SITUATION ANALYSIS FOR MANAGING DIABETIC RETINOPATHY

IN TAKEO PROVINCE, CAMBODIA

Dec 2012 Caritas Takeo Regional Eye Hospital

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ACKNOWLEDGEMENTS

The evaluation team expresses their sincere appreciation to the National Eye Health Program

team, Professor Ngy Meng, Director of NPEH; Professor Do Seiha, Vice Director and Coordinator

for NPEH; and Professor Kong Piseth, a member of NPEH, Deputy Director and Chairman of the

Department of Ophthalmology, Preah Ang Duong Hospital, Phnom Penh, Cambodia. Additionally,

Dr Hem Saret, Director Takeo Provincial Health Department; and Dr.Kheav Samros, Deputy

Director of Provincial Health Department in charge of Dunkeo Referral Hospital (General Hospital)

who also participated in the evaluation.

Special thanks is also expressed toward the Caritas Takeo Eye Hospital management team and

staff, for helping to make the necessary arrangements for appointments and visits to the Kiri Vong

Referral Hospital Vision Centre. Particular acknowledgement to Dr Neang Mao, Mr Te Serey Bonn,

Mr El Nimeth, Sr Myrna Porto, Sr Evangeline Dunton.

The evaluation team also would like to thank the team at the Kiri Vong Referral Hospital and Kiri

Vong Referral Hospital Vision Centre, and Dr Sambo (Director of the Kiri Vong Operational

District).

Funding for this program was provided by the Australia Agency for International Development

(AusAID), Avoidable Blindness Initiative to CBM Australia / Caritas Takeo Eye Hospital.

EVALUATION TEAM

Rahul Chakrabarti1, Gail M Ormsby1, Mufarriq Shah1, Manfred Mörchen2, Jill E Keeffe3

1 PhD candidate, Population Health Unit, Centre for Eye Research Australia, The University of Melbourne,

Royal Victorian Eye and Ear Hospital

2 Caritas Takeo Eye Hospital, Takeo, Cambodia; CBM

3 Head of Population Health Unit, Centre for Eye Research Australia, The University of Melbourne, Royal

Victorian Eye and Ear Hospital

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TABLE OF CONTENTS

Background ......................................................................................................................................... 5

Aim ...................................................................................................................................................... 7

Objectives ............................................................................................................................................ 7

Methods .............................................................................................................................................. 8

Results ............................................................................................................................................... 10

The Need: Current Estimates of Diabetic Retinopathy ................................................................. 10

Health Service Delivery ................................................................................................................. 11

Linkages and Networks ................................................................................................................. 13

Health Workforce and Strengthening Capacity ............................................................................ 15

Health Technologies and Infrastructure ....................................................................................... 17

Health Information Systems and Management ............................................................................ 20

Health Financing and Sustainability .............................................................................................. 20

Governance and Leadership .......................................................................................................... 21

Key Outcomes ................................................................................................................................... 22

References......................................................................................................................................... 24

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ACRONYMS

AusAID Australian Agency for International Development

ABI Avoidable Blindness Initiative

CBMA CBM Australia

CBR Community Based Rehabilitation

CDMD Cambodian Development Mission for Disability

CERA Centre for Eye Research Australia

CTEH Caritas Takeo Eye Hospital

DM Diabetes Mellitus

DR Diabetic Retinopathy

HIMS Health Information Management System

KAP Knowledge, Attitude and Practice

KVRHVC Kiri Vong Referral Hospital Vision Centre

MoH Ministry of Health

MOU Memorandum of Understanding

NGO Non-Government Organisation

NPEH National Program for Eye Health

RAAB Rapid Assessment of Avoidable Blindness

URE Uncorrected Refractive Error

VA Visual Acuity

WHO World Health Organization

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EXECUTIVE SUMMARY

Background and context

Diabetic retinopathy (DR) is a microvascular complication of diabetes. Worldwide, the global

burden of diabetes is estimated at 346 million.1 This is projected to increase to 438 million by the

year 2030 (4.4% of the estimated world population). In Cambodia, it is estimated that the

prevalence of any DR amongst people with diabetes is 30.3%.2 This is consistent with global meta-

analyses data that showed one-third of patients with diabetes will have evidence of any DR, and

one-third of those with DR will have vision threatening retinopathy (VTDR).3 Research has clearly

demonstrated that blindness from diabetes is almost entirely preventable with early diagnosis,

optimisation of risk factors, and timely photocoagulation where appropriate.4-6 Presently, 70 per

cent of diabetes occurs in lower and middle income countries, where systematic screening for

retinopathy is rare.7

The growth of diabetes and diabetic retinopathy is a concern for developing countries. According

to the World Health Organization (WHO) in 2012, the age-standardised estimate of prevalence of

diagnosed diabetes amongst adults (age 20-79) in Cambodia was 5.1%.8 King et al in 2005

estimated the prevalence of diabetes in a community-based survey of 5% in the Siem Riep

province, and 11% in the Kampong Cham province, of which two-thirds of all cases of diabetes

were undiagnosed prior to the survey.9 The WHO estimates the population with diabetes in

Cambodia will increase to 317,000 by the year 2030.10 This will therefore impact upon the burden

of vision impairment secondary to diabetes.

