Victorian Ophthalmology Service Planning Framework ... · PDF file7.1.4 Ophthalmic Nursing...

Victorian Ophthalmology Service Planning Framework

Discussion Paper

March 2004

Metropolitan Health and Aged Care Services

Department of Human Services

Ophthalmology Service Planning Framework Discussion Paper

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1.0 INTRODUCTION...............................................................................................................4 1.1 PURPOSE ..........................................................................................................................4 1.2 BACKGROUND ....................................................................................................................4 1.3 METHODOLOGY...................................................................................................................4 1.4 FEEDBACK.........................................................................................................................4

2.0 SPECIALTY OVERVIEW ....................................................................................................5 2.1 EYE DISEASE EPIDEMIOLOGY ...................................................................................................5

2.1.1 The Visual Impairment Project .....................................................................................5 2.1.2 Diabetes ...................................................................................................................5 2.1.3 Cataract....................................................................................................................6 2.1.4 Glaucoma..................................................................................................................6 2.1.5 Age Related Macular Degeneration ...............................................................................6 2.1.6 Refractive Error..........................................................................................................6 2.1.7 Cost of Vision Loss .....................................................................................................6

2.2 EYE HEALTH CARE PROVIDERS..................................................................................................7 3.0 CURRENT SERVICE PROVISION .......................................................................................8

3.1 OVERVIEW OF SERVICE PROVISION............................................................................................8 3.2 COMMUNITY BASED SERVICES..................................................................................................9

3.2.1 Medicare funded services ............................................................................................9 3.2.2 Non-Medicare funded eye services.............................................................................. 10 3.2.3 Other community eye care services ............................................................................ 10

3.3 HOSPITAL SERVICES........................................................................................................... 12 3.3.1 Emergency .............................................................................................................. 12 3.3.2 Outpatients ............................................................................................................. 16 3.3.3 Inpatients ............................................................................................................... 19

3.4 COORDINATION WITH OTHER SERVICES .................................................................................... 23 4.0 CURRENT DEMAND AND ACCESS....................................................................................24

4.1 KEY ELECTIVE SURGERY STRATEGIES........................................................................................ 24 4.1.1 Elective Surgery Information System.......................................................................... 24 4.1.2 Elective Surgery Access Service ................................................................................. 24 4.1.3 Rural Patient Initiative .............................................................................................. 24

4.2 WAITING TIMES AND EQUITY OF ACCESS ................................................................................... 25 4.2.1 Waiting times for consultations .................................................................................. 25 4.2.2 Waiting times for surgery .......................................................................................... 25

4.3 UTILISATION.................................................................................................................... 29 4.3.1 Utilisation of eye care services ................................................................................... 29

4.4 SELF SUFFICIENCY - PATIENT FLOWS ....................................................................................... 30 4.5 COST OF SERVICES ............................................................................................................ 31

4.5.1 Medicare consultations.............................................................................................. 31 4.5.2 Hospital cost weights ................................................................................................ 31 4.5.3 VACS cost weights.................................................................................................... 32

5.0 FUTURE SERVICE DEMAND ............................................................................................33 5.1 BASE CASE FORECASTS ....................................................................................................... 33 5.2 CATARACT SURGERY ........................................................................................................... 35

5.2.1 Cataract surgery growth ........................................................................................... 36 5.3 PROJECTED INCIDENCE OF EYE DISEASE.................................................................................... 38

5.3.1 Diabetic eye disease ................................................................................................. 38 5.3.2 Glaucoma................................................................................................................ 38 5.3.3 Age-Related Macular Degeneration ............................................................................. 38

5.4 SERVICE INNOVATION......................................................................................................... 39 5.4.1 Clinical developments ............................................................................................... 39 5.4.2 Prevention & health promotion................................................................................... 39

6.0 SERVICE CONFIGURATION AND MODELS OF CARE ........................................................40 6.1 NATIONAL....................................................................................................................... 40

6.1.1 Victoria ................................................................................................................... 40 6.1.2 NSW....................................................................................................................... 42

6.2 INTERNATIONAL ................................................................................................................ 43 6.2.1 United Kingdom ....................................................................................................... 43

6.3 ROLE DELINEATION ............................................................................................................ 44 7.0 WORKFORCE AND TRAINING.........................................................................................45

7.1 WORKFORCE.................................................................................................................... 45 7.1.1 Ophthalmologist Workforce........................................................................................ 45


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7.1.2 Optometrist Workforce.............................................................................................. 46 7.1.3 Orthoptist Workforce ................................................................................................ 46 7.1.4 Ophthalmic Nursing Workforce................................................................................... 47 7.1.5 Anaesthetist Workforce ............................................................................................. 47

7.2 TRAINING ....................................................................................................................... 48 7.2.1 Education providers .................................................................................................. 48 7.2.2 Trainee intake.......................................................................................................... 48

8.0 MONITORING PERFORMANCE AND OUTCOMES..............................................................49 8.1 APPROPRIATENESS............................................................................................................. 49

8.1.1 Prioritisation of services ............................................................................................ 49 8.1.2 Utilisation................................................................................................................ 50 8.1.3 Complexity .............................................................................................................. 50

8.2 EFFECTIVENESS ................................................................................................................ 51 8.3 ACCEPTABILITY................................................................................................................. 51 8.4 SAFETY .......................................................................................................................... 51

9.0 RESEARCH .....................................................................................................................52 9.1 OPHTHALMIC RESEARCH ORGANISATIONS IN VICTORIA .................................................................. 52 9.2 RESEARCH LINKS WITH PUBLIC HOSPITALS................................................................................. 52

APPENDIX 1: STATEWIDE PROVISION OF PUBLIC HOSPITAL EYE SERVICES 2002-03 .............53

APPENDIX 2: VEMD – OPHTHALMOLOGY EMERGENCY PRESENTATIONS 1998-99 TO 2002-03 56

APPENDIX 3: VEMD - OPHTHALMOLOGY EMERGENCY DIAGNOSES 1998-99 TO 2002-03..........57

APPENDIX 4: VEMD - RVEEH OPHTHALMOLOGY EMERGENCY PRESENTATIONS 2002-03 ..........58

APPENDIX 5: VAED - OPHTHALMOLOGY INPATIENT SEPARATIONS 1998-99 TO 2002-03 ........59

APPENDIX 6: VAED - OPHTHALMOLOGY DRGS 1998-99 TO 2002-03 ........................................61

APPENDIX 7: OPHTHALMOLOGY DRGS AND ESRGS..................................................................63

APPENDIX 8: LOCAL GOVERNMENT AREA: AGE STANDARDISED OPHTHALMOLOGY SEPARATIONS PER 1,000 PEOPLE - 2002-03 ............................................................................64

APPENDIX 9: DETAILED OPHTHALMOLOGY FORECASTS ..........................................................70

APPENDIX 10: PROPOSED CLINICAL PATHWAYS, UK ...............................................................73

APPENDIX 11: AUSTRALIAN COUNCIL ON HEALTHCARE STANDARDS - CLINICAL INDICATORS74

APPENDIX 12: WESTERN CANADA WAITING LIST PROJECT - CATARACT SURGERY PRIORITY CRITERIA..................................................................................................................................76

APPENDIX 13: VF-14 ...............................................................................................................78

BIBLIOGRAPHY.........................................................................................................................80

REFERENCES.............................................................................................................................82

GLOSSARY OF TERMS................................................................................................................83

DISCUSSION PAPER: RESPONSE SUBMISSION FORM ..............................................................85


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1.0 Introduction

1.1 Purpose The purpose of this paper is to identify and discuss the key current and future issues that affect ophthalmology practises in Victoria. The document forms the basis of the consultation process in developing a service planning framework that will guide the provision of ophthalmology services for the coming years. The document identifies key issues and questions that need resolution in the development of the framework. Responses from stakeholders to the issues raised in this discussion paper are requested to inform the development of a planning framework for ophthalmology service delivery in Victoria. The response schedule attached to this document should be used to provide feedback to the Department of Human Services.

1.2 Background The Metropolitan Health Strategy (DHS, 2003a) identifies the need to develop clear strategies for the provision of a range of specialist medical services including ophthalmology. The development of statewide service frameworks will guide the future provision of care, both in the design of the service system and the development of a suitable workforce to support it. It provides an opportunity to address long-standing and emerging issues for the delivery of ophthalmology services to Victorians. Ophthalmology inpatient throughput is growing at 1.5% per annum and it is anticipated that growth will continue as the population ages and technologies continue to develop. The development of a framework for ophthalmology services will set the scene for enhancing care delivery and providing an appropriate range of services to meet Victoria’s changing needs in this critical area of health care. This framework will define the role of Victoria’s hospitals in the delivery of ophthalmology services. In Victoria, the Royal Victorian Eye and Ear Hospital (RVEEH) has played a dominant role in the delivery of public sector ophthalmology services. The hospital has served Victoria well by providing a major role in delivery of inpatient, outpatient and emergency services. It is the major venue for training of medical and other clinical staff in ophthalmic care, and provides a focus for research activities. In developing this framework the opportunity exists to improve on Victoria’s excellent system of care, ensuring that service quality and access continues to improve as service demands change.

1.3 Methodology This discussion paper has been developed by the Service Planning Section of the Metropolitan Health and Aged Care Services, Department of Human Services. It has been developed utilising analysis of datasets of the department and other organisations, initial review of current literature and consultations with key stakeholders and members of the Ophthalmology Service Planning Advisory Committee. The Ophthalmology Service Planning Advisory Committee has endorsed the discussion paper.

1.4 Feedback Feedback on this paper can be made by completing the Response Submission Form attached to this document. Electronic Response Submission Forms are available at the website address: http://www.dhs.vic.gov.au/ophthalmology. Consultation forums will be advertised at this website address. Written responses are requested by Thursday 8 April 2004 to: Ophthalmology Service Planning Framework c/o Kerri Martin, Senior Project Officer Metropolitan Health and Aged Care Services Division Department of Human Services Level 10, 589 Collins St Melbourne VIC 3000 Email: [email protected] Ph: 03 9616 1394 Fax: 03 9616 2880 Further information can be found at the above website.


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2.0 Specialty Overview

2.1 Eye disease epidemiology Ophthalmology is the assessment, treatment and prevention of eye disease. The prevalence of eye disease has been studied in various communities and can be represented by understanding the main causes of eye disease and the level of visual impairment resulting from eye disease.

2.1.1 The Visual Impairment Project The Visual Impairment Project (VIP) undertaken by the Centre for Eye Research Australia (CERA) has been studying the prevalence and incidence of eye disease in Victoria since 1992. The main causes of visual impairment – deemed at less than driving vision (<6/12) reflect the main causes of eye disease (Figure 1) – and were identified as refractive error, age related macular degeneration (ARM), cataract, glaucoma and diabetic retinopathy (CERA, 2000).

Diabetes3%

Cataract9%

Others6%

Other Retinal7%

Macular Degeneration13%

Refractive Error52%

Neuro-ophthalmic5% Glaucoma

5%

Source: Eye Care for the Community, Centre for Eye Research Australia, University of Melbourne, p 6, (2000).

Figure 1: Visual Impairment in Australia (2000) - less than 6/12 vision (n=398,200)

The key findings of the VIP include:

• The amount of visual impairment and blindness increases threefold with each decade of age. • Half of visual impairment is due to refractive error. • The prevalence of cataract increases so that by their 90s, everybody will have developed cataract

and half will have cataract surgery. • 450,000 Australians have diagnosed diabetes and an equal number have undiagnosed diabetes.

All are at risk of developing diabetic eye disease. With early diagnosis and treatment up to 98% of severe vision loss can be prevented.

• Only half of people with diabetes had the recommended regular eye exam and one third have never been checked.

• One person in ten will develop glaucoma with half of those not knowing they have it. If detected and treated effectively, the loss of vision from glaucoma can be prevented or delayed.

• Two out of three people will develop AMD and one in four will suffer significant loss of vision from it. There is no effective prevention or treatment for most cases of AMD.

• Half of visual impairment is correctable and one quarter is preventable.

2.1.2 Diabetes Diabetic retinopathy, a microvascular complication of diabetes, is present in almost one-third of people with diabetes and threatens vision in 10 per cent. Compared with the general population, people with diabetes have a 25-fold risk of vision loss (Keeffe, 2003). Using data acquired from the VIP, McKay et al (2000) found that the prevalence of diabetic retinopathy among people with self reported diabetes was 29.1%. The prevalence of untreated, vision threatening retinopathy was 2.8%.


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2.1.3 Cataract Cataract is a progressively developing opacity of the lens of the eye and, if left untreated, leads to progressive visual loss. The crude prevalence for any type of cataract has been estimated at between 30.6% and 33.6% (Rochtchina et al, 2003). McCarty et al (2000) reported from the VIP that the weighted rate of any cataract in Victorians over the age of 40 years was 21.5% and that this rate increased dramatically with age. In an assessment of projected needs for cataract surgery by lens opacity, visual acuity and patient concern, McCarty et al (1999a) found that the overall prevalence of any type of cataract that had not been surgically removed was 18%. Rochtchina et al (2003) found that, in terms of the projected prevalence of age-related cataract and cataract surgery in Australia, the number of Australians aged 50 years and older affected by age-related cataract will be in the order of 2.74 million by the year 2021.

2.1.4 Glaucoma Open-angle glaucoma (OAG) is the most common form of glaucoma accounting for 75-95% primary glaucomas, except in people of Eastern Asian descent. It results from an elevated pressure within the eye and, if left untreated, can cause gradual loss of vision and associated symptoms. The risk factors for developing OAG, identified from population studies, are raised intraocular pressure, increasing age, race, family history and myopia (Burr et al, 2002). The prevalence of OAG in Australia has been found to be between 1.8% and 3%, with an increasing prevalence associated with age, women and diabetes (Weih et al, 2001; Mitchell et al, 1997).

2.1.5 Age Related Macular Degeneration Macular degeneration is a degenerative condition affecting the central area of the retina, called the macular that is responsible for vision. The VIP found that 67% of people will develop AMD and 25% will suffer a significant loss of vision from this condition (CERA, 2000). The determinants of AMD are related to ageing and cigarette smoking and increases significantly from ages 70 and 80 years respectively. The high association with ageing will continue to increase the importance of AMD as the population ages (VanNewkirk et al, 2000). Using data from the Blue Mountains Eye Study, Mitchell et al (1995) found that end-stage age-related macular degeneration was present in 1.9% of the population.

2.1.6 Refractive Error Refractive error is a defect of focussing of the eye which affects distance and/or near vision and if uncorrected leads to vision impairment. It has been identified in a number of population-based studies as the leading cause of visual impairment in the developed world and a leading cause of functional blindness in the developing world. Ten percent of Victorians have significant refractive error leading to an improvement of 1 or more lines of visual acuity with refraction. The risk of under corrected refractive error increased 1.8 times for every decade of life starting at 40 years of age (Liou et al, 1999). Undercorrected refractive error – defined as improvement of >/=10 letters (2+ lines on the logMAR chart) in subjects with presenting acuity 6/9 or worse – may be present in up to 22% (Thiagalingam et al, 2002).

2.1.7 Cost of Vision Loss A number of direct and indirect costs from vision loss have been identified. These include:

Government • Increased costs on the primary health system (vision loss increases the risk of falls and hip

fractures and depression). • Early entry into supported accommodation or aged care facility. • Early reliance on supported home care. • Early reliance on social welfare system (through loss of income and reduced productivity). • Early admission to aged care facilities.

Community • Increased pressure on other community services. • Loss of participation in the community.


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Individual • Prevents healthy aging. • Increased mortality (risk of death is two times greater than the community average). • Creation of other health issues (physical and emotional, particularly depression). • Diminished quality of life through reduced independence, mobility and confidence. (CERA, 2000; Vision 2020, 2003)

2.2 Eye health care providers A range of health professionals are involved in the delivery of eye care services. These include ophthalmologists, general practitioners, optometrists, orthoptists and ophthalmic nurses. Services provided include prevention, education, research and treatment. The roles of these professions in delivering eye care services vary across settings and jurisdictions. Definitions of these professions are provided in Table 1.

