€¦ · Web viewTo create awareness about diabetes and diabetic retinopathy in the population of Orissa. To train general ophthalmologists and general physicians in diagnostic

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Diabetic Retinopathy: Planning for tackling it in Orissa

1. Introduction

- Diabetes

- Diabetic retinopathy

2. Situation Analysis

3. Overview

4. Project modules or areas of work

a) Awareness /Health communications

b) Screening camps including Telescreening

c) Database

e) Advocacy

f) Research

5. Output of the programme after 5 years

6. Long term implications

7. Conclusions

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Orissa Diabetic Retinopathy model

This Diabetic Retinopathy model has been developed to achieve the following objectives.

1. To create awareness about diabetes and diabetic retinopathy in the population of Orissa.

2. To train general ophthalmologists and general physicians in diagnostic techniques to identify patients at risk of developing of DR.

3. To conduct diabetic screening camps for early detection and prompt treatment of sight threatening diabetic retinopathy.

4. To prepare a database of DR patients and perform relevant research to find out risk factors associated with development of DR.

5. To do advocacy for supporting DR related projects.

1. Introduction

Ecosse Lamoureux, 07/06/11,

Do we need to do this? I think there is enough out there. But let’s discuss.


Need to be more precise here.

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Diabetes Mellitus – the Disease

Diabetes is a chronic disease that occurs when the pancreas does not produce enough insulin, or alternatively, when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood sugar. Diabetes mellitus hence is a metabolic abnormality in which there is a failure to utilise glucose and hence a state of hyperglycaemia (raised blood sugar) can occur. If hyperglycaemia continues uncontrolled over time, it will lead to significant and widespread pathological changes, including involvement of the retina, brain and kidney.

Type 1 diabetes (previously known as insulin dependent or childhood-onset or IDDM) is characterised by a lack of insulin production. Without daily administration of insulin, Type 1 diabetes is rapidly fatal.

Symptoms include excessive excretion of urine (Polyuria), thirst (Polydipsia), constant hunger, weight loss, vision changes and fatigue. These symptoms may occur suddenly. Type 1 Diabetes accounts for almost 10-15% of cases of all cases of DM.

Type 2 diabetes (formerly called non-insulin dependent or adult-onset or NIDDM) results from the body’s ineffective use of insulin. Type 2 diabetes comprises 90% of people with diabetes around the world, and is largely the result of excess body weight and physical inactivity.

Symptoms are similar to those of Type 1 diabetes, but are


And poor lifestyle

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often less marked. As a result, the disease is generally dDiagnosed several years after onset, once complications have already arisen. Until recently, this type of diabetes was seen only in adults but it is now also occurring in obese children also .

Gestational diabetes is hyperglycaemia which is first recognised during pregnancy. Symptoms of gestational diabetes are similar to Type 2 diabetes. Gestational diabetes is most often diagnosed through prenatal screening, rather than reported symptoms.

Impaired Glucose Tolerance (IGT) and Impaired Fasting Glycaemia (IFG) is intermediate conditions in the transition between normality and diabetes. People with IGT or IFG are at high risk of progressing to type 2 Diabetes, although this is not inevitable. Source: WHO Fact sheet No 312 September 2006

Criteria for the diagnosis of diabetes mellitus1. Symptoms of diabetes plus casual plasma glucose

concentration = 200 mg/dl. Casual is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss.

2. FPG = 126 mg/dl (7.0 mmol/1). Fasting is defined as no caloric intake for at least 8 h.


Spell out.


Both types?

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3. 2- hour PG = 200 mg/dl (11.1 mmol/1) during an OGTT. The test should be performed as described by WHO (2), using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.

Source: Diabetes care, volume 25, Supplement 1, January 2002

IMPLICATIONS OF Diabetes DM Over time, diabetes can damage the heart, blood vessels, eyes, kidneys, and nerves.

A. Diabetic retinopathy is an important cause of blindness, and occurs as a result of long-term accumulated damage to the small blood vessels in the retina. After 15 years of diabetes, approximately 2% of people become blind, and about 10% develop severe visual impairment.

B. Diabetic neuropathy is damage to the nerves as a result of diabetes, and affects up to 50% of people with diabetes. Although many different problems can occur as a result of diabetic neuropathy, common symptoms are tingling, pain, numbness, or weakness in the feet and hands.

C. Neuropathy in the foot combined with the reduced blood flow - increases the chance of foot ulcers and eventual limb amputation.

D. Diabetic nephropathy Diabetes is one of the leading causes of kidney failure. 10-20% of people with diabetes die of kidney failure.

E. Diabetes increases the risk of heart disease and stroke. 50% of people with diabetes die of cardiovascular diseases (primarily heart disease & stroke).


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Spell out.

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[F.] The overall risk of death among people with diabetes is at least double the risk of those their peers without diabetes.

Source: WHO Fact sheet, September 2006

Diabetes – a problem disease

Diabetes is the most common non-communicable disease globally. According to WHO, there will be an alarming increase in the population with diabetes mellitus, both in the developed and developing countries over the next two decades. Diabetes is one of the major causes of premature illness and death worldwide. Thus Diabetes Mellitus is a major public health concern worldwide.

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The prevalence of diabetes as it is has already reached epidemic proportions. Currently Diabetes affects more than 285 million persons worldwide - and will affect an estimated 366 million (4.5%) by 2030, with the most rapid growth in low and middle-income countries and more importantly among populations of working age.

In the developed world, the estimated increase will be approximately 46%, from 55 million in 2000 to 83 million in 2030; whereas among the developing nations, the estimated increase will be approximately 150%, from 30 million in 2000, to 80 million in 2030 - thus WHO predicts that developing countries will bear the brunt of this epidemic in the 21st century. Currently, more than 70% of people with diabetes live in low- and middle income countries

India as a country is experiencing rapid socioeconomic progress and urbanization and will carry a considerable share of the global diabetes burden. Studies in different parts of India have demonstrated an escalating prevalence of diabetes not only in urban populations, but also in rural populations as a result of the urbanization of lifestyle parameters. The prevalence of pre diabetes is also high. Recent studies have shown that there is a rapid conversion of people having impaired glucose tolerance to diabetes in the southern states of India, where the prevalence of diabetes among adults has reached approximately 20% in urban populations and approximately 10% in rural populations. India in the year 2000 supposedly had 31.7 m diabetics which now have 43 m and expectedly by 2030 the number of diabetics will rise to staggering 79.4 m.


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There is a considerable disparity in the availability and affordability of diabetes care, as well as low awareness of the disease-thus glycemic outcome in treated patients is far from ideal and add to this lLower age at onset of the disease (meaning more number of years patient will have disease)- all these factorsthis increases the chances of occurrence of diabetes related complications including vascular complications.

The economic burden of treating diabetes and its complications areis considerable and investing in Llifestyle modifications is an effective tool for the primary prevention of diabetes. The primary prevention of diabetes is urgently needed in India also to curb the rising burden of dDiabetes.

Country profile – India (as per IDF data)

Percent with diabetes (20-79 years), 2010 (national) - 7.1

Percent with diabetes (20-79 years), 2010 (comparative) -

7.8

Percent with diabetes (20-79 years), 2030 (comparative) -

9.3

Number of people with diabetes, 2010 – 50,768,300

Percent with IGT (20-79 years), 2010 (national) -5.5

Percent with IGT (20-79 years), 2010 (comparative) -5.7

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New cases of type 1 diabetes in children (under 14 years)

2010 (new cases per 100,000 population per year) - 4.2

DIABETIC RETINOPATHY (DR)Diabetic retinopathy is a micro vascular complication of both type 1 and type 2 diabetes mellitus. The condition is a leading cause of blindness in many industrialised countries and is an increasingly becoming more frequent cause of blindness elsewhere. WHO has estimated that diabetic retinopathy is responsible for 4.8% of the 39 million cases of blindness throughout the world.

Diabetic retinopathy is a serious public health problem. It is one of the frequent causes of blindness among adults aged 20- 74 years.

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A diabetic is 25 times more likely to go blind than a person in the general population due to retinopathic or non retinopathic causes (cataract, Optic Atrophy, Glaucoma etc.)

Numbers as it is – is staggering andThe increase in prevalence and incidence of diabetes with increase in life expectancy is further going to increase the problem of DR.

Studies such as the Wisconsin Epidemiological Study have proved that micro vascular complications such as diabetic retinopathy (DR) in the diabetic population are linked to the duration of the disease. While the occurrence of DR cannot be prevented, at least its sight-threatening complications can be minimized.

Relationship between duration of diabetes and incidence of development of Diabetic Retinopathy (DR)

Duration(Diabetic age)

Incidence of Diabetic Retinopathy in Diabetes

Type-1 (IDDM) Type-2 (NIDDM)5 years

10 years

25%

60%

X

X

11

15 years

20 years

80%

100%

X

60%

DIABETIC RETINOPATHY ESTIMATION

ORISSA Total Above 20 yrsPopulation Proportion 60%

Service Area Population42,000,00

0 (42 m)25,200,000

(25.2 m)

Urban/Rural distribution in Population above 20 Years

Rural Urban Total70% 30%

In the Service Area Population

17,640,000

(17.64 m)

7,560,000

(7.56 m)

25,200,000

(25.2 m)

Diabetes Prevalence (in the over 20 yrs age) 4% 10%


705600

(0.71 m)756,000(0.76 m)

1,461,600 (1.46 m)

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DR Prevalence amongst the diabetics 20% 20%

In the Service Area Population141,120(0.14 m)

151,200(0.15 m)

292,320(0.29 m)

DIABETIC RETINOPATHY ESTIMATION

CUTTACK Total Above 20 yrsPopulation Proportion 60%

Service Area Population2,600,00

0 (2.60m)1,560,000

(1.56 m)

Urban/Rural distribution in Population above 20 Years

Rural Urban Total70% 30%


1,092,000

(1.09 m)468,000(0.47 m)

1,560,000 (1.56

m)

Diabetes Prevalence (in the over 20 yrs age) 4% 10%


43,680

(0.044 m)

46,800(0.047

m)

90,480 (0.091

m)

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DR Prevalence amongst the diabetics 20% 20%

In the Service Area Population8,736

(0.009 m)

9360

(0.009 m)

18,096(0.018 m)

DR is often symptomless until visual loss develops and once visual loss occurs mostly treatment is for remaining vision. Prevention, identification and treatment of DR are needed at the earliest to prevent loss of vision.