Presently in Cambodia there is no systematic screening for DR. However, there is interest in using

an evidence-based approach to guide future planning. This report will assess the existing

infrastructure and the potential for the Kiri Vong Referral Hospital Vision Centre and Takeo Eye

Hospital to screen, refer and manage patients with diabetes and diabetic retinopathy. At present,

the Cambodian Government has expressed interest in addressing the issue of how to approach

management of diabetic retinopathy. The NPEH committee has requested AusAID to fund the

establishment of twelve diabetes clinics in 2013. It is intended that this preliminary report will

provide insight into the current strengths and limitations of the health system to manage DR. This

work will contribute to future research for the development of an evidence-based framework to

guide the management of diabetic retinopathy as part of systemic approach to care for the

patient with diabetes.

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Summary of Findings

The situational analysis was conducted using themes adapted from the WHO Health System

‘Building Blocks’ that together constitute a complete system.

1. Health Service Delivery and Performance

2. Linkages and Networks

3. Health Workforce and Strengthening Capacity

4. Health information Systems and Management

5. Health Financing and Sustainability

6. Governance and Leadership

The situation analysis showed that the CTEH is the only facility in the Takeo Province with the

capacity to examine and provide laser treatment of patients with diabetes for DR. Preliminary

data suggests that DR accounts for 12% of all retinal pathology diagnosed at the CTEH. Eight of

thirteen patients diagnosed with DR had mild non-proliferative retinopathy.

People with diabetes access multiple sources of health care in the Takeo Province including health

centres, general hospitals, community vision screening, and private medical practitioners.

However, the CTEH is the only health care facility in the province with the capacity to perform

retinal examination. Patients with diabetes can be referred for eye examinations from the

KVRHVC, community outreach screening and the local NGO, Mo Po Tsyo to the CTEH. However,

there is no referral of patients with diabetes from general hospitals, and currently it is estimated

that only a small proportion patients are referred from KVRHVC or community outreach. Most

patients with diabetes present to the CTEH as “walk-ins”.

The health information management system for recording details of patients with diabetes can be

improved. The CTEH health information system has recently started to record pertinent clinical

information related to the eye examination for the patient with diabetes. However, the data

entered at the KVRHVC is non-specific, and there is no established procedure for recording

outcomes of patient follow-up.

The cost recovery methods of the CTEH and KVRHVC involve sales of spectacles and nominal fees

for cost-recovery. At the CTEH, approximately 30% of retinal examination fees are out-of-pocket

for the patient. The KVRHVC continues to receive technical advice as required from the CTEH.

There are no current national guidelines for diabetic retinopathy in Cambodia. There is no routine

referral system for eye examination amongst patients with diabetes.

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AIM

The aim is to perform a situation analysis of existing infrastructure at the Kiri Vong Referral

Hospital Vision Centre (KVRHVC) and the Caritas Takeo Eye Hospital (CTEH) to examine and

manage patients with diabetes mellitus for diabetic retinopathy.

OBJECTIVES

The objectives of this research were guided by the National Strategic Plan for Blindness

Prevention and Control, 2008-2015 (Cambodian Ministry for Health). The situation analysis

assessed the possible role of the KVRHVC, CTEH and linkages with district hospitals in the care of

patients with diabetes, and assessment and timely referral of people with diabetic retinopathy.

The World Health Organization framework for health systems evaluation has guided the

development of specific research themes to be used in this study. The objectives were:

1. Service Delivery and Performance in managing DR

a. Describe and quantify the spectrum of functions performed by the CTEH to manage DR

including:

I. Diagnosis, treatment, referral, follow-up, and rehabilitation.

II. Role of the CTEH and other health facilities in providing health promotion

(information, education and communication) about diabetes and DR.

2. Linkages and Networks

a. Describe linkages and referral pathways for patients with diabetes and DR between Vision

Centres and primary health centres, CDMD, outreach services, public hospitals and the

Caritas Takeo Eye Hospital.

b. Identify service-related barriers to the delivery and utilisation of linkages and referral

pathways.

c. Describe what and how information is provided to patients with diabetes regarding DR,

referral, the follow-up process, and reminders for screening.

3. Health Workforce and Strengthening Capacity

a. Define the current roles and tasks performed by the workforce.

b. Identify the capacity for training of the workforce and continuing medical education

specifically for management of DR.

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4. Health Information Systems and Management

a. Examine the content of health records, as to how diabetes and diabetic retinopathy and

recorded.

b. Describe the health information systems for patient record collection, storage, follow-up,

and to show compliance with services.

5. Health Technologies and Infrastructure

a. List the equipment at KVRHVC and CTEH to perform eye examinations for patients with

diabetes and treatment of patients with retinopathy.

6. Health Financing and Sustainability

a. For eye care services provided to the patients with diabetes, describe and quantify who

pays (patient, government, NGO, private health insurance)

7. Governance and Leadership

a. Describe the role and involvement of key stakeholders in the operation and overseeing

diabetic retinopathy management at the CTEH and the KVRHVC.

b. Describe the presence and rationale for clinical preferred practice statements or national

guidelines.

