Abstract
Diabetes mellitus continues to increase in epidemic proportions globally as well as in India. Poor glycemic control in long-standing diabetes mellitus eventually leads to chronic complications such as retinopathy, nephropathy, neuropathy, and cardiovascular disease. Diabetic retinopathy is emerging as an important cause of avoidable visual impairment and blindness in India across all strata of society. Much of this vision loss can be prevented by improving control of known risk factors, annual fundus screening, with prompt treatment of individuals with sight-threatening retinopathy. The Queen Elizabeth Diamond Jubilee Trust has made a significant contribution by supporting such a program across India, including Goa. The newly established medical retina clinic at Goa Medical College now provides facilities for screening, a detailed evaluation of advanced retinopathy, and therapeutic modalities such as laser and intravitreal injections. The peripheral centers are equipped to screen all people with diabetes mellitus and refer those with sight-threatening retinopathy to the medical college. The provision of a foot scanner to evaluate the risk of foot ulcers and microalbuminuria assessment as part of the nephropathy screening would encompass the entire gamut of diabetic microvascular complications. The next decade would provide evidence if this initiative, with the enthusiastic partnership of the state government, results in reduction of blindness in the people of Goa and an overall reduction in diabetes-related morbidity and mortality.
Keywords: Comprehensive care, diabetes, Goa, retinopathy, Trust
The microvascular complications of diabetes mellitus (DM) can affect the eyes (diabetic retinopathy [DR]), kidneys (nephropathy), and nerves (neuropathy) and more than one complication can coexist[1] The benefits of comprehensive diabetes care, including lipid and blood pressure control, has been confirmed in the landmark Steno 2 trial.[2]
The objective of the Queen Elizabeth Diamond Jubilee Trust's (the Trust) program was to reduce visual impairment and blindness from DR in India, working in partnership with the State Ministry of Health. The state of Goa was one of the locations for this project.
The prevalence of DR in India is around 20% including 5% with proliferative DR (PDR) and 1% with diabetic macular edema (DME).[3] Clinically significant DME and PDR are termed sight-threatening DR (STDR). In Goa, the epidemic of diabetes started early and the prevalence of diabetes is high (9–10% among people above 20 years).[4] As duration of disease is a major risk factor for complications of DM, these are also likely to be high in Goa, with STDR affecting approximately 10% of people with DM (PwDM).
Goa, a small state (population 1.49 million),[5] has high socioeconomic and demographic indicators. Public health facilities consist of tertiary care at Goa Medical College Hospital (GMCH); secondary care at two district hospitals (DHs), one sub-district hospital (SDH), and primary care at 26 primary health centers (PHCs), four urban health centers (UHCs) and four community health centers (CHCs). Basic eye care is provided by ophthalmic assistants (OAs) at primary care facilities. The Trust's DR project included GMCH, DHs, SDH, five CHCs, and four PHCs [Fig. 1]. The Departments of Ophthalmology, Medicine, and Endocrinology Unit were the focal centers at GMCH.
Figure 1.
Map of Goa with the location of project centers
Methods
A memorandum of understanding (MoU) was signed by the Department of Health and Family Welfare, Government of Goa, GMCH and Indian Institute of Public Health (IIPH) for the DR project. H.V. Desai Eye Hospital, Pune was the mentoring institute and GMCH was the nodal center. The aim of the project was to improve the infrastructure and build capacity in the nodal center in a phased manner (for screening, diagnosis, and management) and the peripheral centers for DR screening. Training of state medical officers (physicians) using the Certificate Course in Evidence-Based Management of DR (CCDR) was partly funded through the project. Toward the end of the project, a foot clinic with a foot scanner (neuropathy care) was set up in the endocrinology clinic in GMCH with plans for microalbuminuria testing (nephropathy care) to provide more comprehensive diabetes care.
To ensure smooth coordination among all stakeholders, a state-level steering committee was set up with Health Secretary, Government of Goa as Chairperson and included representatives from GMCH (Dean and faculty members from Department of Ophthalmology, Medicine and Endocrinology), the Directorate of Health Services (DHS) [Chief Medical Officer, Ophthalmic Cell], the mentor institute and IIPH. A program manager was appointed to coordinate project activities.
Results
The project, which had the following activities, was launched in Goa in May 2016.