Multicentre studies have demonstrated that the incidence of blindness from diabetic retinopathy (DR) can be significantly reduced by early intervention with laser treatment. This applies to both proliferative retinopathy and maculopathy, apart from ischemic maculopathy which is untreatable.

In recent years large, prospective Multicentre trials of therapy in the USA, including the Diabetic Retinopathy Study (DRS), the Early Treatment of Diabetic Retinopathy Study (ETDRS), the Diabetes Control Complications Trial (DCCT) and the Diabetic Retinopathy Vitrectomy Study (DRVS), have provided clear management guidelines.

However, once DR is symptomatic, with significant visual loss, the chance of recovering vision is greatly reduced. Laser treatment may not be possible and even vitrectomy may not lead to visual gain. Effective treatment, therefore, has to be

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initiated at an early stage before the patient is aware of any symptoms, and patients in this category can only be identified by systematic screening.

Awareness and knowledge of diabetes and Diabetic Retinopathy among general public is relatively low, making it difficult for the individual to engage in preventive actions, diagnosis, or treatment. Awareness need to be increased among them to come forward for routine eye examination and early detection of DR.

Studies have found that very few Diabetics were referred from GP’s – meaning awareness among doctors treating Diabetes is not up to the mark also. Studies have further shown that there is a need for training GPs about diabetic retinopathy and its detection with direct ophthalmoscope. Barriers for dilated eye examination, as perceived by GPs, need to be addressed. McCarty et al reported that lack of dilating drops in the practice, lack of confidence in detecting changes, concern about time taken and fear of precipitation of angle-closure glaucoma with their patients were some of the barriers expressed by GPs. Knowledge of the guidelines for DR check up are another important factor to consider. Residency programmes should focus on providing more exposure to ophthalmoscopy practice among GPs, compared to the current low levels of exposure of only a few hours.

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So DR is growing in prevalence, the overall awareness among the general public and in Diabetics is very poor as and so is awareness among the general physicians. The ophthalmologist needs to have more orientation about DR services programmes as was done for cataract services.Then there are issues of service delivery at reasonable costs as there are no established cost effective models for DR services. Resources for delivery of optimum services to optimum number of people are always short. There is lack of manpower starting from retina specialists to general ophthalmologists, paramedicals, counsellors and social workers –so that services do not reach to all who require them. Lack of infrastructure and equipment was and will always be a problem. Maintenance of costly machines required in delivery of VR services is also very difficult.Another barrier is the absence of proper referral tree which would involve public, diabetics, paramedicals, GP’s, Diabetologist, ophthalmologists.Awareness regarding regular follow up of DR is also very important. People have to realise that result cannot be as satisfying as after a cataract surgery. A and treatment may be long and continued process –may need lifelong care. Patient satisfaction should never be compared to cataract management services and neither the results thereof.Rationale for Diabetic Retinopathy Services in India

The eye is the most commonly affected organ by diabetes leading to Diabetic Retinopathy (DR). More than 75% of patients who have diabetes mellitus for more than 20 years will

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have some form of diabetic retinopathy. (Report of WHO consultation in Geneva, Switzerland, 9-11 November 2005).

This initiative of tackling DR is directed towards improving health care services for persons with diabetes and diabetic retinopathy. DR is one of the foremost frequent causes of blindness world-wide. In India, DRit was the 17th cause of blindness 20 years ago but has now ascended to the 6th position. The World Health Organisation, under its VISION 2020 initiative, aims to control eye diseases, and diabetic retinopathy is one among them. And so does Indian chapter of VISION 2020 and Government of India.

According to WHO, 31.7 million people were affected by diabetes in India in the year 2000. This figure is estimated to rise to 79.4 million by 2030, the largest number in any nation in the world. It is estimated that 15 to 25% of the diabetic population have diabetic retinopathy, and everyone has the potential to develop it over a period of time. DR Diabetic Retinopathy is symptomless in its early stage; screening is the only way to identify these patients and to prevent them from going blind. The number of DR patients’ increase with increase in the diabetic population, especially in developing countries where there is resource scarcity. Timely treatment can prevent vision loss from diabetic retinopathy. This Background Information on Diabetes and Diabetic Retinopathy means that all of the diabetics have to be regularly examined for DR. The existing number of medical professionals trained in India to treat diabetic retinopathy is low. Currently there are about 13,000 ophthalmologists, and most of them are trained in


Remove the capital letters.

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cataract surgery. Only 7-8% of the ophthalmologists are trained in the management of DR. Some areas do not have any trained personnel for DR management. Also, people do not access screening and treatment due to lack of awareness of the disease and lack of availability of resources. Awareness of the disease and of its treatment modalities among the community and physicians is low All DR patients have to be detected early, and screening is the only effective way. At present, most of the diabetic patients come to the ophthalmologists only after experiencing considerable vision loss. Good specialised training of ophthalmologists to diagnose and treat diabetic retinopathy thus becomes a key aspect of blindness prevention. The current need is for a holistic model inculcating awareness creation, community screening, service delivery and training to deal with the problems of diabetes and diabetic retinopathy in the community.

Barriers

Economic Factors Costs (direct and indirect cost) Lack of established cost effective models for DR services Household economy and priority for eye care Household economy and priority for DR Service Productive age in relation to DR Marketability and sustainability

Social Factors

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Awareness on diabetes in rural areas Awareness on DR in rural and urban areas (not just among

the general Community but also among medical practitioners and Ophthalmic personnel)

Identifying the unknown diabetics Patient satisfaction with DR services (vis a vis cataract,

where you can restore sight unlike in DR where you cannot restore lost vision but can only perhaps arrest further loss of vision

Clinical and Medical Factors

Result after the treatment Long and continued procedure Lifelong care Cataract still a priority among service providers Need to address the root cause (diabetes) for which

behaviour change is key

Resources

Lack of trained manpower Social workers Counsellors Ophthalmic paramedics Retina Specialists

Infrastructure Cost of equipments Lack of appropriate referral system

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Coordination and Networking

Involving civil hospitals Involving general practitioners Involving Diabetologist

So the problems related to DR in India can be summed up as:

Too many patients Less number of trained personnel Awareness not very high Infrastructure not available specially equipments Cost of treatment very high Inaccessible areas Still orientation towards cataract screening

2. SITUATION ANALYSIS

2.1 GENERAL INFORMATION

India is situated in South East Asia and has a population of 1210 million.

INDIA

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ORISSA

Orissa is a state in India and is located in Eastern part of India. OrissaIt has a population of 42 million which comprises meaning 3 % of the Indian population. lives in Orissa.

Sex wise thereThere are 21.2 million males and 20.7 million females with a sex ratio of 978.

Age Wise the population of Orissa is- 6 years and below is 5.0 million and above 6 years is 37 million 37 million people of Orissa are aged six years or above.

85.01 % of the population lives in rural areas and 14.99 % in urban areas. The density of the population i.e. number of

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persons per square Km, is 269 as compared to 382 for the whole of India. figure of 382

Orissa has the largest percentage of tribal population among the Indian States barring the north‐eastern States viz. Nagaland, Meghalaya, Manipur and Tripura. 24% of the population is tribal. Scheduled Castes and Scheduled Tribes form 16.53% and 22.13% of the state population, constituting 38.66% of the State population.

The decadal growth rate of the state is 13.97% (compared to as against 17.64% for the country) and hence the population of the state is growing at a slower rate than the national rate.

For the year 2001‐06 years, the life expectancy in Orissa of males and females stands at 60.05 and 59.71 years, respectively, which is much below the country average of 63.87 and 66.91 years but it is slightly on the higher side in urban areas. The per capita income of the state is only Rs. 5985/‐ (AUD $120) (http://www.indiahealthtast.org/Resources/Orissa_Health%20Equity%20Status%20Report.pdf)The overall literacy rate is 73.45 % -with males having 82.40 and female literacy being still lower -64.36%.The numbers of people living below poverty line are 47.15%. (Source: India census website)

The state of Orissa is spread over 1.55 thousand sq km2 - the Coastal districts of Orissa take up 1/3rd of the geographical

http://en.wikipedia.org/wiki/Adivasis

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area. The mountainous portions of Orissa cover the other three‐fourths of the entire state and hence determine the economic standard of the state. These mountainous portions have undulating topography and are mostly inhabited by tribal and haves areas which are perhaps one of the most backward areas of the country like Kalahandi, Bolangir and Koraput .The Coastal districts are the more densely populated areas with good communication links but interior areas have difficult terrain and are at times difficult to reach.

The method of subsistence is agriculture for 64% of the population.

Medical care is scarcely available and the majority of people cannot afford it. Economic deprivation plays a significant factor in widening the equity gaps among economically different sections of the population the majority being marginal farmers, Schedule Castes, Schedule Tribes, tribal, daily wage labourers, women etc. Illiteracy perhaps is one of biggest deterrent.

The population is large for the area, low in literacy, ignorant about concept of good health with poor health care services availability. There are large areas which are still inaccessible. The geographical remoteness or inaccessibility of large areas or areas which are underserved having poor or no health care facilities is another crucial factor and add to this belt of tribal population who are cut off from the main stream and thus problems are compounded.


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Do you mena tribes?

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There is also underutilization of health services owing to social, cultural, and economic factors. Some of the problems include difficult terrain, location disadvantage of health facilities, unsuitable timings of health facilities, lack of Information, Education, and Communication (IEC) activities, lack of transport, etc.

2.2 BLINDNESS STATUS .

The prevalence of overall blindness in India is 1.4 %.

National Programme for Control of Blindness was launched in the year 1976 as a 100% Centrally Sponsored scheme with the goal to reduce the prevalence of blindness from 1.4% to 0.3%. As per Survey in 2001-02, prevalence of blindness is estimated to be 1.1% - by 2007 prevalence of Blindness was 1% (2006-07 Survey).