METHODS

Setting

The situation analysis assessed the existing system for eye care management at the KVRHVC and

Caritas Takeo Eye Hospital and their referral sources.

Participants

Key stakeholders consulted in the data collection phase included:

(a) Policy level personnel (NPEH, Country directors for NGOs, Ministry of Health, Director of

Takeo Operational District),

(b) Workers at the Vision Centres and hospitals (Medical director, ophthalmologists,

refractionists, ophthalmic nurse manager and educator, medical records personnel).

Time frame of the Evaluation

Data were collected over a two week period in mid December, 2012.

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Data collection

Data were acquired from two main sources.

1. Existing information available in medical records and databases at Caritas Takeo Eye

Hospital and the Kiri Vong Referral Hospital Vision Centre.

2. Semi-structured interviews and observational data from site visits and consultation with

relevant stakeholders.

Evaluation study questionnaires

The evaluation study questionnaires were developed by the Population Health Unit at the Centre

for Eye Research Australia (CERA). The questionnaires were designed to assess the specific

objectives listed. Each questionnaire included items relevant to the particular health care setting

and stakeholders (KVRHVC, CTEH, and NPEH). The 15 page questionnaire is obtainable from CERA

on request. The questionnaires were divided into the nine themes as listed in the objectives.

Informed consent was obtained from all participants in the evaluation.

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RESULTS

THE NEED: CURRENT ESTIMATES OF DIABETIC RETINOPATHY

Whilst there is a deficiency of absolute data regarding diabetes and DR in the Takeo province,

several sources of information (in addition to RAAB estimates) have provided insight into the

burden of the disease. Contemporary meta-analysis by Yau et al has showed the age-standardised

prevalence of any DR amongst people with known diabetes at 35.4%, proliferative DR (PDR) at

7.2%, diabetic macular oedema (DME) at 7.5%, and vision threatening DR (VTDR) at 11.7%. Using

the World Bank population estimate of for Cambodia (14.3 million) and the IDF estimated

prevalence (3.0%) of known diabetes we estimated the distribution of the severity of DR. (Figure

1)

FIGURE 1. NUMBER OF PATIENTS WITH DIABETES AND SEVERITY OF DIABETIC RETINOPATHY IN CAMBODIA. IT IS

IMPORTANT TO NOTE THAT THE PROPORTION WITH ANY DR INCLUDES PDR AND DME. THE PROPORTION WITH VTDR

INCLUDES DME AND PDR. POPULATION OF CAMBODIA SOURCED FROM WORLD BANK STATISTICS (2011).11

PREVALENCE STATISTICS OF DR FROM YAU ET AL (2012).3

The Caritas Takeo Eye Hospital has a retinal service through its outpatient department that

provides medical management of retinal pathology. We examined data from the CTEH as it was

the only data currently available for patients with diabetes, albeit with a small sample of patients.

Within the most recent time period of available data between January 2011 to September 2012,

102 patients with retinal pathology (n=13 with diabetic retinopathy) were assessed at the CTEH

outpatient clinic.12 (Figure 2) The median duration of diabetes amongst the sample was 4.7 years.

Amongst the patients with DR (n=13), 8 had mild non-proliferative DR (NPDR), 2 with moderate

429,155

148,488

31,071 32,101

0

50000

100000

150000

200000

250000

300000

350000

400000

450000

500000

Population with Diabetes

Any DR Proliferative DR Diabetic Macular Oedema

Estimated number of patients with diabetic retinopathy in Cambodia.

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NPDR, 1 with severe NPDR, and 2 with clinically significant macular oedema. There were no

patients with proliferative DR (PDR).

FIGURE 2. DISTRIBUTION OF RETINAL PATHOLOGY (N=102) DIAGNOSED AND RECORDED AT THE CARITAS TAKEO EYE

HOSPITAL RETINAL UNIT. DATA SOURCED FROM CTEH RECORDS (2011-2012).

HEALTH SERVICE DELIVERY

CARITAS TAKEO EYE HOSPITAL: OVERVIEW

The Caritas Takeo Eye Hospital is a major tertiary ophthalmic facility, performing multiple roles in

the provision of eye care in Cambodia. According to the 2011 NPEH annual report, 191,741

outpatient department examinations were performed in Cambodia, of those, 15% (n=28,964)

were conducted at CTEH. Additionally, of the 22,762 cataract surgeries nationally, 10.5%

(n=2,400) were performed at CTEH.13

Since 2009, the CTEH has provided the following services:

Outpatient clinics: 105,178 outpatient department consultations were performed, of

which 55% (n=57,807) were new consultations, and 45% (n=47,371) were existing patients.

Overall, 14% (n=14,375) of all outpatient department consultations were for cataract, 11%

were for refractive error, and 75% for other conditions which were not specified in the

records.

Surgery: 14,030 ophthalmic operations were performed at the CTEH, of which 61%

(n=8,580) were for cataract extraction.

