Insight of adult health checks an approach to Aboriginal and Torres Strait Islander eye examinations. Prof Hugh Taylor and Mr Mitchell Anjou

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1 Insight of adult health checks an approach to Aboriginal and Torres Strait Islander eye examinations Prof Hugh Taylor and Mr Mitchell Anjou

2 Insight of adult health checks An approach to Aboriginal and Torres Strait Islander eye examinations

3 RACGP Conference GP13 17 October 2013 Darwin Insight of adult health checks an approach to Aboriginal and Torres Strait Islander eye examinations Hugh Taylor and Mitchell Anjou The University of Melbourne

4 Indigenous Eye Health Unit Melbourne School of Population and Global Health Ultimate Aim: To Close the Gap for Vision 1. Define to scope of the problem 2. Characterise current service models 3. Develop recommendations for sustainable, cost-effective eye care services but also fast-track Trachoma

5 National Indigenous Eye Health Survey randomly selected sites 5 15yr old and 40yr and older 2883 people examined

$Blindness in Adults 32% Cataract 14% Refractive Error and Optic Atrophy 9% Trachoma and Diabetic Eye Disease Overall 94% of Vision Impairment is avoidable and 35% have never had an$

6 Overview Vision Loss in Children One fifth as common as in mainstream Vision Loss in Adults Blindness is 6 times more common Low Vision is nearly 3 times more common Causes of Blindness in Adults 32% Cataract 14% Refractive Error and Optic Atrophy 9% Trachoma and Diabetic Eye Disease Overall 94% of Vision Impairment is avoidable and 35% have never had an eye exam

7 We know what we need to do Trachoma Implement the SAFE Strategy Cataract Diabetes Refractive Error If VA is <6/12 or impaired function refer for assessment Ensure provision of surgery Retinal assessment for those with diabetes (every 12 months) Ensure provision of laser treatment Screening for VA (near and distance vision) Ensure provision of spectacles

Trachoma Leading infectious cause of blindness Caused by Chlamydia trachomatis Cycles of re-infection following poor personal and community

8 Trachoma Leading infectious cause of blindness Caused by Chlamydia trachomatis Cycles of re-infection following poor personal and community hygiene 21.3 million children with TF 7.3 million with TT In 52 poorest developing countries and Australia as number 53! 325 million at risk

10 Lack of Clean Faces is the Key Determinant

11 SAFE Strategy, WHO 1993

Trachoma in Australia Trachoma disappeared from mainstream Australia 100 years ago NIEHS showed 20-30% of Outback Aboriginal children still had trachoma In some communities in 2008; 10% of older

13 Trachoma in Australia Trachoma disappeared from mainstream Australia 100 years ago NIEHS showed 20-30% of Outback Aboriginal children still had trachoma In some communities in 2008; 10% of older people have in-turned lashes and half of those have corneal scars. Trachoma can be readily controlled with the SAFE strategy. 27 February 2009 Prime Minister announces $16m over 4 years to eliminate trachoma as part of $58m Indigenous Eye and Ear Package 14 May 2013 $16.5m for a further 4 years

14 The SAFE Strategy Surgery Antibiotics Facial Environmental cleanliness improvements

15 Trichiasis Surgery Pre-op Post -op

16 Antibiotic Distribution Azithromycin Need to treat all family/household members At higher prevalences (10%+) MDA Repeat treatment every 6 to 12 months

17 Collateral Benefits of Azithromycin treatment Decrease in skin infections Decrease in respiratory infections Decrease in otitis media Decrease in STIs Halving of childhood mortality Long-term reductions in rheumatic fever and glomerulonephritis

18 Environment Improvement Africa and Asia; focus on pit latrines and bore holes but need to address the barriers to Clean Faces

19 Emphasis on improving housing, overcrowding and maintenance

20 Promotion of Facial Cleanliness MCH Clinic Crèche/Childcare School Clinic The aim is to change the community norm to keep every kid s face clean. Clean Faces, Strong Eyes

21 Trachoma Story Kit Resource Book Background Material Flip Charts Posters School Curricula Colouring sheets Stickers and Stamps DVDs Mirrors

22 Social Marketing Campaign Imparja TV Children s Program Football club and players Radio announcements Trachoma songs Goanna mascot suits

