Victorian ophthalmology service planning framework
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Victorian ophthalmology service planning framework
Published by the Victorian Government Department of Human Services Melbourne, Victoria
This publication is copyright, no part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968.
Authorised by the State Government of Victoria, 595 Collins Street, Melbourne.
This document may also be downloaded from the Department of Human Services web site at health..au/ophthalmology
© Copyright State of Victoria 2005
October 2005
(050908)
Contents
Contents
1 Executive summary 1
1.1 Background 1
1.2 Methodology 2
1.3 Ophthalmology services in Victoria 2
1.4 Discussion and recommendations 3
2 Introduction 9
2.1 Policy context for the future directions of ophthalmology services 9
2.2 Eye care initiatives 11
2.3 Methodology 13
2.4 Report structure 14
2.5 Scope and definitions 14
Eye care professionals 14
Ophthalmology service system 16
3 Ophthalmology services in Victoria 17
3.1 Geographic distribution of services 17
3.2 Current service provision 19
3.3 Predicted changes to ophthalmology services 20
4 Discussion and recommendations 21
4.1 Access 21
Waiting times for services 21
Elective surgery management and referral 24
Eye care literacy 26
Referral pathways 27
Cost of eye care services 28
Service distribution 30
Royal Victorian Eye and Ear Hospital 35
Forecast demand for eye services 36
Forecast prevalence of eye health conditions 39
Cost of vision loss 42
4.2 Appropriateness 43
Utilisation rates 43
Models of care and workforce roles 46
Workforce 48
4.3 Efficiency 49
Technical efficiency: models of care and work settings 49
Allocative efficiency 52
Funding and price 52
4.4 Acceptability 55
4.5 Effectiveness 56
4.6 Safety 57
4.7 Information management 58
4.8 Competence, education and research 59
Education and training 60
Research 63
4.9 Consumer involvement 64
4.10 Governance and leadership 66
5. Implementation plan 67
5.1 Health service strategic plans and statement of priorities 67
5.2 Implementation plan 68
1 Executive summary 1
1.1 Background 1
1.2 Methodology 2
1.3 Ophthalmology services 2
1.4 Discussion and recommendations 3
2 Introduction 9
2.1 Policy context for the future directions of ophthalmology services 9
2.2 Eye care initiatives 11
2.3 Methodology 13
2.4 Report structure 14
2.5 Scope and definitions 14
Eye care professionals 14
Ophthalmology service system 16
3 Ophthalmology services in Victoria 17
3.1 Geographic distribution of services 17
3.2 Current service provision 19
3.3 Predicted changes to ophthalmology services 20
4 Discussion and recommendations 21
4.1 Access 21
Waiting times for services 21
Elective surgery management and referral 24
Eye care literacy 26
Referral pathways 27
Cost of eye care services 28
Service distribution 30
Royal Victorian Eye and Ear Hospital 35
Forecast demand for eye services 36
Forecast prevalence of eye health conditions 39
Cost of vision loss 42
4.2 Appropriateness 43
Utilisation rates 43
Models of care and the role of eye care professionals 46
Workforce 48
4.3 Efficiency 49
Technical efficiency: models of care and work settings 49
Allocative efficiency 52
Funding and price 52
4.4 Acceptability 55
4.5 Effectiveness 56
4.6 Safety 57
4.7 Information management 58
4.8 Competence, education and research 59
Education and training 60
Research 63
4.9 Consumer involvement 64
4.10 Governance and leadership 66
5. Implementation plan 67
5.1 Health service strategic plans and statement of priorities 67
5.2 Implementation plan 68
Appendices 70
1. Ophthalmology Service Planning Advisory Committee membership 70
2. Terms of reference for the Victorian ophthalmology service planning framework 71
3. List of responses to the discussion paper 72
4. List of attendance at stakeholder consultation meetings 74
5. Quality framework dimensions and organisational elements 77
6. Statewide provision of ophthalmology services 2002–03 79
7.Ophthalmology DRGs and ESRGs 1999-00 to 2002-03 83
8.Detailed ophthalmology forecasts 86
9.Estimated Resident Population - 2003 and 2016 89
10. Key performance indicators suggested by stakeholders 92
Glossary of terms 95
References 98
Websites 101
Appendices
1. Ophthalmology Service Planning Advisory Committee membership 69
2. Terms of reference for service planning framework 70
3. List of responses to the discussion paper 71
4. List of attendance at stakeholder consultation meetings 72
5. Quality framework dimensions and organisational elements 75
6. Statewide provision of ophthalmology services 2002–03 77
7. Ophthalmology DRGs and ESRGs 1999–2000 to 2002-03 81
8. Detailed ophthalmology forecasts 84
9. Estimated resident population 2003 and 2016 87
10. Key performance indicators suggested by stakeholders 90
Glossary of terms 93
References 96
Websites 98
1 Executive summary
Nearly half a million Australians have impaired vision, with the prevalence of vision loss trebling for every decade of life after 40 years of age. The ageing of the population will lead to a doubling of eye disease by the year 2020. Three quarters of visual impairment, however, can be prevented or treated.
There are high costs associated with vision disorders, with an estimated total cost in Australia in 2004 of $9.85 billion. Nationally, the direct health costs of treating eye disease are estimated at $1.8 billion, more than health spending on diabetes and asthma combined. Hospital costs are the largest direct health cost at $692 million with cataract the largest single direct health cost condition at $327 million. Indirect costs of visual impairment are estimated at $3.2 billion.
The Victorian ophthalmology service planning framework (the framework) provides a planning framework for the delivery of public ophthalmology services in Victoria to the year 2016. The framework aims to guide the future provision of care through design of the service system, the development of an appropriate workforce to support it, and address long-standing and emerging issues for the delivery of ophthalmology services.
1.1 Background
The framework has its foundation in recent government policy. The Metropolitan Health Strategy, Directions for your health system (MHS), released in October 2003 by the Department of Human Services (the department), identifies the need to establish service planning frameworks for a range of clinical specialities, including ophthalmology services.
The MHS also provides directions for specialist hospitals, including the Royal Victorian Eye and Ear Hospital (RVEEH). It recommends that specialist hospitals be collocated or affiliated with a general tertiary hospital and that a review and a service plan of the RVEEH be undertaken to identify its future role and optimal location. It also recommends that the RVEEH continue its role in providing complex care, training and research in ear, nose and throat (ENT) services and ophthalmology.
A number of initiatives are being undertaken by government and non-government organisations to prevent avoidable vision loss through strategies to improve awareness of eye health and access to services. The Victorian Government has provided funding over three years towards the Vision Initiative, which is run by Vision 2020 Australia. There is also work underway to develop a National Vision Plan.
1.2 Methodology
To inform the development of the framework, the department undertook broad stakeholder consultation, which included:
• establishing an Ophthalmology Service Planning Advisory Committee with representation from key stakeholder groups
• widely circulating the Victorian ophthalmology service planning framework discussion paper and inviting written submissions
• engaging Phillips Fox Lawyers (Dr Heather Wellington) and Campbell Research and Consulting to undertake broad stakeholder consultation through workshops and interviews
• developing a stakeholder consultation report entitled Victorian ophthalmology services: report on stakeholder consultations, September 2004.
For the purposes of this framework, the term ‘ophthalmology services’ has been defined to encompass medical and non-medical eye health care and related services provided by a range of health care professionals. It includes services provided by specialist and sub-specialist ophthalmologists, general practitioners (GPs), orthoptists, optometrists, ophthalmic nurses and health care professionals working in emergency departments.
1.3 Ophthalmology services
Ophthalmology services are predominantly ambulatory, with a high rate of same day surgery and a large proportion of eye disease managed on an outpatient basis. While ophthalmology services are generally well distributed across the state, there is a high concentration of service provision at the RVEEH, including treating 49 per cent of the state’s ophthalmology emergency presentations, 70 per cent of outpatient encounters and 42 per cent of public inpatient separations.
Future changes predicted to have an incremental but important impact on ophthalmology service delivery include: more emphasis on preventive models of care; an increase in ambulatory/day procedure service provision; a greater focus on multidisciplinary collaboration and holistic disease management models; an increase in the need to provide consumers with information to assist them in understanding eye disease and expectations of outcomes from treatment; and optometry having a major effect on ophthalmology practice, resulting from the ability to prescribe Schedule 4 medications.
The research and consultation process has identified a number of strengths, along with a range of issues to be addressed within the current ophthalmology service system. While the current system has served Victoria well, addressing some issues promises to deliver further improvements, ensuring future demands are met. Strengths of the service system in Victoria include: a high level of service provision across the state, when compared nationally and internationally; a highly trained and skilled eye care workforce; a distributed service system with many public hospitals providing some services; a strong track record in service delivery and professional education provided at the RVEEH; and research networks of high national and international significance.
1.4 Discussion and recommendations
Service access
While waiting times for elective surgery in Victoria compare well to those in other states and territories, variations in waiting times to access services create inequity in the service system. Factors including variations in referral processes, patient categorisation and elective surgery management processes impact on the equity of the service system. Outpatient and elective surgery management will benefit with the development and adoption of guidelines to inform ophthalmology practices.
| |
|Recommendation |
|1. Develop consistent guidelines and practices for accessing public ophthalmology outpatient services and elective surgery to |
|ensure that access is equitable, appropriate and based on clinical need. |
Barriers for consumers accessing eye care services and low cost glasses
A lack of eye care literacy, for both consumers and providers, is a recognised barrier to accessing eye services. Improving practitioners’ understanding of the roles of different eye care professionals, and reducing fragmentation between professional groups, will improve referral pathways. Programs under the Vision Initiative are being developed to educate both consumers and providers about the roles of different eye care professionals and improve consumers eye health literacy.
| |
|Recommendation |
|2. Improve eye health education and promotion programs for consumers and providers through support of the Vision Initiative. |
Affordability has been identified as a barrier to accessing eye care, with considerable criticism about the cost of glasses. The cost of glasses acts as a deterrent for many who need eye care and corrective lenses. The government-funded Victorian Eyecare Service (VES), which provides low cost glasses to concession card holders and their children under 18 years of age, makes a significant contribution towards accessing low cost glasses. Certain population groups, however, still face difficulties accessing eye care services. It was noted that a greater proportion of rural residents access the VES than metropolitan residents.
Recommendation
3. Improve and promote access to low cost glasses.
Access
While ophthalmology services are well distributed across the state, a strategic approach to service distribution which takes demographic changes in to account is an important part of delivering a high quality and equitable health service. Some health services have stopped directly providing elective ophthalmology services and while these health services have developed linkages with other health services to varying degrees, it is important that these closures do not reduce access to services in geographic areas.
Self-sufficiency is a measure of the degree to which people can access services close to home. Self sufficiency varies across the state, with 99.7 per cent of metropolitan residents who received ophthalmology inpatient services receiving these within metropolitan Melbourne, while 77 per cent of rural residents received services within rural Victoria in 2002–03. The Hume and Gippsland regions were the least self-sufficient at 60 per cent and 63 per cent respectively.
There is a strong view amongst stakeholders that all major metropolitan and regional hospitals should have a full range of primary and secondary services, including non-admitted consulting, emergency and surgical services. Establishing primary and secondary services in all public general tertiary hospitals will increase local access to services and reduce the need for referral to other health services for care.
There is a role for both large and small rural health services in providing ophthalmology services. The challenge is to ensure that services are planned and delivered in a coordinated way within a region or sub region.
Paediatric services
Children aged 0 to 14 years constitute only a small proportion of ophthalmology services. Nearly 4 per cent of ophthalmology separations and over 5 per cent of ophthalmology Medicare Benefits Schedule (MBS) claims were for children in 2002-03. Paediatric inpatient services are concentrated centrally, with the Royal Children’s Hospital (RCH) treating 37 per cent and the RVEEH treating 16 per cent in 2002–03. Due to the specialist requirements for treating paediatric patients, there is strong support for the RCH to continue its role as the key provider of public specialist paediatric ophthalmology services.
Recommendation
4. The following health services should ensure the provision of primary and secondary services for their tertiary campuses, including 24-hour on call, inpatient, outpatient and emergency consulting and surgery:
• Metropolitan
– RVEEH
– Western Health
– Northern Health
– Melbourne Health
– Austin Health
– Eastern Health
– Bayside Health
– Southern Health
– Peninsula Health
• Rural and regional
The implications for the five major regional hospitals to provide the range of services specified above will need to be considered in detail. Regional hospitals will play an important role in the provision and coordination of services across their region.
