Summary
The Hillingdon Hospital set up a service embedding a dedicated diabetes eye nurse specialist within the retinopathy treatment eye clinic, obviating the need for referring all patients with suboptimal glycaemic control. A Dedicated Diabetes Eye Nurse Specialist (DDENS) educated these patients and reviewed their diabetes treatments. In the cohort of 116 patients seen between March and December 2015, there was a reduction in median A1c from 89mmol/mol to 72mmol/mol in 102 patients. These results came in patients followed up for three months up to 12 months. Patients found the service acceptable, accessible and convenient. The caregivers found it more satisfying and efficient also. It is projected to save both the ophthalmology and diabetes specialist services money in the medium to long term while improving outcomes for patients.
Results
Between March and December 2015, 116 patients were seen on at least one occasion by the DDENS. (79 male and 37 female, with age ranging between 27-84 years, median 59 years). 74 were of Asian ethnicity, 34 Caucasian and 6 Afro-Caribbean patients - broadly representing the ethnic diversity expected in the coverage area. The majority were under GP-led diabetes care (71%), while 16% were known to hospital based specialist diabetes teams. Another 11% were known to community specialist diabetes services and 2% to both community and hospital specialist team. Most patients (109/116) required some intervention from the DDENS. Education as the only intervention was used in seven patients. 102/116 needed additional therapeutic intervention. 15 patients were commenced on insulin, insulin doses were titrated in 51 patients and oral hypoglycaemics were changed in 34 patients (31%) and timing of medication was adjusted in two patients (2%).
Challenge
Diabetic retinopathy is the second most common cause of vision loss and the leading cause of visual impairment and blindness among working-age adults in the UK. There is sufficient evidence linking chronic suboptimal blood sugar control with development and worsening of diabetic retinopathy in both type 1 and type 2 Diabetes. Currently there are no best practice tariffs or initiatives to improve diabetes control once diabetic retinopathy is diagnosed. The current model of diabetes care existent across UK supports more community based diabetes care and many patients with known microvascular disease do not have access to specialist care. Separating diabetes specialist appointments from the ophthalmology appointment perhaps does not clearly highlight the importance of improving blood sugar control as the mainstay of treatment to this patient group.
Objectives
To identify diabetic patients with suboptimal glycaemic control who have referable diabetic retinopathy in a district general hospital eye clinic. Offering intervention in the form of education, treatment intensification or early referral to secondary care. To measure the efficacy of intervention using A1c as surrogate marker of glycaemic control.
Solution
A formal meeting was arranged with managers of both diabetes and ophthalmology divisions, along with ophthalmology lead and consultant diabetologist. Funding was agreed for two sessions, one paid by the ophthalmology directorate and the other from the diabetes medical directorate. A diabetes nurse specialist was recruited to work alongside the ophthalmologists on the same day of the diabetes retinal clinics to identify and recruit patients for this project. The referral criteria to the dedicated diabetes eye nurse specialist (DDENS) was set to an HbA1c >75 with referable diabetes retinopathy to ensure that the service was sustainable within limited resources and not overwhelmed at the outset. The role of DDENS was to review the patient's diabetes management plan and offer education. Wherever possible, no change was made to the pre-existing arrangement of the diabetes care provider.
Learnings
Hayes is a relatively socio-economically deprived area and provided nearly half (46%) of subjects who benefited from this service. Their average A1c 92.7 (median 89.5) at referral reduced to 75.1 (median 69). There is a very successful retinal screening programme that refers and recalls diabetic patients in the UK it does not necessarily feed into the local diabetes services. Patients who were seen from between 1-5 times by the DDENS showed an improvement in their overall diabetes control as demonstrable by the HbA1c 17.3 average reduction. In those followed up, with a repeat HbA1c from 3-6 months of being seen initially (n=41), their median HbA1c improved by 19 (average 15.8). This improvement was sustained in those followed up for longer: 7-9 months (n=35) and 10-12 months (n=26), with median HbA1c improvement of 16 (average 19) and 15.5 (average 17) respectively. 71% of the cohort had GP-led diabetes care, and have been able to achieve significant improvement in glycaemic control, potentially averting referral to secondary or community led diabetes services. The heightened perception by patients of risk to eyesight in the setting of a retinopathy treatment centre may also make them more receptive to education and intervention generally.
Evaluation
There has been significant reduction in A1c in the cohort, and some evidence of reversal of retinopathy with improving glycaemic control. Data on actual intervention for retinopathy is required over a 12-month period, so is not yet available.
