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, Taylor HR Indigenous Eye Health Melbourne School of Population and Global Health The University of Melbourne
led by Professor Hugh Taylor total 14 staff health systems and translational research advocacy, technical advice and support health promotion our goal to Close the Gap for Vision for Indigenous Australians www.iehu.unimelb.edu.au
Partners collaborators fellow travelers Australian Government DoH, DPMC, DE NACCHO Optometry Australia RANZCO Vision 2020 Australia VACCHO Victorian Government Brien Holden Vision Institute Fred Hollows Foundation Australian College of Optometry Lions Outback Vision/Lions Eye Institute Institute Urban Indigenous Health Outback Eye Service RACGP Diabetes Australia Primary Health Networks State and territory governments State fund holders ACCHO State affiliates ACCHOs, AHSs, AMSs State Indigenous eye health committees Koolin Balit(VIC) NSW, NT, QLD, SA Regional Indigenous eye health committees VIC: Grampians, Great South Coast, Geelong, North and West Metro, Loddon, Mallee NT: Central Australia/Barkly, Top End NSW: Western Sydney, Western NSW QLD: South West QLD, Palm Island Aboriginal Health Workers, GPs, care coordinators Optometrists, ophthalmologists NTSRU State/territory trachoma agencies/groups
National Indigenous Eye Health Survey 2008 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
0% 30% 25% Vision Impairment % 20% 15% 10% 5% 0 0.05 0.1 0.15 0.2 0.25 AMS Optometry FTE Eye services within AMS reduce vision loss
38% of those needing surgery yet to receive surgery (NEHS 2016)
Trachoma in Australia NTSRU 2015 139 at risk communities 40 endemic (>5%) 16 hyperendemic (>20%) Prevalence TF 2009 14% 2015 4.6%
We know what we need to do Trachoma Cataract Diabetes Refractive Error Implement the SAFE Strategy Ensure SAFE until eliminated 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) refer to optometry Ensure provision of spectacles
We have reviewed existing service models service provision and availability service utilisation pathways of care and case-management history of eye health policy and programs We have consulted Field Consultations (21 sites) Focus Groups (10 held in 7 locations) Stakeholder Workshops (x3 with 84 people) Community Controlled Sector (NACCHO and each state affiliate) Ministries and Departments (in each jurisdiction) Over 530 people involved
The Roadmap Launched 23 February 2012 42 recommendations across 9 domains Endorsed by: a whole of system approach to close the gap for vision NACCHO National Aboriginal Community Controlled Health Organisation OA Optometry Australia RANZCO Royal Australian and New Zealand College of Ophthalmologists Vision 2020 Australia
42 Roadmap recommendations Cataract 35/42 recommendations Diabetic retinopathy 35/42 Refractive error 34/42 Trachoma 37/42 The patient journey is like a leaky pipe
Progressing the Roadmap 11/42 recommendations completed action on all 42 recommendations 63% steps completed multipartisan support
National advocacy and progress Sector support/agreement to common plan (Roadmap) Visiting eye services increased Fundholder arrangements improved Mandatory vision checks in health checks (MBS 715) National set of indicators agreed Oversight and coordination funded + $4.8m announced May 2016 Flexible surgery funds increased National approach to affordable spectacle supply MBS items and equipment/training for diabetic retinopathy photography Jurisdictional groups established (VIC, NT, WA, SA, NSW, QLD ) Regional implementation started (not pilots) in >20 regions in VIC, WA, NT, NSW, SA and QLD
MBS Item 715 (Aboriginal and Torres Strait Islander health assessment) includes mandatory eye checks history to include vision examination/assessment to include eye examination what to check for an eye check? 1.(History) Problem with vision or eyes? 2.(VA) 3.(Exam) Visual acuity (near and distance) Include trichiasis 4.(Refer) People with diabetes require annual retinal exams
Challenges in implementation: subsidised spectacle schemes