Main causes of blindness are as follows: - Cataract (62.6%) Refractive Error (19.70%) Corneal Blindness (0.90%), Glaucoma (5.80%), Surgical Complication (1.20%) Posterior Capsular Opacification (0.90%) Posterior Segment Disorder (4.70%), Others (4.19%) Estimated National Prevalence of Childhood Blindness /Low Vision is 0.80 per thousand

2.3 AVAILABLE RESOURCES:

2.3.1 INSTITUTIONAL

There are 3 government medical colleges and 3 private medical colleges in Orissa. One of the government medical colleges’

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ophthalmology departments has been upgraded to Rregional institute of ophthalmology. Besides medical colleges, most districts have got ophthalmologists. In NGO sector JPM, LVP, MJL .KALINGA- all are in and around the capital city of Bhubaneswar – and are doing lot of clinical work and are active in the community also. There are NGO hospitals active in other cities and towns of Orissa like ECOS eye hospital at Berhampur, Lions eye hospital at Rourkela, and others. But in NGO sector except 2 or 3 eye hospitals all are doing mostly cataract work. Besides this there are number of CBR projects and INGO’s like SSI, OEU, LEPRA INDIA, Right to Sight and others are active in Orissa.

VISION 2020, Orissa was launched about 4 years back but very little activity has taken place under its banner. There is a functional Orissa state Ophthalmological society in the state.

There are no specific ongoing projects in the state specifically targeting DR but an effort is on to make more people aware about DR.


2.3.2 HUMAN RESOURCES

There are about 300 ophthalmologists in Orissa out of which 150 are active surgically and about 50 ophthalmologists are in private practice.

There are about 10 trained VR specialists among them only 6 are doing VR surgeries. But all of them except 2-3 are in and around Cuttack and Bhubaneswar in the radius of 30 km.


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Spell out.Do the same for the others further down.

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Many ophthalmologists are oriented mainly towards refraction and cataract and would need CME’s programmes to orient them towards DR and its implications.

There are about 200 optometrists trained in optometry from government medical colleges. But now that training has been stopped and hence that number is not growing. There are 2-3 orthoptists in the state. MLOP training is on at JPM AND LVP and every year 15 are being trained .But these training are unrecognized and MLOP’s are only employed by NGOs-they are not eligible for government jobs. Of all the paramedicals special orientation toward retinal disease has been given to very few of them and most are not oriented towards DR or referrals for DR.

Physicians treating Diabetes would be a large number but again there orientation towards DR and referrals is doubtful specially ones practicing in the periphery.

A large number of endocrinologists are there mainly in the cities and medical colleges and they would be treating or coming in contact with at least 80 % diabetics of the state.


2.3.3 SERVICE DELIVERY

Diagnostic facilities for DR are is available through out the state – but indirect ophthalmoscopes, fFundus cameras , B-scans, OCT are available mainly in and around Cuttack and Bhubaneswar. Retina lasers units and VR surgery set ups are there only at 2-3 places in Orissa, and that to in areas around Cuttack and Bhubaneswar. Full facilities of a retina unit with VR

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surgeons are there at two NGO eye hospitals. The medical college hospital retina unit has machines but most are not in working condition

No concrete programme exists for delivering DR services- however some awareness and screening programmes are being run both by government and NGO’s. But how many people are being benefitted is not known and neither are the results.

No formal primary eye health care curriculum exists for the paramedicals who are being trained in government and NGO’s and their understanding of DR is very little and referrals from them are almost negligible.

Training fellowships in VR for ophthalmologists are available at LVP-Hyderabad, Aravind – Madurai, Sankar Nethralaya - Chennai and will become available after one year at JPM/LVP once these places develop as training centre.

However primary eye care training and awareness programmes can be provided locally from now onwards JPM/LVP/MJ and medical colleges of the state.

Some subsidy is being provided by government agencies for management of DR by lasers. But no comprehensive policy exists regarding DR as it exists for cataract.

2.4 ADMINISTRATIVE DIVISIONS:

The state is divided into 30 districts which are subdivided into subdivision and blocks. The smallest level of administrative division is village. There are in all 314 blocks, 5263 Gram

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Panchayats and 51,057 villages in Orissa. These are the Geo-political –administrative division of the state.

Planning and management of eye care service delivery is decentralized with each district having its own DBCS-district blindness control society- and the state being looked after state programme officer- SPO.

2.5 The main obstacles to providing eye care services are :

1. Poverty - Orissa is a backward state with lot of tribal population. As the per capita income suggests, the money is not enough for the food also-,let alone for Hhealth Care.

2. Lack of Awareness/Sensitisation –Due to lack of education, there are lot of beliefs ves which prevents people from up taking coming forward for eye care. With no health education, many unnecessary fears have developed in population leading to their not taking up services.

3. Poor uptake of services. – Lack of awareness, lack of communication facilities, lack of availability of quality services and poverty has all led to poor uptake of services-whatever is available.

4. Quality services not available – JPM/LVP is the only two Eye Hospitals with full time vVitreo-retina specialists running the retina unit. JPM unit is in place since last 8 years and LVP for last 3 years. More VR units have to be developed with good

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referral and linkages to help Diabetics from all the places in the State.

5. Lack of trained ophthalmic personnel. - It is only since last 6 years that JPM Personnel (anaesthetists, OT nurses, OPD nurses, counsellors) has been trained for Vitreo-retina services. As far as known to us, there are no specially trained personnel for VR services anywhere else in Orissa. Awareness among general ophthalmologists / endocrinologists / General Physicians is also lacking.

6. The stigma, negative social attitude and the differential treatment received by the people at times, haves driven away people from getting eye care.

3. OVERVIEW

DM is a major public health problem and estimates are that the number of diabetics will increase worldwide. India will become the diabetic capital of the world –meaning India will house more number of diabetics than in any other country. Orissa will be no different

DR will increase because the number of diabetics will increase – life span of population is increasing and lifestyle is changing.

Ocular morbidity and blindness due to diabetic retinopathy is on the rise

Awareness regarding DR is poor not only among general population and Diabetics but also among general

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physicians treating Diabetes and paramedicals working in the field of ophthalmology.

Lack of awareness in diabetics is creating problems of follow ups – which are essential in DR management protocol. No proper database of patient exists and follow-ups are need based or problem based and depends entirely on the patients.

Accessibility is a problem considering the geography of the state and most of the services are centre around urban areas.

Not enough trained manpower in VR services nor the required equipments and machines are available. The one’s which are available also are difficult to maintain as the cost of maintenance is very high.

No cost effective models exists hence the treatment which is available also is costly and cannot be afforded by all. So affordability is a problem also

Not enough research has been done in Orissa and in local state on DR – hence exact situation is by guesstimates rather than true estimates.

Not enough resources are made available for either service delivery or research in DR – policy makers and stakeholders have just started to realise problems related to DR – there being very little advocacy in that direction.

4. Project areas of work

4.1. Raising awareness of Diabetic Retinopathy

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4.2. Screening for Diabetic Retinopathy

4.2.1. DR screening programme (camps)

4.2.2. DR screening programme (Telescreening)

4.3. Developing Diabetic Retinopathy Database

4.4. Advocacy for tackling of Diabetic Retinopathy.

4.5. Research on Diabetic Retinopathy.

4.1 PROJECT AREA : Raising awareness of Diabetic Retinopathy

AIM:

Raising awareness about Diabetic Retinopathy

OBJECTIVES:

1. Raising awareness among General Physicians

2. Raising awareness among Ophthalmologists

3. Raising awareness among General Public

4. Raising awareness among Diabetics

5. Raising awareness among Para medicals

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1. Raising awareness among General Physicians

RATIONALE:

Awareness among the GPs treating Diabetes Mellitus in the community is very low. Various studies have demonstrated that patients referred by physicians to DR clinics are to be at the most is ~35% - which is very low. Raising awareness about DR in GP’s will go a long way in raising awareness on DR and its consequences among the diabetics in particular and general public at large.

AIM:

Raising Awareness

about DR

General Public

Diabetics

Paramedicals

General Physicians

Ophthalmologists

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To raise awareness regarding Diabetic retinopathy among the

doctors treating diabetes mellitus.

DURATION OF PROJECT: 3 YEARS

TARGET POPULATION : All the general physicians in the target area (one district with about 2 m population)

OBJECTIVES:

1 To formulate a plan for raising awareness among GP’s about DR

2 Prepare materials/slides/presentations for raising awareness among GP’s about DR

3 Organize seminars, give talks and distribute education materials

4 To give talks/ make presentations at annual meets and conferences

5 Follow up on activities performed to raise awareness.6 Monitor and evaluate the programme for the desired results

ACTIVITIES

Objective To formulate a plan for raising awareness among

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1 GP’s about DR

ACTIVITY OUTPUT

Activity 1 a

Who will be told -Collect list of target audience and a map to show their distribution. Prepare a database of all the GP’s of the area. Doctors in government sector (PHC, CHC. District health centre), private practitioners and in corporate sectors- GP’s, endocrinologists , cardiologists- all should be targeted

Target audience finalized with their details.

Activity 1 b

Who will do it – project officer, IEC expert, ophthalmologists and administrative staff

People will be trained and told exactly what is expected of them

Activity 1 c

How will it be it told – Mails – normal and emails, target medical representatives to reach doctors, seminars, talks in conferences ,distributing literature on DR

More GP’s will be reached

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Activity 1 d

What will be told - Importance of eye check up, consequences of not doing it, how DR can lead to blindness and low vision, and importance of timely follow up.

Relevant and to the point message passed

Objective 2

Prepare materials/slides/presentations for raising awareness among GP’s about DRACTIVITY OUTPUT

Activity2 a

Prepare awareness materials to be distributed – literature articles, brochures, ad materials

Tools to raise awareness ready

Activity2 b

Prepare Talks/slides/presentations - What exactly is to be told is to be decided- Talks initially to be centered on Diabetes and then complications of diabetes especially vascular ones and finally on DR .Rather detailing on DR it will be better highlighting importance of regular eye check up in Diabetes and problems if not done. To further facilitate the referral mechanisms, a

Tools to raise awareness ready

35

protocol for referral of diabetes patients to diabetic retinopathy screening or treatment must be discussed and agreed upon. Follow up schedule of eye examination should be discussed because there are patients who come for first examination but never turns up for routine checkups till some vision is lost due to DR. Issues related to pregnant diabetics; latest treatment methods for Diabetic Retinopathy and what tertiary facilities are available should be discussed too.

Objective 3

Organize seminars, give talks and distribute education materialsACTIVITY OUTPUT

Activity3 a

Place/date /duration /guests –all decided- Every 2 months/half a day /at different places of target areas – VIP to inaugurate the seminar –guest speakers finalized and GP’s to be invited – invitation should be looked after properly otherwise poor attendance can demoralize the

A detailed programme for organizing seminar is ready.

