Dr Satish Chadha
MBBS; MS; ECFMG (USA); FRCS (UK); DRCO (UK); MRCO (UK)
Clinical Lead Ophthalmology, Northamptonshire Diabetic Screening Programme
Introduction:
Our Community Diabetic Eye Screening programme, a part of National Diabetic Eye Screening programme, is a well-established screening programme with 39692 diabetic patients enrolled for Annual Routine Digital Screening. Role of a general Ophthalmologist, as a Gatekeeper, is evaluated over a 5 year period from 1st
Review of grading process over 5 year period was done. Strict National criteria are followed in the program for Primary, Secondary, Arbitration grading and referral to referral outcome grader (ROG).
Programme Overview of staff of the programme
,
| Grading (1st April 2011 to 31st March 2016 ) | |||
| Total Grading Episodes | |||
| Primary Grading | 113150 | ||
| Secondary Grading | 57232 | ||
| Arbitration Grading | 8666 | ||
| ROG Grading | 6605 | ||
| Total ROG | R0M0 | R1M0 | R1M1 | R2M0 | R2M1 | R3AM0 | R3AM1 | R3SM0 | U | |
| Ophthalmologist 1 | 4338 | 1808 | 1049 | 539 | 83 | 71 | 44 | 72 | 7 | 665 |
| Ophthalmologist 2 | 95 | 26 | 25 | 14 | 4 | 5 | 0 | 1 | 0 | 20 |
| Ophthalmologist 3 | 28 | 11 | 10 | 5 | 0 | 1 | 1 | 0 | 0 | 0 |
| Senior grader 1 | 1973 | 790 | 417 | 303 | 51 | 46 | 28 | 31 | 3 | 304 |
| Senior grader 2 | 132 | 45 | 28 | 21 | 2 | 2 | 2 | 6 | 0 | 26 |
| Senior grader 3 | 39 | 5 | 2 | 13 | 0 | 2 | 4 | 2 | 0 | 11 |
| Total | 6605 | 2685 | 1531 | 895 | 140 | 127 | 79 | 112 | 10 | 1026 |
ROG: referral outcome grading; R0M0 (no retinopathy, no maculopathy) R1: Mild non proliferative diabetic retinopathy; R2 moderate diabetic retinopathy; M1(maculopathy);R3A( active proliferative diabetic retinopathy);R3S( stable proliferative diabetic retinopathy ;U(unclassified grading)
| Outcome of ROG grading | |||||||||||||
| ROG Grader | Annual Digital Screening | Routine referrals to HES | Urgent referral to HES | Stable R3 | Referred to Slit lamp Bio microscopy clinic | ||||||||
| Ophthalmologist | 4461 (67.5%) | 2929 (65.65% | 722 (16.19%) | 118 (2.64%) | 7 (0.15%) | 685 (15.35%) | |||||||
| Senior grader | 2144 (32.5%) | 1287 (60.02%) | 444 (20.5%) | 73 (3.40%) | 3 ((0.13%) | 341 (15.90%) | |||||||
Results:
Analysis of the results of total number of 6605 Referral Outcome Grading (ROG) revealed as under
- 5% ROG grading was done by Ophthalmologists and 32.5% of ROG grading was done by Senior Graders.
- Of all the grading done by Ophthalmologists 2% was done by one Ophthalmologist.
- Referral back to the screening programme for Annual Digital Screening was 65% by the Ophthalmologists and 60.2% by the senior graders.
- Routine referrals to the Hospital Eye Service were19% by the Ophthalmologists and 20.5%by the senior graders.
- Urgent referrals to the HES were 64% by the Ophthalmologists and 3.40 % by the senior graders.
- Unclassified grading patients referred to slit lamp Bio microscopy clinics were 35% by the Ophthalmologists and 15.90% by the senior graders.
- Stable R3 was noted 15% by the Ophthalmologist and 0.13% by the senior graders.
- All the graders get quarterly supervision by the Clinical Lead who is an Ophthalmologist.
- 10% of ROG grading done by the senior graders is also reviewed by the Ophthalmologist in order to maintain high standard of internal quality assurance of the gradings.
- Discussion: The role of ROG is crucial in any community diabetic screening programme to ensure that the patient is in the right pathway. General Ophthalmologist can be entrusted the role of ROG, so that quality of the grading is maintained and unnecessary referral to the Hospital Eye Service is avoided. General ophthalmologist can also be entrusted the role of supervision of all the grading process including primary, secondary and arbitration gradings to ensure internal quality assurance in the community screening program. General ophthalmologist can also be entrusted the role of training senior grader to the level of ROG grading, where senior graders can independently take up the role of Gate keeping.
Review of the outcome of the ROG grading revealed that 64% of the referrals to the ROG were referred back to the Annual Digital Screening and only 36% needed referral for further investigation and or treatment (R1M1, R2M0, R2M1, R3M0, R3M1). The study also revealed that the general Ophthalmologist can play an important role as a gatekeeper in the diabetic community screening programme.
Summary: The Referral outcome grading over a period of 5 years is analysed. The importance of general Ophthalmologist as a gate keeper in the community diabetic eye screening services is discussed and the role of maintaining the internal quality assurance of the graders by regular supervision and training of all grading by an Ophthalmologist is emphasized.