Table 1: Eye care professionals

Ophthalmologist An ophthalmologist is a medical doctor who is educated, trained and registered to provide total care of the eyes, from performing comprehensive eye examinations to prescribing corrective lenses, diagnosing diseases and disorders of the eye, and carrying out the medical and surgical procedures necessary for their treatment. General Practitioner General practitioners diagnose, treat and prevent human physical and mental disorders and injuries. They act as a gateway to the rest of the health care systems by virtue of their referrals to specialists and allied health professionals, hospital admissions, and pathology and imaging. Optometrist Optometrists are non-medical practitioners trained to assess the eye and the visual system, and diagnose refractive disorders. The optometrist prescribes and dispenses corrective and preventative devices and works hand in hand with other eye care professionals in assuring that patients are referred appropriately for diagnostic and therapeutic needs. Optometrists also prescribe drugs for certain eye conditions and monitor long-term eye conditions. Orthoptist Orthoptists specialise in the diagnosis and management of disorders of eye movements and associated vision problems. They perform investigative procedures appropriate to disorders of the eye and visual system and assist with the rehabilitation of patients with vision loss. Orthoptists also diagnose refractive disorders and prescribe glasses. Ophthalmic nurse An ophthalmic nurse has completed general nurse training then additional training to specialise in the nursing care of patients who have eye problems, whether they are in hospital, clinics or the community. Ophthalmic nurses test vision and perform other eye tests under medical direction. (NSW Health, 2002; AMWAC, 2000; ASCO, 1997) Traditionally there has been a close working relationship between ophthalmologists, orthoptists and ophthalmic nurses in the public and private sectors. Ophthalmologists often employ orthoptists and ophthalmic nurses in their private practices and day surgeries. Optometry, however, has traditionally worked independently in primary care with little direct interaction with other eye care professions. Until recently, all training for optometrists has been carried out separately from the other eye health care professionals. The scope of practice for optometrists and orthoptists has increased in recent years due to changes to Victorian legislation. Changes to legislation introduced in 1996 allow orthoptists to prescribe glasses at the request or referral from an ophthalmologist or optometrist (where the request or referral has been made within six months before that measurement or prescription). Prescribing rights for optometrists have been in place in Victoria since August 2000, with over 100 trained and endorsed optometrists prescribing topical ophthalmic or ocular drugs for the treatment of anterior eye disease (DHS, 2003b).


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3.0 Current Service Provision

3.1 Overview of service provision A range of providers in a range of settings provide eye health care services. The types of settings and their interactions are illustrated in Table 2.

Table 2: Eye care services and providers

Non-hospital clinic (ophthalmologist, optometrist rooms)

Hospital emergency department

Hospital outpatient

Hospital/day procedure centre inpatient

General practice

Low vision clinic

Setting

Ophthalmic nurse

General Practitioner

Orthoptist

Optometrist

Ophthalmologist

Practitioner

Surgical correction

Prescribe drugs

Non-surgical care

Screen for disease/

visual impair.

Prescribe refractive

lenses

Provide glasses

Provide visual aids

Role/Function

Non-hospital clinic (ophthalmologist, optometrist rooms)

Hospital emergency department

Hospital outpatient

Hospital/day procedure centre inpatient

General practice

Low vision clinic

Setting

Ophthalmic nurse

General Practitioner

Orthoptist

Optometrist

Ophthalmologist

Practitioner

Surgical correction

Prescribe drugs

Non-surgical care

Screen for disease/

visual impair.

Prescribe refractive

lenses

Provide glasses

Provide visual aids

Role/Function

Table 2 indicates that general practitioners along with all other eye health care professionals are involved in screening for eye disease or impairment across a number of settings. Ophthalmologists are the only providers of surgical correction of eye disease with ophthalmic nurses providing a key role in the delivery of surgical services in public and private facilities. Ophthalmologists, optometrists and orthoptists are all involved in prescribing glasses and a range of non-surgical forms of eye care while ophthalmologists, general practitioners and suitably qualified optometrists can prescribe drugs.


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3.2 Community based services

3.2.1 Medicare funded services More than one million eye care services per year are provided on a non-admitted basis in private ophthalmology and optometry consulting rooms. Private ophthalmology and optometry services are subsidised through the Commonwealth Medicare Benefit Schedule (MBS). In 2002-03, Victorian ophthalmologists provided a large number of consultations that were rebated through the MBS (Refer Table 3). Ophthalmology MBS data includes services provided by ophthalmologists and by other eye care practitioners on behalf of ophthalmologists such as orthoptists and nurses.

Table 3: Ophthalmologist claims on Medicare Benefits Schedule 1996-97 to 2002-03 (Victoria) – Health Insurance Commission.

Claims

Claim Number 1996-97 1997-98 1998-99 1999-00 2000-01 2001-02 2002-03

Table to be completed and provided in final report once data available from Health Insurance Commission

Other

Grand Total In 2002-03, Victorian optometrists provided more than 1 million services that were rebated through the MBS (Table 4).

Table 4: Optometrist claims on Medicare Benefits Schedule 1996-97 to 2002-03 (Victoria) – Health Insurance Commission. 1

Claims Claim Number 1996-97 1997-98 1998-99 1999-00 2000-01 2001-02 2002-03

10900 594,486 538,549 540,070 555,193 559,613 580,994 592,978

10918 193,652 221,877 250,088 269,733 283,472 298,875 312,568

10907 N/A 48,754 78,381 66,274 59,755 56,089 54,979

10916 15,615 23,034 26,823 31,456 35,568 37,855 42,637

10914 11,954 15,821 22,762 25,984 28,814 33,195 41,323

10913 15,933 17,148 19,630 19,775 19,598 18,913 21,696

10921 10,812 7,855 5,424 5,900 6,453 6,376 6,690

Other 2,616 3,744 4,909 4,837 4,694 4,652 5,309

Grand Total 845,068 876,782 948,087 979,152 997,967 1,036,949 1,078,180 General practitioners are also a provider of eye care, with 1.8% of reasons for encounter relating specifically to eye conditions and 7.3% of referrals from general practitioners are to ophthalmologists and 0.9% are to optometrists (AIHW and Uni Sydney, 2003). In 2002-03 general practitioners provided 22,078,244 services2 that were rebated through the MBS in Victoria. If 1.8% of these services related to eye conditions it can be estimated that 397,408 attendances were related to eye conditions. With regard to referrals, it can be estimated that Victorian general practitioners made 1,611,712 referrals to ophthalmologists and 198,704 referrals to optometrists.

1 Optometry MBS claim numbers: 10900: Comprehensive Initial Consultation 10918: Subsequent Consultation 10907: Comp. Initial Consult. by another practitioner within 24 months of previous comp. consult. 10916: Brief Initial Consultation 10914: Other Comprehensive Consultation – progressive disorder 10913: Other Comprehensive Consultation – new signs or symptoms 10921: Contact lenses – myopia of 5.0 dioptres or greater. 2 HIC MBS Group Statistics Reports www.hic.gov.au


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3.2.2 Non-Medicare funded eye services 3.2.2.1 Refractive laser surgery There are five refractive laser surgery centres in Victoria. Only a small number of therapeutic procedures funded through Medicare or the public hospital sector are reported to government. Refractive surgery activity is undocumented, as licensing and billing arrangements do not require reporting of activity to State and Commonwealth governments. However, despite the paucity of data, refractive laser surgery appears to be a significant area of ophthalmic practice in the private sector. 3.2.2.2 Orthoptics Orthoptists provide services in a range of settings including public hospitals, private ophthalmology clinics, low vision clinics and in orthoptic private practices. As orthoptic services provided in the community are not Medicare funded there is no data source that demonstrates the extent of services provided in Victoria. Limited data are collected on orthoptic services by public hospitals however orthoptic services provided in ophthalmology practices are not recorded. There is a range of ophthalmology services billed under Medicare that are commonly performed by orthoptists on behalf of the ophthalmologists such as computerised perimetry and ultrasonography (A scans). 3.2.2.3 Ophthalmic nursing Ophthalmic nurses provide services in public and private hospitals in surgical and non-surgical settings. They may also be employed in ophthalmology private practices. Like orthoptists data on the services provided in the community are not recorded.

3.2.3 Other community eye care services 3.2.3.1 Glasses With refractive error being the most common cause of visual impairment in Australia, access to eye tests and affordable glasses is an important issue. Glasses are commonly provided through optometrists and optical dispensers at market prices of which some private health insurance schemes provide a subsidy. The Victorian Eyecare Service (VES) provides eye tests and glasses at a nominal cost for Victorians who hold a pensioner concession card or have a health care card for at least six months and their dependants under the age of 18 years. The VES is funded through the Department of Human Services and is run by the Victorian College of Optometry. Rural patients can have their eyes tested and glasses prescribed through a network of optometrists and ophthalmologists participating in the service. In 2002-03 VES received $3.4 million to provide 67,000 people with subsidised glasses3. Metropolitan Melbourne VES provided 35,256 services and Country Victoria VES provided 29,180 services. An estimated budget of $3.5 million has been allocated for 2003-04. Subsidised glasses are also available from some Victorian public hospitals. The RVEEH provides subsidised glasses to eligible patients through a contracted service provider, currently the Victorian Eye Care Network (VECN). The Royal Children’s Hospital provides vouchers for discount glasses. 3.2.3.2 Rehabilitation/low vision services There are a number of non-government organisations that provide services for the blind and visually impaired in Victoria. These include the Vision Australia Foundation (VAF), the Royal Victorian Institute for the Blind (RVIB), Guide Dogs Victoria, Lady Nell Seeing Eye Dogs, Villa Maria Society and the Christian Blind Mission International (CBMI). The RVIB provides services to children and adults who are blind or vision impaired. RVIB is a non-profit organisation with more than 12,000 clients throughout Victoria. VAF provides services and facilities for people who are blind and vision impaired, or are experiencing other disabilities. VAF helps older persons who have acquired vision loss later in life to remain independent in their homes for as long as possible by maximising the use of their remaining vision. Guide Dogs Victoria is best known for the provision of Guide Dog Mobility. Guide dogs can enhance the independence and quality of life of many vision impaired people. Guide Dogs Victoria also provides a wider range of specialist mobility services including the Neurological Mobility Service and Children's Mobility Service. Project Nexus has been formed to consider the amalgamation of the RVIB, the VAF and the Royal Blind Society of New South Wales (RBS). The governing bodies of all three organisations have unanimously agreed to proceed to merge and have signed a Heads of Agreement. Final approval for the merger is subject to a positive vote from members. This vote is expected to be held in 2004.

3 Media release from the Minister for Aged Care, Tuesday 24 June 2003


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The proposed merged organisation is expected to offer: new and additional services; the opportunity to secure more funding from government and corporate bodies to invest in services; increased exposure, sponsorship opportunities and advocacy; and a greater influence on government policy. 3.2.3.3 Consumer support groups There is a variety of consumer groups in Victoria that provide support services to people with eye disease. These include (but are not limited to):

• Vision Australia Foundation (VAF) • Royal Victorian Institute for the Blind (RVIB) • Guide Dogs Australia • Blepharospasm Support Group • Blind Citizens Australia • Diabetes Australia Victoria • Eyes on Diabetes • Glaucoma Australia / Melbourne Glaucoma Support Group • The Lions Eye Health Program Australia - diabetes/glaucoma/amblyopia • Macular Vision Loss Support Society of Australia (Victoria) • Monovision Support Group of Victoria • Retina Australia (Vic) Inc. • Keratoconus Australia • Vision 2020 Australia/The Vision Initiative

Q1. What are the barriers to people obtaining correction to refractive error? Q2. How can these barriers be addressed?


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3.3 Hospital services Ophthalmology services are provided in hospital emergency, outpatient and inpatient departments. The department has three main data collections used in the hospital system for these services. These are the:

• Victorian Emergency Minimum Dataset (VEMD): o Records hospital emergency department presentations. o Only the major public emergency department with 24 hour emergency departments

report data. • Victorian Ambulatory Classification and Funding System (VACS):

o Records outpatient attendances. • Victorian Admitted Episode Dataset (VAED):

o Records hospital inpatient separations o All public and private hospitals report data.

Emergency, outpatient and inpatient services exist to varying degrees across the public hospital sector. Appendix 1 provides an overview of the ophthalmology services provided by Victorian public hospitals that report to these data sources. Data from each of these sources are presented in the next sections for the 5 year period 1998-99 to 2002-03.

3.3.1 Emergency The VEMD contains de-identified demographic, administrative and clinical data of presentations at the main Victorian public hospitals with 24-hour emergency departments. Data is not available from hospitals that do not provide 24-hour emergency services. In 2002-03 there were 35,001 public ophthalmology emergency presentations reported through the VEMD. These were provided at 31 hospitals of which 21 (68%) were metropolitan hospitals and 10 (32%) were rural and regional. The RVEEH was the largest provider of emergency services with 17,192 (49%) presentations followed by Ballarat Health Service with 1,1314 (4%) and the Angliss Hospital with 949 (3%). Table 5 lists Victoria’s ten largest public providers of emergency ophthalmology services. The full list is provided in Appendix 2. There was an increase of 2,602 (8%) ophthalmology emergency presentations between 1998-99 and 2002-03 (Table 5) with most hospitals experiencing growth in demand during this period. The RVEEH, however, had a decrease in presentations of 3,021 (-15%) with the proportion of Victoria’s ophthalmology emergency presentations treated at the RVEEH decreasing from 62% to 49%.

Table 5: Ophthalmology emergency presentations in Victorian public hospitals - 1998-99 to 2002-03 (VEMD)

Hospital 98-99 99-00 00-01 01-02 02-03 % 02-03 Growth

Royal Victorian Eye & Ear Hospital 20,213 21,172 18,017 17,056 17,192 49% -15%

Ballarat Health Services 944 966 1,048 1,181 1,314 4% 39%

Angliss Hospital 705 727 788 849 949 3% 35%

Sunshine Hospital 159 260 312 636 893 3% 462%

New Mildura Base Hospital 364 735 751 814 885 3% 143%

Bendigo Health Care Group 891 945 960 937 874 2% -2%

Latrobe Regional Hospital 811 941 962 867 859 2% 6%

Barwon Health [Geelong] 878 911 854 833 827 2% -6%

Mercy Public Hospital [Werribee] 339 624 639 749 819 2% 142%

The Northern Hospital 477 715 668 650 742 2% 56%

Other 6,618 8,944 9,154 9,563 9,647 28% 46%

Total 32,399 36,940 34,153 34,135 35,001 100% 8%

% treated at RVEEH 62% 57% 53% 50% 49% 3.3.1.1 Metropolitan providers The 21 metropolitan providers of ophthalmology emergency services treated a total of 27,412 emergency presentations in 2002-03, 78% of the State’s presentations. There was an increase of 1,193 (5%) presentations in metropolitan hospitals between 1998-99 and 2002-03 (Table 6). Outer metropolitan hospitals experienced growth of 2,078 (77%) presentations while the inner metropolitan hospitals had a decrease of 885 (-4%) presentations. This decreased growth reflects the decreased growth of the RVEEH as most other inner metropolitan hospitals experienced positive growth during this period (Refer Appendix 2).


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3.3.1.2 Rural providers The ten rural providers of ophthalmology emergency services that report to the VEMD treated a total of 7,589 (22%) ophthalmology presentations in 2002-03. This was an increase of 1,409 (23%) presentations since 1998-99 (Table 6).

Table 6: Ophthalmology emergency presentations in metropolitan and rural Victoria - 1998-99 to 2002-03 (VEMD)

98-99 99-00 00-01 01-02 02-03 % 02-03 Difference Growth Inner metropolitan hospitals 23,536 25,932 22,698 22,051 22,651 65% -885 -4% Outer metropolitan hospitals 2,683 3,618 3,754 4,300 4,761 14% 2,078 77% Total metropolitan hospitals 26,219 29,550 26,452 26,351 27,412 78% 1,193 5% Rural and regional hospitals 6,180 7,390 7,701 7,784 7,589 22% 1,409 23% Total Victorian hospitals 32,399 36,940 34,153 34,135 35,001 100% 2,602 8% % Rural 19% 20% 23% 23% 22% 3.3.1.3 Referral In 2002-03, the majority of referrals for ophthalmology emergency presentations were by self, family or friends (85%) followed by Local Medical Officers (LMO) (8.8%). The RVEEH had a lower proportion of referrals by self, family or friends (81%) when compared with other public hospitals (88%) and a higher proportion of referrals by LMOs (13%) compared to 5% (Refer Table 7). The decrease in numbers of emergency presentations to the RVEEH between 1998-99 and 2002-03 reflects the large decrease in the number of patients being reviewed in the emergency department from 3,308 to 506 (-85%). This is likely to reflect changes in the processes for reviewing emergency patients at the RVEEH. Referrals by self, family or friends increased by 7% at the RVEEH and 52% across other public hospitals while referrals by LMOs decreased 31% at the RVEEH and increased 23% across other hospitals. The RVEEH treated 71% of all referrals from LMOs in 2002-03. Patients referred from private specialists and other hospitals accounted for only a small proportion of referrals (0.4% and 0.2% respectively). Referrals from private specialists increased by 109% at the RVEEH and 6% at other hospitals while referrals from staff at other hospitals decreased by 90% at the RVEEH and increased by 163% across other hospitals.