36

team.Activity3 b

Detail of a seminar to be finalized including detailed minute to minute programme

A detailed seminar plan is ready to be organized

Activity 3 c

List of things required - Laptop, LCD projector, materials to be distributed, registration forms, etc

Seminar is ready to be organized

Activity3 d

After seminar prepare a detail report on seminar – who attended who did not – topics for discussion and a detailed expenditure list to be made

Direction to future programmes and short term impact of the programme known. Cost cutting method can be looked into.

Activity3 e

Distribute education materials at regular intervals through mails, emails through couriers - Somebody must be in touch with the GP’s all the year round

GP’s under sustained awareness generation mode.

Objective 4

To give talks/ make presentations at annual meets and conferencesACTIVITY OUTPUT

Activity4 a

Identify conferences to be attended and fix up guest speakers for it

More awareness programmes identified

Activity During the talk make sure More GP’s will

37

4 b what is to told and distribute necessary awareness material and make sure delegates attend the session.

attend a fruitful session.

Objective 5

Follow up on activities performed to raise awareness.ACTIVITY OUTPUT

Activity5 a

GP’s who have attended seminars or are being sent education materials will be contacted once in 3 months and will be requested to complete an short questionnaire – which will reflect their increase in awareness about DR, whether they are referring diabetics for Eye examinations ,etc

Impact of programme starts becoming obvious.

Objective 6

Monitor and evaluate the programme for the desired resultsACTIVITY OUTPUT

Activity6 a

As the programme is going on of planning, getting awareness material ready, seminars and talks – the programme officers, ophthalmologists, people from administration will review

Proper programme monitoring will be done

38

reports and see that programme is on track. Monitoring indicators will be there and will give fair indication that the programme is being implemented.

Activity 6 b

Once the programme is over in one district –it will be evaluated by external agencies and impacts will be looked into

Evaluation of the programme -will improve similar programmes in other districts.

RESOURCE REQUIREMENTS

1. EQUIPMENTS AND OTHER THINGS:

1. Laptop

2. LCD projector

3. Phone

4. Stationery

5. Brochures, pamphlets, banners

6. Camera

2. PERSON (STAFF)

1. Project officer

2. Ophthalmologists/Retina Specialists

3. IEC expert

39

4. Field coordinator

5. Administrative assistant

3. TRANSPORT:

1. Transport for field work of collecting list of GP’s.

2. Transport of personnel in contacting GP’s for invitation, to distribute ad materials, follow ups of meetings

3. Transport of guests faculty for the seminars or meets.

SPECIFIC REQUIREMENT FOR A SEMINAR

Manpower requirements (Retina specialist – 1, Project officer-1

IEC Expert-1; Field coordinator -1;

Administrative assistant - 1)

1. Field coordinator travel and food expenses for 2 days for seminar pre arrangement

2. Phone3. Postage

4. Stationery (Note pad, pen, Registration note)

5. Seminar hall rent

6. Handouts – Booklet/Pamphlets

7. Tea, Snacks, Lunch

40

8. Lap top and LCD projector - 1

9. Mementos for guests

10. Charges for Photo developing and printing for documentation

ACTIVITIES MONTHS

1

–

2

3

-

4

5

-

6

7

-

8

9

-

10

11

-

12

13

-

14

15

-

16

17

-

18

19

-

20

21

-

22

23

-

24

25

-

26

27

-

28

29

-

30

31

-

32

33

-

34

35

-

36

1 Draw a plan how to raise awareness among GP’s

2 List of all the GP’S

3 Materials in readiness for raising awareness -brochures, emails, slides pr

4 seminar organization

5 Targeting annual meets &conferences

6 Follow up after attending seminars

7 Evaluation

TIMELINE

41

MONITORING

1. Number of GPs targeted2. Number of seminars held3. Number of mails send to GP’s[4.] Number of referrals increased from Ttreating physicians4.[5.] Number of talks given at annual /monthly meetings5.[6.] Time line being adhered to

IMPACT

As awareness starts improving rising among treating physicians more number of diabetices patients will turn up for eye examination. Diabetes patients who have DR will not be lost to follow up –since their pPhysicians will be reminding them of for follow up visits. More diabetics will become aware about DR and its consequences and awareness regarding DR will increase among Diabetics. Early intervention will be possible and morbidity and blindness due to DR will decrease.

42

BUDGET

ACTIVITY ITEM TO BE COSTED Cost of items

subtotal

1 Plan 50,000 50,000 50,000

2 Making of list

10,000 10,000 10,000

3 Materials 50,000 50,000 50,000

4 Seminars 40,000 X 12 seminars 4,80,000 4,80,000

5 Annual meets

10,000 X 6 meets 60,000 60,000

6 Follow ups 1,00,000 1,00,000 1,00,000

7 Evaluation 50,000 50,000 50,000

TOTAL

Rs 8,00,000

(AUD 16,000)

FIRST YEAR: Rs 3, 00,000 (AUD$ 6000)

SECOND YEAR: Rs 3, 00,000 (AUD$ 6000)

THIRD YEAR: Rs 2, 00,000 (£AUD$ 4000)

(1 AUD = 50 INDIAN RUPEES)


I think this needs to be further detailed.

43

2 Raising awareness among Ophthalmologists

a) Total number of ophthalmologists in Orissa /Cuttack b) Their spread in Orissa c) DR CME programmes every 3 – 6 months – 3/4

programmes and not only one off programme at least for 3 years

d) Target Orissa ophthalmological meet held once a yeare) Mailing list and emails of all the ophthalmologists and

send regular write ups and publicity materials

3 Raising awareness among Para medicals

a) One ophthalmic assistant and one nurse from all government units and eye hospitals.

b) Target all ophthalmic assistantsc) One day programme every 3-6 monthsd) TA/DA – lunch with some reading materials and publicity

materials.[e)] Clear cut instructions what to tell is to be told to them

and what is expected of them.[f)] Inform Tell them something on how to raise awareness

among common people, in Ddiabetics and about the referral tree.

4 Raising awareness among General Public i. Talksii. Pamphlets


What does this mean? Do you mean pathway?

44

iii. Postersiv. TV talks /ad

5 Raising awareness among Diabetics

a) Target diabetics in diabetic clinics of medical colleges and endocrinologists

b) Show video, reading materials, visits from someone from an eye hospital to raise awareness.

c) Drive home the importance of regular eye check up in Diabetics and consequences of not doing it.

i. Develop a database of Diabetics and DR patients in the district of Cuttack – meaning the list will be of approx 11,400 DR patients.

ii. All diabetics database if possible iii. All diabetics and/or informed about DR and its relation to

vision lossiv. Database centre with a software where all the details and

can be held maintaining privacy clause of the patients. The software should record every visit of the patient to DR Clinic and if the patient does not report in time a mailing system to be incorporated. Some sort of encouragement for patients who report on time

4.2.1 PROJECT AREA :

DR screening programme (camps)RATIONALE:

45

Diabetes and DR are reaching alarming proportions in developing countries. Our understanding of the disease Diabetes and its complication i.e., DR has increased and the fact that early diagnosis and prompt treatment can prevent blindness and morbidity associated with Diabetic eye diseases has been well established but less than half the population of diabetes get their eyes check routinely once in a year. Management of DR in its end stage does not give satisfactory results and can lead to loss of important manpower especially amongst the working age. Screening for DR has been proved to be a cost effective model. It is less costlier to screen and save than making disability payments to Diabetic patients who has gone blind in absence of an screening programme

AIM: To combat Diabetic Retinopathy (DR) related morbidity and blindness


TARGET POPULATION: In a phased manner, initially involving two districts of Orissa and then to other districts of the state.

OBJECTIVES:

1 To create awareness about Diabetes and DR in the population of target area.

2 To conduct Diabetes and DR screening camps and facilitate management

3 To train GP’s and general ophthalmologists in identifying patients having risk of developing DR.

4 To prepare a database of all the patients with DR.

46

ACTIVITIES

Objective

1

To create awareness about Diabetes and DR in the population of target area.

ACTIVITY OUTPUT

Activity

1 a

Raising awareness among General Physicians

( A DETAILED PROJECT)

Awareness among the GP’s will rise and more diabetics will be referred for eye check

47

up.

Activity

1 b

Raising awareness among Ophthalmologists

More number of ophthalmologists will be able to detect and treat DR- Resources adequate

Activity

1 c

Raising awareness among General Public

Overall awareness about Diabetes and DR will rise and morbidity /blindness due to DR will decrease

Activity

1 d

Raising awareness among Diabetics

.

They are the target group & awareness among them will go a long way in solving problems related to DR

Activity

1 e

Raising awareness among Para medicals

Rate of referrals will increase.

Objective2

To conduct Diabetes and DR screening camps and facilitate management

48

ACTIVITY OUTPUTActivity2 a

Prepare a plan for screening camps- areas where camps will be held, when, duration of camps and timings, composition of team, things that will be required, logistics, publicity, estimated number of patients and expenditure to be incurred on the camp. ( detail later)

Detailed plan for conducting DR screening camp ready

Activity2 b

Detail record of the camp is maintained –target Area, population targeted, number of diabetics found, number of DR found, advice given. Organizational aspect is also detailed including cost incurred

Detailed report will go long way in understanding the problem better – improving implementation of the programme and doing further research.

Activity 2 c

Making logistics arrangement for the DR patients who are referred to eye hospital for further management.

DR patients requiring hospital based services are provided for – less disease morbidity and blindness due to DR.

49

Objective3

To train GP’s and general ophthalmologists in identifying patients having risk of developing DR.


A group of interested GP’s and ophthalmologists and paramedicals can be given a short hands on training course for using direct/indirect ophthalmoscope for detection of DR.

Resource mobilization – more people available in the community to detect DR and load on Hospitals and people going to hospitals for routine checkup will decrease

Objective4

To prepare a database of all the patients with DR. ( A DETAILED PROJECT LATER)

ACTIVITY OUTPUTActivity 4 a

To enumerate and develop a database of all the diabetic retinopathy patients in the district of Cuttack and the state of Orissa

For planning better service delivery, do advocacy and for research purposes.

