INTRODUCTION

As part of the health reform process in New Zealand,Regional Health Authorities (RHAs) were established infour areas as funding bodies to provide health-caredelivery to their populations. Some RHAs established net-works of general practitioners (GPs), rather like Divisionsof General Practice in Australia, to audit immunisationsin their practices. Funding was for an initial 18 monthsand based on a budget which was to include set-up andcommittee costs and the employment of nurse-facilitatorsto assist with setting up patient registers and the processof audit. The Kapiti GP Network included 29 GPs in acoastal area with a population of 25 000. The resultsdemonstrated high immunisation rates which improved

further with the audit, and increased practice nurse edu-cation and cold-chain preservation of vaccines.

Because of the success of the immunisation facilitatorin working with practice nurses to set up recall registersand perform the immunisation audits, the Network com-mittee was encouraged to look for another project relatedto the care of diabetic patients. A local optometrist (J.G.)had recently acquired a retinal camera, and since screen-ing for diabetic retinopathy was not easily available tolocal patients, this was chosen as the focus.

The value of screening for diabetic retinopathy is wellestablished in the medical literature,1 and is part of thenational guidelines of the New Zealand Society for theStudy of Diabetes2 and the National Diabetic Strategy inAustralia.3 Since diabetic retinopathy is a major treatablecomplication of diabetes and a major cause of eyesightloss in adults,4,5 any measures to detect and treat it at anearly stage are important.6 Screening using retinal photog-raphy has been shown to be effective7,8 and perhaps themost sensitive method of detection.9,10

Aust. J. Rural Health (1999) 7, 237–239

Correspondence: Dr Andrew McKenzie.Email: andrew.mckenzie@racgp.org.au

Accepted for publication January 1999.

DIABETIC RETINAL PHOTOGRAPHICSCREENING: A MODEL FOR INTRODUCINGAUDIT AND IMPROVING GENERALPRACTITIONER CARE OF DIABETICPATIENTS IN A RURAL SETTING

1RACGP Training Program North Queensland, Townsville, Queensland, Australia, and2Paraparaumu, New Zealand

ABSTRACT: This paper describes the addition of diabetic retinal screening using retinal photography to an existingimmunisation audit by a General Practitioner (GP) Network in a semi-rural area 60-min drive from centralWellington, New Zealand. The employment of a nurse-facilitator who visited practices to assist the setting up ofdiabetic registers and the subsequent auditing of patterns of referral for retinal photography was seen as a first step ina process that would lead to audit of the care of diabetic patients by GPs in the Network. This should lead to ameasurable improvement in health-care delivery to diabetic patients in this area and is a model that could be adaptedby any group of rural or semirural GPs within a defined geographical area.

KEY WORDS: audit, diabetes education, nurse-facilitator, retinal screening.

Andrew McKenzie1 and John Grylls2

Original Article

238 AUSTRALIAN JOURNAL OF RURAL HEALTH

Funding for the new project, including the employ-ment of the nurse-facilitator, was obtained through theCentral RHA by a fully prepared proposal. Funding wasfor an initial 18 months and required 6-monthly audit andcollation of statistics on current referral patterns ofscreening for diabetic retinal disease. This paper reportsthe implementation of this project, along with early find-ings and lessons learned.

METHODS

The project provided fundus examination and photographsfor all diabetic patients seen by GPs in the Kapiti GP Net-work. Support was provided by an ophthalmologist inWellington. Each person had the following examinations:visual acuity; anterior angle depth check (Van Herrickratio) and lateral gonioscopy; direct ophthalmoscopicexamination of media; intraocular pressures (Topcon non-contact tonometer); two 45° retinal photographs of eacheye for Type 2 diabetes; three 45° photographs for Type 1diabetes.

Protocols were drawn up with the optometrist to detailhow referrals would be made and the process of reporting,recall data, standards for reporting and specialist ophthal-mological review for difficult-to-interpret tests.

The RHA required a 6-monthly audit to includepooled data to show numbers of: diabetic patients on theregisters of Network practices; patients referred forscreening photography; patients referred for specialistevaluation and treatment; patients already being screenedby private ophthalmologists and at public hospital eyeclinics.