VASSS Victorian Aboriginal Subsidised Spectacle Scheme established 2010 Initial funding for ~1,300 spectacles per year over 3 years Extended 2x now to 2018 over 3,300 spectacles per year 1,400 1,200 ACO state-wide Number of visual aids delivered 1,000 800 600 400 200 VES Rural practices Increased consultation services and supply of spectacles 0
The importance of diabetes
Timely laser treatment can prevent 98% of blindness Rates of Severe Visual Loss % 40 30 20 10 0 DRS Untreated Eyes ETDRS by Eye ETDRS by Patient 0 1 2 3 4 5 Years of Study Ferris JAMA 1993
Prevalence of Diabetic Retinopathy ~30% Any Retinopathy Prevalence, % 60 50 40 30 20 10 0 Barbados Eye BDES BMES Melbourne VIP Proyecto VER SAHS SLVDS WESDR Pooled UAE SiMES Vision Threatening Retinopathy ~8% Vision Threatening Retinopathy 50% 30% 30% Prevalence, % 12 10 8 6 4 2 0 Whole population All diabetes Diagnosed diabetes Retinopathy Need to treat Barbados Eye Study BDES, Beaver Dam Eye Study; BMES, Blue Mountains Eye Study; VIP, Visual Impairment Project; VER, Vision Evaluation Research; SAHS, San Antonio Heart Study; SLVDS, San Luis Valley Diabetes Study; WESDR, Wisconsin Epidemiologic Study of Diabetic Retinopathy BDES BMES Melbourne VIP Proyecto VER SAHS SLVDS WESDR Pooled SiMES
Diabetes Retinal Examination (NHMRC guidelines) At diagnosis of diabetes Every 12 months for Indigenous people with diabetes; two years otherwise Visual acuity Ophthalmoscopy Retinal photography Refer to optometrist or ophthalmologist
Medicare Item Number non-mydriatic retinal photography for people with diabetes 1994 -request to RACO to submit an application 1998 - request supported by Health Minister; rejected by Cabinet 2000 - full MSAC application; rejected Nov 2008 start a new submission CCRE Sep 2009 start rewriting -new process Oct 2010 draft submitted, Jun 2011 re-submitted Sep 2011 rejection another new process Aug 2012 high level meetings with DoHA and MBD start to assist Dec 2012 application submitted; Mar 2013 PASC review Jan 2014 economic evaluation; Oct 2014 review by ESC Nov 2014 MSAC approval May 2016 Budget approval Nov 2016 implementation!
New MBS items for NMRP non-mydriatic retinal photography Commenced 1 November 2016 Rebate is $50 Item 12325 for Aboriginal and Torres Strait Islander people with diabetes annual Item 12326 for non Aboriginal people with diabetes every 2 years
Fully automated alignment, focus and image capture Weight 19 kg Size 580 x 550 x 330 mm dark room for dilation ~1500 mm ~700 mm 40 degree field of view 3.8 minimum pupil size Less than 10 minutes per person
Clinical pathway for DR screening Patient with diabetes VA and retinal photograph Normal photograph/ no retinopathy VA <6/12, VA difference of > two lines, abnormal or ungradable photograph Refer to optometry/ ophthalmology
When to refer? for further examination (comprehensive eye examination optometry/ophthalmology) Any change in vision Vision less than 6/12 VA difference greater than 2 lines DR retinal abnormalities Cannot examine/capture image
On-line Diabetic Retinopathy Grading Course drgrading.iehu.unimelb.edu.au
Diabetic Retinopathy Screening Card www.iehu.unimelb.edu.au
On line module A comprehensive guide in establishing a functional diabetic retinopathy screening service in GP practice Practice or GP-only training suitable for RACGP Cat 1 ALM Small Group Learning options Developed by Professor Claire Jackson with RANZCO Contact: g.vey@uq.edu.au
Check Today, See Tomorrow resources supports the key diabetes eye care messages Promoting annual eye exams for those with diabetes, includes multimedia resources www.iehu.unimelb.edu.au
$4.8m over 3 years 2017-2019 105 cameras and training
Age standardised eye examination rate Hospitalisation rate for cataract surgery
Summary Indigenous vision loss is largely unnecessary Diabetic eye disease is a growing problem that we must work together to address we can stop almost all the vision loss with regular screening The new MBS Item numbers are a real game changer We encourage incorporating eye care and diabetes eye care into GP pathways of care it is now time to close the gap for vision - by 2020! manjou@unimelb.edu.au philip.roberts@unimelb.edu.au www.iehu.unimelb.edu.au