50


1. EQUIPMENTS AND OTHER THINGS:

1. Publicity materials for the camps –posters, handouts, banners etc.

2. Mike system for announcements and doing publicity.

3. Phone

4. Stationery

5. Registers, registration cards, etc

6 .For diagnosing Diabetes – Glucometer, strips, cotton .spirit,

tapes etc.

6.[7.] For diagnosing DR – Torch, slit lamp, direct / indirect Ophthalmoscopes,Tonometer, Snellen’s charts, Trial frame, Trial set etc.

8. Computers /printers and necessary accessories

9. Camera

2. PERSON (STAFF)

1. Project officer

2. Public health specialist

3. Ophthalmologists/Retina Specialists

4. Ophthalmic assistants.

4. IEC expert


????

51

5. Field coordinator

6. Administrative assistant

7. Social workers

3. TRANSPORT:

1. Transport for field work – Like publicity of screening camps, invitations to all the ophthalmologists and GP’s for the camp etc.

2. Transport of team to screening site

3. Transport patients for further management at the base hospital

TIME LINE (FOR SCREENING PROGRAMME)

Activities Months1-3

4-6

7-9

10-12

13-15

16-18

19-21

22-24

25-27

28-30

31-33

34-36

37-39

40-42

43-45

46-48

49-51

52-54

55-57

58-60

1 Draw a plan

2 Train people to run the programme/do screening

3 Proper screening camps

52

4 Logistic arrangements for the patients

5 Report compilation from camps

6 Evaluation

MONITORING

[1.] Number screening camps planned and organized.1.[2.] Number of patients found to have DR.2.[3.] Number of patients found to have DR and referred3.[4.] Number of patients found to have DR and treated4.[5.] Area of coverage by the screening camps.5.[6.] Number of patient referred by GP’s to the camps6.[7.] Time line being adhered to7.[8.] Number of GP’s, optometrists trained in diagnosing DR.

IMPACT

As screening programmes will take place – awareness will rise among general population and diabetes regarding DR and its sequel if not treated. Diabetics having DR will be diagnosed in time and treated in time if required and unnecessary morbidity

53

associated with DR and blindness will be avoided. Loss to follow-up by DR patients will be minimized. More research will be possible on service delivery aspect of DR. Awareness will be widespread and not localized to one region or one urban pocket. Accessibility of services will not be a problem.

BUDGET (for one district)

ACTIVITY ITEM TO BE COSTED

Cost of items

subtotal

1 Plan for screening camps

1,00,000 1,00,000 1,00,000

2 Training of manpower

1,00,000 1,00,000 1,00,000

4 EQUIPMENTS / AMC/Maintenance

7,00,000 7,00,000 7,00,000

3 Publicity materials , banners ,etc

50,000 50,000 50,000

4 Screening camps including

Rs 15,000 X 75 11,25,000 11,25,000


Is this correct?

54

consumables camps

5 Patient transport and other.

Rs 2000X 75 camps

1,50,000 1,50,000

6 Report compilation

1,00,000 1,00,000 1,00,000

7 Evaluation 1,00,000 1,00,000 1,00,000

TOTAL Rs 24,25,000

(AUD 48,500)

FIRST YEAR: Rs 11, 00,000 (AUD 22,000)

SECOND YEAR: Rs 3, 00,000 (AUD 6000)

THIRD YEAR: Rs 3, 00,000 (£AUD 6000)

FOURTH YEAR: Rs 3, 00,000 (AUD 6000)

FIFTH YEAR: Rs 4, 25,000 (AUD 8500)

(1 AUD = 50 INDIAN RUPEES)

55

Diabetic retinopathy screening camp protocol

Step one: Diabetes screening

The details of the patient’s name, age, sex and address will be registered in the register notebook and the patients will be given a card for diabetic screening. Then, the patients will undergo Random Blood Glucose (RBS) tests with the help of a strip and a glucometer. Patient’s height, weight and hypertension are also measured. The patients are asked whether he/she is a known diabetic or has come to learn about his/her diabetic status. This information will also be entered in the card. All the patients will be referred to the physician for his advice. The physician will see all the patients, gives advice and refer the diabetic patients for Diabetic Retinopathy screening. The non-diabetic patients will receive the physician’s advice only. IEC materials will be given to all the outpatients at registration counter.

Flow chart: Illustrating diabetes screening strategy.

56

Step two: Diabetic Retinopathy Screening

[1.] Registration : All the diabetic patients will be registered in another separate register. A screening card along with the details collected during the diabetic screening will also be provided.

1.[2.] Vision test : All diabetics are tested for visual acuity. This is done in a separate Room with the Snellen’s chart at a distance of 6 meters.

2.[3.] Preliminary Eye Examination : After the visual acuity test, patients would undergo a preliminary vision examination to decide whether the patient’s eyes should be dilated. The patients are asked about their eye history, quick examination for cataracts, glaucoma and other visual complications is made, and information is noted on the patient’s cards.

3.[4.] Dilatation : After the preliminary eye examination, intraocular pressure is measured with the help of Tonometer before dilatation. The dilating eye drops are

57

applied for all the diabetic patients. Patient’s sit in a darkroom till the eyes are fully dilated, then are taken for a more thorough Diabetic Retinopathy screening.

[5.] Diabetic retinopathy screening : Examination takes place in a darkened room using direct / indirect ophthalmoscope. This provides a wide field of vision but low magnification and patients who detected with the signs of Diabetic Retinopathy are referred to the base hospital. Others are given suitable advice.

4.[6.] Counselling: All diabetics leave with information concerning the diagnosis of Diabetes and Diabetic Retinopathy. They are given more detailed information about the disease, its effects, and the treatment options, including the recommended course of action and laser treatment. They are informed of the locations where treatment is available, and encouraged to come to the hospital to receive treatment.

Flow chart: Illustrating DR screening strategy

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4.2.2 PROJECT AREA : DR screening programme (Telescreening)

Teleophthalmology project for DR screening

INTRODUCTION

Teleophthalmology is a techno savvy method by which medical facility is taken to rural or remote areas by using computers, video conferencing and internet. Teleophthalmology enables a doctor from one end to interact with the patient sitting at a remote end in a faraway place through videoconferencing, share data’s through computers and diagnose the patient eye disease with the help of a local doctor or paramedical or

59

technician who uses ophthalmic diagnostic equipments to transfer images.

Ophthalmology is one field of medicine where imaging plays a major role and many a times diagnosis can be made viewing these images. So it is apt and rationale to use IT in ophthalmology for reducing the rural urban divide.

SCOPE OF SERVICES IN TELEOPHTHALMOLOGY

1. PATIENT CARE . – Expert opinion can be provided, comprehensive eye examination in rural areas can be done, eye screening for school children, for DR can be done. Home care, community care, primary care, screening, secondary care, tertiary care services can be provided and screening too can be done at levels of service delivery.

2. EDUCATION CME’s for physicians, specialists and paramedicals. Training for paramedicals. Higher education can be provided because of international and national connectivity. Broadcasting of live surgeries can be done.

3. AWARENESS PatientsGeneral public

4. RESEARCH Connectivity across research centres.

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The success of Teleophthalmology will depend on – connectivity - stability of connectivity is a must. Availability of connectivity at affordable costs of broadband required, availability of trained and experienced human resources would be another challenge. Security and confidentiality of the patient data and data protection will always be a concern.

The sustainability of such a project can be a big challenge. The idea of seeking tele consultation is still new and will take time to pick up. Then there is considerable investment done to provide tele consultations in terms of equipment, manpower and other resources .Teleophthalmology services like any services should be sustainable both to who seek services and to those too who provide such services. So ultimately an appropriate payment model has to be developed. But there is a definite rationale to such a programme.

RATIONALE

Teleophthalmology can make eye care service accessible and affordable by reducing travel cost and time for the patients; will enable people from remote areas accessible to specialized eye care facilities and act as an interface between doctors to share their experiences. Diabetic Retinopathy Telescreening may be appropriate as a screening technique for the detection of diabetic retinopathy for those patients diagnosed with type 1 or type II diabetes at a frequency according to the American Diabetes Association’s retinopathy screening recommendations. The images should be of sufficient resolution

61

for judgment regarding the presence or absence of pathology. Telescreening is nearly half the cost compared to base hospital screening

Aim: To tackle morbidity and blindness due to DR.

Objectives:

1 To make a plan for setting set up a Teleophthalmology unit.

2 Establishing the unit

3 To plan Screening and Awareness camps

4 To screen diabetic patients for DR and suggest management avenues

5 To raise awareness among the general public and diabetics about DR.

6 To monitor and evaluate performance of this Teleophthalmology unit

Project duration: 5 years

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Target population : Initially in 2 districts and then to be extended to all districts of Orissa.

Activities

Objective 1

To make a plan for setting up a Teleophthalmology unit.

ACTIVITY OUTPUT

Activity1 a

Need is established and existing facilities available is understood

Situation analysis completed

Activity1 b

Site preparation Size and type of room Lighting Electricity and back up Background and audio engineering Air conditioning General ambience required.

Planning

Activity1 c

Vehicle design What is to be done with mobile unit

exactly? Selection of chassis and body works Air conditioning and dust proof

Planning

63

Vibrations due to road condition Power back up – dual Tele consultation – connectivity

options- VSAT/ISDN/WIRELESS

Activity1 d

Connectivity and network protocol. Available bandwidth in the area Estimate general quality /frequency

of information transmission required.

Determine what you need to do with bandwidth

And then only start researching hardware and software required.

Planning

Activity1 e

Computer hardware Servers Clients ( desktops) Grabbing card for audio and video.

Computer software Internet or server and client Chatting utility Desktop video collaboration Picture acquiring Electronic medical records In house development or select the

vendor Standards ( DICOM OR HL7)

Planning

Activity1 f

Equipments and instruments. Slit lamp/Ophthalmoscope/ Non

mydriatic cameras Analog to digital output Digital output from all equipments Video cameras Digital still camera Support from the vendor

Detail plan is ready

64

Objective 2

Execution of the Plan and Establishing the unit


All the things connected and to make sure the unit is working.

The technology part is ready

Activity2 b

Train the persons who will run the unit – doctors, paramedicals, technicians, drivers etc

Trained manpower ready to run the project. Developing a dedicated and integrated diabetes care team is mandatory for the prevention of blindness caused by diabetic retinopathy.

Activity 2 c

Test the system by running in the hospital envoirment and in a nearby known area

Teleophthalmology unit is ready for screening for DR among the diabetics.

