more health: A global Leadership Group for the initiative includes: information please contact the Global compendium of good The Fred Hollows Foundation; Helen Keller Partnerships and Advocacy Division, The Fred practice. Melbourne, International; The International Agency for Hollows Foundation [email protected] Australia, 2018. the Prevention of Blindness; International Council of Ophthalmology; International Note: Photos have been used with the Diabetes Federation; Lions Clubs International permission of the case study authors and or Foundation; Orbis International; Sightsavers provided by The Fred Hollows Foundation International; The Queen Elizabeth Diamond Jubilee Trust; World Council of Optometry; and in association with the World Health Organisation.

Disclaimer:

Case studies presented in this compendium were selected following an international call for expressions of interest and reflect an intention to provide readers with brief examples of programs from a broad range of contexts. Inclusion of individual case studies in this compendium does not reflect endorsement by the initiative or individual partners on the validity or efficacy of works either in part or as a whole nor should it be read as a statement

Hospital screening for DR in the Pilbara region of Western Australia. Photo: Alan McDonald on the success or otherwise of each program in achieving health outcomes.

4 5 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018 Why this report

ACRONYMS As global awareness of Diabetic Retinopathy Drawing on evidence from a range of (DR) has increased so too has the projects and programs showing promising Frequently used acronyms throughout the Compendium development of resources and tools to assist results from 17 countries, the document will health care providers in the early detection provide guidance to policy makers, medical and treatment of this growing public health organisations, service providers and social DR Diabetic Retinopathy problem associated with the rising prevalence investors. of diabetes. However, few of these resources The intended outcome is that decision makers DR-NET Diabetic Retinopathy Network have focused on providing insight into innovative approaches to integrating eye and practitioners will be able to build on the findings and learnings presented in this report DM Diabetes Mellitus health with diabetes management and control, across the health care spectrum. to implement their own strategic and tactical approaches to addressing the challenges DME Diabetic Macular Edema For this reason the ‘Integrated care of blindness and vision loss from diabetes. for diabetes and eye health: A global Ultimately, it is our hope that those living with GP General Practitioner compendium of good practice’ has been or at risk of DR around the world will be able developed. It documents a series of ‘real- to access the support they need, when and IDF International Diabetes Federation world’ case studies that showcase current where they need it. initiatives to advance integrated care for DR LMIC Low to middle income country across the spectrum of health promotion, prevention, early intervention and treatment MoH Ministry of Health (relative to specific country) in a range of different contexts and resource settings. NCD Non-Communicable Disease The compendium has been designed to help PHC Primary Health Centre fill a crucial knowledge gap and to strengthen the existing evidence base through providing PWD People with diabetes insights on a range of different models, lessons learned and key recommendations on STDR Sight Threatening Diabetic Retinopathy how to effectively implement integrated care.

WHO World Health Organisation

6 7 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018 Introduction High Level Summary All seventeen case studies presented in this compendium have been mapped against integration type. Many of these case studies reflect multiple approaches to integration articulated within this report.

CASE STUDY COUNTRY REGION PRIMARY INTEGRATION TYPE SUBMITTING ORGANISATION(S) Integration of eye care into The Australian Centre for Evidence-based leaflet to promote uptake East Asia & Australia routine diabetes care/primary Behavioural Research in of retinal screening among young adults Pacific care Diabetes Preventing Blindness from Diabetic Diabetic eye disease refers to a group In order to address this escalating epidemic, Europe & Horizontal and vertical Retinopathy and Other Diabetes-Related Armenia Armenian EyeCare Project of conditions affecting the structure or a coordinated and collaborative response is Central Asia integration of services Eye Diseases function of the eye, and are associated with required so that prevention, early detection Integration of eye care into or result as complications of long-standing and timely treatment of DR becomes an Comprehensive, integrated diabetes care Bangladesh South Asia routine diabetes care/primary Orbis International for children diabetes. These include cataract, glaucoma, integral part of the ongoing primary care care refractive error and loss of focussing ability of PWD, and that well-defined and effective A successful integration of DR into Integration of diabetes care East Asia & (accommodation), nerve involvement such as referral pathways to specialist care are comprehensive, county-level eye care in China into comprehensive/primary Orbis International Pacific rural China eye care ischemic optic neuropathy and ocular nerve established for those who need further palsies resulting in double vision but most examination and treatment are accessible, Integration of diabetes care Reduction in Blindness in the County of Europe & Gloucestershire Diabetic Eye England into comprehensive/primary importantly, diabetic retinopathy (DR), which affordable and of good quality. Gloucestershire Central Asia Screening Programme eye care includes diabetic macular edema (DME) and 1 Too frequently, however, eye health care Integration of DR policies, proliferative diabetic retinopathy . Diabetes eye care awareness training for East Asia & guidelines and training into The Fred Hollows Foundation remains outside of routine diabetes care Fiji primary level clinicians Pacific all relevant national health (NZ) & Pacific Eye Institute Diabetic retinal disease or DR occurs as and is left to eye health specialists who are policies, and guidelines a direct result of chronic hyperglycaemia often difficult to access. Many PWD do not International Centre for Eye causing damage to the retinal capillaries, undergo regular eye examinations because Integration of DR policies, Health, London School for Integrated Models of Care for Diabetic guidelines and training into leading to capillary leakage and capillary they, as well as many health professionals, are India South Asia Hygiene and Tropical Medicine Retinopathy all relevant national health blockage. It may lead to loss of vision and unaware that diabetes can cause vision loss policies, and guidelines & Indian Institute of Public Health, Public Health Foundation of India eventually blindness. When such damage and irreversible blindness. Limited awareness, Integration of DR policies, occur in the macula region, DME occurs, the combined with financial and geographical East Asia & guidelines and training into most common cause of vision loss in persons barriers to access needed services, and Addressing Diabetic Retinopathy Indonesia Helen Keller International Pacific all relevant national health with diabetes. uneven distribution of skilled personnel, lack policies, and guidelines of medical devices and technology for the Modelling a Telemedicine Screening Ophthalmic Research Center, DR already affects an estimated one third of Middle East & Horizontal and vertical available personnel to use, all impede access Program for Diabetic Retinopathy and Iran Shahid Beheshti University of North Africa integration of services all people with diabetes (PWD) and is the to vital sight-saving services, particularly for Implementing a Pilot Project Medical Sciences leading cause of vision loss in working-age people in rural and remote areas. Integration of eye care into Instituto Mexicano de Oftal- 2 Screening for Diabetic Retinopathy, Latin America adults. In fact, every person with diabetes is Mexico routine diabetes care/primary mología. IMO, Querétaro (Mexi- Telemedicine: Pilot Project & Caribbean at risk of developing DR and all will potentially With only 233,000 ophthalmologists worldwide, care can Institute of Ophthalmology) have it – if they live long enough. it would be impossible for them to perform Integrated Approaches to Address Diabetic Horizontal and vertical Pakistan South Asia Sightsavers annual eye examinations that are required Retinopathy in three Districts integration of services As the incidence of diabetes increases as a routine to detect those at risk of vision Palestin- Integration of eye care into exponentially worldwide, so too will the 5 Comprehensive Model of Diabetic retinopa- Middle East & loss and in need of treatment . A “business 1 Wong, T. Y., Cheung, C. M. G., ian Territo- routine diabetes care/primary St. John Eye Hospital Group thy Management North Africa number of people living with its complications Larsen, M., Sharma, S., & Simó, ries care as usual” approach cannot prevail. We must including DR. At any one time, one third of R. (2016). Diabetic retinopathy. Integration of eye care into go beyond doing more of the same isolated Nature Reviews Disease Primers, Implementing an Integrated Diabetic Latin America people with diabetes will have DR and about 2, 16012. doi:10.1038/nrdp.2016.12 Peru routine diabetes care/primary Orbis International interventions and instead create a collective Retinopathy Health System Model & Caribbean one third of them, 8-10% of all, will have 2 Yau JW et al. Global prevalence care approach to address the burden of need and and major risk factors of diabetic Singapore National Eye Centre sight-threatening DR requiring treatment. improve eye health outcomes for PWD. retinopathy. Diabetes Care. 2012 Evidence-Based Shared Care Eye Model: Integration of diabetes care Mar; 35(3):556-64. East Asia & Singapore Eye Research Institute Predictions suggest that by 2040, 642 million Right Siting Of Stable Diabetic Retinopathy Singapore into comprehensive/primary 3 Kourgialis, N, Helen Keller Pacific Duke-NUS Graduate Medical Patients To Primary Eye Clinic eye care adults will be living with diabetes, 224 million An integrated approach to quality International, Diabetic School will have some form of DR and 70 million will comprehensive eye care across eye health Retinopathy – silently blinding millions of people world-wides, Integration of eye care into 3 Sub-Saharan London School of Hygiene & have vision threatening DR . However, with and diabetes is needed and will significantly accessed from IAPB Vision atlas, Upscaling of diabetic retinopathy screening Tanzania routine diabetes care/primary http://atlas.iapb.org/vision-trends/ Africa Tropical Medicine appropriately timed treatment up to 98% of reduce the incidence and burden of vision care diabetic-retinopathy/ blindness from DR can be prevented. Given loss from DR, by ensuring services; support 4 Sabanayagam, C., & Cheng, C.-Y. Diabetic eye health care model of North Horizontal and vertical inte- Lynn Community Health Centre the rising incidence of this largely avoidable and information are available and accessible (2017). Global causes of vision integration at the inter and intra-professional USA & The New England College of loss in 2015: are we on track to America gration of services 4 levels at a community health center Optometry cause of vision loss , there must be a focus on for all PWD. Integration is by no means the achieve the Vision 2020 target? addressing DR by the international eye health singular solution to overcoming the increase The Lancet Global Health, 5(12), Integration of DR policies, e1164–e1165. doi:10.1016/s2214- Diabetic retinopathy screening and Sub-Saharan guidelines and training into and diabetes care communities. in DR rates globally, but it will play an 109x(17)30412-6 Zambia Frimley Park Hospital (UK) treatment Africa all relevant national health important role in reversing the trend. 5 Taylor, Hugh, R, AC, Immediate policies, and guidelines Past President, International Council for Ophthalmology.

8 9 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018 Integration What do we mean and what does it look like?

Fully integrated care for diabetes and eye system. Truly integrated care will seek to health will require significant strategic and create clear pathways from health promotion operational changes to existing healthcare to disease prevention, from identification systems, in order to create sustainable care of DR to management and from treatment solutions that will reduce the incidence of to rehabilitation, for both beneficiaries and vision loss attributed to DR globally in the long service providers alike. term7. Beyond provision of care at the frontline, Integrated care – at its core – will require integration of DR into related healthcare a coordinated approach across diabetes, policy is of critical importance to ensure 6 Delivering quality health 8 9 services: a global imperative primary , secondary and tertiary health care that appropriate resources, standards for universal health coverage. providers within the disciplines of general and guidelines are established10. Such an Geneva: World Health Organization, Organisation for diabetes care and eye-health, to jointly approach will create an operating framework Economic Co-operation and address the complications of DR. It will for health care providers to work within, Development, and The World Bank; 2018. require those responsible for the provision of in order to appropriately respond to the 7 Planning and developing care at each level of the health care system to complications of diabetes in a coordinated services for diabetic retinopathy in Sub-Saharan Africa, Sophie take ownership of the services they provide manner. Poore, Allen Foster, Marcia to address DR while supporting other points Zondervan, Karl Blanchet Int J Health Policy Manag. 2015 Jan; of care to do the same, ensuring continuity The case studies included in this compendium 4(1): 19–28. Published online 2014 along the care pathway. Doing so will showcase a range of approaches to effectively Dec 16. doi: 10.15171/ijhpm.2015.04 8 Primary healthcare denotes ensure that all PWD and/or DR will be able bring together and align management of the first level of contact between to access the required services when and diabetes with eye health care, in order to individuals and families with the health system. According to Alma where they need them, in the most efficient ensure that the needs of those living with or at Ata Declaration of 1978, Primary and effective manner across the healthcare risk of DR are met. Health Care was based within and served the community; it included care for mother and child which included “While no single actor will be able to effect family planning, immunization, prevention of locally endemic diseases, treatment of common all these changes, an integrated approach diseases or injuries, provision of essential facilities, health whereby different actors work together to education, provision of food and nutrition and adequate supply of safe drinking water. achieve their part will have a demonstrable 9 Secondary Healthcare refers to a second tier of health system, effect on the quality of health care services in which patients from primary 6 health care are referred to around the world.” specialists in higher hospitals for treatment. Tertiary Health care refers to a third level of health system, in which specialized consultative care is provided usually on referral from primary and secondary medical care. Specialised Intensive Care Units, advanced diagnostic support services and specialized medical personnel on the key features of tertiary health care. 10 Wang, L. Z., Cheung, C. Y., Tapp, R. J., Hamzah, H., Tan, G., Ting, D., … Wong, T. Y. (2017). Availability and variability in guidelines on diabetic retinopathy screening in Asian countries. British Journal of Ophthalmology, Photograph Copyright: The Fred Hollows Foundation NZ 101(10), 1352–1360. doi:10.1136/ bjophthalmol-2016-310002

10 11 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018

Four broad categories of integrated care have tertiary points of care practitioners to achieve AND GUIDELINES to a set of protocols by all secondary and been identified and are outlined below. They standardised outcomes for people with tertiary points of care addressing DR are by no means an exhaustive list, but rather DR through training, accountability, and a. Inclusion of DR specific policies serve to demonstrate that “integrated DR monitoring and evaluation in National Diabetes Plans, National e. Government approved guidelines for care” can involve a range of approaches and Noncommunicable Disease Strategic training and implementation of integrated strategies to create an integrated diabetes and c. Establishment of safe and quality value- Planning and other relevant high level care models eye health ecosystem. based treatment and clinical care systems government policies. A transition towards integrated diabetes INTEGRATION OF EYE CARE INTO d. Optimised secondary and tertiary point b. Creation of National Action Plans for DR and eye health systems will always be 1 ROUTINE DIABETES CARE/PRIMARY CARE of care services for people with DR through dependent upon available resources and the improved health systems and processes c. Inclusion of DR into national health complexities of each operating environment. a. Training for primary health (e.g., enabling care providers to: insurance schemes to ensure that sufficient This transition process will be particularly general practitioners) and diabetes care coverage is provided to facilitate cost challenging in geographies where there is professionals (e.g., endocrinologists) on how i. Be more efficient to address the effective screening and treatment for those a greater prevalence of vertical healthcare to educate and raise awareness of DR with complications of DR living with the burden of DR systems – such as low to middle income patients and how to properly identify DR, countries (LMIC) where health services advise patients on appropriate management ii. Be positioned to be able to address d. Standardisation of care (for people are often developed to meet specific health strategies, and refer patients for treatment. anticipated increases in demand for DR with diabetes) – achieved through the conditions associated with poverty and responses implementation of and required adherence epidemics11. b. Provision of regular eye health examinations/screening as part of routine e. Patient support with appropriate diabetes care by service providers management strategies to reduce the risk of vision loss attributed to DR c. Service providers ensuring that patients detected to have DR are guided to access HORIZONTAL AND VERTICAL specialist eye services for timely treatment 3 INTEGRATION OF SERVICES and follow up. a. Improved referral/recall pathways within d. Making effective use of available and across all levels of the healthcare system resources at lower levels of the health care spectrum to encourage preventative b. Establishment of joint strategies across behaviour, and reduce the unnecessary primary, secondary and tertiary levels of care escalation of DR treatment to secondary and to ensure patient access to effective and tertiary care levels timely information, treatment and follow up

INTEGRATION OF DIABETES INTO c. Establishment of innovative tactics to 2 COMPREHENSIVE/PRIMARY EYE CARE reduce the dropout rate of patients across the DR continuum of care a. Skills enhancement of eye health professionals (e.g., ophthalmologists, d. Utilisation of tools such as clinical decision optometrists, other eye care providers) making trees in order to enhance the relevant to understanding the consequences identification of appropriate level of support of DR, and identification, diagnosis, required for those at risk or living with DR management and treatment of DR, diabetes 11 Vertical–horizontal synergy of the health workforce Gijs Elzinga and its complications INTEGRATION OF DR POLICIES, (1), Bulletin note of the world GUIDELINES AND TRAINING INTO ALL health organisation. http://www. 4 who.int/bulletin/volumes/83/4/ Patients are screened and treated b. Capacity building of secondary and RELEVANT NATIONAL HEALTH POLICIES, editorial10405/en/ for diabteic retinopathy. Nepal.