Elective surgery may be provided in alternate settings to the tertiary site or regional hospital, such as in same day and elective surgery centres or other rural hospitals.
The Royal Children’s Hospital should continue its role in specialist provision of paediatric ophthalmology services.
A distributed service system should be maintained through the provision of a range of primary and secondary services at rural hospitals.
Royal Victorian Eye and Ear Hospital
The majority of stakeholders believe that the RVEEH provides a very good service for tertiary patients. For efficiency and quality reasons, there is considerable support for maintaining a specialist tertiary hospital with a concentration of highly specialised services, possibly collocated with a general tertiary hospital. There is support for the maintenance and growth, over time, of integrated services in all metropolitan and regional tertiary general hospitals.
As recommended in the MHS, the RVEEH requires a detailed service plan and review to determine its future role and optimal location. The detailed service plan for the RVEEH will determine its catchment for primary and secondary services. There is support for the RVEEH to continue an active teaching and research role and to assist in ensuring equitable service provision across the state, through outreach services and other mechanisms.
| |
|Recommendation |
|5. The RVEEH should continue its role in teaching, research and specialist provision of ophthalmology services. The RVEEH will |
|provide primary and secondary services to its local population and provide elective surgical services to a broader population. |
Demand for eye services
Eye disease is forecast to double by the year 2020, which will lead to increased demands for eye care services. The Visual Impairment Project (VIP) found that the incidence of visual impairment and blindness increases threefold with each decade of age after 40 and that the ageing of the population will see the prevalence of eye disease double by 2020.
Consistent with the VIP, the department’s inpatient forecasts (2003–04) indicate public and private ophthalmology separations will grow by 3.4 per cent per annum, and bed days will increase by 2.9 per cent per annum to 2016–17. This growth is led by cataract procedures with a forecast growth in separations of 4.2 per cent per annum or a doubling by 2016–17.
Models of care and the role of eye care professionals
Models of care for ophthalmology service have undergone significant changes in the past two decades with an increasing trend toward ambulatory care. Ambulatory eye care services are provided as a day attendance at a health care facility or at a person’s home.
Within the context of ambulatory care, the emergence of new ophthalmology models of care locally, nationally and internationally, has created debate about the appropriateness and effectiveness of these new models. Condition-specific models of care for cataract surgery including pre and post operative care, the management of refractive error, and the screening for and management of glaucoma and diabetic retinopathy have been highlighted. Debate relates to where services are provided, whether in hospital or community settings, who provides the service, and the clinical care pathway.
There is considerable stakeholder support for high volume elective surgery facilities for ophthalmology services. As a large proportion of eye surgery is done on a same day basis, significant opportunity exists for further expansion of services without high capital investment. The use of dedicated elective theatres enables a critical mass of patients to be treated whose procedures will not be cancelled due to priority being given to emergency cases from other specialties.
There are further opportunities to better utilise the skills of the current workforce through a reconfiguration of workforce models. There is a general recognition that there is a good supply of eye health care professionals with specific ophthalmic training and skills, including ophthalmologists, optometrists, orthoptists and ophthalmic nurses. Consultations suggest general support for looking at options to make better use of medical and non-medical staff in the delivery of eye care.
| |
|Recommendation |
|6. The following will increase the capacity of the system to provide for future demand: |
|• establishment and expansion of services in general tertiary hospitals |
|• development and expansion of models of care that promote effective and efficient delivery of eye care services |
|• increased use of elective surgery centres for ophthalmology surgery (in particular cataract surgery) |
|• establishment and/or expansion of workforce models that make best use of the existing workforce in public hospitals and in |
|community settings (optometrists, orthoptists and nurses undertaking greater roles in the provision of eye care). |
Funding
The cost of service provision varies between hospitals. Through efficiencies in work practices or staffing arrangements, some hospitals achieve costs that differ markedly from the casemix payment. Salary arrangements for surgeons have been noted as a significant factor in whether a hospital is able to deliver the service within the casemix payment, with some hospitals providing sessional payments and others fee-for-service.
Recommendation
7. Develop a funding model that supports the system structure.
Performance monitoring
A performance monitoring system ensures accountability for the efficient and effective use of resources. A performance monitoring system would include a range of clinical and non-clinical performance measures that could be monitored at a local, regional and statewide level. Ophthalmology management measures, including waiting times for elective surgery and activity data, are already collected by health services and reported to the department. However, patient outcome measures are not routinely collected by health services and require development. Possible performance outcome measures would include monitoring the appropriateness, acceptability, safety and effectiveness of ophthalmology clinical interventions.
A performance monitoring system requires meaningful performance measures, data collection systems, reporting requirements and mechanisms. The development and operation of a performance monitoring system will require the involvement of clinicians, professional colleges and associations, hospitals and health services.
| |
|Recommendation |
|8. Develop a performance monitoring system for ophthalmology management and patient outcomes. |
Service leadership and coordination
Greater statewide coordination and leadership in planning for service growth is needed to ensure high quality and accessible ophthalmology services. There is general agreement among stakeholders that the department, hospitals and health care professionals have a shared interest and responsibility in ensuring optimal use of resources within the system. It is recognised that leadership capability needs to be developed with more system-wide goal setting and accountability. It was agreed that governance arrangements could be instituted at a regional and/or statewide level. There is support for more system-wide leadership from the RVEEH.
| |
|Recommendation |
|9. Develop a capacity for statewide leadership in public ophthalmology service provision to provide ongoing direction in models of |
|care, education and support systems for service providers. |
2 Introduction
The Victorian ophthalmology service planning framework provides a planning framework for the delivery of public ophthalmology services in Victoria to the year 2016. The framework aims to guide the future provision of care, both in the design of the service system and the development of an appropriate workforce to support it. It aims to address long-standing and emerging issues faced when delivering ophthalmology services.
2.1 Policy context for the future directions of ophthalmology services
The framework has its foundation in government policy that has been developed in recent years. In 2001, the Victorian Government released Growing Victoria Together, a statement of the Government’s strategies and priorities for the next ten years. In its Departmental Plan 2004–05, the Victorian Department of Human Services (the department) established objectives that reflect the strategic directions laid down in Growing Victoria Together. These objectives include:
• building sustainable, well managed and efficient human services
• providing timely and accessible human services
• improving human service safety and quality
• promoting least intrusive human service options
• strengthening the capacity of individuals, families and communities
• reducing inequalities in health and wellbeing.
The Metropolitan Health Strategy, Directions for your health system (MHS), released in October 2003 by the department, sets the key directions and objectives for metropolitan health services over the next five to ten years. A principal objective of the MHS is to position the health system to best meet future demand for services while ensuring those services are safe, of high quality, responsive to individual needs, and delivered in a timely, responsible and efficient manner.
The MHS identifies four strategic directions to position the health service system in Victoria to meet future demand for services. These include:
• increasing capacity of the current service system
• redistributing and reconfiguring existing capacity of the service system
• substituting and diverting existing services to new, more appropriate services
• developing new service models.
2 Introduction
Under the strategic direction of redistributing and reconfiguring capacity, the MHS identifisidentifies the need to establish service planning frameworks for a range of clinical specialities, including ophthalmology services to be a priority. Other directions include:
• a review and a service plan outlining the future role and optimal location for the Royal Victorian Eye and Ear Hospital (RVEEH)
• specialist hospitals to be collocated or affiliated with a general tertiary hospital
• the RVEEH to continue its role in providing complex care, training and research in ear, nose and throat (ENT) services and ophthalmology.
The MHS acknowledges the important role of specialist hospitals in training, workforce and research.
The department’s document Metropolitan Health Strategy, Directions for your health system: ambulatory care services, 2003 provides direction for ambulatory services. Ambulatory care describes care that takes place as a day attendance at a health care facility or at the consumer’s home. Directions for ambulatory care are as follows:
• ambulatory care services should be provided in a community-based setting unless considered inappropriate for safety, quality of care and efficiency reasons
• management processes and models of care should ensure continuity of care across hospital and community based settings
• service practice and distribution should ensure equitable, timely and appropriate access
• community-based ambulatory services should be collocated and/or integrated with hospitals where there are service and patient/client synergies, to improve continuity of care, maximise limited staffing resources, reduce professional isolation and enhance service organisation and coordination
• ambulatory services should be planned to meet the specific population health needs of a defined geographic catchment area, while maintaining flexibility to respond to changes in service demand.
The Hospital Demand Management (HDM) strategy was established in October 2000 in response to increases in demand and deterioration in access to acute public hospital services. The HDM strategy aims to strengthen the capacity of the health system to manage increasing demand pressures in six key ways:
• funding targeted growth in the activity performed within hospitals
• substitution through expansion of non-bed-based models of care
• encouraging clinical practice change to achieve best practice
• funding the Hospital Admission Risk Program (HARP) to improve health outcomes and reduce the avoidable use of hospitals
• providing improved working conditions that attract and retain nurses
• expanding opportunities for people to access elective surgery.
This service planning framework for ophthalmology services aims to address issues specific to delivering ophthalmology services in Victoria within the context of these government policies.
2.2 Eye care initiatives
There are a number of initiatives being undertaken by government and non-government organisations to prevent avoidable vision loss through strategies to improve awareness of eye health and improve access to services. These initiatives include:
• Vision 2020 Australia
• the Vision Initiative being implemented in Victoria
• a National Vision Plan for Australia.
Vision 2020 Australia was established in 2000 as part of Vision 2020: The Right to Sight, an initiative of the World Health Organisation (WHO) and the International Agency for the Prevention of Blindness. Vision 2020: The Right to Sight was established in 1996 and aims to eliminate avoidable blindness and vision loss by the year 2020.
Vision 2020 Australia is a national partnership of more than 40 Australian-based organisations involved in eye care service delivery, eye research, education and development, low vision support, vision rehabilitation, professional assistance and community support. It aims to build strong foundations for a cohesive and collaborative public health approach within the eye health sector in Australia, and support the same in selected international communities.
Vision 2020 Australia seeks to eliminate avoidable blindness by the year 2020 and ensure that blindness and vision impairment are no longer barriers to full participation in the community. In Victoria, the State Government has provided $1.8 million over three years towards the Vision Initiative run by Vision 2020 Australia. The Vision Initiative, which commenced in 2003, takes a collaborative public health approach to increase awareness and education of the public, health professionals, and other sectors about the importance of eye care. The program is run in collaboration with eye health care providers, researchers and rehabilitation and support services. The goal of the Vision Initiative is:
To prevent avoidable blindness and to reduce the impact of severe vision loss for all Australians.
The Vision Initiative is currently being implemented in Victoria and is expected to be implemented in other states and become a national program. It focuses on the five conditions that cause 80 per cent of vision impairment in Australia:
• uncorrected refractive error
• cataracts
• diabetic retinopathy
• glaucoma
• age-related macular degeneration.
There is work underway to develop a National Vision Plan for Australia. This work commenced following the World Health Assembly resolution WHA56.26 passed in May 2003 to eliminate avoidable blindness. The resolution calls on WHO member states to:
• establish a national Vision 2020 plan by 2005 in partnership with the WHO and in collaboration with non-government organisations (NGOs) and the private sector
• establish a national coordinating committee or blindness prevention committee to help develop and implement the plan
• begin implementing the plan by 2007
• include effective information systems with standardised indicators and periodic monitoring and evaluating, aiming to show reduced magnitude of avoidable blindness by 2010 in the plan
• support mobilising resources to eliminate avoidable blindness.
As part of Australia’s commitment to the WHO Resolution, the Commonwealth Government sponsored the inaugural National Vision Forum in March 2004. More than 85 participants from the eye care and related health sectors attended the forum to discuss the development of a National Vision Plan. Forum members agreed to establish a task group which would develop a submission outlining the purpose, scope and content of a national plan to be submitted to government.
The task group developed the submission which outlined the collaborative views of the community and the eye health sector in relation to the formulation and content of a National Vision Plan for Australia. It was presented to the government for inclusion on the agenda at the Australian Health Ministers Conference (AHMC) meeting held in July 2004. The agenda item was passed by AHMC members and the National Vision Plan for Australia is being finalised for tabling at AHMC later this year. Discussions are currently underway between the Commonwealth and State Government health departments to determine strategies for developing and implementing a national plan.
A key strategy towards achieving a National Vision Plan for Australia is the national implementation of the Vision Initiative. The Vision Initiative is seen as a benchmark for public eye health programs and discussions are currently underway between Vision 2020 partners, stakeholders and other State Governments for similar programs to be implemented in other states.