Table 7: Referral sources for ophthalmology emergency presentations - 1998-99 to 2002-03 (VEMD)

Presentations RVEEH Other public hospitals Total Victoria Referral source 98-99 02-03 %02-03 Growth 98-99 02-03 %02-03 Growth 02-03 %02-03 Self family friends 13,085 13,942 81.0% 7% 10,370 15,730 88.0% 52% 29,672 85% LMO incl local GP/Dentist 3,156 2,180 13.0% -31% 730 899 5.0% 23% 3,079 8.8% ED review this hospital 3,308 506 2.9% -85% 754 816 4.6% 8% 1,322 3.8% Other 320 423 2.5% 32% 186 172 1.0% -8% 595 1.7% Private specialist 35 73 0.4% 109% 49 52 0.3% 6% 125 0.4% Outpatients any hospital 9 35 0.2% 289% 46 45 0.3% -2% 80 0.2% Staff from other hospitals 293 28 0.2% -90% 16 42 0.2% 163% 70 0.2% Nursing Home 6 5 0.0% -17% 6 23 0.1% 283% 28 0.1% Community Services Staff - - 0.0% - 21 14 0.1% -33% 14 0.0% Ward/Inpatient this hosp - - 0.0% - 0 6 0.0% - 6 0.0% Correctional Officer/Police - - 0.0% - 5 5 0.0% 0% 5 0.0% Hospital In The Home - - 0.0% - 2 3 0.0% 50% 3 0.0%Crisis Assessment Team 1 - 0.0% -100% 1 2 0.0% 100% 2 0.0%Grand Total 20,213 17,192 100.0% -15% 12,186 17,809 100% 46% 35,001 100.0% 3.3.1.4 Triage The VEMD has five triage categories which are listed in Table 8. In 2002-03 the majority of ophthalmology presentations were classified as non-urgent (50%) or semi-urgent (35%). Urgent presentations accounted for 13% of presentations while 2% of presentations were classified emergency. Compared to the combined total of other public hospitals, the RVEEH has a less urgent cohort of ophthalmology emergency presentations. Non-urgent presentations accounted for 81% of RVEEH’s presentations compared with 20% for other public hospitals (Table 8). Presentations classified as semi urgent, urgent and emergency were reported in lower proportions at the RVEEH when compared to other public hospitals. The RVEEH classified 0.1% of patients as emergency while other public hospitals reported 4.3% as emergency presentations.


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Non-urgent presentations decreased by 25% at the RVEEH from 1998-99 to 2002-03 while semi-urgent patients increased 126%. Growth in emergency presentations at other public hospitals occurred for semi-urgent, urgent and emergency presentations while non-urgent presentations remained static.

Table 8: Triage categories for ophthalmology emergency presentations - 1998-99 to 2002-03 (VEMD)

Presentations

RVEEH Other public hospitals Victoria Triage category 98-99 02-03 % 02-03 Growth 98-99 02-03 % 02-03Growth 02-03 %02-03 1 Resuscitation - 3 0.0% - 15 13 0.1% -13% 16 0% 2 Emergency 47 15 0.1% -68% 334 763 4.3% 128% 778 2% 3 Urgent 268 276 2% 3% 2,194 4,287 24% 95% 4,563 13% 4 Semi-urgent 1,333 3,013 18% 126% 6,114 9,216 52% 51% 12,229 35% 5 Non-urgent 18,563 13,876 81% -25% 3,527 3,530 20% 0% 17,406 50% 6 Dead on arrival 2 9 0% 350% - 0% 9 0% Total 20,213 17,192 100% -15% 12,186 17,809 100% 46% 35,001 100% 3.3.1.5 Diagnosis The most common reason for ophthalmology emergency presentations was “other specified disorders of the eye and adnexa” (26%) followed by “foreign body external eye” (24%) and “injury of the eye and orbit” (19%). Table 9 lists the ten most frequent diagnoses for ophthalmology emergency presentations. Refer Appendix 3 for all emergency diagnoses from 1998-99 to 2002-03. In 2002-03 the most common reason for emergency presentation at the RVEEH was for “other disorders of the eye and adnexa” (36%) followed by “injury of the eye and orbit” (18%) and “foreign body external eye” (16%). Other public hospitals treated higher proportions of patients with “foreign body external eye” (32%) and “injury of the eye and orbit” (21%) when compared with the RVEEH. There has been a decrease in presentations diagnosed as “other specified disorders of the eye and adnexa” at both the RVEEH and other public hospitals with increases in presentations diagnosed with “foreign body external eye” and “injury of the eye and orbit”. This may be accounted for by improvements in coding standards over time.

Table 9: Diagnosis of ophthalmology emergency presentation - 1998-99 to 2002-03 (VEMD)

Presentations RVEEH Other public hospitals Total Victoria Diagnosis 98-99 02-03 %02-03Growth 98-99 02-03 %02-03Growth 02-03 %02-03Other disorders eye/adnexa 8,818 6,228 36% -29% 2,906 2,698 15% -7% 8,926 26% Foreign body external eye 2,729 2,819 16% 3% 3136 5,643 32% 80% 8,462 24% Injury of eye and orbit 2,378 3,009 18% 27% 2061 3,680 21% 79% 6,689 19% Conjunctivitis, unspecified 1,274 821 5% -36% 751 1014 6% 35% 1,835 5% Ocular pain 714 470 3% -34% 802 1007 6% 26% 1,477 4% Laboratory examination - - 0% - 632 893 5% 41% 893 3% Iridocyclitis, unspecified 864 634 4% -27% 40 44 0% 10% 678 2% Corneal ulcer - 322 2% - 238 347 2% 46% 669 2% Acute atopic conjunctivitis 412 384 2% -7% 188 271 2% 44% 655 2% Keratitis, unspecified 824 594 3% -28% 46 40 0% -13% 634 2% Other 2,200 1,911 11% - 1385 2172 12% 57% 4,083 12% Total 20,213 17,192 100% -15% 12,185 17,809 100% 46% 35,001 100% Some emergency diagnoses were more frequently treated at the RVEEH than at other hospitals. Such conditions include iridocyclitis, keratitis and retinal detachment. A full list of the proportion of presentations treated at the RVEEH by diagnoses is provided in Appendix 4. 3.3.1.6 Outcome In 2002-03, 96% of Statewide ophthalmology presentations were “discharged to home” with 3.2% “admitted to a ward” and 0.8% “transferred to another hospital”. At the RVEEH 96% of presentations were “discharged to home” with 3.9% “admitted to a ward” and 0.1% “transferred to another hospital”. At other public hospitals 96% of presentations were also “discharged to home” with 2.5% “admitted to a ward” and 1.4% “transferred to another hospital” (Table 10). Of the 1,137 (3.2%) presentations that were admitted Statewide, 61% were treated at the RVEEH. At the RVEEH the number of emergency presentations “discharged to home” decreased by 14% compared with an increase of 47% at other public hospitals between 1998-99 and 2002-03. “Admission to a ward” increased by 9% at the RVEEH compared with 40% at other public hospitals. “Transfers to another hospital” decreased by 8% at the RVEEH and increased by 76% at other public hospitals.


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Table 10: Departure status of ophthalmology emergency presentations - 2002-03 (VEMD)

Presentations RVEEH Other public hospitals Total Victoria Departure status 98-99 02-03 %02-03 Growth 98-99 02-03 %02-03 Growth 02-03 %02-03 Discharge to home 19,258 16,471 92% -14% 11,574 17,035 96% 47% 33,506 96% Admission to Ward 634 692 3.9% 9% 318 445 2.5% 40% 1,137 3.2% Admission Short Stay Obs. - - 0.0% - 57 20 0.1% -65% 20 0.1% Transfer another Hospital 25 23 0.1% -8% 146 257 1.4% 76% 280 0.8% Left/treatment started 4 6 0.0% 50% 30 51 0.3% 70% 57 0.2% Left before seen by Dr 291 - 0.0% -100% 60 0 0.0% -100% - 0.0% Dead on Arrival 1 - 0.0% -100% 0 0 0.0% - - 0.0% Mental Health residency - - 0.0% - 0 1 0.0% - 1 0.0% Not categorised - - 0.0% - 1 0 0.0% -100% - 0.0% Grand Total 20,213 17,192 97% -15% 12,186 17,809 100% 46% 35,001 100% A summary of the types of diagnoses that were admitted or transferred to another hospital is presented in Table 11. Of the 1,137 patients admitted to a ward the most common diagnoses were other “disorders of the eye and adnexa” (25%), “injury of the eye and orbit” (20%) and “serous retinal detachment” (11%). Of the 280 patients transferred to another hospital the most common diagnoses were injury of the eye and orbit (36%), other disorders of the eye and adnexa (19%) and foreign body external eye (11%).

Table 11: Ophthalmology emergency presentations admitted or transferred by diagnosis – 2002-03 (VEMD)

Presentations Admission to Ward Transfer another hospital Diagnoses Number Percent Number Percent Other disorders of eye and adnexa 279 25% 52 19% Injury of eye and orbit 228 20% 101 36% Serous retinal detachment 126 11% 12 4% Hordeolum/other deep inflammation of eyelid 115 10% 16 6% Keratitis, unspecified 87 8% 2 1% Glaucoma, unspecified 50 4% 15 5% Acute inflammation of orbit 47 4% 3 1% Foreign body external eye 46 4% 30 11% Other visual disturbances 23 2% 13 5% Ocular pain 19 2% 10 4% Other 117 10% 26 9% Total 1,137 100% 280 100% Q3. How can it be ensured that appropriate patients attend specialist ophthalmology emergency departments and that appropriate treatment is available at other emergency departments? Q4. How can appropriate ophthalmic expertise be available in non-specialist emergency departments?


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3.3.2 Outpatients Outpatient services in public acute hospitals play a key role in the health system and represent a vital interface between inpatient and community care (Sharwood & O’Connell, 2001). They provide specialist medical services, pre and post hospital care, and other medical and allied health services. Attendance at outpatient clinics represents one of the most common reasons for contact with health institutions. In Victoria between 8 and 10 million occasions of service are provided each year (Sharwood & O’Connell, 2001). 3.3.2.1 Victorian Ambulatory Classification and Funding System On 1 July 1997 the Victorian Ambulatory Classification and Funding System (VACS) was introduced for 19 major Victorian hospitals. VACS is a casemix based funding system for public outpatient services where hospitals are funded on the basis of patient encounters for medical and surgical services. Encounters are defined as the clinic visit, plus all ancillary services (pathology, radiology and pharmacy), which are provided within 30 days either side of the clinic visit. There are 47 clinical categories, all of which are weighted except for allied health and emergency services. Annual throughput targets are set for VACS services and hospitals are funded up to this target. VACS targets are not set at a specialty level. They are set for each health service and it is the health services responsibility to allocate funding across outpatient clinics. VACS cost weights are detailed in section 4.5. Activity data is reported for each clinical specialty; no patient clinical information is reported. Hospitals that do not receive VACS funding, receive outpatient funding through a non-admitted patient grant. Data is not reported to the department for these services provided through this grant or the MBS. 3.3.2.2 VACS Outpatient activity Twelve hospitals provided a total of 89,364 public ophthalmology outpatient VACS encounters in 2002-03 (Table 12). Ophthalmology is the third largest provider of VACS encounters accounting for 8% of all VACS categories, following obstetrics (18%) and orthopaedics (9%). Ophthalmology outpatient services are concentrated in metropolitan areas with 70.0% of services provided at the RVEEH in 2002-03. The Royal Children’s Hospital was the next largest provider with 5.9% of encounters followed by the Royal Melbourne Hospital with 5.2%. Only 5% of ophthalmology VACS encounters occurred in regional hospitals, which include Barwon Health (3.2%), Ballarat Health Services (1.0%) and the Bendigo Healthcare Group (0.8%). VACS encounters have increased 7% since 1998-99. All the major providers of ophthalmology outpatient services experienced growth over this time period, except the ARMC which had a 36% decrease in encounters, moving from the second largest provider in 1998-99 (7.6%) to fifth in 2002-03 (4.5%). The Royal Children’s Hospital experienced the largest growth of 2,628 encounters (100%) since 1998-99. Box Hill Hospital and Frankston Hospital ceased providing publicly funded ophthalmology outpatient clinics in 1998-99 and 2000-01 respectively. St Vincent’s Hospital also ceased providing ophthalmology services in 1997. There are no VACS funded outpatient facilities located in the western metropolitan areas.

Table 12: Ophthalmology VACS Encounters 1998-99 to 2002-03

Agency Name 98-99 99-00 00-01 01-02 02-03 % 02-03 Growth Royal Victorian Eye & Ear Hospital 58,972 58,459 57,986 60,679 62,306 70.0% 6% Royal Children's Hospital 2,638 1,783 2,066 7,906 5,266 5.9% 100% Royal Melbourne Hospital 3,726 3,655 3,968 3,770 4,689 5.2% 26% Monash Medical Centre 2,950 2,948 2,372 2,356 4,620 5.2% 57% Austin & Repat. Medical Centre 6,336 3,528 4,091 4,258 4,063 4.5% -36% Alfred Hospital 3,451 3,195 2,320 2,343 3,437 3.8% 0% Barwon Health 2,760 2,986 3,026 2,945 2,831 3.2% 3% Ballarat Health Services 475 609 796 865 858 1.0% 81% Bendigo Healthcare Group 594 646 543 568 685 0.8% 15% Northern Hospital 767 168 406 455 440 0.5% -43% Royal Women's Hospital 99 101 90 98 92 0.1% -7% Peter MacCallum Cancer Institute 62 59 79 77 77 0.1% 24% Box Hill Hospital 12 - - - - 0.0% -100% Frankston Hospital 856 270 - - - 0.0% -100%

Grand Total 83,698 78,407 77,743 86,320 89,364 100.0% 7%


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3.3.2.3 Ratio of outpatient to inpatient services A large proportion of eye disease is managed on an outpatient basis. This is reflected in the high ratio of ophthalmology VACS encounters to inpatient separations in comparison to other specialties. In 2002-03 there were 89,364 VACS outpatient encounters to 15,592 public inpatient separations for ophthalmology which is a ratio of 5.73:1. In 2000-01 the RVEEH had the highest ratio of both encounters to separations and encounters to WIES, with 6.41 and 9.28 respectively compared to a state average of 1.56 and 1.89 (DHS, 2002). Possible factors related to the high ratio of outpatient attendances to inpatient occasions of service include:

• Shift from inpatient care to outpatient through use of improved technologies (laser) and improved pharmacology therapies.

• Ongoing monitoring and treatment of chronic conditions, ie. Glaucoma, diabetes, age related macula degeneration.

• High volumes of ophthalmic surgery and the associated pre/post-operative assessments undertaken ie. 3-4 outpatient visits per cataract surgery.

3.3.2.4 Allied health Allied health occasions of service provided in all VACS hospitals are listed in Table 13. Allied health services linked closely with ophthalmology service are orthoptics, optometry and medical photography. Other allied health services may be involved in the care of ophthalmology patients such as social work and occupational therapy. Orthoptics is the main provider of eye related allied health services in public hospitals with most patients presenting to ophthalmology outpatient clinics being seen by an orthoptist. Orthoptic services are provided at most hospitals that provide ophthalmology outpatient services. There is no reliable data to illustrate orthoptic activity statewide as orthoptic services along with medical photography are grouped in the category ‘other allied health services’. A sample of orthoptic data was acquired, however, from the RVEEH and the Royal Children’s Hospital (RCH). The RVEEH reported 57,280 orthoptic occasions in 2002-03, which included 17,388 refractions, 4,753 visual field examinations and 1,871, A scans. The RCH reported 7,111 orthoptic occasions of services in 2002-03.

