Tool for the assessment of diabetic retinopathy and diabetes management systems ISBN 978 92 4 150919 0 Department for Management of NCDs, Disability, Violence and Injury Prevention (NVI) World Health Organization 20, avenue Appia CH-1211 Geneva 27 Switzerland Tel: +41 22 791 2111 Fax: +41 22 791 3111 www.who.int/blindness WHO Library Cataloguing-in-Publication Data Tool for the assessment of diabetic retinopathy and diabetes management systems. 1.Diabetic Retinopathy. 2.Diabetes Complications. 3.Diabetes Mellitus. 4.Delivery of Health Care. Visual impairment I.World Health Organization. ISBN 978 92 4 150919 0 (NLM classification: WK 835) © World Health Organization 2015 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for non-commercial distribution – should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed by the WHO Document Production Services, Geneva, Switzerland Design: Inis Communication – www.iniscommunication.com Tool for the assessment of diabetic retinopathy and diabetes management systems ACKNOWLEDGEMENTS This project has been developed as part of the cooperative agreement between Lions Clubs International Foundation and the World Health Organization. The development of the tool, the field testing and translations were supported by funds from the Ministry of Foreign Affairs and Development Cooperation of Italy. Development of the TADDS was coordinated by the World Health Organization, Prevention of Blindness and Deafness, and technically supported by the Centre for Eye Research Australia (University of Melbourne) and the Menzies Centre for Health Policy (University of Sydney). The International Council of Ophthalmology provided technical comments throughout. CONTENTS Facts on diabetes and diabetic retinopathy 4 Content of the TADDS (Tool for the assessment of diabetic retinopathy and diabetes management systems) 6 Suggested methodology 8 Assessment tool 10 Ethics 12 Section 1: Priorities, policies and programmes 13 Section 2: Service delivery 17 Section 3: Health workforce 22 Section 4: Health technology 23 Section 5: Health information management systems 24 Section 6: Health promotion for diabetes and diabetic retinopathy 26 Section 7: Health financing 28 People who participated in the assessment 29 TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS4 FACTS ON DIABETES AND DIABETIC RETINOPATHY Diabetes (DM) today constitutes one of the emerging threats to public health all over the world: • 455 million people worldwide have diabetes (2014 estimates). • In 2012, an estimated 3.8 million people died from the consequences of high fasting blood sugar. • More than 80% of diabetes deaths occur in low- and middle-income countries. • WHO projects that diabetes will be the seventh leading cause of death in 2030. Simple lifestyle measures (healthy body weight; physical activity; healthy diet) have been shown to be effective in preventing or delaying the onset of type 2 diabetes. Early diagnosis can be accomplished through relatively inexpensive blood testing. Treatment of diabetes involves lowering blood glucose and the levels of other known risk factors that damage blood vessels. Diabetic retinopathy (DR) is the fifth leading cause of visual impairment and the fourth leading cause of blindness in the world: • 285 million people worldwide are visually impaired. • In 2010, an estimated 39.3 million people were blind. • More than 80% of people with visual impairments live in low-income settings. • More than 80% of people blind are >50 years old. • Diabetic retinopathy is the cause of visual impairment for 4.2 million people. The onset of diabetic retinopathy is the result of long-lasting diabetes; the condition is worse if diabetes is poorly controlled. Prevention of visual impairment from diabetic retinopathy is achieved principally through control of diabetes, early detection of reti- nal changes, and timely treatment of sight-threatening lesions of the retina once the damage from diabetes is established. Anti-VEGF (vascular endothelial growth factor) agents can reduce the progression of the disease and preserve visual function. TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS 5 The most critical role of health systems in managing diabetes and preventing irre- versible blindness from the disease is cooperation between those responsible for diabetes management and those concerned with diabetic retinopathy. While this may seem obvious, it is not a consistent practice in the health systems of low-income countries, and indeed is often also lacking in middle- and high-income countries. PURPOSE OF THE DOCUMENT In order to assess both management of diabetes and diabetic retinopathy in countries and to estimate the level of cooperation and synergy between these two branches of health care, WHO has designed this assessment tool. The tool will make it possi- ble to carry out situation analysis, define service provision levels, and identify the gaps to be addressed in ensuring universal access to diabetes care and to effec- tive prevention and treatment of diabetic retinopathy. TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS6 CONTENT OF THE TADDS (TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS) The WHO Health Systems Framework guided the development of the survey items, which are organized into the following themes1: 1. Service delivery: Estimates of needs from available data, priorities, policies and health care programmes for diabetes and diabetic retinopathy; how they are inte- grated into the public health system and each other (networks); presence and nature of referral pathways between diabetes care and eye care; locations of services; provision of care in public and private services. 