The UK-Philippines Remote Retinal Evaluation Collaboration in Health: Diabetic Retinopathy (REACH-DR)

One of the major complications of diabetes is vision loss due to a disease known as diabetic retinopathy (DR) that includes diabetic maculopathy affecting predominantly the centre part of the back of the eye, the place of high acuity vision. One of the greatest success stories in diabetes eye care is the United Kingdom's National Diabetic Retinopathy Screening Programme (UK-DRSP). In 2014, for the first time in 5 decades, DR was no longer the leading cause of legal blindness in the working-age population in England and Wales, likely due to the early detection of DR by screening, along with improved control of blood sugar levels. Later, similar results have been found in other populations. Therefore, the prevalence of diabetes-related blindness and visual impairment is lowest where continuous retinal evaluations for all persons with diabetes exist. Outside the UK, only 18-60% persons with diabetes undergo annual DR examinations, usually by dilated retinal examination by eye-care professionals. However, in the Philippines, in-person retinal evaluation is not always possible, due to lack of trained personnel and suitable equipment. Telemedicine uses telecommunication and information technology to provide clinical health care from a distance and provides an alternative to in-person examination. In the UK, over 2 million persons with diabetes mellitus are screened using telemedicine annually.

The Philippine telecommunication and health-care infrastructure is being developed to sustain centralized telemedicine programmes. The Philippine government showed significant interest and support for the development of such programmes by passing the National Telehealth Service Act of 2009. In 2012-2013, a hospital-based retinal imaging reading center and a limited scale DR specific tele-ophthalmology programme was established in collaboration with the Joslin Diabetes Center. However, deployment of a population based DRSP, for which the well-established UK-DRSP is the ideal partner, especially at remote locations is still lacking. Current conditions in the Philippine health-care setting are optimal for the development of such a programme and this application aims to fully develop this.

The objectives of this proposal will be to first establish a DRSP in the Philippines within a well characterized but underserved target population. This objective will be pursued in three phases: i) In the initial phase we will develop the necessary infrastructure jointly by the UK and the Philippine teams. The UK and Philippine principal investigators will perform analysis and validation of existing telemedicine technology with independent expert review from the Joslin Diabetes Center. ii) The second phase will involve adapting selected technologies into the Philippine setting, with the first DR screening being performed under the direct guidance and supervision of the UK team. iii) In the last phase there will be a complete technology transfer to the Philippine stakeholders. Long-term quality assurance and control (QA/QC) programmes will be based on UK-DRSP but will be carefully adapted to the Philippine environment to ensure standards and key performance indicators will be continually maintained and patients remain safe in the DRSP.
The proposed teleophthalmology programme for DRSP will help to identify eyes at high risk for losing sight, and this will have direct benefit for individuals. An additional benefit will be the promotion of awareness for the need for eye evaluations which will significantly improve the overall level of eye care and reduce the risk of DR related visual loss in PwDM. The ultimate aim of this project will be the implementation of a national programme in the Philippines with a country-wide benefit.

Systematic population based screening for diabetic retinopathy (DR) through remote retinal imaging has been shown to reduce the rate of diabetes-related visual loss. This approach has been successfully employed in the UK national DR screening programs (DRSP). However, UK-DRSP utilize costly retinal imaging devices and operates on a budget of an average £26 per screening episode. Establishing DRSP in Lower and Middle Income countries (LMICs) has to date been difficult due to limited resources coupled with cultural and geographic barriers that prevent access to care. However, there have been significant advances in mobile retinal imaging devices which are suitable for implementation in LMICs at a significantly lower cost. Information technology platforms have also substantially developed allowing rapid integration of new technology.
In this project we intend to prospectively perform a head to head multiple device validation study to evaluate the agreement on image analysis outcomes and treatment requirements and subsequently cost effectiveness of current retinal imaging devices in the context of a resource limited setting. Retinal imaging platforms will be compared to accepted standard Early Treatment Diabetic Retinopathy Study (ETDRS) 7 field photography, ultrawide imaging and macular optical coherence tomography. Results of this validation study will allow modelling of various screening strategies and selection of the most cost effective device in the Philippines and similar regions globally.
The ultimate goal of our study is to establish a DRSP within the target population and provide the framework for development and implementation of DRSP in the Philippines. We intend to rapidly translate the validation and cost-effectiveness analysis into clinical use by performing an initial screening of the target communities for DR. This will allow the benefit to be immediately realized and deployed in a real-world setting.

Ocular complications from diabetes are one of the leading causes of vision loss in working-age adults worldwide. Current evidenced based care is remarkably effective and, when delivered in a timely and appropriate manner, reduces the risk of visual loss to less than 2%. However, due to disparities in health care delivery, it is estimated that over half of the patients with diabetes do not receive appropriate eye care. The unique ability of teleophthalmology initiatives to promote cutting edge research, innovative eye care delivery and diabetes education is fundamental to future global delivery of accessible, cost-effective, and high quality eye care. As seen in the experience in the U.K., the success of a telemedicine programme for diabetic eye disease greatly reduces the incidence of visual loss.
Population-based data from the International Diabetes Federation (IDF) for 2015 report a national prevalence of diabetes in Philippines of 6.9%, affecting 3,506,500 people with diabetes aged 20-79 years. A significant increase in diabetes-related eye complications and visual loss is expected to accompany the projected increase in persons with diabetes over the next two decades. Previous reports from multiple populations showed that DR telemedicine programs can reduce diabetes-related blindness in a cost-effective manner. In this project we aim to provide the Philippines with a sustainable model for a diabetic retinopathy screening programme (DRSP). The successful completion will allow knowledge transfer from 15 years of experience of the UK-DRSP on all levels of screening (from administration to grading and treatment) to benefit the Philippines.
This project is to develop a sustainable and culturally and technically acceptable DRSP by providing training and accreditation, software development and technical know-how to the Philippine Institute that has all pre-requisites in place. The ultimate aim is to reduce blindness and visual impairment secondary to DR, in the Philippines. This will allow people to remain employed and be able to live independently, which will reduce dependence on social services and as such have the possibility of reducing poverty in the long-run. With the high level of PwDM, this programme will have far-reaching consequences in years to come as the population is to benefit from timely DR treatment. Success of this project will be measured by the establishment of a local, functioning DRSP. Impact will be ensured by timely treatment and saving sight and keeping PwDMs socially active.
The proposed teleophthalmology programme for DRSP will identify eyes at high risk for visual loss and will promote awareness on the need for eye evaluations, which will significantly improve the overall level of care and reduce the risk of vision loss in individuals with diabetes in the target population. Furthermore, experience obtained from this initiative will allow implementation of a broader programme on a national scale in the Philippines, thereby increasing the benefit several fold.
Regional diabetic retinopathy screening programmes, particularly in Southeast Asian that share similar demographic characteristics to the Philippines (Vietnam, Thailand, Indonesia, Cambodia, Laos, Myanmar), may significantly benefit from the data that will be obtained in the validation and cost-effectiveness studies.
The growth of the teleophthalmology and retinal image reading center at the Philippine Eye Research Institute will strengthen retinal and diabetes research in the Philippines by providing clinical trials level retinal image evaluations and coordination for ophthalmic clinical research that is essential in the advancement of both medical and ophthalmic fields.