These initiatives provide strong support for enhancing the delivery of ophthalmology services in Victoria.
2.3 Methodology
To inform the development of the framework, the department:
• established an Ophthalmology Service Planning Advisory Committee (the advisory committee) with representation from key stakeholder groups (membership of the advisory committee is in Appendix 1)
• developed terms of reference in consultation with the advisory committee (refer Appendix 2)
• developed and widely circulated the Victorian ophthalmology service planning framework discussion paper (the discussion paper) and invited written submissions
• undertook broad stakeholder consultation.
The discussion paper provided a basis for analysis and consideration of current ophthalmology service provision and related services in Victoria. It drew on the views of stakeholders, analysis of datasets and a review of the literature. Its aim was to identify and discuss the key current and future issues that effect ophthalmology practice in Victoria.
The discussion paper was widely circulated to stakeholders and 49 submissions were received. A list of individuals and organisations that responded to the discussion paper is included in Appendix 3.
The department contracted Phillips Fox Lawyers (Dr Heather Wellington) and Campbell Research and Consulting to undertake the stakeholder consultation. To determine stakeholder views on issues pertinent to the delivery of ophthalmology services, the consultants reviewed stakeholder feedback on the discussion paper and engaged key stakeholders through a series of workshops and face-to-face interviews.
Stakeholder views were elicited through:
• a review and analysis of responses to the department’s discussion paper
• five forums, three in rural areas and two in metropolitan areas, with a range of service providers
• one forum with consumer representative groups
• two forums (one metropolitan and one rural) with consumers
• a number of face-to-face interviews with individual providers and small groups.
Data from stakeholder consultations and submissions were collated by the consultants and presented back to the department in a report entitled Victorian ophthalmology services: report on stakeholder consultations, September 2004. A list of individuals and groups who participated in interviews and workshops is included in Appendix 4.
2.4 Report structure
Section 3 of this report is presented in the structure developed by the Victorian Quality Council, Better quality, better health care: a safety and quality improvement framework for Victorian health services (VQC, 2003).
The safety and quality framework document was developed as a component of a strategic approach to improving the safety and quality of patient care in Victoria. While it has been developed for application by health services rather than across a health system, it identifies six dimensions of quality - safety, effectiveness, appropriateness, acceptability, access and efficiency - and four key organisational elements - governance and leadership, consumer involvement, competence and education, and information management - which are important considerations when ensuring a safe and high quality health system. These are equally applicable to system-wide safety and quality of care. Definitions of the six dimensions of quality and four key organisational elements are provided in Appendix 5.
2.5 Scope and definitions
Eye care professionals
In this framework, the term ‘ophthalmology services’ has been interpreted to encompass medical and non-medical eye health care and related services provided by a range of health care professionals. It includes services provided by specialist and sub-specialist ophthalmologists, general practitioners (GPs), orthoptists, optometrists, ophthalmic nurses and health care professionals working in emergency department settings. Definitions of these professions are provided in Table 1.
Table 1: Eye care professionals
|Ophthalmologist |
| |
|An ophthalmologist is a medical doctor who is educated, trained and registered to provide total care of the eyes, from performing |
|comprehensive eye examinations to prescribing corrective lenses, diagnosing diseases and disorders of the eye, and carrying out the|
|medical and surgical procedures necessary for their treatment. |
|General practitioner (GP) |
|A GP is a registered medical practitioner who is qualified and competent for general practice in Australia. A GP: |
|• has the skills and experience to provide whole person, comprehensive, coordinated and continuing medical care |
|• maintains professional competence for general practice. |
| |
|Optometrist |
| |
|Optometrists are non-medical practitioners trained to assess the eye and the visual system, and diagnose refractive disorders and |
|eye disease. An optometrist prescribes and dispenses corrective and preventative devices and works with other eye care |
|professionals to ensure that patients are referred appropriately for diagnostic and therapeutic needs. Optometrists also prescribe |
|drugs for certain eye conditions and monitor long-term eye conditions. |
| |
|Orthoptist |
| |
|Orthoptists specialise in diagnosing and managing disorders of eye movements and associated vision problems. They perform |
|investigative procedures appropriate to disorders of the eye and visual system and assist with rehabilitating patients with vision |
|loss. Orthoptists also diagnose refractive disorders and prescribe glasses on referral from an ophthalmologist or optometrist. |
| |
|Ophthalmic nurse |
| |
|An ophthalmic nurse has completed general nurse training then additional training to specialise in the nursing care of patients who|
|have eye problems, whether they are in hospital, clinics or the community. Ophthalmic nurses test vision and perform other eye |
|tests under medical direction. |
(NSW Health, 2002; AMWAC, 2000; RACGP, 2002)
Ophthalmology service system
During the consultation, the ophthalmology service system was conceptualised according to primary, secondary and tertiary service delivery (Table 2).
Table 2: Definitions of primary, secondary and tertiary eye care
|Primary care |
| |
|Primary care is characterised as care provided following self-referral. It includes care provided by community optometrists, GPs |
|and hospital emergency departments for conditions such as refractive error, screening for eye health, monitoring of chronic eye |
|conditions, removing foreign bodies and managing conjunctivitis. |
| |
|Secondary care |
| |
|Secondary care is characterised as specialist care provided following referral from another practitioner, but not including highly |
|specialised care which, because of cost, quality or technical issues, is best provided from a small number of service sites. It |
|includes most ophthalmic surgical and medical services (including monitoring and management of cataract, glaucoma, diabetic eye |
|disease and macular degeneration, management of most eye trauma, and optometry services provided on referral from another |
|practitioner). |
| |
|Tertiary care |
| |
|Tertiary care is characterised as highly specialised care provided in a limited number of locations following referral from another|
|practitioner. It includes monitoring and managing complicated glaucoma, diabetic eye disease, trauma and complicated and/or rare |
|vitreo-retinal and other conditions. |
This framework is primarily focused on the provision of services funded and/or provided by the public sector. Issues are, however, discussed in the context of the public sector as a component of an overall service system that has a substantial private component
3 Ophthalmology services in Victoria
3.1 Geographic distribution of services
The department has divided the state into eight regions—five rural and three metropolitan. The regional boundaries are based on Local Government Areas (LGAs).
Figure 1 illustrates metropolitan regions and the location of public hospitals.
[pic]
Figure 2 illustrates rural regions and the locations of public hospitals.
3.2 Current service provision
The distribution and activity of ophthalmology services in Victoria is described in the discussion paper. Some key activity data for ophthalmology service provision in 2002–03 indicate that:
• ophthalmology services are predominantly ambulatory with a large proportion of eye disease managed on an outpatient basis and a high rate of same day surgery
• while ophthalmology services are generally well distributed across the state, there is a high concentration of service provision at the RVEEH. The RVEEH treats 49 per cent of ophthalmology emergency presentations, 70 per cent of outpatient encounters and 42 per cent of public inpatient separations
• the majority of consulting services are provided in private ophthalmology and optometric practices
• of all encounters with GPs, 1.8 per cent relate specifically to eye conditions; 7.3 per cent of referrals from GPs are to ophthalmologists and 0.9 per cent are to optometrists
• there were 49,700 ophthalmology inpatient separations, at 102 public hospitals and 76 private hospitals. Twenty-two per cent were from rural hospitals, while the RVEEH treated 19 per cent of all separations
• there has been a 5.9 per cent per annum increase in ophthalmology separations from 1998–99 to 2002–03. There was 7.9 per cent per annum growth in the rural sector and 5.4 per cent per annum in the metropolitan sector. The growth rate in the private hospitals was 8.1 per cent per annum compared to 3.4 per cent in public hospitals
• high growth rates were recorded in outer metropolitan hospitals for inpatient separations and emergency presentations
• overall, approximately 30 per cent of ophthalmology separations from public hospitals are from private or compensable patients
• the Victorian Eyecare Scheme (VES) provides eye tests and glasses at a nominal cost for Victorians who hold a pensioner concession card or have a health care card and their dependents. The VES is funded through the department and is run by the Victorian College of Optometry (VCO). VES provided 35,256 services in metropolitan Melbourne and 29,180 services in rural Victoria.
Table 3: Summary of Victorian ophthalmology service provision in 2002–03
|Inpatient separations |
|• 49,700 separations statewide |
|– 70 per cent cataract procedures |
|– 84 per cent same day |
|– 96 per cent elective |
|– 22,031 separations at public hospitals |
| |
|Non-admitted services |
|• 91,480 outpatient encounters provided by 12 public hospitals |
|• 35,001 emergency presentations to 35 public hospitals |
|• 660,507 ophthalmology MBS claims1 |
|– 513,105 consultations |
|• 1,078,180 optometry MBS claims |
| |
|1 MBS data provided from the HIC. Data includes claims for private inpatient procedures captured in VAED. |
3.3 Predicted changes to ophthalmology services
The research and consultation process identified that the following incremental changes in ophthalmology services are expected, including:
• more emphasis on preventive models of care
• an increase in ambulatory/day procedure service provision
• a greater focus on multidisciplinary collaboration and holistic disease management models
• an increase in the need to provide consumers with information to assist them understand eye disease and expectations of outcomes from treatment
• optometry having a major effect on ophthalmology practice, in particular on glaucoma, resulting from the ability of optometrists to prescribe S4 medications
• increased use of highly specialised equipment for both diagnostic and therapeutic purposes
• new prostheses, which could improve outcomes and increase demand for the surgical correction of presbyopia
• more targeted drug therapies
• an increasing role for molecular engineering techniques and stem cell technology
• an increase in the ability to correctly diagnose genetic diseases and provide accurate counselling information on prognosis and the recurrence risk.
4 Discussion and recommendations
The research and consultation process identified a number of strengths, along with a range of issues to be addressed within the current ophthalmology service system. While the current system has served Victoria well, addressing some issues promises to deliver further improvements, ensuring future demands are met. These issues will be discussed in more detail throughout the following sections.
4.1 Access
‘Access refers to the extent to which a population or individual can obtain health services. This may include when it is appropriate to seek health care and the ability to geographically, physically and economically seek out appropriate care’ (VQC, 2003).
Waiting times for services, along with cost and self-sufficiency, are often equated with the accessibility of a health service.
Waiting times for services
Victoria manages ophthalmology elective surgery well compared to other Australian states and territories. Data reported by the Australian Institute of Health and Welfare (AIHW) indicates that Victoria has the one of the lowest proportions of patients waiting more than 12 months for surgery in Australia (Table 4).
Despite these comparisons, waiting times have been identified as a barrier to accessing public ophthalmology services. In particular, variations in waiting times between organisations has created inequity in access across the state.
Table 4: Ophthalmology and cataract surgery waiting list statistics–Australian states and territories, 2001–02 (AIHW)
|NSW |VIC |QLD |WA |SA |TAS |ACT |NT |Total |
|Ophthalmology |
|Admissions |19,064 |13,854 |7,313 |4,789 |3,741 |645 |720 |694 |50,820 |
|Days waited at 50th |98 |37 |26 |88 |42 |154 |82 |160 |57 |
|percentile | | | | | | | | | |
|Days waited at 90th |441 |227 |464 |322 |264 |557 |621 |308 |395 |
|percentile | | | | | | | | | |
|Proportion waited > 12 |19.0 |4.3 |12.9 |5.8 |4.3 |36.3 |27.1 |5.5 |11.9 |
|mths | | | | | | | | | |
|Cataract extraction |
|Admissions |14,345 |9,232 |4,567 |3,503 |2,431 |394 |615 |487 |35,574 |
|Days waited at 50th |159 |53 |30 |113 |60 |395 |98 |175 |88 |
|percentile | | | | | | | | | |
|Days waited at 90th |471 |256 |544 |322 |303 |632 |638 |313 |430 |
|percentile | | | | | | | | | |
|Proportion waited > 12 |24.1 |5.1 |16.8 |5.2 |5.9 |56.6 |31.2 |6.4 |15.4 |
|mths | | | | | | | | | |
Outpatient services
Outpatient services in public acute hospitals play a key role in the health system and represent a vital interface between inpatient and community care (Sharwood & O’Connell, 2001). They provide specialist medical services, pre and post hospital care, and other medical and allied health services.
Long waiting times for initial outpatient consultation has been identified as a key barrier to accessing public services. While there are no routine collections of waiting times for outpatient appointments, a survey of Victorian hospitals that provide public ophthalmology services in January 2004, revealed variation in the average waiting times for non-urgent ophthalmology appointments from five weeks to 42 weeks, with some patients waiting over two years for non-urgent appointments.