2. Health workforce: Cadres, numbers, distribution and training of staff involved in diabetes and eye care services. 3. Health information management systems: Key performance indicators; what information is recorded for the individual patient with diabetes; data collation and communication; patient follow-up systems. Where possible, medical records should be used to assess compliance with regular monitoring of both diabetes and eye examinations. 4. Medical products and technologies: Availability, accessibility and functionality of equipment for diagnosis, management and monitoring by health care providers. 5. Health financing: Government expenditure, health insurance schemes, social security schemes; provision of all stages and types of care for vulnerable popula- tion groups (remote rural areas, poor people, elderly people and ethnic minorities). 6. Leadership and governance: Key stakeholders and their roles in manage- ment of diabetes and diabetic retinopathy; existence of, and compliance with, guidelines for management of diabetes and diabetic retinopathy. 1 http://www.wpro.who.int/health_services/health_systems_framework/en/ TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS 7 OBJECTIVES OF THE ASSESSMENT The primary objectives of the TADDS are to: • assess the existence, availability and accessibility of health care services for diabetes mellitus (DM) and diabetic retinopathy (DR) in a given territory or country; • provide a picture of the existence and effectiveness of links between manage- ment of patients with diabetes and management of diabetic retinopathy; • identify the challenges faced by different levels of a national health system in providing eye care for patients with diabetes; • inform the government and stakeholders of aspects of a health system that need to be prioritized for future research and development. The scope of the situation analysis is from a national health systems approach and not to focus on individual care providers or institutions. TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS8 SUGGESTED METHODOLOGY DESK-BASED DATA COLLECTION Prevalence data for both diabetes and vision loss from diabetic retinopathy are required to assist in determining needs at the national level. They can be obtained from recent national or district level surveys (if available); otherwise, the WHO Global Health Observatory1 by country for diabetic retinopathy may be used. It is estimated that one-third of people with diabetes have some level of vision loss.2 Data may be requested from the ministry of health on the number and distribution of health services providing diabetes and eye care, and health professional organizations may be contacted for information on the number and distribution of members (e.g. endocrinologists, ophthalmologists) by state or province. IDENTIFY ALL RELEVANT STAKEHOLDERS AND KEY INFORMANTS It is recommended that key informants from the following organizations/departments be interviewed, starting with the ministry of health and the WHO country office: • Ministry of health – secretary or assistant secretary of health – division of chronic diseases management /lifestyle – division of food and nutrition • World Health Organization country office • National prevention of blindness committee • Local and international nongovernmental organizations (NGOs) involved in the provision of diabetes and eye care • Professional organizations – primary care: general practitioners (primary care/family physicians), primary care nurses 1 WHO Global Health Observatory (http://www.who.int/gho/en/) 2 Prevention of Blindness from Diabetes Mellitus (http://www.who.int/diabetes/publications/ prevention_diabetes2006/en/) TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS 9 – diabetes and endocrinology: endocrinologists, diabetologists, internal medi- cine physicians, primary care diabetes educators, diabetes nurses – eye care: ophthalmologists, vitreoretinal specialists, optometrists (if available) • Consumer/patient representative organizations • Diabetes association MAKE APPOINTMENTS TO ARRANGE INTERVIEWS The situation analysis list of topics should be sent to all individuals to be interviewed so that they can collect any necessary data in advance. TADDS will take approxi- mately one hour to complete but not all sections will be answered by everyone. Group interviews with multiple stakeholders or informants from a similar area of experience or involvement in diabetes or eye care may be appropriate. DATA ANALYSIS Results from key informant interviews can be recorded in hand or computer-written notes or – with the permission of interviewees – as audio files. Responses should be transcribed under the individual section headings of the survey in order to facil- itate qualitative