Infrastructure upgradation
The equipment provided [Table 1] enabled GMCH to set up a comprehensive DR diagnostic and treatment unit in the ophthalmology department, and screening services at the peripheral centers. The utility of the foot scanner is currently being pilot tested.
Table 1.
List of equipment provided to upgrade
| Name of equipment, location | No. | Date of installation |
|---|---|---|
| For DR screening | ||
| Forus mydriatic fundus camera (with laptop): GMCH | 1 | 25/10/2016 |
| Non-mydriatic fundus cameras: peripheral centers | 12 | 25/10/2016 and 8/06/2019 |
| 22” digital vision charts: centers | 7 | 05/04/2017 |
| For diagnosis | ||
| Indirect ophthalmoscopes: GMCH, DHs | 3 | 25/10/2016 |
| OCT machine (Zeiss Primus 200 ®): GMCH | 1 | 03/02/2017 |
| B-scan machine: GMCH | 1 | 25/10/2016 |
| Lenses: 20D, 160 aspheric pan funduscopic lens, 78 D: GMCH, DHs | 3 | 25/10/2016 |
| Handheld slit lamp: GMCH | 1 | 25/10/2016 |
| For the treatment of DR | ||
| Diode laser: GMCH | 1 | 25/10/2016 |
| Others | ||
| Foot scan: GMCH | 1 | 18/02/2019 |
| Set of projector: GMCH | 1 | 20/05/2019 |
| Laptop (Lenovo ®): GMCH | 1 | 16/02/2017 |
| Software devices (electronic tablets): four peripheral centers | 4 | 17/03/2017 |
DR: Diabetic retinopathy, GMCH: Goa Medical College Hospital, DHs: District hospitals, OCT: Optical coherence tomography
Capacity building
Four ophthalmologists (two each from GMCH and DHS) received 6 weeks of training in medical retina at the mentor institute in a phased manner. Following training, they were able to diagnose and treat DR with laser or intravitreal anti-vascular endothelial growth factor (anti-VEGF). All OAs received 2 days' training in imaging the fundus with a non-mydriatic camera at GMCH, followed by a refresher course 2 years later. Trained OAs could grade the images as DR present, DR absent, or poor quality image, with the referral of those with DR or ungradable images.
Fifteen state medical officers were trained in the optimal management of PwDM using the CCDR, which covered the pathophysiology, clinical assessment, and screening strategy for DR. Following training, they identified and referred patients for DR screening to trained OAs or ophthalmologists.
Clinical activities of the project
The major clinical activity was integrating DR screening of all PwDM using a non-mydriatic fundus camera at all levels of public health care. Over the course of the project, the quality of images improved and ungradable images reduced from approximately 20% to 6%. Patients' details were recorded on a self-retained card and data were entered into an online database using tablets and computers. This facilitated the tracking of individuals requiring initial/follow-up screening and referral. It also contributed to effective program management by identifying centers with poor uptake of services. Regular monitoring of program implementation was undertaken by the state steering committee. Information, education, and communications activities were undertaken at all health care levels to increase awareness about DR.
Currently, medical retina service is provided twice a week at the DHs, once a week at the SDH, and daily screening at the PHCs/CHCs by the OAs. The International Disease Severity Scale Classification of Diabetic Retinopathy and DME are used to grade DR.[6] All patients with moderate to severe nonproliferative DR (NPDR) and PDR are referred for further evaluation and treatment to the retina clinic at GMCH which is available thrice a week.
During the project, 5,336 PwDM were screened for DR, 26% (n = 1389) of whom were diagnosed with any DR [Table 2]. During the same period, 967 individuals were treated for DR at the GMCH [Table 3] which includes those screened under the project as well as those identified elsewhere (non-project centers and private sector). PwDM with DR are being referred to the diabetic foot clinic. However, as this initiative started recently, no data are available.
Table 2.
