Updated inventory and projections for Canada's ophthalmology workforce.

OBJECTIVE: To update Canadian ophthalmology workforce data and provide future predictions. DESIGN: Cross-sectional study. PARTICIPANTS: Ophthalmologists working in Canada from 1968 to 2019. METHODS: Supply and demographics of physicians in Canada were obtained from the Canadian Institute for Health Information. Physician training numbers were obtained from the Canadian Post-MD Education Registry. Using Statistic Canada population projections, future predictions about Canada's ophthalmology workforce were determined. RESULTS: In 2020, there were 1323 ophthalmologists in Canada; 27.3% were female and 20.9% were aged ≥65 years. Overall, there were 3.48 ophthalmologists per 100,000 population. Provincial distributions varied from 2.32 in Manitoba to 5.00 in Nova Scotia. For the population aged ≥65 years, there were 19.35 ophthalmologists per 100,000 population. If the yearly change in ophthalmologists' numbers remains as during the past 10 years, the number of ophthalmologists per 100,000 population is predicted to be slightly reduced to 3.21 in 2068 in a high-growth scenario and increased to 4.08 and 5.08 in a medium- and low-growth scenario, respectively. For the population aged ≥65 years, corresponding predicted ratios are 14.00 in a high-growth scenario, 17.72 in a medium-growth scenario, and 18.40 in a low-growth scenario. CONCLUSIONS: The ratio of ophthalmologists to population aged ≥65 years, the predominant cohort treated by ophthalmologists, is projected to drop by 4.9% and 27.7% in the low- and high-growth scenarios, respectively, potentially creating a challenge to vision care delivery. A small increase in ophthalmology residency positions could protect against this.

Infection rate following elective oculoplastic surgery in a minor procedure setting: a single-centre retrospective study.

OBJECTIVE: A surgical site infection after oculoplastic surgery is a serious complication that can lead to endophthalmitis and vision loss. Although performing these procedures in a minor-surgery setting is common, there is a lack of evidence in the literature regarding the incidence of postoperative infections. The objective of this study was to determine the infection rate associated with elective outpatient oculoplastic procedures performed in a minor-surgery setting. METHODS: A retrospective review was completed for all patients who underwent elective oculoplastic surgery in the minor-procedure room at the Misericordia Health Centre in Winnipeg between April and December 2018. Operations were performed by 2 senior oculoplastic surgeons. Data collected included the type of procedure, number of surgical incisions, type and number of sutures, use of prophylactic antibiotics, time to follow-up, complications, and presence of surgical site infection. RESULTS: Review of 539 patients showed an infection rate of 0.37% (2 of 539). Infection cases were an exposed orbital implant using a temporalis fascia graft and ptosis repair using a frontalis sling. Thirteen complications were identified, corresponding to a complication rate of 2.41% (13 of 539). CONCLUSION: Study results show an infection rate of 0.37% for elective oculoplastic surgery in a minor-procedure setting.

Does eliminating the preoperative history and physical make a difference in low-risk cataract surgery patients? A before and after study of 30-day morbidity and mortality.

OBJECTIVE: To evaluate the safety of omitting the conventional preoperative history and physical examination (H&P) for low-risk cataract surgery patients. DESIGN: Comparison of outcomes before and after the January 1, 2015 system wide implementation of a program that eliminated the conventional preoperative H&P for low-risk patients as identified by a 12-item risk stratification questionnaire. PARTICIPANTS: Two separate groups of Winnipeg residents who had cataract surgery at the city's sole ophthalmological referral centre between July 1 and December 31, 2014 (preimplementation reference group) or between October 1, 2015 and March 31, 2016 (postimplementation intervention group). METHODS: A detailed chart review was completed for cataract surgery patients who experienced a postoperative medical event (a composite of death or hospital admission or emergency department visit, identified within administrative databases) within 30 days of surgery. Nonfatal events were captured for all 7 hospitals and urgent care centres in the city, including the ophthalmological referral centre. RESULTS: Postoperative medical events occurred in 114 of 2981 (3.82%) intervention group surgeries and 125 of 3037 (4.12%) reference group surgeries (Relative risk 0.92, 95% confidence interval 0.72 to 1.19, p = 0.6 Fisher exact test). Subgroup analyses of major medical events and medical events by affected organ system yielded no significant differences between the 2 groups. In the opinion of the physician chart reviewers, none of the events among low-risk patients in the intervention group were related to the omission of a conventional preoperative H&P. CONCLUSIONS: The risk of adverse medical events within 30 days of cataract surgery was not higher after the omission of the conventional preoperative H&P in patients screened to be low risk by a validated preoperative questionnaire.

