Audit of suspected DMR case screening by GOPD in RAMP (Risk Assessment and Management Program) Dr. Amy ML Sze MRCS Hong Kong Eye Hospital

Background

R isk factor A ssessment & M anagement P rogram All DM patient FU in GOPD Ophthalmologist FU No / Mild NPDMR Otherwise Follow Up in GOPD Refer to ophthalmologist

Objectives

• Audit of screening quality in terms of • Correlation of diagnosis of referred case between GOPD and ophthalmologist • The true negativity ophthalmologist of those not being referred to • Possible implications to eye clinic • Generation of cases need intervention s (e.g. laser, surgery) • Generation of extra case load • Route to download stable cases for FU in GOPD

Methods

• Case review of patients referred from KCC GOPD through RAMP from April - December 2010 • Random audit of fundus photos from patients not being referred to ophthalmologist • • Audit of referral and download statistic Statistical Method: Weighted Kappa by SPSS

Demographics of seen RAMP cases

(April – Dec 2010)

• • 265 patients [ 530 eyes ] Average age 65 yo • M/F : 1.2/1 • Average HbA1C: 7.6

(< 7 good control) • One patient on insulin, other on OHA • • Nephropathy: 22 patients (9.8%) Neuropathy: 3 patients (1.3%)

Diagnosis from GOPD and HKEH 400 350 300 250 200 150 100 50 0 No DMR Mild NPDR Mod NPDR Severe NPDR PDMR Poor photo quality Others HKEH GOPD

Results - Correlation of diagnosis

0.6

0.5

0.4

0.3

0.2

0.1

0 Visual Acuity (Snellen) RE LE HKEH GOPD

Correlation of diagnosis

(April – Dec 2010)

GOPD

U O R0M0 R1M0 R1M1 R2M0 R2M1 R2M2 R3M0 R3M1 R3M2 R4

21 1 5 1 0 0 0 0 0

R4

0

O

90

Subtotal

364 2 13 29 99 1 6 22 3 0 1 1 0 0 1 13 31 0 1 6 1 0 2 2 0 0 0 0 4 0 2 1 0 0 0 0 0 1 1 1 0 0 4 8 0 0 0 0 2 0 0 2 0 0 0 0 0 0 0 0 1 0 8 13 0 0 0 0 0 3 1 0 0 0 0 1 0 0 0 0 0 0 0 1 4 1 0 8 0 0 0 0 0 2 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Subtotal

147 2 19 48 5 0 11 6 2 9 136 145 530

Statistical Correlation Weighted Cohen Kappa Value Measure percentage of data values and adjusts these values for the amount of agreement that could be expected due to chance alone

0.053 p < 0.001

95% CI 0.026 – 0.08

< 0.2 Poor 0.2 - 0.4 Fair 0.4 - 0.6 Moderate 0.6 - 0.8 Good 0.8 - 1.0 Very Good

Audit of Photos not being referred to ophthalmologist • 144 fundus photos screened • One with poor photo quality not being referred • 143 eyes were all normal • Negative Predictive value: 99.3%

Referral & Discharge Statistic

140

Referral Statistic

(from GOPD)

Feedback

120 100 80 60 40 20 0 No. of Referral from RAMP No of Patient seen in eye April May June July August Sept Oct Nov Dec

HKEH Discharge Statistic

200 180 160 140 120 100 80 60 40 20 0 July Aug Sept Oct Nov Dec Jan Feb Discharged from HKEH to GOPD

** Guidelines for download: No/Mild NPDR without other significant eye diseases

300 250 200 150 100 50 0

SRC Statistic – Feb 2011

KCC Non-KCC Discharged Case FU in HKEH

Possible Implications

Intervention

• X Six eyes (1.1%) X Eleven eyes (2.1%)

Extra case load generated • 318 eyes with cataract, 18 listed (5.7%) for cataract OT • 49 eyes with dry ARMD (age-related macular degeneration) for observation • 12 eyes with ERM (epiretinal membrane) for observation

Summary

•

Poor Diagnostic correlation between GOPD and ophthalmologist

•

High negative predictive values of fundus photo screening under RAMP

•

Generation of case load with stable disease (e.g. mild cataract with good VA) to specialty clinic

•

Route to download stable cases for GOPD FU

Conclusions

• Fundus photo screening under RAMP is a major move to facilitate DM patient to have regular eye check up • Good platform for communication between general practitioners and ophthalmologists • Better communication - better allocation of cases - better patient care

Acknowledgements

• Dr. PP Yip • • Dr. Dexter Leung Dr. CW Tsang • Dr. NM Lam • Dr. CC Chi • Nursing Staff • • MRO staff All ECAs • Appointment Staff

Thanks