12 13 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018 Guiding Principles for Integrated Diabetes and Eye Health Care

As health providers adopt integrated care marginalised including the those that are poor, for diabetes and eye health, a principles people with disabilities and women12. Such an based approach will be key to advancing approach will emphasise that the rights and optimised care for people living with or at needs of the most vulnerable people are not risk of DR. These guiding principles can be forgotten. applied across a variety of approaches and contexts regardless of the nature or degree Priority should be placed upon ensuring that of integration, as demonstrated in the case all PWD have access to the care they need studies provided in this compendium. to detect and treat DR without experiencing increased financial difficulty. Cost should not PEOPLE-CENTRED CARE be a barrier to access for required medical care or support services. Health strategies for the detection and treatment of DR need to be set up in a way that Priority should be placed upon ensuring that starts from the perspective and the needs of a all people with diabetes have access to the person diagnosed with diabetes. Approaches care they need to detect and treat DR without to reduce known barriers to access, such experiencing increased financial difficulty. Cost as costs and distances to services, as well should not be a barrier to access for required as ensuring that information, education and medical care or support services. services are provided in a culturally acceptable and context appropriate manner and language QUALITY for patients should be prioritised. Quality care outcomes are achieved through Adherence to this principle will ensure that: an adequately trained, supported and deployed health workforce. Staff implementing n Patients understand the costs and the health programmes for PWD should receive benefits of co-delivered care for diabetes and appropriate training, accreditation and its complications ongoing professional development to ensure appropriate care is provided safely and is of a n Patients understand what to expect during good standard. To achieve that end, staff needs and after diagnostic and treatment procedures must be analysed and planned to manage knowledge and skills gaps, and competent staff n Patients understand the importance of and should be distributed equitably. take responsibility for self-management Ultimately, and within local regulatory n Patients have an opportunity to discuss fears frameworks, the most appropriate trained regarding blindness and treatment personnel, should be available to provide the level of service needed for the individuals n Patients are supported to bring about and communities in their catchment area. In positive behavioural change some contexts this may involve co-delivery of care, task-sharing and task-shifting to ensure EQUITY that system wide care is optimised, while also recognising the unique responsibilities and Eye health services for PWD must be competencies of health care practitioners at 12 The Commonwealth Diabetic Retinopathy Symposium, planned and resourced to meet the needs the three levels of service delivery (primary, ‘Preserving the sight of people of the whole of a target population, but secondary and tertiary). with diabetes across the Commonwealth – 8 Point Photograph Copyright: The Fred Hollows Foundation NZ sufficiently responsive to the needs of the most Manifesto’, 2016

14 15 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018 Recommendations

COLLABORATION evidence on the prevalence and the burden of RECOMMENDATIONS DR and of effectiveness of interventions can be Recommendations for Collaboration among care providers is generated, analysed and harnessed to inform Recommendations for Secondary & Tertiary Care coordinated across the multiple entry points advocacy and policy decisions to shape an Primary Health Care Providers: Working in along the diabetes care pathway, starting from enabling environment for integrated care. Providers: Preventative Action, Collaboration to Overcome support for self-care, detection of DR, through Improved Results Barriers referral to treatment and vision rehabilitation. COST EFFICIENT Interventions for eye health, diabetes and Non- Primary health care providers have a unique Resourced with specialist skills and knowledge Communicable Diseases (NCDs) will together Investments in the establishment and scale opportunity and responsibility to dramatically – secondary and tertiary care providers can result in effective, safe and personalised up of DR programs must represent good reduce the anticipated growth of DR rates foster the development of integrated eye and services that meet the health needs of a person value for money for social, public and private globally. Being the first and often only point of diabetes care through playing a leading role with diabetes. The intent is for DR services investors whilst also being effective14. While care for people living with diabetes they can in collaborating with other components of the to be available and accessible for all people maintaining standards of care and equitable spearhead integrated care by: health system. In particular, they can: around the world living with diabetes, for access, service providers should use finances, practitioners to provide services that are of staff, medicines, medical devices, equipment n Building the capacity of existing human n Enable appropriate task-sharing and a good standard, and for health information and technology, and physical infrastructure resources through regular training and task-shifting among healthcare personnel: systems to operate in a collaborative manner that are the most cost effective within the local professional development to; improve health understanding what is the appropriate training and in both ways, along referral pathways. setting. Towards achieving universal health literacy of DR among people with diabetes, (training type, format and frequency), skill Service delivery systems are flexible and coverage, people and families affected by promote and support self-management and sets and support health care professionals responsive to the national and local context, diabetic retinopathy should be protected from increase detection of DR before the onset of and clinic staff at the primary point of care adapting to resources available locally within catastrophic expenditure that can push them vision loss, and direct people in need of further require, so that they are able to provide at risk the private and public sector, and at community into poverty and or perpetuate the poverty care to appropriate treatment pathways patients with accurate information, support level. cycle from having to pay for treatment and management of DR, and provide or facilitate supportive healthcare for diabetes and DR. n Making eye examinations a standard essential regular eye examinations as part of EVIDENCE BASE component of periodic diabetes check-ups at routine diabetes care the primary point of care (local diabetes clinic) Provision of care for DR should be based on the to ensure more people are examined and to n Ensure DR treatment and clinical care best available evidence. Providing evidence- facilitate early detection of DR options are available, accessible, acceptable informed care will ensure that finite health and of good quality and that patients are linked resources are used widely and that the care n Prioritising health communication through the back into their primary diabetes care providers provided is likely to be effective13. Programs development and distribution of evidence-based for seamless ongoing diabetes and eye care that utilise evidence and data will also be best lay-language information to inform and educate management positioned for continual improvement in the 13 Wong, T.Y., Sun, J., Kawasaki, people with or at risk of DR of actions to be R., Ruamviboonsuk, P., Gupta, nature and process of service provision, with N., Lansingh, V.C., Maia, M., taken to avoid progression of DR and to manage n Improve collaboration across diabetes and findings being applied to: Mathenge, W., Moreker, S., vision loss eye health sectors, including through: Muqit, M M.K., Resnikoff, S., Verdaguer, J., Zhao, P., Ferris, l Establishing robust referral pathways from n Program planning and implementation F., Aiello, L.P., Taylor, H. R. n Providing sufficient information to primary care to specialist services to ensure (2018). Guidelines on Diabetic Eye Care: The International people with or at risk of DR so that they are appropriate and timely clinical care – including n Deploying appropriate technology Council of Ophthalmology empowered to make informed decisions about clear referral criteria, improved information Recommendations for Screening, Follow-up, Referral, and their care, and are aware of how to access sharing, established relationships and joint n Quality of care Treatment Based on Resource appropriate treatment, follow up and support strategies between different levels of health Settings. American Academy of Ophthalmology. systems providers n Evaluation and use of information to improve 14 McDonald, L, WHO, Eliminating l Clear definition of the roles and avoidable blindness: a wise accountability. investment in developing responsibilities of different health care countries, accessed from IAPB providers in supporting PWD Vision atlas, http://atlas.iapb. Beyond program cycle management and the org/socio-economics/wise- provision of safe and effective healthcare, investment/

16 17 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018 International Case Studies of Integrated Care for Diabetes and Eye Health Evidence-based leaflet to promote uptake of retinal screening among young adults in Australia

Recommendations for n Include eye health considerations, including ABOUT THE CASE STUDY INTEGRATION TYPE Government: Driving Change, DR, particularly in workforce planning for Exerting Influence services to be provided at primary, secondary Integration of eye care into routine The problem and tertiary level healthcare facilities diabetes care/primary care Governments and Departments of Health The average age of onset of type 2 diabetes have the capacity to accelerate migration TARGET POPULATION is decreasing, with more people developing towards integrated care through the creation of Recommendations for Donors, Young adults with type 2 the condition before 40 years of age. However, an enabling environment for service providers. Funding and Investment diabetes, aged 18-39 years few complication awareness/diabetes In particular, governments can: Partners: Financing for Impact self-management education resources are SETTING tailored to this population. Early exposure n Develop and strengthen regulations, Donors, funding and investment partners can Income Group: High income to this aggressive form of type 2 diabetes laws, policies and guidelines that support significantly shape the diabetes and eye health Region: Statewide (Victoria) predisposes affected individuals to increased integrated approaches, promote co-delivery landscape through prioritising and channelling – urban, regional and rural risk of early development, and rapid of care, including appropriate task-sharing investments into integrated care. In particular, progression of diabetic retinopathy which is and task-shifting among clinicians and health they can: IMPACT the leading cause of vision loss and blindness professionals, and provide context and Initially: 2,049 young adults. in working-age adults. Young adults with type culturally-appropriate guidance to service n Convene multi-stakeholder dialogues to Ongoing impact via Vision 2 diabetes have low engagement with diabetes providers15 promote the piloting and scale up of integrated Initiative campaigns. self-care, including retinal screening, the care and provide resources and finances for proven clinical pathway to prevention of vision PROJECT BUDGET n Incentivising provision and uptake of the development, incubation and scale up of loss from diabetic retinopathy16. Collectively, appropriate clinical care and support services such initiatives USD $198,000 PWD and health professionals have called for by PWD, such as appropriate financial resources and services to promote the uptake PROJECT TIMELINE coverage of DR services in health insurance n Establish protocols and targets for of retinal screening specifically tailored to the or other benefit schemes recipients to adhere to, in order to advance the Dec 2012 – June 2015 unmet needs of this priority population. implementation of integrated diabetes care and AUTHORS n Develop National Action Plans for addressing eye health services Overview of the intervention/program Dr Amelia Lake and Professor Jane DR in consultation with relevant stakeholders Speight from The Australian Centre for across the diabetic and eye healthcare n Work with national and local governments to The aim was to develop a public health Behavioural Research in Diabetes, a spectrum including civil society, the private prioritise populations and regions of greatest intervention to promote uptake of retinal partnership for better health between sector and provincial governments and ensure need for integrated care and direct funding to screening among young adults with type 2 Diabetes Victoria and Deakin University the integration of such plans into National support advancement in those geographies diabetes. Our three key objectives were to: a) www.acbrd.org.au Diabetes Strategies, Noncommunicable identify their barriers to and enablers of retinal Disease Strategic Planning n Strengthen human resources through ACKNOWLEDGEMENTS screening uptake; b) develop a brief, tailored, increased investment in appropriate training Vision 2020 Australia, Diabetes Victoria, and culture/age-appropriate leaflet, which n Invest in infrastructure and technology – and tools for health care professionals and Centre for Eye Research Australia, could be distributed to the priority population particularly more cost effective, sturdy and support services to manage diabetes and University of Exeter. by Diabetes Victoria; and c) evaluate the automated technologies more suitable to improve eye-health. leaflet’s effectiveness in increasing self- LMICs for diagnostic and treatment services, PROJECT EXPENDITURE – PRIMARY COSTS reported uptake of retinal screening and and prioritise the development of robust The case studies presented in this report have 1) Staffing addressing the factors underlying this information management and referral systems been mapped against integration type. Many of behaviour. to promote enhanced integration along the care these case studies reflect multiple approaches 2) PhD scholarship pathway to integration and reflect a number of the 15 International Agency for 3) Production and distribution Intervention/program details the Prevention of Blindness, 16 guiding principles articulated in this report. International Council of For further reading see: Lake SOURCE OF FUNDING: n Incentivise adherence to clinical standards Ophthalmology, The key feature was the content (targeted AJ, Rees G, Speight J. Clinical and World Council of Optometry and Vision 2020 Australia provided the Psychosocial Factors Influencing and protocols by all, especially for hospital psycho-educational messages), reinforced Retinal Screening Uptake International Diabetes Federation, finances required for this project through and healthcare-facility based services for PWD ‘Strengthening Health Systems to with verbatim quotes and appealing design/ Among Young Adults with Type Manager Diabetic Eye Disease: Vision Initiative funding for the Diabetes 2 Diabetes. Curr Diab Rep. 2018 and diabetic retinopathy at the secondary and Integrated Care for Diabetes and and Eye Health project. imagery. Our comprehensive needs May 24;18(7):41 tertiary levels of service delivery Eye Health’

18 19 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018

Diabetes Services Scheme) was determined CONCLUSION as the best reference point. However, use of the (primarily postal) NDSS database dictated Why is this case study important for improving the intervention format, which needed to be integrated care for diabetes and eye health: print-based. Fortunately, previous research Protect your sight for life What is diabetes demonstrated that young adults with type 2 With the combined benefits of low cost, broad For more information on eye health Who is and diabetes management eye disease? diabetes prioritise credibility of information reach, consistency of message and wide • Visit diabetesvic.org.au, or call the looking after Diabetes eye disease is also called NDSS Helpline on 1300 136 588 Diabetic Retinopathy (DR). over format. Importantly, we learned that public acceptance, leaflets are widely used It is caused by having high blood glucose • Multilingual infoline 1300 801 164 your eyes? levels over a long time. Other things that multiculturalportal.ndss.com.au flexibility in the face of real-world constraints for health promotion purposes. However, increase your risk of DR are high blood To find an optometrist in your area pressure and high cholesterol. But I’m still young. Am I at was a key factor. many leaflets are not evidence-based and, • Scan the QR code to download the free DR damages the tiny blood vessels in the risk of DR? Diabetes Australia app back of your eye. If left untreated, your vision can be affected. consequently, waste resources and miss a Yes you are. Anyone with diabetes can • Visit Optometry Australia develop DR, which is the leading cause of www.optometry.org.au/find-an-optometrist/ The good news is this leaflet provides the Most studies evaluating interventions crucial opportunity to promote health. This vision loss for people under 60 years. information you need to help prevent vision There are over 37,000 Australians with type loss from DR. 2 diabetes who are under 40 years of age. targeting youth/young adults with type 2 case study is important because it provides a More than 9,200 will already have DR. Will I know if I have DR? • The longer you have diabetes the more at You may not know. In the early stages, diabetes face recruitment/attrition challenges. blueprint for others wishing to systematically risk you are of DR. DR has no symptoms at all. In the later stages, you may notice blurred, hazy or Some barriers that we faced were: low develop a brief, print-based resource, • The good news is there are things you can double vision or you may have sudden do to reduce your risk. loss of vision. • Having a diabetes eye health check and overall prevalence of young adults with type especially for those typically considered ‘hard- treating DR early can prevent severe Month The only way to know if you have DR is Book a diabetes to have a diabetes eye health check. vision loss. eye health check now 2 diabetes, lack of engagement with diabetes to-reach’. Our work involved multidisciplinary Lucas, aged 34, diagnosed with Jane, 25 years, diagnosed with research; and over-representation of racial/ collaboration and involvement of members of type 2 diabetes 2 years ago type 2 diabetes 3 years ago

“I didn’t know that I was at risk. I’m a Proudly sponsored by “ You might have good vision, ethnic minority groups. To address these, we: the priority population throughout (considered busy person and my family depend you might think that your eyes on me. I know I can’t do all the are absolutely brilliant and there’s ‘best practice’ in intervention development things I do without my sight.” no issue. But in the back of your eye, there could be a problem n engaged with key health advocacy and evaluation). Further, our collaboration with those little tiny veins that Your guide to preventing you don’t realise.” stakeholders with Diabetes Victoria enabled us to ensure vision loss from diabetes sustainability of the resource via their website eye disease n ensured that the leaflet was developed to and wide-spread distribution via Australia’s ISO-583 Who is looking after your eyes? (young adults) V03 20180817 appropriate literacy levels NDSS. Finally, this work also provides important insight into the unmet psychosocial n involved members of the priority population needs of young adults with type 2 diabetes,

Leaflet used for promotion of retinal screening for young adults. ©Vision 2020 Australia, 2018. All rights reserved from inception which will assist with the development of more diabetes self-management resources tailored See a range of publications arising from this to this priority population. assessment (in-depth interviews, nationwide The study demonstrated: a) high engagement project for more information20. survey, literature review17) identified with the leaflet among young adults with factors impacting retinal screening uptake type 2 diabetes,18 and b) that reading the among young adults with type 2 diabetes. leaflet significantly increased knowledge of We used this evidence base to develop diabetic retinopathy, an important enabler psycho-educational message content using of retinal screening19. This was achieved theoretically-grounded behaviour change because our needs assessment identified the methods. For example, messages addressed specific knowledge, motivational factors and 20 Lake AJ, Browne JL, Abraham Getting a diabetes eye Jenny’s story C, Tumino D, Hines C, Rees knowledge gaps, encouraged positive behavioural skills impacting retinal screening health check is easy. Jenny, aged 36, • You don’t need a referral from your GP. diagnosed with type 2 G, Speight J (2018) A tailored You can book an appointment directly with diabetes 6 years ago attitudes toward retinal screening, reinforced uptake among this priority population. In an optometrist. When you do, be sure to intervention to promote uptake of tell them you have diabetes. Before the diabetes eye retinal screening among young (normative) beliefs about the screening tailoring the leaflet to young adults with health check What is a diabetes eye adults with type 2 diabetes - an health check? “I was scared. I was scared behaviour of similar others, and promoted type 2 diabetes, we were able to address What can I do to protect • It is different to a standard eye check of what damage was intervention mapping approach. done… of confronting myself from DR and prevent because it specifically looks to see whether BMC Health Services Research. behavioural skills to overcome screening a key concern – i.e. a lack of diabetes self- diabetes is affecting your eyes. the fact that my eyesight 17 For further information see: vision loss? • It is usually done by an optometrist who will could be damaged, and Jenny’s advice to you 18(1):396 1. Have a diabetes eye health check take a photo of the back of your eye. of going through the exam and “I suppose if I was telling someone barriers. The messages were reinforced with management resources addressing the needs Lake AJ, Browne JL, Abraham Have a diabetes eye health check when • Your optometrist will look at the photo to being confronted with what’s there. that’s just been diagnosed, I would Lake AJ, Rees G, Speight J (2018) C, Tumino D, Hines C, Rees G, diabetes is first diagnosed and then at least check the blood vessels at the back of your But I want to take care of my kids; be saying to them ‘Don’t wait to be Clinical and Psychosocial Factors every two years (more often if recommended eye for signs of diabetes-related eye damage. I want to be able to see their children told and don’t wait until you notice verbatim quotes and age-appropriate imagery and characteristics of this group. Finally, the by your optometrist). Speight. A tailored intervention What else do I need to know? one day. I do want to be able to grow changes – book an eye health Influencing Retinal Screening 2. Treat DR early older and have my vision.” check now.’ and incorporated into an 8-panel leaflet: ‘Who leaflet has had widespread reach: it was to promote uptake of retinal Early treatment can prevent up to 98% of • A diabetes eye health check takes about Uptake among Young Adults severe vision loss. 30 minutes. Discuss with the optometrist what to After the eye health check expect, what you should be aware of screening among young adults 3. Follow your diabetes treatment plan which • It may be free (bulk-billed) or there may with Type 2 Diabetes. Current and so on. I had a lovely optometrist, is looking after your eyes?’ These features distributed to all young adults with type 2 includes the diabetes ABCs. be a small fee. with type 2 diabetes - an “It was actually quite fun; I don’t know she really put me at ease.” Diabetes Reports. 18(7):41 • Your optometrist may use eye drops which why I put if off. I was really scared helps them to see the back of your eye. ensured the leaflet was appealing, accurate, diabetes throughout the Australian state intervention mapping approach. Average blood glucose going in there, but definitely not now – Lake AJ, Browne JL, Rees G, If you do have eye drops, they may be a little What happens if I have DR? A (HbA1c) below 7% I’m not fazed by it at all. BMC Health Services Research. (53mmol/mol) uncomfortable. The drops will also leave you • Your eye health professional will advise Speight J (2017) What factors acceptable and addressed the needs of the sensitive to light, so bring your sunglasses you of your treatment options. of Victoria (N=2049) and remains freely Every 1% (11mmol/mol) decrease in The eye drops were a bit 2018 18:396 and be prepared to wait a while for your influence uptake of retinal HbA1c lowers your risk of developing DR uncomfortable and there was a small • In the early stages, treatment may not be vision to return to normal. priority population. available in electronic format. 18 ibid. Fidelity checks were by 30–40%. cost – but I think it’s a wise spend needed, but you may be asked to have eye screening among young adults What happens next? considering what you’re preventing. health checks more frequently to monitor also conducted during the Blood pressure below 130/80 mm Hg the DR. with type 2 diabetes? A qualitative • If they see any signs of damage to the back Overall, it was worth it and the thought Keeping your blood pressure at target • You can slow progression of DR by B of your eye, your optometrist will either that I can control this gives me real Randomised Controlled slows progression of DR. keeping your blood glucose, blood study informed by the Theoretical monitor it or arrange treatment with an peace of mind.” pressure and cholesterol as close to Challenges and learning Trial evaluation. The checks Cholesterol at target ophthalmologist (medical eye specialist). target as possible. Domains Framework. Journal of demonstrated that the eye health C LDL cholesterol less than 2.0 mmol/L, Either way, discuss your results with your GP • If DR progresses, you may need to take Diabetes and Its Complications. triglycerides less than 2.0 mmol/L. or your diabetes specialist. tablets or have specialist treatment leaflet was read by the majority of (usually laser therapy). 31(6):997-1106 IMPACT AND LEARNING With a lack of dedicated programs or services those who had received it (95%). Lake AJ, Browne JL, Speight J for young adults with type 2 diabetes, our 19 At follow-up, the leaflet (2018) Comment on ‘Adherence intervention group reported to diabetic eye examination What was the impact and why first challenge was how to contact the priority greater knowledge of DR relative guidelines in Australia: The National Eye Health Survey’ did it work? population and deliver the intervention. to the control group (t(72)=- 2.213, p<.05; CI-2.14 to -.11), with Medical Journal of Australia. Australia’s largest diabetes register (National moderate effect size (n2=.05) Leaflet used for promotion of retinal screening for young adults. ©Vision 2020 Australia, 2018. All rights reserved (IF:4.227), 208(2):97