62% 12%

8%

8%

6%

2% 1% 1%

Types of retinal pathology diagnosed at the CTEH retinal clinic

Retinal Detachment

Diabetic Retinopathy

Retinal Degeneration

Retinal Dystrophy

Retinal Scar

Retinal Vein Occlusion

Retinal Artery Occlusion

Retinal Hole

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Vision screening in the Takeo province: 8,828 people were screened for vision loss. 11% of

the screened population had “normal” eyes. Amongst the population with ophthalmic

pathology, 44% were diagnosed with cataract, of which 67% (n=2,198) were referred for

surgery at the CTEH.

Refractive Services and Optical workshop: Since 2009, the CTEH has performed 11,802

refractions and dispensed 6419 spectacles.

Training: In 2011, the CTEH provided training of 9 resident doctors in the national

ophthalmology training program, an additional 3 doctors in the diploma of ophthalmology

program, 18 nurses in diploma of ophthalmic nursing, and training of one paediatric nurse

and one orthoptic nurse. The diploma of ophthalmology program has since ceased.

Diploma qualified and Basic Eye Doctors are now receiving training to be upgraded to

ophthalmologists.

CARITAS TAKEO EYE HOSPITAL AND DIABETIC RETINOPATHY

Screening patients with diabetes for diabetic retinopathy has been a recent addition to the

services of the outpatient department at the CTEH. The screening examination involves

assessment of the patient’s visual acuity, measurement of intraocular pressure (IOP), and dilated

fundoscopy which is performed by ophthalmologists. Patients with suspected refractive error are

assessed by ophthalmic nurses trained in refraction; and those requiring spectacles are referred

to the optical workshop. The CTEH currently does not provide pathology services for patients

with diabetes as such services are located nearby in Provincial Regional Hospital (general

hospital). The typical examination interval for patients with varying severity of DR attending the

CTEH outpatient clinic is shown in the table below. Interestingly, for patients with nil to mild NPDR

the current practised examination interval is 12 months. However, it was shown in the small

cohort from CTEH that patients with diabetes had short duration from the diabetes diagnosis

(median 4.7 years), and had mild DR. Further longitudinal data will provide insight into the true

distribution of DR severity at CTEH. However, evidence has shown that extending the screening

interval to two years for the majority of patients with diabetes who have nil-mild NPDR is a safe

and practical approach to meet the demands of screening.14

TABLE 1. EXAMINATION INTERVAL FOR PATIENTS AT VARYING SEVERITY OF DR. SOURCED FROM CORRESPONDENCE

WITH OPHTHALMOLOGIST AT THE CTEH, 2012.

Severity of DR Examination interval

Nil-Mild Non Proliferative DR 12 months

Moderate Non Proliferative DR 6 months

Severe Non Proliferative DR 3 months

Clinically significant Macular Oedema 1 month

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The CTEH also has the capacity for non-surgical treatment of retinopathy. It is estimated that two

patients with diabetes referred to the CTEH outpatient department have been treated with retinal

laser. The CTEH does not have vitreoretinal surgical expertise or equipment. Those requiring

surgery for vitreous haemorrhage or vitreoretinal traction related issues are referred to the

National Eye Hospital in Phnom Penh; the number of patients referred was not available.

Beyond screening, the retinal unit is also involved in health promotion for patients with diabetes.

Through the CTEH vision screening program, health education is provided during the screening

days. Additionally, most patients referred for surgical assessment at the outpatient department

are routinely asked of their diabetes status, but are not usually asked whether they have had a

previous examination to the back of their eye. For all patients with diabetes, the CTEH provides

general advice on diabetes control, and education about blindness from diabetes and treatment.

Specifically, patients are educated on the complications of diabetes and the importance of regular

eye examination. At present, there are no data regarding the quality of these services provided,

and the impact of their effect on change in knowledge, attitudes and practice.

LINKAGES AND NETWORKS

The CTEH is the only facility in the province that has the capacity to perform dilated retinal

examinations for patients with diabetes. People with diabetes are referred the CTEH outpatient

department for examination and management from several sources including the Kiri Vong

Referral Hospital Vision Centre (KVRHVC), outreach vision screening clinics, general medical

hospitals, private clinics, and from Mo Po Tsyo (a local NGO involved in screening for diabetes in

the community).

Kiri Vong Referral Hospital Vision Centre

The KVRHVC has been in operation since April 2010. The primary functions of the KVRHVC are

provision of primary eye care, refraction, provision of ready-made spectacles and sunglasses, and

participation in community eye screening. The staff at the KVRHVC cannot perform dilated retinal

examinations so patients with diabetes are referred for eye examination at the CTEH.

Review of the KVRHVC records between April 2010 and November 2012 documented 7,858

consultations of which 1,774 patients were referred to the CTEH. Amongst the patients referred

from the KVRHVC to the CTEH, 47% (n=826) were for management of cataract, 44% (n=788) for

“other” conditions, 8% (n=153) refractive error, and <1% (n=7) for glaucoma. However, there

were no records to estimate the proportion of patients with diabetes seen at the KVRHVC or the

proportion of those that were referred to the CTEH.