analysis. Quantitative data should be summarized by categories used in the TADDS. TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS10 ASSESSMENT TOOL Section 1: Priorities, policies and programmes • Existence of and, if known, compliance with the guidelines currently used in the country for diabetes management and for diabetic retinopathy. Section 2: Service delivery • National data on the prevalence of diabetes. • National data on the prevalence and causes of vision impairment. • National list of public (government) and private hospitals, any information regarding their capacity to provide eye care, and lists of equipment. At least approximate numbers and distribution (by state/province or by level of health system) of health care facilities (village, district, provincial, tertiary hospitals and medical centres). Section 3: Health workforce • Estimated number and distribution of registered ophthalmologists (including vitreoretinal surgeons and medical retinal specialists), internal medicine physi- cians, general practitioners, nurses, optometrists (if national regulations include this professional category). Section 4: Health technology • Description of equipment for diagnosis and monitoring of diabetes. • Inventory of ophthalmic equipment across all hospitals. Section 5: Health information management systems • Details from locally or nationally aggregated data on use of diabetes and eye care services based on diagnosis or type of service. • Information on methods of sharing patient data between providers of health care services. • Details from any national registers for chronic diseases and/or vision impairment. • Use of reminder systems to recall patients with diabetes or diabetic retinopathy for review appointments. TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS 11 Section 6: Health promotion for diabetes and diabetic retinopathy • Titles and details of public health materials used for community awareness or patient education. • Use of World Sight Day and World Diabetes Day for major awareness initiatives. Section 7: Health financing • Coverage (% of population) of population with government health insurance for diabetes detection, monitoring and treatment. • Coverage (% of population) of population with private health insurance. • List of items/services that can be claimed under government health insurance for diabetes and eye care. TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS12 ETHICS Ethics approval for this assessment might need to be obtained in accordance with government (ministry of health) regulations and protocols in individual countries as a final assessment report is expected to be published. All information should be recorded anonymously: the source of information is impor- tant but individuals should not be named. The perspectives of different stakeholders should be retrievable for analysis. PLEASE USE THE QUESTIONNAIRE PROVIDED TO COMPLETE THE REQUIRED INFORMATION. ANY ADDITIONAL TABLE OR DOCUMENT CAN BE PROVIDED AS AN ANNEX ENSURE THAT THE GRADING AT THE END OF EACH SECTION IS DULY COMPLETED. SUMMARIES OF REPLIES RECEIVED BY INTERVIEWEES SHOULD BE PROVIDED IN ORDER TO APPROPRIATELY REPRESENT THE SITUATION IN DIFFERENT PLACES OF THE COUNTRY. TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS 13 PRIORITIES, POLICIES AND PROGRAMMES NATIONAL DIABETES PLAN/PROGRAMME 1. Is diabetes listed as a national health priority? Yes No 2. Is diabetic retinopathy (DR) listed as a priority in the national prevention of blindness plan? Yes No 3. Does your country have a national diabetes plan? Yes No 4. If so, what does this national plan cover? Primary prevention of diabetes Complications (including vision impairment) Community awareness and patient education Clinical care, services, and supplies Remarks: 5. Is there a national policy on food and/or nutrition? Yes No 6. Is there a national programme on food and/or nutrition? Yes No Name of programme: Lead organization responsible for the programme: 1 TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS14 7. Is there a national policy on diabetes prevention? Yes No 8. Is there a national diabetes prevention programme? Yes No Name of programme: Lead organization responsible for the programme: 9. Is there a national diabetes association? Yes No a. What does it do? Patient education and awareness Clinician education and awareness Policy development and advocacy Networks between service providers and people with diabetes b. What health promotion and patient education strategies are used by the diabetes association? Select the number1 below that best represents the situation in the country: Existence of priority, policies and programmes for DM: 1 2 3 4 1 Key: 1 – DM is not a priority; there is no national plan and no national programme. 2 – DM is listed as a priority; there is a national plan but no programme has been implemented. 3 – DM is listed as a priority; a national plan has been formulated and a programme is in place but does not cover the whole country. 