Neural network and logistic regression diagnostic prediction models for giant cell arteritis: development and validation.

PURPOSE: To develop and validate neural network (NN) vs logistic regression (LR) diagnostic prediction models in patients with suspected giant cell arteritis (GCA). Design: Multicenter retrospective chart review. METHODS: An audit of consecutive patients undergoing temporal artery biopsy (TABx) for suspected GCA was conducted at 14 international medical centers. The outcome variable was biopsy-proven GCA. The predictor variables were age, gender, headache, clinical temporal artery abnormality, jaw claudication, vision loss, diplopia, erythrocyte sedimentation rate, C-reactive protein, and platelet level. The data were divided into three groups to train, validate, and test the models. The NN model with the lowest false-negative rate was chosen. Internal and external validations were performed. RESULTS: Of 1,833 patients who underwent TABx, there was complete information on 1,201 patients, 300 (25%) of whom had a positive TABx. On multivariable LR age, platelets, jaw claudication, vision loss, log C-reactive protein, log erythrocyte sedimentation rate, headache, and clinical temporal artery abnormality were statistically significant predictors of a positive TABx (P≤0.05). The area under the receiver operating characteristic curve/Hosmer-Lemeshow P for LR was 0.867 (95% CI, 0.794, 0.917)/0.119 vs NN 0.860 (95% CI, 0.786, 0.911)/0.805, with no statistically significant difference of the area under the curves (P=0.316). The misclassification rate/false-negative rate of LR was 20.6%/47.5% vs 18.1%/30.5% for NN. Missing data analysis did not change the results. CONCLUSION: Statistical models can aid in the triage of patients with suspected GCA. Misclassification remains a concern, but cutoff values for 95% and 99% sensitivities are provided (https://goo.gl/THCnuU).

Crossover clinical trial of pain relief in cataract surgery.

PURPOSE: To determine the effects of intra-operative Korean traditional music on pain experienced by Korean patients undergoing sequential bilateral cataract surgery. METHODS: This was a two-sequence, two-period, and two-treatment crossover study. Fifty-two patients with cataracts were divided into two groups by block randomization, and bilateral cataract surgery was performed. In group 1, patients listened to Korean traditional music (KTM) during their first but not second cataract surgery. This sequence was reversed for patients in group 2. After each surgery, patients scored their pain intensity (PI) using a visual analog scale (VAS) ranging from 0 to 10, where 0 was 'no pain' and 10 was 'unbearable pain.' RESULT: There was a statistically significant reduction in the mean VAS score with KTM (3.1 ± 2.0) compared to that without KTM (4.1 ± 2.2; p = 0.013). However, there were no statistically significant differences in blood pressure or pulse rates. CONCLUSION: KTM had a significant effect on reducing pain experienced by patients during cataract surgery. This may be useful in the context of other surgical procedures to reduce pain in Korean patients.

Future trends in ophthalmology health human resources in Canada.

Projections of future Canadian ratios of ophthalmologists to population have fluctuated because of changes in numbers of residency spots and retirement rates. Although this ratio plateaued in recent years, the ratio of ophthalmologists to the population over 65 years of age is projected to steadily deteriorate. All graduating residents are going to be needed to meet the upcoming workload, yet current graduates are finding increasing difficulty obtaining full-time positions with operating room privileges. This problem is affecting all specialties who require hospital facilities, and exploration of this problem by the Royal College, Canadian Medical Association (CMA), Resident Doctors of Canada, and council of the Provincial Deputy Ministers of Health is presented. Proposed solutions to the current job shortages include residents starting in positions outside of major metropolitan areas, clinicians in practice giving up some operating room time to make way for new graduates, government increasing infrastructure commensurate with the increased number of medical school positions, and optimizing use of current resources by running operating rooms for longer hours and on the weekends.

The underemployed ophthalmologist-results of a survey of recent ophthalmology graduates.