Many providers suggested that current outpatient waiting times at some public hospitals are unacceptable. Suggestions for acceptable waiting times for non-urgent outpatient appointments ranged from four weeks to three months.
There is a view amongst providers that there is too much system-wide emphasis on cataract surgery to the detriment of some rare and treatable diseases. There were concerns that patients with cataract may wait less time for cataract surgery than people with other more serious conditions who require services provided in the outpatient setting.
Elective surgery
Access to public hospital elective surgery in Victoria is monitored through the Elective Surgery Information System (ESIS). ESIS information is not collected for small rural hospitals.
Patients added to an elective surgery list are assigned a clinical urgency category. Specialists assess the clinical urgency of their patient’s condition and categorise it as one of three levels. These categories have been developed through the department’s HDM strategy and are defined below. A summary of elective surgery waiting times is provided in Table 5.
Category 1 (urgent): A condition that has the potential to deteriorate quickly to the point that it may become an emergency. Admission is desirable within 30 days.
Category 2 (semi urgent): A condition causing some pain, dysfunction or disability but which is not likely to deteriorate quickly or become an emergency. Admission is desirable within 90 days.
Category 3 (non urgent): A condition causing minimal or no pain, dysfunction or disability, which is unlikely to deteriorate quickly and which does not have the potential to become an emergency. Admission is acceptable sometime in the future.
Table 5: Elective surgery waiting list (ESIS, 30 April 2004)
|• 3,816 patients on ophthalmology surgical waiting lists: |
|– 3,295 category 3 patients |
|– 496 category 2 patients |
|– 25 category 1 patients. |
| |
|• 2,772 patients (84 per cent of total waiting list) were waiting for cataract surgery |
| |
|• Average patient waiting times ranging between: |
|– 26 and 245 days for category 3 (non-urgent) |
|– 20 and 79 days for category 2 (semi-urgent). |
| |
|• 39 (8 per cent) category 2 patients and 150 (5 per cent) category 3 patients were waiting longer than clinically recommended. |
| |
|• Average clearance times for cataract surgery of 1.9 months for category 2 patients and 6.4 months for category 3 patients. |
The majority of ophthalmology elective surgery is classified as category 3. Some inconsistencies in categorisation have been noted across health services, which may contribute to variations in waiting times for elective surgery.
Some providers suggested during the consultations that current surgical waiting times in Victoria are generally ‘not too bad’ and in some areas have improved significantly in recent years. Although surgical waiting times for public patients are generally acceptable, when combined with waiting times for outpatient appointments overall, waiting times in some major metropolitan and regional hospitals are considered to be excessive.
Suggestions by providers for acceptable waiting times for non-urgent surgery varied, with lengths of up to 18 months considered acceptable if there is a triage system to expedite urgent patients. Providers advised that in some cases patients are put on the waiting list earlier than the clinical condition would indicate, in anticipation of a long wait for surgery.
Consumers cited examples of waiting times of three or four months and generally considered them reasonable for access to treatment in the public system. Consumers perceived, however, that waiting times in the public system varied considerably depending on the specialist seen and the facility where the treatment is provided.
The Cranbourne Integrated Care Centre (CICC) at Southern Health commenced delivery of ophthalmology service in 2002 and was established as a designated ophthalmology Elective Surgery Access Service (ESAS) provider. ESAS aims to assist semi-urgent (Category 2) elective surgery patients with prolonged waiting times receive care.
Long waiting patients with little prospect of receiving treatment within their own hospital in the immediate future are offered the opportunity of surgery at another hospital. As an ESAS hospital, the CICC received additional funding to treat same day, low risk, long waiting patients from other hospitals. In 2003–04, CICC treated long waiting patients from Frankston Hospital, Ballarat Health Services and The Alfred Hospital, which has significantly reduced waiting times at these hospitals.
Elective surgery management and referral
Elective surgery management practices can impact on access to elective surgery. This not only relates to differences in waiting times for elective surgery but also systems for accessing elective surgery. For example, some patients are referred to outpatient clinics for assessment prior to being placed on elective surgery lists while others are referred directly onto public elective surgery lists from private surgeons’ rooms, bypassing the need for outpatient appointments. Direct referral from private rooms to public hospital elective surgery lists is common for private patients, and for public patients in rural hospitals where there are few public outpatient clinics. Direct referral has been introduced for public patients at some hospitals, such as those at Southern Health, including CICC.
Some medical practitioners expressed confusion over their indemnity for patients they refer directly on to public elective surgery waiting lists. The Public Healthcare Insurance Program, Victorian Managed Insurance Authority (VMIA), provides medical indemnity insurance coverage to medical practitioners who refer patients on to elective surgery waiting lists at public hospitals, provided a series of conditions are met. (see health..au/electivesurgery for more information, and a full list of conditions of indemnity).
In 2002–03, 70 per cent of ophthalmology inpatient separations in public hospitals were treated as public patients and 24 per cent were treated as private patients. Between 1998–99 and 2002–03, the number of public ophthalmology inpatients treated in public hospitals grew 4.0 per cent per annum while private patients treated in public hospitals grew 5.6 per cent per annum.
Table 6: Inpatient separations by account type 1998–99 to 2002–03
|Separations |
|Account type |1998-99 |1999-00 |2000-01 |2001-02 |2002-03 |Per cent |% pa growth |
|Compensable |214 |196 |233 |216 |213 |1% |-0.1% |
|DVA* |1,445 |1,344 |986 |965 |876 |4% |-11.8% |
|Ineligible |31 |34 |33 |29 |57 |0% |16.4% |
|Private |4,334 |4,338 |4,501 |5,261 |5,394 |24% |5.6% |
|Public |13,222 |13,601 |13,963 |14,340 |15,491 |70% |4.0% |
|Total |19,246 |19,513 |19,716 |20,811 |22,031 |100% |3.4% |
*Department of Veterans’ Affairs
*Department of Veterans’ Affairs
According to providers, many regional and some metropolitan hospitals have limited their volume of public ophthalmology surgery because of concerns about its financial sustainability. Excess theatre capacity is often made available for treating private patients, many of whom are self-funding. Waiting times for private patients in these hospitals are often significantly less than waiting times for public patients.
Some health service managers are concerned about equity of access. They consider that public facilities should be available solely on the basis of clinical need rather than capacity to pay, whereas others consider that the admission of higher numbers of private patients ensures the sustainability of the service. Larger numbers of private patients allow a better use of facilities and assists in the retention of
ophthalmologists, for whom public operating is relatively financially unrewarding, compared to private practice.
In many rural hospitals, public and private elective surgery lists are managed by individual ophthalmologists without the hospital’s direct involvement. It was suggested by some health service managers that there needs to be a more transparent arrangement for treating public and private patients in the public hospital sector.
The introduction of outpatient and elective surgery management guidelines aim to ensure consistency in elective surgery management regardless of who manages the elective surgery waiting lists.
Prioritisation
There have been attempts internationally to develop prioritisation systems for managing elective surgical and medical waiting lists, including waiting lists for cataract surgery. These include the Western Canada Waiting List Project () and the Clinical Priority Assessment Criteria (CPAC) developed by the New Zealand National Advisory Committee on Health and Disability (Derret et al, 2003). Evaluation of these systems showed that while they had some limitations, they also had significant face validity and potential to be used in clinical settings (WCWL, 2001; Derret et al, 2003).
During the consultations, the utility of these prioritisation tools was questioned. Many clinicians expressed a belief that decisions about intervention should be left entirely to the ophthalmologist, in conjunction with the patient.
Others strongly supported consideration of a more explicit and transparent prioritisation system, such as the VF-14. The VF-14 is a widely internationally adopted instrument used in the assessment of visual function. The VF-14 has a high internal consistency and is a reliable and valid instrument providing information not conveyed by visual acuity or general health status measures (Steinberg, 1995; Alonso et al 1997). There is some interest by providers to prioritise elective surgery according to functional impairment.
To ensure equitable and appropriate access to public outpatient services and elective surgery, the department has developed two elective surgery management policies which outline how elective surgery waiting lists are to be managed. These documents are called Elective Surgery Waiting List Referral Policy and Elective Surgery Access Policy and are available online at health..au/elective surgery.
| |
|Recommendation |
|1. Develop consistent guidelines and practices for accessing public ophthalmology outpatient services and elective surgery to |
|ensure that access is equitable, appropriate and based on clinical need. |
Eye care literacy
Access to information about a particular condition is important in any high quality health care system as it empowers the patient and carer to make well informed decisions about their health and course of treatment. Access to information also enables consumers to gain a better understanding of the role of different health care professionals and to seek appropriate care pathways.
Stakeholders suggested that current eye care information was not reaching as many people as it should be. Evidence suggests that many people on low incomes do not prioritise eye care and are unaware of the benefits of a regular eye examination. Moreover, many patients, particularly the elderly, were said to be unaware that their vision is capable of correction, or do not want correction. Inadequate monitoring of conditions such as diabetes, reflects a lack of patient awareness of the need for services, or poor referral practices, rather than a lack of available services.
Consumer consultation also confirmed that consumers generally have only a vague understanding of the distinction between the roles and responsibilities of various ophthalmology professionals and ophthalmology support services. This situation was reinforced by the experiences and perceptions of consumer representatives:
‘A lot of the consumers get confused what people’s roles are. They get conflicting messages…’
Consumers, however, were more able to identify the functions performed by optometrists than those of other eye professionals.
Through improving access to, and promotion of, eye care information, consumers will be able to make more informed decisions about their health. The Vision Initiative is an eye health promotion and education program that aims to reduce the incidence of preventable blindness and the impact of severe vision loss.
Referral pathways
Just as it is important for patients to understand their condition so they can make informed decisions and seek appropriate care pathways, it is important that health professionals understand the roles of other health professionals and services available so that they can make the most appropriate referrals.
Concerns were raised about variations in referral pathways and the appropriateness of some referrals by eye care professionals. For example, some patients are referred to tertiary public hospitals for refraction and routine eye examinations rather than to community providers such as optometrists and the VES.
Variations in referral pathways were suggested to be due to a lack of understanding of the roles of different eye care professionals by other health care professionals and consumers, and the fragmentation between certain professional groups. The fragmentation was seen to be due to inherent professional boundaries and traditional factors.
Referral to low vision services was also highlighted as an issue. Low vision services aim to optimise vision and provide aids and assistance to improve quality of life to people with permanent low vision. Providers believe that improved referral to low vision services is required, given that utilisation rates for low vision services are universally low. Estimates indicate that between only 5–10 per cent of people with low vision use low vision services (Pollard et al, 2003). This concern was echoed by consumers who, in general, believe that ophthalmologists (and, to a lesser extent optometrists) have a narrow perspective on treatment options for people diagnosed with eye conditions, especially those conditions which are ongoing or incurable.
Other barriers to accessing low vision services identified in the literature include awareness of services among the general public and eye health professionals, understanding of low vision and the services available, acceptance of low vision, the referral process, and transport (Pollard et al, 2003). Education, pre-admission clinics and evidence-based guidelines are methods to increase appropriate referrals. These methods are supported by stakeholders, and work is already being done by the Vision Initiative to educate eye health professionals to promote best practice.
| |
|Recommendation |
|2. Improve eye health education and promotion programs for consumers and providers through support of the Vision Initiative. |
Cost of eye care services
Affordability of ophthalmology services has been identified as a significant barrier in both metropolitan and rural Victoria. While ophthalmology services are generally well geographically distributed, not all public hospitals provide ophthalmology services. For some patients, especially those in rural Victoria, the only options to access ophthalmology services include visiting a private provider, or travelling to Melbourne or another rural area to access treatment at a public facility.
While the affordability of private services is a concern, some providers reported positive experiences with private clinics collocated with public hospitals:
‘In public hospitals where the initial entry point is a collocated private clinic, an appointment can be arranged over the phone and there is usually a written response from the ophthalmologist once they have seen the patient. The disadvantage is if the collocated private clinic does not bulk bill pensioners. There do not seem to be any disadvantages in terms of surgical outcomes. Further consideration of the public/private collaborations in public health care may have some benefits.’
Some private ophthalmology clinics collocated with public hospitals have equipment and infrastructure provided by the hospital, in return for treating public patients with no out of pocket expenses.
A report by the Brotherhood of St Laurence, Seeing clearly: Access to affordable eyecare for low income Victorians (Diviney & Lillywhite, 2004), found that where public ophthalmology services were available, long waiting times for initial consultations were considered a barrier to access. In areas such as Shepparton, with no public provision of eye surgery, patients choose between paying for private surgery or travelling to Melbourne or another rural hospital to access treatment at a public facility.