65

Objective 3

To plan screening and awareness camps


To make a detail plan of the district which is to be taken up for DR screening by Teleophthalmology unit- the spots were the camps will be held, internet connectivity in that place, the roads must be good,

Proper spot selection for the Teleophthalmology based screening camp for DR.

Activity3 b

Number of spots in one area / district – area to be covered ,population covered by one camp- all to be detailed and a monthly plan drawn - and publicity of the camp should be well planned and implemented

Adequate patients for Teleconsultations.

Objective 4

T o screen diabetic patients for DR and suggest management avenues


On the camp date – vehicle is parked at a convenient place and connectivity established

Camp is ready for Teleconsultations

66

Activity4 b

Proper guideline as is predetermined is followed and patients are advised

Screening done

Activity4 c

Patients needing referral to base hospital are advised accordingly and arrangements made for their transportation.

DR patients requiring hospital based services are provided for

Activity4 d

An inbuilt recall system will monitor follow up of treated patients, as well as those patients who drop out of the program.

Follow up will be strengthened

Objective 5

To raise awareness among the general public and diabetics about DR.


Awareness programme is planned ,the day Teleophthalmology vehicle is the camp area-Time of awareness talk is well publicized. Community participation is a must for success of any awareness programme. Local clubs, welfare organizations, and

Adequate attendance during the awareness raising event.

67

women self help group all will be taken on board.

Activity5 b

Talks are given, slides are shown, discussions are initiated and questions are answered. Pamphlets are distributed.

General awareness among public and diabetics rose about Diabetic Retinopathy.

Activity5 c

Training local ophthalmologists and GPs in rural areas helps in the continuity of diabetic care.

Awareness among GP,s will rise also

Objective 6

To monitor and evaluate performance of this Teleophthalmology unit


District to be covered, List of camps planned , coverage area , population target , number of people coming

forward for Teleconsultations ,

patients referred/Advice given

problems facedall are noted

A detailed reporting system is in place and all the reports are compiled

Activity Problem related to Teleophthalmology unit itself is

The unit functioning is

68

6 b noted on day to day to basis and compiled and acted upon to make the unit more efficient and fault free.

optimized.

Activity6 c

The whole programme is evaluated 6 monthly/yearly and end of 5 years to look into implementation of the programme, services rendered and impacts and will suggest methods to make the programmes more efficient in the other districts.

Proper programme evaluation done with a detailed report on achievements, shortfalls and guidelines for future such programmes.

Resources required

Human Resources:

1. Project /programme officer2. Ophthalmologists/Retina specialists3. Optometrists4. Paramedicals5. IT specialists6. Technicians7. Data recorder8. Social workers9. Drivers

69

Equipments & Instrument

1. Slit lamp with digital camera and necessary attachments2. Indirect ophthalmoscope with digital camera and

necessary attachments3. Non mydriatic camera with digital camera and necessary

attachments4. Basic eye examination instruments and equipments5. Proper computers with attachments and proper

connectivity.

Vehicle

o Proper vehicle with special shock absorbing body.o Instruments/equipments properly fitted o Proper equipments to transmit images from the rural

settings to base hospital.o Set up for uninterrupted power supply

Time line

70

Activities Months1-3

4-6

7-9

10-12

13-15

16-18

19-21

22-24

25-27

28-30

31-33

34-36

37-39

40-42

43-45

46-48

49-51

52-54

55-57

58-60

1 Draw a plan

2 Establish the unit and train people to run the programme

3 To plan screening and awareness camps

4 To conduct screening and awareness camps

5 Continuous monitoring of the programme

6 Evaluation

Monitoring

1. Districts to be covered2. Population to be covered3. Timeline for plan 4. Timeline for establishing the unit5. Number of places selected for Teleconsultations

71

6. Number of patients given Teleconsultations7. Number of patients screened/DR Detected8. Number of patients advised regular follow up /referred to

base hospital.9. List of problems faced related to connectivity.10. List of problems faced related to vehicle.11. Number of review meetings held12. Number of awareness programmes organised

Impact of Teleophthalmology services

Accessibility of services will not be a problem .More number of people will be reached and more diabetics will come for routine eye examinations. Load at the tertiary centre will go down as only patient with referrals will be there. Awareness will be rise both about DM and DR.

Budget

Activity Item to be costed

Cost of items

Subtotal

1 Plan Making of detail plan with IT consultations

200,000

200,000

2 Establishing the unit

Slit lamp 400.000

IO 300,000

Non mydriatic camera

700,000

Computers 200,000

Computers

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software /hardware

200,000

Vehicle with proper chassis & AC

1000,000

Others – including room furnishings etc

300,000

Training of human resources

200,000

3,300,000

3 Screening camps/awareness camps

Rs 10,000 x 250 camps

2500,000 2500,000

4 Monitoring and evaluation

200,000

200,000

5 Recurring expenses

Salaries 6000,000

Connectivity cost

300,000

Consumables 200,000

Computer peripherals replacements

200,000

6,700,000

Total

12,900,000

(AUD 258,000)

FIRST YEAR: Rs 49, 00,000.00 (AUD 98, 000)

SECOND YEAR: Rs 20, 00,000.00 (AUD 40,000)

THIRD YEAR: Rs 20, 00,000.00 (AUD 40,000)

FOURTH YEAR: Rs 20, 00,000.00 (AUD 40,000)

FIFTH YEAR: Rs 20, 00,000.00 (AUD 40,000)

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4.3 PROJECT AREA :

DEVELOP DR DATABASE FOR THE DISTRICT OF

CUTTACK AND STATE OF ORISSA

RATIONALE:

No formal database is being maintained for DR patients in India. Orissa will be one of the pioneers in such a project. Though estimates states that the number of diabetics in the district of Cuttack would be 90,480 (in state of Orissa would be 1.46 m) and number of DR patients would be 18,096(in Orissa 292,320) – the real picture will be obvious once database is readied. The database will help in treating patients better,

74

making them aware of developments in an organized manner and at regular intervals, reminding them about their timely follow-ups, sending them regular mails regarding understanding the disease.

This database can also be used for doing effective Advocacy – not having quality data has been one of the main problems of doing effective advocacy.

Research in diabetic retinopathy can be done on regular basis and temporal trends can be studied- if such a database is available.

INDIA ORISSA

POPULATION 1210 M 41.9M

PRVELANCE OF BLINDNESS

1% 1%

CALCULATION1/100 x 1000 1/100 x 41.9

TOTAL NUMBER OF BLIND

12.1 m 0.419 m(4,19,000)

TOTAL NUMBER OF DIABETICS

43 m 1.46

TOTAL NUMBER OF DR PATIENTS

8.6 m 0.29 m(292,320)

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PROJECT DURATION: 3 YEARS

TARGET POPULATION: Orissa population of 41.9 million –especially diabetic retinopathy patients numbering 0.29 million (292,320)

AIM:

To enumerate and develop a database of all the diabetic retinopathy patients in the district of Cuttack and the state of Orissa for planning better service delivery, do advocacy and for research purposes.

OBJECTIVES:

1 To formulate a template with the help of CERA for recording DR data and database for Cuttack and Orissa

2 To pilot this template. Reassess and finalize the data recording form both software and paper version. .Finalize DR database software.

3 To calculate total number of DR patients is expected in the area – make a plan of locating how to find them, who will find them, who will examine the patient and who will record the data

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4 Actual finding of DR patients and recording their data.

5 Entry of data in the database being formed at the centre, checking the data for errors and removing them if any.

6 Updating of data at any opportunistic interval of time.

.

ACTIVITIES

Objective 1

To formulate a template with the help of CERA for recording DR data and database for Cuttack and Orissa

ACTIVITY OUTPUT

Activity

1 a

Search literature for templates

Copy of all formats used for databases

Activity

1 b

Prepare a template Template is ready

Objective 2

To pilot this template. Reassess and finalize the data recording form both in software and paper

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version. Finalize DR database template.

ACTIVITY OUTPUT

Activity

2 a

Pilot the template in a eye hospital who have a DR unit in place

Temporary database on some DR patients made.

Activity

2 b

Have a meeting of all concerned regarding difficulties faced – at field level, in filling the template and in feeding the data in the computer.

Make necessary corrections

Activity

2 c

Finalize the form and the database format.

Forms and database are ready to be used

Objective 3

To calculate total number of DR patient expected in the area – make a plan of how to find them, who will find them, who will examine the patient and who will record the data.

ACTIVITY OUTPUT

Activity

3 a

Make a detail report of number of DR patients in the district /state. Breakup the figures district wise, block wise.

Total number of diabetic clinics

A detailed map of DR patients in Cuttack/ Orissa is ready.

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in the area with possible number of DR patients in them.

Activity

3 b

Decide how these patients will be found and enumerated. By Key informants or health education volunteer or PEC worker or primary health worker.

Manpower requirement to find DR patients ready

Activity

3c

Train or briefing of these personnel.

Personnel knows exactly what is expected of them

Objective 4

Actual finding of DR patients and recording of their data.


DR patients are enumerated from the clinics and hospitals

List of DR patients ready

Activity4 b

An examination day is fixed for areas – all the DR patients are invited for examination – their travel arrangement to site of examination made. Volunteers/Enumerators to help in these activities.

All the DR patients of the designatedarea present at the examination area.

Activity A team comprising of an Examination

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4 c Ophthalmologist, Refractionist with low vision training, with a support staff to visit the examination area. All the equipment required for examination is made ready.

team with equipments / instruments is ready for examining the DR patients

Activity4 d

All the DR patients are examined, refracted, detailed history sought and all the details are filled in the forms prepared for recording of database.

All the data recorded

Activity4 e

All the data are checked for completeness by the personnel present

Quality data ready

Activity4 f

Patients who were invited but did not come – are followed up and made sure they come during next round of examination in the adjoining area.

Drop out cases will be taken care ofand their numbers can be kept to minimum

Objective 5

Entry of data in the database being formed at the centre, checking the data for errors and removing them if any.

ACTIVITY OUTPUT

Activity As the team returns to the base Database of that

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5 a station after a set of data from an area- these are fed into computer by two data operators –errors corrected and data recorded

area completed. Gradually data for the district/state is built.

Objective 6

Updating of data at any opportunistic interval of time.