4 – DM is listed as a priority; both a plan and a programme are in place and there is national coverage. TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS 15 CLINICAL MANAGEMENT GUIDELINES 10. Are there guidelines for the management of diabetes? Yes No (If yes, please give the full title of the clinical management guidelines most commonly used and provide a copy.) a. Is diabetic retinopathy included as a component of these guidelines? Yes No b. For what levels of the health care system (primary, secondary, tertiary) are the guidelines applicable? c. What is the intended target audience (e.g. primary care workers, specialists) for the guidelines? 11. Are evidence-based guidelines available for the management of diabetic retinopathy? Yes No (If yes, please give the full title of the clinical management guidelines most commonly used and provide a copy.) a. Do they cover: prevention of vision loss from diabetic retinopathy? treatment? follow-up? b. For what levels of the health care system are the guidelines applicable? Primary Secondary Tertiary c. The guidelines are: Evidence-based Consensus-based Mixture of both TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS16 If consensus-based, who (stakeholders) was involved in guideline development? 12. Are the guidelines being used? Subjective rating scale: 1 = unused, 12 = widely used (click the appropriate number) 1 2 3 4 5 6 7 8 9 10 11 12 13. Describe how the intended audience is made aware of the existence of the guidelines? How were they disseminated (e.g. in print, by website)? In what languages are they produced? Select the number1 below that best represents the situation in the country: Guidelines for clinical management of DM: 1 2 3 4 Guidelines for clinical management of DR: 1 2 3 4 1 Key: 1 – There are no ministry of health-recommended guidelines. 2 – Ministry of health guidelines have been formulated but health professionals are unaware of their availability and thus they are not widely used. 3 – Ministry of health guidelines are available and known to the appropriate audience but they are not widely followed. 4 – Ministry of health guidelines have been formulated and are commonly followed. Additional information for Section 1 TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS 17 SERVICE DELIVERY NETWORKS AND LINKAGES 14. Describe how people with newly diagnosed diabetes are identified. a. Where are the services located (village, district, regional, provincial, tertiary levels of care)? b. The facilities are: Private Public 15. Describe how ongoing care of people with diabetes is performed. a. Where are the facilities located (village, district, regional, provincial, tertiary levels of care)? b. The facilities are: Private Public 16. Describe the access to care services for people with diabetes. a. What proportion of the population can access this service? b. What are the barriers that prevent access to services? 17. What services are available at the community level for people with diabetes? a. Clinical services: for patient identification and risk assessment b. Patient education and support services: for diabetes for diabetic retinopathy 2 TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS18 18. Is there a specialist diabetes centre? Yes No a. If yes, what services does it provide? b. What proportion of the population has access to these services? Select the number1 below that best represents the situation in the country: Location of DM services and accessibility to population in need: 1 2 3 4 1 Key: 1 – Services available in few places and to few people. • Services are not available everywhere; they can be found only in large hospitals and are accessible only to those who can pay. 2 – Some services are available to part of the population. • Services are available in regional hospitals or health centres and are partly paid by the patients. Populations in rural areas cannot reach services easily; transport to the health facilities and the cost of service are the main barriers. 3 – Services are available everywhere but do not reach some of the population. • Services are available in most rural and urban areas providing care at district, regional, provincial and tertiary levels; however, costs and transport are barriers for some patients. 4 – Services are available everywhere for the whole population. • Services are available in all locations and costs are paid by insurance schemes, are subsidized by the state, or are available free of charge. DIABETIC RETINOPATHY SCREENING 19. Are people with diabetes routinely referred for eye examinations? Yes No a. Does this include referral of people who are asymptomatic? Yes No TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS 19 b. Are people referred only if they report symptoms of vision loss? Yes No c. Is an eye examination incorporated into the annual cycle of care for people with diabetes? Yes No 20. Is there a community screening programme for diabetic retinopathy? Yes No a. How are people with diabetes recruited for screening? b. What personnel are involved? c. Is any outreach screening provided? Yes No d. Coverage of screening? e. Who pays for the screening? 