Delivery of Eye and Vision Services in Aboriginal and Torres Strait Islander Primary Healthcare Centers.

BACKGROUND: Routine eye and vision assessments are vital for the detection and subsequent management of vision loss, which is particularly important for Aboriginal and Torres Strait Islander people who face higher rates of vision loss than other Australians. In order to guide improvements, this paper will describe patterns, variations, and gaps in these eye and vision assessments for Aboriginal and Torres Strait Islander people. METHODS: Clinical audits from 124 primary healthcare centers (sample size 15,175) from five Australian states and territories were conducted during 2005-2012. Main outcome measure was adherence to current guidelines for delivery of eye and vision assessments to adults with diabetes, those without a diagnosed major chronic disease and children attending primary healthcare centers. RESULTS: Overall delivery of recommended eye and vision assessments varied widely between health centers. Of the adults with diabetes, 46% had a visual acuity assessment recorded within the previous 12 months (health center range 0-88%) and 33% had a retinal examination recorded (health center range 0-73%). Of the adults with no diagnosed major chronic disease, 31% had a visual acuity assessment recorded within the previous 2 years (health center range 0-86%) and 13% had received an examination for trichiasis (health center range 0-40%). In children, 49% had a record of a vision assessment (health center range 0-97%) and 25% had a record of an examination for trachoma within the previous 12 months (health center range 0-100%). CONCLUSION: There was considerable range and variation in the recorded delivery of scheduled eye and vision assessments across health centers. Sharing the successful strategies of the better-performing health centers to support focused improvements in key areas of need may increase overall rates of eye examinations, which is important for the timely detection, referral, and treatment of eye conditions affecting Aboriginal and Torres Strait Islander people, especially for those with diabetes.

Impact of diabetes on eye care service needs: the National Indigenous Eye Health Survey.

BACKGROUND: To assess the proportion of Australian Indigenous adults who require eye care services (separately among those with and without diabetes) and determine implications for eye care service planning. DESIGN: The National Indigenous Eye Health Survey (NIEHS) was a population-based study of 30 randomly selected geographical areas. PARTICIPANTS: The NIEHS included 1189 Indigenous adults aged 40-80 years. METHODS: A standardized eye examination was performed. MAIN OUTCOME MEASURE: The number requiring eye care services by diabetes status. RESULTS: Those with diabetes were older (median 53 years) than those without diabetes (median age 50 years), P < 0.001. The total estimated population-based need for annual eye care in the NIEHS population was 52% (n = 615), and of those 72% were people with diabetes. Among those with diabetes, 29% required further primary referral for diabetic retinopathy, 12% for cataract, 1% for trachomatous trichiasis and 5% for uncorrected distance refractive error. Among those without diabetes 13% required further primary referral for cataract, 0% for trachomatous trichiasis and 5% for uncorrected distance refractive error. CONCLUSION: This study has shown that among Indigenous adults, those with diabetes form 72% of those requiring an eye examination in any year. A key strategy to close the gap for vision for Australia's Indigenous population is to ensure those with diabetes undergo annual eye screening, have clearly defined care pathways and receive timely treatment. Establishing care pathways for those who have diabetes would also improve access to eye care services for others in the community.

Australian Football League clinics promoting health, hygiene and trachoma elimination: the Northern Territory experience.

Australia is the only developed country to suffer trachoma and it is only found in remote Indigenous communities. In 2009, trachoma prevalence was 14%, but through screening, treatment and health promotion, rates had fallen to 4% in 2012. More work needs to be done to sustain these declining rates. In 2012, 25% of screened communities still had endemic trachoma and 8% had hyperendemic trachoma. In addition, only 58% of communities had reached clean face targets in children aged 5-9 years. Australian Football League (AFL) players are highly influential role models and the community love of football provides a platform to engage and strengthen community participation in health promotion. The University of Melbourne has partnered with Melbourne Football Club since 2010 to run trachoma football hygiene clinics in the Northern Territory (NT) to raise awareness of the importance of clean faces in order to reduce the spread of trachoma. This activity supports Federal and state government trachoma screening and treatment programs. Between 2010 and 2013, 12 football clinics were held in major towns and remote communities in the NT. Almost 2000 children and adults attended football clinics run by 16 partner organisations. Awareness of the football clinics has grown and has become a media feature in the NT trachoma elimination campaign. The hygiene station featured within the football clinic could be adapted for other events hosted in remote NT community events to add value to the experience and reinforce good holistic health and hygiene messages, as well as encourage interagency collaboration.

Establishing the value of Indigenous eye health programs: health needs, economic priority and performance assessment approaches.