ACTIVITY OUTPUT

Activity 6 a

If any camp or health activity is taking place in an area – one Refractionist is sent with paper records of DR patients in that area- he tries to contact them and checks them and updates their data

Updating of data and more advice is given

Activity

6 b

These corrected data are fed into computers and electronic updating of data is also done.

Data is updated

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TIME LINE (for district of Cuttack only)

ACTIVITIES MONTHS

1

-

2

3

-

4

5-6

7-8

9

-

10

11

-

12

13

-

14

15

-

16

17

-

18

19

-

20

21

-

22

23

-

24

25

-

26

27

-

28

29

-

30

31

-

32

33

-

34

35

-

36

1 TEMPLATE PREPARATION

2 PILOT THE TEMPLATE

3 PLANNING OF DR PATIENTS DETECTION

4 FINDING THE DR PATIENTS AND RECORDING THE DATA

5 DATA ENTRY

6 UPDATING THE DATA

7 EVALUATION


1. EQUIPMENTS:

1. All equipment and instrument required for doing

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Comprehensive eye examination including hand held slit Lamp, indirect Ophthalmoscopes, etc.

2. Vehicle for transportation 3. Computers with attachments

4. Writing and printed stationary

2. PERSON (STAFF)

1. Trained ophthalmologist2. Trained Refractionist 3. Support staffs4. Data operators 5. field workers

3. TRANSPORT:

Travelling allowances to cover hospitals/clinics and other areas.

MONITORING

Monitoring will be done by looking at the following indicators:

1. Template ready in the stipulated time.2. Piloting of the template and finalizing it in stipulated time.

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3. Plan made is really comprehensive and covers all of Cuttack district initially and whole of the state of Orissa ultimately.

4. In finding the DR patients – area wise/clinic wise report to be prepared and checks put in place so that number of DR patients expected and Number found tallies.

[5.] Quality of data collected checked at random .Data should be doubly entered typed into computers by two people to minimise errors.so errors in data while collecting it and while typing it can be found.

IMPACT

Database will help in providing various forms of services. It may be curative in nature, rehabilitative or low vision services, education services or any other type of supportive services.

Database will help in research – in finding cause of blindness, change in causes of blindness over the years, risk factors of DR, and change in quality of life of the blinds/DR treated patients and not treated patients in the state.

The lesson learned from the project and methodology used in the project can be replicated and scaled up to use in other states of India and other South East Asian countries.

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BUDGET (CUTTACK DISTRICT ONLY)

ACTIVITY ITEM TO BE COSTED COST OF ITEMS(Rs)

SUBTOTAL

1 Template Making of template 25,000 25,000

2 Piloting of Template

Piloting it in the hospitals, making necessary correction and finalizing it

25,000 25,000

3 Planning Detailing every thing 25,000 25,000

4 Actual finding of DR patients and recording data

Finding the DR patients in the clinics , Diabetic units or in the community –recording/collecting their data

20,00,000 20,00,000

5 Entry of data Continuous entry of data 10,000 x 12

1,20,000 1,20,000

6 Regular updating of data

Occasional entry of data 3000 x 12

36,000 36,000

7 Monitoring & evaluation

Monitoring –continuous and evaluation of the project

25,000 25,000

TOTAL Rs 22,56,000

(AUD 45128)

FIRST YEAR: Rs 8, 00,000.00 (AUD 16000)

SECOND YEAR: Rs 8, 56,000.00 (AUD 17128)

THIRD YEAR: Rs 6, 00,000.00 (AUD12000)

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4.4 PROJECT AREA : Advocacy for tackling of DR related ocular Morbidity and blindness.

RATIONALE:

Advocacy is the act of arguing on behalf of a particular issue – so that it gets the attention it deserves. The aim of advocacy is to persuade those in power or having authority to use their authority to promote actions that are desirable and beneficial for a particular group of people- in this case Diabetics and DR patients. Advocacy will draw attention of decision makers towards DR related problems. Advocacy will raise public awareness regarding DR and its complications. Advocacy will help in gaining more funding for tackling DR in the community. Advocacy done with high quality information in a sustained and rigorous manner with well prepared advocacy materials to people who matter will definitely give rewards.


TARGET POPULATION:

All the people who matter regarding eye health

AIM:


Who are they? Provide some example.

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To advocate the need to tackle DR- related ocular morbidity and blindness.

OBJECTIVES:

1 To find material for doing advocacy –Diabetes and DR is the issue- high quality information (evidence) is must for doing effective advocacy.

2 To find who to advocate- target audience-stakeholders, decision makers – they may be in Government, non government organization, Social sector-they may be doctors, donors or others - all should be taken on board.

3 To develop advocacy material - Once high quality information is available –it can be used to develop appropriate messages or arguments to support the aims of advocacy. Finalize advocacy material - catch lines, letters, presentations etc.

4 To finalize channels of communication – how will the decision makers be approached. Plan meetings, seminars, individual appointments with people who matter.

5 To do advocacy and monitor its progress and successes.

ACTIVITIES

Objective 1

To find material for doing advocacy –Diabetes and DR is the issue- high quality information (evidence) is must for doing effective advocacy.

87

ACTIVITY OUTPUT

Activity

1 a

Find in literature evidence based information regarding Diabetes and DR which can be material for advocacy. In the past advocacy has been done without the help of high quality information and has failed on most occasions.

High quality evidence based/research based information is ready

Objective 2

To find who to advocate- target audience-stakeholders, decision makers – they may be in Government, non government organization, Social sector-they may be doctors, donors or others - all should be taken on board.

ACTIVITY OUTPUT

Activity

2 a

A list of people to whom advocacy will be done is prepared.

Exact list of whom to target during advocacy is ready.

Activity

2 b

Direct talk with key decision makers in government ,NGOs, Institutes and hospitals

Activity

2 c

Personal contacts (formal and informal) with people who matter in the society.

Activity

2 d

Politicians, mayors, municipality members, Panchayat leaders.

Activity

2 e

Build alliances with other NGOs, corporate houses etc.

Objective

3

To develop advocacy material - Once high quality information is available, –it can be used to develop appropriate messages or arguments to support the aims of advocacy. Finalize advocacy material - catch lines, letters, presentations etc.

ACTIVITY OUTPUT

Activity

3 a

Prepare your advocacy material- depending on local situation prepare slogans, catch lines. Get ready with arguments points, letter drafts etc. Advocacy material should highlight the problems and suggest solutions. Presentations, slide shows all should be prepared. Examples – Medical colleges will have directive that all diabetics must be referred for eye examination, changes in the curriculum so that graduates coming out of medical colleges must know to diagnose DR and refer.

Advocacy Material Is Ready.


????

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Objective

4

To finalize channels of communication – how will the decision makers be approached. Plan meetings, seminars, individual appointments with people who matter,

ACTIVITY OUTPUT

Activity

4 a

All channels of communication to be planned. A sustained and rigorous advocacy must be planned.

Detailed plan of “how, who, when and what” is ready.

Activity

4 b

Organize meets – two major meets – one after 6 months of the project and one after 2 years of project. Invite government officials , NGOs, ophthalmologists, institute directors, media, press and others

Two workshops are planned.

Activity

4 c

Organize one to one meeting/writing of letters/media talks

Channels of communication planned.

Objective

To do advocacy and monitor its progress and successes.

89

5

ACTIVITY OUTPUT

Activity

5 a

Do proper advocacy- do your homework- what to say and to whom. In meets say your matter but let decision makers opine on the situation. Take feedbacks after meets

Good advocacy is done and some tangible output is looked for.

Activity

5 b

Write letters – make sure they are well drafted, well printed and well read. May be sending a questionnaire on what they feel about Diabetes and DR in the state.

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TIME LINE

ACTIVITIES

MONTHS

1

-

2

3

-

4

5

-

6

7

-

8

9

-

10

11

-

12

13

-

14

15

-

16

17

-

18

19

-

20

21

-

22

23

-

24

25

-

26

27

-

28

29

-

30

31

-

32

33

-

34

35

-

36

1 Find material

2 Find stakeholders

3 Develop advocacy materials

4 Finalize channels of communication

5 Detailed plan

6 Advocacy proper

7 Evaluation


1. EQUIPMENTS:

1. Vehicle for transportation 2. Computers with attachments

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3. Writing and printed stationary

2. PERSON (STAFF) Trained Ophthalmologist

Trained Programme officers

3. TRANSPORT:

Travelling allowances

MONITORING

Monitoring will be done by looking at the following indicators:

1. Quality of advocacy materials.2. Complete list of people to be approached and how they

will be approached.3. List of meets organized with target audience- with

feedback forms of how did it go.

4. Details of letters written, appointments, one to one meetings.

5. Details of how advocacy was done in sustained manner.6. What has changed over a period of time - to be assessed

every three monthsMonitoring will be done every three months of the progress made and a report prepared and shared by the funders’ .At

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the end of the project an evaluation will be done involving outside agency of the objectives met and lessons learnt.

IMPACT

There will be improved more awareness about Diabetes and DR among general public. Diabetics and GP’s treating Diabetes will also become more aware about DR and complications thereof. Hopefully more support will come from NGO’s, government and other funders. Advocacy for tackling DR will change policies and practices of institutions, Medical colleges working in the field of Diabetes and DR .It will also change attitudes and behaviours of those individuals whose actions affect the tackling of DR.

BUDGET

ACTIVITY ITEM TO BE COSTED COST OF ITEMS

SUBTOTAL

93

(Rs)

1 Find material Evidence based findings 20,000 20,000

Finalize stakeholders

Target audiences 10,000 10,000

3 Prepare advocacy material

Catch lines, slogans, letters, presentations

50,000 50,000

4 Finalize channels of communication

Letters, meets ,seminars 10,000 10,000

5 Plan how to go about it

Details, whom to talk, what to talk, when with what material.

10,000 10,000

6 Advocacy proper

Meetings, one to one meets, letters etc.

3,00,000 3,00,000

TOTAL Rs 4,00,000

(AUD 8000)

FIRST YEAR: Rs 1, 00,000.00 (AUD 2000)


THIRD YEAR: Rs 1, 50,000.00 (AUD 3000)

4.5[5.5] PROJECT AREA

RESEARCH ON DR – THE DISEASE & THE SERVICE DELIVERY

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RATIONALE

Research in Diabetic Retinopathy can be broadly classified into two major categories:

- Clinical- Ophthalmic services research - which integrates in

ophthalmology – epidemiology, economics and operation research methods.

