Author: Nanayakkara Godakandage Isuru Ravihansa De Silva (United Kingdom)
Co-authors: Yasir Khan, Niaz Islam
In the United Kingdom, the diabetic retinopathy (DR) referral pathway is initiated when a referable condition is detected at the DESP screening visit. The patient is then referred to the HES within a set timeframe for further management. Once this request is received by the hospital, a clinic appointment date is offered to the patient. If the patient fails to attend the 1st offered appointment date, a 2nd appointment is offered, depending on the severity of referable retinopathy and clinic availability. The purpose of this study was to assess the efficacy of the referral pathway in relation to the urgency of the referral and time seen in HES. We looked at each step of the multistep process to identify any bottlenecks, as well as show how well targets are achieved as compared to set national standards. We also looked at the level of agreement of DR grading, between the graders at DESP and doctors at HES and the final outcome of the HES visit of those who attended.
The Moorfields North East London outreach clinic, which is closely linked to North East London DESP was the setting used for this study. The study included referrals received in 7 months (September 2019 to March 2020. Some of the referral appointments were affected due to the COVID-19 pandemic.
All diabetic referrals made from DESP to HES were identified through the Diabetic Retinopathy Service database, which is a dedicated failsafe tracking system for all diabetic referrals. All non-Diabetic referrals were also recorded but were not used in further analysis. The following dates were recorded for all the Diabetic Retinopathy referrals:- DESP screening visit, Referral made to HES, Referral received by HES, 1st HES appointment offered and 1st HES attendance. The time taken for each step in the referral process was calculated and compared against the following Public Health England, Diabetic Eye Screening Standards. DES-S11: timely referral of people with diabetes with positive screening results from DESP to HES (Urgent referrals ≥ 95.0% referred within 2 weeks and Routine referrals : ≥ 90.0% referred within 3 weeks). DES-S12: timely consultation at HES for people with diabetes who are screen-positive (Urgent referrals : ≥ 80.0% seen within 6 weeks and Routine referrals : ≥ 70.0% seen within 13 weeks). The following data was recorded from DESP referrals and HES clinical records:- Type of referral (Urgent or routine), DR Grading at DESP and HES, referral outcome within the HES and reason for non-attendance
The 173 referrals received included 44 non-DR referrals. Of the DR referrals, 15.5% were urgent and the rest were routine. All DESP to HES referrals were made within recommendations (5 days for urgent and 7.5 days for routine, on average). Patients were offered their 1st HES appointment within the recommended timeframe for all urgent (100%) and most (98.4%) routine cases. 61.9% of routine and 70% of urgent referrals attended the 1st offered HES clinic appointment for review. The Did Not Attend (DNA) rate was 21.9% for routine and 10% for urgent referrals. 17 routine and 4 urgent appointments were cancelled, mainly due to Covid-19. These Non-attendees were rebooked. However, 13 of 40 routine and 5 of 6 urgent referrals were rebooked beyond their respectively 13 and 6-week timeframes. Satisfactory agreement was seen between DESP and HES DR grading (74.1% for retinopathy and 78.2% for maculopathy) on 220 eyes graded independently. Notably, when there was disagreement in Maculopathy grading, it was usually (93.8%) overestimated by DESP. 66.6% of urgent referrals seen in HES received laser or intravitreal injections, mostly on 1st visit. Only 15.3% of routine referrals needed any intervention. 58.8% of routine referrals were actively monitored within the HES.
This multi-step referral pathway should be audited regularly to identify correctable issues. 100% of urgent and 98.1% of routine referrals were offered a 1st clinic appointment by the HES within the respective timeframes (6 weeks and 13 weeks respectively). However, Only 83.3% of urgent and 94.1% of routine referrals were seen within the recommended timeframe in the HES. This discrepancy is due to non-attendees being rebooked for a date beyond their breach date. Failure of screen-positive subjects to attend HES appointments within nationally agreed timeframes may be due to administrative delays, lack of capacity within the HES and failure by the individual to attend their appointment. All of which were exacerbated by the COVID-19 pandemic. Improving training for DR grade assessors would improve the agreement of DR grading overall. The prospect of AI-assisted grading and risk stratification exists, which warrants further scrutiny. Only 15% of routine referrals needed active interventions at HES, while the rest could be actively monitored. This highlights the opportunity for developing virtual clinic pathways, where monitoring patients using multimodal imaging would reduce the burden on HES. This in turn would free HES capacity to see urgent referrals within recommended timeframes, despite DNAs and cancellations.