Experiences of Patients With Diabetes Attending a Publicly Funded Eye Care Pathway in Western Sydney: A Qualitative Study.

Diabetic retinopathy (DR) complications can be prevented with regular screening and timely access to an ophthalmologist for treatment. But there are patient and health system barriers that can impact access to DR services. This study aims to identify enablers and barriers for accessing public DR eye care services in a low socio-economic urban area of Australia. We conducted a qualitative study using semi-structured interviews for patients with diabetes aged 35 years and older attending public ophthalmology services. Interviews were analyzed to identify themes and subthemes; and the COM-B framework was used to interpret the complex behavioral mechanisms, including capability, opportunity, and motivation factors, to explain adherence to DR eye care. Three main themes and 7 sub-themes relating to patient experiences of DR care were derived. Patients were found to be passive actors in their DR eye care, but patients trusted clinicians and were determined to maintain their vision and quality of life. The barriers and facilitators of care related to the health system (service availability and recall-reminder systems) and patient experiences (choices, knowledge, and fear). The findings of this study will guide patient-centered initiatives to target and improve access to DR care. Strategies should focus on improving communication between eye care providers, and communication with patients to empower them to become more active players in healthcare decisions.

Glaucoma referrals from primary care and subsequent hospital management in an urban Australian hospital.

BACKGROUND: Public hospital ophthalmology services are in high demand and patients requiring medical or surgical intervention for glaucoma may worsen while awaiting care. In Australia, tertiary hospital care requires a referral from primary care providers. This study investigates the quality of glaucoma referrals received at a tertiary public hospital in Australia, and describes the types of glaucoma cases referred for hospital management. METHODS: An investigation of 200 sequential glaucoma referrals received at a major Australian public hospital from 2013-2016, and the subsequent hospital management. A clinical file audit was made of patient medical records, including referral letters to extract the referral content, and the hospital glaucoma diagnostic outcomes and patient management. RESULTS: Most referrals came from optometrists (72 per cent) and general practitioners (22 per cent) with the remainder from other specialists. The majority of the referrals contained less than 50 per cent of the key clinical and demographic parameters. Referrals from optometrists provided more ophthalmic information (visual acuity, visual field, intraocular pressure, ocular history). Referrals from general practitioners contained more medical information (systemic co-morbidities medication and allergies). The median wait-time from referral to hospital appointment was 400 days. Of patients attending a hospital appointment, 59 per cent required surgical or medical management, and 16 per cent did not have glaucoma. Overall 18 per cent were discharged, with no differences noted by referral content or referring practitioner. CONCLUSION: Most referrals did not include useful diagnostic information on ocular, medical and social risks for glaucoma. There is an opportunity to improve targeting of primary care referrals for glaucoma, since patients who were discharged immediately after their hospital appointment are exacerbating the long hospital wait-time. Better information transfer may help to identify patients requiring more urgent intervention. A standardised referral template and guidelines would support collaborative care and streamline access to hospital services.

Improving Patient Access and Reducing Costs for Glaucoma with Integrated Hospital and Community Care: A Case Study from Australia.

INTRODUCTION: Glaucoma, a chronic eye disease requires regular monitoring and treatment to prevent vision-loss. In Australia, most public ophthalmology departments are overburdened. Community Eye Care is a 'collaborative' care model, involving community-based optometrist assessment and 'virtual review' by ophthalmologists to manage low-risk patients. C-EYE-C was implemented at one Australian hospital. This study aims to determine whether C-EYE-C improves access to care and better utilises resources, compared to hospital-based care. METHODS: A clinical and financial audit was conducted to compare access to care and health system costs for hospital care and C-EYE-C. Attendance, wait-time, patient outcomes, and the average cost per encounter were calculated. A weighted kappa assessed agreement between the optometrist and ophthalmologist decisions. RESULTS: There were 503 low-risk referrals, hospital (n = 182) and C-EYE-C (n = 321). C-EYE-C had higher attendance (81.6% vs 68.7%, p = 0.001); and shorter appointment wait-time (89 vs 386 days, p < 0.001). Following C-EYE-C, 57% of patients avoided hospital; with 39% requiring glaucoma management. C-EYE-C costs were 22% less than hospital care. There was substantial agreement between optometrists and ophthalmologist for diagnosis (k = 0.69, CI 0.61-0.76) and management (k = 0.66, CI 0.57-0.74). DISCUSSION: C-EYE-C showed higher attendance, and reduced wait-times and health system costs. CONCLUSIONS: Upscale of the C-EYE-C model should be considered to further improve capacity of public eye services in Australia.

Incomplete recording of Indigenous identification status under-estimates the prevalence of Indigenous population attending Australian general practices: a cross sectional study.

BACKGROUND: Australian Aboriginal and Torres Strait Islander (Indigenous) peoples face major health disadvantage across many conditions. Recording of patients' Indigenous status in general practice records supports equitable delivery of effective clinical services. National policy and accreditation standards mandate recording of Indigenous status in patient records, however for a large proportion of general practice patient records it remains incomplete. We assessed the completeness of Indigenous status in general practice patient records, and compared the patient self-reported Indigenous status to general practice medical records. METHODS: A cross sectional analysis of Indigenous status recorded at 95 Australian general practices, participating in the Australian Chlamydia Control Effectiveness Pilot (ACCEPt) in 2011. Demographic data were collected from medical records and patient surveys from 16 to 29 year old patients at general practices, and population composition from the 2011 Australian census. General practitioners (GPs) at the same practices were also surveyed. Completeness of Indigenous status in general practice patient records was measured with a 75% benchmark used in accreditation standards. Indigenous population composition from a patient self-reported survey was compared to Indigenous population composition in general practice records, and Australian census data. RESULTS: Indigenous status was complete in 56% (median 60%, IQR 7-81%) of general practice records for 109,970 patients aged 16-29 years, and Indigenous status was complete for 92.5% of the 3355 patients aged 16-29 years who completed the survey at the same clinics. The median proportion per clinic of patients identified as Indigenous was 0.9%, lower than the 1.8% from the patient surveys and the 1.7% in clinic postcodes (ABS). Correlations between the proportion of Indigenous people self-reporting in the patient survey (5.2%) compared to status recorded in all patient records (2.1%) showed a fair association (r = 0.6468; p < 0.01). After excluding unknown /missing data, correlations weakened. CONCLUSIONS: Incomplete Indigenous status records may under-estimate the true proportion of Indigenous people attending clinics but have higher association with self-reported status than estimates which exclude missing/unknown data. The reasons for incomplete Indigenous status recording in general practice should be explored so efforts to improve recording can be targeted and strengthened. TRIAL REGISTRATION: ACTRN12610000297022 . Registered 13th April 2010.