The eye doctor: how to get earlier diagnoses and shorter waiting lists

According to the most recent estimates, a million Italians suffer from diabetic retinopathy, and 800,000 from glaucoma; 3.5 million have macular degeneration, half of whom are unaware of their condition.

In all three cases, we’re talking about potentially debilitating pathologies, but too often medical intervention comes too late. In fact, at-risk patients struggle to access the system and get eye checkups, in part due to endless waiting lists. As a result, although guidelines advise all patients with diabetes to have a comprehensive eye exam every year, only 17.46% actually do so.

With the current system, people experiencing the initial stages of eye afflictions easily slip through the cracks, which means missed opportunities to intervene and slow the progress of the diseases. This prompted us to ask ourselves how to speed up diagnosis and find organizational solutions that make this change sustainable in the NHS.

From July 2023 to March 2024, three CERGAS-IAPB Italy working groups collaborated to identify innovative, sustainable solutions. The most deployable solution emerged for diabetic retinopathy.

At a national level, the most frequently utilized diagnostic for diabetic retinopathy is a comprehensive eye exam and a fundus exam. Although it’s not as common, a digital photograph of the fundus, or retinography, is recommended by the World Health Organization (WHO) as the preferred screening option.

If all diabetics in Italy had a comprehensive eye exam every year (as per current recommendations), this would take up the full-time working hours of 890 of the NHS’s 1,500 ophthalmologists. In contrast, retinography is easy to do via telemedicine. In this case, performing the diagnostic exam and making a clinical assessment of the results are two separate tasks. That means retinography can happen outside ophthalmology day hospitals (for instance in outpatient diabetes clinics), and it can be done by nurses or other health professionals, not necessarily doctors. The clinical assessment, instead, is still delegated to specialist physicians with specific training in this type of diagnosis. What’s more, in the future retinography will make it possible to apply automation to interpret diagnostic imaging thanks to AI, automating the process and escalating only suspicious cases to eye specialists.

We’ve done calculations that take into account different organizational strategies and various adoption scenarios. What we’ve found is that with an added expenditure ranging from €1.5 million to €3.5 million (for nursing staff and machines), the outcome could be 400,000 additional patient screenings, or 150,000 more slots for eye exams, shrinking the waiting list considerably.

After the UK adopted a similar program, for the first time in over fifty years diabetic retinopathy/macular degeneration is no longer the leading cause of blindness in working age adults there. At a global level, it still is.

Naturally this approach can’t be used for all the pathologies that would theoretically require it. We’re proposing a full rollout for diabetic retinopathy, but there is still a long way to go before we can apply it to glaucoma and macular degeneration.

Yet we do believe we’ve mapped out a useful path that makes prevention a vital tool in safeguarding people’s health and securing the efficiency of public resources. The real goal is to create a system that not only intercepts patients in the early stages of the disease in question, but one that can do so in a sustainable way throughout the country, lightening the load on an overburdened healthcare system.

CERGAS – SDA Bocconi. Il ruolo della prevenzione nella definizione di nuovi modelli di organizzazione e di gestione della diagnosi precoce oftalmica nel SSN. Il caso della retinopatia diabetica e prime valutazioni per glaucoma e maculopatie. Research report for IAPB Italia.