Number of people with diabetes screened and the proportion with different stages of diabetic retinopathy and diabetic macular edema
| Screened | DR lesions | OCT confirmation | ||||
|---|---|---|---|---|---|---|
| NPDR | PDR | STDR | DME | CSME | ||
| Male | 2748 (51.5%) | 464 (16.8%) | 134 (4.8%) | 273 (9.9%) | 189 (6.8%) | 85 (3.1%) |
| Female | 2588 (48.5%) | 258 (9.9%) | 112 (4.4%) | 148 (5.8%) | 118 (4.6%) | 105 (4.1%) |
| Total | 5336 | 722 (13.5%) | 246 (4.6%) | 421 (7.8%) | 307 (5.7%) | 190 (3.5%) |
NPDR: Non-proliferative diabetic retinopathy, PDR: Proliferative diabetic retinopathy, STDR: Sight-threatening diabetic retinopathy, DME: Diabetic macular edema, CSME: Clinically significant macular edema, OCT: Optical coherence tomography
Table 3.
Investigations and treatment of sight-threatening diabetic retinopathy at Goa Medical College during the project period
| B scan | Laser treatment* | Intravitreal anti-VEGF injections* | ||
|---|---|---|---|---|
| PRP | Focal | |||
| Male | 229 | 441 | 84 | 126 |
| Female | 131 | 219 | 27 | 70 |
| Total | 360 | 660 | 111 | 196 |
*Note: this includes those screened under the project as well as other non-project patients, VEGF: vascular endothelial growth factor, PRP: pan-retinal photocoagulation
State Government support
The state government took an active interest in the DR project with six steering-committee meetings over the 3 years. The state also committed to the annual maintenance of all the equipment provided by the project and to set up a surgical retina center at GMCH.
Discussion
In this project, screening centers were integrated into the government health system for non-communicable diseases at different levels and were established in 10 states across the country. In Goa, diagnostic and treatment services were also made available in the state medical college. In addition, the Government of Goa has recently established 15 community diabetes centers (CDC) manned by trained diabetes educators at all levels of public health care to help PwDM in self-management as part of its diabetes care program with Novo Nordisk Education Foundation®.
The trained OAs not only reduced the burden on ophthalmologists but also allowed timely feedback to patients. The good distribution of screening services suggests that about 10% of the PwDM in the state were screened. However, most PwDM seek care from private medical practitioners and greater awareness is needed to increase the uptake of screening, especially among those visiting private providers. During the project period, almost 1,000 PwDM were treated for DR in the newly established medical retina clinic.
A unique feature in Goa was the intention to provide comprehensive screening for other microvascular complications and the feasibility of introducing foot scanning for people with DR is currently being investigated. Comprehensive evaluation needs to train human resources and should improve the quality of diabetes care.
The commitment of the state government was crucial for the success of the program. The Goa DR experience demonstrates that if state ministries of health take a leadership role, it is possible to leverage experience and capacities of non-governmental organizations to build the capacity of public health system to provide integrated care for prevention of blindness from DR. Screening for early identification of DM complications needs to be integrated with usual diabetes care. This ensures efficient uptake of screening services and early referral for advanced complications. An integrated health management information system to improve the tracking of patients needing follow-up and referral is essential to ensure that the neediest receive timely services.
The infrastructure and manpower needed for DR screening have not been considered a priority in the country. The Trust has made the right investment to give impetus to set up the medical retina facilities in Goa.
The future
Ensuring annual fundus examination in every patient with DM is the key. The state government has committed to install a non-mydriatic fundus camera at all primary health care centers. Diabetes educators at the CDCs will sensitize the patients about fundus examination. The OAs will perform the retinal examination, grade the images, and advice review or referral as appropriate. The GMCH would provide retinal surgical care.
Conclusion
The Trust envisaged a reduction in the incidence of avoidable blindness from DR. As a result of partnerships and capacity-building, screening and treatment have been established in a high proportion of public health facilities. With the state government continuing the work after the project closes, we should be able to see measurable changes over the next decade, and taking a holistic approach to DM management should improve the quality of life of our patients.
Financial support and sponsorship
The Queen Elizabeth Diamond Jubilee Trust, London, UK.
Conflicts of interest
There are no conflicts of interest.
Acknowledgements
The authors gratefully acknowledge the support of the Ministry of Health and Family Welfare, Government of Goa, Directorate of Health Services, Goa and Dean, Goa Medical College for the conduct of the project in the state of Goa. The authors also acknowledge the technical advisory role of the London School of Hygiene and Tropical Medicine, UK and the overall coordination of the Indian Institute of Public Health, Hyderabad for the successful conduct of the project. The help of Prof Clare Gilbert in guidance and review of this manuscript is deeply appreciated.
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