As well as the barriers to accessing public eye care services, there was considerable criticism by consumers and consumer representatives about the cost of glasses and other visual aids. Consumer representatives with experience of lower socioeconomic patients were strongly critical of the costs associated with prescription glasses, claiming it acted as a serious deterrent for many who needed corrective lenses. This was reinforced by consumers who admitted deferring visits to the optometrist, even knowing their eye sight was deteriorating, because they could not afford new glasses.
The VES provides eye tests and glasses at a nominal cost for Victorians who hold a pensioner concession card (or have a health care card for at least six months) and their dependants under the age of 18 years. The VES is funded by the department and is run by the VCO. Rural patients can have their eyes tested and glasses prescribed through a network of optometrists and ophthalmologists participating in the service. The RVEEH and RCH also provide subsidised glasses to their patients.
Research conducted by the Brotherhood of St Laurence indicates that the VES is making a significant contribution towards ensuring low income earners are able to access affordable eye care, but that certain groups of low income and socially disadvantaged people still face difficulties accessing these services (Diviney & Lillywhite, 2004). Victorians who have low uptake of services were reported to include those living in supported residential services and aged care facilities, homeless people, rural residents, young people and culturally and linguistically diverse communities, particularly newly arrived migrants and refugees.
Data from the VES for 2002–03 showed that a greater proportion of rural residents access the VES than metropolitan residents with 35,256 services provided in metropolitan Melbourne and 29,180 services provided in rural Victoria.
Specific concerns regarding the provision of spectacles through the VES include:
• perceived and actual waiting times for outpatient consultation
• eligibility for the scheme
• limited selection of glasses
• withdrawal of some practices in rural areas because of perceived excessive bureaucracy and opportunity costs
• lack of promotion of the VES by participating optometrists due to a lack of incentive.
The Department of Veterans’ Affairs (DVA) provides a comprehensive range of optical services, including a range of frames and lenses at no cost for veterans and war widows.
In the 2005–06 budget, the Victorian Government announced an additional $334,000 to expand the capacity of VES to provide glasses at low cost to pensioners and other low income earners. This funding will provide eye care and subsidise glasses for 3000 extra clients. An further $250,000 was allocated to develop a new service model that will target eye care in aged care, disability accommodation and supported residential services. A review of VES services will be undertaken in 2005 which will consider the service model, linkages to other elements of the public eye care service system and future demand. The review will provide recommendations with regard to the future extension of eye care services.
It was proposed that opportunities to provide of low cost glasses to patients following ophthalmology care, in particular cataract surgery, be reviewed. The VES was suggested as a possible provider, however this would need to take into account the potential impact on overall demand for services. Improved linkages between the VCO and the RVEEH were also suggested to increase access to low cost glasses. Opportunities such as improving access to services in metropolitan areas, improved awareness of the service and developing more streamlined processes for consumers and providers were also highlighted.
Recommendation
3. Improve and promote access to low cost glasses
Service distribution
Ophthalmology services are well distributed with ophthalmology inpatient separations reported through the VAED by 102 public hospitals and 76 private hospitals. Appendix 6 provides details of ophthalmology service provision across Victorian public hospitals in 2002–03. Cataract procedures were performed at 46 public hospitals, 21 metropolitan and 25 rural.
Twelve Victorian hospitals, nine metropolitan and three rural, provide publicly funded outpatient services through the Victorian Ambulatory Classification System (VACS). Public outpatient services are concentrated centrally with 70 per cent of the state’s services provided at the RVEEH. Statewide ophthalmology VACS encounters have increased 2.2 per cent per annum between 1998–99 and 2002–03 (9 per cent in total).
Self-sufficiency measures the degree to which people can access services close to home, and is an indicator of service distribution. Self-sufficiency varies across that state with 99.7 per cent of metropolitan residents receiving inpatient ophthalmology services in metropolitan Melbourne and 77 per cent of rural residents receiving services in rural Victoria in 2002–03.
Despite having a well-distributed system, some large general metropolitan and rural hospitals have discontinued or limited their ophthalmology services in favour of developing linkages with other providers. Establishing primary and secondary services in all public general tertiary hospitals will increase local access to services and reduce the need for referral to other health services for care. This is particularly relevant to rural residents who often have long travel times and costs if required to travel to Melbourne.
Broader distribution of services will ensure a greater presence of ophthalmologists in general tertiary hospitals to provide integrated and timely care for persons with multi-system conditions, such as diabetes, neurological and neurosurgical conditions, neonatology and trauma. A greater presence of ophthalmologists in general hospitals will improve educational opportunities in eye health for students and health care professionals.
Metropolitan services
Most public metropolitan health services provide access to a range of ophthalmology services. The largest providers of inpatient separations in 2002–03 were the RVEEH (9,322 separations), CICC (1,800 separations) and the RCH (731 separations).
There are several large metropolitan public hospitals that have ceased directly providing a full range of ophthalmology services and have developed partnerships with other health services for service provision instead. These include St Vincent’s Health, Eastern Health and Peninsula Health.
St. Vincent’s Health ceased providing ophthalmology services directly in 1997. Instead, St Vincent’s Health has developed a strong collaborative arrangement with the RVEEH, whereby the RVEEH provides eye services to St Vincent’s Health patients and St Vincent’s Health provides some clinical support services to RVEEH.
Eastern Health ceased providing ophthalmology services at Box Hill Hospital in 1998–99 and established a service at the Maroondah Hospital through a hub and spoke arrangement with the RVEEH. This was established in 1998 when both hospitals were part of the Inner and Eastern Health Care Network. Box Hill Hospital currently operates a small non-VACS funded outpatient clinic.
Peninsula Health ceased providing public outpatient services at Frankston Hospital in 2000–01. In 2003 Peninsula Health transferred its elective surgery from Frankston Hospital to the CICC at Southern Health, with complex cases and those requiring overnight or multiday stay treated at the Monash Medical Centre, Moorabbin campus. The ophthalmologists appointed at Peninsula Health continue to provide an on-call emergency consulting service, inpatient consultation, neonatal checks and service the multidisciplinary diabetic clinics.
Public outpatient services are concentrated in metropolitan Melbourne with 95 per cent of the state’s outpatient encounters provided in nine metropolitan hospitals in 2002-03. There are no VACS funded outpatient clinics in western metropolitan areas.
Several hospitals provide outpatient services through collocated private clinics or a mix of private and publicly funded clinics. Examples include the Western Hospital, the Northern Hospital and the RVEEH’s spoke service at Broadmeadows Health Service. Data for clinics that are not state-funded are not collected at a state level.
The majority of providers agreed that a range of specialist ophthalmology services including emergency, consulting and surgical should be locally accessible in all general metropolitan hospitals. However, there were some providers who favour centralising services to a smaller number of metropolitan centres for volume, quality and efficiency reasons, with only emergency consulting services being provided at other general metropolitan hospitals.
Those who favour providing integrated services at a more local level advised that staff would not be attracted to general hospitals if they did not have the opportunity to provide a range of consulting and surgical services. They consider elective surgical services to be essential to attracting ophthalmologists to provide other medical and emergency services.
Rural services
Self-sufficiency in metropolitan areas is high, however there is variable self-sufficiency in rural Victoria. The Hume and Gippsland regions were the least self-sufficient at 60 per cent and 63 per cent respectively. Self-sufficiency for rural regions is summarised below:
• 60 per cent for Hume residents (62 per cent treated in rural Victoria)
• 63 per cent for Gippsland residents (63 per cent treated in rural Victoria)
• 71 per cent for Loddon-Mallee (79 per cent treated in rural Victoria)
• 76 per cent for Grampians (82 per cent treated in rural Victoria)
• 90 per cent for Barwon South Western (91 per cent treated in rural Victoria)
Most regional centres provide a range of ophthalmology services, and some visiting surgical services are also available in a range of sub-regional and small rural hospitals. In 2002–03, 20 rural hospitals treated more than 100 ophthalmology separations each.
Four regional centres provided a total of 2,300 ophthalmology inpatient separations or 39 per cent of all rural separations. These included Barwon Health (985 separations), Ballarat Health Services (479 separations), Latrobe Regional Hospital (433 separations) and Bendigo Health Care Group (403 separations).
The largest providers of inpatient separations outside regional centres were the New Mildura Base Hospital (422 separations), Bass Coast Regional Health (288 separations) and Bairnsdale Regional Health Service (273 separations). The importance of border flows in towns such as Albury/Wodonga and Mildura was highlighted during the consultations.
Gaps in rural public ophthalmology services were noted throughout the review. The cessation of elective ophthalmology surgery provision, including cataract surgery, at Goulburn Valley Health (Shepparton) in 1993 was highlighted. It was also noted that access to ophthalmology outpatient services in rural Victoria is variable. There are three VACS funded outpatient departments in rural Victoria; Ballarat Health Service, Bendigo Health Care Group and Barwon Health. Together they treated 5 per cent of the state’s public outpatient clients in 2002–03.
Some rural hospitals that do not receive VACS funding receive outpatient funding through a non-admitted patient grant. As data is not reported to the department for services provided through this grant or the MBS, outpatient access is difficult to determine.
Where public outpatient consultations are not available locally, ophthalmology consulting services are generally provided by private ophthalmologists in private consulting rooms. The ophthalmologists generally provide the equipment and infrastructure necessary to support these services. There are some concerns about the affordability for individual patients with this arrangement.
Of particular concern is the lack of publicly funded laser surgery for rural patients. Laser surgery is provided on a non-admitted basis for a range of eye conditions including retinal disease, such as diabetic retinopathy, and posterior capsule opacification following cataract surgery.
Gaps in regional service provision are seen to relate to a range of factors including service demands, availability of some staff (particularly ophthalmologists) and the costs associated with equipment and employing or contracting an ophthalmologist. In some areas, this has lead to a distribution of services based on a health service’s ability to negotiate a financial arrangement with an ophthalmologist rather than a planned approach to service delivery.
Ophthalmology services in rural areas depend on the hospital’s successful negotiation of cost of fees with ophthalmologists and their ability to provide the associated equipment and consumables. Many rural hospital CEOs are seeking assistance from the department to resolve these problems and would prefer an increased central service planning role with local input.
There is a strong view that all regional areas should have comprehensive ophthalmology services, that is non-admitted consulting, emergency, operating and community based services. Limited access to public ophthalmological services in some major regional centres is viewed as a major issue, although most stakeholders believe the service provision should not be at too higher cost.
There is a role for both large and small rural health services in providing ophthalmology services. The challenge is to ensure that services are planned and delivered in a coordinated way within a region or sub region. Regional hospitals will play a lead role in the providing and coordinating of services. Further work needs to be undertaken to determine which services need to be delivered at the regional hospital.
Stakeholder suggestions for improving rural service delivery include:
• regional service coordination, with distributed service centres
• a hub and spoke regional model with a mobile facility regularly visiting smaller centres while procedures are made available from regional centres
• telemedicine linkages between smaller rural and regional/metropolitan centres, and between regional centres and metropolitan centres.
• more rural registrar training posts created to support service delivery in regional centres.
Paediatric services
Children aged 0 to 14 years constitute 3.8 per cent of ophthalmology separations and 5.4 per cent of ophthalmology MBS claims. Paediatric inpatient services are concentrated centrally with the RCH treating 37 per cent and the RVEEH treating 16 per cent in 2002–03. Private hospitals treated 22 per cent of separations.
There is stakeholder support for the RCH to continue its role as the key provider of tertiary paediatric ophthalmology services. Due to the specialist requirements for treating paediatric patients, it is recommended that the RCH continue its role in specialist provision of paediatric services.
Recommendation
4. The following health services should ensure the provision of primary and secondary services for their tertiary campuses, including 24-hour on call, inpatient, outpatient and emergency consulting and surgery:
• Metropolitan
– RVEEH
– Western Health
– Northern Health
– Melbourne Health
– Austin Health
– Eastern Health
– Bayside Health
– Southern Health
– Peninsula Health
• Rural and regional
The implications for the five major regional hospitals to provide the range of services specified above will need to be considered in detail. Regional hospitals will play an important role in the provision and coordination of services across their region.
Elective surgery may be provided in alternate settings to the tertiary site or regional hospital, such as in same day and elective surgery centres or other rural hospitals.
The Royal Children’s Hospital should continue its role in specialist provision of paediatric ophthalmology services.
A distributed service system should be maintained through the provision of a range of primary and secondary services at rural hospitals.
