Should persistent DNA be treated as illness

1
Should persistent DNA be treated as illness?

• Dr Paul OHare, Reader in Medicine

2
(No Transcript)
3
Higher prevalence and earlier onset of Diabetic
Retinopathy in South Asians compared to
Caucasians A Substudy from UKADS (United
Kingdom Asian Diabetes Study) Varadhan L, Ullah
Z, Reynold DR, Bondugulapathi LR, OHare K, Johal
K, Tithecott D, Raymond NT, Sailesh S, Kumar S,
Barnett AH, OHare JP On behalf of UKADS Study
group
4
Background Aims

• Diabetes is four times more common in Asians
• Age of onset of diabetes is a decade earlier
  among Asians so the chance of microvascular
  complications increases
• Diabetic retinopathy (DR) is a major cause of
  blindness in the working population world wide
• UKADS is a community based study conducted at 18
  different general practices in the areas of
  Coventry and Birmingham in UK

5
Methods

• 1081 patients with type 2 Diabetes
• 432 Asians 649 Caucasians
• Patients were participants of the UKAD study from
  6 GP surgeries in Coventry area
• 4324 fundi photographs 2 eyes x 2 fields per
  patient
• Digital fundus photograph using 3072x2906 Canon
  D20 back on Canon DGi non mydriatic camera taking
  a 45 degree image
• Graded by the Retinal Screening team based on the
  NSC guidelines

6
Results Prevalence of DR
7
Results Distribution of DR
plt0.06
of patients
plt0.05
plt0.08
8
Results Risk factors for DR
plt0.0001
plt0.0001
plt0.0001

• Systolic BP-important risk factor for developing
  DR in either group
• Diastolic BP and creatinine were not associated
  with the development of DR in either

9
Results Risk factors for DR
plt0.001
plt0.05

• HbA1c risk factor for developing DR in either
  group, Total cholesterol was not
• In patients with DR, HbA1c was comparable
  between the 2 groups

10
Stats

• Conditional logistical regression - Significant
  effect for ethnicity
• retinopathy unadjusted OR SAWH 1.66 (1.22 to
  2.25) P0.001 and adjusted for gender, age at
  diagnosis, systolic blood pressure
• HbA1c and total cholesterol 1.41 (1.01 to 1.97)
  P0.045
• analysis for STR gave unadjusted OR 1.61 (1.04
  to 1.68) and adjusted OR 1.44 (0.90 to 2.28)
  P0.13

11
Conclusion

• Prevalence of any DR and STR is significantly
  higher in South Asians compared to Caucasians in
  our study
• Age, Duration of diabetes, HbA1c and Systolic
  Blood pressure were found to be important risk
  factors for developing DR in both groups
• For a comparable duration of diabetes and
  glycemic control, South Asians tend to have
  higher prevalence of DR
• Onset of diabetes and microvascular complications
  is earlier in South Asians
• More aggressive control of established risk
  factors of Diabetic retinopathy is needed among
  South Asians

12

• Can the use of a link worker
• improve attendance for
• Diabetic Retinal Screening in the South Asian
  population of Coventry?
• K. Bush, R. Thomas, D. Tithecott, S. Mali, J.
  Hancox, P. Barker, P. OHare
• Coventry and Warwickshire Retinal Screening Unit
• and Warwick Medical School, University of Warwick

13
Methods

• Individual GP surgeries in Asian areas were
  allocated to intervention (link worker contact
  for re-screen) or control (routine letter
  appointment)
• Comparison of screening rates were made pre and
  post intervention

14
Link Worker Role

• Able to communicate with South Asian population
  and share cultural awareness of this group
• Acted as focus in practice to identify those who
  did not attend first screen and to work with
  these patients by written contact and a phone
  reminder about the second screen
• Phone call reminder
• ensure language barriers not in
  place
• ensure patient understands why
  screening
  is necessary
• keep diary and log time

15
Screening in South Asian Population

• Lower uptake of screening in South Asian women in
  national programmes for breast and cervical
  screening
• Link workers used with variable success in
  programmes
• Evidence in local population that practices with
  high South Asian population were performing less
  well in screening attendance.
• During study UKADS coverage 85

16
Results

• Randomised
• Group 1
• Mishra, Lyell, Mistry, Kakhad, Chandra-Mohan
• Group 2
• Alijah, Sihota, Dutta, Dadhania, Agarwal
• Offered additional DNA sessions. Link workers

17
Results Provisional 2 practice to re-screen
18
Conclusion

• Screening rates have improved with successive
  years. Screening rates in deprived urban South
  Asian communities can be improved
• Link workers phoning patients/family to remind
  and educate can bring up screening rates to meet
  national targets and equal best achieved in
  country

19

• Non-Adherence
• and Missed Appointments should persistent DNA
  be treated as illness?

20
Non-Adherence and Non-Attendance

• p.c or not p.c?
• compliance
• DNAs
• refusals
• missed appointments
• lost tribe transitional care

21
Problem of Coverage

• High coverage necessary for effective screening
  programme discuss
• How high?
• Are targets achievable/fit for purpose
• Inaccessible groups
• Reasons for non-adherence
• Patient perception
• Ethnicity
• Social deprivation

22
Problem of Coverage cont.

• Co-morbid illness
• depression
• psychosis
• psychopathy
• youth
• infirm elderly
• Care homes access
• Transport systems wheelchairs

23
Solutions

• Attitude Change screeners practices ownership
  
• DNA in chronic disease is a symptom to be
  diagnosed and treated
• Resources to areas of socio-economic deprivation
  and high immigrant/ethnic group
• Communication and language barriers
• Use of phone reminder/motivation

24
Solutions cont.

• Use of link workers as culturally sensitive means
  to reinforce adherence
• Joined up working by team
• hospital eye service
• diabetes team
• primary care team
• screening service
• Patient education/motivation
• Call/recall