Table 13: Allied health VACS clinics and occasions of services for 2002-03 (VACS)

Allied health profession 2002-03

601 Audiology 9,151

602 Nutrition 34,556

603 Optometry 840

604 Occupational Therapy 65,379

605 Physiotherapy 140,207

606 Podiatry 10,566

607 Speech Pathology 20,691

608 Social Work 72,618

609 Other Allied Health Services 156,328

610 Cardiac Rehabilitation Program 6,426

611 Hydrotherapy 7,256

Total Allied Health 524,018 A small number of VACS funded optometry services are provided in Victorian public health services. Only the Northern Hospital has consistently provided public optometry services since 1998-99 and was the only provider in 2002-03 (Table 14). The Royal Melbourne Hospital provided VACS funded optometry services in 1999-00 and 2000-01 while St Vincent’s Hospital provided VACS optometry services in 2000-01 only.

Table 14: Provision of VACS funded optometry Occasions of Service 1998-99 to 2002-03

Hospital Name 1998-99 1999-00 2000-01 2001-02 2002-03

Ballarat Health Services - 30 - 1 -

Barwon Health 22 - - - -

Northern Hospital 699 1,375 1,121 894 840 Royal Melbourne Hospital - 49 171 - -

Royal Victorian Eye and Ear Hospital - - - - -

St Vincent's Hospital - - 307 - -

Total 721 1,454 1,599 895 840


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3.3.2.5 Provision of outpatient services in rural Victoria As shown in Table 12, VACS outpatient services are provided in three regional hospitals - Barwon Health, Ballarat Health Services and Bendigo Healthcare Group. No VACS outpatient services are provided in the Hume and Gippsland regions. Rural hospitals receive a non-admitted patient grant for the provision of public outpatient services, however, they are not required to report activity data to the department. Q5. How can ophthalmology outpatient services be optimised? Q6. What ophthalmology outpatient services should be provided in the following settings –

• Specialist tertiary hospital (RVEEH) • General hospitals • Community settings

o Ophthalmologists o Optometrists o Other

Q7. What are the specific issues of rural Victorians in accessing ophthalmology outpatient services?


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3.3.3 Inpatients 3.3.3.1 Providers In 2002-03 there were 49,700 ophthalmology inpatient separations reported through the VAED by 102 public hospitals and 76 private hospitals in Victoria. Of the public hospitals, 32 (31%) were located in metropolitan Melbourne and 70 (69%) were located in rural areas. Of the 76 private hospitals, 64 (84%) were metropolitan and 12 (16%) were rural. Private hospitals treated 27,669 (56%) separations compared to 22,031 separations (44%) treated by public hospitals. Appendix 5 lists all public hospitals that provided greater than 10 separations in 2002-03 while private hospital data is aggregated. The RVEEH is the largest provider of ophthalmology separations with 19% of the State’s ophthalmology separations and 42% of public separations in 2002-03. The Cranbourne Integrated Care Centre (CICC) was the next largest public provider (8%) followed by Barwon Health (4%) (Refer Table 15). While 102 public hospitals treated ophthalmology inpatients in 2002-03, fifty percent were treated at two hospitals, the RVEEH and the CICC. CICC is a campus of Southern Health and provides same day ophthalmology services. Patients requiring overnight or multiday stay are treated at the Monash Medical Centre, Moorabbin campus. The CICC commenced treating ophthalmology inpatients in 2000-01 and is now the second largest public provider of ophthalmology surgical services in the State. In 2003-03, Monash Medical Centre, Moorabbin provided 126 separations (Refer Appendix 5). Twelve public hospitals treated greater than 400 ophthalmology separations (Table 15) while fifty public hospitals provided less than ten ophthalmology separations.

Table 15: Providers of public ophthalmology inpatient separations treating over 400 separations in 2002-03.

Hospital Total separations

% State (public & private) % Public

The Royal Victorian Eye & Ear Hospital 9,322 19% 42% Cranbourne Integrated Care Centre 1,800 4% 8% Barwon Health [Geelong] 985 2% 4% Royal Children’s Hospital [Parkville] 731 1% 3% Heidelberg Repatriation Hospital 542 1% 2% Royal Melbourne Hospital 541 1% 2% Ballarat Health Services 479 1% 2% Sunshine Hospital 462 1% 2% Latrobe Regional Hospital [Traralgon] 433 1% 2% New Mildura Base Hospital 422 1% 2% Bendigo Health Care Group 403 1% 2% Broadmeadows Health Service 402 1% 2% Other (less than 400 separations) 5,509 11% 25% Total public hospital separations 22,031 44% 100% Total private hospital separations 27,669 56% Total 49,700 100% 3.3.3.2 Metropolitan and rural services Of the 49,700 ophthalmology separations in Victoria in 2002-03, 11,037 (22%) were treated in rural hospitals and 38,663 (78%) were treated in metropolitan hospitals. Appendix 5 provides details of metropolitan and rural providers. Of separations treated in metropolitan hospitals, public hospitals treated 32% while private hospitals treated 45%. Of separations treated in rural hospitals, public hospitals treated 12% while private hospitals treated 10%. 3.3.3.3 Growth There was 26% growth in ophthalmology separations (private and public) between 1998-99 and 2002-03. Of the providers that treated over 400 separations listed in table 15 the only ones that experienced a decrease in separations were the Royal Children’s Hospital (-14%) and Ballarat Health Service (-31%). (Refer Appendix 5). The growth rate for the rural sector was 35% compared to 23% in the metropolitan sector. The proportion of the states separations provided in rural hospitals has remained between 21-23% (Table 16).


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Private hospitals experienced a growth rate of 37% compared to 14% in public hospitals. The proportion of ophthalmology separations provided in the private sector increased from 51% in 1998-99 to 57% in 2000-01 and has remained at 56% for the past two years (Table 16).

Table 16: Ophthalmology separations in metropolitan and rural Victoria and public and private hospitals 1998-99 to 2002-03 (VAED)

Hospital 98-99 99-00 00-01 01-02 02-03 % 02-03 Growth Metropolitan (public/private) 31,351 33,316 35,097 36,589 38,663 78% 23% Rural (public/private) 8,149 9,137 10,228 10,363 11,037 22% 35% Total (public/private) 39,500 42,453 45,325 46,952 49,700 100% 26% % Rural 21% 22% 23% 22% 22% Private (metro/rural) 20,254 22,940 25,609 26,141 27,669 56% 37% Public (metro/rural) 19,246 19,513 19,716 20,811 22,031 44% 14% Total 39,500 42,453 45,325 46,952 49,700 100% 26% % Private 51% 54% 57% 56% 56% 3.3.3.4 Patient type In 2002-03, 58% of ophthalmology separations were treated as private patients, 31% were public, 11% DVA and 1% compensable. Of the 22,031 patients treated in public hospitals 15,492 (70%) were public patients and 5,394 (24%) were private patients (Table 17). There has been a 33% increase in private ophthalmology separations and a 16% increase in public ophthalmology separations treated between 1998-99 and 2002-03. Private patients treated in public and private hospitals increased 24% and 35%, respectively. Public patients treated in public hospitals increased 17%. The higher growth rates in private ophthalmology separations compared with public separations has resulted in the overall proportion of private separations increasing from 54% in 1998-99 to 58% in 2002-03 while the proportion of public separations decreased from 34% to 31%. A high proportion of ophthalmology separations provided at the RVEEH are treated as private patients. Of the 9,322 separations provided at the RVEEH in 2002-03, 5,360 (57%) were public patients and 3,487 (37%) were private patients.

Table 17: Ophthalmology separations by hospital type and account type 1998-99 to 2002-03 (VAED)

Hospital type Account type 98-99 99-00 00-01 01-02 02-03 02-03 % Growth Private Compensable 116 116 69 64 77 0% -34% DVA 2,749 3,741 4,420 4,233 4,382 9% 59% Ineligible 17 5 11 7 11 0% -35% Private 17,187 19,055 21,099 21,830 23,198 47% 35% Public 185 23 10 7 1 0% -99% Private Total 20,254 22,940 25,609 26,141 27,669 56% 37% Public Compensable 214 196 233 216 213 0% 0% DVA 1,445 1,344 986 965 876 2% -39% Ineligible 31 34 33 29 57 0% 84% Private 4,334 4,338 4,501 5,261 5,394 11% 24% Public 13,222 13,601 13,963 14,340 15,491 31% 17% Public Total 19,246 19,513 19,716 20,811 22,031 44% 14% Total 39,500 42,453 45,325 46,952 49,700 100% 26%

Total private patients 21,521 23,393 25,600 27,091 28,592 58% 33%

Total public patients 13,407 13,624 13,973 14,347 15,492 31% 16% % private patients 54% 55% 56% 58% 58% % public patients 34% 32% 31% 31% 31%


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3.3.3.5 Length of Stay While the total number of ophthalmology separations has increased by 26% the number of bed days only increased by 15%. The growth in bed days has been greater in private hospitals (28%) than in public hospitals (3%) (Table 18).

Table 18: Ophthalmology separations and beddays 1998-99 to 2002-03 - public and private (VAED)

98-99 99-00 00-01 01-02 02-03 Growth Private Separations 20,254 22,940 25,609 26,141 27,669 37% Bed days 22,618 25,163 27,380 27,209 28,873 28% Public Separations 19,246 19,513 19,716 20,811 22,031 14% Bed days 25,361 25,089 24,890 26,331 26,116 3% Total separations 39,500 42,453 45,325 46,952 49,700 26% Total beddays 47,979 50,252 52,270 53,540 54,989 15% The majority of ophthalmology separations are same day. Same day ophthalmology separations have increased by 12%, from 72% in 1998-99 to 84% in 2002-03. All other stay types have decreased with 12% of separations overnight, 2% staying 2 to 3 days and 1% staying greater than 3 days in 2002-03 (Table 19). The private sector had a consistently higher same day rate than the public sector over the past 5 years which may reflect the higher concentration of cataract surgery within the sector. In 2002-03 the sameday rate was 88% in the private sector compared with 80% in the public sector.

Table 19: Length of stay for ophthalmology separations (private and public)

Length of Stay 98-99 99-00 00-01 01-02 02-03 % 02-03 % change Sameday 28,496 31,988 35,985 38,411 41,902 84% 47% Overnight 7,593 7,796 7,119 6,664 6,147 12% -19% Multiday 2-3 days 2,604 1,838 1,492 1,181 1,059 2% -59% Multiday 4-7 days 603 563 498 425 422 1% -30% Multiday 8+ days 204 268 231 271 170 0% -17% Grand Total 39,500 42,453 45,325 46,952 49,700 100% 26% % sameday total 72% 75% 79% 82% 84% % public sameday 68% 71% 74% 76% 80% % private sameday 76% 79% 84% 86% 88% 3.3.3.6 Elective/emergency In 2002-03, 96% of ophthalmology separations were elective and 4% emergency. Nine percent of public hospital ophthalmology separations were emergency while 0.2% of private hospital separations were emergency (Table 20).

Table 20: Ophthalmology separations by hospital and admission type – 2002-03 (VAED)

Private Hospitals Public Hospitals Total

Admission type Number Percent Number Percent Number Percent

Elective 27,624 99.8% 20,035 90.9% 47,660 96%

Emergency 44 0.2% 1,987 9.0% 2,031 4%

Maternity - 0.0% 2 0.0% 2 0%

Statistical 1 0.0% 7 0.0% 8 0%

Grand Total 27,669 100.0% 22,031 100% 49,701 100% 3.3.3.7 Medical/surgical Ophthalmology separations are predominantly surgical. In 2002-03, 96% of ophthalmology separations were surgical and 4% medical. The most common surgical separation was for “Major Lens Procedures” (63.1%). Combined (major and other) lens procedures constituted 70% of ophthalmology separations. “Other eye procedures” (6.2%) and “Eyelid procedures” (5.7%) were the next most common reasons for admission. The most common medical separations were “Other Disorders of the Eye W/O CC4” (1.8% of all ophthalmology separations) followed by “Hyphema & Medically Managed Trauma to Eye” (1.5%). Infections were responsible for 0.5% of ophthalmology separations. The majority of medical separations are treated in public hospitals (85%) while private hospitals treated a higher proportion of surgical separations (57%) (Refer Table 21).

4 W = with; W/O = without; CC = complications/co-morbidities; Cat/Sev = catastrophic/severe


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In 2002-03, the Diagnostic Related Groups (DRGs) with the greatest proportion treated in public hospitals were “Hyphema & Medically Managed Trauma to Eye” (96%), “Procedures for Penetrating Eye Injury” (94%) and “Acute and Major Eye Infections Age<55” (90%). The DRGs with the greatest proportion treated in private hospitals were “Other Lens Procedures” (66%), “Eyelid Procedures” (62%) and “Major Lens Procedures” (60%). Growth rates for ophthalmology DRGs in both the private and public sectors are listed in Appendix 6. From 1999-20005 to 2002-03 the greatest growth in ophthalmology separations was for “Major Lens Procedures” with 7,442 separations (31%). This growth was consistent across the public and private sectors with growth of 33% and 30% respectively. “Other Eye Procedures” increased by 569 separations (23%) and “Eyelid Procedures” increased by 331 separations (13%). The majority of growth for “eyelid procedures” occurred in the private sector 21%, compared to 2% in the public sector. Statewide decreases in separations were noted for “Other Lens Procedures” (-22%), “Strabismus Procedures” (-11%), “Glaucoma procedures” (for both complex –36% and other -18%) and “Major Corneal, Scleral & Conjunctival Procedures” (-58%).

Table 21: Ophthalmology medical and surgical separations by DRG –2002-03 (VAED)

Separations

DRG RVEEH Percent RVEEH

Other public hospitals

Percent other public

Private hospital

Percent private hospital Total %Total

Medical Acute and Major Eye Infections Age>54 46 29% 76 48% 37 23% 159 0.3% Acute and Major Eye Infections Age<55 22 22% 66 67% 10 10% 98 0.2% Hyphema & Medical Man Trauma to Eye 107 15% 586 81% 29 4% 722 1.5% Other Disorders of the Eye W CC 12 9% 97 73% 24 18% 133 0.3% Other Disorders of the Eye W/O CC 111 13% 576 66% 191 22% 878 1.8% Medical Total 298 15% 1,401 70% 291 15% 1,990 4.0%

Surgical Procedures for Penetrating Eye Injury 109 66% 47 28% 10 6% 166 0.3% Enucleations and Orbital Procedures 84 36% 76 33% 71 31% 231 0.5% Retinal Procedures 1,041 54% 352 18% 626 33% 1,919 3.9% Maj Corneal, Scleral & Conjunctival Procs 112 42% 13 5% 139 53% 264 0.5% Dacryocystorhinostomy 250 40% 119 19% 257 41% 626 1.3% Complex Glaucoma Procedures 94 71% 23 17% 15 11% 132 0.3% Other Glaucoma Procedures 285 37% 129 17% 364 47% 778 1.6% Major Lens Procedures 5,047 16% 7,606 24% 18,727 60% 31,380 63.1% Other Lens Procedures 347 10% 821 24% 2,258 66% 3,426 6.9% Strabismus Procedures 200 24% 333 40% 295 36% 828 1.7% Eyelid Procedures 427 15% 661 23% 1,768 62% 2,856 5.7% Oth Corneal, Scleral & Conjunctival Procs 363 25% 244 17% 855 58% 1,462 2.9% Lacrimal Procedures 87 16% 236 42% 236 42% 559 1.1% Other Eye Procedures 578 19% 748 24% 1,757 57% 3,083 6.2% Surgical Total 9,024 19% 11,308 24% 27,378 57% 47,710 96.0% Total 9,322 19% 12,709 26% 27,669 56% 49,700 100.0% As the Statewide tertiary referral hospital for ophthalmology services, the RVEEH activity was compared with other public hospitals and private hospitals (Table 21). The DRGs with the highest proportions of separations treated at the RVEEH in 2002-03 were “Complex Glaucoma Procedures” (71%), “Procedures for Penetrating Eye Injury” (66%) and “Retinal Procedures” (54%). An analysis of “Complex Glaucoma Procedures” showed that while 94 separations (71%) were treated at RVEEH the other 38 (29%) were treated at public and private facilities that each treated 10 or less such cases. Similarly for “Procedures for Penetrating Eye Injury” performed in 2002-03, the RVEEH performed 109 (66%) procedures while the remaining 47 (34%) were performed at public and private hospitals that each treated less than 10 such cases. Of the 1,919 “Retinal Procedures” separations treated in 2002-03, the RVEEH treated 1,041 (54%) separations. There were 67 (3.5%) separations treated in hospitals that each treated less than 10 procedures. Private hospitals treated 626 separations (33%).

