Nayana Project
Management of diabetic retinopathy entails repeated ophthalmic examinations and
treatment sessions requiring multiple visits to treatment centres. Apart from the cost of
actual care delivery, the overall cost to patients includes transportation, incidental
expenses, loss of income due to absence from work for the patient and / or the attendant.
This constitutes a substantial financial burden on the already stretched and meagre
personal resources. Moreover, poor illiterate people from rural areas unaccustomed to city
life feel overwhelmed when required to travel to big cites for further treatment, further
constraining compliance and treatment adherence. Because of the need for mulitiple visits,
screening patients in camps and referring them for treatment to a base hospital as done
very successfully for dealing with blindness related to cataracts is therefore unlikely to
work for diabetic retinopathy, even if the treatment is offered free of cost. Therefore health
care delivery models for chronic diseases such as diabetes which provide screening,
treatment and follow up closest to the patient’s familiar “home” environment in the semi
urban and rural areas involving local service providers, (including ophthalmic practices)
are likely to be more successful. A significant hindrance to deliver these services in rural
and semi urban areas is the lack of trained manpower and equipment required to diagnose
and treat diabetic retinopathy. Given the relatively smaller number of cases at each rural
centre the economic viability and recouping investment costs of expensive equipments to
provide advanced care to relatively poor, non affording and often uninsured rural
communities is a challenge. Given the fact that 80% of health care delivery in India is
through the private sector, that only a very small fraction (less than 5%) of the Indian rural
population receives medical reimbursement for chronic diseases like diabetes and the fact
that health care infrastructure for diabetes care in the public system is woefully inadequate
the barriers to provide advanced diabetes eye care to this section of the population seem
enormous.
We describe a model of distributive advanced outreach care designed and implemented to
bring screening and treatment of diabetic retinopathy literally at the patient’s doorstep in
rural and semi urban areas of Karnataka, by addressing some the barriers described
above.
Research design and methods:
To test our hypothesis that chronic health care delivery model which provides screening,
treatment and follow up closest to the patient’s familiar “home” environment in the semi
urban and rural areas involving local service providers (including ophthalmic practices) will
be more successful in the management of DR and will enhance compliance to care, we
designed and implemented a program for advanced eye care services in rural parts of
Karnataka State in India.
Designing and building NAYANA the advanced eye care treatment unit (AETU) van:
Nicknamed Nayana - beautiful eyes in Hindi, the specially designed AETU van (Fig 1A)
was custom built on a cargo chasis from Ashok Leyland Ltd. India. The van has a 2+1
driver’s cabin and an insulated and air conditioned treatment chamber measuring 8 x 14 x
6.5 ft. Humidity within the chamber is maintained at 56% with a dehumidifier (Fig 1B). As
power supply in rural areas of Karnataka can be erratic, the van carries its own 7 KVA
generator, which powers the running of all the equipments on the van along with the air
conditioner and dehumidifier when external power is not available. The generator is
transported in a custom made cubicle in the van. When available, the van derives power
supply from local power source. A voltage stabilizer ensures constant 220 volts current (Fig
1C). The cabin is hermetically sealed during travel.
In addition to routine clinical furniture, the unit carries a fundus camera with angiography
and fundus photography facilities (Carl Zeiss Visucam Lite); a diode laser retinal
photocoagulator (Carl Zeiss 532 S diode laser) ; B-scan ultrasound (Appasamy A/B scan) ;
ultrasound biomicroscope (Appasamy UBM ) ; visual field analyser (Carl Zeiss Humphrey
visual field analyser 720i make) ; applanation tonometer (Clement Clarke HS) ;
pachymeter and YAG laser (Carl Zeiss Visulas Yag laser III).
To protect these sensitive equipment from severe jerks and vibrations which occur during
travel, particularly on illmaintained rural roads and state highways, the equipments are
disassembled and packed in custom made boxes during transportation. The boxes contain
moulded polyurethane
packing including movement arrestors (Fig 1D).
During
transportation packed boxes are placed in a shock-absorbing floating cage - four large
springs at its base and 7 other springs at the sides and top support the cage ensuring that
the entire weight of the cage floats in air without vibrations being transferred to the
equipments (Fig 1E). The special suspension was designed and tested by Vortex
engineering group, Chennai. The instruments are reassembled at each location and with
experience can be done very quickly by the ophthalmic technician who travels with the
van.