21. Where are eye examinations for diabetic retinopathy performed most commonly in villages, at district, regional, provincial, tertiary levels of care)? a. What proportion of the population can access this service (no one, 30%, 60%, 90%, 100%)? b. What are the barriers that prevent access to services? TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS20 c. The services are: Private Public Select the number1 below that best represents the situation in the country: Location of DM services and accessibility to population in need: 1 2 3 4 1 Key: 1 – Services available in few places and to few people. • Services are not available everywhere; they can be found only in large hospitals and are accessible only to those who can pay. 2 – Some services are available to part of the population. • Services are available in regional hospitals or health centres and are partly paid by the patients. Populations in rural areas cannot reach services easily; transport to the health facilities and the cost of service are the main barriers. 3 – Services are available everywhere but do not reach some of the population. • Services are available in most rural and urban areas providing care at district, regional, provincial and tertiary levels; however, costs and transport are barriers for some patients. 4 – Services are available everywhere for the whole population. • Services are available in all locations and costs are paid by insurance schemes, are subsidized by the state, or are available free of charge. 22. Describe the networks between services for diabetes care and eye care. a. Stakeholders b. Referral pathways (one-way, reciprocal) c. What information is shared between practitioners? 23. Are any nongovernmental organizations (NGOs) involved in the care of people with diabetes and diabetic retinopathy? Yes No TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS 21 If so, what roles do they perform in diabetes and in eye examination for people with diabetes (health promotion, screening, laser, vitreoretinal surgery)? Select the number1 below that best represents the situation in the country: Networks between the care providers for DM and DR: 1 2 3 4 1 Key: 1 – There is no known collaboration between separate providers of care for DM and DR. 2 – Few centres provide patient-centred care. 3 – Some centres provide patient-centred care by means of collaboration between DM and DR services. 4 – Most centres provide patient-centred care based on collaboration between DM and DR services. Additional information for Section 2 TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS22 HEALTH WORKFORCE 24. What categories of health professionals (endocrinologist; ophthalmologist; primary care physician; general, diabetes or ophthalmic-trained nurse; dieti- cian; etc.) are available to care for people with diabetes? What is the ratio of providers to patients at each level of the health system? 25. What aspects of diabetes management are included in the teaching curriculum for primary health care workers (nurses and primary care physicians)? Awareness of complications of diabetes – specifically, vision loss from diabetic retinopathy Health education for patients Need for and timing of referral for eye examination Management of diabetic retinopathy 26. How is continuing medical education provided to primary health care workers? Formal training by government, university, professional organizations Regular informal updates Workshops Updates on guidelines Select the number1 below that best represents the situation in the country: Training opportunities and quality for DM and DR care providers: 1 2 3 4 1 Key: 1 – Largely inadequate. 2 – Few training opportunities; consequently fewer human resources than needed. 3 – Training available only in large cities and hospitals. 4 – Training for DM and DR is appropriate and of good quality. 3 TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS 23 HEALTH TECHNOLOGY 27. Are the following investigations/equipment available? Biochemical laboratory tests for HbA1c (glycated haemoglobin), lipids, creatinine, urinary protein Blood glucose meter (owned/kept by patients with diabetes or by the health service) Slit lamp Direct ophthalmoscope 28. What technologies are used to perform retinal examination for diabetic retinopathy? Dilated eye examination by ophthalmologist Dilated eye examination by refractionist/optometrist Retinal imaging – mydriatic camera Retinal imaging – non-mydriatic camera 29. Where are these technologies available (villages, district, regional, provincial, tertiary levels of care)? Select the number1 below that best represents the situation in the country: Accessibility of health technology: 1 2 3 4 1 Key: 1 – Modern examination technology not available to the majority of patients. 2 – Modern examination technology available only in major hospitals and private clinics. 3 – Modern examination technology available in most provincial hospitals and clinics. 4 – Modern examination technology available to all patients. Additional information for Sections 3 and 4 4 TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS24 HEALTH INFORMATION MANAGEMENT SYSTEMS 30. What nationally agreed health population indicators of diabetes are monitored? Prevalence Incidence Not measured How often are they measured? 31. What nationally agreed health population indicators of diabetic retinopathy are monitored? Prevalence of vision impairment and blindness Not measured How often are they measured? 