Outreach vision screening

The community outreach vision screening programs conducted by the KVRHVC and the CTEH are

important sources of referral of patients to the CTEH outpatient department. Between January

2010 to October 2012, 8,828 patients were screened through the CTEH outreach program, of

which 3,534 people were referred for examination at the CTEH. From the proportion of patients

referred to the CTEH, 62% (n=2,198) were for cataract, and the remainder were for “other”

Page 14 of 26

conditions. As patients with diabetes were not identified specifically at screening, it was reported

that few patients with DR were referred from outreach screening for eye examination.

Vision screening is conducted by the Kiri Vong Referral Hospital Vision Centre outreach program in

the Kiri Vong District. From data obtained of referrals made from screening in the Kiri Vong

District (2010-2011, n=2,997), it was estimated that cataract accounted for 39% (n=1158),

refractive error 15% (n=439), and 46% (n=1,396) were recorded as “other” conditions. Analysis of

the sources for patient referral to the KVRHVC showed that 82% of consultations were from

“walk-in” patients. This opens the opportunity to enquire about the known diagnosis of diabetes

or previous eye examination amongst patients with diabetes during the consultation as a simple

method to facilitate early identification of people needing follow-up eye examination for diabetes

related ocular complications.

General Medical Hospital (Chronic Disease Clinic of Dunkeo Referral Hospital)

General hospitals are a potential source of referral of patients with diabetes for an eye

examination.

The Dunkeo Referral Hospital is a general hospital in close proximity to the CTEH was staffed by

three medical officers (doctors), and six nurses. Typically, patients with diabetes are asked by

attending clinicians about their diabetes type, duration since diagnosis, and current treatment

(oral medication, insulin). General hospitals have the facilities to perform and record a basic

examination (weight and blood pressure measurement), and simple pathology tests for patients

with diabetes. Patients with diabetes are provided general advice on diabetes control and

informed about the complications of diabetes (including vision threatening disease). However,

patients are not routinely asked if they have ever had an eye examination.

Data on the proportion of patients with diabetes attending general hospital and those referred to

CTEH were not available. There is no eye care provided at general hospitals, or referral protocol

for patients with diabetes attending a general hospital to have an eye examination.

Consequently, very few patients are referred to CTEH for eye examination. If required, patients

with diabetes reporting or found to have deterioration in their vision are provided a verbal

referral to attend the CTEH.

Local Non-Government Organisation – Mo Po Tsyo

The close network between CTEH and the local NGO, Mo Po Tsyo, offers an insight into how DR

can be approached in low-resource settings. The Mo Po Tsyo program performs a screening for

diabetes amongst the population at high risk across five provinces of Cambodia. In their referral

pathway, a research assistant visits households and those with evidence of an abnormal urinalysis

(urine dipstick test for glucose, protein) are requested to have further blood tests and are advised

to visit a referral hospital in their district on a particular date. That particular hospital is visited by

a diabetologist (who is employed by Mo Po Tsyo) who performs the examination and investigation

of these patients. Whilst this method may only capture the proportion of patients with diabetes

with renal impairment, through interview with Mo Po Tsyo staff it was explained that this is a

relatively inexpensive tool in a setting where glucometers (and their random blood sugar sampling

Page 15 of 26

strips) are not readily affordable. After consultation with the endocrinologist, patients with high

risk factors (duration since diagnosis of diabetes, hypertension, poor glycaemic control) are

referred for a retinal examination at CTEH and the Kien Khleang National Rehabilitation Centre

Ophthalmology Service (Phnom Penh). The Kien Khleang ophthalmology service has the capacity

to measure visual acuity, slit-lamp examination and retinal photography. Findings are recorded in

a computerised health information system, and reported back to Mo Po Tsyo. (Appendix) The

strength of collaboration between the Mo Po Tsyo clinic and the CTEH is evidenced by the

increased numbers of referrals of patients with diabetes to the retina clinic from 44 patients in

2011, to 136 patients in 2012.

HEALTH WORKFORCE AND STRENGTHENING CAPACITY

CARITAS TAKEO EYE HOSPITAL

The CTEH has 3 ophthalmologists, 2 refractionists, 4 ophthalmic nurses (2 who are trained to

perform refraction, and 2 who are also trained in low-vision and orthoptics), 2 nurse assistants,

and 4 administrative staff. (Table 2)

TABLE 2. HUMAN RESOURCES AT THE CARITAS TAKEO EYE HOSPITAL, AND THEIR CURRENT TASKS PERFORMED, AND

ADDITIONAL TASKS THAT COULD BE REALISTICALLY PERFORMED.

Cadre Number Current Tasks performed relating to the assessment and management of diabetic retinopathy

Additional tasks that could be performed with additional training and resources

Ophthalmic Nurse

5

History taking

Examine visual acuity

2 trained in performing refraction

2 trained in low-vision and orthoptics

Measure intraocular pressure

Administer mydriatic drops

Conduct patient counseling

Provide medicine according to the prescription of doctor

Instruct patients on how to use medication.

Fundus photography

Ophthalmologist 3 History taking

Dilated fundus examination

Diagnosis

Treatment (Laser)

Grading retinal photographs

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Intra-vitreal triamcinolone (corticosteroid for severe CSME)

Nurse assistants 2 Examine visual acuity

Complete health information records and forms

Fundus photography

Administrative staff

4 Patient registration

Record keeping

Retrieve patient records

Enter patient data into the hospital health information system

Facilitate patient after examination for other services

Optical technician

2 Make spectacle

Provide advice to the patient on how to use or to care for their spectacle or sunglass.