Other features of the van: An automated Dish antenna with the satellite transmitter is
folded and fixed on the depressed roof of the van (HCL Comsat 1.8 metre motorised
satellite antenna with GPS). When needed the antenna is lifted and connected to the base
hospital through the satellite links provided by the Indian Space Research Organisation
(ISRO), enabling teleconsultations for second opinions (Bharat Electronics Satellite
Modem, PolyCom Lite Video Camera). While this connectivity is useful, it was not deemed
to be critical in the successful implementation of the project.
Identifying and recruiting semi urban and rural ophthalmologist to be part of
project: Through network of the ophthalmology society and word of mouth, 83
ophthalmologists with no previous training or experience in medical and surgical retinal
work, from 23 different locations in 13 districts of Karnataka to be covered on the charted
route of the mobile unit were identified, interviewed and recruited. The ophthalmologists
signed a memorandum of understanding with the implementing agency the Vittala
International Institute of Ophthalmology (VIIO) Bangalore agreeing to participate in the
training program, comply with the protocol of care established for the project as well as to
provide professional services at the agreed rates during the project and to treat patients
earning less than 30$ a month free of cost. Patients requiring advanced vitreo retinal
surgical procedures were referred to the base hospital for surgical treatment.
Training of local ophthalmologists: All participating local ophthalmologists underwent
training in the diagnosis and management of diabetic retinopathy in a phased manner over
6 months, at the VIIO, Bangalore; as well as on-site hands on practical training on the
mobile unit. Apart from the standard training protocol, participants received additional
training tailored to individual needs based upon a self-assessment survey conducted prior
to the project. The training sessions included seminars, continued medical education
(CMEs) sessions and practical training, e.g., ophthalmologists first practiced laser on
model eyes made of ping-pong balls giving them an idea of the power settings, spot size
and duration of burns. (Fig 1F) This was followed by performing laser on patients with DR
initially supervised by a trained retina specialist through the observer side tube of the laser
machine (Fig 1G).
Patients undergoing fluorescein angiography received intra dermal test dose to identify
people hypersensitive to fluorescein. However, keeping in mind rare instances of
anaphylactic reactions that can occur, the AETU van is equipped with emergency medical
kit, a laryngoscope, Ambu bag and oxygen. During its field halt the van is stationed at or
very close to a medical facility.
Awareness Raising: While building on the supply side, in terms of strengthening capacity
to deliver care, the project also implemented strategies to deal with the demand side to
enhance service utilization. This was done by organising educational sessions among the
community health workers and local general practioners(GPs) on the importance of good
diabetes care and screening for complications. Posters were put up at various locations
including local clinics and pharmacies increasing awareness about need for eye screening
among diabetics and the project.
Participating ophthalmologists encouraged local
physicians and GPs to refer patients with diabetes for screening. The project also received
publicity in the local media and over time through word of mouth awareness grew. A fixed
monthly route for the Nayana AETU van ensured that local ophthalmologist pre screened
people with diabetes and those needing further evaluation were given appointment on day
Nayana visited them.
To evaluate the impact of training and assess changes in clinical skills, participating
ophthalmologists were interviewed using a questionnaire before and after the introduction
of the project on 11 clinical skills in their clinical practice. The 11 skills included slit lamp
examination, indirect ophthalmoscope examination, +78D examination of macula in
diabetic retinopathy, applanation tonometry, gonioscopy, fluorescein angiography, B scan
examination, ultrasound biomicroscopy (UBM), visual field examination, yag laser for
iridotomies,
capsulotomies and retinal laser for diabetic retinopathy. The data was
analysed and significance estimated by the McNemar's test.
To assess impact of project intervention on the cost of treatment for diabetic retinopathy
forty four random patients treated on the van for diabetic retinopathy were interviewed with
the help of a standard questionnaire between June 2006 and July 2006 by one of the
authors (NL). Questionnaire to determine the total cost of treatment was prepared in 3
languages namely English, Kannada and Hindi and pretested for comprehension.
Questionnaire was designed to segregate expenses for 1) transport; 2) food,
accommodation and miscellaneous expenses 3) treatment expenses and 4) loss in income
for patients and attendants. The one time cost incurred on the van (A) was compared with
the cost patients would incur if the same procedure was carried out in the nearest town
with treatment facilities (B), at
private treatment facility in Bangalore(C) and at
Government run Regional Institute of Ophthalmology in Bangalore (D).
Results:
The targeted project area serves a population of 16.3 million people. Travelling 25 days
every month the van visits 23 locations on fixed days across 13 districts and covering a
distance of 4500 Kilometres (KM). The project has been operational from 2005 till date.