OBJECTIVE: To survey recent graduates of Canadian ophthalmology residency programs with regard to current employment, fellowship, job finding strategies, operating room time and resources, scope of practice, and reasons for difficulty in finding a job. DESIGN: Cross-sectional survey. PARTICIPANTS: Graduates of Canadian ophthalmology residency programs between 2009 and 2013 inclusive. METHODS: An electronic survey in English and French distributed via Surveymonkey to Canadian ophthalmology graduates from 2009 to 2013. RESULTS: Of the eligible ophthalmologists, 72% responded, and 81% of respondents had what they considered a job placement. The class of 2009 had the highest (100%) and the class of 2012 had the lowest (55%) employment rate. Of the respondents, 68% completed or were completing a fellowship, with retina being the most popular. Eighty percent of those with a job had operating room time with a median of 4 days per month, and 61% stated that their practice was open to all consultations, with cataract being the most common. Respondents felt adequately trained within the CanMEDS roles with the exception of manager. Only 11% felt they were adequately trained to run a business. CONCLUSIONS: It is important that an ophthalmology health human resources strategy is developed to ensure that newly trained ophthalmologists can practice their skills to serve health-care needs now and in the future.

Safety and comparative costs of preoperative assessments for cataract surgery: traditional mandatory assessment versus a novel graded assessment system.

PURPOSE: We conducted this study to evaluate the safety and costs of traditional mandatory preoperative assessment for cataract surgery patients compared with a novel graded preoperative assessment system. METHODS: Patients were recruited at a high-volume surgical centre from May to November 2013. Patients completed a health-related questionnaire which allowed for a graded preoperative assessment of all participants. Based on responses to the questionnaire, patients were classified preoperatively into a) low-risk patients not requiring a preoperative assessment and b) high-risk patients requiring this assessment. Anesthesiologists still assessed all patients immediately before surgery but with staff blinded to preoperative assessment information for low-risk patients. Observed complication rates and costs were compared with those expected in the mandatory assessment system. RESULTS: We examined 3,347 cataract surgeries on 2,766 patients and categorized 59.9% of patients as low risk. In the graded system cohort, there were no major complications and a low rate of minor complications occurred. Wherever a complication occurred in a low-risk patient, the anesthesiologist doubted that the preoperative assessment information would have prevented the complication. If implemented, the graded system would save approximately 4,414 preoperative assessments per year in our region, with an associated cost of approximately $40.00 per surgery, or $359,000 in total. The cost to prevent a single minor complication with the mandatory system was approximately $8,976, with a number needed to treat of 223. CONCLUSION: The graded system resulted in no major complications and a low rate of minor complications. The information obtained from the mandatory assessment is unlikely to prevent complications. Additionally, the cost effectiveness of the mandatory system was poor. This novel graded preoperative assessment system for cataract surgery patients can save time and resources by eliminating unnecessary patient visits.

The landscape of ophthalmologists in Canada: present and future.

OBJECTIVE: To describe the current national and regional population distribution of ophthalmologists in Canada and provide national predictions up to 2030. DESIGN: Cross-sectional, study. PARTICIPANTS: Ophthalmologists listed in the Canadian Medical Association (CMA) database and Canadian population. METHODS: The CMA database was used to determine the number and location of currently licensed ophthalmologists in Canada. Using Statistics Canada population data, we determined the ratio of ophthalmologists to 100,000 population. Projections were also made for the supply of ophthalmologists up to 2030 using the CMA Physician Resource Evaluation Template and assuming a status quo scenario in terms of attrition and gain factors. RESULTS: In Canada, there are currently 3.35 ophthalmologists per 100,000 population. There is, however, significant regional disparity; provincial ratios vary from 5.40 (Nova Scotia) to 1.96 (Saskatchewan) and 0.89 in the territories. If 3 ophthalmologists per 100,000 is the ideal ratio, then 4 provinces and the territories were below this ratio, and of the 104 regions with an ophthalmologist, 22 were below the ratio. The national projection to 2030 is a slight increase to 3.38; however, the full-time equivalent ratio is expected to decrease from 3.29 in 2012 to 3.06 in 2030. For the population ≥ 65 years old, with a projected growth 4 times greater than that of ophthalmologists, the ratio of ophthalmologists to population ≥ 65 years old is projected to decline by 34%. CONCLUSIONS: Although national estimates appear stable, there is significant regional variation. The projected marked growth of the population ≥ 65 years old may compromise our future ability to provide care at the current standard.

Recent Canadian ophthalmology graduates: experiences in finding jobs and assessment of their training.