OBJECTIVES: The aim of this paper was to compare three different approaches that are used in support of additional funding of health programs, using Indigenous eye health programs (IEHPs) as an example. These approaches are Heath and Health Care Needs, Economic Priority (Value for Money) and Conformity with Health Services Performance Standards. METHODS: A review of relevant literature was conducted to identify relevant benchmarks and assess IEHPs. RESULTS: In terms of health needs, vision loss is the fourth highest contributor to the Indigenous health gap. Additional funding for Indigenous eye treatment services to remove the gap is estimated at A$28.1million per annum. As an economic priority, IEHPs (specifically for refractive error, cataract, diabetic retinopathy and trachoma) demonstrate excellent value for money and compare favourably with other better-researched health programs. Evaluation of health performance measures indicated that IEHPs also perform well, as judged by Australian performance standards for health services generally and Indigenous health services more specifically, the later involving local delivery, including care coordination through Aboriginal-controlled community health services. CONCLUSION: The value of IEHPs was demonstrated using all three approaches. Different approaches are likely to be more or less persuasive with different audiences. The application of these approaches is relevant to other health programs. WHAT IS KNOWN ABOUT THIS TOPIC? Supporters of additional funding for health programs frequently use the impact of this additional funding on the health and health care needs of the affected populations and individuals. Indigenous Eye Health programs are considered for illustrative purposes. This argument is not necessarily persuasive to funders of health programs. WHAT DOES THIS PAPER ADD? This paper demonstrates that two further approaches, namely Economic Priority and Conformity with Health Performance Measure Standards, both demonstrate good arguments in support of additional funding and that these outcomes may be more persuasive to funders of health programs. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? Practitioners are able to harness additional approaches with a higher likelihood of success of submissions for additional funding for the program they are promoting.

Close the gap for vision: The key is to invest on coordination.

OBJECTIVE: The study aims to estimate costs required for coordination and case management activities support access to treatment for the three most common eye conditions among Indigenous Australians, cataract, refractive error and diabetic retinopathy. DESIGN: Coordination activities were identified using in-depth interviews, focus groups and face-to-face consultations. Data were collected at 21 sites across Australia. The estimation of costs used salary data from relevant government websites and was organised by diagnosis and type of coordination activity. SETTING: Urban and remote regions of Australia. INTERVENTIONS: Needs-based provision support services to facilitate access to eye care for cataract, refractive error and diabetic retinopathy to Indigenous Australians. MAIN OUTCOME MEASURES: Cost (AUD$ in 2011) of equivalent full time (EFT) coordination staff. RESULTS: The annual coordination workforce required for the three eye conditions was 8.3 EFT staff per 10 000 Indigenous Australians. The annual cost of eye care coordination workforce is estimated to be AUD$21 337 012 in 2011. CONCLUSIONS: This innovative, 'activity-based' model identified the workforce required to support the provision of eye care for Indigenous Australians and estimated their costs. The findings are of clear value to government funders and other decision makers. The model can potentially be used to estimate staffing and associated costs for other Indigenous and non-Indigenous health needs.

Cost of close the gap for vision of Indigenous Australians: On estimating the extra resources required.

OBJECTIVE: To estimate the costs of the extra resources required to close the gap of vision between Indigenous and non-Indigenous Australians. DESIGN: Constructing comprehensive eye care pathways for Indigenous Australians with their related probabilities, to capture full eye care usage compared with current usage rate for cataract surgery, refractive error and diabetic retinopathy using the best available data. SETTING: Urban and remote regions of Australia. INTERVENTIONS: The provision of eye care for cataract surgery, refractive error and diabetic retinopathy. MAIN OUTCOME MEASURES: Estimated cost needed for full access, estimated current spending and estimated extra cost required to close the gaps of cataract surgery, refractive error and diabetic retinopathy for Indigenous Australians. RESULTS: Total cost needed for full coverage of all three major eye conditions is $45.5 million per year in 2011 Australian dollars. Current annual spending is $17.4 million. Additional yearly cost required to close the gap of vision is $28 million. This includes extra-capped funds of $3 million from the Commonwealth Government and $2 million from the State and Territory Governments. Additional coordination costs per year are $13.3 million. CONCLUSIONS: Although available data are limited, this study has produced the first estimates that are indicative of the need for planning and provide equity in eye care.

Local co-ordination and case management can enhance Indigenous eye care--a qualitative study.

BACKGROUND: Indigenous adults suffer six times more blindness than other Australians but 94% of this vision loss is unnecessary being preventable or treatable. We have explored the barriers and solutions to improve Indigenous eye health and proposed significant system changes required to close the gap for Indigenous eye health. This paper aims to identify the local co-ordination and case management requirements necessary to improve eye care for Indigenous Australians. METHODS: A qualitative study, using semi-structured interviews, focus groups, stakeholder workshops and meetings was conducted in community, private practice, hospital, non-government organisation and government settings. Data were collected at 21 sites across Australia. Semi-structured interviews were conducted with 289 people working in Indigenous health and eye care; focus group discussions with 81 community members; stakeholder workshops involving 86 individuals; and separate meetings with 75 people. 531 people participated in the consultations. Barriers and issues were identified through thematic analysis and policy solutions developed through iterative consultation. RESULTS: Poorly co-ordinated eye care services for Indigenous Australians are inefficient and costly and result in poorer outcomes for patients, communities and health care providers. Services are more effective where there is good co-ordination of services and case management of patients along the pathway of care. The establishment of clear pathways of care, development local and regional partnerships to manage services and service providers and the application of sufficient workforce with clear roles and responsibilities have the potential to achieve important improvements in eye care. CONCLUSIONS: Co-ordination is a key to close the gap in eye care for Indigenous Australians. Properly co-ordinated care and support along the patient pathway through case management will save money by preventing dropout of patients who haven't received treatment and a successfully functioning system will encourage more people to enter for care.