20 21 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018 International Case Studies of Integrated Care for Diabetes and Eye Health Preventing Blindness from Diabetic Retinopathy and Other Diabetes-Related Eye Diseases in Armenia

ABOUT THE CASE STUDY INTEGRATION TYPE

Horizontal and vertical integration The problem of services Quality health care remains inaccessible TARGET POPULATION for most of the population of Armenia and is People with diabetes subpar in several specialty areas of medicine with special attention to including endocrinology and chronic disease management. While the majority of patients residing outside of the the population lives throughout the regions capital city Yerevan of Armenia, healthcare sub-specialists are concentrated in the capital city of Yerevan SETTING further restricting the accessibility of Income Group: Upper middle healthcare services for those in need. income (Lower middle income at inception of the project); Overview of the intervention/program Region: Rural

IMPACT Since 2012, Armenia has been implementing a strategy to prevent diabetes and improve Anticipated 40% increase disease management and care. Unfortunately, in identified cases of and this strategy did not envisage specific action laser treatments for DR on diabetes-related eye diseases. The performed via the Mobile Eye Armenian EyeCare Project (AECP) bridges Hospital and Regional Eye Centers this gap by integrating DR screening and treatment of people with diabetes into its PROJECT BUDGET ongoing countrywide eye care program. USD $642,064 Intervention/program details PROJECT TIMELINE March 2017 Provide medical technology and – June 2020 artificial intelligence. AECP has provided ophthalmoscopes and smartphone-based AUTHORS portable fundus cameras for the screening, Armenian EyeCare Project imaging, diagnosis, and DR treatment at the primary level in the regions. At the secondary level (made up of AECP Regional PROJECT EXPENDITURE – PRIMARY COSTS Eye Centers - REC and the Mobile Eye 1) Equipment Hospital – MEH), the Project has provided 2) Training non-portable fundus cameras and state-of- 3) Public Awareness the-art lasers for DR treatment. AECP has introduced an innovative software program to SOURCE OF FUNDING: Armenia, which uses artificial intelligence to World Diabetes Foundation, AECP, grade fundus photographs and to diagnose corporate and private donors DR. This method eliminates the need for a physician to diagnose each patient, and a database of retinal images, available on DR screening with the use of smartphone-based portable fundus cameras a cloud-based network, also enables peer

22 23 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018

review and unified record keeping. family doctors receive training on diabetes diabetes-related eye diseases and overall includes the development and training of and eye care so that they can educate their integrated care for PWD. local professionals, reinforcing links among Build professional capacity. AECP is diabetic patients on the characteristics and them, providing necessary equipment and providing training for family doctors, nurses, management of their disease. Challenges and learning materials for public education, as well as endocrinologists and ophthalmologists. The bringing key issues for action to the attention structure of the project reinforces the crucial The use of Artificial Intelligence requires a of policy makers key issues for action. links among family doctors, endocrinologists IMPACT AND LEARNING strong and uninterrupted Internet connection, and ophthalmologists throughout Armenia. which is not available in all regions at this Quick and quality service delivery can be What was the impact and why did it work? time. The Project has supplemented fundus achieved if performed by Yerevan-based Increase access to quality care. Patients cameras with mobile Internet connections, specialists traveling from region to region to with diabetes and those at risk are referred The impact of the project will be determined which partially overcome this infrastructure perform DR screening and photographing for eye screening at the primary level and in by monitoring and evaluating each of the gap. AECP continues to search for the the retinas of people living with diabetes. screening camps in poor and underserved individual components of the project. These best long-term operating model, which will However, this is not a long-term or efficient communities. Diagnosed DR cases are components will include training of health achieve a balance between sustainability and solution. AECP is working towards a truly referred for treatment at the AECP RECs or care specialists, an increase in the number of quality service delivery. sustainable solution through developing and MEH where specialized care is provided. identified cases of diabetic retinopathy, and contributing to a more efficient eye health an increase in the number of laser treatments system in Armenia by training regional Raise public awareness. The Project aims for diabetic retinopathy performed via the CONCLUSION ophthalmic personnel and partnering them to increase the national demand for DR Mobile Eye Hospital — approximately 40 with project trainers who will supervise their identification and treatment, and to provide percent. AECP’s comprehensive design and Why is this case study important for improving work in the field. public education on the links between implementation approach has motivated other integrated care for diabetes diabetes, eye health and general health. non-profit organizations to donate two lasers and eye health? The integration of the DR project into the Through creating awareness of lifestyle to perform treatments for diabetic retinopathy. AECP’s country-wide program “Bringing management and the risk factors of DR, the The project also aims to use knowledge In the absence of government policy for Sight to Armenian Eyes” ensures wide Project encourages people with diabetes to gained to impact national decision-making diabetes related eye diseases, this case coverage and timely specialized care and undergo regular eye screenings. In addition, processes on diabetes, including policy for study demonstrates how one organisation builds on existing expertize and capacity. can create significant impact through a This new approach to DR prevention in targeted approach towards the identification country has great potential and will be Total March 2017 Planned results and treatment of DR. This specific health expanded in Armenia. –July 2018 for the project TOTAL ARMENIA intervention is comprehensive in nature and 2017–2020

EYE HEALTH SERVICES General screening 15,500 50,000 Total people referred to MEH or REC for detailed examination 5,000 8,000 Total PWD passed photo imaging 6,548 18,000 Revealed having Non-proliferative DR 1,697 n/a Revealed having Proliferative DR 404 n/a People who had DR Laser treatments 232 300 People passed surgical treatment of diabetic cataract 208 200 TRAINING OF HEALTH CARE SPECIALISTS Ophthalmologists 40 100 Endocrinologists 34 100 Family Medical Doctor/GP (including ToT for public education) 289 550

Training sessions for regional FMDs on diabetes and healthy lifestyle with the use of newly-designed posters in Armenian

24 25 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018 International Case Studies of Integrated Care for Diabetes and Eye Health Comprehensive, integrated diabetes care for children in Bangladesh

INTEGRATION TYPE PROJECT EXPENDITURE – PRIMARY COSTS Integration of eye care into routine 1) Equipment and supplies diabetes care/primary care 2) Training, outreach, treatment, and promotional materials TARGET POPULATION 3) Partner salaries Children 18 years and below living with diabetes SOURCE OF FUNDING: USAID Childhood Blindness Program SETTING (USAID-CBP) Income Group: Lower middle income; Region: Rural and urban ABOUT THE CASE STUDY IMPACT 3,018 children screened The problem for eye disease and There are an estimated 530,000 children < 15 refractive error years of age with Type 1 Diabetes (T1DM) 21 PROJECT BUDGET globally , and possibly as many with Type 222. Six of 10 countries with the most known USD $98,810 children with diabetes are in developing areas23. The global number of children with diabetes PROJECT TIMELINE is growing rapidly and evidence shows that November 2016 poor care during childhood increases the – February 2018 risk of ocular complications throughout later 21 Patterson C, Guariguata L, life24. The International Diabetes Federation Dahlquist G, Soltész G, Ogle G, AUTHORS Silink M. Diabetes in the young - (IDF) estimates the incidence of T1DM among Orbis International; Mohammed Awlad a global view and worldwide children 0-14 years in Bangladesh at 4.2 new estimates of numbers of children Hossain, Senior Monitoring and Evaluation with type 1 diabetes. Diabetes Res cases per 100,000/year, or over 3,000 children Manager, Mohammed Alauddin, Director Clin Pract. 2014 Feb;103(2):161-75. newly developing this disease annually25. At 22 Demmer RT, Zuk AM, of Programs, Dr. Lutful Husain, Senior Rosenbaum M, Desvarieux M. the Bangladesh Institute of Research and Medical Specialist, Clare Szalay Timbo, Prevalence of Diagnosed and Rehabilitation in Diabetes, Endocrine and Undiagnosed Type 2 Diabetes Senior Program Manager, Asia Region and Mellitus Among US Adolescents: Metabolic Disorders (BIRDEM), there has Dr. Munir Ahmed, Country Director, Orbis Results From the Continuous been an upward trend in the number of newly NHANES, 1999–2010. American International Bangladesh and CDiC; Dr. Journal of Epidemiology. diagnosed children, from 112 cases in 2008 Bedowra Zabeen, Pediatric Diabetologist. 2013;178(7):1106-1113. to 319 cases in 2013, as documented by the 23 Rwiza HT, Swai AB, McLarty DG. Failure to diagnose diabetic ACKNOWLEDGMENTS Changing Diabetes in Children (CDiC) program ketoacidosis in Tanzania. Diabet at BIRDEM. 26However, this project has detected Med. 1986 Mar;3(2):181-3. Changing Diabetes in Children Program 24 Anderzén J, Samuelsson U, (CDiC), Diabetes Association of 3018 children with diabetes through walk-in and Gudbjörnsdottir S, Hanberger L, outreach camps up to February 2018. Åkesson K. Teenagers with poor Bangladesh (BADAS), USAID-CBP. metabolic control already have a higher risk of microvascular Overview of the intervention/program complications as young adults. J Diabetes Complications. 2016 Apr;30(3):533-6. doi: 10.1016/j. From September 2016 to February 2018, Orbis jdiacomp.2015.12.004. 25 IDF Word Atlas (8th Edition). 1 International worked with BADAS to create a June 2018 (Ref. Indian J Endocrinol Metab. Capturing a fundus photo from a patient in Bangladesh scalable, comprehensive model of eye care 2015 Apr; 19(Suppl 1): S9–S11 (Photo Credit: Orbis International) for children living with diabetes in Bangladesh. 26 (Ref. Indian J Endocrinol Metab. 2015 Apr; 19(Suppl 1): S9–S11

26 27 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018

Outreach camps were organized in strategic CONCLUSION locations to ensure children living in remote areas could access screening services. A total Why is this case study important for improving of 3,018 children were screened for eye disease integrated care for diabetes and eye health?: and refractive error over two years; 469 children received treatment, 307 received eyeglasses This project validates the importance of and 81 paediatric surgeries (including 44 integrating eye care into primary diabetes cataract) were performed. A total of 113 children care for children, and the need to strengthen were detected to have DR and all of them networks for eye care treatment. Two research received treatment in the form of DM control, projects are currently underway to better laser, etc. as per grading protocol. The data understand the incidence and risk factors of from this project demonstrate that children with diabetic retinopathy and cataract in children diabetes in Bangladesh experience high rates of living with diabetes. This knowledge will reduce conditions such as cataract and refractive error, the burden of ocular complications and allow us as well as diabetic retinopathy. to advocate effectively for better health coverage, including eye care, for children with diabetes in Bangladesh.

Challenges and learning BADAS hospitals have established a scalable and sustainable model of eye care for children An external evaluation conducted by Dr. with diabetes, and continue to deliver high Naushad Faiz27 in November 2017 provided the quality diabetic care. The BADAS staff work following lessons learned: closely with children and their parents to ensure families are aware of the importance The project built on the existing CDiC program Importantly, this program has become self- n Outreach camps ensure access to rural of providing timely, routine care to manage all for the delivery of high-quality diabetes care sustaining and is continuing beyond the funding populations facets diabetes, including care for the eyes. for children living in low-resource settings. It is cycle for the project. The fundus camera that among the first in the world focused specifically was provided for this centre is being used for n Children with diabetes need to be provided on reducing the burden of vision impairment adults and children and is generating revenue. follow up care at least until they reach the age of among children living with diabetes in LMICs. Staff trained for this project have been retained, 26 years and as a result patient volume has increased Intervention/program details at the hospital further contributing to the n Facilities caring for children with diabetes sustainability of the program. should employ an ophthalmologist full time to Through the integration of eye care into an cater to their eye needs existing, child-focused model of diabetic care Ensuring that costs are kept to a minimum, services, and establishing referral pathways patients are paying subsidized fee for services n Strong management and regular coordination between communities, government facilities and project partners are receiving insulin at no meetings ensured the project was implemented and specialized hospitals, this program cost from associated pharmaceutical companies. smoothly enabled children living with diabetes in poor communities in Bangladesh to receive IMPACT AND LEARNING n World Sight Day and World Diabetes Day both life-saving and sight-preserving care. activities raised awareness around eye care and Two child-friendly centers were established What was the impact and why did it work? diabetes, and at BADAS hospitals in Bogra and Dhaka and were supported by Orbis through the By integrating eye care services into the n Information, Education and Communication provision of training in diabetic retinopathy care delivered by CDiC and BADAS, the (IEC) materials are important to impart to ophthalmologists, image graders and project enabled children living with diabetes knowledge on diabetes and eye care to children counsellors. Through outreach efforts and to be screened regularly for diabetic eye and families. events, children living in communities in hard disease, and provided timely treatment and to reach areas were provided screening and appropriate monitoring. Collaborating closely A major challenge faced was working to ensure education. with CDiC, Orbis provided technical support children came for follow up visits after receiving and essential equipment to ensure screening initial screening and treatment. The barriers

This model has become an integral part of and identification of eye conditions were identified around this challenge included high 27 Mr. Naushad Faiz holds a PhD comprehensive diabetic care for children, incorporated into children’s routine diabetic direct and indirect costs for care, particularly in Economics. He has 34 years of experience in working in the field with eye care services being incorporated care, and a strong referral network was transportation and parents’ time away from work. of development as a researcher, into service packages at BADAS hospitals. established within the hospitals in two cities. consultant and program manager. He has conducted consultancies in a wide variety of areas, including evaluation and design of eye care and disability inclusive projects.

28 29 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018 International Case Studies of Integrated Care for Diabetes and Eye Health A successful integration of DR into comprehensive, county-level eye care in rural China

ABOUT THE CASE STUDY INTEGRATION TYPE

Integration of diabetes into The problem comprehensive/primary eye care Guangdong is among China’s most populous TARGET POPULATION provinces with approximately 104 million General populations inhabitants.28 The recent national, rural-based served by 10 rural country survey found blindness rates in Guangdong second only to Yunnan province.29 While cataract hospitals in Guangdong Province remains the leading cause of vision impairment in China, surgical rates are rising rapidly to SETTING meet demand and the government provides Income Group: Upper middle national insurance to 98% of its rural population, income; Region: Rural providing support for further expansion of IMPACT service delivery. The Comprehensive Rural Eye Anticipated 313,713 eye Service and Training (CREST) project focuses on glaucoma and diabetic retinopathy (DR) which examinations completed are increasingly common in rural China, and are

PROJECT BUDGET more complex to diagnose and treat than cataract. Diabetes has increased ten-fold in China since USD $3.185 million (PHASE I) 1980, and fewer than 10% of those with DR in rural areas receive treatment.30 It is estimated that 120 PROJECT TIMELINE million people in China are living with diabetes, Phase I: July 2012 the largest number of any country in the world, a – September 2017. third of whom are believed to have DR. A major barrier to sight-saving treatments for DR in rural Phase II: December 2017 China is the lack of training and equipment at – March 2020 county hospitals, and lack of understanding of the disease among rural patients. AUTHORS Orbis International: Dr. Nathan Congdon, Overview of the intervention/program Director of Research and North Asia Strategy; Dr. Peter Xu, Director of Phase I of the CREST project sought to create a Programs; Clare Szalay Timbo, Senior high-quality model of diabetic care in a network Program Manager, Asia Region of 10 rural country hospitals by providing comprehensive training at ZOC, the coordinating ACKNOWLEDGEMENTS center for country eye professionals. The project Zhongshan Ophthalmic Center (ZOC) established and tested a sustainable and scalable model of photo-based, county-level DR screening, PROJECT EXPENDITURE – PRIMARY COSTS and increased the knowledge of those living in 28 China NBS: 6th National 1) Medical supplies the catchment area about the need for screening Population Census (31 May 2018) and treatment. Intervention/program details 29 Zhao JL, et al. Prevalence of 2) Partner salaries vision impairment in older adults 3) Partner travel costs in rural China: the China Nine- The creation of a comprehensive vision network province survey. Ophthalmology, 2010. SOURCE OF FUNDING: at the rural country level was essential to ensure 30 Wang FH, et al. Prevalence World Diabetes Foundation, private funds that rural-dwellers could accesses care and be of diabetic retinopathy in rural China: The Handan Eye Study. Patient having his eyes screened (Photo credit: Orbis International) and partner contributions screened for conditions before they became Ophthalmology, 2008.