OBJECTIVE: To examine the ability of recent Canadian ophthalmology graduates to commence clinical practice and obtain surgical privileges. A secondary objective was to assess their perception of the adequacy of their residency training. DESIGN: An Internet questionnaire survey. PARTICIPANTS: Canadian graduates of Canadian ophthalmology residency programs between 2005 and 2009, inclusive. METHODS: Email addresses for the participants were obtained from the Canadian Ophthalmological Society and invitations to participate were sent, followed by 2 reminder emails. RESULTS: A 44% response rate was obtained (65 out of 154 emails sent). Of the respondents, 91% were working full time, and 89% had operating-room time. Training was adequate for all CanMEDs competencies except working as a manager. Assessment that one's practice did not live up to expectations correlated with male gender, dissatisfaction with location, inability to get operating-room time, inability to get other hospital resources, feelings about fairness of distribution of resources, and net income below expectations. CONCLUSIONS: For the most part, recent graduates are successful in establishing practices that meet their expectations. Training in management skills should be improved in residency programs.

The cost of vision loss in Canada. 1. Methodology.

OBJECTIVE: This paper outlines the methodology used to estimate the cost of vision loss in Canada. The results of this study will be presented in a second paper. DESIGN: The cost of vision loss (VL) in Canada was estimated using a prevalence-based approach. This was done by estimating the number of people with VL in a base period (2007) and the costs associated with treating them. The cost estimates included direct health system expenditures on eye conditions that cause VL, as well as other indirect financial costs such as productivity losses. Estimates were also made of the value of the loss of healthy life, measured in Disability Adjusted Life Years or DALY's. To estimate the number of cases of VL in the population, epidemiological data on prevalence rates were applied to population data. The number of cases of VL was stratified by gender, age, ethnicity, severity and cause. The following sources were used for estimating prevalence: Population-based eye studies; Canadian Surveys; Canadian journal articles and research studies; and International Population Based Eye Studies. Direct health costs were obtained primarily from Health Canada and Canadian Institute for Health Information (CIHI) sources, while costs associated with productivity losses were based on employment information compiled by Statistics Canada and on economic theory of productivity loss. Costs related to vision rehabilitation (VR) were obtained from Canadian VR organizations. CONCLUSIONS: This study shows that it is possible to estimate the costs for VL for a country in the absence of ongoing local epidemiological studies.

The cost of vision loss in Canada. 2. Results.

OBJECTIVE: This study was conducted to provide the financial underpinnings necessary for effective planning for the provision of eye health services in Canada. Canada is facing an aging demographic and all the major eye diseases are diseases associated with aging. It is essential that we have information based on the best available data to support national and provincial vision health plans. DESIGN: The design associated with the prevalence-based approach used in this study was outlined previously in detail in The Cost of Vision Loss in Canada: Methodology. METHODS: The methods associated with the prevalence-based approach used in this study were previously outlined in detail in The Cost of Vision Loss in Canada: Methodology. RESULTS: The financial cost of VL in Canada in 2007 was estimated to be $15.8 billion per annum: $8.6 billion (54.6%) represents direct health system expenditure; $4.4 billion (28.0%) was productivity lost due to lower employment, higher absenteeism, and premature death of Canadians with VL; $1.8 billion (11.1%) was the dead weight losses (DWL) from transfers including welfare payments and taxation forgone; $0.7 billion (4.4%) was the value of the care for people with VL; $305 million (1.9%) was other indirect costs such as aids and home modifications and the bring forward of funeral costs. Additionally, the value of the lost well-being (disability and premature death) was estimated at a further $11.7 billion. In per capita terms, this amounts to a financial cost of $19370 per person with VL per annum. Including the value of lost well-being, the cost is $33704 per person per annum. CONCLUSIONS: There is a growing awareness in Canada and around the world of the impact of VL on health costs and on the economy in general. This awareness is supported by the growing number of independent studies on the cost of vision loss both nationally and globally. Because most of these studies are limited by the minimal amount of available data, the overall cost of vision loss is likely underestimated. Nevertheless, this study reports the cost of vision loss in Canada as being greater than previously reported, making the problem even more urgent to address. A comprehensive national vision health plan, that is a coordinated federal, provincial and territorial initiative dealing with all aspects of vision loss prevention, sight restoration, and vision rehabilitation is called for.