Improving eye care for Indigenous Australians in primary health care settings.

BACKGROUND: This paper aims to assess the barriers and solutions to the delivery of eye care in primary care settings and solutions to improve the use of comprehensive eye care among Indigenous Australians. DESIGN, SETTING, PARTICIPANTS: Qualitative, mixed method study participants include Aboriginal community members, and health and eye care providers in urban, rural and remote settings. MAIN OUTCOME MEASURES: Present evidence for health care providers to better understand and address some of the barriers that limit access to eye care in primary care settings. RESULTS: Patient perspectives on barriers to accessing eye care and reasons they choose to seek care or not are presented. Health system barriers identified by health and eye care providers are also presented. Additionally, key enablers for improving access to eye care through primary care services are identified. CONCLUSION: Primary health care services have an important role in Indigenous eye health. There is a critical role for primary care in the coordination of the patient journey and cooperating with other services to improve access to comprehensive eye care. Through improved provision of primary eye care, monitoring of Indigenous eye health indicators and supporting patients to access eye care, it is possible to close the gap for vision.

Indigenous access to cataract surgery: an assessment of the barriers and solutions within the Australian health system.

BACKGROUND: To identify barriers in the health systems that limit access to cataract surgery for Indigenous Australians and present strategies to overcome these barriers. DESIGN: Interview and focus group-based qualitative study. PARTICIPANTS: Five hundred thirty participants were consulted in semi-structured interviews, focus group discussions and stakeholder workshops. METHODS: Semi-structured interviews with a cross-section of health-care professionals, eye care practitioners, primary health-care workers, hospital staff and health department staff were conducted in 21 site locations. Focus group discussions with clients from seven Aboriginal Health Services in Victoria were conducted. Stakeholder workshops included Aboriginal Community Controlled Health sector, eye care sector, government departments and non-government organizations. A total of 279 semi-structured interviews were conducted in the Northern Territory, New South Wales, Queensland, South Australia, Victoria and Western Australia. Three stakeholder workshops were held. MAIN OUTCOME MEASURES: Barriers and solutions to increase access to cataract surgery for Indigenous Australians. RESULTS: Analysis of the participant responses identified health system barriers at primary care, specialist care and hospital levels. These included: long waiting times, cost of surgery, complexity of the steps involved in treatment, lack of surgical capacity and low awareness of regional eye health needs. Strategies to overcome these barriers involve a system-wide approach to increase provision and utilization of services. CONCLUSION: The need for surgery is real and services need to expand beyond current levels. The solutions for overcoming barriers to cataract surgery could be used as a model for other health interventions which rely on close interaction between primary and specialist care services.

Correcting Indigenous Australians' refractive error and presbyopia.

BACKGROUND: This paper aims to identify the barriers and solutions for refractive error and presbyopia vision correction for Indigenous Australians. DESIGN: A qualitative study, using semistructured interviews, focus groups, stakeholder workshops and consultation, conducted in community, private practice, hospital, non-government organization and government settings. PARTICIPANTS: Five hundred and thirty-one people participated in consultations. METHODS: Data were collected at 21 sites across Australia. Semistructured interviews were conducted with 289 people working in Indigenous health and eye care sectors; focus group discussions with 81 community members; stakeholder workshops involving 86 individuals; and separate meetings with 75 people. Barriers were identified through thematic analysis and policy solutions developed through iterative consultation. MAIN OUTCOME MEASURES: Barriers and solutions to remedy Indigenous Australians' uncorrected refractive error and presbyopia. RESULTS: Indigenous Australians' uncorrected refractive error and presbyopia can be eliminated through improvement of primary care identification and referral of people with poor vision, increased availability of optometry services in Aboriginal Health Services, introduction of a nationally consistent Indigenous subsidized spectacle scheme and proper coordination, promotion and monitoring of these services. CONCLUSIONS: The refractive error and presbyopia correction needs of Indigenous Australians are immediately treatable by the simple provision of glasses. The workforce capacity exists to provide the eye exams to prescribe glasses and the cost is modest. What is required is identification of patients with refractive needs within community, referral to accessible optometry services, a good supply system for appropriate and affordable glasses and the coordination and integration of this service within a broader eye care system.

Why optometry must work from urban and regional Aboriginal Health Services.

The gap in vision and ocular health between Aboriginal and Torres Strait Islander Australians and other Australians continues to be significant, yet three-quarters of the identified Aboriginal and Torres Strait Islander population live in urban and regional areas of Australia where existing eye-care services are available. In urban Australia, an improvement in the access and use of eye-health services is required to provide equitable eye-care outcomes for Australia's Indigenous peoples. Optometric services need to be available within Aboriginal Health Services in urban areas to effectively close the gap for vision.