Royal Victorian Eye and Ear Hospital
The RVEEH is a specialist teaching, training and referral hospital for ophthalmology and ear note and throat services. Internationally, it is one of about 20 major stand-alone specialist hospitals in eye and ear medicine. The RVEEH plays a key role in teaching and training health professionals in ophthalmology and has an international reputation in medical research through its close association with the University of Melbourne Department of Ophthalmology and its affiliation with the Centre for Eye Research Australia (CERA).
The RVEEH provides a range of general and sub-speciality ophthalmology services. Sub-speciality services include glaucoma treatment, vitreo-retinal, ocular motility, orbito-plastics, corneal, ocular diagnostics, neuro-ophthalmology, medical retinal and ocular immunology. The RVEEH provides 39 per cent of the state’s public cataract surgery and treats a high proportion of specialty surgery including:
• 90 per cent of the state’s public major corneal, scleral and conjunctival procedures
• 75 per cent of the state’s public retinal surgery
• 71 per cent of the state’s public glaucoma procedures.
Many stakeholders commented that the RVEEH is centrally located and is, therefore, very accessible to patients. The majority of stakeholders believe that the RVEEH provides a very good service for tertiary patients.
There was considerable support to maintain the multidisciplinary sub-specialty clinics provided by the RVEEH, and for ophthalmology care to be provided in a coordinated fashion with specialist care at other hospitals (for example, diabetic and immunological), ensuring appropriate care for complex patients. There was support for the maintenance and growth, over time, of integrated services in all metropolitan and regional tertiary general hospitals.
It was also suggested that some specialised procedures should be limited, through credentialing processes, to the RVEEH.
As recommended in the MHS, the RVEEH requires a detailed service plan and review to determine its future role and optimal location. This detailed service plan for the RVEEH will determine its catchment for primary and secondary services as well.
There is strong support for the RVEEH to continue its role as a statewide provider of public tertiary ophthalmology services with a high concentration of specialised services, possibly collocated with a general tertiary hospital. As a specialist centre, the RVEEH should:
• reduce its emphasis on routine care, and more actively triage primary care patients to more appropriate settings
• more actively discharge patients from both emergency and outpatient departments back to the community as appropriate, thereby creating additional capacity to manage new referrals more efficiently
• maintain its focus on multidisciplinary specialist clinics
• provide a combination of teaching and service operating sessions
• with the Royal Australian and New Zealand College of Ophthalmologists (RANZCO), the department and other eye care stakeholders, lead the evaluation of new models of care
• provide enhanced clinical support to other elements of the service system
• actively participate in statewide monitoring of the performance of the service system
• assist to ensure equitable service provision across the state, through outreach services and other mechanisms
• continue an active teaching and research role.
Melbourne consumers and consumer representatives were highly conscious that people living in rural Victoria did not have the same access to a facility such as the RVEEH. However, the overall consensus amongst consumers was to keep the RVEEH as a centralised, specialty hospital, even though its location was not central to those living in rural and regional Victoria.
Moreover, St Vincent’s Health should continue to ensure access through linkages with the RVEEH. This arrangement will need to be reviewed within the context of service planning for the RVEEH redevelopment.
| |
|Recommendation |
|5. The RVEEH should continue its role in teaching, research and specialist provision of ophthalmology services. The RVEEH will |
|provide primary and secondary services to its local population and provide elective surgical services to a broader population. |
Forecast demand for eye services
Eye disease is forecast to double by the year 2020, which will lead to more demands on eye care services.
The Visual Impairment Project (VIP) was conducted by CERA from 1991 to 1999 to determine the prevalence and causes of visual impairment in Victoria and to examine health care utilisation. Key findings include:
• more than 80 per cent of vision loss is caused by five conditions: refractive error, age related macular degeneration (AMD), cataract, glaucoma and diabetes
• the amount of visual impairment and blindness increases threefold with each decade of age over 40 years
• the ageing of the population will lead to a doubling in the amount of eye disease by 2020
• three quarters of visual impairment can be prevented or treated.
Figure 3 illustrates the projected prevalence of visual impairment in Australia from 1995 to 2020, based on data extrapolated from the VIP.
Figure 3: Projected visual impairment in Australia
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Hospital inpatient forecasts
The department’s method of forecasting uses linear regression methods where forecasts are generated for utilisation rates based on retrospective years of data. This approach assumes that the past relationship between variables will be the same in future years.
For forecasting purposes, Diagnostic Related Groups (DRGs) are rolled into Enhanced Service Related Groups (ESRGs) and subsequently Specialty Related Groups (SRGs). ESRGs for ophthalmology are cataract procedures, other eye procedures and non-procedural ophthalmology. Details of DRGs included under each of these ophthalmology ESRGs and their growth from 1999–00 to 2002–03 are listed in Appendix 7.
There is forecast growth in ophthalmology (public and private) separations of 3.4 per cent per annum and bed days of 2.9 per cent per annum to 2016–17. This growth is led by cataract procedures with a forecast growth in separations of 4.2 per cent per annum or a doubling by 2016–17 (Figure 4). Other eye procedures are forecast to grow at 1.1 per cent per annum and non-procedural ophthalmology is forecast to grow at 2.0 per cent per annum (Figures 5 and 6). Detailed forecasts for each ESRG are listed in Appendix 8.
Figure 4: Cataract procedures forecast (separations) – Victorian public and private hospitals, 2001–02 to 2016–172
[pic]
2 To maintain consistency throughout the framework development process, the July 2003 version of the forecasting model, with 2001–02 as base year, was used for the entirety of this project, from the development of the discussion paper to the publication of the framework.
Figure 5: Other eye procedures forecast (separations) – Victorian public and private hospitals, 2001–02 to 2016–17
[pic]
Figure 6: Non-procedural ophthalmology forecasts (separations) – Victorian public and private hospitals, 2001–02 to 2016–17
[pic]
Public hospital inpatient forecasts
Forecasts for public hospital activity indicate that by 2016–17 there will be a 3.3 per cent per annum increase in ophthalmology inpatient separations, with a 4.3 per cent per annum increase in same day separations and a 1.0 per cent per annum decrease in multiday separations (refer Appendix 8).
The average length of stay (ALOS) for multiday ophthalmology separations is forecast to reduce from 2.08 days in 2001–02 to 1.88 days in 2016–17, a reduction of 0.7 per cent per annum.
Public cataract procedures are forecast to grow at 4.5 per cent per annum to 2016–17, with a continued shift to sameday activity and a decline in multiday ALOS from 1.28 to 1.19 days. Public other eye procedure separations are forecast to grow at 0.7 per cent per annum to 2016–17. This will occur in the setting of a shift from multiday to sameday separations with an overall decline in bed days at 0.3 per cent per annum. Multiday ALOS will decline from 1.94 days to 1.66 days.
Public non-procedural ophthalmology is a small but important component of ophthalmology practice. There is expected to be a 2.0 per cent per annum growth in sseparations and a 0.2 per cent per annum growth in bed days. Multiday ALOS will decline from 3.48 to 3.19 days.
The Victorian resident population is forecast to grow by 1.11 per cent per annum in metropolitan Melbourne and 0.71 per cent per annum in rural Victoria (Appendix 9). Ophthalmology forecasts, however, indicate that by 2016–17 there will be higher growth in rural (3.8 per cent growth per annum) compared to metropolitan areas (3.3 per cent annual growth). Forecast annual growth for each region is as follows:
• Eastern - 3.0 per cent
• Northern and Western – 3.4 per cent
• Southern – 3.5 per cent
• Barwon South West - 3.1 per cent
• Grampians – 3.9 per cent
• Loddon Mallee – 3.9 per cent
• Hume - 4.5 per cent
• Gippsland – 4.2 per cent
Forecast prevalence of eye health conditions
The forecasts provided by the department are for inpatient care. A large proportion of eye health conditions, however, require little or no inpatient treatment and can be effectively managed in the community or outpatient settings, and therefore are not captured in these forecasts. The following forecasts for diabetic eye disease, glaucoma, AMD and refractive error are based on current prevalence and population forecasts.
With an increased focus on health promotion through the Vision Initiative the potential exists to increase demand for eye services, as many of the following eye disorders are undiagnosed.
Diabetic eye disease
The Australian Diabetes, Obesity and Lifestyle Study undertaken in 1999–2000 found that one in 13 Australian adults (940,000 people, or 7.5 per cent of the adult population) have diabetes, but half do not know it. It was found that 15.3 per cent of those with diabetes had retinopathy. The prevalence of retinopathy was 21.9 per cent in those with known type-2 diabetes and 6.2 per cent in those newly diagnosed. The prevalence of proliferative diabetic retinopathy was 2.1 per cent in those with known diabetes, with no cases of proliferative diabetic retinopathy found in those newly diagnosed. Untreated vision threatening retinopathy was present in 1.2 per cent of known cases (Tapp et al, 2003).
Current estimates extrapolated from this study indicate that the prevalence of diabetic retinopathy in Victoria will grow from nearly 38,000 people aged 25 and over in 2003 to nearly 45,600 in 2016. This assumes no change in the proportion of the adult population with type-2 diabetes and diabetic retinopathy in 2016.
As all people with diabetes are at risk of developing eye disease, and only half of these people have regular eye examinations, a large unmet demand for services exists. Considering that early diagnosis and treatment can prevent up to 98 per cent of severe vision loss, strategies that address the barriers to regular screening (lack of awareness and communication breakdowns) have been identified as the means of managing this condition (CERA, 2000).
Glaucoma
As glaucoma prevalence is closely correlated with ageing, the ageing of the population over coming years will have a profound effect on the prevalence of the disease. Current estimates extrapolated from the VIP (Figure 7) indicate that the prevalence of glaucoma will grow from approximately 41,000 people aged over 40 years to more than 55,000 by 2016 in Victoria.
As half of all glaucoma is undiagnosed, early detection and effective treatment are likely to have a positive impact on the level of consequential visual impairment from the disease.
Figure 7: Age specific prevalence of glaucoma (CERA, 2000)
[pic]
Age-related macular degeneration
As with glaucoma, prevalence of AMD is age-related (Figure 8). The prevalence of the disease is forecast to grow from 330,000 people in 2003 to more than 430,000 people in Victoria by 2016. While the effectiveness of treatments are currently limited, the development and uptake of new technologies (such as photodynamic therapy) will be in high demand in the future. Access to low vision services is required for people with vision loss through AMD in order to optimise visual function.
Figure 8: Age specific prevalence of AMD (CERA, 2000)
[pic]
Refractive error
Refractive error is a defect of the eye’s focus which effects distance and/or near vision, and if uncorrected, results in vision impairment. It has been identified in a number of population-based studies as the leading cause of visual impairment in the developed world and a leading cause of functional blindness in the developing world.
Ten per cent of Victorians have significant refractive error leading to an improvement of one or more lines of visual acuity with glasses. The risk of under corrected refractive error increases 1.8 times for every decade of life after 40 years of age (Liou et al, 1999). Under-corrected refractive error, defined as improvement of greater than or equal to 10 letters (2+ lines on the log MAR chart) in people with presenting visual acuity of 6/9 or worse, may be present in up to 22 per cent (Thiagalingam et al, 2002). Refractive error can be corrected by glasses, contact lenses or surgery.
There are five refractive laser surgery centres in Victoria. These are all private facilities with only a small number of therapeutic procedures funded through the MBS or the public hospital sector. Apart from government funded procedures, refractive surgery activity is undocumented, as licensing and billing arrangements do not require reporting of activity to State and Commonwealth Governments. Despite the paucity of data, refractive laser surgery appears to be a significant area of ophthalmic practice in the private sector.
Paediatric services
Paediatric inpatient separations have declined 2.0 per cent per anum since 1998–99 and MBS claims have declined 2.4 per cent since 1999–2000. Most paediatric separations are grouped into the ESRG other eye procedures (81 per cent) followed by non-procedural ophthalmology (13 per cent) and cataract procedures (4 per cent). Paediatric separations are forecast to decline 2.8 per cent per annum to 2016–17 with other eye procedures forecast to decline 3.8 per cent per annum (Figure 9).
Figure 9: Paediatric forecasts for other eye procedures (separations) – Victorian public and private hospitals, 2001–02 to 2016–17
Cost of vision loss
A study by Access Economics (2004) estimated that the total cost of vision disorders in Australia in 2004 is $9.85 billion. Growth in the prevalence of eye disease will increase the direct and indirect costs from vision loss.