Refer patient to refraction department for re-check with their spectacle.

Screening for DR at the CTEH involves a vision technician, ophthalmologist, and an ophthalmic

nurse. Patients referred to the outpatient clinic have visual acuity measured by a vision

technician. The patient is then referred to the ophthalmologist. The ophthalmologist, after

performing a primary examination then refers the patient directly for pupil dilatation. Once

dilated, the patients are examined using dilated fundoscopy by the ophthalmologist. The

ophthalmologist recommends further management (treatment with retinal laser or further

observation). Patients who require refraction are provided another appointment specifically for

refraction assessment at the CTEH.

The CTEH is an important centre for clinical education of its staff. Whilst continuing medical

education and training is provided to all staff at the CTEH, there is limited training specific to DR

provided on-site. Currently, an ophthalmic nurse has received training to perform fundus

photography at the Aravind Eye Hospital in Madurai, India. Additionally, in early 2013, a senior

local ophthalmologist is scheduled to attend a two month training course in laser treatment

methods for DR. Training for junior medical and nursing staff is provided at regular intervals, but

also through informal updates and once-off workshops. Amongst other components, the retinal

curriculum emphasises enabling doctors to distinguish between a normal fundus from that with

DR.

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KIRI VONG REFERRAL HOSPITAL AND VISION CENTRE

The Kiri Vong Referral Hospital Vision Centre is staffed by two ophthalmic nurses, who are

employees of the Kiri Vong Referral Hospital. The nurses are both ophthalmic trained, and one has

additional training in refraction. (Table 3) Ophthalmic training for both nurses was provided as a

one year course at the Caritas Takeo Eye Hospital. For refraction, a 3 month training program was

facilitated at the national level Eye Hospital in Phnom Penh coordinated through the Brien Holden

Vision Institute.

TABLE 3. HUMAN RESOURCES AT THE KIRI VONG REFERRAL HOSPITAL VISION CENTRE, THEIR CURRENT TASKS

PERFORMED, AND ADDITIONAL TASKS THAT COULD BE REALISTICALLY PERFORMED.

Cadre Number Current Tasks performed relating to the assessment and management of diabetic retinopathy

Additional tasks that could be performed with additional training and resources

Ophthalmic Nurse

2

History taking

Examine visual acuity

1 trained in performing refraction

Measure intraocular pressure

Primary eye care tasks (eye swabbing, removal of corneal foreign bodies, removal of sutures)

Diagnosis and referral to CTEH for surgical and emergent conditions (penetrating trauma, corneal ulcer, sudden loss of vision, cataract, posterior segment disease, suspected uveitis, trichiasis)

Administrative – register and record all patient details, retrieve data for patient follow-up

Fundus photography

Low vision assessment

HEALTH TECHNOLOGIES AND INFRASTRUCTURE

Overall, the CTEH has the basic infrastructure for retinal screening and non-surgical management

of diabetic retinopathy. The current equipment available for dilated retinal examination includes a

direct ophthalmoscope, slit-lamp with indirect lens, and binocular indirect ophthalmoscope. The

CTEH has recently placed order for its first retinal camera (mydriatic camera, Carl Zeiss Inc.) which

is estimated to be functioning in early 2013. The CTEH has capacity to perform retinal laser. (Table

4)

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TABLE 4. LIST OF EQUIPMENT AVAILABLE AND FUNCTIONAL AT THE CTEH THAT ARE RELEVANT TO THE ASSESSMENT

AND MANAGEMENT OF DIABETIC RETINOPATHY.

Item Available and Functional

Direct ophthalmoscope

Slit lamp with indirect lens

Binocular indirect ophthalmoscope

Non-mydriatic retinal camera

Mydriatic retinal camera

*Estimated to arrive in early 2013

Argon Laser

Yag Laser

Fundus fluorescein angiography

*Estimated to arrive in 2013

Ultrasonography (A scan)

Ultrasonography (B Scan)

Vitrectomy console

Vitreoretinal surgical equipment

Surgical operating microscope

Optical coherence tomography (OCT)

Telemedicine equipment

Telemedicine infrastructure (internet)

Generator

Surgical standard clean running water

Autoclave (steam steriliser)

Steriliser (other)

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The KVRHVC have a good inventory of ‘Essential’, and ‘desirable’ equipment (based on the Vision

2020 suggestions for Vision Centres).15 The equipment that is pertinent to the identification of

those requiring referral for formal diagnosis of DR is highlighted in the table. (Table 5)