The Network estimated that there were 450 diabeticsin the Kapiti Coast area of which 250 would be eligible forscreening. Those who were already being seen by anophthalmologist, either privately or at a hospital clinic,were not eligible for screening. The nurse-facilitatorvisited every practice explaining the project and helpingpractice nurses to set up diabetic registers. Referrals weremade on triplicate forms similar to an X-ray referral.

Screening was free to patients, who could simplyphone the optometrist for an appointment. The optometristinstalled a non-contact tonometer soon after the projectstarted to screen for glaucoma, as he discovered morepeople with retinal changes suggesting raised intraocularpressures than major diabetic retinal disease. This servicewas provided at no extra charge to the Network. Where itwas not possible to get good photographs, the optometristperformed a visual fundus examination so as to make areport. Any photographs difficult to interpret werereviewed with a visiting ophthalmologist.

Screening reports were sent to the GPs along withcopies of the photographs. Recommendations for anyreferral and the repeat screening interval were clearlystated. Any further action was entirely up to the referringGP, as was any entry into their recall register, but theoptometrist undertook to maintain his own recall registeras a back up.

RESULTS

To date, 15 months after the program commenced, 300 dia-betics (67% of estimated pool) have been screened. Thir-teen per cent of photos were unacceptable and full visualexamination was performed on these patients by theoptometrist using dilation and stereoscopic fundoscopy onthe slit lamp.

Twenty per cent of retinal photographs showed evi-dence of background diabetic retinopathy, 2% (sixpatients) were referred for specialist review (laser or fluor-escein angiography), 2% (six patients) were suspected ofglaucoma, of which three were treated.

Discussion between the optometrist and the consultantophthalmologist occurred a number of times in the earlystages, but was not significant to the reporting process inthat the discussions confirmed the opinion of the optomet-rist and did not alter management.

DISCUSSION

This model of diabetic retinal screening is attractivebecause it requires minimal effort from the participatingGPs by working through their practice nurses, who arealready well motivated towards screening, age/sex regis-ters and recalls.

The biggest attraction, however, is the potential forthis project to lead on to improved care for diabetics inthe participating practices. The nurse-facilitator canprovide educational courses for the practice nurses ontopics related to diabetic care with the assistance of thelocal dietitian, diabetic educator, podiatrist and diabeticspecialist physician. At present, the diabetic nurse educa-tor in the Kapiti area (in common with many hospital out-reach services) is under-resourced and unable to copewith the workload of newly diagnosed diabetic patients,let alone meet the needs of all diabetics in the area. How-ever, if the nurse-facilitator and the diabetic educatorcould help the practice nurses of the Network becomemore skilled in diabetic education and care, this wouldgreatly improve their effectiveness.

The care of diabetic patients is time consuming andmay be perceived by GPs as onerous. In time, on the

DIABETIC RETINAL PHOTOGRAPHIC SCREENING: A. MCKENZIE AND J . GRYLLS 239

Kapiti Coast it can be expected that practice nurses willhelp to change attitudes to diabetic care in the practiceswhere they work, especially as the GPs become aware ofthe potential for teamwork to provide an enhanced servicein a more enjoyable way. The implications for cost andfinancial return need to be considered, but such teamworkis likely to be cost-neutral or even cost-beneficial for theGPs.

In the longer term, it would be quite possible for theNetwork to successfully introduce to the GPs some otherways to audit diabetes care. Since diabetic registers11 arealready in place, practice nurses are trained and em-powered to provide education and support services fordiabetics, and a nurse-facilitator is available to assist withaudit activities, this should not be difficult. Such an incre-mental approach to audit is likely to meet less resistancefrom busy GPs than any attempt to impose a system foraudit such as the Royal New Zealand College of GeneralPractitioners Diabetic Audit Module.12

This model should be easy to apply in the Australiansetting as a project for a group of GPs such as a Divisionof General Practice. The essential element would seem tobe that the process is controlled by local GPs who regardthe service as their own, and find it user-friendly.

ACKNOWLEDGEMENTS

We wish to thank the committee and nurse-facilitator ofthe Kapiti GP Network for their support and permission topublish this review.

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