Nationally, direct health costs of treating eye disease are estimated at $1.8 billion, more than health spending on diabetes and asthma combined. Hospital costs are the largest at $692 million (38 per cent) followed by specialists and other out-of-hospital referred medical costs at $226.0 million (12 per cent) and pharmaceutical costs at $208.8 million (11 per cent). By 2020, direct costs are projected to more that double to $3.7 billion.
Cataract is the largest single direct health cost condition at $327 million (18 per cent), followed by refractive error at $261 million (14 per cent) and glaucoma at $144 million (8 per cent).
Indirect costs of visual impairment are estimated at $3.2 billion. These include lost earnings at $1,800 million (56 per cent) and carers’ costs at $845 million (26 per cent).
Indirect costs have been identified by CERA as follows:
Government
• increased costs on the primary health system (vision loss increases the risk of falls and hip fractures and depression)
• early entry into supported accommodation or aged care facility
• early reliance on supported home care
• early reliance on social welfare system (through loss of income and reduced productivity)
• early admission to aged care facilities.
Community
• increased pressure on other community services
• loss of participation in the community.
Individual
• prevents healthy ageing
• increased mortality (risk of death is two times greater than the community average)
• creation of other health issues (physical and emotional, particularly depression)
• diminished quality of life through reduced independence, mobility and confidence.
Projections of health care expenditure on eye care
Nationally, by 2020, direct health costs for eye care are projected to more than double to $3.7 billion, primarily due to demographic ageing. Hospital costs are projected to reach $1.45 billion, with cataract costing $668 million per annum (Access Economics, 2004).
4.2 Appropriateness
‘Essentially, the appropriateness of health care is about using evidence to do the right thing to the right patient, at the right time, avoiding over and under utilisation’ (VQC, 2003).
Utilisation rates
Service utilisation can be used as a measure of appropriateness of care. A number of studies have examined the utilisation of eye care services in Australia. Findings include:
• geographic variability in rates of ophthalmology care despite similarity in the prevalence of eye disease between rural and urban areas
• utilisation of eye care services increases with age
• gender, private health insurance, urban residence, and English language skills are significant factors associated with eye health care service use
• incongruence between the proportion of the ophthalmology practice sites and the proportion of the population in various urban and rural areas.
(Keefe et al, 2002; Madden et al, 2002)
An age-standardised analysis of ophthalmology inpatient separations undertaken at a local government area (LGA) level demonstrated large variations between LGAs in utilisation rates for each ophthalmology ESRG. This is similar to analysis undertaken in NSW (NSW Health, 2002).
Cataract surgery
Debate exists over the appropriateness of some cataract procedures. While the effectiveness of cataract surgery is well established, disagreement exists about there being any evidence of inappropriate intervention in relation to cataract surgery. With the lower threshold for cataract surgery there were concerns raised by some stakeholders that, in some cases, cataract surgery was being performed earlier than ideal.
As well as the threshold for cataract surgery being lowered, it was suggested that there is a growing trend in cataract surgery being performed to correct refractive error. Some clinicians are eliminating the need for glasses through customising surgery with new intraocular implants, surgical astigmatic correction and early second eye surgery.
Data suggests that cataract procedures are increasing at a rate greater than the population is ageing, with the change in threshold for surgery attributed as the biggest factor in this disproportionate rise.
Table 7 demonstrates that while Victoria’s total population has grown at 1.1 per cent per annum and the population aged over 70 years has grown at 3.0 per cent per annum over the period 1995–96 to 2001–02, cataract procedures have grown at 8.1 per cent per annum over the same period. The age standardised growth rate of cataract procedures has been 5.5 per cent per annum, attributable to the reduction in threshold of surgery.
The common unit of measure of cataract surgery is the cataract surgery rate (CSR), defined as the number of procedures per million people per year. The Victorian CSR of 6,116 (Table 8) is among the highest reported in the literature, compared to other Australian states and higher than international comparisons (about 5,700 for the United States, 4,000 for Sweden and 2,700 for the United Kingdom) (Taylor, 2000).
Table 7: Growth in population and cataract procedures - Victoria 1995–96 to 2001–02
|1995–96 |2001–02 |Growth pa 1995–96 – 2001–02 |
|Victorians 70+ years of age |391,194 |452,604 |3.0% |
|Total Victorian population |4,560,155 |4,822,663 |1.1% |
|Cataract procedures |21,152 |31,259 |8.1% |
|Age adjusted cataract procedures (adjusted to 2001–02 population|23,925 |31,259 |5.5% |
|distribution) | | | |
The common unit of measure of cataract surgery is the cataract surgery rate (CSR), defined as the number of procedures per million people per year. The Victorian CSR of 6,116 (Table 8) is among the highest reported in the literature, compared to other Australian states and higher than international comparisons (about 5,700 for the United States, 4,000 for Sweden and 2,700 for the United Kingdom) (Taylor, 2000).
Table 8: Cataract surgery rate per million population 2001–023 – Australian states and territories – ABS and AIHW (2003)
|NSW |VIC |QLD |WA |SA |TAS |ACT |NT |Total |
|Public |13,531 |11,803 |4,761 |4,232 |4,489 |112 |652 |303 |39,883 |
|hospitals | | | | | | | | | |
|Private |34,284 |17,774 |20,733 |7,989 |6,782 |N/A |N/A |N/A |91,257 |
|hospitals | | | | | | | | | |
|Total |47,815 |29,577 |25,494 |12,221 |11,271 |112 |652 |303 |131,140 |
|Total |6,608,792 |4,836,196 |3,664,284 |1,913,850 |1,515,748 |472,116 |320,275 |197,617 |19,531,464 |
|population | | | | | | | | | |
|CSR |7,235 |6,116 |6,957 |6,386 |7,436 |237 |2,036 |1,533 |6,714 |
3 Separations relating to ICD block 197: Extracapsular crystalline lens extraction by phacoemulsification
While incentives to over-service may exist in the private sector, this was not considered by most providers to be a problem in public hospitals with sessional payment structures, although there is no information to support either view.
Second eye surgery
There was specific debate during the consultations about whether surgery on a patient’s second cataract should be prioritised over first eye surgery in other patients. Approximately one-third of patients receiving first eye surgery will have surgery on their second eye within the following year and 50 per cent will do so within two years (Acosta & Tuni, 2002).
The benefit of second eye surgery has been questioned, given the allocation of substantial resources. Efficiency arguments (obviating the need to undergo another pre-operative assessment) support early operation on the second cataract. Equity arguments may support the proposition that the patient should be placed on the waiting list behind others with a more urgent need. Others argue that the benefit from second eye surgery is almost equal to that of first eye surgery. There was no consensus amongst providers on this issue.
A study from the United States on cost-utility of cataract surgery in the second eye concluded that that second eye cataract surgery is one of the most cost-effective procedures in ophthalmology and across medical specialities. Second eye cataract surgery, at US$2,727 per quality-adjusted life-years (QALY) gained, seemed nearly as valuable as initial cataract surgery at US$2,023 per QALY gained (Busbee et al, 2002). A protocol for a Cochrane review has been proposed to evaluate the effects of cataract surgery in both eyes in comparison with surgery in only one eye (Acosta & Tuni, 2002).
Table 8: Cataract surgery rate per million population 2001–023 – Australian states and territories – ABS and AIHW (2003)
|NSW|VIC|QLD|WA |SA |TAS|ACT|NT |Tot|
| | | | | | | | |al |
|Pub|13,|11,|4,7|4,2|4,4|112|652|303|39,|
|lic|531|803|61 |32 |89 | | | |883|
|hos| | | | | | | | | |
|pit| | | | | | | | | |
|als| | | | | | | | | |
|Pri|34,|17,|20,|7,9|6,7|N/A|N/A|N/A|91,|
|vat|284|774|733|89 |82 | | | |257|
|e | | | | | | | | | |
|hos| | | | | | | | | |
|pit| | | | | | | | | |
|als| | | | | | | | | |
|Tot|47,|29,|25,|12,|11,|112|652|303|131|
|al |815|577|494|221|271| | | |,14|
| | | | | | | | | |0 |
|Tot|6,6|4,8|3,6|1,9|1,5|472|320|197|19,|
|al |08,|36,|64,|13,|15,|,11|,27|,61|531|
|pop|792|196|284|850|748|6 |5 |7 |,46|
|ula| | | | | | | | |4 |
|tio| | | | | | | | | |
|n | | | | | | | | | |
|CSR|7,2|6,1|6,9|6,3|7,4|237|2,0|1,5|6,7|
| |35 |16 |57 |86 |36 | |36 |33 |14 |
3 Separations relating to ICD block 197: Extracapsular crystalline lens extraction by phacoemulsification
Models of care and the role of eye care professionals
There is debate locally, nationally and internationally regarding the appropriateness of emerging ophthalmology models of care and the roles played by different eye care professionals. The following are examples of different models of care that have developed for the five eye conditions recognised as causing 80 per cent of visual impairment. Patients may experience eye health conditions in isolation or in combination.
Cataract
As stated previously, there are variations in managing cataract waiting lists, prioritisation systems and second eye surgery. Given its high volume, models of care for patients with cataract have gained significant attention locally and internationally. These models have ignited debate about the appropriateness and effectiveness of care pathways and the health care professionals most suitably qualified and skilled to provide the care.
The preoperative care of cataract is currently managed in a range of settings, including community-based ophthalmology and optometry practices and hospital-based outpatient clinics. As cataracts generally develop over many years, some hospital outpatient clinics refer patients to community providers to monitor the development of cataracts while others continue to monitor patients until surgery is required.
Models of care for the postoperative management of patients following cataract surgery have gained significant attention, with new models of postoperative care emerging locally and internationally. Throughout the consultations there was robust debate about the model of care that has been introduced at the CICC in which the day one review is not routinely undertaken. On one hand, the model was defended as providing good patient outcomes and having a growing base of evidence on safety and outcomes (Tinley et al, 2003). On the other hand, it was criticised for being introduced without prior evaluation in the Australian context, despite the traditional model of care not being systematically evaluated either. An evaluation has now taken place. Results are available at health..au/electivesurgery.
It was noted, however, that the day one postoperative review has been removed from routine care by some ophthalmologists, particularly in rural areas, and that some ophthalmologists and optometrists have established a model of care in the private sector whereby optometrists perform the first postoperative review.
Refractive error
Refractive error is managed by appropriate refractive aids, including glasses and contact lenses. It is managed in a number of settings by a range of providers, including ophthalmologists, optometrists and orthoptists. State Government legislation (Optometrists Registration Act 1996) restricts glasses’ prescriptions to optometrists, medical practitioners and orthoptists on request or referral from an ophthalmologist or optometrist.
4 This legislative restriction is currently under review as part of a review of the regulation of the health professions in Victoria being undertaken by the department.
4 This legislative restriction is currently under review as part of a review of the regulation of the health professions in Victoria being undertaken by the department.
Many providers suggested that prescriptions for glasses should be provided by as wide a group of appropriately trained specialists as possible (ophthalmologists, optometrists and orthoptists) and across as broad a geographic area as possible. Increased use of orthoptists in the primary care sector may improve access and provide another level of competition to the market. Some providers believe that more refractive services should be provided in the hospital setting (for example, expand refraction clinics at the RVEEH), while the dominant view is that this would be inappropriate and that these services should only be provided in community settings.
Glaucoma
A number of models of care exist for managing glaucoma patients, these include a range of health care professionals and technologies.
Optometrists have traditionally screened for glaucoma as part of a routine eye examination and referred patients to ophthalmologists for treatment if required. Ophthalmic care has been supported by orthoptists and ophthalmic nurses in the ongoing monitoring of patients through testing procedures such as intraocular pressure monitoring and visual field examination. Some optometrists have developed co-management arrangements with ophthalmologists to care for glaucoma patients.
New models of care for managing glaucoma are evolving following the changes to Victorian legislation and training programs allowing optometrists to prescribe S4 drugs to manage glaucoma and a range of other eye disorders. Protocols for shared care of glaucoma patients by ophthalmologists and optometrists have been developed by the Optometrists Registration Board of Victoria. These could be used to inform new workforce models for management of glaucoma.
Some concerns about quality of care were expressed about optometrists extending their services to chronic disease management, however, there is no evidence that quality of care is compromised.
Diabetic retinopathy
A number of models of care for screening for diabetic retinopathy that include a range of health care professionals and technologies have been shown to be effective. These range from dilated fundus examinations by ophthalmologists, GPs, endocrinologists and optometrists, to the use of non-mydriatic cameras by orthoptists and ophthalmic nurses. These models should be considered for future adoption. Similarly, previous pilot projects funded by the department explored alternative workforce roles and approaches to manage patients with diabetic retinopathy that could be considered for broader application into the future.