NTSRU-2012 15/1 6 Prevalence TF 2009 14% 2012 4% 31/3 1

24 NTSRU /1 6 Prevalence TF % % 31/3 1 19/1 9 6/7 8/ /17 26/30 8/8 23/24 8/9 6/6 8/8 14/15

25 Trachoma Prevalence Central Australia Increased number of communities screened Treatment coverage improved Increased number of children screened Health promotion materials available Clean faces, strong eyes campaign active

26 Trachoma Summary - We know how to eliminate blinding trachoma We have the commitment and resources We now need to do the work; Attention to coverage Family-based intervention Trichiasis screening Clean Faces

$Diabetes Refractive Error If VA is <6/12 or$ Ensure provision of surgery Retinal

months) Ensure provision of laser treatment

27 We know what we need to do Trachoma Implement the SAFE Strategy Cataract Diabetes Refractive Error If VA is <6/12 or impaired function refer for assessment Ensure provision of surgery Retinal assessment for those with diabetes (every 12 months) Ensure provision of laser treatment Screening for VA (near and distance vision) Ensure provision of spectacles

28 Number of Blind and Visually Impaired Indigenous Australians No leadership - Incomplete programs - Status quo ,000 15,000 - Leadership - Roadmap fully implemented - Coherent, sustainable 2,000

29 Vision Loss - Everyone s Responsibility Vision loss is common Vision loss has a big impact Vision loss is discrete and fixable Vision care can provide a model for other specialist services to link with comprehensive primary care

31 There is a huge disparity in the distribution of eye care provided across Australia

32 Vision Loss is not less in Urban and Regional Areas even though services are readily available.

Well co ordinated services work better and cost less Surgical Case Rate % 20 NT Central Outreach Cape York 15 Longreach loop Great Southern WA 10 Pilbara Good co ordination = clinic throughput up 40%

33 Well co ordinated services work better and cost less Surgical Case Rate % 20 NT Central Outreach Cape York 15 Longreach loop Great Southern WA 10 Pilbara Good co ordination = clinic throughput up 40% waiting times 5 months less cataract surgery up 80% costs down 15% 5 NT Top End Outreach Kimberley 30% r 2 = % Service Integration Score Vision Impairment % 20% 15% 10% 5% 0% AMS Optometry FTE Eye services within AMS reduce vision loss

34 The patient journey is like a leaky pipe

37 Katherine Region NT annual need for eye services 12,043 people (ABS 2011) Comprehensive optometry exams 2,047 includes glasses 770 includes diabetes exams 1,158 Ophthalmology referrals/consults 293 Diabetic laser surgery 134 Trichiasis surgery 44 Cataract surgery 114 Workforce Ophthalmologists 0.4 FTE (88 days) Optometrists 1.2 FTE (256 days) Coordination workforce 10 FTE

attending at least one Community Controlled Sector NACCHO and each state

38 Stakeholder Consultation Field Consultations 21 sites across the country Focus Groups 10 held in 7 locations in Victoria Stakeholder Workshops 3 with 84 people attending at least one Community Controlled Sector NACCHO and each state affiliate Ministries and Departments In each jurisdiction In all some 530 people were involved

The Roadmap Launched 23 February 2012 Develop

services 42 recommendations across 9 domains Endorsed by:

Organisation OAA Optometrists Association Australia RANZCO

39 The Roadmap Launched 23 February 2012 Develop recommendations for sustainable, cost effective, eye care services 42 recommendations across 9 domains Endorsed by: NACCHO National Aboriginal Community Controlled Health Organisation OAA Optometrists Association Australia RANZCO Royal Australian and New Zealand College of Ophthalmologists Vision 2020 Australia

40 The Roadmap to Close the Gap for Vision

$Refractive error 34/42 Diabetic retinopathy 35/42 Trachoma$

41 42 Roadmap recommendations Cataract 35/42 recommendations Refractive error 34/42 Diabetic retinopathy 35/42 Trachoma 37/42

Medicare Locals Indigenous eye health collaborative framework Funding for

42 National progress Improvement in MSOAP/RHOF and VOS MSAC application for DR photography screening MBS item Mandatory vision checks in Adult Health Assessments Medicare Locals Indigenous eye health collaborative framework Funding for coordination and oversight Commonwealth, NACCHO, OAA, RANZCO, V2020A Continuation of funding for trachoma

Victorian Advisory Council for Koori Health (VACKH) Eye Health Subcommittee Aboriginal Eye Health Strategy 2013 2014 1. Linked to State DH Aboriginal Health Plan 2012 2022 Koolin Balit 2.