5 Growth in DRGs is recorded from 1999-2000 due to coding changes.


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3.4 Coordination with other services Access to ophthalmology services is important to a range of specialities. Eye disease is common in endocrine conditions, such as diabetes and thyroid disease; neurological and neurosurgical conditions; neonatology; patients with HIV/AIDS; and trauma patients (NSW Health, 2002). It has been demonstrated in Table 15, that public ophthalmology services are concentrated at 12 hospitals, with more providing services on a more limited basis. Q8. To what extent should the public system treat private ophthalmology patients (insured or uninsured)? Q9. What types of ophthalmology services (emergency, outpatient, surgical, non-surgical) should be available to patients at general hospitals? Q10. How could ophthalmology services be coordinated more effectively with non-ophthalmology specialties such as trauma, diabetes, and immunology?


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4.0 Current demand and access Access refers to the extent to which a population or individual can obtain health services. The Victorian public health system should offer equitable access to health services for the population they service on the basis of need, irrespective of geography, socio-economic group, ethnicity, age or sex. This includes availability of services, waiting times for services and processes involved in accessing services and information (VQC, 2003). Advances in surgical techniques, technology and waiting list management strategies are contributing to an increase in the accessibility of services. A retrospective study conducted at the RVEEH between 1994 and 1999 showed that despite increasing numbers of patients undergoing surgery annually there were decreasing trends in patients waiting times, overnight hospitalisation and length of hospitalisation. An increasing trend in the use of phacoemulsification cataract surgery (PKE) combined with local anaesthesia was considered a major factor in increased efficiency of cataract services (Qing et al, 2001). Waiting list management strategies at a health service level have also contributed to reductions in long waits for cataract patients. For example substantial reductions in waiting times for long waiting patients can result by treating routine patients in turn.

4.1 Key elective surgery strategies In recent years a number of strategies have been implemented by the department aimed at monitoring and improving access to elective surgery in public hospitals. As ophthalmology surgery is predominantly elective, these are of particular relevance.

4.1.1 Elective Surgery Information System Access to public hospital elective surgery is monitored through the Elective Surgery Information System (ESIS). On a monthly basis the major metropolitan and rural public hospitals provide information about people waiting or admitted for elective surgery. The information held includes demographic, morbidity, and the waiting experience. The information provided is used to monitor hospital performance and for service planning.

4.1.2 Elective Surgery Access Service The Elective Surgery Access Service (ESAS) aims to assist semi-urgent (Category 2) elective surgery patients with prolonged waiting times receive care. Long waiting patients with little prospect of receiving treatment within their own hospital in the immediate future are offered the opportunity of surgery at another hospital. Patients in the following specialty areas have been identified as priority areas for action:

• Ophthalmology • Orthopaedics • Plastic Surgery • General Surgery

The main criteria for selection are the waiting time and the patient’s suitability for treatment at another hospital. Patients with significant medical issues, which are under active management by the target hospital, are felt to be unsuitable for treatment at another hospital. Patients are treated at (designated) hospitals, which have indicated they have capacity to treat additional elective surgery patients. The following (designated) hospitals have received funding to treat additional patients:

• Cranbourne Integrated Care Centre – Southern Health (Ophthalmology) • St Vincent’s (Orthopaedic and Plastic Surgery) • Western Hospital (General Surgery) • RVEEH (ENT)

4.1.3 Rural Patient Initiative The Rural Patient Initiative (RPI) consists of a range of strategies that aim to:

• Improve access to elective surgery and selected medical services for rural and regional Victoria. • Increase multiday capacity to treat additional elective surgery patients and accommodate patients

admitted through emergency departments within appropriate time frames. RPI strategies include grants and funding to support:

• Practice change from multiday to sameday surgery. • Medihotel type arrangements. • Short Stay Unit arrangements. • Elective surgery waiting list manager or coordinator positions.


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• Increased elective surgery activity that targets long waiting category 2 and 3 surgical patients and/or long waiting medical patients. Ophthalmology is one of the targeted specialty areas.

Table 22 provides additional background information related to elective surgery.

Table 22: Elective surgery background information

Elective Surgery is defined by the department as “surgical care that, in the opinion of the treating clinician, is necessary and admission for which can be delayed for more than 24 hours”. In Victoria's public hospitals, specialists assess the clinical urgency of their patient's condition and categorise it as one of three levels. Category 1: A condition that has the potential to deteriorate quickly to the point that it may become an emergency. Admission is desirable within 30 days. Category 2: A condition causing some pain, dysfunction or disability but which is not likely to deteriorate quickly or become an emergency. Admission is desirable within 90 days. Category 3: A condition causing minimal or no pain, dysfunction or disability, which is unlikely to deteriorate quickly and which does not have the potential to become an emergency. Admission is acceptable

4.2 Waiting times and equity of access The data presented in Section 3 can be seen as a measure of supply from the health care system. Demand is more difficult to measure. An analysis of waiting list data provides one indication of demand.

4.2.1 Waiting times for consultations The department does not routinely collect outpatient waiting time data. However, a survey of hospitals that provide VACS funded ophthalmology services in January 2004 showed variation in the average waiting times for routine ophthalmology appointments from 5 weeks to 42 weeks.

4.2.2 Waiting times for surgery In comparison with other states and territories in Australia, Victoria is performing well in managing ophthalmology surgical waiting lists. Data reported by the Australian Institute of Health and Welfare indicates that Victoria has the one of the lowest proportions of patients waiting more than 12 months for surgery (Table 23).

Table 23: Ophthalmology and cataract surgery waiting list statistics –Australian states and territories, 2001-02 (AIHW)

NSW Vic Qld WA SA Tas ACT NT Total

Ophthalmology

Admissions 19,064 13,854 7,313 4,789 3,741 645 720 694 50,820

Days waited at 50th percentile 98 37 26 88 42 154 82 160 57


Proportion waited > 12 mths 19.0 4.3 12.9 5.8 4.3 36.3 27.1 5.5 11.9

Cataract extraction

Admissions 14,345 9,232 4,567 3,503 2,431 394 615 487 35,574



Proportion waited > 12 mths 24.1 5.1 16.8 5.2 5.9 56.6 31.2 6.4 15.4 4.2.2.1 Victorian ophthalmology waiting list data Private hospitals do not report on waiting times for treatment at their facilities and little is known of the waiting times for surgery within the sector. The following data is reported from Victorian public hospitals that provide data to ESIS. ESIS groups the following hospitals into "group sites:"

• Monash Medical Centre Clayton and Moorabbin. • Dandenong Hospital and Cranbourne Integrated Care Centre. • Austin Hospital and Heidelberg Repatriation Hospital. • Rosebud Hospital and Frankston Hospital.


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On 31 October 2003 there were 3,406 patients on Victoria’s ophthalmology surgical waiting lists. The RVEEH had the largest waiting list of 1,486 patients or 44% of the waiting list, followed by Barwon Health with 308 patients (9%) and the Northern Hospital with 303 patients (9%) (Refer Table 24).

Table 24: Number of patients on Victorian public ophthalmology waiting lists - 31 October 2003 (ESIS)

Hospital Category 1 Category 2 Category 3 Total Percent Cumulative %

The Royal Vic Eye & Ear 12 280 1,194 1,486 44% 44%

Barwon Health - 39 269 308 9% 53%

The Northern Hospital 1 61 241 303 9% 62%

Sunshine Hospital - 9 249 258 8% 69%

Dandenong Hospital6 1 18 163 182 5% 74%

Ballarat Health Services 0 20 159 179 5% 80% Royal Children's Hospital 5 18 123 146 4% 84%

Latrobe Regional Hospital - - 127 127 4% 88%

Royal Melbourne Hospital 1 24 82 107 3% 91%

Frankston Hospital 1 84 19 104 3% 94%

Bendigo Healthcare - 2 68 70 2% 96%

The Alfred 1 32 11 44 1% 97% Maroondah Hospital - - 35 35 1% 98%

Austin Health - 3 31 34 1% 99%

Monash Medical Centre - 3 19 22 1% 100%

St Vincent's Hospital 1 - - 1 0% 100%

Western Hospital - - - - - -

Total 23 593 2,790 3,406 100% 100% Patients classified as category 3 (non-urgent) have average waiting times ranging between 39 and 409 days. Category 2 patients (semi-urgent) who require treatment within 90 days have average waiting times ranging between 17 and 120 days (Table 25). On 30 October 2003, 114 category 2 patients and 236 category 3 patients were waiting longer than clinically recommended. This represents 19% of category 2 patients and 8% of category 3 patients. Despite having the longest waiting list the RVEEH has one of the shortest surgical waiting times with category 3 patients having an average waiting time of 77 days and only 3% experiencing long waits.

6 Dandenong data includes Cranbourne


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Table 25: Waiting times (days) for ophthalmology - 30 October 2003 (ESIS)

Average wait Number of long waiters % long waits

Hospital Category 2 Category 3 Category 2 Category 3 Category 2 Category3

Ballarat Health Services 60 409 3 82 15% 52%

The Northern Hospital 85 303 24 78 39% 32%

Maroondah Hospital - 300 - 3 - 9%

Barwon Health 30 213 1 29 3% 11%

Monash Medical Centre 85 156 1 0 33% 0% The Alfred 62 148 5 2 16% 18%

Bendigo Healthcare 49 112 1 1 50% 1%

Frankston Hospital 120 107 47 0 56% 0%

Latrobe Regional Hospital - 92 - 1 - 1%

Sunshine Hospital 64 87 2 1 22% 0%

The Royal Vic Eye & Ear 34 77 28 38 10% 3% Royal Children's Hospital 18 66 0 1 0% 1%

Austin Health 17 66 0 0 0% 0%

Royal Melbourne Hospital 29 57 0 0 0% 0%

Dandenong Hospital 63 39 2 0 11% 0%

St Vincent's Hospital - - - - - -

Western Hospital - - 0 - - -

Statewide ave (patients) 54 132 114 236 19% 8%

Average hospital 55 149 8 16 20% 9%

Average hospital + two SDs 115 368 36 73 58% 39% Clearance time is the number of patients waiting divided by the number of admissions in the previous month. It is a measure of how long the list would take to clear if there were no further admissions. The average hospital clearance time for category 3 patients is 6.1 months while the average for all patients on the waiting list is 3.2 months. Several hospitals experience large variations from the mean for category 3 clearance rates which range between 0.7 and 26.5 months (Table 26).

Table 26: Clearance rates (months) for ophthalmology waiting lists- 30 October 2003 (ESIS)

Hospital name Category 1 (months) Category 2 (months) Category 3 (months)

Ballarat Health Services 0.0 2.9 26.5

The Northern Hospital - 2.3 11.5

Barwon Health - 1.1 9.0

Sunshine Hospital 0.0 3.0 6.9 Monash Medical Centre 0.0 0.8 6.3

Frankston Hospital - 5.6 6.3

The Alfred 0.3 1.1 5.5

Royal Melbourne Hospital 0.5 1.7 5.5

Latrobe Regional Hospital - - 3.5

The Royal Vic Eye & Ear 0.2 0.6 3.2 Bendigo Healthcare 0.0 2.0 2.6

Royal Children's Hospital 0.6 1.5 1.6

Dandenong Hospital 0.1 1.6 1.1

St Vincent's Hospital 1.0 - -

Maroondah Hospital - - 0.8

Austin Health 0.0 0.4 0.7 Western Hospital - 0.0 -

State Wide 0.3 0.9 3.2

Average hospital 0.2 1.8 6.1

Average + two SDs 0.9 4.6 19.0


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4.2.2.1 Cataract waiting lists Patients waiting for cataract surgery account for 74% of Victoria’s ophthalmology waiting list (2,523). As the major component of ophthalmology waiting lists, cataract surgery has come under scrutiny in many jurisdictions and warrants specific attention. Table 27 demonstrates that the hospitals with the largest cataract waiting lists are the RVEEH, Barwon Health and The Northern Hospital. Comparison of the number waiting for cataract surgery and the average number of admissions per months (clearance rate) shows that the RVEEH requires 0.7 months to clear its category 2 list and 3.5 months to clear its category 3 cataract list compared to hospital averages of 2.1 months and 8.3 months respectively.

Table 27: Numbers of patients waiting for cataract surgery 30 October 2003 (ESIS)

Number patients waiting for cataract surgery

Hospital Cat 2 Cat 3 Total Cat 1

and 2 % Total Clearance rate Cat 2 (months)

Clearance rate Cat 3 (months)

The Royal Vic Eye & Ear 164 839 1,003 40% 0.7 3.5 Barwon Health 30 257 287 11% 1.5 8.5 Sunshine Hospital 7 225 232 9% 2.8 7.9 The Northern Hospital 48 206 254 10% 4.2 14.5 Ballarat Health Services 13 146 159 6% 3.4 40.7 Latrobe Regional Hospital - 125 125 5% - 4.4 Dandenong Hospital* 5 116 121 5% 2.2 1.0 Royal Melbourne Hospital 17 78 95 4% 1.4 5.9 Bendigo Healthcare 1 54 55 2% 1.0 3.3 Maroondah Hospital - 30 30 1% - 3.8 Austin Health - 23 23 1% - 0.7 Frankston Hospital 75 18 93 4% 4.5 2.8 Monash Med Centre 1 11 12 0% - 13.2 The Alfred 22 9 31 1% 1.1 7.7 Royal Children's Hospital - 3 3 0% 0.0 7.2 Total waiting cataract 383 2,140 2,523 100% Ave hosp 2.1 Ave hosp 8.3 Total waiting ophthalmology 593 2,790 3,406 % cataract waiting 65% 77% 74% * No cataract surgery was performed at Dandenong Hospital in 2002-03. All cataract operations listed under Dandenong were performed at Cranbourne. Q11. What is an acceptable waiting time for non-urgent outpatient and inpatient ophthalmology care? Q 12. What strategies are required to ensure timely provision of ophthalmic surgical services?


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4.3 Utilisation A study of utilisation rates in small areas is often used to as a measure of the allocative efficiency of a health care system, or the level by which services are equitably distributed throughout the system.

4.3.1 Utilisation of eye care services A number of studies have examined the utilisation of eye care services in Australia. Findings include:

• Geographic variability in rates of ophthalmology care despite similarity in the prevalence of eye disease in rural and urban areas.

• Utilisation of eye care services increases with age. • Sex, private health insurance, urban residence, and the ability to converse in English are

significant factors associated with eye health care services use. • A mismatch between the proportion of the ophthalmology practice sites and the proportion of the

population in various urban and rural areas. (Keefe et al, 2002; Madden et al, 2002)

With regard to cataract surgery it has been found that cataract surgery services are well accessed by the Victorian population and that no particular sub-group is systematically under-serviced (McCarty et al, 2000). For this paper an analysis of ophthalmology inpatient separations has been undertaken at a Local Government Area level to document the age-standardised separation rates per 1,000 people for each ophthalmology Enhanced Service Related Group (ESRG)7. Similar to analysis undertaken in NSW, there is a large variation in utilisation rates. These data are detailed in Appendix 7. Small area variations in practice (such as demonstrated here for ophthalmology) are not unique and have previously been described in Australia (Robertson et al, 1998; Mooney & Scotton, 1999). Causes of variation are seen to relate to a number of factors, including:

• The degree of medical practitioner uncertainty with respect to diagnosis and treatment. • Uncertainty about the effects and value of a medical procedure. • Inability of the patient to judge the need for medical procedures. • The extent of overservicing that is possible. • Where a wide range of practices are considered to be within the bounds of appropriate care. • The degree of medical practitioner discretion in whether to hospitalise (and operate).

(Folland et al, 1997; Mooney & Scotton, 1999).

7 See Appendix 6 for definition of ESRGs


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4.4 Self sufficiency - Patient flows Self sufficiency measures the degree to which people can access services close to home. This is of most relevance to rural Victorians who often have longer travel times to hospitals than metropolitan people experience. Table 28 demonstrates that 77% of rural people receive inpatient ophthalmology services within rural Victoria. This varies from 60% for Hume residents receiving care in the Grampians area to 90% for Barwon South Western residents receiving care within the Barwon South Western region. 99.7% of metropolitan people receive treatment within metropolitan Melbourne. Self sufficiency calculations in metropolitan Melbourne are more difficult to interpret because three major hospitals (The Alfred, Royal Melbourne Hospital and RVEEH) are all located in the Melbourne local government area which is allocated to the Western metropolitan region.