TABLE 5. TABLE OF OPHTHALMIC EQUIPMENT FOR KIRI VONG REFERRAL HOSPITAL VISION CENTRES. DATA SOURCED

FROM THE KIRI VONG REFERRAL HOSPITAL VISION CENTRE. GROUP STRATIFICATION DERIVED FROM VISION 2020

MANUAL (2011)15

Essential equipment

Available and functional

Desirable Equipment

Available and functional

Ideal equipment Available and functional

Flash light Tonometer Lea symbols

Distance Vision charts

Slit lamp with applanation tonometer

Low vision testing kit

Near vision charts Auto refractor Glucometer

Trial set Colour vision chart

Standardised medical records software

Trial frames Blood pressure instrument

Non-mydriatic retinal camera

Paediatric trial frames

Thermometer

Slit lamp Telephone/ Mobile phone

Streak retinoscope

Computer

Direct ophthalmoscope

Hand washing solutions

Generator

Lensometer

Occluder

Near vision light

Big mirror

Optical rule

Cross cylinder

Medical Record books

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HEALTH INFORMATION SYSTEMS AND MANAGEMENT

Health records of patients attending the CTEH are hand-written and then entered into a computer

database. The basic parameters that are routinely documented in the clinical notes for a patient

with diabetes are demographics (age, gender, address), type of diabetes, presence of

hypertension and hyperlipidaemia, presence and severity of retinopathy, current treatment

regimen for diabetes, previous treatment of DR (laser, vitreoretinal surgery), and the

management plan. For patients referred to the CTEH from Mo Po Tsyo, clinical parameters

including duration of diabetes, presence and severity of DR, additional health co-morbidities and

follow-up schedule are entered as a separate entity in the computer database. For ongoing follow

up patients are provided with a card which states the date of their next appointment.

The KVRHVC uses a similar combination to the CTEH of hand-written and computerised database

methods for recording patient details. For all patients, standard recorded information includes:

demographics (name, address, age, gender, socio-economic status, presence of self-reported

disability), relevant brief general medical history, relevant family history, probable diagnosis,

visual acuity, and a management plan. However, when clinical notes are entered into the

database, there is omission of ophthalmic-relevant patient co-morbidities (such as diabetes). The

referral system from KVRHVC to CTEH typically involves a referral note or letter. However, the

KVRHVC does not receive notification if the patient has attended their appointment unless they

are referred back from CTEH for follow-up. The KVRHVC does not have a system to enable

accurate recording from periodic assessments of the same patient. In this context, it is

foreseeable that the introduction of the non-mydriatic camera will be beneficial for diagnostic

accuracy, teaching, and to facilitate monitoring the quality of services and follow-up for patients

with diabetes.

HEALTH FINANCING AND SUSTAINABILITY

There were limited data regarding out-of-pocket expenditure for patients with diabetes attending

outpatient department at the CTEH for management of DR. The cost recovery strategy at the

CTEH has set the platform for its expansion of services. The hospital estimates that approximately

30% of costs for retinal examinations are paid for by patients and 70% from NGO funding.

According to the CTEH Annual Report in 2011, the hospital has three private rooms designated for

full-fee paying patients. The optical workshop based at the CTEH estimates 49% of spectacles

dispensed are paid the full price (ranging from US$2 to $6).16 Furthermore, according to the

memorandum of understanding between Mo Po Tsyo and CTEH, patients referred from Mo Po

Tsyo to CTEH are required to pay a registration fee of 4,000 Riel (US$1), which includes the fee for

the first consultation. The fee for follow-up consultations is 2,000 Riel (US$0.5). For patients

referred from Mo Po Tsyo, transport costs are incurred by the CTEH, and any laser treatment for

DR is provided free of charge.

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In the case at the KVRHVC, records specific to the out-of-pocket expenditure for patients with

diabetes were not available. Previously, the KVRHVC had an ‘Equity fund’ for patients from lower

socioeconomic backgrounds with limited resources to obtain their spectacles. This funding now

comes from the Government. The KVRHVC also accepts a nominal user fee from patients who can

afford a certain percentage but not the full cost of their care. The KVRHVC has generated cost

recovery from the sale of glasses. This has made a positive contribution to the income of the Kiri

Vong Referral Hospital. It currently supports the cost of salaries and provides a sustainable supply

of glasses. Within the region is it stated that approximately 30% of the population is below the

poverty line. There are some patients who cannot afford the total cost of eye care and glasses.

Some patients have been subsidised by the hospital.

GOVERNANCE AND LEADERSHIP

The CTEH and the KVRHVC are the only providers of public eye care services in the Takeo

Province. The sustained performance of the CTEH and the KVRHVC can largely be attributed to the

strength of governance and stakeholder (Government and Non-Government Organisation)

contributions. Both these facilities have established themselves as trusted points of eye care

within the public health system. In addition to community outreach screening, the CTEH and

KVRHVC have engaged with local stakeholders (general hospitals, CDMD, health centres) to

conduct eye health promotion as an important component of the holistic approach to healthcare,

and to facilitate early referral of people with vision impairment.

In the context of DR, progression to blindness can almost always be prevented through early

detection of diabetes and timely referral for eye examination. Opportunistic referral of patients

with diabetes for eye examination occurs from KVRHVC and Mo Po Tsyo to the CTEH. However, at

present, the presence and use of clinical practice guidelines for screening and treatment of DR do

not exist in Cambodia. There is no process of routine referral of patients with diabetes who

attend other medical facilities.

