Dear Bruce,

Warm autumn greetings the East of England.

I am sure your team will be putting together a paper outlining the clinical 
effectiveness and cost effectiveness rationale behind lengthening the 
interval for specific groups of people and show how it will not compromise 
clinical care. When resources are scare, we need to spend the health care £s 
where we will derive maximum health gain for our communities. As long as 
your PCT makes an explicit and transparent decision based on evidence I do 
not see there is a problem. I am sure we all do explicit clinical 
prioritisation as commissioners all the time. Here is some info for a start. 
May be you have already got most or all of them.

Good luck in maximising the health gain for your population within the 
allocated resources.

You might find this position statement from the ADA of interest. References 
5 and 6 would be useful. Full text available @
http://care.diabetesjournals.org/cgi/reprint/27/suppl_1/s84.pdf

The other paper of interest is “What is a reasonable interval for 
retinopathy screening in patients with diabetes? - Patient Oriented Evidence 
That Matters: practice recommendations from key studies – Full text @
http://www.jfponline.com/pdf/5205/5205JFP_POEMs6.pdf (Page 357)
According to this paper “Assuming that a given patient is reliable for 
follow-up and that a clinical system is in place to handle a more 
individualized screening protocol, the investigators suggest the following 
approach: 3-year intervals for patients with no retinopathy and no risk 
factors (risk factors being diabetes for longer than 20 years or use of 
insulin); annual screening for patients with no retinopathy and 1 or both 
risk factors or for patients with background retinopathy; and 4-month 
intervals for patients with mild preproliferative retinopathy”.

CRD review - Cost-utility analysis of screening intervals for diabetic 
retinopathy in patients with type 2 diabetes mellitus
http://agatha.york.ac.uk/online/nhseed/20008037.htm

Another paper showing the safety of longer intervals
http://www.dtu.ox.ac.uk/Manuscripts/DTU030_Abstract.pdf

Here is the conclusion of a paper in JAMA titled “Cost-Utility Analysis of 
Screening Intervals for Diabetic Retinopathy in Patients with Type 2 
Diabetes Mellitus”.  “Annual retinal screening for all patients with type 2 
diabetes without previously detected retinopathy may not be warranted on the 
basis of cost-effectiveness, and tailoring recommendations to individual 
circumstances may be preferable. Organizations evaluating quality of care 
should consider costs and benefits carefully before setting universal 
standards”  Abstract at
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=10685713&query_hl=2&itool=pubmed_docsum

Warm regards & very best wishes,
Badri

Dr P Badrinath MD M.Phil MPH FFPH PhD (Cantab)
Consultant in Public Health Medicine & Affiliated Clinical Lecturer
Suffolk PCT & University of Cambridge
Thingoe House, Bury St Edmunds, Suffolk, UK
http://myprofile.cos.com/badrishanthi