Table 28: Ophthalmology self sufficiency

Patient region of residence

Hospital region

Bar

won

SW

Gip

psla

nd

Gra

mpi

ans

Hum

e

Lodd

on M

alle

e

Rur

al to

tal

Met

ro E

aste

rn

Met

ro N

orth

ern

Met

ro S

outh

ern

Met

ro W

este

rn

Met

ro to

tal

Mis

sing

Inte

rsta

te

Tota

l

Barwon SW 90% 0% 4% 0% 0% 0% 0% 0% 0% 2% 2% 7%

Gippsland 0% 63% 0% 0% 0% 0% 0% 0% 0% 2% 0% 4%

Grampians 1% 0% 76% 0% 5% 0% 0% 0% 0% 0% 3% 4%

Hume 0% 0% 0% 60% 3% 0% 0% 0% 0% 0% 16% 3%

Loddon Mallee 0% 0% 2% 1% 71% 0% 0% 0% 0% 30% 32% 5%

Rural total 91% 63% 82% 62% 79% 77% 0% 0% 0% 0% 0.3% 33% 53% 22%

Metro Eastern 1% 13% 1% 7% 2% 62% 17% 13% 10% 6% 9% 21%

Metro Northern 1% 2% 2% 6% 6% 4% 31% 3% 9% 6% 6% 8%

Metro Southern 1% 8% 1% 2% 1% 8% 1% 58% 2% 0% 6% 16%

Metro Western 6% 15% 14% 24% 12% 26% 52% 26% 79% 56% 26% 33%

Metro total 9% 37% 18% 38% 21% 23% 100% 100% 100% 100% 99.7% 67% 47% 78%

Grand Total 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Total separations 3,848 2,706 2,002 1,798 3,227 10,242 7,174 11,751 6,114 54 770 49,686


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4.5 Cost of services The costs of ophthalmology services can be defined from two perspectives, the cost to the payer of the service (government or consumer) or the cost of delivery of service (hospital or practitioner).

4.5.1 Medicare consultations The Medicare Benefits Schedule documents the fee that the Health Insurance Commission (HIC) will pay for medical services provided. The bulk billing rate for ophthalmologists is not known but 27.8% of “specialist attendances” and 96.5% of optometry consultations were bulk billed in 2002-038. The cost to the patient at point-of-care for non-public hospital ophthalmology consultations is not known, but is likely to be higher than the schedule fee and approximate the Australian Medical Association (AMA) recommended fee in many instances.

4.5.2 Hospital cost weights Public hospitals are funded on a casemix basis. The cost-weights are developed through an indepth study of hospitals activities. The cost weights for same day ophthalmology DRGs from 2000-01 to 2003-04 are listed in Table 299. The standard rate per Weighted Inlier Equivalent Separation (WIES) is approximately $2,600 in 2003-04 and varies between metropolitan and rural hospitals in recognition of the higher fixed costs of running small hospitals. Public hospitals receive additional funding through a range of grants. It is known that the cost of service provision varies between hospitals. It is likely that, through efficiencies in work practices or staffing arrangements, some hospitals achieve costs that differ markedly from the casemix payment. Some hospitals will deliver the service at a lower cost to the payment and others will deliver it at a higher cost to the payment. Salary arrangements for surgeons have been noted as a significant factor in whether a hospital is able to deliver the service within the casemix payment, with some hospitals providing sessional payments and others fee-for-service.

Table 29: WIES11 - Victorian ophthalmology same day cost weights

Same Day Weight

DRG Code and Name 2000-01 2001-02 2002-03 2003-04

C01Z Procedures for Penetrating Eye Injury 0.6175 0.6316 0.6050 1.1162

C02Z Enucleations and Orbital Procedures 0.9300 1.1506 1.0703 0.9444

C03Z Retinal Procedures 0.8436 0.8669 0.8472 0.8430

C04Z Maj Corneal, Scleral & Conjunctival Procs 0.7637 0.9147 0.9368 0.7871

C05Z Dacryocystorhinostomy 0.7287 0.7554 0.7787 0.7915

C06Z Complex Glaucoma Procedures 0.5738 0.4661 0.4538 0.4736

C07Z Other Glaucoma Procedures 0.6563 0.7070 0.5909 0.5991

C08Z Major Lens Procedures 0.6214 0.5925 0.5995 0.5845

C09Z Other Lens Procedures 0.6160 0.7208 0.7518 0.8231

C10Z Strabismus Procedures 0.4275 0.4867 0.4791 0.4275

C11Z Eyelid Procedures 0.4056 0.4282 0.4103 0.3999

C12Z Oth Corneal, Scleral & Conjunctival Procs 0.3211 0.3296 0.3256 0.4379

C13Z Lacrimal Procedures 0.3703 0.2705 0.2778 0.2687

C14Z Other Eye Procedures 0.3420 0.3429 0.3292 0.3042

C60A Acute and Major Eye Infections Age>54 0.3796 0.4313 0.4411 0.4604

C60B Acute and Major Eye Infections Age<55 0.4147 0.3060 0.3078 0.6019

C61Z Neurological & Vascular Disorders of Eye 0.5523 0.5212 0.5196 0.4226

C62Z Hyphema & Medically Man. Trauma Eye 0.1889 0.1839 0.1516 0.1575

C63A Other Disorders of the Eye W CC 0.3630 0.3080 0.2652 0.3170

C63B Other Disorders of the Eye W/O CC 0.2778 0.2245 0.1916 0.1905

8 http://www.hic.gov.au/statistics 9 The weighting is derived through annual costing studies which compare, in participating hospitals, the relative resource consumption of each DRG against all others. Intra-hospital costing systems are fundamental to casemix. While they vary between hospitals, the relativity in resource consumption for each DRG within each hospital produces a reliable weighting.


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4.5.3 VACS cost weights The 2003-04 VACS case payment is $133 per weighted public encounter for medical and surgical services. This has increased from $125 in 2002-03. Cost weights have remained the same as in 2002-03. Details of VACS funding for clinical categories related to ophthalmology services are outlined in Table 30. Allied health funding is determined on the basis of occasions of service which in 2003-04 is $47 regardless of type of allied health service provided.

Table 30: Ophthalmology related VACS funding

Category VACS code Weight /cost 02-03

Weight / cost 03-04

Surgical Ophthalmology 204 0.771 0.771 Medical Neurology (inc. neuro-ophthalmology) 109 1.43 1.43 Allied Health Optometry 603 $45 $47 Other Allied Health (inc. orthoptics) 609 $45 $47 Q13. What are the cost and funding issues in ophthalmology that require action (inpatient, outpatient, emergency, Commonwealth, state)?


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5.0 Future service demand Planning for future hospital services requires quantification of activity based on the population needs (demand) and how these needs are met (supply). Understanding and describing current and future patterns of acute health service utilisation is a major component of health service-planning projects. In order to estimate future requirements an assessment of past trends is essential to inform strategic policy and planning. This section will describe the base case forecasts produced by the department and outlined in the Metropolitan Health Strategy10. See Appendix 6 for description of the DRGs that are included in each of the ophthalmology Enhanced Service Related Groups (ESRGs). These will be further examined in detail and compared to other indicators of future demand.

5.1 Base case forecasts The method of forecasting hospital in-patient activity in the department has changed over time. In the past, one would forecast by multiplying the activity of the current year with population projections to ascertain future activity. This type of forecasting, referred to as ‘population projection’, has usually been out stripped by the actual growth in the system. The department’s current method of forecasting uses linear regression methods where forecasts are generated for utilisation rates based on retrospective years of data. This approach assumes that the past relationship between variables will be the same in future years. The advantage of this approach is that a change in the intensity of activity in the past this will be projected into the future. With a population projection the activity is ONLY linked to changes in population and aging. Graphs of total public and private forecasts for each ESRG are included in this document. These base case forecasts indicate that by 2016-17 there will be a:

3.3% per annum increase in public ophthalmology inpatient separations. 4.3% per annum increase in same day separations. 1.0% per annum decrease in multiday separations.

The average length of stay (ALOS) for multiday ophthalmology separations is forecast to reduce from 2.08 in 2001-02 to 1.88 in 2016-17, a reduction of 0.7% pa. Public “Cataract Procedures” are forecast to grow at 4.5% pa to 2016-17, with a continued shift to sameday activity and a decline in multiday ALOS from 1.28 to 1.19 days (Appendix 9, Figure 2 and 3). As this ESRG is already predominately sameday, beddays for “Cataract Procedures” will also increase at 4.3% pa. Public “Other Eye Procedures” separations are forecast to grow at 0.7% pa to 2016-17. This will occur in the setting of a shift from multiday to sameday separations with an overall decline in beddays at 0.3% pa. Multiday ALOS will decline from 1.94 days to 1.66 days (Appendix 9, Figures 4 and 5). Public “Non-Procedural Ophthalmology” is a minor but important component of ophthalmology practice. There is expected to be a 2.0% pa growth in separations and 0.2% pa growth in beddays. Multiday ALOS will decline from 3.48 days to 3.19 days (Appendix 9, Figures 6 and 7).

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017

Sepa

ratio

ns

Sameday Multiday

Figure 2: Cataract Procedures forecast (separations) –Victorian public and private hospitals, 2001-02 to 2016-17

10 http://www.health.vic.gov.au/metrohealthstrategy/inpat-forecasts.pdf


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0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017

ALO

S (d

ays)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% D

ay O

nly

ALOS multiday Sameday %

Figure 3: Cataract Procedures forecast (ALOS and % sameday) – Victorian public and private hospitals, 2001-02 to 2016-17

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017

Sepa

ratio

ns

Sameday Multiday

Figure 4: Other Eye Procedures forecast (separations) – Victorian public and private hospitals, 2001-02 to 2016-17

0.0

0.5

1.0

1.5

2.0

2.5

1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017

ALO

S (d

ays)

0%

10%

20%

30%

40%

50%

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Figure 5: Other Eye Procedures forecast (ALOS and % sameday) – Victorian public and private hospitals, 2001-02 to 2016-17


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Figure 7: Non-procedural ophthalmology forecasts (ALOS and % sameday) – Victorian public and private hospitals, 2001-02 to 2016-17

Forecast growth for private hospital ophthalmology separations are similar to the public sector with forecast growth of 3.5% pa to 2016-17 (Appendix 9). The ALOS for multiday ophthalmology separations are lower in private hospitals than public and is forecast to reduce from 1.32 in 2001-02 to 1.28 in 2011-12, a reduction of 3%. As is demonstrated in the above tables and graphs, the main area that is forecast to change in volume is Cataract Procedures. As this is the major component of ophthalmology practice and is forecast to become even more dominant, specific attention will be given to the issues relating to cataract surgery growth and demand.

5.2 Cataract surgery Cataract surgery is now one of the most common surgical procedures. Its effectiveness is well established with around 80 to 95% of patients having improved visual acuity and functioning after surgery. The procedure is safe, with approximately 20 percent of patients needing follow-up laser treatment within two years of surgery because of opacification of the posterior capsule (Acosta & Tuni, 2003). Longer life expectancy and decreased surgical risks (safer, less invasive techniques) lower the threshold for surgery. In addition there is a greater social demand for surgery as a result of it being perceived as a highly cost effective intervention (Busbee, 2002). Approximately one-third of patients receiving first eye surgery will have surgery on their second eye within the following year and 50 percent will do so within two years. The benefit of second eye surgery, however, has been questioned given the allocation of substantial resources. A Cochrane review has been established to evaluate the effects of cataract surgery in both eyes in comparison with surgery in only one eye (Acosta & Tuni, 2002). Whilst the outcomes of the Cochrane review are not yet reported a recent study from the United States on cost-utility of cataract surgery in the second eye concluded that that second eye cataract surgery is one of the most cost-effective procedures in ophthalmology and across medical specialities. Second eye cataract surgery at $2,727 per quality-adjusted life-years (QALY) gained, seemed nearly as valuable as initial cataract surgery at $2023 per QALY gained (Busbee et al, 2003).


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5.2.1 Cataract surgery growth The main determinants of future growth in demand for cataract surgery are recognised as:

• Ageing of the population. • Population growth. • Change in threshold for surgery.

While ageing and population growth have been influences in the growth rate of cataract surgery, the change in threshold for surgery has been the major influence over the past 6 years. Table 31 demonstrates that while Victoria’s total population has grown at 1.1% pa and the population aged over 70 years has grown at 3.0% pa, cataract procedures have grown at 8.1% pa. The age standardised growth rate of cataract procedures has been 5.5% pa, attributable to the reduction in threshold of surgery.

Table 31: Growth in population and cataract procedures - Victoria 1995-96 to 2001-02

1995-96 2001-02 Growth pa-

1995-96 – 2001-02 Victorians 70+ years of age 391,194 452,604 3.0%

Total Victorian Population 4,560,155 4,822,663 1.1%

Cataract Procedures 21,152 31,259 8.1% Age adjusted Cataract Procedures (adjusted to 2001/02 population distribution)

23,925 31,259 5.5%

This high growth in cataract surgery is not unique to Victoria and has been reported in many jurisdictions. The common unit of measure of cataract surgery is the Cataract Surgery Rate (CSR) defined as the number of procedures per million people per year. The Victorian CSR of 6,116 is among the highest reported in the literature, comparable to other Australian states and higher than international comparisons (about 5,700 for the United States, 4,000 for Sweden and 2,700 for the United Kingdom) (Taylor, 2000).

Table 32: Cataract Surgery Rate per million people 2001-0211 – Australian States and Territories –ABS and AIHW (2003)

NSW Vic Qld WA SA Tas ACT NT Total

Public hospitals 13,531 11,803 4,761 4,232 4,489 112 652 303 39,883

Private hospitals 34,284 17,774 20,733 7,989 6,782 N/A N/A N/A 91,257

Total 47,815 29,577 25,494 12,221 11,271 112 652 303 131,140

Total populn 6,608,792 4,836,196 3,664,284 1,913,850 1,515,748 472,116 320,275 197,617 19,531,464

CSR 7,235 6,116 6,957 6,386 7,436 237 2,036 1,533 6,714 The forecast CSR for 2016-17 is approximately 12,000 (Figure 8). This data can be used to estimate the future reduction in surgery threshold by relating it to “The Golden Triangle of Ophthalmology” (Figure 9) (Taylor, 2000). As the threshold for surgery continues to decline, the marginal benefit from surgery will also decline, leading to less value for money for society (Hurst & Siciliani, 2003). Priority setting initiatives may be appropriate to implement to ensure that the most appropriate people are receiving surgery and that the payers (Consumers and Government) achieve best value for money. In a comment on priority setting for ophthalmology services, Mordue (1998) suggests that it would be valuable to have information on different base levels of need to assist health boards and authorities in decisions about the costs and benefits of different levels of service provision since they must compare the health improvements that would be generated by treating patients at various levels of visual acuity with those from investing resources in other ophthalmological treatments or in other specialities. It is generally agreed worldwide that the decision to perform cataract surgery should not be based on visual acuity or the presence of a cataract alone, but should depend mainly on whether the visual function of a person limits their ability to undertake activities of daily living (Lee, 2000;Wright & Robens-Paradise, 2001).

11 Separations relating to ICD block 197: Extracapsular crystalline lens extraction by phacoemulsification


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In Canada, however, a large project to assess the feasibility of assessing surgical indications and outcomes on a routine basis found

‘ that many cataract operations are now carried out for patients with minor visual acuity deficit and minimal self-reported visual disability. In some cases, no significant cataract exists at all…..Questions must be raised about the level of visual disability that constitutes medical necessity and whether refractive error is an acceptable indication for surgery. These questions would be of little importance if the procedure was free of risk, but this is never the case in any form of surgery and cataract operations carry a 2-4% risk of serious complications to the eye’ (Wright & Robens-Paradise, 2001).

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Figure 8: Forecast Cataract Surgery Rate (CSR) and separations - Victoria 2002-03 to 2016-17

Figure 9: The golden triangle of ophthalmology; the relation between different thresholds of visual acuity and the cataract surgery rate.

A number of strategies have been proposed to manage demand for cataract surgery. These include:

• Adoption of agreed indicators for cataract surgery to ensure appropriateness based on available evidence.

• Development of prioritisation systems for surgery based on measurements of disability, visual function, quality of life etc. Examples of prioritisation systems are provided in Section 8.

• Improved efficiency of cataract surgical services, including waiting list management, review of models of care, operating theatre utilisation.

• Increase the number of trained ophthalmologists to perform cataract extraction. • Improve technology. • Implementation of primary prevention strategies.