Emphasis must also be placed upon data collection and reporting of diabetes and its

complications. This may be enhanced by the presence of guidelines for health management

information systems across all levels of health care. Accurate collection and reporting of data

pertaining to diabetes and DR will also enable essential key performance indicators to be

monitored for future planning of service delivery.17 (Table 6)

TABLE 6 KEY PERFORMANCE INDICATORS AT A NATIONAL LEVEL RELEVANT TO DIABETIC RETINOPATHY. SOURCED

FROM THE GLOBAL INDICATORS TO MONITOR ELIMINATION OF AVOIDABLE BLINDNESS REPORT, 2012.18

Prevalence of blindness and vision impairment due to diabetic retinopathy

Coverage of screening services: Percentage of patients with diabetes that undergo eye examination

Coverage of treatment services: Percentage of patients with diabetes that are treated with retinal laser

Page 22 of 26

KEY OUTCOMES

Health Services

The CTEH is the only facility in the Takeo Province with the capacity to examine and provide laser

treatment of patients with diabetes for diabetic retinopathy. People with diabetes access multiple

sources of health care including health centres, general hospitals, community vision screening,

and private medical practitioners. However, currently there is a paucity of information on the

quality of services provided for patients with diabetes due to health information management

systems.

Health Workforce and Training

Currently there is no capacity for posterior segment examination at the secondary (district

hospital) level. This could possibly be achieved with non-mydriatic retinal imaging and training

vision centre workers to use the technology.

Health Management Information Systems

Currently there is no accurate record of the number of people with diabetes who are presenting

to health care facilities or the proportion who are being referred for eye examination at the CTEH.

The CTEH health information system does record pertinent clinical information related to the eye

examination for the patient with diabetes. However, the data entered at the KVRHVC is non-

specific, thus not providing specific information on all important causes of vision impairment that

is required to estimate the need, monitor key performance indicators, and plan service

development. Additionally, there is no established procedure for recording of follow-up

management of patients.

Referral Pathways

Patients with diabetes can be referred for eye examinations from the KVRHVC, community

outreach screening and the local NGO, Mo Po Tsyo to the CTEH. However, there is no referral of

patients with diabetes from general hospitals, and currently it is estimated that only a small

proportion patients are referred from KVRHVC or community outreach. Most patients with

diabetes present to the CTEH as “walk-ins”. Although it is at early stages, the collaboration

between CTEH and Mo Po Tsyo has demonstrated that such a partnership can be a successful

approach to conduct a DR screening program in Cambodia.

The large proportion of “walk-in” patients attending the KVRHVC and community outreach

presents the opportunity at these sites of primary care to increase community awareness of

diabetes, identify patients at risk of DR, and facilitate early referral for eye examination.

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Sustainability

The sustainability of the CTEH and KVRHVC has been demonstrated through their successful

integration into the public health care system. Both facilities have used sales of spectacles and

nominal fees for cost-recovery. At the CTEH, approximately 30% of retinal examination fees are

out-of-pocket for the patient. The KVRHVC continues to receive technical advice as required from

the CTEH.

Governance

There are no current national guidelines for diabetic retinopathy in Cambodia. There is no routine

referral system for eye examination amongst patients with diabetes.

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APPENDIX

APPENDIX A: RECORD OF AN EYE EXAMINATION OF A PATIENT WITH DIABETES REFERRED

FROM MO PO TSYO TO THE KIEN KHLEAN NATIONAL REHABILITATION CENTRE

OPHTHALMOLOGY SERVICE. SOURCED FROM MO PO TSYO (NOVEMBER, 2012)

Page 25 of 26

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3. Yau JW, Rogers SL, Kawasaki R, et al. Global Prevalence and Major Risk Factors of Diabetic Retinopathy. Diabetes Care. Mar 2012;35(3):556-564.

4. Photocoagulation treatment of proliferative diabetic retinopathy. Clinical application of Diabetic Retinopathy Study (DRS) findings, DRS Report Number 8. The Diabetic Retinopathy Study Research Group. Ophthalmology. Jul 1981;88(7):583-600.

5. Early photocoagulation for diabetic retinopathy. ETDRS report number 9. Early Treatment Diabetic Retinopathy Study Research Group. Ophthalmology. May 1991;98(5 Suppl):766-785.

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8. Global Health Observatory Data Repository: Blood glucose. In: WHO, ed. Geneva2012.

9. King H, Keuky L, Seng S, Khun T, Roglic G, Pinget M. Diabetes and associated disorders in Cambodia: two epidemiological surveys. Lancet. Nov 5 2005;366(9497):1633-1639.

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12. Morchen M, Ang C, Mao N, Van Pelt M. Outcome of screening for diabetic retinopathy in collaboration with community based peer educators in Takeo province, Cambodia. Asia Pacific Ophthalmology Association (APAO), 2012. Busan, Korea.2012.

13. NPEH. Annual report of the National Committee for Prevention of Blindness, Cambodia. Phnom Penh2011.

14. Chakrabarti R, Harper C, Keeffe J. Diabetic retinopathy management guidelines. Expert Review of Ophthalmology. 2012;7(5):417-439.

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17. WHO. Global initiative for the elimination of avoidable blindness. Action Plan 2006-2011. Geneva: WHO;2007.

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