32. Describe the methods used (surveys, hospital data, health insurance statistics) to collect this information. 33. Describe how the information is collated and reported (standardized data set). 34. What information about individual patients with diabetes is recorded in their patient medical records in hospitals? Risk factors Complications – including diabetic retinopathy Previous eye examination for diabetic retinopathy Treatments Follow-up 5 TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS 25 35. Is there a recall system for people with diabetes to have follow-up eye examination? Yes No Communication methods: personal record books, information cards mHealth: text messaging reminders using mobile phones Select the number1 below that best represents the situation in the country: Knowledge of disease burden: 1 2 3 4 1 Key: 1 – Prevalence of DM and DR is neither known nor estimated; information about patients is inadequate. 2 – Prevalence of DM is known but not the prevalence of DR. or Prevalence of DR is known but not the prevalence of DM, and patients’ records are not utilized. 3 – Prevalence of both DM and DR is known or has been estimated; patients’ records are used to analyse data at national level. 4 – Prevalence of both DM and DR is known or has been estimated; patients’ records are collated, analysed and regularly published. Additional information for Section 5 TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS26 HEALTH PROMOTION FOR DIABETES AND DIABETIC RETINOPATHY 36. Is information provided to the community about diabetes? Symptoms and signs Risk factors Complications Management Where to seek help 37. Is information provided to the community about diabetic retinopathy? Yes No 38. How is community education regarding diabetes delivered? Print media mHealth: text messaging reminders using mobile phones Radio/television 39. What is the coverage of health promotion and patient education? National Provincial District 40. Are people with diabetes made aware of diabetic patients’ organizations? Yes No How are patients’ support organizations made accessible to disadvantaged groups of the population: In rural locations? In what languages/dialects? 6 TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS 27 For people with disabilities? 41. Give examples of how initiatives such as World Diabetes Day and World Sight Day are used to educate people and medical professionals on vision impair- ment from diabetes. Select the number1 below that best represents the situation in the country: Information and education provided to the community and to patients on DM and DR: 1 2 3 4 1 Key: 1 – Little information is provided to the community and little education to patients . 2 – Information to the community is provided occasionally and only through national-level media; not all patients receive education. 3 – Information is provided at national and provincial level; most patients receive education. 4 – Information is provided to the community at all levels; all patients receive education and patients’ organizations are actively involved. Additional information for Section 6 TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS28 HEALTH FINANCING 42. How are interventions for people with diabetes financed? Activity % of cost funded by government % of cost funded by private insurance % of cost funded by patient (out-of-pocket) % of cost funded by NGO % of cost funded by others (please specify) Medical treatment Hospital treatment Medications Laboratory tests Other: 43. How are interventions for people with diabetic retinopathy financed? Activity % of cost funded by government % of cost funded by private insurance % of cost funded by patient (out-of-pocket) % of cost funded by NGO % of cost funded by others (please specify) Prevention (retinal screening) Laser photocoagulation Vitreoretinal surgery Other: Additional information for Section 7 7 TOOL FOR THE ASSESSMENT OF DIABETIC RETINOPATHY AND DIABETES MANAGEMENT SYSTEMS 29 PEOPLE WHO PARTICIPATED IN THE ASSESSMENT NAME POSITION/ORGANISATION EMAIL
Tool for the assessment of diabetic retinopathy and diabetes management systems ISBN 978 92 4 150919 0 Department for Management of NCDs, Disability, Violence and Injury Prevention (NVI) World Health Organization 20, avenue Appia CH-1211 Geneva 27 Switzerland Tel: +41 22 791 2111 Fax: +41 22 791 3111 www.who.int/blindness
糖尿病视网膜病变和糖尿病管理系统评估 工具 ISBN 978 92 4 550919 6 世界卫生组织 * * Tool for the assessment of diabetic retinopathy and diabetes management system 世界卫生组织 非传染性疾病、残疾、暴力和伤害预防管理司 世界卫生组织 20, avenue Appia CH-1211 Geneva 27 Tel: +41 22 791 2111 Fax: +41 22 791 3111 www.who.int/blindness WHO Library Cataloguing-in-Publication Data Tool for the assessment of diabetic retinopathy and diabetes management systems. 1.Diabetic Retinopathy. 2.Diabetes Complications. 3.Diabetes Mellitus. 4.Delivery of Health Care. Visual impairment I.World Health Organization. ISBN 978 92 4 550919 6 (NLM classification: WK 835) © 世界卫生组织，2015年 版权所有。世界卫生组织出版物可从世卫组织网站（www.who.int）获得，或者自WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland（电 话：+41 22 791 3264；传真：+41 22 791 4857；电子邮件：bookorders@who.int）购 买。要获得复制许可或翻译世界卫生组织出版物的许可 – 无论是为了出售或非商业性分 发，应通过世卫组织网站http://www.who.int/about/licensing/copyright_form/en/index.html） 向世界卫生组织出版处提出申请。 