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5.3 Projected incidence of eye disease The forecasts provided by the department are for inpatient care. A large proportion of eye disease, however, requires little or no inpatient treatment and can be effectively managed in the community or outpatient settings. The VIP has demonstrated the demand for eye care in the most common conditions:

5.3.1 Diabetic eye disease As all people with diabetes are at risk of developing eye disease and only half of these people have regular eye examinations, a large unmet demand for services exists. Considering that early diagnosis and treatment can prevent up to 98% of severe vision loss, strategies that address the barriers to regular screening (lack of awareness and communication breakdowns) have been identified as the means of managing this condition.

5.3.2 Glaucoma As glaucoma prevalence is closely correlated with ageing, the ageing of the population over coming years will have a profound effect on the incidence of the disease (Figure 10). Current estimates extrapolated from the VIP indicates that the prevalence of glaucoma will grow from approximately 41,000 people aged over 40 years to more than 55,000 by 2016 in Victoria. Early detection and effective treatment are likely to have a significant impact on the level of consequential visual impairment from the disease, as half of all glaucoma is undiagnosed.

Figure 10: Age specific prevalence of glaucoma (Centre for Eye Research Australia)

5.3.3 Age-Related Macular Degeneration As with glaucoma above, prevalence of AMD is also age-related (Figure 11). The prevalence of the disease is forecast to grow from 330,000 people in 2003 to more than 430,000 people in Victoria by 2016. While the effectiveness of treatment strategies is currently limited, the development and uptake of new technologies (ie. photodynamic therapy) will be in high demand.

Figure 11: Age specific prevalence of AMD (Centre for Eye Research Australia)

Table 33 illustrates the primary treatment strategies and their settings for each of the five most common forms of eye conditions. With an ageing population the prevalence of each of these eye conditions is expected to increase. Findings from the VIP suggest that the amount of visual impairment and blindness increases three fold with each decade of age and without specific intervention the amount of eye disease in Australia with double in the next 20 years (CERA, 2000). These finding have implications on the provision of ophthalmology services in the outpatient and community setting.


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Table 33: Management settings for the treatment of eye conditions

Outpatient/community (non admitted) Inpatient

(admitted)

Eye condition Visual aids/

rehabilitation

Glasses/ contact

lens Monitoring Drugs Laser Surgery Refractive error AMD Cataract Glaucoma Diabetic retinopathy Note: Visual aids and rehabilitation strategies may be used for all eye conditions if irreversible visual impairment results. Vision deterioration from early cataract may be corrected with glasses.

5.4 Service innovation Innovations in service delivery and technology are likely to continue to occur. A recognition of future clinical changes offers insights into future models of care.

5.4.1 Clinical developments Speculation on future advances in ophthalmology has been undertaken by Taylor and Keeffe (2002) and include:

• Improved glaucoma screening technologies and protocols for community use. • New non mydriatic fundus cameras for use by non-specialised staff for the early detection of

diabetic retinopathy. • An accommodating intraocular lens that will remove the need for reading glasses after surgery

(probably 5 – 15 years away). • Photodynamic therapy to reduce or delay vision loss from AMD. Long term benefits are still

unclear. • Dietary supplements for age related eye disease. • The identification of genes related to the presence and severity of glaucoma. It was considered

unlikely that gene therapy will prevent eye disease in the short term but will identify those at risk. • Even though the bionic ear is highly successful, a successful bionic eye is unlikely in the next 10

years.

5.4.2 Prevention & health promotion There is an increasing focus on health promotion which has the potential to increase demand for eye services, as many eye disorders are undiagnosed. The Victorian State Government will provide $1.8 million over 3 years towards the ‘Vision Initiative’ run by Vision 2020. This initiative is a public eye health program run in collaboration with eye health care providers, researchers, rehabilitation and support services aimed at encouraging the general public to have regular eye tests. Q14. What strategies should be developed and implemented to manage demand for treatment of eye disease such as cataract surgery, glaucoma, diabetic retinopathy and ARM? Q15. What innovations in clinical practice, models of care, technology and health promotion will change treatment patterns over the next decade?


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6.0 Service configuration and models of care

6.1 National

6.1.1 Victoria The Metropolitan Health Care Services Plan (1996) announced that a review of statewide ophthalmology services would be undertaken to determine optimal service configuration and funding arrangements for ophthalmology services across the state, with particular focus on the need to make high quality and efficient ophthalmology services more accessible to rural Victorians. Whilst the review of ophthalmology services did not occur, a ‘hub and spoke’ model was implemented at the RVEEH with spoke facilities developed for ophthalmology at Maroondah Hospital and Broadmeadows Health Service. A hub and spoke model is a model of service delivery where highly specialised services are maintained at one or two locations (hubs), while high volume or lower complexity same day services will be provided by staff from the hub in distant locations, called spokes. The hub supplies the staff and pays the spoke only for the hire of facilities. 6.1.1.1 RVEEH The Royal Victorian Eye and Ear Hospital (RVEEH) is a statewide specialist teaching, training and referral hospital in Ophthalmology and ENT. Internationally, it is one of about twenty major stand-alone specialist hospitals in eye and ear medicine. The main hub in East Melbourne provides comprehensive specialist and emergency services with spoke services for ophthalmology delivered in East Ringwood (Maroondah), Broadmeadows and spoke services for ENT delivered in Blackburn. The RVEEH plays a key role in teaching and training for health professionals in the areas of ophthalmology and ENT and has an international reputation in medical research through its close association with the University of Melbourne Departments of Ophthalmology and Otolaryngology, its affiliation with the Centre for Eye Research Australia (CERA), the Bionic Ear Institute and the Cochlear Implant program Ophthalmology services As discussed in Section 3 the RVEEH performs 42% of the State’s public ophthalmology admitted patient services, 70% of VACS funded ophthalmology outpatient services and treats 49% of ophthalmology emergency presentations captured through the VEMD. The Broadmeadows and Maroondah spokes provide specialist ophthalmology outpatient and surgical services. Broadmeadows provides same day surgery, with patients requiring specialist support or overnight or multiday stay treated at the East Melbourne site. The implementation of spoke services has improved access to basic ophthalmology services in the northern and eastern growth corridors. It has been met, however, with high infrastructure costs and the costs of transporting staff and equipment across campuses. The RVEEH supports rural Victoria through a program of statewide registrar rotations in several rural locations and through a number of joint appointments of consultant ophthalmologists at rural hospitals. RVEEH provides the largest ophthalmology service with 42% of all public inpatient separations in Victoria. It has a high proportion of super-specialty surgery and service delivery, including:

• 90% of the state’s public major corneal, scleral and conjunctival procedures • 75% of the state’s public retinal surgery • 71% of the state’s public glaucoma procedures • 39% of the state’s public cataract surgery

As well as providing general ophthalmology outpatients services the RVEEH provides a range of sub-speciality outpatient clinics. Specialty areas include: glaucoma, vitreo-retinal, ocular motility, orbito-plastics, corneal, ocular diagnostics, medical retinal and ocular immunology. The RVEEH undertakes the medical teaching of all ophthalmology trainees in Victoria in conjunction with the University of Melbourne and the RANZCO. It provides sub-specialty medical training in ophthalmology and accredited training in ophthalmic nursing, and orthoptics and is affiliated with the relevant university schools including the University of Melbourne, Latrobe University, RMIT, and Deakin University. The RVEEH houses a number of academic and research groups for ophthalmology which include:

• Centre for Eye Research Australia (CERA) • The University of Melbourne Department of Ophthalmology • Lions Eye Bank


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• W.H.O. Collaborating Centre for Prevention of Blindness • McComas Family Laboratory (Ophthalmology)

As part of their quality improvement program the RVEEH has been involved in benchmarking its practices and performance in cataract surgery with a range of international hospitals with similar profiles. When compared to these other hospitals the RVEEH had:

• The highest number of outpatient visits for cataract patients providing three post operative reviews after cataract surgery compared to one or two.

• The lowest day surgery rate. • The lowest number of cataracts per teaching list: RVEEH treats 8 patients on a full day operating

list compared with 11 or 12 patients per list for international benchmarks. • One of the longest waits for cataract surgery, at 32 weeks. (EAEH, 2000; RVEEH Quality of Care Report, 2003)

The role of teaching and training should be considered when benchmarking services as the involvement of trainee ophthalmologists and their level of experience can affect surgical productivity. Data provided by the RVEEH demonstrates the numbers of patients booked for surgical operating list and the registrar level (Table 34). Increases in surgical productivity have occurred at the RVEEH since 2001 by one patient per list for most registrar levels to make the RVEEH comparable with some national and international hospitals.

Table 34: Number of patients booked per ophthalmology surgical list and registrar level

RVEEH 1st Year 2nd Year 3rd Year 4th Year

Jul-01 2 3 3 4

Sep-02 3 3 4 4 - 5

Sep-03 3 3 4 5

Benchmarks

Massachusetts Eye and Ear Infirmary 3 3 3 3

Sydney Eye Hospital 3 3 4 5

Singapore National Eye Centre 3 4 5 5 - 6

Cranbourne Integrated Care Centre 5 6.1.1.2 Southern Health Ophthalmology In 2002, Southern Health Ophthalmology established ophthalmology surgical services at the Cranbourne Integrated Care Centre (CICC). The CICC provides same day surgery for low risk ophthalmology patients. Patients considered high risk or requiring overnight or multiday stay are treated at Southern Health’s Moorabbin campus. As discussed in Section 4, CICC is a designated ophthalmology ESAS hospital. In 2003-03, CICC treated 1,800 (8%) public inpatient ophthalmology separations making it the second largest provider of public ophthalmology surgery. Cataract surgery constituted 82% of all separations treated at CICC. A new model of service delivery for cataract surgery has been implemented at the CICC which is outlined below.

• First day post-operative reviews for straightforward small incision cataract cases have been discontinued and all post-operative cataract patients attend a one week post-operative review clinic. Only high-risk patients, such as those who have had complicated surgery, large incision surgery, an only eye, or at the discretion of the surgeon, are reviewed on the first post-operative day.

• Alternatives to conventional post-operative review visits are being explored. These include shared care with non-ophthalmologists, improved peri-operative patient education, and the use of both specific and general health related quality of life instruments (VF14 & SF-12).

• If required, patients receive one pre-admission visit and are given a date for surgery on that day. This model has not been independently evaluated although preliminary audit estimates indicate this to be an economic and resource-efficient model with comparatively high-volume of patients treated and short waiting times.

6.1.1.3 Post-operative Review for Cataracts There is a number of viewpoints in Australia and overseas in relation to first-day and first or second-week post-operative review. As noted above, Southern Health Ophthalmology at CICC, has discontinued the first day post-operative review for straightforward small incision cataract cases. Southern Health Ophthalmology’s decision is consistent with the Royal College of Ophthalmologist's (UK) cataract surgery guidelines published in 2001. These state that patients should be seen on the first day if they have had complicated surgery, large incision surgery, have co-existing eye disease, or have an only eye. Patients not reviewed on the first day must be given clear instructions regarding expectations, post-operative management, follow-up arrangements and help.


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The Royal Australian and New Zealand College of Ophthalmology (RANZCO) Preferred Practice Patterns for Intraocular Lens Surgery do not make specific reference to first day post-operative review and recommend that the minimal frequency of patient review following phacoemulsification and implant surgery should include a review within 3 days of surgery with a final visit approximately 2-3 weeks following surgery (RANZCO, 2003). Although it is acknowledged that there is a small incidence of early post-operative complications following cataract surgery, some studies suggest that there is no additional risk for patients who do not attend for the first day review. For example, Wu and Morrell (2001) in a nationwide survey reported a considerable heterogeneity of post-operative instructions following uncomplicated cataract surgery provided by 115 cataract centres in the UK, with 35% of centres adopting a single post-operative review. In a prospective study of uncomplicated phacoemulsification cataract surgery, Tan et al (2000) reported first day review complications of corneal oedema (4.4%), raised intraocular pressure >=30mm Hg (1.3%), hyphaema (0.9%), corneal abrasion (0.4%), and anterior uveitis (0.4%). These findings led to the standard postoperative management being altered for 2.2% of patients. They concluded that routine first day post-operative review following uncomplicated cataract surgery could be safely withdrawn with a post-operative review required at 1-2 weeks supplemented by patient initiated post-operative review in the interim. The need for explicit post-operative instructions regarding warning symptoms and easy access to advice and review if needed was emphasised. A recent randomised trial in the United Kingdom examined the safety implications of omitting first day clinical review following phacoemulsification cataract surgery by comparing “same day discharge” with a planned post-operative review at two weeks to “next day review” (Tinley et al, 2003). It was reported that the “same day discharge” group was associated with a low frequency of ocular complications and differences in the proportions achieving good visual outcomes, were not significant. In addition it was reported that within the first month of surgery there was 1.0 outpatient visit saved for every patient managed as a “same day discharge”.

6.1.2 NSW The Statewide Services Development Branch of the NSW Health Department commissioned a review and report on Ophthalmology activity in NSW. This report was released in 2003 and identifies key issues and provides a service plan for the provision of ophthalmological services in NSW. The review highlighted:

• A substantial shift of ophthalmology inpatient services to the private sector. • Loss of ophthalmology wards from most general hospitals and therefore a much reduced presence

of ophthalmologists in these hospitals. • Promotion of efficient same day surgical models for cataract surgery. • Eye outpatient activity has greatly reduced since the introductions of medicare and now retained

at only those hospitals with accredited registrar training positions. • Provision of public outpatient services in some centres has been negotiated with private practices. • A number of models of care involving private funding models. • Fee for service arrangements in rural areas where registrar support is not available.

Key issues identified were:

• Inequitable access to ophthalmology services across NSW resulting from variances in: o The availability of the specialised workforce. o The ability of the community to pay for private services. o Resource availability within the public sector. o The relative weighting given to ophthalmology within those resources.

• 27% of public ophthalmology separations involve residents having treatment outside their area. • Long waiting times for surgery with 22% of patients waiting greater than 12 months. • Substantial area variation in utilisation of services. Most rural areas have high utilisation rates. • Projections of demand forecast a 52% increases in ophthalmology separations from 2000 to 2011.

The main driver is cataract surgery with projected increase of 66% by 2011. Key recommendations include:

• Statewide: Establishment of a ‘Statewide Ophthalmology Service’ (SOS), with responsibilities related to models of care, ensuring best practice, promoting cooperation between public and private providers, co-ordinating and promoting statewide initiatives related to visual impairment, its prevention and other community and public health eye care services, workforce, training and fostering research across networks. An interim SOS has been established along with working groups formed for the following areas:

o Public hospital cataract services o Provision of hospital services o Nursing issues o Orthoptic issues o Rural issues


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• Local Networks should ensure:

o Local delivery for non-complex ophthalmology with cross-area networking for complex procedures.

o Links with general practice. o All emergency departments have facilities for basic eye examinations and treatment.

Designated trauma centres have specialist ophthalmologist on-call rosters. o No tight controls on sites performing complex ophthalmology. o Closer networking arrangement of outer metropolitan areas with other areas. o Sydney Eye Hospital (currently co-located with Sydney Hospital) should remain the State

referral centre for the most complex tertiary conditions, continue to have substantial volumes of local patient activity, clarify its role as a major supplier of routine services to adjacent areas, become the major provider of outreach services and support for ophthalmologists in rural areas.

o Recognise logical relationships of border areas to services in other states to ensure appropriate access to their networks for complex services as required.

6.2 International

6.2.1 United Kingdom In 2000 the United Kingdom National Health Service (NHS) provided approximately $130m (Aus) funding for the purpose of reducing cataract waiting lists to less than three months with the average waiting time falling to six weeks (The NHS Plan: A Plan For Investment A Plan For Reform, 2000a). It is envisaged that these goals would be achieved by means of:

• An expansion of service capacity. • An increase in staff numbers and the recruitment of specialists, consultant surgeons, outpatient

nurses and technical support staff from overseas. • The establishment of Diagnostic and Treatment Centres (DTCs) to increase the number of elective

operations which can be treated in a single day or with a short stay. These Centres aim to separate routine hospital surgery from hospital emergency.

The Department of Health (2003) has developed a draft strategic plan for national eye care services for the delivery of modernised services and improved pathways. This plan acknowledges that the NHS needs to develop primary care ophthalmic services in order to meet increased need, particularly from demographic change. The main areas of change in the pathways concern the interface between primary and secondary care, with recommendations for a greater community-based role for optometrists. This would comprise appropriate training, audit and clinical governance. The proposed care pathways are considerably streamlined and designed to achieve:

• Support for the development of integrated eye care services across primary and secondary care and social services.