30 31 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018 International Case Studies of Integrated Care for Diabetes and Eye Health Reduction in Blindness in the English County of Gloucestershire

symptomatic and missed the window for Challenges and learning: INTEGRATION TYPE PROJECT EXPENDITURE – PRIMARY COSTS timely treatment. Integrating glaucoma and DR screening into comprehensive primary eye care A formal evaluation was carried out by Dr. Tao Integration of eye care into routine 1) Staff services demonstrated that county-level facilities Ran, MD, MPH by WDF in 2017. The report noted diabetes care/primary care 2) Equipment could provide high-quality care, and would in that while most of the country-level partners 3) Training fact invest their own resources in purchasing had been successful in acquiring the capacity TARGET POPULATION necessary equipment, due to the potential for to manage glaucoma and DR independently, Community of people with SOURCE OF FUNDING: Recurring public funding cost recovery (Chinese National Health Insurance the largest challenge was incorporating diabetes covers 70% of the cost, with patient out of pocket comprehensive examination, fundus photography

payments averaging 30%). The key factors that by nurses and the use of EMR into their formal SETTING make the program scalable are that screening routine. The lessons learned from project-based Income Group: High income; involves non-medical personnel (freeing up research include: Region: County of Gloucestershire scarce medical resources for treatment), and that – semi rural basic laser care is delivered at the county level, n non-medical graders can more accurately relieving the burden of care at tertiary facilities. detect DR than trained local ophthalmologists IMPACT ABOUT THE CASE STUDY and they achieve or surpass UK NHS standards 23, 452 screenings of accuracy in 2017 The problem IMPACT AND LEARNING n automated SMS messages can triple the rates PROJECT BUDGET A Gloucestershire countywide Primary Care What was the impact and why did it work of eye care follow-up among DR patients Audit undertaken in 1995/6 identified 9566 people USD $977,528 at a cost of with diabetes over the age of 16 years (2.1% of $42 USD per screen (2018/2019) Phase I ended in September 2017 with numerous n more important than educational videos to the county’s population). However, for those achievements, including: convince patients to accept comprehensive eye PROJECT TIMELINE identified to have diabetes, 32% had no record exams for detecting DR is providing such exams 1998 – present of eye examination results in the proceeding n 129 trainings of local doctors in management of for free. 15-month period. As a result, diabetes patients DR and glaucoma (280% of target), were regularly presenting late to the Hospital Eye Service with advanced DR that was difficult to AUTHORS n 199,819 comprehensive eye examinations CONCLUSION treat. Professor Peter Scanlon, Clinical Lead, completed at the 10 clinics and 113,894 Gloucestershire Diabetic Eye Screening examinations done during community outreach Why is this case study important for Overview of the intervention/program Programme & Clinical Director NHS activities improving integrated care for diabetes and Diabetic Eye Screening Programme in eye health?: At the countywide audit day, a proposal was England n 2,343 glaucoma cases detected in the clinics made to commence a screening programme and 767 in communities This case study shows that county hospitals, ACKNOWLEDGEMENTS based on digital photography. This was a novel the major eye care provider for China’s rural- The Gloucestershire Diabetic Eye approach at that time because all previous n 6,241 DR cases identified in the clinics and 685 dwellers, will sustain and invest their own Screening Team, Stephen J Aldington, photographic screening programmes had used in communities resources in a model of high-quality integrated Gloucestershire Research and 35mm film or Polaroid film. The Gloucestershire eye care which includes DR services. The Education Manager, Irene M Stratton, Diabetic Eye Screening Programme (GEDSP) n 1,439 glaucoma surgeries (180% of target) and project has served as a laboratory for research SeniorStatistician, Gloucestershire Retinal was the first digital diabetic eye screening 757 laser DR treatments done at county hospitals to highlight key aspects of a successful model. Research Group programme in England. GDESP commenced in The research findings in CREST are now helping 1998 with the aim of reducing blindness within the Phase II of the project, designed to improve to drive Orbis’ global DR programs in the population with diabetes - in the county, through systemic diabetes care and outreach to township direction of using non-medical graders in order early detection and effective treatment of sight facilities, began in 2017 and six of the most to maximize accuracy and reduce the burden threatening DR. The research programme was successful facilities are involved in the second on practitioners, freeing them up to focus on designed to demonstrate the effectiveness, and phase of programming. providing DR care. cost-effectiveness of digital photography in diabetic eye screening.

32 33 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018

PS Diabetic Macular Oedema PS Vitreous Haemorrhage

Artist: Kelly Noble Artist: Kelly Noble

Intervention/program details IMPACT AND LEARNING Between April 2014 and March 2017, there non-sight-threatening diabetic retinopathy was were only 2 notifications of blindness due to DR not. Uptake of screening was less in those with Through GDESP a reliable screening test What was the impact and why did it work? (annual rate 2.0 per 100,000 with diabetes, 95% c.i. most socioeconomic deprivation. was provided by professional and friendly 0.3 to 6.7) and 10 notifications of partial sight (10 staff, which was appreciated by patients. The introduction of the Gloucestershire Eye per 100,000 with diabetes, 95% c.i. 5.1 to 17.9). Other factors that were shownv to influence Importantly, the costs of screening and Screening Programme 20 years ago has meant 3 uptake were factors relating to primary care. effective treatment were not only affordable that the vitreoretinal surgeons in Gloucestershire The reductions in rates of blindness (SSI) and in iii Liew G, Michaelides M, Bunce within the health care budget but also proved are performing fewer vitrectomies for advanced partial sight (SI) were significant (p<0.0001 for Delay in diabetic retinopathy screening was C. A comparison of the causes of to be less than the cost of blindness. This diabetic eye disease. Moreover, the vitrectomies both). 4 also shownvi to increase the rate of detection of blindness certifications in England and Wales in working age adults approach meant that the program was found are now usually performed for conditions like sight threatening DR. (16-64 years), 1999-2000 with to be effective, cost effective and have recurrent vitreous haemorrhage rather than the In 2014 it was reportediii that diabetic retinopathy 2009-2010. BMJ Open 2014;4 iv vii Scanlon PH, Carter SC, Foy C, high population coverage with the results more advanced fibro-proliferative disease with was no longer the leading cause of blindness in Certain groups have been shown to be at et al. Diabetic retinopathy and published in 2003i ii. retinal detachment, which was more frequent the working age group in England. 5 lower risk of development of sight threatening socioeconomic deprivation in Gloucestershire. J Med Screen in 1998. This trend has been observed across retinopathy and can safely be screened every two 2008;15(3):118-21. doi: 10.1258/ As a follow on from the success of the England with the roll out of the NHS Diabetic Eye Challenges and learning years. jms.2008.008013 v Lindenmeyer A, Sturt JA, Hipwell GDEP, a National Screening Programme was Screening Programme. A, et al. Influence of primary care announced in 2003 with the Gloucestershire In the Gloucestershire population: practices on patients’ uptake of diabetic retinopathy screening: team asked to oversee the roll out of the Between August 2005 and July 2008, 16 people in a qualitative case study. Br J National Screening Programme in England Gloucestershire were registered blind (Seriously The number of people with diabetes has risen CONCLUSION Gen Pract 2014;64(625):e484-92. doi: 10.3399/bjgp14X680965 until the formation of Public Health England Sight Impaired SSI) with the principal cause 1 from 9566 people with diabetes (2.1% of the vi Scanlon PH, Aldington SJ, in 2012. The Gloucestershire Clinical DR, an annual rate of 25.4 per 100,000 of those population) in 1995/96 to 35,874 (5.7% of the The relative reductions in vision loss in this Stratton IM. Delay in diabetic i Scanlon PH, Malhotra R, Thomas retinopathy screening increases Lead has continued in the role of Clinical with diabetes (95% confidence intervals c.i. 15.0 G, et al. The effectiveness of population) in 2017/18. Of the 35,874 people with area of England due to systematic screening, the rate of detection of referable Director for the NHS Diabetic Eye Screening to 40.4). A further 26 were registered as Partially screening for diabetic retinopathy diabetes in the county, 30,696 were eligible to treatment for diabetic eye disease, tighter control diabetic retinopathy. Diabet Med by digital imaging photography 2014;31(4):439-42. doi: 10.1111/ Programme in England. Sighted (Sight Impaired SI) with the principal and technician ophthalmoscopy. be invited (some were already under the HES or of glycaemia and hypertension and earlier dme.12313 [published Online First: cause DR, an annual rate of 41.3 per 100,000 of Diabet Med 2003;20(6):467-74. were terminally ill etc..) and 23,452 (76.4%) were diagnosis of diabetes cannot be estimated from 2013/10/08] ii Scanlon PH, Malhotra R, vii Scanlon PH AS, Leal J, those with diabetes (95% c.i. 27.6 to 59.6). Greenwood RH, et al. Comparison actually screened in the 12 month period. these data but all are likely to have contributed to Luengo-Fernandez R, Oke J, of two reference standards in this welcome change. Sivaprasad S, et al. Development validating two field mydriatic of a cost-effectiveness model iv digital photography as a method A study demonstrated that diabetes and for optimisation of the screening of screening for diabetic 2 sight-threatening diabetic retinopathy was interval in diabetic retinopathy retinopathy. Br J Ophthalmol screening. Health Technol Assess 2003;87(10):1258-63. associated with socioeconomic deprivation, but 2015;19(74)

34 35 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018 International Case Studies of Integrated Care for Diabetes and Eye Health Diabetes eye care awareness training for primary level clinicians in Fiji

INTEGRATION TYPE ACKNOWLEDGEMENTS Integration of DR policies, The Queen Elizabeth Diamond Jubilee guidelines and training into all Trust, Fiji - Ministry of Health and Medical Services relevant national health policies,

and guidelines PROJECT EXPENDITURE – PRIMARY COSTS 1) DR Training for Primary level TARGET POPULATION 1) Primary level clinicians, clinicians which include community 2) Development of the DR health nurses and some training facilitators’ manual

general practitioners and nurse SOURCE OF FUNDING: practitioners The Queen Elizabeth Diamond Jubilee Trust 2) Individuals over the age of 35 who are at greater

risk of diabetes and ABOUT THE CASE STUDY diabetic retinopathy The problem SETTING Income Group: Upper middle A study by Brian et al. (2010) found that the income, Region: Nationwide - prevalence rate of diabetes, adjusted for rural and urban ethnicity, age, and gender, in Fijians aged 40

IMPACT years or older was 41 percent. Approximately 382 primary level clinicians 60 percent of people with diabetes in Fiji are undiagnosed (Brian et al. 2011). Inequities trained in terms of geographic area, have also been identified in Fiji, with those living in rural PROJECT BUDGET areas also less likely to have their diabetes USD $41,000 diagnosed (Brian et al, 2011). Every person with diabetes is at a risk of developing PROJECT TIMELINE diabetic retinopathy (DR). Since DR is often Commenced 2015 asymptomatic and many patients are not even – continuing aware they have diabetes, it is imperative to ensure patients are diagnosed and referred AUTHORS timely for retinal screening. The Fred Hollows Foundation New Zealand: Grace Johnstone, Programme The Fred Hollows Foundation New Zealand Analyst; Prarthana Dalmia, Diabetic (FHFNZ), in consultation with the Ministry Retinopathy Programme Coordinator; of Health and Medical Services Fiji, has Komal Ram, Pacific Diabetic Retinopathy been working to strengthen and expand Programme Manager. Pacific Eye Institute DR screening and treatment since 2011, (PEI), Suva, Fiji: Dr. Biu Sikivou, Director including the delivery of postgraduate training and Lead DR Ophthalmologist programmes in eye care for nurses and doctors at the Pacific Eye Institute (Ramke et al., 2012).

36 37 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018

n Conduct eye screening assessment for were released from their positions to attend diabetic patients the trainings. To overcome this challenge, it was important that these workshops were n Identify and manage other basic eye conditions locally led. The DR coordinator was able to utilise her existing networks to advocate n Implement standard management guidelines for this programme to nurse managers and for eye care NCD groups. It is a continuing challenge to ensure the nurses have ongoing support n Advice patients about diabetes eye care and and resources to implement their learnings. promote health education in communities The DR coordinator has facilitated the distribution of additional equipment and materials to participants and promoted further IMPACT AND LEARNING professional development opportunities including refresher training. What was the impact and why did it work? The training programme was designed in Fiji Since the programme commenced in 2015, and formed the basis for the development of the 382 primary level clinicians have been trained, Pacific DR Practice Manual. This was hugely including over 75% of the target community valuable for the roll-out of the programme to health nurses. An evaluation of the programme other Pacific Island countries, now delivered demonstrated a highly positive response with an in 5 other countries, and was vital to ensure average of 96% of respondents rating the training a consistent standard of quality education as either ‘Excellent’ or ‘Very good’ across several regionally. The manual provides the basic measures. curriculum which local DR Coordinators can adapt to their own country context. “The more knowledge we have the better for the community because we will be disseminating Recognising knowledge gaps in their the right knowledge and information for them colleagues, the participant nurses Photograph Copyright: The Fred Hollows Foundation NZ to understand and to come forward.” recommended that the training be available to other tiers of the workforce, including more Outstanding barriers to diabetic retinopathy health nurses, ward nurses, reproductive Between 2014 and 2017, there was a 58% increase general practitioners and community health management include a lack of appropriate nurses and some general practitioners. in the number of new diabetic patients screened workers. The programme has now been resources in health centres, and primary level The training has been conducted across by the PEI diabetes outreach programme in modified for content and the DR coordinators clinicians’ limited knowledge of diabetic all divisions in Fiji over a 2 day workshop the health centres and specialist outpatient have commenced training of community health retinopathy management and diagnosis (Kool facilitated by the in-country Diabetic department clinics at sub divisional hospitals workers. et al., 2015). Given that in most cases primary Retinopathy Coordinator, a senior nurse surrounding Suva, Fiji. level clinicians such as community health employed by PEI to implement DR activities. nurses are the first point of medical contact for Supported by the lead ophthalmologist, Factors contributing to the programme’s success CONCLUSION patients, it is important to acknowledge them training covers diabetes management, DR include: as pivotal players in diabetes management awareness, screening and management, Why is this case study important for and train them in diabetes eye disease and visual acuity testing, referral pathways, use of n Established referral pathways throughout the improving integrated care for diabetes and referral pathways to eye clinics. DR referral forms and DR data management. country, including a skilled eye care workforce eye health?: During these workshops, the participants are capable of screening and treating DR. Overview of the intervention/program provided with essential course equipment The management of diabetes is a ‘whole of such as Snellen charts, occluders, referral n Locally led training, delivered by a life’ task and requires an integrated approach With the help of The Queen Elizabeth forms and health promotion material such combination of NCD nurses, eye care nurses and operating from the prevention of the disease Diamond Jubilee Trust, FHFNZ developed as IEC pamphlets. Further infrastructural ophthalmologists. to its management across acute and chronic and launched a programme to upskill 80% of support is provided through the provision of stages. To address the current gaps in diabetes community health nurses in DR in late 2015. essential diagnostic equipment such as the While the primary objective of the programme eye care across the region, the DR awareness The aim of the programme was to provide HbA1c machines in some of the NCD clinics. was to increase awareness and referrals for training of primary health clinicians enable this competency based training designed to build DR, the training curriculum was much broader, cadre to work in collaboration with diabetes knowledge and skills in the area of diabetes A DR Practice Manual titled “Diabetes and including general diabetes and eye care, to services to support and refer diabetes patient and DR prevention and management. The Eye” was developed by PEI in 2017 for leverage this opportunity further. to access specific point of care, screening and the purpose of eye care education for primary treatment services. This effort to strengthen Intervention/program details level clinicians. This manual is a valuable Challenges and learning the referral system aims to streamline care and training resource that assists primary level work within the current standards of diabetes The DR awareness training is provided to clinicians in developing competencies to: Our DR Coordinator faced challenges service delivery in each country. primary level clinicians including community organising the workshops and ensuring nurses

38 39 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018 International Case Studies of Integrated Care for Diabetes and Eye Health Integrated Models of Care for Diabetic Retinopathy in India

INTEGRATION TYPE PROJECT EXPENDITURE – PRIMARY COSTS Integration of DR policies, 1) Equipment guidelines and training into all 2) Project Costs (transport, relevant national health policies, staffing, monitoring, etc.) and guidelines 3) Training 4) Advocacy TARGET POPULATION People with diabetes SOURCE OF FUNDING: and registered at The Queen Elizabeth Diamond Jubilee Non Communicable Trust. Physical space, staff providing the services, medicines, and operating Disease Clinics expenses were met by the respective State Governments where the project was SETTING implemented. Income Group: Lower middle income; Region: Rural – 10 districts – Vijayanagaram(Andhra Pradesh), Surat(Gujarat), Goa (Goa),Tumkur (Karnataka), Trissur (Kerala), ABOUT THE CASE STUDY Wardha (Maharashtra), Khurda (Odisha), Pali (Rajasthan), Tirunelveli (Tamil Nadu), The problem West Midnapur (West Bengal) PwDM registered at the recently IMPACT operationalized NCDC at Primary Health 34,450 people with Centres(PHC) (1:30,000 population) and diabetes screened Community Health Centres (CHC) (1:100,000 population) are provided free diabetic PROJECT BUDGET medications. No systematic screening USD $3.25 million program for detection and management of DR exists at these clinics. Opportunistic PROJECT TIMELINE screening for DR is available at some eye March 2015 and the clinics at secondary or tertiary level. Two end date is June 2019 separate public-funded programs, the National Program for Prevention and Control AUTHORS of Cardiovascular Diseases, Cancers, International Centre for Eye Health, Diabetes and Stroke (NPCDCS) and the Clinical Research Department, London National Program for Control of Blindness School for Hygiene & Tropical Medicine: (NPCB) are involved in diabetes management Murthy GVS and Clare Gilbert; Indian and eye care, respectively. Managing diabetes Institute of Public Health, Public Health and its complications need an integrated Foundation of India: Rajan Shukla approach at all levels of care to optimize benefits. ACKNOWLEDGMENTS India DR Partners Project Implementation Overview of the intervention/program Consortium; The Queen Elizabeth Diamond Jubilee Trust DR screening in rural district The public health system ensures long

40 41 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018

term sustainability as it meets the needs Intervention/program details of the poor, especially women in rural areas, for whom accessing private facilities The Ministry of Health, Government of India is unaffordable. Only a public-funded constituted a task force, which shortlisted health system can ensure that services will districts based on diabetes magnitude, continue to be provided to all segments of functioning NCDC availability, and mentors the population in an equitable manner. A to support capacity building. Agreements situational analysis revealed that 45% of were signed with the respective governments the PwDM had some degree of visual loss to ensure sustainability and scaling up. when they first presented to an eye clinic. Physicians, ophthalmologists and ophthalmic Therefore, a paradigm shift was essential assistants were skilled. Public health where PwDM are offered screening at a facilities were supported with equipment. physician’s clinic, before vision loss occurs. Customised software was developed to track registered PwDM. Advocacy with the The objectives of the project included different stakeholders was critical for getting developing integrated sustainable services their buy-in. Regular monitoring and reviews Kerala State Launch through: provided quality assurance.

n advocacy for policy change with the Challenges and learning CONCLUSION government IMPACT AND LEARNING In many States, signing the agreements took Why is this case study important for improving n capacity building of ophthalmologists and What was the impact and why did it work? time. Eleven States were initially identified, integrated care for diabetes physicians but one State had to be dropped as it was and eye health? Integration of the two vertical programs taking inordinately long to get them on board. n orientation of auxiliaries (making them (NPCB and NPCDCS), ophthalmologists The initial reluctance of providers to support Diabetes affects the poor as much as the aware of complications of diabetes and and diabetic physicians, public health and task-sharing and the lack of structured rich. In rural areas, the poor, especially the need for early screening for eye the NGO sectors and different levels of follow up mechanisms were challenges. women do not access DR screening services complications to prevent visual impairment) care were facilitated by the core planning The competing priorities with other health because of affordability and the distance and monitoring team and the implementing programs were also a challenge as was they need to travel. An integrated approach n increasing awareness on risk factors and partners. This included sharing evidence on availability of affordable Anti-VEGF agents. improves access to diabetic medicines their management by PwDM how partnerships would improve uptake of In many districts, initially, dedicated and control of risk factors while providing screening services and ensure follow up and personnel and space for the NPCDCS services for screening of complications of n implementation and evaluation of the need for a team approach rather than an clinic was not available. In some States, diabetes, including DR. This will reduce integrated models of care for DR in 10 pilot individual speciality. Screening was initiated coordination hampered scaling up. the risk of visual loss in diabetes and meet districts. in the physician’s clinics across 50 CHC the needs of rural populations where such across 10 States. Treatment facilities were The pilot also provided key learnings. facilities are not routinely available. There Operational feasibility and benefits of the augmented at 10 district hospitals. Review Government buy-in is critical for success is a need to empower persons with diabetes integrated model, embedded in public health meetings provided important insights into and sustainability. Once the governments are also as compliance with medical advice and systems is currently being assessed. implementation. 480 health professionals convinced of the benefits, there is enthusiasm lifestyle modifications will only be successful were trained and 3153 auxiliaries oriented. for scaling up DR screening activities. if people are aware and willing. A pilot project Expected outcomes include 50% increase 34,450 known PwDM were screened and Time needs to be invested in building trust, spread across 10 districts in India showed in screening for DR among clinic-registered 1601 treated in the first two years which confidence and understanding among the that an integrated service delivery model for PwDM, 75% registered PwDM aware of the matched the expected outcomes. Six State different stakeholders to work together if management of diabetes and its complications risk of STDR and 50% increase in known governments have allocated finances for integration is to be achieved. PwDM have is feasible, pragmatic and acceptable to the PwDM attending for repeat annual screening. scaling up DR screening in districts not to be supported through mediums like peer providers and persons with diabetes. covered by the pilot. groups so that they can act as advocacy pressure groups.

