on those public health aspects not covered in other sections. 5.2 THE BURDEN OF DISEASE FROM DIABETIC RETINOPATHY Vision loss due to DR is an important cause of disability in the working age population. The public health impact of DR can be assessed using methodology developed by The World Health Organisation to measure and value the burden of disease. The disability adjusted life year (DALY) measures the loss in a healthy life year and is used to quantify non-fatal health outcomes. In a study of the costs of sight loss commissioned by the Royal National Institute for Blind People (RNIB) (Access Economics, 2009)1 it was estimated that 190,000 DALYs were lost in 2008 in the UK due to disability associated with partial sight and 35 blindness. Of this visual disability, 6%, (equivalent to 11,300 DALYs in 2008) was attributed to DR. This figure compares to 31% attributed to aged-related macular degeneration (AMD). However, if just the working age population is considered, DR accounted for 17.5% of disability, compared to 0.5% due to AMD. Further studies are required to provide up to date data to quantify the burden of disease due to DR in 2012. 5.3 QUALITY OF LIFE DR has a negative impact on quality of life, particularly in the advanced stages2,3,4 although variations in assessment tools and outcomes (quality of general health -HRQoL vs. quality of vision) make comparisons of studies difficult. At similar levels of visual acuity loss, the impact on quality of life related to DR was shown to be comparable to that related to AMD5 , which has implications for cost utility analyses of ophthalmic interventions. Bailey and Sparrow6 (2001) also described significant levels of co-morbidity in patients with DR, including angina, myocardial infarction and renal impairment, which has an impact on the clinical management of eye disease. Brown7 , however, indicated that the presence of co-morbidities in patients with ocular disease did not affect ocular utility values. Depression has also been shown to be more prevalent in the diabetic population compared to the non-diabetic population (24% vs. 17%) and is an important co-morbidity that should be considered in the treatment of patients with diabetes8 . 5.4 SOCIO-ECONOMIC INEQUALITIES The impact of socio-economic status on the outcome from DR may be mediated through a number of mechanisms: · The prevalence of diabetes · The prevention, diagnosis, treatment and control of diabetes,hypertension and other co-morbidities · The uptake of screening for DR · The prevalence of sight threatening DR · The diagnosis, control and treatment of DR 5.4.1 Socio-economic status and prevalence of diabetes. There is a significant body of evidence that demonstrates that the prevalence of type 2 diabetes but not type 1 diabetes is adversely affected by deprivation 9,10,11,12 . Robbins (2005) 12 also found that in women the incidence of diabetes was inversely associated with educational status, income and occupational status. Scanlon13(2008) demonstrated that prevalence of diabetes also increased with increasing deprivation quintiles and that prevalence of sight threatening DR amongst those screened also increased. 36 5.4.2 Socio-economic influences on the prevention, diagnosis, treatment and control of diabetes Ricci-Cabello14 in a review of the literature in 2010 concluded that in Organisation for Economic Co-operation and Development (OECD) countries which have universal healthcare systems there is evidence that socio-economic inequalities were found in the diagnosis and control of disease and the existence of ethnic inequalities in treatment, metabolic control and use of healthcare services. Earlier studies in the UK indicate similar findings. Robinson in 1998 found a significant association between social deprivation and mortality in people with type 2 diabetes (OR 2.0 CI 1.41 – 2.85) but not in people with type 1 diabetes15. In 2000 Weng et al in London showed that patients with diabetes living in more deprived areas had significantly worse glycaemic control and a higher BMI16 . In 2001 Roper et al17 showed that the risk of premature death in people with diabetes in South Tees increased significantly with increasing material deprivation. In 2004, Hippisley-Cox reported on quality indicators for diabetes in GP Practices. On many indicators, scores were worse for women, those from BME communities and those with high levels of material deprivation18 . 5.4.3 Socio-economic status and uptake for DR screening In 2006 Millet and Dodhia looked at screening uptake in South East London. Ages younger than 40 years, Type 1 diabetes and deprivation were all risk factors for nonattendance19. In 2008, Scanlon had similar findings in a study in Gloucestershire, with increasing deprivation associated with poorer uptake13 . Similarly, a more recent study indicated that non-attendance for screening was particularly poor amongst those aged 18-34 and those over 85 years but suggested that the DR screening inequalities attributed to socio-economic factors (primarily deprivation), although still evident, may not be quite as marked as previously reported20 . 5.4.4 Implications for policy It is notable that these factors all act in the same direction. Those from more deprived communities are more likely to develop type 2 diabetes, have poorer control and be less likely to access care and take up offers of screening. Achieving a reduction in the burden of disease from DR therefore requires a focus on those from more deprived communities. Failure to develop strategies to address the needs of those known to be at higher risk of developing diabetes and its complications will mean that approaches such as screening will not deliver their potential to reduce sight loss and will have the potential to increase health inequalities. Recommendation: Further research should be undertaken to understand the impact of socio-economic status on DR and what steps can be taken to reduce inequalities in access and outcome. (Level B) 37 5.5 PREVENTION Modifiable risk factors for DR are discussed in detail in the following chapter and include control of glycaemia, blood pressure and lipid levels. On a population level, modifying