43 Victorian Advisory Council for Koori Health (VACKH) Eye Health Subcommittee Aboriginal Eye Health Strategy Linked to State DH Aboriginal Health Plan Koolin Balit 2. Endorsed by Minister for Health 3. Maintain VACKH EHS existing programs beyond 2013 VACCHO officer, RVEEH ALO, spec scheme 4. Implement regional plans in 3 health regions in Progressively implement regional plans in other DH areas

44 Regional implementation of the Roadmap has started VIC NT NSW WA QLD Loddon Mallee, Barwon South West and Southern Metro VACKH Eye Health Subcommittee Katherine Region, Central Australia/Barkly, Greater Darwin/East Arnhem Fred Hollows Foundation, BHVI West and Far West NSW FHF, BHVI Kimberley and Pilbara Lions Outback Vision Program South East Institute for Urban Indigenous Health

45 Pathways for eye care people with diabetes

46 Same pathways for eye care

47 National guide to a preventative health assessment for Aboriginal and Torres Strait Islander people Chapter 6: Eye Health

48 MBS mandatory eye checks in Health Assessments for Aboriginal and Torres Strait Islander adults and older people history to include vision examination/assessment to include eye examination

Normal vision Can you see clearly and comfortably both for things: held in your hands?

49 History Are you having any problems/difficulties with your vision or eyes? Are you having any problems with your glasses or contact lenses? Normal vision Can you see clearly and comfortably both for things: held in your hands? looking far away? Do you have diabetes? Consider sore or watery eye as possible symptom of trichiasis Cataract vision

50 Vision Measure near vision (both eyes, with glasses if normally worn) Can they read normal sized print at any comfortable distance? Measure distance vision (each eye, with glasses if normally worn) Can they read 6/12?

51 Eye Examination Check eye movements, pupils Check external and anterior eye Lids, lashes, conjunctiva, cornea (trichiasis, pterygium, corneal scarring ) Consider trachoma trichiasis 3 Ts Think, Thumb, Torch

52 Diabetes Retinal Examination Every 12 months for people with diabetes Ophthalmoscopy (dilated fundoscopy, retinal photography) Refer to optometrist or ophthalmologist

53 Refer to optometry or ophthalmology. eye problems; change in vision reduced vision (Distance <6/12; Near <N8 ) patients with diabetes every year (or take retinal photograph with camera) Refer to ophthalmology. trichiasis patients with diabetic retinopathy

54 Coming soon

55 What to check Vision and eye examinations in MBS Aboriginal and Torres Strait Islander health assessments 1. Problem with vision or eyes? 2. Visual acuity (near and distance) 3. People with diabetes require annual retinal exam 4. Trichiasis

56 We now have the evidence, strategy and capacity to eliminate unnecessary vision loss for Indigenous Australians We are looking for the support of primary care to identify and manage eye health We need concerted government commitment toimplement the Roadmap across Australia and so close the gap for vision

57 Thank you

Information technology and ehealth Develop standard clinical prompts for eye

systemsprimary care and eye care practitioners Automated referrals and

Sector agreed indicators for eye care into existing data monitoring streams

59 Information technology and ehealth Develop standard clinical prompts for eye care and incorporate into existing software Promote use of recall and messaging systemsprimary care and eye care practitioners Automated referrals and electronic discharge summaries Use of telehealth and other emergent technologies Sector agreed indicators for eye care into existing data monitoring streams Aggregate local eye health data into a regional dataset to be used for regional eye health planning.

60 Eye care indicators Developed by eye care sector through Vision 2020 Australia to be included in Australia s National Framework and WHO Global Action Plan Prevalence and causes of vision impairment population survey Cataract surgery rate Cataract surgery coverage Plus other indicators to include Cataract patients waiting, waiting >90 days Refractive error eye exams, subsidised glasses Diabetes retinal exams, laser treatment Trachoma collected through NTSRU

61 Thank you

Enhancing eye health capacity in primary health care: closing the gap for vision

Rural Health West Aboriginal Health Conference Perth 1 July 2017 Enhancing eye health capacity in primary health care: closing the gap for vision Anjou MD, Jatkar U, Gilden R, Schubert NS, Roberts PI,