本出版物采用的名称和陈述的材料并不代表世界卫生组织对任何国家、领地、城市或地区 或其当局的合法地位，或关于边界或分界线的规定有任何意见。地图上的虚线表示可能尚 未完全达成一致的大致边界线。 凡提及某些公司或某些制造商的产品时，并不意味着它们已为世界卫生组织所认可或推荐， 或比其它未提及的同类公司或产品更好。除差错和疏忽外，凡专利产品名称均冠以大写字 母，以示区别。 世界卫生组织已采取一切合理的预防措施来核实本出版物中包含的信息。但是，已出版材 料的分发无任何明确或含蓄的保证。解释和使用材料的责任取决于读者。世界卫生组织对 于因使用这些材料造成的损失不承担责任。 Printed by the WHO Document Production Services, Geneva, Switzerland 设计：Inís Communication – www.iniscommunication.com 糖尿病视网膜病变和糖尿病管理系统 评估工具 世界卫生组织 * Tool for the assessment of diabetic retinopathy and diabetes management system 致谢 本项目是狮子会国际基金会和世界卫生组织合作协议的一部分。 工具的开发、实地试验和翻译得到了意大利外交与发展合作部的资金支持。 《糖尿病视网膜病变和糖尿病管理系统评估工具》的开发由世界卫生组织预防 盲症和耳聋处协调，并得到了澳大利亚眼科研究中心（墨尔本大学）和孟席斯卫生 政策中心（悉尼大学）的技术支持。在本文件编写过程中，国际眼科理事会提供了 技术评论。 目录 有关糖尿病和糖尿病视网膜病变的事实 4 糖尿病和糖尿病视网膜病变管理系统评估工具的内容 6 建议的方法 8 评估工具 10 伦理 12 第1部分：重点、政策和规划 13 第2部分：服务提供 17 第3部分：卫生人力 22 第4部分：卫生技术 23 第5部分：卫生信息管理系统 24 第6部分：有关糖尿病和糖尿病视网膜病变的健康促进活动 26 第7部分：卫生供资 28 参与评估的人员 29 糖尿病视网膜病变和糖尿病管理系统评估工具4 有关糖尿病和糖尿病视网膜病变 的事实 当前，糖尿病（DM）是全世界公共卫生面临的一种新威胁： • 全世界有4.22亿人患糖尿病。 • 据估计，2012年有380 万人死于空腹血糖高造成的后果。 • 百分之八十以上糖尿病死亡发生在低收入和中等收入国家。 • 世卫组织预计，到2030年，糖尿病将成为第七大死因。 有证据表明，简单的生活方式措施（健康的体重；身体活动；健康饮食）可以 有效地预防或推迟2型糖尿病发病。 可以通过相对而言并不昂贵的验血措施实现及早诊断。 治疗糖尿病涉及降低血糖及降低破坏血管的其它已知危险因素水平。 糖尿病视网膜病变（DR）是全世界视力损害的第五大原因，也是失明的第 四大原因： • 全世界有2.85亿人视力受损。 • 据估计，2010年，全世界有3930万人患有盲症。 • 百分之八十以上视力受损者生活在低收入环境下。 • 百分之八十以上盲人为50岁以上。 • 糖尿病视网膜病变是导致420万人视力损害的原因。 糖尿病视网膜病变的发病是由长期糖尿病造成的；如果糖尿病控制得不好，则 该病的情况会更糟糕。要预防糖尿病视网膜病变导致的视力损害，主要是通过控制 糖尿病、及早发现视网膜改变以及在确定出现糖尿病造成的损害后及时治疗威胁视 力的视网膜病变。抗血管内皮生长因子制剂可以减少疾病发展并维持视功能。 在管理糖尿病并预防该病造成不可逆失明的工作中，卫生系统可以发挥的最关 键作用就是促进糖尿病管理者和糖尿病视网膜病变管理者之间的合作。这似乎显而 易见，但在低收入国家的卫生系统中并未得到普遍实施，实际上在中等收入和高收 入国家也落实得不够。 糖尿病视网膜病变和糖尿病管理系统评估工具 5 本文件宗旨 为评估各国糖尿病和糖尿病视网膜病变管理状况并评估卫生保健系统这两项工 作之间的合作和协同水平，世卫组织在支持下设计了本评估工具。可以使用该工具 进行形势分析，确定服务提供水平并找出在确保普遍获得糖尿病治疗和有效预防治 疗糖尿病视网膜病变方面还存在哪些差距。 糖尿病视网膜病变和糖尿病管理系统评估工具6 糖尿病和糖尿病视网膜病变管理 系统评估工具的内容 根据世卫组织卫生系统框架确定了调查项目，并按如下主题加以组织1： 1. 服务提供：根据有关糖尿病和糖尿病视网膜病变的可获得数据、重点、政策和卫 生保健规划估算需求情况；它们是如何纳入公共卫生系统和对方（网络）的；糖 尿病治疗和眼科治疗之间是否存在转诊途径及其性质；服务处所；公共和私营服 务部门提供治疗的情况。 2. 卫生人力：参与糖尿病和眼保健服务的工作人员的结构、数量、分布和培训 情况。 3. 卫生信息管理系统：关键绩效指标；针对糖尿病患者个人记录了哪些信息；数据 收集和沟通；患者随访系统。在可能的情况下，应利用病历评估是否根据规定定 期进行糖尿病和眼科检查监测。 4. 医疗产品和技术：卫生保健提供者能够获得和使用诊断、管理和监测疾病的设 备，这些设备是否功能运转正常。 5. 卫生供资：政府支出、医保方案、社会保障计划；为弱势人群（偏远农村地区、 穷人、老人和少数民族）在各个阶段提供各种类型的治疗服务。 6. 领导和治理：重要利益攸关方及其在糖尿病和糖尿病视网膜病变管理中的作用； 是否存在管理糖尿病和糖尿病视网膜病变的指南，遵守情况如何。 1 http://www.wpro.who.int/health_services/health_systems_framework/en/ 糖尿病视网膜病变和糖尿病管理系统评估工具 7 评估目标 糖尿病和糖尿病视网膜病变管理系统评估工具的主要目标是： • 评估特定领土或国家是否存在针对糖尿病和糖尿病视网膜病变的卫生保健服务及 其可用性和可获得性； • 描述糖尿病患者管理和糖尿病视网膜病变管理之间是否存在联系以及这种联系是 否有效； • 确定国家卫生系统各级在为糖尿病患者提供眼保健方面面临哪些挑战； • 向政府和利益攸关方提供有关卫生系统哪些方面应予重点强调以促进未来研究和 开发工作的信息。 形势分析应从国家卫生系统的角度出发而不是关注个别服务提供者或机构。 糖尿病视网膜病变和糖尿病管理系统评估工具8 建议的方法 按主管业务收集数据 需要获得糖尿病流行率和糖尿病视网膜病变造成的视力损失流行率数据，以便 确定国家层面的需求。如果最近进行过国家或省市一级的调查，就可以从这些调查 中获得数据；如果没有此类调查数据，则可以使用世卫组织全球卫生观察站1的各国 糖尿病视网膜病变数据。据估计，约有三分之一糖尿病患者存在某种程度的视力损 失2。可以请卫生部提供给有关提供糖尿病治疗和眼保健的卫生服务机构的数量和分 布情况数据，还可联系卫生专业人员组织以获得有关全国和各省市相关专业人员（ 例如内分泌科医生、眼科医生）数量和分布情况的信息。 确定所有相关利益攸关方和重要信息提供者 建议采访以下组织和部门的重要信息提供者，先从卫生部和世卫组织国家办 事处开始： • 卫生部 – 主管部领导 – 慢性病管理/生活方式相关部门 – 食品和营养相关部门 • 世界卫生组织国家办事处 • 国家预防盲症委员会 • 参与提供糖尿病保健和眼保健的地方和国际非政府组织 • 专业组织 – 初级保健：全科医生（初级保健医生/家庭医生）、初级保健护士 – 糖尿病和内分泌科：内分泌科医生、糖尿病专家、内科医生、初级保健糖尿 病知识教育者、糖尿病护士 – 眼保健：眼科医生、玻璃体视网膜专家、验光师（如有） • 消费者/患者代表组织 • 糖尿病协会 1 世卫组织全球卫生观察站 (http://www.who.int/gho/en/) 2 预防糖尿病造成的盲症 (http://www.who.int/diabetes/publications/prevention_diabetes2006/en/) 糖尿病视网膜病变和糖尿病管理系统评估工具 9 预约采访 应将形势分析主题清单发给所有要采访的个人，以便其预先收集必要数据。 完成《糖尿病视网膜病变和糖尿病管理系统评估工具》约需一个小时，但并不需 要每个人都填完所有部分的内容。也可根据具体情况对在糖尿病或眼保健领域具 备类似具体领域经验的多个利益攸关方或信息提供者进行集体采访。 数据分析 可以手写或用电脑记录采访重要信息提供者获得的信息，在被采访者同意的情 况下，也可使用音频文件。被采访者所做回答应誊写到调查问卷相关部分，以便利 定性分析。应按照糖尿病视网膜病变和糖尿病管理系统评估工具所用类别总结定量 数据。 糖尿病视网膜病变和糖尿病管理系统评估工具10 评估工具 第1部分：重点、政策和规划 • 国内是否已有糖尿病管理指南和糖尿病视网膜病变管理指南？如果有，遵守现行 指南的情况如何？ 第2部分：服务提供 • 有关糖尿病流行率的国家数据。 • 有关视力损害流行率和病因的国家数据。 • 本国公立（政府）和私立医院名单、有关其提供眼保健服务能力的信息以及设备 清单。（村、区、省、三级医院和医疗中心）卫生保健机构的大概数量和（按省 市或按卫生系统级别）分布情况。 第3部分：卫生人力 • 注册眼科医生（包括玻璃体视网膜手术和医学视网膜专家）、内科医生、全科医 生、护士和验光师（如果本国法规包括这个专业类别）的估计数量和分布。 第4部分：卫生技术 • 描述用于诊断和监测糖尿病的设备。 • 各医院的眼科设备情况。 第5部分：卫生信息管理系统 • 按诊断或服务类型分解的有关使用糖尿病和眼保健服务的地方或国家数据。 • 有关卫生保健服务提供者之间分享患者数据的方法的信息。 • 来自任何慢性病和/或视力损害国家登记册的细节。 • 利用提醒系统召回糖尿病或糖尿病视网膜病变患者进行复查预约。 糖尿病视网膜病变和糖尿病管理系统评估工具 11 第6部分：促进糖尿病和糖尿病视网膜病变管理的健康促进 活动 • 用于社区宣传和患者教育的公共卫生材料的题目和细节。 • 利用世界视力日和世界糖尿病日开展提高公众认识的大型活动。 第7部分：卫生供资 • 由政府医疗保险支持糖尿病检查、监测和治疗的人群占人口比例。 • 有商业医疗保险的人群占人口比例。 • 可以申请政府医保报销的糖尿病和眼保健项目/服务清单。 糖尿病视网膜病变和糖尿病管理系统评估工具12 伦理 鉴于预计将发表最终评估报告，可能需要根据各国政府（卫生部）法规和规定 获得进行本评估的伦理审批。 所有信息均应以匿名方式记录：信息来源很重要，但不应提及个人姓名。 应该能够获得不同利益攸关方的观点，以便用于分析。 请利用提供的调查问卷提供所要求的信息。任何额外表格或文件均可作 为附件提供。确保完整填写每部分结尾处的评分表。 应提供所收到回答的摘要，以便适当反映一国不同地区的情况。 糖尿病视网膜病变和糖尿病管理系统评估工具 13 重点、政策和规划 国家糖尿病防治计划/规划 1. 糖尿病是否被确定为国家卫生重点？ 是 否 2. 糖尿病视网膜病变是否被列为国家预防盲症计划的重点？ 是 否 3. 是否有国家糖尿病防治计划？ 是 否 4. 如果有，该国家计划包括哪些内容？ 糖尿病的初级预防 并发症（包括视力损害） 社区意识和患者教育 临床治疗、服务和物资 评论： 5. 有无有关食品和/或营养的国家政策？ 有 无 6. 有无有关食品和/或营养的国家规划？ 有 无 规划名称： 负责该规划的牵头单位： 第1部分： 糖尿病视网膜病变和糖尿病管理系统评估工具14 7. 有无有关预防糖尿病的国家政策？ 有 无 8. 有无有关预防糖尿病的国家规划？ 有 无 规划名称： 负责该规划的牵头单位： 9. 有无国家级糖尿病协会？ 有 无 a. 该机构开展哪些工作？ 患者教育和提高认识 临床人员教育和提高认识 政策制定和宣传 服务提供者和糖尿病患者之间的网络 b. 糖尿病协会利用了哪些健康促进和患者教育策略？ 选择最能反映本国情况的数字1 糖尿病是否成为重点，具备相应政策和规划： 1 2 3 4 1 选择依据： 1 – 糖尿病并非重点；不存在国家计划或国家规划。 2 – 糖尿病被列为重点；有国家计划，但尚未实施规划。 3 – 糖尿病被列为重点；已经制定了国家计划，已有国家规划，但尚未覆盖全国。 4 – 糖尿病被列为重点；以及制定了国家计划并建立规划且实现了覆盖全国。 糖尿病视网膜病变和糖尿病管理系统评估工具 15 临床管理指南 10. 是否已有糖尿病管理指南？ 是 否 （如回答“是”，请注明最常用临床管理指南的全名，并提供一份副本。） a. 指南内容是否包括糖尿病视网膜病变？ 