Ophthalmic services research attempts to use both clinical and non clinical methods to ensure that delivery of eye care services (medical /surgical) in a given region maximised to fullest extent.

Research priorities will vary depending on the status of DR in any given population and they will also change over time as avoidable conditions are managed and controlled and new problems emerge or assume greater importance. However existing conditions can be better understood by research and research alone. Disease prevalence, incidence, causation, risk factors, treatment, barriers to treatment, service delivery problems all can understood by in depth research.

Resource crunch is always there in health sector and for eye still more. In depth research will help in proper resource utilization also.

There are problems with service delivery also which can only be known and corrected through research initiatives only. So be it epidemiological concerns, economic initiatives or operational activities – the way to solution is research.

95

DURATION OF PROJECT : 4 YEARS

TARGET POPULATION: Orissa population of 42 million –especially diabetics and DR patients

AIM :

Research in the field of eye and eye related diseases are rarely done in Orissa. Research will give us better understanding of the existing situation in regards to eye disease in Orissa –their prevalence, their incidence, what are causing it, beliefs about the disease, services available to tackle it , why people are not availing existing services, how existing services can be made better etc. A well conducted research can provide invaluable insight into eye care related health behaviours and the use of services. All the study designs like quantitative research, qualitative research and others put together can improve our understanding of how eye care is managed in the context of everyday life.

OBJECTIVES:

1 A Study can be planned on looking at the potential risk factors for progression of DR /DME: A. Blood pressure

B. Lipids C Hgb A1c D BMI

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E Renal function F Physical activity

2 A study can be planned looking at different methods of interventions to maintain diagnosed patients in long-term treatment for DR.Interventions could be : Peer-peer counselling Community group/Diabetes Club Intensive case management by nurses

3 An Evaluation study on different approaches to the detection of and treatment of DR using standardized outcomes and indicators:a. Outreach camps with referral of sight-threatening DRb. Outreach camps with in-site treatmentc. Telemedicine with real-time grading of imagesd. Initial examination by physicians/ophthalmologist with confirmation in mobile van

4 A study on routine use of dilated examination of the fundus by rural doctors and referrals thereof.

5 A study can be planned to look into the challenges and barriers to uptake of services especially in relation to DR

ACTIVITIES

Objective

1

A Study can be planned on looking at the potential risk factors for progression of DR /DME:

97

A. Blood pressure B. Lipids

C Hgb A1c D BMI E Renal function F Physical activity ACTIVITY OUTPUT

Activity

1 a

A proposal is drafted. An extensive literature review is done since lot of work has been done in this area already – local conditions are incorporated in the proposal – hospitals and institutions are identified – can be part of a larger clinical study.

Proposal is ready

Activity

1 b

Funds are sought Fund is ready

Activity

1 c

Study is done Study is completed

Activity

1 d

Results are compiled/analysed & report prepared

Report is ready

Activity

1 e

Report is discussed with funders and published

Publication of reports in peer reviewed

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journals

Objective 2

A study can be planned looking at different methods of interventions to maintain diagnosed patients in long-term treatment for DR. Interventions could be :

Peer-peer counselling Community group/Diabetes Club Intensive case management by nurses

ACTIVITY

OUTPUT

Activity

2 a

A Study is planned to look into follow up aspects of DR and best it can be made efficient. The Outcome would be what proportion of scheduled follow up visits occurs in each group

Proposal is ready

Activity

2 b

Fund is sought / collaboration with a centre established

Fund is ready

Activity

2 c

Study is done – timeline is followed Study is done

Activity

2 d

Report is prepared and published Publication in journals

99

Objective 3

An Evaluation study on different approaches to the detection of and treatment of DR using standardized outcomes and indicators:a. Outreach camps with referral of sight-threatening DRb. Outreach camps with in-site treatmentc. Telemedicine with real-time grading of imagesd. Initial examination by physicians/ophthalmologist with confirmation in mobile van

100

ACTIVITY OUTPUT

Activity

3 a

A study can be planned to look into different methods of detection of DR patients and subsequent delivery of services

Proposal is ready

Activity

3 b

Collaboration and funding is sought

Funds are made available

Activity

3 c

Study is done – timeline is followed

Study is done

Activity

3 d

Report is prepared and published

Publication in journals

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Objective 4

A study on routine use of dilated examination of the fundus by rural doctors and referrals thereof.

ACTIVITY OUTPUT

Activity

4 a

A proposal is prepared to find out how GP’s treating Diabetics especially in the rural areas can be made to refer all diabetics for routine eye examination.

Proposal is ready

Activity Funding is sought Fund is

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4 b ready

Activity

4 c


Activity

4 d


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Objective 5

A study can be planned to look into the challenges and barriers to uptake of services especially in relation to DR

ACTIVITY OUTPUT

Activity

5 a

A proposal is prepared to find out main causes of people not taking up DR services - both in rural and urban areas Orissa – which will give an insight into barriers. CERA collaboration is sought

Proposal is ready with CERA as consultants

Activity

5 b

Funding is sought Fund is ready

Activity

5 c


Activity

5 d


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TIMELINE

ACTIVITIES MONTHS

1

-

3

4

-

6

7

-

9

1

0-

1

2

13

-

15

16

-

18

19

-

21

22

-

24

25

-

27

28

-

30

31

-

33

34

-

36

37

-

39

40

-

42

43

-

45

46

-

48

1 Risk factors

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2 Follow up study

3 Different approaches for detection of DR patients

4 Referrals from GP’s

5 Barriers

7 Evaluation


1. EQUIPMENTS:

Equipments needs require will depend on the ongoing study but a computer with attachments and all the eye examination equipments and instruments will be required in all studies. Then there may be specific requirements for specific studies. Hand held slit lamps, indirect ophthalmoscopes etc

2. PERSON (STAFF)

Person required will vary according to study – Refractionist, ophthalmologists, field workers, data operators, statistician, and others.

106

Epidemiologists, public health specialists may be required and would be support from institutions doing research regularly like CERA.

3. TRANSPORT:

Vehicle is a must for doing field work.

MONITORING

1. Proposals should be ready within a time frame of 3 months.

2. Funds should be sought within a fixed period of time – maximum within 3-4 months of application for funds.

3. Study should start within the time set and timeline maintained for each activity.

4. Result tabulation and analysis and writing of report should not take more than 3 months.

5. Publication of reports and paper within one year of reporting.

IMPACT

Research is essential to guide improvements in health systems and develop new initiatives. Situation analysis arising out of research will be Orissa specific and implementation of programmes more evidence based

BUDGET

ACTIVITY ITEM TO BE COSTED COST OF ITEMS(Rs)

SUBTOTAL(Rs)

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1 Risk factors 6,00,000 6,00,000 6,00,000

2 Follow up study 1,00,000 1,00,000 1,00,000

3 Different approaches for detection of DR patients

10,00,000 10,00,000 10,00,000

4 Referrals from GP’s

3,00,000 3,00,000 3,00,000

5 Barriers 6,00,000 6,00,000 6,00,000

6 Evaluation 2,00,000 2,00,000 2,00,000

TOTAL Rs 28,00,000

(AUD 56,000)

FIRST YEAR: Rs 7, 00,000.00 (AUD 14000)


THIRD YEAR: Rs 8, 00,000.00 (AUD 16000)

5 OUTPUT OF THE PROGRAMME AFTER 5 YEARS.

Awareness programmes

1. For general public – 120

2. For Diabetics – 120

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3. For GP’s – 12

4. For Ophthalmologists –12

5. For paramedicals – 12

Screening camps - 40

Telescreening camps -36

A database of all DR patients in the programme area

Advocacy activities – 10

Research work and publications – 2/5

6. LONG TERM IMPLICATIONS OF THE PROJECT

1. Awareness regarding DR will rise among general public, Diabetics, Paramedicals, Diabetes treating physicians and ophthalmologists – hence prevention and early management of the disease will become order of the day.

2. DR related morbidity and blindness will decrease as patients will be aware and will come forward for timely treatment. Service delivery will be more accessible, affordable and of high quality as more centres for

109

treatment will be developed, cost effective models for service delivery will be developed and more people will be trained to take care of DR patients.

3. A ready database of all DR patients will not only facilitate patient management but also help looking into temporal trends of the disease and doing more research on DR related areas both in areas of clinical domain and in non clinical aspects like public health and service delivery aspects. So future plans to tackle DR in Orissa and surrounding areas will be formulated from the research done in that area and thus more target area oriented project will come up.

4. More funding will be there for DR related projects – again both in service delivery and in doing research – also because of sustained evidence based Advocacy. The stake holders and policy makers will realise importance of DR and DR related blindness.

5. As more and more people will come forward for DR follow ups –other retinal disease diagnosis will increase leading to finding treatment of other blindness causing posterior segment diseases. A more comprehensive care for posterior segment disease services would be possible at all levels – primary, secondary and tertiary with well integrated with overall delivery of eye care services.

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All the above will lead to a programme which fits target of VISION 2020: THE RIGHT TO SIGHT. A programme which when implemented will have positive impacts as desired in MDGs, a programme which will be sustainable, accessible to all and will have long lasting impact.

7. Conclusions:

DR is increasing worldwide and with India being billed as Diabetic capital of the world – the problem of DR in India will be large and difficult to tackle as it happened with cataract problem in India. We need not delay the programme and let millions to suffer as it happened with cataract programme .This is the time – to plan both at macro level and micro levels, and start implementing it. Cataract programme had advantages of being relatively simple both in terms of service delivery and training personnel – DR programme will have no such advantage and further it will require lifelong monitoring. So not only a cost effective model is required but also a sustainable programme has to be developed. And as in other service delivery programme it has to be well integrated into other eye care services and made comprehensive in nature and also tied in with other branch of medicine. Then there is a factor of some sort of service delivery at all levels –may be it primary, secondary or tertiary.

The needs of Orissa in regards to tackling of DR related morbidity and blindness are identified – anecdotally and by drawing information from work done in states adjoining to

111

Orissa. Various models of service delivery were explored with experts of CERA, literature review done and then strategies were developed in consultation with CERA faculty. A detail plan was made in the form of 5 modules for tackling of DR related ocular morbidity and blindness in the state.

Documents

€¦ · Web viewTo create awareness about diabetes and diabetic retinopathy in the population of Orissa. To train general ophthalmologists and general physicians in diagnostic