The first 3 years of operations was funded by the World Diabetes Foundation. Since the
last 5 years the project has been self sustaining without any external funding. Twenty nine
thousand patients with diabetes have been examined, 1000 fluorescein angiograms, and
7000 laser treatments have been performed on the van. 513 sight restoring or sight saving
vitreo retinal surgeries have been performed on patients referred to the base hospital,
most of them either free of cost or at heavily subsidized rates.
Practice pattern changes among rural ophthalmologists
Table 1
Table 1 Changes in practice pattern in 11 skills before and after the Nayana project implementation
Clinical Skill
P value
Remarks
Slit lamp examination
1
All doctors were already using slit lamp
Indirect ophthalmoscopy
0.02*
61.5% who used it minimally now used it extensively, 25% who never
used started using.
0.039*
+78D examination
80% who did not use started using, 66.7% who used it minimally started
using extensively.
0.039*
Applanation tonometry
69.5% who did not use started using, 12.5% who used it minimally
started using extensively.
Fluorescein angiography
0.001*
81.8% who did not use started using, 12.5% who used it minimally
started using extensively.
0.001*
B Scan
71.4% who did not use started using, 9.1% who used minimally started
using extensively.
0.001*
Visual field analysis
70.6% who did not use started using, 50% who used minimally started
using extensively
Gonioscopic examination
0.581
57% who did not use started using, 30.8% who used it minimally started
using extensively.
0.012*
Yag laser
92.3% who did not use started using, 80% who used it minimally started
using extensively
0.001*
Retinal laser
80% who did not use started using, 12.4% who used it minimally started
using extensively
Ultrasound biomicroscope
0.012*
40.9% who did not use started using , 12.5% who used it minimally
started using extensively
*
McNemar test p value statistical significance (p<0.05)
Table 2
Table 2 Comparative cost of single laser treatment sitting for diabetic retinopathy at different locations for a
rural patient in USD
(1 USD = 45 Rupees)
(Data presented in trimean) (Inter quartile range)
Locations
Transportation costs
Food,
Loss of income
Treatment cost
0.11
1.51
11.11
(0-0.43)
(0-4.26)
(11.11-11.11)
accommodation,
miscellaneous
A) Nayana mobile unit 0.82
(0.44-1.51)
B) Nearest city
C)
Private
0.83
1.51
21.11
(2.06-6.13)
(0.08-1.78)
(0-4.26)
(17.77-22.22)
5.81
3.01
22.78
(2.89-12.61)
(0-8.52)
(22.22-24.44)
9.65
4.53
22.50
(6.67-27.78)
eye 14.55
hospital, Bangalore
D)
3.83
(7.54-20.52)
Government 14.55
hospital, Bangalore
(7.54-20.52)
(3.67-23.56)
(0-12.78)
Significance
A-B:P<0.001**
A-B:P<0.001**
A-B:P<0.05 (ns) A-B:P<0.001**
A-C:P<0.001**
A-C:P<0.001**
A-C:P<0.001**
A-C:P<0.001**
A-D:P<0.001**
A-D:P<0.001**
A-D:P<0.001**
A-D:P<0.001**
** strongly
significant (p<0.01)
350% reduction in cost of procedure when treated on the mobile van in comparison to
being treated in the government hospital
The Nayana project model has built a sustainable solution by enhancing local capacity and
skills and sharing a set of expensive equipment amongst ophthalmologists practicing in
semi urban and rural areas thereby helping them successfully provide hitherto non
available services to their local communities at highly subsidized prices. Patients in the
project area do not have to travel more than 50 KM to receive treatment for diabetic
retinopathy and can be followed by a familiar doctor from the same area. These factors are
likely to significantly improve compliance. The local ophthalmologists also benefit by this
programme. They now have a whole range of expensive equipment at their disposal for 1
day in a month without the economic burden of paying for all of them. Their skills in
diagnosing and treating medical retina cases are greatly improved and they are able to
retain a substantial volume of patients who previously had to be referred elsewhere, thus
improving their practice and image. The local ophthalmologists are also in the unique
position to form networks with local diabetes care providers.
By providing diagnosis and treatment of DR within a distance of 50 km of the patient's
residence, training of local ophthalmologists and sharing expensive equipment between
the different trained practicing ophthalmologists the model described offers opportunity to
fill the gap between required and available services for DR in countries facing a huge
burden of diabetes such as India. The approach outlined above will bring quality care for
diabetes and its complications such as DR to the local population at a relatively low cost.
The large scale implementation of this approach will however require availability of
qualified manpower; active involvement of both the public and private sector and other
stakeholders such as third party payers.