42 43 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018 International Case Studies of Integrated Care for Diabetes and Eye Health Addressing Diabetic Retinopathy in Indonesia

INTEGRATION TYPE NCDs unit, Provincial and District Integration of DR policies, Departments of Health in Bandung, guidelines and training into all Yogyakarta and Jakarta. relevant national health policies, Rumah Sakit Cipto Mangunkusumo, Rumah and guidelines Sakit Dr. Sardjito, Rumah Sakit Mata Cicendo. TARGET POPULATION Professional associations of People with diabetes Ophthalmologists and Endocrinologists across Indonesia (aged 15 years and above) PROJECT EXPENDITURE – PRIMARY COSTS 1) Advocacy SETTING Income Group: Lower middle 2) Screening Activities income; Region: Urban and rural 3) Training districts within the provinces of SOURCE OF FUNDING: Jakarta, Bandung and Yogyakarta World Diabetes Foundation IMPACT The Ministry of Health ABOUT THE CASE STUDY has included vision assessment in screening tools The problem for early detection of risk factors for non-communicable diseases Indonesia has the one of the largest number including diabetes of people with diabetes (PWD) in the world - an estimated 10,276,000 million people in the

PROJECT BUDGET year 2017 which is expected to increase to over 16 million by the end of 2040i. Globally, USD $325,000 the prevalence of diabetic retinopathy (DR) ii PROJECT TIMELINE among PWD is estimated to be 34.6% which, 2015 – 2018 if applied to Indonesia, means that over 3.5 million Indonesians with diabetes currently have DR and an estimated 5.5 million AUTHORS Indonesians will have DR at the end of 2040. Helen Keller International: Dr. Satyaprabha Kotha; Ame Stormer; Nick Kourgialis; Early detection through development Michael Lynch of screening programs and provision of appropriate treatment is critical to reduce ACKNOWLEDGEMENTS visual impairment and blindness due to DR. Divisions of Diabetes and metabolic disorders and Disorders of the senses, Overview of the intervention/program Directorate of Non-communicable diseases, Directorate of Primary Health The objectives of the DR screening program services and Directorate of Referral were to develop a strategy to integrate DR services, Ministry of Health care into national standards of care for PWD

DR screening activity during a World Diabetes day event in Indonesia and to improve the awareness of

44 45 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018

Patients with Diabetes being educated using simulation eye glasses at a World Diabetes day event in Jakarta. DR screening by a non-medical technician in Yogyakarta

General practitioners, nurses, educators and tiers of the health system, which could be for further assessment. activities at the PHC by the tertiary hospitals ophthalmologists to screening, referral and used to inform policy change. HKI supported cannot be recovered through the insurance treatment for DR. the development of these guidelines as well The developed guidelines for screening system because such an outreach activity as the incorporation of DR messages into of DR and the Information, Education and is beyond the mandate of the hospital. It Intervention/program details advocacy packages for dissemination to the Communication materials have been shared would be most sustainable for the screening provinces and the integration of modules for with the MoH to incorporate DR screening services at the PHC to be integrated into the The key features were: DR into national training modules. into National guidelines of diabetes care and health system, where costs can be recovered to improve awareness towards prevention of through the insurance system. Screening services for DR at the primary blindness due to DR. 1 health centres (PHCs) in the three IMPACT AND LEARNING provinces was carried out in partnership Challenges and learning: CONCLUSION with the tertiary hospitals who provided What was the impact and why did it work? the staff and the equipment while HKI Since DR is typically asymptomatic in its Why is this case study important for facilitated training and the operational The MoH has now included vision and early stages, using visual complaints as improving integrated care for diabetes and expenditure for the screening. The PHCs hearing assessment into screening tools for a pre-requisite for referral can result in eye health? at the district were mapped and key staff early detection of risk factors for NCDs such delayed care and irreversible vision loss. from health offices were informed of the as Diabetes, Hypertension, Obesity, Heart Evidence from an operations research By inclusion of guidelines for screening for importance of DR screening. HKI-trained Disease, Chronic Obstructed Pulmonary project carried out in Jakarta and Yogyakarta DR into the National standards of care for staff carried out the retinal photography, Disease and Cancer. This activity is carried demonstrated that PWD served at the NCDs diabetes; provision of screening services for photo grading and education of PWD during out in accordance with MoH set guidelines, clinics in the PHCs were not referred to DR within the NCD clinics at the PHCs and every screening event. PWD identified with through the PHCs all over the country by secondary hospitals for DR screening education of health care providers at all the DR were referred to the secondary hospitals health workers at integrated health posts in unless they reported visual complaints. In tiers of the health system, this case study for further management. An ophthalmologist the communities called ‘POSBINDU’. The the selected intervention districts where demonstrates the integration of diabetes and from each hospital was responsible for the screening kits include devices to test blood vision assessment, fundus photography, and eye health. Further, to ensure sustainability, DR screening program in their respective glucose, cholesterol, body fat, measure education were carried out for PWD, they the developed guidelines must inform change province. weight, waist and height, and vision. The were consistently referred to the secondary in policy to recover costs for screening for target beneficiaries are ages 15 and above. hospitals for further management when DR. Although this was beyond the scope of the Advocating for the inclusion of DR Regular health check-ups are carried out identified with DR. Most patients (84%) program, constant advocacy will be continued 2 screening into the National Guidelines by trained health volunteers supervised by visited a hospital for further treatment when to make this a possibility soon. for Care of Diabetes: A task force was staff at the PHC. Counselling to live a healthy they received a referral note from their (http://www.diabetesatlas.org/acro ss-the-globe.html) established that recommended that DR lifestyle is also encouraged. Those identified physician. An important challenge is that (Yau et al Global Prevalence and Major risk factors of Diabetic Retinopathy Diabetes Care screening guidelines be reviewed at the three with risk factors are then referred to the PHC currently, the operational costs for screening 35:556-564, 2012)

46 47 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018 International Case Studies of Integrated Care for Diabetes and Eye Health

Educational course for general practitioners Modelling a Telemedicine Screening Program for Diabetic Retinopathy and Implementing a Pilot Project in Iran

INTEGRATION TYPE Rabbani; Ms. Zahra Sadeghian and Horizontal and vertical integration Ms. Shima Narimani. Furthermore, we of services would like to thank all colleagues of the Optometry Department at Torfeh Hospital.

TARGET POPULATION This study was performed in collaboration Patients with diabetes with the New Technologies Research over 12 years of age and Center, Amirkabir University of Technology registered at the Iranian and Iranian Diabetes Society. Diabetes Society - Islamshahr PROJECT EXPENDITURE – PRIMARY COSTS Branch (IDSIB) 1) Equipment, developing the SETTING web-application and server Income Group: Upper middle 2) Staffing income; Region: Urban, capital 3) Training city suburb -Islamshahr

SOURCE OF FUNDING: IMPACT Ophthalmic Research Center affiliated 604 patients to Shahid Beheshti University of Medical screened Sciences

PROJECT BUDGET USD $18,500 ABOUT THE CASE STUDY

PROJECT TIMELINE The problem Program modelled 2014 – 2016. Project implemented The burden of diabetes mellitus (DM) is high in Iran, rising by 35% among Iranian in 2017. adult population from 2005 to 2011. Diabetic retinopathy (DR) is the most important ocular complication of DM and almost 30% AUTHORS of adult persons with DM suffer from this Ophthalmic Research Center, Shahid complication in Iran. Population-based Beheshti University of Medical Sciences, studies indicated that DR is the leading Tehran, Iran (WHO Collaborating Center preventable cause of visual impairment (VI) for the Eye Health and Prevention of in the working age population. Evidence Blindness Program in Iran); Center for showed that early detection and timely Global Health, Department of Public treatment is an effective strategy to reduce Health, Aarhus University, Denmark.See VI attributed to DR. However, a noticeable end of case study for co-authors. percent of Iranian patients with DM are ACKNOWLEDGEMENTS unaware of this important issue. Dr. Mohammad Ali Javadi; Dr. Hossein Ziaei; Dr. Hossein Mohammad-Rabei; Dr. The WHO has designed a tool for assessment Mohammad Faghihi; Ms. Sonia Nourozali; of DR and DM management systems known Ms. Marzieh Mollamohammad Rahimi; as WHO-TADDS. It makes situation analysis Ms. Masoumeh Zarei; Ms. Maryam possible at the national level through a seven

48 49 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018

section framework including 1) Priorities, 3) visual acuity (VA) was assessed and the mobile text message usage for informing providers and to improve the network policies and programs 2)Service delivery fundus images captured the patients. This method can be considered between DM and DR care services. 3)Health workforce 4)Health technology 5) as an initial version of the mobile health Health information management systems 4) fundus images were sent to the reading (mHealth) which overcomes transport and n The project resulted in two fundamental 6)Health promotion for DM and DR and center at Ophthalmic Research Center, cost barriers. The impact of the IDSIB staff deliverables; a) A user friendly web 7)Health financing. The national WHO- Shahid Beheshti University of Medical in increasing the patients’ awareness was application system in Farsi language for TADDS assessment of Iran, headed by the Sciences in the north of Tehran via IRTOS. another factor for high compliance rate. screening of DR in Iran; b) the Ministry of Ophthalmic Research Center (as the WHO However, we learned that this rate may be Health (MoH) approved training package for Collaborating Center for the Eye Health 5) Images were graded by the trained GPs increased further through raising the patients’ screening of DR to upskill GPs. and Prevention of Blindness Program), at the reading center. Images were also awareness about the value of early detection demonstrated an appropriate status in terms independently reviewed by a retina specialist of DR for prevention of severe visual n The pilot phase findings revealed that of workforce and essential technologies for as the gold standard at the reading center. impairement and blindness. In addition, this grading by GPs had a high sensitivity and DR care. However, the analysis showed that rate may even be increased by providing specificity for any stage of DR. integration of DM and eye care services and 6) Finally, patients and the IDSIB were more diagnosis and treatment facilities. the screening coverage for DR needed to be informed of the results via mobile text n Current model identified 50% of low risk promoted further. messages and the IRTOS, respectively. n Most of the screened patients were women. diabetic patients who might be followed at This might be explained by the increasing the IDSIB as the primary setting and resulted Overview of the intervention/program 7) Patients who needed further assessment access of women to the DR screening care in allocating more diagnosis and treatment were referred to an eye hospital. facilities through overcoming the transport facilities and resources to patients at a high Telemedicine is an ingenious strategy to barriers. risk of VI. overcome the access barriers and increase the rate of screening by promoting the n The sensitivity of DME grading by GPs n The findings were reviewed at the Center network between care providers in primary IMPACT AND LEARNING was not appropriate enough. To compensate for Non-communicable Diseases Control, and referral care settings and improving the this limitation, VA assessment was included MoH, to promote diabetic eye care services patients’ awareness. The United Kingdom, What was the impact and why did it work? in the screening process and resulted in a at the national level. This led to designing the United States, France, Australia and India high referral rate. Therefore, we decided a new project that mostly focused on the have reported successful tele-screening Overall, 604 subjects with diabetes were to exclude patients with moderate non- integration of IRTOS into the ongoing national programs for DR. Despite the advantages of screened; of these, 415 (68.7%) were women. proliferative diabetic retinopathy from the public health database (SIB) and also this approach, a tele-screening program has The retinal images had sufficient quality for referral pathway. These cases would be changing the approach of the DR screening not been implemented yet in Iran. grading in 93.5% of cases. The sensitivity followed by fundus photography based on training course into a distance learning and specificity for diagnosis of any stage a 4 month schedule. model. Intervention/program details of DR by trained GPs was 82.8% and 86.2%, respectively. Corresponding values were In this mixed model study, a DR 63.5% and 96.6% for DME. The rate of CO-AUTHORS screening referral pathway and a web sight-threatening DR was 15.5%. Half of the CONCLUSION application called “Iranian Retinopathy screened subjects needed to be referred for Sare Safi, MSc; Hamid Ahmadieh, MD; Teleophthalmology Screening (IRTOS)” was further evaluation. Totally 24.2% of patients Why is this case study important for Marzieh Katibeh, MD; MPH (Center for launched. At the same time, an educational did not comply with recommended further improving integrated care for diabetes and Global Health, Department of Public Health, course for general practitioners (GPs) was assessment. eye health?: Aarhus University, Denmark) Mehdi Yaseri, established. To conduct the pilot phase, PhD; Homayoun Nikkhah, MD; Saeed registered patients at the IDSIB were Challenges and learning (what challenges A tele-screening program for DR screening Karimi, MD; Ramin Nourinia, MD; Ali Tivay, recalled. After admission at IDSIB: did you face and what important lessons was designed in Iran and implemented in MSc; Mohammad Zareinejad, PhD; Davood were learned): Tehran suburb. Abbasi, MD; Afshin Eshghi Fallah, MD; 1) patients were informed about the aims of Alireza Ramezani, MD; Siamak Moradian, the study and the procedure n In our study, the majority of patients n This model was focused on involving MD; Mohsen Azarmina, MD; Mohammad complied with the recommended further the primary care setting to promote the Hosein Dehghan, MD; Narsis Daftarian, MD; 2) written consent was obtained assessment. It may be explained by the awareness of both patients and DM care Bahareh Kheiri, MSc

50 51 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018 International Case Studies of Integrated Care for Diabetes and Eye Health Screening for Diabetic Retinopathy in Mexico, Telemedicine: Pilot Project

INTEGRATION TYPE PROJECT EXPENDITURE – PRIMARY COSTS Integration of eye care into routine 1) Training at the Singapore diabetes care/primary care Eye Research Institute and related costs TARGET POPULATION Adults 18 years of age 2) Server and computer and above with or without equipment as well as development software a history of systemic disease including DM 3)Portable, non-mydriatic cameras SETTING Income Group: Upper middle SOURCE OF FUNDING: income; Region: Querétaro, NGOs as listed above and own funding Querétaro - urban from the IMO

IMPACT 24,402 eyes analysed in 78 different primary care clinics, ABOUT THE CASE STUDY in 23 out of the 32 states of the Mexican Republic The problem

PROJECT BUDGET Diabetic retinopathy is a leading cause of USD $76,000 blindness worldwide and the main cause of visual disability between patients of PROJECT TIMELINE productive age. December 2015 – May 2016 The overall prevalence of diabetic retinopathy of any severity is 34.6% globallyi and the stages that cause visual threat AUTHORS such as proliferative diabetic retinopathy Instituto Mexicano de Oftalmología. and macular edema can be asymptomatic, IMO, Querétaro (Mexican Institute of therefore, it is vital to carry out an Ophthalmology). Dr. Renata García, Dr. appropriate, timely, easy to reproduce Ellery López, Dr. Van C. Lansingh, Dr. screening that does not generate an increase Dalia Méndez, Dr. Alejandro Arias. in medical care costs. We also conducted a ACKNOWLEDGEMENTS Rapid Assessment of Avoidable Blindness SEVA USA, Vision for the Poor, Singapore (RAAB) study in 2016, which showed that we Eye Research Institute. had a 1% prevalence of bilateral blindness and of which 18.8% was due to DRii. i Yau JW, Rogers SL, Kawasaki R, et al. Global prevalence and major risk factors of diabetic retinopathy. Overview of the intervention/program Diabetes Care 2012;35:556–64. ii López EM, Allison K, Limburg H, et al. Rapid assessment of The objective of the intervention was avoidable blindness including diabetic retinopathy in Queretaro, to determine the prevalence of DR and México. Rev Mex Oftalmol (Eng). other retinal diseases within the Mexican 2018;92(2):70-79 Acquisition of images with Volk Pictor Plus® camera.