是 否 b. 该指南适用于卫生保健系统哪个级别（初级、二级、三级）？ c. 该指南的目标读者是谁（例如初级卫生保健工作者、专科医生）？ 11. 是否可以获得有关糖尿病视网膜病变管理的循证指南？ 是 否 （如回答“是”，请注明最常用临床管理指南的全名，并提供一份副本。） a. 该指南是否涵盖以下内容： 预防糖尿病视网膜病变造成的视力损失？ 治疗？ 随访？ b. 该指南适用于卫生保健系统哪个级别？ 初级 二级 三级 c. 指南是： 以证据为基础 还是以共识为基础 还是两者的结合 糖尿病视网膜病变和糖尿病管理系统评估工具16 如果指南是以共识为基础的，哪些利益攸关方参与了指南的拟定？ 12. 指南是否得到使用？ 主观评分：1 = 未使用， 12 =广泛使用（请圈上您认为最适合的数字） 1 2 3 4 5 6 7 8 9 10 11 12 13. 请介绍采取了哪些措施使目标读者了解到存在这些指南？指南是怎么传播的 （例如印刷材料或是在网站上发布）？使用了哪种语言？ 选择最能反映本国情况的数字1： 糖尿病临床管理指南： 1 2 3 4 糖尿病视网膜病变流程管理指南： 1 2 3 4 1 选择依据： 1 – 不存在卫生部推荐的指南。 2 – 已经形成了卫生部指南，但卫生公众者不知道还有指南，因此指南未得到广泛使用。 3 – 存在卫生部指南，而且为相应目标读者所知，但并非得到广泛遵循。 4 – 存在卫生部指南，并得到了普遍遵循。 有关第1部分内容的更多信息 糖尿病视网膜病变和糖尿病管理系统评估工具 17 服务提供 网络和联系 14. 描述新诊断糖尿病患者是怎么被发现的。 a. 相关服务机构的处所（村、区、地区、省、三级诊疗机构）？ b. 该设施？ 是私立 还是公立 15. 描述糖尿病患者正在接受的诊疗服务是如何开展的。 a. 相关服务机构的处所（村、区、地区、省、三级诊疗机构）？ b. 该设施？ 是私立 还是公立 16. 描述糖尿病患者获得服务的情况。 a. 多大比例人口能够获得该服务？ b. 存在哪些障碍造成人们无法获得服务？ 17. 在社区一级为糖尿病患者提供哪些服务？ a. 临床服务： 以便发现病人并评估风险 b. 患者教育和支持服务： 针对糖尿病的 针对糖尿病视网膜病变的 第2部分： 糖尿病视网膜病变和糖尿病管理系统评估工具18 18. 是否有糖尿病专科诊疗中心？ 是 否 a. 如回答“是”，该中心提供什么服务？ b. 多大比例人口能获得这些服务？ 选择最能反映本国情况的数字1 糖尿病服务的地点和有需求人群能否获得该服务： 1 2 3 4 1 选择依据： 1 – 没有多少地方和人可以获得服务。 • 服务并不是在所有地方都可以获得；服务仅存在于大型医院，只有支付得起的人能够 获得。 2 – 部分人口可以获得一些服务。 • 地区医院或卫生中心提供服务，患者需支付部分费用。农村地区人口无法便捷地获得服 务；前往卫生设施的交通和服务费用是存在的主要障碍。 3 – 全国各地均提供相关服务，但部分人口无法获得。 • 大部分城乡地区的区、地区、省和三级医疗机构均提供服务；但是，对一些患者而言， 就医费用和交通是主要障碍。 4 – 全国各地均提供相关服务，所有人口均可获得。 • 所有地点均提供服务，服务费用由保险报销、国家补贴或者免费提供。 糖尿病视网膜病变筛查 19. 是否安排糖尿病患者定期进行眼科会诊？ 是 否 a. 这是否包括对无症状者进行眼科会诊？ 是 否 糖尿病视网膜病变和糖尿病管理系统评估工具 19 b. 是否只在人们包括出现视力损失症状时才对其进行眼科会诊？ 是 否 c. 眼科检查是否纳入糖尿病患者年度诊疗周期？ 是 否 20. 是否存在糖尿病视网膜病变社区筛查规划？ 是 否 a. 如何征集糖尿病患者进行筛查？ b. 有哪些人员参与筛查工作？ c. 是否提供延伸筛查？ 是 否 d. 筛查覆盖率？ e. 谁支付筛查费用？ 21. 哪一级诊疗机构最经常提供针对糖尿病视网膜病变的眼科检查，村、区、地区、 省还是三级医疗机构？ a. 多大比例人口能够获得该服务（没有人、30%、60%、90%、100%）？ b. 存在哪些障碍使人们无法获得服务？ 糖尿病视网膜病变和糖尿病管理系统评估工具20 c. 提供服务的？ 是私立 还是公立机构 选择最能反映本国情况的数字1 糖尿病视网膜病变服务的地点和有需求人群能否获得该服务： 1 2 3 4 1 选择依据： 1 – 没有多少地方和人可以获得服务。 • 服务并不是在所有地方都可以获得；只有大医院提供该服务，也只有那些能够付费的人 可以获得。 2 – 部分人口可以获得一些服务。 • 地区级医院或卫生中心提供服务，患者需支付部分费用。农村地区人口无法轻易获得服 务；到卫生机构的交通和服务费用是主要障碍。 3 – 全国各地均提供相关服务，但部分人口无法获得。 • 大部分城乡地区的区、地区、省和三级医疗机构均提供服务；但是，对一些患者而言， 费用和交通仍构成障碍。 4 – 全国各地均提供相关服务，所有人口均可获得。 • 所有地点均提供服务，服务费用由保险报销、国家补贴或者免费提供。 22. 描述糖尿病诊疗服务和眼保健服务之间的网络。 a. 利益攸关方 b. 转诊路径（单向、双向） c. 从业人员之间分享哪些信息？ 23. 是否有任何非政府组织参与糖尿病和糖尿病视网膜病变患者的诊疗服务？ 是 否 糖尿病视网膜病变和糖尿病管理系统评估工具 21 如答案为“是”，它们在糖尿病管理和糖尿病患者的眼科检查中发挥什么作用 （健康促进、筛查、激光、玻璃体视网膜手术）？ 选择最能反映本国情况的数字1 糖尿病和糖尿病视网膜病变诊疗服务提供者之间的网络： 1 2 3 4 1 选择依据： 1 – 分别提供糖尿病和糖尿病视网膜病变诊疗的机构之间不存在已知的合作。 2 – 少数中心提供以患者为中心的诊疗服务。 3 – 一些中心提供以患者为中心的诊疗服务，在糖尿病服务和糖尿病视网膜病变服务之间存 在合作关系。 4 – 大部分中心提供以患者为中心的诊疗服务，在糖尿病服务和糖尿病视网膜病变服务之间 存在合作关系。 有关第2部分内容的更多信息 糖尿病视网膜病变和糖尿病管理系统评估工具22 卫生人力 24. 哪些类别的卫生专业人员（内分泌科医生、眼科医生、初级保健医生、普通护 士或接受过糖尿病或眼科培训的护士、营养师等）能够为糖尿病患者提供诊疗 服务？ 卫生系统各级服务提供者和患者之间的比例是多少？ 25. 糖尿病管理的哪些方面已经纳入初级卫生保健工作者（护士和初级保健医生） 的培训课程？ 糖尿病并发症相关知识，具体而言，糖尿病视网膜病变带来的视力损失 对患者进行健康教育 进行眼科会诊的需求和时机 糖尿病视网膜病变的管理 26. 向初级卫生保健工作者提供的继续医学教育是什么形式的？ 政府、大学、专业组织提供的正式培训 定期的非正式信息更新 研讨班 更新指南 选择最能反映本国情况的数字1 糖尿病和糖尿病视网膜病变诊疗提供者的培训机会和质量： 1 2 3 4 1 选择依据： 1 – 很大程度上是不够的。 2 – 培训机会不多；造成所需人力资源不足。 3 – 只有在大城市和大医院才提供培训。 4 – 有关糖尿病和糖尿病视网膜病变的培训数量适当、质量高。 第3部分： 糖尿病视网膜病变和糖尿病管理系统评估工具 23 卫生技术 27. 是否提供以下调查/设备？ 糖化血红蛋白、脂类、肌酐、尿蛋白的生化实验室检验 血糖仪（由糖尿病患者或卫生服务机构拥有或保管） 裂隙灯 直接检眼镜 28. 使用哪些技术进行视网膜检查，以发现糖尿病视网膜病变？ 眼科医生进行散瞳检查 验光师进行散瞳检查 视网膜成像，使用散瞳相机 视网膜成像，使用非散瞳相机 29. 哪些机构能够提供这些技术（村、区、地区、省、三级诊疗机构）？ 选择最能反映本国情况的数字1 卫生技术的可获得性： 1 2 3 4 1 选择依据： 1 – 现代检查技术无法为大部分患者所获得。 2 – 只有主要医院和私立诊所能够提供现代检查技术。 3 – 大部分省级医院和诊所均提供现代检查技术。 4 – 所有患者均可获得现代检查技术。 有关第3部分和第4部分的更多信息 第4部分： 糖尿病视网膜病变和糖尿病管理系统评估工具24 卫生信息管理系统 30. 对哪些国家一级商定的糖尿病相关卫生人口指标进行监测？ 流行率 患病率 未测量 测量的频率如何？ 31. 对哪些国家一级商定的糖尿病视网膜病变相关卫生人口指标进行监测？ 视力损害和盲症流行率 未测量 测量的频率如何？ 32. 描述收集信息所使用的方法（调查、医院数据、健康保险统计数字）。 33. 描述整理和报告该信息的方法（标准化数据集）。 34. 医院的患者病历中记录那些有关糖尿病患者个人的信息？ 危险因素 并发症，包括糖尿病视网膜病变 之前进行的针对糖尿病视网膜病变的眼科检查 治疗情况 随访情况 第5部分： 糖尿病视网膜病变和糖尿病管理系统评估工具 25 35. 是否存在召回糖尿病患者进行后续眼科检查的制度？ 是 否 沟通方法：个人记录册、信息卡 移动卫生保健：利用手机短信提醒 选择最能反映本国情况的数字1 疾病负担相关知识： 1 2 3 4 1 选择依据： 1 – 不了解或未估算过糖尿病和糖尿病视网膜病变流行率；有关患者的信息不足。 2 – 已知糖尿病流行率但不知糖尿病视网膜病变流行率。 或者 已知糖尿病视网膜病变流行率但不知糖尿病流行率，未利用患者记录。 3 – 已知或估算过糖尿病和糖尿病视网膜病变流行率；使用患者记录分析全国范围的数据。 4 – 已知或估算过糖尿病和糖尿病视网膜病变流行率；整理、分析并定期发布患者记录。 有关第5部分的更多信息 糖尿病视网膜病变和糖尿病管理系统评估工具26 有关糖尿病和糖尿病视网膜 病变的健康促进活动 36. 是否向社区提供有关糖尿病的信息？ 症状和体征 危险因素 并发症 管理 去哪里寻求帮助 37. 是否向社区提供有关糖尿病视网膜病变的信息？ 是 否 38. 采用什么方式就糖尿病开展社区教育？ 印刷媒体 移动卫生保健：利用手机短信提醒 电台/电视 39. 健康促进和患者教育的覆盖面有多广？ 全国范围 省市 区 40. 是否让糖尿病患者了解了糖尿病患者组织？ 是 否 采用什么方式让患者支持组织接触到弱势群体： 在农村地区？ 使用哪种语言/方言？ 针对残疾人？ 第6部分： 糖尿病视网膜病变和糖尿病管理系统评估工具 27 41. 举例说明如何利用世界糖尿病日和世界视力日等倡议就糖尿病造成的视力损害 教育普通人和医务工作者。 选择最能反映本国情况的数字1 向社区和患者提供的有关糖尿病和糖尿病视网膜病变的信息和教育： 1 2 3 4 1 选择依据： 1 – 向社区提供的信息不多，也很少进行患者教育。 2 – 偶尔通过国家级媒体向社区提供信息；不是所有患者都得到教育。 3 – 在国家和省一级提供了信息；大部分患者都得到教育。 4 – 各个级别都提供了信息；所有患者都得到教育，患者组织积极参与。 有关第6部分的更多信息 糖尿病视网膜病变和糖尿病管理系统评估工具28 卫生供资 42. 以什么方式为针对糖尿病患者的干预措施提供资金？ 活动 多大比例 资金由政 府提供 多大比例资 金由私人保 险提供 多大比例资 金由患者提 供（自费） 多大比例资 金由非政府 组织提供 多大比例资金由 其它行动者提供 （具体说明） 医疗 住院治疗 药物 实验室检验 其它 （请具体说明） 43. 以什么方式为针对糖尿病视网膜病变患者的干预措施提供资金？ 活动 多大比例 资金由政 府提供 多大比例资 金由私人保 险提供 多大比例资 金由患者提 供（自费） 多大比例资 金由非政府 组织提供 多大比例资金 由其它行动 者提供 （具体说明） 预防 （视网膜筛查） 激光凝固疗法 玻璃体视网膜手术 其它 （请具体说明） 有关第7部分的更多信息 第7部分： 糖尿病视网膜病变和糖尿病管理系统评估工具 29 参与评估的人员 姓名 职称/单位 电子邮件
糖尿病视网膜病变和糖尿病管理系统评估 工具 ISBN 978 92 4 550919 6 世界卫生组织 * * Tool for the assessment of diabetic retinopathy and diabetes management system 世界卫生组织 非传染性疾病、残疾、暴力和伤害预防管理司 世界卫生组织 20, avenue Appia CH-1211 Geneva 27 Tel: +41 22 791 2111 Fax: +41 22 791 3111 www.who.int/blindness