Screening for diabetic retinopathy by ophthalmologists every two years has a cost effectiveness of US$49,760 QALY compared with costs of US$15,000 for annual screening with a non-mydriatic camera (Vijan, 2000, and Maberley, 2003, cited in Access Economics, 2004).
Age-related macular degeneration
While there are currently only limited treatment options for AMD, access to low vision services is considered important for people to develop skills to support their lifestyle with limited vision. Low vision services are currently provided across a range of settings and professional groups. Service provision ranges from individual practitioners to large community organisations such as the Vision Australia Foundation and the Royal Victorian Institute for the Blind (RVIB).
To improve access to low vision services, the RVEEH has developed an arrangement with Vision Australia Foundation to provide onsite access to services. Services include rehabilitation, low vision assessment clinics and living support services.
The predicted development of new treatment modalities for AMD may require new models of care.
Workforce
There is a relatively good supply of health care professionals with specific ophthalmic training and skills, however, there is a general view amongst stakeholders that better use could be made of the existing workforce, particularly those with specialist skills. In many instances, arrangements already exist between ophthalmologists and orthoptists, ophthalmologists and nurses, or ophthalmologists and optometrists at a local level, including varying roles for practitioners in areas such as pre and post operative assessment of cataract patients and the management and monitoring of some glaucoma patients.
There have been several barriers to achieving more widespread, multidisciplinary workforce models that make best use of available skills, including:
• funding models that prevent less qualified staff taking on less complex aspects of eye care
• a long history of acrimony between professional groups which has prevented effective collaboration at a statewide level
• legislative restrictions on who can prescribe glasses without referral and prescribing therapeutics, which has limited which groups can prescribe and under what circumstances.
According to stakeholders, there is a range of areas in which the roles of non-medical staff could potentially be used. Optometrists are highly regarded for their expertise and accessibility, and are recognised by many as an under-utilised resource. Many stakeholders believe that other health care professionals, including GPs, orthoptists and nurses, also have considerable potential to contribute to more efficient, effective and accessible service delivery. There is support for exploring more multidisciplinary approaches to care that make best use of available workforce skills and also improve patient access to care.
Suggested areas in which non-medical staff could be better utilised include:
• pre and post operative cataract management
• refractive error
• glaucoma screening and management
• diabetic screening and monitoring.
4.3 Efficiency
‘Efficiency refers to the way in which resources are utilised to achieve value for money. This can be achieved by focusing on minimising the cost combination of resource inputs in the production of a particular service (technical efficiency) as well as the allocation of resources to those services to provide the greatest benefit to consumers. Allocative efficiency informs decisions on what services or treatments to deliver, whereas technical efficiency is concerned with reducing costs and minimisation of waste.’ (VQC, 2003).
Technical efficiency: models of care and work settings
Ophthalmology surgical procedures are generally considered to be efficient in comparison to other surgical procedures. However, many providers recognise that there is potential to enhance the efficiency of the system through better coordination of care, better use of dedicated facilities and better utilisation of optometrists, orthoptists, nurses and GPs.
Developing new service models that improve service efficiency and enhance continuity of care is a key direction of the MHS in meeting demand for services. Of particular relevance to the delivery of ophthalmology services are the directions for the development of new models of care for elective surgery and ambulatory care services.
Models of care for surgical services in ophthalmology have undergone significant changes in the past two decades with an increasing trend for ambulatory care through the introduction of day case, local anaesthetic cataract surgery and phacoemulsification surgery.
Elective surgery
The ability to meet elective surgery demand has been affected by increasing emergency admissions (MHS, 2003). This is particularly relevant to ophthalmology services provided in large general tertiary hospitals where elective surgery may be cancelled to allow for emergency procedures.
ESAS has indicated that there is value in providing targeted elective surgery capacity that can be separated from the impact of emergency demand. The new Elective Surgery Centre being developed at the Alfred Hospital will provide a new model of care for the delivery of short stay elective surgery. It will physically separate scheduled short stay services from emergency and acute inpatient services to avoid delays and improve the efficiency of delivering elective surgery.
This model will support the delivery of ophthalmology services due to its elective and short stay profile. The model of care implemented at Southern Health’s CICC also promotes efficient service delivery through the provision of same day elective surgery only.
A recent Cochrane review was conducted to provide reliable evidence about the safety, feasibility, effectiveness and cost-effectiveness of cataract extraction performed as day care versus inpatient procedure (Hamed & Fedorowicz, 2004). This review provides some evidence that there is a cost saving but no significant difference in outcome or risk of postoperative complications between day care and inpatient cataract surgery. Evidence regarding patient preferences for day care surgery versus inpatient admission was inconclusive.
There is considerable stakeholder support for high volume elective surgery facilities for ophthalmology services. In their view, the fact that a large proportion of eye surgery is done on a same day basis provides opportunity for further expansion of services without very high capital investment. Many providers consider that using dedicated elective surgery theatres will enable a critical mass of patients to be treated whose procedures are often cancelled due to priority being given to emergency cases from other specialties.
It was suggested that throughput for an individual operating theatre needs to be at least ten operations per day, five days per week (2,500 operations per year, which would include approximately 2,000 cataract operations per year) to be optimally efficient. High volume centres would ensure a critical mass to make the provision of expensive equipment and staff sustainable. The CICC model of care which promotes enhanced community links may provide direction for future development. It was noted by many providers that private day-surgery centres have a high level of productivity and there may be opportunity for collaboration between the public and private sectors.
It is uniformly agreed that surgical teaching lists are relatively slower and more expensive than consultant surgical lists. There is an opportunity to establish guidelines to allow sufficient teaching lists to be retained while allowing more consultant-run service lists.
Ambulatory care
There is considerable scope to provide alternative eye care in public hospitals, as a range of accessible and affordable community eye care providers are already available. This is consistent with the MHS, which has identified the expansion of ambulatory care services in the community as a key direction for the future and states that:
Ambulatory care services should be provided in a community-based setting unless considered inappropriate for safety, quality of care and efficiency reasons.
Developing an ambulatory services framework will guide this policy direction and will focus on developing models of care that effectively manage of people with chronic and complex conditions across the care continuum from prevention, early intervention, diagnosis, treatment, continuing care to palliation.
A range of strategies have been identified to support the delivery of ambulatory care services relevant to ophthalmology. The first is the creation of health precincts. Health precincts aim to bring together a range of health and related services to create a community hub of the local service system. They will be the first point of call for a range of primary and secondary health services, tailored to meet local needs, all within a comprehensive environment. These precincts will allow existing public and private, primary and secondary services to be collocated with new services such as super clinics.
The second is the creation of super clinics. Super clinics will be new community-based facilities that will treat people with complex medical conditions requiring specialist intervention in a community setting as a substitute for hospitalisation. The super clinic concept builds on established hospital outreach services such as Integrated Care Centres and hub and spoke service delivery by relocating hospital services to community-based settings. Hospital-based ambulatory services should continue to target secondary and some tertiary health services of a more complex level, for example, day surgery, diagnostic services and outpatient pre-admission.
Workforce change
The potential exists to improve efficiency of eye care delivery through better use of the available skills of the current eye care workforce across various streams of care. In particular, new service models and settings such as super clinics and health precincts offer the opportunity to establish and/or expand workforce models that make best use of available specialist skills. This could involve reorganising existing work and/or expanding roles for existing practitioners, depending on the forecast service needs and workforce availability in local regions.
| |
|Recommendation |
|6. The following will increase the capacity of the system to provide for future demand: |
|• establishment and expansion of services in general tertiary hospitals |
|• development and expansion of models of care that promote effective and efficient delivery of eye care services |
|• increased use of elective surgery centres for ophthalmology surgery (in particular cataract surgery) |
|• establishment and/or expansion of workforce models that make best use of the existing workforce in public hospitals and in |
|community settings (that is, optometrists, orthoptists and nurses undertaking greater roles in the provision of eye care). |
Allocative efficiency
There was considerable debate about the large number of low complexity patients that present to the RVEEH emergency department for management, when they could be managed in other general hospital or community settings. It was suggested, however, that patients self-triage and cannot be stopped from presenting at the RVEEH and that once they present they need to be managed in that setting.
Others thought that emergency care should, by preference, be centred on the RVEEH. Overall, however, there was support for the concept of the majority of ophthalmic emergency care being provided in general emergency departments with a much more active triaging system at the RVEEH, with on-referral of appropriate patients to community or other settings.
It was suggested during consultation that discharge of outpatients to community-based providers should become the norm at the RVEEH, rather than patients continuing to be reviewed in a hospital setting. This would increase capacity to treat new patients who currently experience long waiting periods for outpatient clinics.
Funding and price
Public hospitals are funded through a combination of casemix payments and specified grants. The casemix cost weights are developed through an in depth study of hospital activities. The cost weights for same day ophthalmology DRGs from 2000–01 to 2004–05 are listed in Table 95 . The standard rate per Weighted Inlier Equivalent Separation (WIES) for rural hospitals is slightly more than the WEIS for metropolitan hospitals, in recognition of the higher costs of running small hospitals.
5 The weighting is derived through annual costing studies which compare, in participating hospitals, the relative resource consumption of each DRG against all others. Intra-hospital costing systems are fundamental to casemix. While they vary between hospitals, the relativity in resource consumption for each DRG within each hospital produces a reliable weighting.
5 The weighting is derived through annual costing studies which compare, in participating hospitals, the relative resource consumption of each DRG against all others. Intra-hospital costing systems are fundamental to casemix. While they vary between hospitals, the relativity in resource consumption for each DRG within each hospital produces a reliable weighting.
The cost of service provision varies between hospitals. Through efficiencies in work practices or staffing arrangements, some hospitals achieve costs that differ markedly from the casemix payment. Salary arrangements for surgeons have been noted as a significant factor in whether a hospital is able to deliver the service within the casemix payment, with some hospitals providing sessional payments and others fee-for-service.
Stakeholders believed that funding models need to be more transparent, that WIES funding is inadequate in some settings, and that efficiency objectives in the provision of patient care should be explicit and balanced with explicit objectives for teaching and training. It was noted that the cost weight for cataract surgery has been reduced by from 0.6214 in 2001–02 to 0.5845 in 2003–04.6
|DRG Code and Name |Same day weight |
| |2000–01 |2001–02 |2002–03 |2003–04 |2004–05 |
|c01Z |Procedures for penetrating eye injury |0.6175 |0.6316 |0.605 |1.1162 |0.7883 |
|c02Z |Enucleations and orbital procedures |0.93 |1.1506 |1.0703 |0.9444 |0.7017 |
|c03Z |Retinal procedures |0.8436 |0.8669 |0.8472 |0.843 |0.8433 |
|c04Z |Maj corneal, scleral & conjunctival procs |0.7637 |0.9147 |0.9368 |0.7871 |1.0693 |
|c05Z |Dacryocystorhinostomy |0.7287 |0.7554 |0.7787 |0.7915 |0.7302 |
|c06Z |Complex glaucoma procedures |0.5738 |0.4661 |0.4538 |0.4736 |
|c07Z |Other glaucoma procedures |0.6563 |0.707 |0.5909 |0.5991 |
|c08Z |Major lens procedures |0.6214 |0.5925 |0.5995 |0.5845 |
|c09Z |Other lens procedures |0.616 |0.7208 |0.7518 |0.8231 |
|c10Z |Strabismus procedures |0.4275 |0.4867 |0.4791 |0.4275 |0.4226 |
|c11Z |Eyelid procedures |0.4056 |0.4282 |0.4103 |0.3999 |0.4148 |
|c12Z |Oth corneal, scleral & conjunctival procs |0.3211 |0.3296 |0.3256 |0.4379 |0.3708 |
|c13Z |Lacrimal procedures |0.3703 |0.2705 |0.2778 |0.2687 |0.2309 |
|c14Z |Other eye procedures |0.342 |0.3429 |0.3292 |0.3042 |0.3112 |
|c15A |Glaucoma/cx cataract procedures |0.7051 |
|c15B |Glaucoma/cx cataract procedures, sd |0.5228 |
|c16A |Lens procedures |0.7398 |
|c16B |Lens procedures, sd |0.6003 |
|c60A |Acute and major eye infections age>54 |0.3796 |0.4313 |0.4411 |0.4604 |0.3442 |
|c60B |Acute and major eye infections age ................
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