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population that participated in a telemedicine undertaken by a retinologist certified by the retinopathy in at least one eye. screening program. Singapore Ocular Reading Center (SORC) and The University of Melbourne in grading The prevalence of macular degeneration in Secondary objectives: determine the DR at the Melbourne School of Population this study was 5.61% and 5.7% with suspected sociodemographic characteristics, and Global Health. The criteria for qualifying glaucoma. 0.21% (n = 26) of the total patients prevalence of Diabetes and Hypertension, a photograph as non-gradable were: had clinical findings of diabetic retinopathy Diabetic Retinopathy, age related macular overexposure, or underexposure, dark areas, and were not aware of diabetes mellitus. degeneration, suspicion of glaucoma, and artifacts, and out of focus. prevalence of other fundus findings. Challenges and learning The modified Scottish classification of Hypothesis: is there similarity between the diabetic retinopathy was used. (NHS). When rolling out this program in several prevalence of diabetic retinopathy in our states of México, as a detection method for RAAB study to that reported. A screening Suspect glaucoma was defined as: cup/ the entire population, there was difficulty in program for diabetic retinopathy through disc ratio equal to or greater than 0.6 in any breaking distance barriers and acquiring telemedicine, could represent a cost-effective eye, disk asymmetry equal to or greater non-mydriatic cameras to avoid the possible tool that allows detecting early stages of DR than 0.2, disc hemorrhages or any notching complications of drug dilation. to establish timely treatment. of the neuroretinal ring. After graduation of each eye, the system indicates a clinical A joint work was carried out in the institute Macula centered color photo of left eye. Intervention/program details recommendation from the Reading Center to implement ophthalmological prevention and the period in which ideally the patient campaigns and recruitment of patients. Health prevention campaigns in 78 different should be assessed if required. primary care units were carried out in several Training of personnel such as optometrists for states of the Mexican Republic, where they the capture of images and ophthalmologists recruited a total of 24,402 eyes. The analysis and retinologists for the reading and of the photographs was carried out at the IMPACT AND LEARNING evaluation of retinographies. reading center of the Mexican Institute of Ophthalmology in Querétaro, México: What was the impact and why did it work? The implementation of the program showed Mexican Advanced Imaging Laboratory a higher cost benefit when a screening for Ocular Research (MAILOR), between A total of 12,201 people participated in diagnostic test was performed to detect March 2016 and February 2018 through screening from 78 clinics and hospitals diabetic retinopathy, as well as other retinal the program. To support this analysis, located throughout México. Most of the diseases. an electronic platform was designed for studied population was concentrated in storage, transfer and evaluation of data Mexico City, Guanajuato, Queretaro and and the generation of reports. The platform the State of Mexico. The medium age was includes a questionnaire with personal and 61.31 years (18-98) and 66.26% were women. CONCLUSION sociodemographic data, as well as medical The prevalence of arterial hypertension and ophthalmic history. Optometrists were was 53.04% (n = 3987). The prevalence of The implementation of this program has trained for this purpose, as well as for taking Diabetes Mellitus was 82.75% (n = 8279) ensured that adequate referrals are made for visual acuity (simplified E-test was used) and the average duration of the disease patients evaluated and that require treatment. and taking pictures (Pictor Plus® non- was 11.38 years (SD = 8.04). Only 4.61% The outcome being that the over saturation of mydriatic camera (Volk, Ohio, USA), 2 color of diabetic patients had follow-up with health services is reduced. Optic disc centered color photo of left eye. photographs 40 degrees per eye were taken , glycosylated hemoglobin (HbA1c). 48,804 one centered on the macula and the other in fundus photographs were analyzed. 12.37% of the optic disk. the photographs were non-gradable. 12.56% (n = 1532) of the population presented The evaluation of images captured was corresponding findings with diabetic

54 55 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018 International Case Studies of Integrated Care for Diabetes and Eye Health Integrated Approaches to Address Diabetic Retinopathy in three Districts of Pakistan

INTEGRATION TYPE PROJECT EXPENDITURE – PRIMARY COSTS Horizontal and vertical integration 1) Service Delivery Costs of services 2) Training of Doctors, Lady Health Workers, GPs, MOs, TARGET POPULATION project team 57,103 known patients 3) Monitoring & Evaluation with diabetes across 4) Advocacy and Community Karachi, Lahore and Awareness Rawalpindi in Pakistan 5) Research

SETTING SOURCE OF FUNDING: Income Group: Lower middle Standard Chartered Bank through the income, Region: Urban ‘Seeing is Believing’ programme (80%) Sightsavers (20%) IMPACT 34,982 people screened for DR, 9,574 patients referred to partner hospitals (to date)

PROJECT BUDGET ABOUT THE CASE STUDY USD $1.25 million The problem PROJECT TIMELINE April 2014 This case study is based on a project titled “Strengthening Pakistan’s Response – March 2019 to Diabetic Retinopathy” designed and implemented by Sightsavers and funded AUTHORS by Standard Chartered Bank for a duration Sightsavers Pakistan Country Office: of five years (March 2014 to April 2019). Munazza Gillani, Country Director; Diabetic Retinopathy (DR) and Sight Muhammad Bilal, Programme Manager; Threatening DR (STDR) are among the Leena Ahmed, Senior Programme Officer most common causes of blindness amongst Diabetes Mellitus (DM) patients in Pakistan. ACKNOWLEDGEMENTS Al-Ibrahim Eye Hospital Karachi, The International Diabetes Federation (IDF) Holy Family Hospital Rawalpindi ranks Pakistan at number seven globally for and Mayo Hospital Lahore. high rates of diabetes in the population, with prevalence estimated at 7 million in 2010 National Eye Health Committee and projected to increase to 11.5 million by 2025. National DR task Force Pakistan Various population-based studies conducted in Pakistan suggest that approximately 25% of people with diabetes have DR, and 10% have STDR, around 94% of STDR will need Laser treatment/Intra Vitreal injections and about 6% will need advanced Vitro-retinal (VR) surgery. Lady health workers educating women at the community level regarding DM and its effect on eye health

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Overview of the intervention/program n Multi-Disciplinary team approach for with STDR and is also capturing valuable emails to patients and project teams. DR prevention and treatment and training data, which will provide information for The overall purpose of the project is to of various medical cadres. This includes further analysis and research purposes and HEALTH SYSTEM STRENGTHENING and prevent visual impairment due to DR through training of Ophthalmologists in vitreo wider learning. IMPROVED SERVICE DELIVERY: Training early detection, regular follow up and retinal surgical skills and laser procedures. the existing community and health workers appropriate management of STDR amongst Moreover General Physicians (GPs) and (Ophthalmic technicians and other para- known persons with diabetes in the three Medical officers (MOs), Medical and IMPACT AND LEARNING medical staff) and specialist eye care districts of Pakistan. The key focus of the Ophthalmic Technicians, and Lady Health workers, including ophthalmologists, who project is on developing a referral system Workers (key workforce of Pakistan’s Primary What was the impact and why did it work? will leave behind a legacy of knowledgeable, from primary to secondary and tertiary Health Care system) working in the project skilled and committed human resources level to ensure known diabetic patients are areas have been oriented about DM and its COMMUNITY MOBILIZATION FOR for the prevention and treatment of DR. The screened for DR and a management plan is complications on eye health. DEMAND GENERATION THROUGH PHC training materials developed for LHWs were established. SYSTEM’S WORKFORCE: At the community endorsed by National Eye Health Committee level, 3,884 LHWs (Backbone of PHC system) and PHC system and are now part and parcel were trained in spreading awareness of the PHC system. DIABETICS within general population Community mobilisation regarding DM management and DR Community targeted at diabetics mobilisation screening. LHWs have been an excellent tool The project has equipped all three DR units for reaching out to women at the household with desirable technology and HR, which has Known diabetics Undiagnosed diabetics level and as a result a good gender balance helped in screening of 34,982 for DR, out Effective information tracking mechanisms was achieved for women’s access to DR of which 9,130 were identified with DR and screening/treatment services as reflected in 3,066 with STDR; 2,425 people were provided Referral BHUs, RHCs, GPs Systems the data captured. laser treatment and Intra-Vitreal injections; Existing Diabetology/ DR Screening and 112 received VR surgeries under the endocrinology Units (DR Clinics) The importance of DM management and project support free of cost. units (DM Clinics) its direct impact on the regression of the retinopathy was validated by project data HORIZONTAL and VERTICAL Screening & early analysis. The hospital selected for this INTEGRATION of SERVICES for STRONG detection NO analysis is purely an eye hospital where no REFFERAL SYSTEM: Training MOs, Diabetic Retinopathy DM management services available at start Technicians and LHWs helped in developing Follow up tracking of this project. The hospital started providing a referral protocol from primary to tertiary YES & DM Care DM management services in second year levels of healthcare system, and as a result, Sight Threatening NO Appropriate Diabetic Retinopathy of this project and within three years, the 9,574 patients were referred from different treatment & progression from normal fundus to DR sources and reported at partner hospitals compliance YES monitoring decreased from 13.57% to 10.04%, whereas during the last 4 years Laser or the progression from DR to STDR decreased VR Surgery from 31.63% to 27.19%. To ensure that maximum DM patients 31 Within the project MIS, the information about source of reporting in hospitals undergo DR screening, referral is recorded for each COMPLIANCE, RECAL AND REFERRAL: inter-departmental linkages within hospitals patient, this enable us to Intervention/program details n Robust IEC Strategy for demand determine different sources and Treatment compliance for the visiting patients were established. The patterns of referral generation and improved uptake of services numbers of referrals from primary was achieved mainly through counsellors practice are very variable within and between level. LHWs are provided with n Strong referral chain (primary to tertiary for DM and DR. referral slips (with 3 parts) one who counsel patients and their families to locations, and in some locations are still level) for screening of all DM patients for remains with LHW, one goes with follow a regular treatment plan and secondly low considering the likely need within these patient and one is submitted at early detection of DR and its treatment. n Treatment compliance, through an effective the project’s partner hospital level. through the project-based patient tracking communities. Cross referral within various departments tracking system and DR MIS that records This mechanism helps in getting MIS software that is serving to record an insight on different types and (medical, endocrinology, diabetic clinics referrals, screening, treatment follow up of ratios of referrals. Furthermore, it systematic patient data, details regarding and ophthalmology) for screening of all DM people with diabetes. This MIS tracks the reveals that how many people management and follow up through 31 were referred by LHWs and how patients to detect DR (if any ). treatment compliance of patients especially many have actually reported to automated cell phone SMS and reminder the facilities.

58 59 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018 International Case Studies of Integrated Care for Diabetes and Eye Health Comprehensive Model of Diabetic retinopathy Management in the Palestinian Territories

Challenges and learning (what challenges CONCLUSION INTEGRATION TYPE PROJECT EXPENDITURE – PRIMARY COSTS did you face and what important lessons were learned): Why is this case study important for Integration of eye care into routine 1) Salaries improving integrated care for diabetes diabetes care/primary care 2) Medical Devices n The existing underpinning health system and eye health?: 3) Medications/ Medical and for diabetes mellitus treatment services is not TARGET POPULATION Surgical Disposables well established in project areas and each This case study provides an overview of the Patients with diabetes hospital is making efforts to overcome the approaches used for integrated care of DM (type 1 and type 2) SOURCE OF FUNDING: particular constraints of the individual settings. within eye health system, mainly: attending clinics from all Fred Hollows Foundation, CBM, Federal Ministry of Economic Cooperation n Health facilities for different interventions n Adopting multi-disciplinary team approach sectors in refugee camps, cities (BMZ) and Development, World Diabetes should be selected closer to the available and inter-departmental linkages for treatment and villages in the West Bank in Foundation DR services, patient flow and easy access. of DR, resulting in a referral system and the Palestinian territories Much larger number of diabetic patients screening and examination of DM patients by can benefit, if the DR screening services are all relevant medical professionals, including ABOUT THE CASE STUDY SETTING available nearest to the DM management Diabetologist, Nephrologist, Medical Refugee camps, cities and facilities. Specialist, Optometrist, Ophthalmologist, VR/ villages in the West Bank in The problem Retina specialist, counsellor, diabetic foot the Palestinian Territories which n One-Window operation with easy access clinic etc. are considered a lower-middle income Diabetes Mellitus and DR are major health was introduced at one partner hospital that country problems in Palestinian territories. DM is enhanced patients’ treatment compliance. It n Training of HR at primary, secondary and projected to affect 23% of Palestinians by motivated patients significantly for uptake of tertiary level to develop a referral protocol IMPACT 2030 and highlighting the emerging issue of treatment from registration to treatment. from community to tertiary levels. 40,000 patients DR, in a clinic-based study in Ramallah, 37% screened of DM patients were identified to be affected n Awareness raising sessions organized n Effective treatment compliance through by DR. Compounding this problem there, is

nearer to communities through LHWs counselling and patients’ data/tracking PROJECT BUDGET an insufficient number of ophthalmologists resulted in increased self-reporting and system, and introduction of one-window to offer screening services to all patients at demand generation. operation at hospital level for patient’s USD $1.72 million risk of DR across the Palestinian Territories.

facilitation. PROJECT TIMELINE Despite these issues, DR was not a priority n A robust MIS system helped in follow up November 2012 in the latest (2017) Strategic National Health with patients to ensure treatment compliance Community awareness and advocacy Plan, and there is no national integrated DR and created evidence for research and with National Eye Health Committee and – December 2015 screening program at primary health care advocacy. National DR working group for standardized level or any plans to improve the capacity of guidelines for implementation of DR projects. AUTHORS health care providers to screen for DR. n Building capacities of health professional St. John Eye Hospital Group at primary, secondary and tertiary levels is United Nations Refugees and Works Agency ACKNOWLEDGEMENTS necessary for timely diagnosis and referral (UNRWA) is the second largest health Fred Hollows Foundation, CBM, Federal of DM patient for DR management that provider in Palestinians territories. It offers Ministry of Economic Cooperation strengthen referral protocol. health services to refugees who are the most (BMZ) and Development, World Diabetes vulnerable populations except for ophthalmic Foundation services. Co-authors: Sare Safi, MSc; Hamid Ahmadieh, MD; Marzieh Katibeh, MD; Mehdi Yaseri, PhD; Homayoun St. John Eye Hospital Group (SJEHG) is Nikkhah, MD; Saeed Karimi, MD; Ramin Nourinia, MD; Ali Tivay, MSc; Mohammad Zareinejad, the largest and the only expert provider of PhD; Davood Abbasi, MD; Afshin Eshghi Fallah, MD; Alireza Ramezani, MD; Siamak Moradian, eye care in Palestinian territories with five MD; Mohsen Azarmina, MD; Mohammad Hosein Dehghan, MD; Narsis Daftarian, MD; facilities including hospitals in Jerusalem, Bahareh Kheiri, MSc Hebron and Gaza and clinics in Anabta (in

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the north of Palestine) and the old city in Palestinian living in the West Bank and Gaza of patients received different types of Jerusalem. Because of restricted movement, needs a special permit to enter Jerusalem. management and treatment. This contributed many Palestinians cannot access SJEHG In general all patients are given permits to improving the well-being and the quality of services. for treatment at St. John hospital except for life of Palestinian DM patients by discovering very few patients who are denied permits for and treating their DR at an early stage and Overview of the intervention/program security reasons. preserving their sight.

The objective was to introduce a workable, The program was conducted between Management and treatment modalities accessible DR screening model for DM November 2012 and April 2016 and the costs that the patients received patients in primary health care clinics from for refugees to access these services were Laser Avastin Phaco Vitrectomy OCT FFA different sectors and to increase capacity of covered by the project. health care providers (non-clinicians) in DR 3104 1357 426 97 1,719 2381 screening. It also aimed to establish referral mechanisms between primary health care IMPACT AND LEARNING Challenges and learning Partnership with UNRWA was very important clinics and SJEHG facilities. UNRWA was the for the success of the program and for main partner in this project. What was the impact and why did it work? n Successful screening should be planning future projects. We hope to work on a undertaken through community-based national level and involve Palestinian Ministry Intervention/program details The main impact of the project was national programs of health despite all obstacles. establishing a real partnership with UNRWA A semi-static model was used. Two screening and introducing a systematic DR screening n Using a desk mounted camera was not At the completion of the project, one fundus desk-mounted fundus cameras (Canon-CX1) program at the primary health care level. practical (very expensive, heavy, required camera was donated to UNRWA and one was were stationed in primary health care clinics. Importantly, it was the first well- established continuous maintenance and was difficult to donated to the Palestinian Ministry of Health One team screened DM patients in middle comprehensive screening project in move from one clinic to another). Hand-held to continue screening patients and to integrate and northern areas of the West Bank and Palestine. cameras might be a better option. screening activities at primary health care one team screened DM patients in southern facilities. areas to improve accessibility. Patients Cameras were donated to UNRWA and the n While the partnership with UNRWA (as were screened in their respective clinics Palestinian Ministry of Health. 30 trained service delivery agency) was very successful, by trained nurses from UNRWA and SJEHG. UNRWA nurses screened DM patients after improved involvement and partnership with DR screening in primary health care clinics When all patients in a clinic were screened, the end of the project in different UNRWA the Palestinian Ministry of Health is required camera was moved to another clinic. clinics. Patients with retinopathy were to ensure the scalability, sustainability and referred for further management to SJEHG financial security of the approach going Screeners provided primary grading facilities. forward. and referred patients with retinopathy or any eye abnormality to the closest As a result of the establishment of the secondary and tertiary SJEHG facilities screening project at UNRWA clinics, the CONCLUSION for further management. Patients received numbers of referred patients to the SJEHG comprehensive management by well-trained facilities decreased and only complicated The prevalence of DR among DM patients ophthalmologists and were followed up in cases were referred which improved the in the West Bank was high. As a result, early coordination with their primary health care efficiency of the group’s services. screening for DR and timely management physicians. Quality control measures were is essential to preserve patient’s sight and conducted on regular basis to minimize false Over 40000 patients were screened in all improve their quality of life. negative and false positive results. across 33 clinics through this program. This is believed to be the largest number Screening using fundus cameras by well Patients who needed complicated operations of patients ever screened in any screening trained nurses at the primary health care level at the main tertiary hospital in Jerusalem program in the world. One third was found can decrease number of referred DM patients were given appointments to apply for to have DR and was referred to SJEHG to secondary and tertiary health facilities and permits from the Israeli authorities as every facilities for further management. Thousands increase the efficiency of these facilities.

62 63 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018 International Case Studies of Integrated Care for Diabetes and Eye Health Implementing an Integrated Diabetic Retinopathy Health System Model in La Libertad, Peru

INTEGRATION TYPE PROJECT EXPENDITURE – PRIMARY COSTS Integration of eye care into routine 1) Equipment diabetes care/primary care 2) Medical supplies 3) Training, staffing and TARGET POPULATION professional fees An estimated 54,84132 people with diabetes SOURCE OF FUNDING: Orbis International and IRO (a public ≥30 years old within the hospital funded by the Ministry of Health) catchment area of Instituto Regional de Oftalmologia, two regional Ministry of Health ABOUT THE CASE STUDY hospitals and 12 health centres in La Libertad The problem

SETTING The International Diabetes Federation Income Group: Upper middle reported a prevalence of diabetes of 5.2% 32 income, Region: La Libertad for Peru in 2017, among whom an estimated Region 23.1% to 30% have DR, and who are twice as Estimated Percentage 50% 30% DM likely to be blind as those without diabetes.33 7% IMPACT Although access to health services in Peru Nº 54,841 16,452 1,814,276 27,420 11,849 patients with has improved, there are still challenges for 783,445 diabetes screened, many people, especially for low-income and rural populations34. IRO is in Trujillo, the 426 medical practitioners trained capital of La Libertad, and provides high quality, comprehensive ophthalmological PROJECT BUDGET USD $2.345 million services for patients with limited resources. Overview of the intervention/program PROJECT TIMELINE

January 2014 The implementation of a program for early People with diabetes who will develop DR People Population projected La Libertad > 30yo projected La Population DM Prevalence * (for testing in Health centers) Diabetes diagnosed * (require annual eye exam) Target population at time of project design 2013 Target – December 2017 detection and timely referral of patients with Libertad in La Population Total

DR was the result of an agreement between (*) calculated based on ALAD, AUTHORS Orbis and IRO in 2014. Project objectives Guide4 (**) additional info based on Orbis International: Amelia Geary, include: Chiapas RAAB13 Director of Program Quality and 33 Villena JE, Yoshiyama CA, Sánchez JE, Hilario NL, Merin Development; Sara Benavent, Senior To provide access to ocular care, early LM. Prevalence of diabetic retin- Program Manager 1 assessment and timely treatment to the opathy in Peruvian patients with type 2 diabetes: results of a hos- Orbis Trujillo FEH 2014 Program – Week 2. low-income population with diabetes. pital-based retinal telescreening ACKNOWLEDGEMENTS program. Rev Panam Salud IRO: Dr. Nancy Suarez. Publica. 2011 Nov;30(5):408-14. Retina. Dr. Gary Lane, volunteer faculty retinal specialist To establish a care network including 34 Neelsen S, O’Donnell O. from San Antonio, Texas, examined patients at IRO during 2 IRO (tertiary level), two regional hospitals Progressive universalism? The impact of targeted coverage week 2 of the program. (secondary level) and 12 public health on health care access and centers (primary level) for the referral of expenditures in Peru. Health Econ. 2017 Dec;26(12):e179-e203. doi: Credit: Geoff Oliver Bugbee/Orbis patients with 10.1002/hec.3492.

