Spain – making regional screening programmes work nationally
13 November 2020
Spain’s screening for diabetic retinopathy varies according to locality and the organizational model of each autonomous region. Although some regions already have an organized screening programme, many do not. Andalucia, for example, reaches over 90% of people with diabetes, while other regions only have opportunistic screening programmes which are further restricted by availability of equipment.
The country is now focusing on ensuring national consistency and standards. The National Strategy on Diabetes, last updated in 2012, is the umbrella for retinopathy screening programmes. New recommendations are being developed through wide consultation with all the regions and many professionals. A scientific advisory group, consisting of a general practitioner, an ophthalmologist, an endocrinologist and a nurse, is leading the initiative. The recommendations will go for approval to the autonomous regions and the technical committee of the National Strategy on Diabetes, resulting in a consensus document.
“We hope these recommendations will be very visible, available and much used,” said Dr Nuria Prieto Santos, Technical Coordinator of the National Strategy on Diabetes at the Ministry of Health. “We don’t just want documents for documents’ sake! It is important to involve all relevant health professionals in addressing diabetes.”
Following a situation analysis of each region to map the screening programmes and their implementation, the recommendations will fall into 3 categories: minimum, maximum and excellent. These will reflect good practices and what regions can aim for.
Dr Prieto Santos observed: “We are glad to see this approach very much reflected in WHO/Europe’s new publication, ‘Diabetic retinopathy screening: a short guide’.”
In Spain, general practitioners are the entry point to the initial level of diabetes care. This guarantees continuity of care throughout the patient’s life and ensures health maintenance and integrated care, including the management of complications such as diabetic retinopathy – particularly for type 2 diabetes.
In the case of type 1 diabetes, where endocrinologists play an important role, the approach is slightly different. In the majority of cases, general practitioners send patients for screening once they have been diagnosed with diabetes, and they are part of the screening process itself. A training programme and infrastructure for retinal imaging are available for technicians – usually clinical assistants or nurses – as well as general practitioners so they can differentiate between patients with relatively healthy eyes and those with retinopathy. Specially trained staff perform the screening test, and family doctors, trained nurse personnel or endocrinologists undertake the initial interpretation of results. An ophthalmologist then assesses the diagnosis.
This is a common feature of diabetic retinopathy screening programmes in Spain. Screening invitations reach approximately 70% of people with diabetes in the country, depending on the programme in their region.
The new recommendations will build on 2 earlier reports from health technology assessment agencies on the cost–effectiveness of screening, and on clinical practices, guidelines and frequency of screening. Both reports supported screening programmes.
One of the strengths of a regional screening system is that it is put into practice by local general practitioners with local priorities in mind, taking into account the territorial and geographical variability of each region, such as whether the population is rural, urban, older or younger. However, all will benefit from this cohesive and inclusive approach.
