Identifying best-practice features of diabetic retinopathy treatment models for Aboriginal and Torres Strait Islander Australians.

OBJECTIVE: Indigenous Australians are nearly three times more likely to have diabetes than non-Indigenous Australians. The prevalence of diabetes-related vision impairment for Indigenous Australians is 5.5% compared to 1.5% for non-Indigenous Australians, and treatment rates are lower for Indigenous Australians. Despite this situation, there is limited evidence on effective service delivery models for diabetic retinopathy care and treatment. This study seeks to identify best-practice features of diabetic retinopathy care that could be used to inform current and future service delivery models for Indigenous Australians with diabetic retinopathy. SETTING: All states, territories and geographic remoteness categories in Australia. PARTICIPANTS: Eight ophthalmologists engaged in providing eye healthcare to Indigenous Australians. DESIGN: Semi-structured interviews were conducted. The Framework Approach was used to conduct a thematic analysis of the interviews to facilitate identification of key themes and issues that emerged from these discussions. RESULTS: Seven best-practice features for service delivery of diabetic retinopathy treatment for Indigenous Australians were identified. These were: cultural safety, affordability and accessibility, partnerships with key stakeholders, timeliness, integration with primary care, clarity of guidelines, and clinician attitude and motivation. CONCLUSION: The findings from this study identified seven best-practice features for diabetic retinopathy treatment. These have the potential to inform and influence how care is delivered to Indigenous Australians. Although further research is warranted to capture other service provider inputs and Indigenous end-user perspectives, these features in the meantime can begin to inform the decisions of the Indigenous eyecare sector on policy reforms and best-practice diabetic retinopathy treatment approaches.

Lessons learned from a subsidised spectacles scheme aiming to improve eye health in Aboriginal people in Victoria, Australia.

The Victorian Aboriginal Spectacles Subsidy Scheme (VASSS) aimed to improve access to visual aids and eye care for Aboriginal and Torres Strait Islander Victorians. The VASSS started in July 2010 and has operated continually since. In 2016, we explored the collaborations, planning, adaptations and performance of the VASSS over the first 6 years by reviewing and analysing service data, as well as data from semistructured interviews, focus groups and surveys. An estimated 10853 VASSS cofunded visual aids were delivered over 6 years, and the mean annual number of comprehensive eye examinations provided within services using VASSS grew 4.6-fold faster compared with the 4 years preceding the VASSS. We estimate that 16% and 19% of recipients presented with distance and near vision impairments respectively, all of which were corrected with visual aids. VASSS achievements were attained through collaborations, flexibility, trust and communication between organisations, all facilitated by funding resulting from evidence-based advocacy. Access to visual aids and eye examinations by Aboriginal Victorians has improved during the operation of the VASSS, with associated direct and indirect benefits to Aboriginal health, productivity and quality of life. The success of the VASSS may be replicable in other jurisdictions and provides lessons that may be applicable in other fields.

Cataract surgery and Indigenous eye care: A review.

Cataract remains the leading cause of blindness in Aboriginal and Torres Strait Islander peoples and is still a major cause of vision loss. The pathway of care to cataract surgery has many potential gaps and barriers. Although there has been a significant increase in services over the last few years, there is still the urgent need to facilitate timely and affordable cataract surgery. Particularly for public surgery there needs to be a significant decrease in waiting times for the clinical assessment of those needing surgery and for those on a surgical waiting list.

Breaking down barriers to eye care for Indigenous people: a new scheme for delivery of eye care in Victoria.

This report describes the implementation of and outcomes from a new spectacle subsidy scheme and de-centralised care options for Aboriginal and Torres Strait Islander peoples in Victoria, Australia. The Victorian Aboriginal Spectacle Subsidy Scheme (VASSS) commenced in 2010, as an additional subsidy to the long-established Victorian Eyecare Service (VES). The Victorian Aboriginal Spectacle Subsidy Scheme aimed to improve access to and uptake of affordable spectacles and eye examinations by Indigenous Victorians. The scheme is overseen by a committee convened by the Victorian Government's Department of Health and Human Services and includes eye-health stakeholders from the Aboriginal community and government, not-for-profit, university and Aboriginal communities. Key features of the Victorian Aboriginal Spectacle Subsidy Scheme include reduced and certain patient co-payments of $10, expanded spectacle frame range, broadened eligibility and community participation in service design and implementation. We describe the services implemented by the Australian College of Optometry (ACO) in Victoria and their impact on access to eye-care services. In 2014, optometric services were available at 36 service sites across Victoria, including 21 Aboriginal Health Services (AHS) sites. Patient services have increased from 400 services per year in 2009, to 1,800 services provided in 2014. During the first three years of the Victorian Aboriginal Spectacle Subsidy Scheme program (2010 to 2013), 4,200 pairs of glasses (1,400 pairs per year) were provided. Further funding to 2016/17 will lift the number of glasses to be delivered to 6,600 pairs (1,650 per year). This compares to population projected needs of 2,400 pairs per year. Overcoming the barriers to using eye-care services by Indigenous people can be difficult and resource intensive; however the Victorian Aboriginal Spectacle Subsidy Scheme provides an example of positive outcomes achieved through carefully designed and targeted approaches that engender sector and stakeholder support. Sustained support for the Victorian Aboriginal Spectacle Subsidy Scheme at a level that meets population needs is an ongoing challenge.

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.

How Australian and New Zealand schools of optometry prepare students for culturally competent practice.

BACKGROUND: This study is an investigation of how Australian and New Zealand schools of optometry prepare students for culturally competent practice. The aims are: (1) to review how optometric courses and educators teach and prepare their students to work with culturally diverse patients; and (2) to determine the demographic characteristics of current optometric students and obtain their views on cultural diversity. METHODS: All Australian and New Zealand schools of optometry were invited to participate in the study. Data were collected with two surveys: a curriculum survey about the content of the optometric courses in relation to cultural competency issues and a survey for second year optometry students containing questions in relation to cultural awareness, cultural sensitivity and attitudes to cultural diversity. RESULTS: Four schools of optometry participated in the curriculum survey (Deakin University, Flinders University, University of Melbourne and University of New South Wales). Sixty-three students (22.3 per cent) from these four schools as well as the University of Auckland participated in the student survey. Cultural competency training was reported to be included in the curriculum of some schools, to varying degrees in terms of structure, content, teaching method and hours of teaching. Among second year optometry students across Australia and New Zealand, training in cultural diversity issues was the strongest predictor of cultural awareness and sensitivity after adjusting for school, age, gender, country of birth and language other than English. CONCLUSION: This study provides some evidence that previous cultural competency-related training is associated with better cultural awareness and sensitivity among optometric students. The variable approaches to cultural competency training reported by the schools of optometry participating in the study suggest that there may be opportunity for further development in all schools to consider best practice training in cultural competency.

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.