Scotland, United Kingdom – using technology to safely manage increased demand for screening
13 November 2020
Since 2003, Scotland’s national Diabetic Retinopathy Screening (DRS) Programme has been delivered by the National Health Service (NHS) Health Boards in Scotland and integrated with routine diabetes care. It benefits from being a national scheme that is offered to everyone over 12 years of age with diabetes, is free of charge to the patient, and has central funding, auditing, standard-setting and quality assurance.
“The foundation of our Programme is our wonderful, comprehensive register,” says Garrick Wagner, Senior Programme Manager. “It enables us to work collaboratively across the 14 Health Boards in Scotland, not commissioning from outside providers but sharing information that is up to date and immediately available to all partners.”
Set up by the Scottish Government in 2002, The Scottish Care Information – Diabetes Collaboration, known as SCI-Diabetes, provides a fully integrated, shared electronic patient record to support the treatment of NHS Scotland patients with diabetes. Every general practitioner has the software, and all clinicians and professionals in both primary and secondary care involved in diagnosing and treating people with diabetes have access to this single point for data entry, with information flowing into it and out of it.
SCI-Diabetes also has a portal for patients called “My Diabetes My Way”. The interactive website helps support people who have diabetes and their family and friends, and gives patients access to their results and other information.
The Scottish DRS Programme also runs on a national information technology system. The system stores digital retinal images, patients’ demographic details and their screening results. It invites patients to screenings and tracks them through the screening pathway. Invitations are sent to almost 100% of people diagnosed with diabetes, as all newly diagnosed patients are registered centrally in the database. The Health Boards across Scotland meet and work together to ensure consistency, regular reporting and training.
Another technology is helping to manage the pressure as prevalence of diabetes increases by 3–5% every year. In 2012, Scotland introduced an automated system to read all retinal images, called an autograder. The autograder accurately identifies patients with the lowest risk of developing retinopathy (approximately 40% of patients), who do not need further analysis now but will be recalled every 1 or 2 years. Images from the remaining patients are then manually graded.
Introducing automated grading was an opportunity to ensure that manual graders, who are highly trained, work at the top of their skill set to ensure timely identification of those with sight-threatening retinopathy among the many thousands with no retinopathy.
Garrick Wagner says, “The autograder helps us meet the challenge of screening increasing numbers of patients. It reduces the burden of grading while allowing quality to be maintained, making the DRS Programme more cost-effective and sustainable for the future.”
Autograder results are quality-assessed as part of ongoing internal (continuous) and external (biannual) quality-assurance processes. The Programme carries out a rigorous quality-assurance exercise twice a year to check that everyone is working to the same level. All the graders are given up to 100 images to grade over approximately 1 month, and are required to meet defined standards. The autograder also participates in this exercise to ensure its accuracy.
Scotland has now embarked on an initiative to introduce more sophisticated grading capability using the latest artificial intelligence technologies. The aim is to further reduce manual grading and enhance the quality and management of clinical risk.
As with any risk-reduction programme, there are still some outstanding issues. Despite efforts to reach people who may be missed by letter (for example, by contacting them by mobile phone) and producing materials, including videos, in plain English and a number of other languages, about 14% of people do not respond to the invitation or recall to attend screening over a 2-year period. Sadly, they are missing out on a high-quality programme that could prevent them from losing their sight.