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Table 1. LEVEL I Patients with diabetes diagnosed at 12 primary health centres Population Cumulative No. of new No. of No. of patients Cumulative census Projected nominal census patients Follow-up treated at IRO 2014–2017 of >30yo (SIS) 2014–2017 screened for patients of registered DR at referral screened for registered patients patients with hospitals DR at referral with diabetes at all SUSPECT DR diabetes hospitals levels of care in the General Require diabetic retinopathy Ophthal- Diagnose Patients with treatment Alto Trujillo 4,002 217 141 38 12 referral network in diabetes mologist the stage referred: examines of DR northern Peru, by Nurse Ascope 2,039 428 267 78 37 Screening, patients Technician primary health-care imagining Cruz Vilca 3,458 499 283 81 16 LEVEL II decided: centre and grading a. Normal by nurse El Esfuerzo 6,114 577 354 123 22 OR b. technicians at Suspect DR the Belen and El Milagro 5,021 473 332 125 36 the Regional Jerusalén 11,667 787 685 273 94 hospitals NORMAL Not require treatment return for annual Return for periodic La Noria 33,649 939 818 271 74 ophthalmic check ophthalmic Laredo 3,351 393 196 97 23 Santa Isabel 9,902 693 487 151 53 Virú 5,427 341 154 26 19 Vista Alegre 6,193 491 369 113 40 Instito Regional de LEVEL III Oftalmologia IRO Laser Avastin Surgery Wichanzao 2,994 174 118 52 15 Total 93,817 6012 4204 1428 441

DR for screening, evaluation, diagnosis and tertiary level focused on building the capacity The project ended in December 2017. Currently implemented to reduce the burden of DR must treatment, if required. of retina specialists to deliver different IRO is conducting their standard DR screening be planned with a horizon of 10 years37, ideally modalities of treatment for DR. and treatment work, as well as liaising with with the input of diabetes educators38, meaning To strengthen the technical capacity of the DR network. A project evaluation is being that additional phases of the project may be 3 the medical teams within the network, conducted and plans for a next phase being required to sustain results. providing adequate training to improve the IMPACT AND LEARNING considered. efficiency and quality of DR services. What was the impact and why did it work? Challenges and learning CONCLUSION Intervention/program details The collaboration between Orbis and IRO has A comprehensive treatment network for DR Why is this case study important for IRO and Orbis advocated with the successfully established an efficient DR referral requires ocular care to be integrated into improving integrated care for diabetes Regional Health Directorate to obtain a system every level of the healthcare system, supplying and eye health? signed agreement to establish the DR staff with the appropriate knowledge, skills screening network, in accordance with which has increased the number of PWD who and infrastructure to diagnose, refer and This project proved the following: national regulations35 and international have received eye examinations, accurate treat DR. Besides ophthalmic services, the recommendations36. referrals and timely treatment for DR. This network must include health professionals of Effective and timely treatment for DR is project demonstrates that effective management all disciplines, including doctors specializing 1 possible when patient education, screening During the first year of the project (2014) of DR is possible when education, screening in general medicine and endocrinology, nurses, and care are fully integrated into the general three non-mydriatic cameras were acquired and treatment are fully integrated into the technicians, and counselors. health care system across primary, secondary for retinal screening and a laser for DR general health care system. and tertiary levels. treatment, all supported by Orbis. The By employing multidisciplinary training cameras were installed at secondary and A total of 426 medical professionals were strategies, advocating with the government and This integration requires that health 37 A second phase of the project tertiary hospitals, and a pathway was trained by the project, including 323 general promoting public awareness and education, the 2 professionals at primary, secondary and is required to improve the established to refer all patients diagnosed physicians, 27 ophthalmologists, 29 residents, DR referral network increased the screening tertiary health centers are furnished with the referral systems, information management, and demand of with diabetes for an ophthalmological 30 nurses and 17 technicians. Between 2014 and treatment of patients with diabetes, appropriate knowledge, skills and infrastructure services. Ten years represents examination and treatment if required (see and 2017, 11,849 patients with diabetes were without placing undue strain on resources at to diagnose, refer and treat DR. the average length of time that is required to establish a functional Figure below). screened with non-mydriatic cameras through specialized facilities. and efficient DR program, which the DR network. DR screenings in the area 35 National Health Strategy for Besides ophthalmic services, the network ensures DR awareness raising the prevention of NCD launched and preventative education Multidisciplinary training was provided for increased by 138.1%, from a baseline of 4,977 in 2004 However, the challenge remains to ensure the 3 must include health professionals of all amongst the target population staff at primary and secondary facilities, patients screened only at IRO over the period of 36 International Council of sustainability of the DR referral network over disciplines, including doctors specializing in 38 Von-Bischhoffshausen FB, Opthamology Guidelines for Dia- Castro FM, Gomez-Bastar P. focusing on management of DM and 2010 - 2013. Nearly half of those screened in the betic Eye Care available from time. general medicine and endocrinology, nurses, Planning diabetic retinopathy screening of DR through the capture and project (5,632, 47.5%) were low-income patients http://www.icoph.org/downloads/ technicians, and counselors. services - lessons ICOGuidelinesforDiabeticEyeCare. from Latin America. Community grading of retinal photos. Training at the attending public health centers. pdf (Cited 2018 Mar 03) Our experience suggests that programs Eye Health. 2011 Sep;24(75):14-6.

66 67 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018 International Case Studies of Integrated Care for Diabetes and Eye Health Evidence-Based Shared Care Eye Model: Right Siting Of Stable Diabetic Retinopathy Patients To Primary Eye Clinic In Singapore

INTEGRATION TYPE SystemsResearch, Duke-NUS Medical Integration of diabetes care into School, Prof Ecosse Lamoureux, Health comprehensive/primary eye care Services and Systems Research, Duke-NUS Medical School. TARGET POPULATION

Patients with Type I or PROJECT EXPENDITURE – PRIMARY COSTS Type II Diabetes; 1) Training primary eye care staff Age Group (21-85 years); referred to tertiary eye hospital 2) Manpower cost (SNEC) for management of diabetic 3) Equipment and rental retinopathy with stable low risk DR SOURCE OF FUNDING: SETTING SNEC Income Group: High income; Urban

IMPACT Out of all cases of screened for DR ABOUT THE CASE STUDY in the Singapore Integrated Diabetic Retinopathy Programme, up to 10% of The problem the patients are currently managed in tertiary hospitals. With the implementation of this step Currently, public tertiary eye centres, and down care model, 6-8% of cases are decanted private ophthalmology clinics provide the to Primary stable eye clinic in SNEC. bulk of eye care services in Singapore. PROJECT BUDGET Predicted increase in prevalence of type II DM in Singapore to 15% by 2050 will USD $419,857 PER YEAR inundate specialist clinics with patients with PROJECT TIMELINE diabetic retinopathy (DR). Of these only 2013 to ongoing 25% or so may have vision-threatening DR that requires intensive specialist care. That leaves the bulk of DR patients with low risk AUTHORS of vision impairment, which may potentially Singapore National Eye Centre (SNEC) be followed by primary eye care providers. Singapore Eye Research Institute However, overcrowded specialist outpatient Duke-NUS Medical School clinics (SOC) have not been able to decant stable patients to polyclinics for long term ACKNOWLEDGEMENTS care due to lack of clinical expertise to Dr Ranjana Mathur, Clinical Director, perform comprehensive eye examination in Primary Eye Care, SNEC, Prof Tien Y Wong, primary eye care (PEC) at the polyclinics in Medical Director, SNEC, Prof Donald Tan, Singapore. past Medical Director, SNEC, and PI of the PEC research project, Mr Lee Kai Yin, This has resulted in high retention rates of Chief Project Officer, SNEC. Ms Charity all grades of DR patients at SNECs general Wai, Chief Operating Officer, SNEC. as well as specialist eye clinics with a mix Adj A/Prof Edmund Wong, Dy Medical of simple and complex cases. This reduced Director, Clinical Service, SNEC. Adj Asst efficiency of SOC and could potentially result Prof Dirk De Korne, Health Services and PEC optometrist conducting slit-lamp examination in less time devoted to complex cases.

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Clinical Pathway for referral of Diabetic Retina Service (D.R.S) patients to PEC Clinical Pathway for referral of PEC patients back to D.R.S Exclusion Criteria Patient Under D.R.S. Follow-Up (Not to be referred to PEC) D.R.S. Patient under PEC follow-up – Standard follow-up duration of 12 months (with option to follow-up at 6-9 months)

1. Ocular Co-Morbidity: Other Subspecialty Follow Up At SNEC REFER BACK TO D.R.S. REFER to PEC Must be vetted by 2. Diabetic Maculopathy (As Associate Consultant and above Defined) 3. Require Drs Follow Up ≤ 6 DEVELOP DIABETIC DEVELOP SEVERE/ UNABLE TO EXAMINE PATIENT DEVELOPS Months MACULOPATHY/ PROLIFERATIVE FUNDUS IN DETAIL EXCLUSION CRITERIA Inclusion Criteria for 4. Unstable/Progressive FOCAL EDEMA DIABETIC RETINOPATHY One Eyed Patients: Worsening Visual Acuity On Drs n To be seen at D.R.S. n To be seen at D.R.S. Good eye with BCVA or pinhole Follow Ups n To be seen at D.R.S. n Severe NPDR: To be within 2 to 4 weeks within 3 months better or equal to 6/18 within 2 to 4 weeks seen at D.R.S. within Advancing Cataract 5. One Eyed Patient and Better ▶ Retinal Thickening 4 weeks or PCO eye worse than 6/18 ▶ located 500µ from Foveal n PDR/VH/RD: To be ▶ Diffi culty in Examining 6. Lens Opacity Classification: ≥ Centre seen at D.R.S. /DRLC on Patient No4, Nc4 And/Or C5 And /Or P4 ▶ Retinal Thickening ≥ 1 DA same/next day prevents fundus exam from Foveal Centre NO DIABETIC MILD DIABETIC MODERATE DIABETIC POST-PRP BURNT-OUT ▶ Hemorrhage and/or *(EXCLUDES VH) Hard Exudates With RETINOPATHY RETINOPATHY RETINOPATHY RETINOPATHY ▶ Microaneurysm > Std Photo Retinal Thickening 500µ 2A in 4 Quadrants n Not suitable for n At least one n Retinopathy stable for n No Visual from Foveal Centre ▶ Venous Beading in 2 yearly DRP Microaneurysm past 2 years with Deterioration for ▶ Any Focal Retinal Quadrants Stable Risk Factors at least one year Thickening at Macula n No Exclusion Criteria n No Maculopathy ▶ IRMA in 1 Quadrant n No Maculopathy n No Maculopathy ▶ New Vessels, Vitreous n No Exclusion Criteria Hemorrhage n No Exclusion Criteria n No Exclusion Criteria

Intuitively, due to already burgeoning SOC, Intervention/program details new patients need longer waiting time to get specialist appointment. Patients requiring We developed a stringent training program, stable DR, glaucoma and cataract. Patients The sustainability of step down PEC is immediate eye care may have delayed referral clinical pathway and protocols for are referred to a specialist clinic based on dependent on the perceived financial and access to eye care resulting in significant stable DR, based on strict inclusion/exclusion pre-defined protocols. (Fig) practical benefits for both patients and visual morbidity. This led us to develop criteria. Stable DR patients included those decanting specialists. The costs differences an eye model of right-siting these patients with stable condition at the SOC for at least between PEC and SOC are related to to an appropriate location to be managed 2 years, diagnosed with mild to moderate manpower and overhead cost. by a clinically competent team of medical NPDR, post-pan retinal photocoagulation, IMPACT AND LEARNING professionals at the lowest possible cost. burnt-out retinopathy, no maculopathy and no In Asia, patient convictions that only visual deterioration for at least one year. What was the impact and why did it work? the specialist doctor delivers the most Overview of the intervention/program appropriate care are strong. Therefore, Our SNEC PEC research study looking at Singapore Integrated Diabetic Retinopathy patients are willing to pay their fee ‘to see Due to lack of evidence whether primary care right-siting of stable diabetic retinopathy Programme (SiDRP) telemedicine model, a the ophthalmologist’. Task-substitution of physicians in Singapore can provide similar (with or without cataract) has shown clinical national programme, screens for DR at the eye care to non-doctors (e.g. optometrists, quality of care with regard to diagnosis, decision making and clinical management primary care level and makes appropriate nurses) is a novel concept. Related management and patient satisfaction, at a by PEC physician is equivalent to gold referrals to tertiary centres based on the financial and reimbursement schemes will reduced costs and we designed a study to standards of management by a specialist recommendations. Approximately 10% of total play an important role in the successful look at these parameters. ophthalmologist. Patients are equally patients screened are referred for specialist implementation of PEC on a larger scale. satisfied with the PEC compared to the SOC appointment at tertiary eye clinics. Of these The objective of SNEC PEC research project setting and the total costs of a visit to PEC 6-8% cases are right sited to PEC stable DR Our PEC concept might need to be more (2012) which conducted a randomized were estimated to be 55.4% of a visit to SOC. clinic for further follow up. closely interwoven with the public primary equivalence study was to compare quality policlinics and close collaboration with of clinical care, patient satisfaction and Encouraged by these results, we have Our integrated PEC model demonstrates the private general practitioners should be economic benefits of managing patients with upscaled our PEC concept and have trained effectiveness and feasibility of secondary or explored. stable DR in a PEC, seen by trained primary several family medicine practitioners and step-down eye care models and relieve the care physician; compared with a tertiary SOC institutional optometrists with a targeted strain on tertiary centres. in SNEC. The primary outcome was correct approach towards management of chronic clinical assessment and management, using stable eye conditions. Skill transfer included Challenges and learning CONCLUSION a dichotomous masked tick box approach history taking, clinical exam (detailed according to attending retinal specialist slit lamp exam, dilated fundus exam with Right siting of eye care requires critical Right-siting of patient and task-shifting of eye ophthalmologist. Secondary outcomes were non-contact fundus lens, IOP assessment), system approach and strategies that care to competent PEC trained optometrist patient satisfaction and consultation costs. management and disease counselling. need to be strengthened such that all the and non-specialist physician reduced burden Equivalence testing was used to analyse The team of trained PEC physician and stakeholders, the patient, physicians and of managing non-complex cases from the generalized odds ratio and associate optometrists run stable eye clinic offsite, employer perceive the benefit and comply specialists in tertiary institutions and allowed confidence intervals. which includes casemix of patients with with appropriate pathways and guidelines. them to manage more complex cases.

70 71 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018 International Case Studies of Integrated Care for Diabetes and Eye Health Upscaling of diabetic retinopathy screening in Tanzania

INTEGRATION TYPE PROJECT EXPENDITURE – PRIMARY COSTS Integration of eye care into routine VISION 2020 LINKS capacity diabetes care/primary care building and training

SOURCE OF FUNDING: TARGET POPULATION The Queen Elizabeth Diamond Jubilee An Adults attending the Trust. Some small equipment provided in diabetic and eye clinics kind by the charity Eyehope. at Muhimbili National Hospital ABOUT THE CASE STUDY SETTING Income Group: Low income; The problem Region: Urban – Dar es Salaam The scale of the epidemic of DM and IMPACT diabetic retinopathy DR in Tanzania is 1,638 patients screened, only just becoming apparent. The adult 815 laser treatments for DR population of Dar es Salaam is 3.6 million, with a prevalence of DM of 7.8%. One third PROJECT BUDGET of people with DM have DR, of whom 10% USD $20,000 require treatment to prevent unnecessary sight loss. It is estimated that annually, PROJECT TIMELINE 25,000 people from the population of Dar es November 2014 Salaam require screening and 2,500 require treatment. – January 2016 However, screening and treatment for DR are AUTHORS still in their infancy with Muhimbili National London School of Hygiene & Tropical Hospital being the only government facility Medicine. Mrs Denise Mabey, Miss offering DR screening and treatment in Marcia Zondervan, Miss Claire Walker, Dr Dar es Salaam. This case study provides Radhika Patel information about the development of DR screening and treatment services at ACKNOWLEDGEMENTS Muhimbili University of Health & Allied Muhimbili. Sciences, Tanzania (MUHAS) – St Thomas’ Hospital, London (STH) VISION Overview of the intervention/program 39 The VISION 2020 LINKS 2020 LINK, Diabetic Retinopathy Network Programme works to improve 39 (DR-NET) of the Queen Elizabeth The MUHAS – STH VISION 2020 LINK quality and quantity of eye care was set up in 2007 with one of the key focus training, mainly in Africa. The Diamond Jubilee Trust. Dr Celina Mhina, programme, which began in Dr Faraja Chiwanga, Mr Moin Mohamed areas being on human resource development 2004, has so far established 21 for medical retina. In 2014 the LINK joined links between training institutions in Africa and the UK. It works the DR-NET funded by the Queen Elizabeth by matching an African eye Diamond Jubilee Trust and started collecting department with a UK eye department in a partnership to monthly data on the number of screening and train the whole eye care team. treatment episodes for diabetic retinopathy For more information on LINKS visit http://iceh.lshtm.ac.uk/vision- Optometrist Redempta Kessy has been made responsible for DR screening at Muhimbili National Hospital that occurred at MUHAS. In collaboration 2020-links-programme/

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Diabetes clinic Muhimbili, Tanzania

Optometrist Redempta Kessy has been made responsible for DR screening at Muhimbili National Hospital

with the Ministry of Health, the Tanzanian IMPACT AND LEARNING Challenges and learning CONCLUSION Diabetic Association (TDA) donated a retinal camera to the diabetic clinic at Muhimbili What was the impact and why did it work? The setting up of a retinal camera in Why is this case study important for National Hospital (MNH), in the expectation the diabetic clinic requires space and improving integrated care for diabetes that screening numbers would increase if the The total number of patients screened for DR involvement of staff from outside the eye and eye health?: patient pathway were simplified in 2015 was 217. Since the introduction of the department and is unlikely to be successful camera in the diabetic clinic there has been without positive input from the diabetic n This case study demonstrates how moving Intervention/program details a sustained increase in number of patients doctors and nurses. diabetic retinopathy screening from the screened with 706 screened in 2016 and 715 eye clinic to the diabetes clinic can, with Redempta Kessy is an optometrist at MUHAS screened in 2017. In 2015 there were 215 Collaboration between ophthalmologists and immediate effect, triple the number of who has been made responsible for DR laser treatments, 270 in 2016 and 330 in 2017. diabetologists at an early stage of planning is screening episodes at an urban hospital. screening. She attended the opening DR- essential to foster a sense of joint ownership. NET workshop in 2014 and has been on two The project has enabled increased Involvement of Ministry of Health in in n The success in increasing screening subsequent LINKS training visits to STH and awareness and training for health workers planning and budgeting for development of episodes has encouraged the team to plan Gloucester to learn grading skills. She is now in the diabetic clinic in screening and DR services, allocation of staff and provision for outreach screening and four people have taking the Gloucester DRS online course. management of diabetic eye disease. There of equipment is essential. requested registration for further online has been a marked increase in the numbers training as DR screeners. Throughout 2015 DR screening took place of screening episodes, especially since the Training opportunities in DR screening only in the eye clinic. Patients seen in the installation of the camera in the diabetic have been made available to nurses, who n Another camera has been purchased by the diabetic clinic were given an appointment clinic. previously had no knowledge of the eye St Thomas’ – Muhimbili LINK and the plan is to attend the eye clinic on another day. It complications of diabetes. Shared learning for it to go out to secondary hospitals as part was recognised that many did not return for Simplification of the patient pathway with a from other DR-NET LINKS has been both of an outreach programme their eye screening appointment, which is one-stop shop approach has enabled patients encouraging and supportive for planning. on the same site but a 10-min walk from the at risk to be more easily identified, screened n A significant expansion of DR screening diabetes clinic. and treated. and treatment services is needed in Africa to address the growing need and prevent The retinal camera donated by the TDA In addition referral processes have been huge numbers of people losing their sight was placed in the diabetic clinic at MNH in optimised through people being given an unnecessarily January 2016. From then on, DR screening appointment for treatment at the time of has been performed in the diabetic clinic and screening. on the same day as the diabetic appointment.

74 75 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018 International Case Studies of Integrated Care for Diabetes and Eye Health Diabetic eye health care model of integration at the inter and intraprofessional levels at a community health center in the US

INTEGRATION TYPE PROJECT EXPENDITURE – PRIMARY COSTS Horizontal and vertical integration 1) Staffing of services 2) Equipment costs

SOURCE OF FUNDING: TARGET POPULATION LCHC Patients with diabetes at the Lynn Community Health Centre (LCHC). Sixty four percent of the total ABOUT THE CASE STUDY patient population at the LCHC is at or below the US federal The problem poverty level. LCHC is a non-profit, multicultural, community health center and has grown SETTING significantly in recent years with professional Income Group: High income, services ranging from medical care, eye Region: Urban – Lynn, services, dental services, women and Massachusetts children health needs, nutrition programs, IMPACT behavioral health, and elderly care services. 1,155 dilated diabetic The team members include highly qualified mental health therapists, nurse practitioners, eye examinations physician assistants, dentists, optometrists, and pharmacists, and other specialists who PROJECT BUDGET work together to create a patient-centered N/A medical home.

PROJECT TIMELINE Commenced 2017 – ongoing OB/GYN Primary AUTHORS Care/Urgent Pediatrics Care Timothy Bossie, OD F.A.A.O, Former Director of Eye Care Services, LCHC and Assistant Professor of Clinical Optometry, The New England College of Optometry School Patient Infectious (NECO); Bina Patel OD F.A.A.O, Professor, Based Health Centered Disease (HIV/ Care STD Clinic) New England College of Optometry, Care Director of International Programs

ACKNOWLEDGEMENTS Behavioural Dental Figure 1: LCHC and NECO Health Services Showing the Eye Care multidisciplinary Services care provided at Lynn Community

Eye examination lane at Lynn Community Health Center Health Center.

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(medical doctors, doctors of osteopathic with more advanced diabetic retinopathy medicine) work together to provide receive care or referrals sooner. collaborative care to patients. The health care professionals work together to provide the Challenges and learning best possible interdisciplinary care to each patient examined at the health center. The Some of the challenges and lessons we have use of the health maintenance application learned at LCHC include and universal referral process has made it easier to for primary care physicians to refer n The primary care physician’s (PCP) diabetic patients. These changes have also understanding the importance of annual eye made it easier for all health professionals examinations along with how to properly The center uses an integrated care model allowed all of the health center providers to involved in collaborative care to understand process an internal referral to the eye clinic. offering inter and intra professional access submit the standardized referral to the eye when the last dilated eye examination took for all patients seen at the health center. Care clinic referral coordinator. place. The referral process for PWD was n Data acquiring process in the EHR system is coordinated among providers, with special incredibly complex prior to the changes that regarding patient “health maintenance.” This attention paid to medical and behavioural n The eye clinic has created more we made. This made it difficult for providers was a challenge to get all providers and staff health clinicians, who practice together in the examination slots for patients with diabetes. to understand if a diabetic patient needed a encountering the patient to ensure that the same location. Additionally, diabetics are scheduled by our dilated eye examination. Additionally, due to proper information was completed. front desk staff prior to the schedule being the significant difference in provider referrals The number of examinations provided by the opened for all patients. This schedule change we were unable to sometimes get diabetic n Finding ways to adjust the eye clinic eye clinic has increased year to year since its ensures that we are able to book a significant patients scheduled. Routinely, specific ocular schedule in order to schedule more diabetic opening. There has also been a steady influx number of our diabetic referrals. The health findings noted in the examination (more patients for examination. of new patients including diabetic patients center stresses that diabetic patients are a routinely retinal findings) are communicated needing a routine eye examination. Patients high priority and this policy is also used in to the primary care physicians to ensure the n Communication about the importance with ocular complaints or diabetes all receive the eye clinic. patient’s overall systemic health. The future of annual eye examinations, examination a referral for Optometric services as the first goals of the health center are to continue findings, and/or follow ups with patients from entry point. Comprehensive eye examinations n The ability for the eye clinic to examine all with this initiative to ensure that a majority various ethnic backgrounds. Handouts and include dilated fundus examinations. In 3,552 diabetic patients annually would be a of the diabetic population in Lynn, MA is educational materials regarding diabetic eye the fiscal year 2017 (FY2017) the LCHC eye significant challenge. The eye examination receiving annual diabetic eye examinations. care were dispensed to patients in Spanish. clinic examined 8,223 patients. The clinic has space, number of providers, and total number Data run in the spring revealed that the eye If the patients were able to read and write struggled to ensure that all of our patients of appointments slots has a major role in clinic was currently screening about ~30% of educational materials from the electronic with diabetes have annual eye examinations this issue. However, with the changes to our the diabetic population at the health center health record system were dispensed to the because of the substantial growth in patient workflow described above, we have been with a long term goal being set closer to patient. numbers. able to schedule more diabetic patients into 50%. In addition, the health center has been the eye clinic annually. discussing the idea of tele-retinal health n Booking issues: Originally, the eye clinic Overview of the intervention/program screenings conducted in the primary care presumed that all patients were being department. Tele-retinal medicine could referred to the eye clinic for evaluation Several projects have been initiated between further the effort involving annual retinal following an examination by their primary the eye clinic and other departments IMPACT AND LEARNING screenings while also ensuring that patients care physician. throughout the health center to improve our diabetic care. These include the following: What was the impact and why did it work?

n Using a health maintenance application From March 2017 to March 2018, the LCHC in our electronic health records (EHR) eye clinic has conducted 1,155 dilated system. The health maintenance application, diabetic eye examinations. In the year prior allows all providers to visualize the last eye, with similar examinations room and staffing podiatry, and primary care examination for the eye clinic encounter approximately each person with diabetes. Specifically, eye 875 diabetic patients. This increase in care providers enter the date and ocular examinations demonstrates that our workflow findings from their dilated eye examination. changes have been beneficial to the diabetic This information is easily visualized by other population. (Reference-Lynn Community providers on the patient’s care team. Health Center).

n Streamlining the referral process. We have A major impact has been the collaboration created a universal referral process for all and overall communication between primary diabetic patients. The title and information care, behavioural health and the eye clinic. included in the referral from physicians is the At LCHC, behavioural health providers same now for all diabetic patients. This has (therapists) and primary care physicians Front reception at Lynn Community Health Center

78 79 INTEGRATED CARE FOR DIABETES AND EYE HEALTH A GLOBAL COMPENDIUM OF GOOD PRACTICE 2018 International Case Studies of Integrated Care for Diabetes and Eye Health Diabetic retinopathy screening and treatment in Zambia

CONCLUSION INTEGRATION TYPE PROJECT EXPENDITURE – PRIMARY COSTS

Why is this case study important for Integration of DR policies, 1) Annual training costs improving integrated care for diabetes guidelines and training into all including international support and eye health?: relevant national health policies, and experts and guidelines 2) Equipment costs for five This case study is an important

demonstration of how improving integrated hospitals in Zambia TARGET POPULATION care for diabetes and ocular health is critical SOURCE OF FUNDING: for the patient’s health. It shows the focus at Adults with diabetes Zambian Ministry of Health, Tropical LCHC and its overall success, is based on mellitus living in Zambia Health Education Trust (THET), The prioritizing the patient and making them the Queen Elizabeth Diamond Jubilee Trust, center of care. SETTING Christian Blind Mission, Konkola Private Income Group: Lower middle Hospital, Chingola In conclusion, improved communication income; Region: Urban – Kitwe between patient’s integrated care providers has been critical. We improved the IMPACT ABOUT THE CASE STUDY understanding or importance of annual eye Incorporation of DR into examinations to provider and the community Zambia’s National Health The problem health center patients. Most importantly, we Strategic Plan 2017-2021 increased the number of PWD receiving With a per capita gross domestic product

annual ocular care in the eye clinic. In PROJECT BUDGET (GDP) of around US$1,700, Zambia is now a FY 2017, LCHC eye clinic has conducted lower middle-income country (LMIC). Large 1,155 dilated diabetic eye examinations. In USD $630,000 portions of the population, however, have not

the year prior with similar examinations PROJECT TIMELINE shared in the overall improvement in national room and staffing the eye clinic encounter Initial partnership prosperity seen in recent years. 60% of the approximately 875 diabetic patients. This population live in rural areas and depend increase in examinations demonstrates that commenced in 2011. on subsistence farming. Lack of access our workflow changes have been beneficial Project has since been scaled up to quality health care services is a major to the diabetic population. (Reference-Lynn across Zambia and problem faced by poor, rural communities. Community Health Center). is continuing Improved health outcomes are constrained by poor quality health and medical services; AUTHORS non-availability of medicines, equipment Frimley Park Hospital, Frimley, UK and supplies; shortages of skilled human ACKNOWLEDGEMENTS resources, especially in rural areas; and Kitwe Central Hospital, Zambia; VISION by social determinants of health such as 2020 LINKS Programme, International low income, gender inequality, lack of Centre for Eye Health, London School of information and access to services. Hygiene & Tropical Medicine In 2011, Frimley Park Hospital Eye Unit began working with the Kitwe Central Hospital Eye Unit in Zambia as part of the International Centre for Eye Health’s VISION 2020 LINKS Programme. A scoping visit carried out in 2011 revealed that a major problem in Zambia was the absence of a

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diabetic retinopathy screening and treatment Intervention/program details an appointment at Kitwe Central Hospital. A Health Strategic Plan 2017-2021 programme, which meant that patients with list was kept of patients who did not attend, diabetic eye disease inevitably presented The intervention was to initiate and develop so that they could be targeted when they next n The success of the screening project very late, often at an untreatable stage. diabetic retinopathy services in Zambia. appeared in the local health system. in Kitwe has enabled the LINK to expand screening services across Zambia and now Data from the IDF Atlas show that there Multidisciplinary teams from Kitwe and The funding for the screening programme covers other provinces including Lusaka and are 8.2 million adults in Zambia. The age- Frimley Park worked together through their was obtained partly from the Ministry of Southern province and is being rolled out adjusted prevalence of DM amongst this VISION 2020 LINK to develop and implement Health and partly from the Konkola private countrywide population is 3.7%. There are therefore a DR screening and treatment programme in hospital. As part of the project, screener/ 228,000 adults with DM in Zambia. People the Copperbelt province for the first time in graders from Konkola hospital were trained. n Establishment of a competency-based with DM need an annual eye examination Zambia. training programme for the DR service using to identify changes indicative of diabetic The training of health workers in screening a multi-disciplinary team approach with a mix retinopathy (DR), a sight-threatening side In order to identify PWD in the Copperbelt, and treating PWD for DR is now being of hands-on classroom and clinical teaching effect of DM. Each year, 228,000 adults in lists of people receiving treatment for expanded to hospitals in all the 10 provinces in Zambia. This educational programme is Zambia need to be screened for DR. DM were obtained from pharmacies and of Zambia. now being introduced in Kenya, Tanzania and checked against lists of people already being Malawi. In LMICs, it is generally accepted that 35% screened for DR at Kitwe Central Hospital. Through the LINK, the Frimley team provided of adults with DM have signs of diabetic the expertise to develop DR screening, and n An innovative approach within the DR retinopathy (DR). 10% of adults with DM will Outreach screening was promoted via radio, trained (and continues to train) staff at all service was the screening results given already have vision-threatening DR, which TV, billboards and in churches, stating where levels to capture high quality retinal images following consultation through a nurse-led needs immediate treatment. This means that and when the outreach clinic would be held. and to grade them and know when and with counselling service. in Zambia 80,000 people have a measureable These community DR screening sessions what urgency to refer patients for treatment to degree of DR and, of them, 23,000 need were promoted in advance in places where preserve their sight. Challenges and learning: urgent treatment in order to preserve their people who might traditionally have reduced remaining sight and prevent unnecessary access to eye care services – especially Through the LINK, the Frimley team provided Retinal cameras and lasers were not routinely blindness. women – could be reached. additional laser expertise, and trained (and available in Zambia. During the LINK training continues to train) ophthalmologists and project, Kitwe Central Hospital was able to Overview of the intervention/program Screening using a portable retinal camera residents in laser treatment of DR. procure a retinal camera with the help of (i.e. objectives, hypothesis or what did the took place in five community hospitals – funding from Christian Blind Mission. Kitwe program set out to achieve etc.): secondary centres – all over the Copperbelt. Through the DR-NET the Zambia-Frimley already had a laser. As well as nurses, hospital-based health teams are working alongside teams from The key objectives of the project were: workers known as Patient Aids were eight other countries in Africa to share The Zambian government noticed the trained to screen patients with the retinal learning for development of DR services success of the screening programme in n Annual retinal screening to be offered to camera; some were also trained to grade and preparation of national frameworks the Copperbelt and there was significant adults with diabetes the resulting images. In this regard, the use and guidelines (Kenya, Tanzania, Uganda, investment by the Ministry of Health in the of competency-based training enabled a Nigeria, Ghana, Malawi, Zambia, Botswana). DR service infrastructure across Zambia. n Screening using digital retinal photographs relatively low cadre of health workers to be There are now cameras, lasers and Optical effective, accurate screeners and graders. Coherence Tomography machines in five of n People identified as having potentially This ensured that the workload of DR the ten provinces at a total cost of about USD sight-threatening retinopathy to have access screening was not all done by nurses, freeing IMPACT AND LEARNING $250,000 for the Zambian Government. to specialist assessment and treatment them to do nursing tasks. What was the impact and why did it work? Research focusing on the prevalence of n National framework and guidelines for As part of the outreach session, nurses diabetes in the Copperbelt and exploring diabetic retinopathy (DR) services across trained in counselling talked to the patients n Implementation of a DR service that is the factors contributing to its development in Zambia about DM, DR and the need for systemic first of its kind in Zambia this mixed urban and rural population in control of their DM. Those needing referral to Zambia has been published in Eye journal. an ophthalmologist for treatment were given n Incorporation of DR into Zambia’s National The findings showed that 2,600 patients

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were screened in a year; 52% of patients had n That taking eye care to the patients is of evidence of DR and over a third of patients critical importance and that its effectiveness had sight-threatening DR40. can be enhanced by taking a portable retinal camera out into the community and arranging community-based eye screening sessions

CONCLUSION n The importance of promoting screening sessions in advance in places where people Why is this case study important for who might traditionally have reduced access improving integrated care for diabetes and to eye care services – especially women – eye health?: can be reached, such as churches

This approach developed in Zambia is n Using a counsellor to explain to patients important because it demonstrates a range the risk that DM presents to their sight of strategies that can be utilised to achieve and the need to attend annual screening integration. In particular it shows: is important in enabling patients to have a better understanding of their condition n How links between eye specialists and diabetologists can been strengthened n The Ministry of Health has a greater 40 Adam D. Lewis, Ruth E. Hogg, Manju Chandran, Lillian understanding of the needs of DM patients Musonda, Lorraine North, Usha Contact details n How links can be strengthened with PWD for DR services and gives a high priority to Chakravarthy, Sobha Sivaprasad & Geeta Menon, ‘Prevalence through third parties such as pharmacies, delivering DR services nationwide thanks to of diabetic retinopathy and Global Diabetic Retinopathy where lists of people receiving treatment for an evidence based approach visual impairment in patients Advocacy Initiative with diabetes mellitus in Zambia DM are held; and with diabetes specialists through the implementation of in Kitwe Central Hospital and other tertiary a mobile diabetic retinopathy Contact: Global Partnerships screening project in the hospitals throughout Zambia Copperbelt province: a cross- and Advocacy Division, sectional study’, Eye, The Royal The Fred Hollows Foundation College of Ophthalmologists, (http://www.diabetesatlas.org/acro ss-the-globe.html) 2018 (http://www.diabetesatlas. (Yau et al Global Prevalence and Major risk factors of Diabetic Retinopathy Diabetes Care 35:556-564, 2012) org/acro ss-the-globe.html) Email: [email protected]

84 Contact details

Global Diabetic Retinopathy Advocacy Initiative

Contact: Global Partnerships and Advocacy Division, The Fred Hollows Foundation

Email: [email protected]