• Better use of the skills available in primary care. • An increased role for professional groups, such as optometrists and Dispensing Opticians, working

in primary care. Proposed pathways for a range of eye conditions are outlined in Appendix 10. The NHS ‘Action On Cataract’ program is aimed at improving access to treatment for people who need cataract surgery. A Good Practice Guide (2000b) was developed drawing on experience and on best practice identified in cataract surgery. Recommendations were developed relating to the following themes:

• Streamline the pathway of diagnosis and treatment. • High volume high quality surgery. • High quality patient information. • Audit outcomes.

Best practice was described as:

• Population access rates of more than 3000 cases per 100,000 people aged 65 and over. • One-stop diagnosis and pre-operative assessment clinics. • Waiting times for outpatient appointments of 4 weeks or less. • Booked admission dates, and waiting times for surgery of 2-3 months. • Day case rates of 85%-95%. • Day of surgery: patients spend not more than 90 minutes at the hospital. Post-operative review: one visit only for uncomplicated patients.


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6.3 Role delineation Role delineation is a process that determines what support services, staff skills and minimum safety standards are required to ensure that clinical services are provided safely and appropriately (QLD Health, 1994). Several jurisdictions in Australia, including Victoria, NSW and Queensland have developed, or are in the process of developing service framework guidelines to enable hospital boards and executive staff determine their ability to provide safe, appropriate clinical services. Q16. What service configuration and models of care for ophthalmology services in Victoria would best meet the needs of stakeholders (consumers, providers, teaching and research), including:

• Primary care (screening and prevention) • Community care • Hospital based services (emergency, outpatient and inpatient) • Public and private collaboration

Q17. What are the barriers to achieving optimal service configuration? Q18. What support services, staff skills, minimum safety standards and other requirements are needed to ensure that ophthalmology services are provided safely and appropriately across a variety of settings?


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7.0 Workforce and training

7.1 Workforce Since the mid-1990s, various studies have been undertaken into the nature and supply of eye health care professions in Australia. These studies examined issues relating to the adequacy of the existing workforce, projected workforce requirements as well as supply affecting service capacity in relation to the demand for services. This section provides an overview of these studies and possible implications for the provision of statewide ophthalmology services in Victoria. Table 35 provides a summary of the workforce profiles for each eye professional group. While the data are not provided for the same year for each group this table shows that there are just over 1,000 eye care professionals working in Victoria (excluding general practitioners).

Table 35: Workforce profiles of eye care professionals

Ophthalmologists Orthoptists Optometrists Ophthalmic nurses

1996 AMWAC 2003 RANZCO 2001 1998-99 2003

No. practising

Nationally 675 - 434 2,786 -

Victoria 173 168 165 684 54

Gender/Age

Male 148 (87%) 142 (85%) 5 (3%) 400 (58%) 0%

Female 19 (13%) 26 (15%) 160 (97%) 284 (42%) 100%

Average age (years) 48%<50 yrs 92%<70yrs 60%<35 yrs 46% < 35 yrs Ave yrs 45

Sector

Public 70% have appointments - 27 (16%) - 29 (54%)

Private - - 140 (84%) - 25 (46%)

Rural 11.6% 18 (11%)* 12 (7%)* 128 (18%) 6 (11%)

Metropolitan 88.5% 150 (89%) 153 (93%) 567 (82%) 48 (89%)

Number: population 3.6: 100,000 3.4: 100,000 3.4: 100,000 14.9: 100,000 1.1: 100,000

* Figures do not include the number of metropolitan ophthalmologists and orthoptists who provide services to rural areas.

7.1.1 Ophthalmologist Workforce In 1996 the Australian Medical Workforce Advisory Committee (AMWAC) undertook a comprehensive study of the ophthalmology workforce. The main objective of this study was to “…promote an optimal supply and appropriate distribution of ophthalmologists, including projections for future requirements to the year 2006.” The findings of this study are as follows:

• The practising workforce was estimated to be 675 in 1996, with Victoria having 173. ophthalmologists or 25.6% of all ophthalmologists nationwide.

• The ophthalmology workforce had grown by 25.6% nationally and by 29.1% in Victoria in the ten years to 1994-1995.

• The number of ophthalmologist per head of population in Victoria had increased from 1:30,747 to 1:26,016 in the ten years to 1994-1995.

• In Victoria 85% of ophthalmologists had their primary practice in a capital city, 3.5% in major urban areas and the remaining 11.6% in rural and remote areas.

• A 1994 study by the then RACO (now RANZCO) found that 70% of ophthalmologist had one or more public hospitals appointments, 8% were seeking public hospital appointments, 27% of those with appointments were willing to do more work, and nine vacant positions were identified in public hospitals.

• No evidence was found to suggest that laser treatments and other technology will be a major factor in determining future requirements in the ophthalmology workforce.

Although undertaken eight years ago, the AMWAC study concluded that the ophthalmology workforce is “… probably adequate in total, but that there appears to be some misdistribution of the workforce between the States.” Further, the report concluded that “…the current projected level of graduate output will not be sufficient to meet expected future requirements, which is estimated to grow by 1.6% per annum.”


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Among the key recommendations of the AMWAC study were:

• An increase in the number of funded ophthalmology training positions and trainees. For Victoria training posts were recommended to increased from 22 in 1995 to 23 by 2002 and 25 by 2006.

• That State/Territory health departments undertake negotiations with the then RACO for the establishment of additional training positions.

• Options to meet localised shortfalls include use of appropriately qualified and skilled overseas trained ophthalmologists; and increased skilling and use of general practitioners, particularly in rural areas.

More recent ophthalmology workforce details were provided by the RANZCO for 2003. These are as follows:

• Victoria has 168 practising ophthalmologists (150 metropolitan and 18 rural). Details were not available on the number of metropolitan ophthalmologists who provide regular services to non-metropolitan areas.

• Of the 168 ophthalmologists 156 (93%) were under the age of 70 years. • 142 were male and 26 female. • The number of ophthalmology trainees in Australia is 92, 33 of whom are based in Victoria. Four

of the trainees are overseas trained specialists. The commencement of a five year post graduate training course for specialist ophthalmologists in 2004 will reduce the number of graduates in Victoria from 8 to 6 per year (a reduction of 25% per annum).

• RANZCO is commencing a workforce study and needs analysis in February 2004, due for completion in June 2004.

7.1.2 Optometrist Workforce In 1999, the Australian Institute of Health and Welfare (AIHW) undertook a study of trends in the optometrist labour force for the period 1991 to 1999. Among some of the findings of this study were the following:

• In 1998-99 there were 2,786 optometrists employed in Australia, with 684 in Victoria (24.6%). • Over the period from 1986 to 1996, the number of persons working as optometrists per 100,000

population increased from 9.2 to 12.3. • The number of optometrists per 100,000 population increased from 13.4 to 14.8. • The optometry workforce is relatively young. Almost half (46%) of the workforce was aged less

than 35 years • Considerable variation in the distribution of optometrists among the States and Territories.

Nationally, there were 14.9 optometrists per 100,000 population in 1998-1999. New South Wales, Tasmania and Queensland had higher ratios while the Northern Territory, South Australia and the ACT had lower ratios. In Victorian the figure was 14.9 per 100,000.

• Optometrists were also unevenly distributed by geographic region. In 1998-1999 in Victoria there were more per 100,000 population in large rural centres (18.7), capital cities (16.8), and small rural centres (16.1), compared with other metropolitan areas (13.2), remote centres (11.6), other rural areas (6.2) and other remote areas (0.9).

Based on an extrapolation of current trends, the AIHW study found that there appears to be no evidence of a projected shortage of optometrists to 2009, nor of significant excess supply.

7.1.3 Orthoptist Workforce A draft report of the orthoptist workforce by the National Rural and Remote Allied Health Advisory Service (2003), found:

• 434 respondents to the 2001 census recorded their occupation as orthoptist, with 165 (38%) residing in Victoria.

• Nearly 90% are located on the eastern seaboard. • 12% of orthoptists were in rural and remote regions of Australia. • In Victoria, 93% were employed in capital cities, 8% were employed in inner regional areas • The split between private and public was 84% and 16% respectively. • Sixty per cent of orthoptists were aged less than 35 years. • The orthoptic workforce has grown by 19% over the past 5 years. • The numbers of orthoptists per population is on average 1:100,000, rising to 4:100,000 in capital

cities and none for residents in remote regions. In Victoria the average is also 1:100,000, rising to 4:100,000 in capital cities and 1:100,000 in inner regional areas.

• 86% were female The report concluded that employment prospects for orthoptists to 2007-2008 were rated as strong.


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7.1.4 Ophthalmic Nursing Workforce Data relating to ophthalmic nurses were acquired from the Department of Human Services, Nurse Policy Branch. In 2003, there were a total of 54 ophthalmic nurses employed in Victoria, at an average age of 45 years compared with 43.8 years for all nurses. Over half of ophthalmic nurses were employed in the public sector (53.7%) compared with 65.8% for all nurses. Three-quarters were employed on a permanent basis (74.1%). Almost half of ophthalmic nurses are employed as registered Grade 1 or Grade 2 nurses as opposed to a third for all nurses. There were 11.1% classified as Clinical Nurse Specialists compared with 8.7% for all nurses. Almost all (88.9%) ophthalmic nurses are employed in the metropolitan Melbourne compared with 63.0% for all nurses.

7.1.5 Anaesthetist Workforce An AMWAC review of the anaesthetic workforce was conducted in 1996. In acknowledgement of the changing nature of the medical workforce, this review was updated in 2001. The findings of the 2001 review are as follows:

• In 2001 the Australian and New Zealand College of Anaesthetists (ANZCA) reported there were 2,103 anaesthetists in Australia with 538 in Victoria.

• The number of anaesthetists per one hundred thousand of population was estimated as 11.3. • The number of public hospital vacancies was estimated at 21 for Victoria. • Nationally, 85.2% of anaesthetists were located in metropolitan areas (77.9% in a capital city and

7.3% in a major urban centre) and 14.8% were located in rural areas (9.9% in large rural centres and 4.9% in other rural areas).

• To meet projected anaesthesia service requirements for the period 2001 to 2011 of 2.2% per year, the average number of anaesthesia graduates should increase to 128 per year requiring the number of training positions to be increased to a minimum to 512 by 2003. It was recommended that by 2003 Victoria have a minimum number of training positions of 123, however, it was noted that in 2001 they already exceeded this figure with 130 training positions.

• While some technological advances are increasing demand for anaesthetists other advances reduce demand. For example the use of ophthalmological lasers has increased 295% since 1985-86 and is expected to increase. Overall it was concluded that there was no evidence that technology would dramatically increase or decrease the current trend in demand for anaesthesia.

• It was recommended a further update of the anaesthesia workforce be undertaken in 2006-07.


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7.2 Training

7.2.1 Education providers 7.2.1.1 Universities and educational facilities Providers of education for eye health care professions include:

• Department of Ophthalmology, University of Melbourne • Department of Optometry & Vision Sciences, University of Melbourne • School of Orthoptics, Latrobe University • Deakin University (Ophthalmic nursing) • Royal Melbourne Institute of Technology (medical photography)

The RVEEH coordinates the medical teaching of ophthalmology trainees in Victoria in conjunction with the University of Melbourne and the Royal Australian and New Zealand College of Ophthalmologists (RANZCO). Fellows of the RANZCO provide registrar training across twenty-four registrar training positions, 14 at the RVEEH and 11 in other general public hospitals. Rural training posts are located in Geelong, Ballarat and Albury-Wodonga. The RVEEH provides accredited training in ophthalmic nursing and orthoptics. Orthoptic clinical training occurs in the public and private sectors with the RVEEH being the largest provider of clinical placements. The RVEEH provides training in ophthalmology for medical students and post graduate training in ocular therapeutics for optometrists. 7.2.1.2 Rural Training Programs A number of training programs have been developed to encourage healthcare professionals to practice in rural areas (Madden, 2002). A rural ophthalmic registrar, for example, has been established in Albury-Wodonga. An evaluation of this program found that six of 30 registrars who had undertaken the program established a practice in a rural area, and a further six registrars who were still training at the time intended to work in the country. Madden (2002) reports that the then RACO has developed a curriculum for training a variety of rural health workers in basic ophthalmological assessment and care, as a means of redressing the lack of ophthalmological services in some rural and remote areas.

7.2.2 Trainee intake 7.2.2.1 Ophthalmology The RANZCO has announced that its postgraduate program for the training of specialist ophthalmologists, currently four years, will become a five-year program with the intake of trainees for commencement in the year 2004. The rationale is to incorporate the ophthalmic basic sciences within the training program, rather than require them as a pre-requisite for entry. As a result of this initiative the number of graduates in Victoria will reduce from 8 to 6 (25%) per year as the number of training positions has not changed. Trainee intake figures for 2004 are 20, with a total of six to commence training in Victoria. Q19. Does Victoria have an adequate eye care workforce across metropolitan and rural settings? Q20. Is current training adequate to meet future demand for services in Victoria? Q21. What service configurations are required to support training requirements in order to meet future demand for health care professionals in the delivery of ophthalmology services in metropolitan and rural settings? Q22. Can other health professionals be integrated into the delivery of ophthalmology services (ie. Optometrists are having a greater role in chronic disease management)? What enablers are required to implement these changes? Q23. What is the role of the private health care sector in providing training opportunities?


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8.0 Monitoring performance and outcomes Few statewide performance and outcome indicators for ophthalmology services are used in Victoria. Data collected at a state level mostly relates to access and efficiency, which includes waiting times for services and services costs. These are discussed in Section 4. The Australian Council on Healthcare Standards (ACHS) collects a range of clinical indicators for ophthalmology services at a national level for benchmarking purposes as part of the EQuIP accreditation program. These have been developed by the ACHS in collaboration with the RANCZO as measures of the clinical management and outcome of care. Indicators have been developed for cataract surgery, glaucoma surgery, retinal detachment surgery and excimer laser. Indicator details are provided in Appendix 11. Many Victorian hospitals involved in EQuIP accreditation report clinical indicator data to the ACHS. However, ACHS indicator data is not routinely reported to state Governments.

8.1 Appropriateness Appropriateness of health care is about using evidence to do the right thing to the right patient, at the right time, avoiding under and over utilisation (VQC, 2003). There is debate about the appropriateness of some ophthalmology procedures, prioritising non-urgent eye surgery and the usefulness of cataract surgery in some patients.

8.1.1 Prioritisation of services There have been attempts internationally to develop prioritisation systems for managing elective surgical and medical waiting lists, including waiting lists for cataract surgery. The Western Canada Waiting List Project (WCWL) was established to improve the fairness of the healthcare system to ensure that access to appropriate and effective medical services is prioritised on the basis of need and potential to benefit from surgery. The project focused on the development of valid, reliable, practical, and clinically transparent tools to assist in the management of waiting lists for selected diagnostic, procedural, and consultative procedures (WCWL, 2001). Among the main findings of the WCWL were the following:

• Priority criteria tools had significant face validity and potential to be useful in clinical settings. • General support from regional health authorities as a transparent and consistent method for

assigning priority to patients on waiting lists. • The public believed that the prioritization tools represent potential improvement of the health care

system. • Interest in expanding the existing scoring systems (eg. from cataract surgery to a broader range

of ophthalmologic procedures) and to develop a prioritisation system for referrals. An outline of the cataract surgery priority criteria used in the WCWL Project is provided in Appendix 12. The New Zealand National Advisory Committee on Health and Disability developed the Clinical Priority Assessment Criteria (CPAC) criteria12 that incorporate the factors used by experienced clinicians to arrive at judgements of severity of illness and expected benefit from treatment. It includes a range of clinical, patient-experienced and social measures. An assessment of this method found that the priority criteria score faithfully reflects clinical judgement concerning the degree of benefit expected from cataract extraction. It was found that the CPAC scores prioritised moderately well according to a patient’s experienced measure of need. However, most CPAC dimensions were not at all, or only weakly, correlated with a measure of ability to benefit: the extent of change in patient-experienced condition-specific health status for those receiving surgery (Derret et al, 2003). Visual Function Assessment and the VF-14 Greater attention is now paid to the functional impact of lens opacities and the requirements of the patient as an individual in considering cataract surgery. This had led to additional weight being given to the patient’s perceived difficulties in their daily life and their visual needs (Taylor, 2000). The VF-14 is a widely adopted instrument used in the assessment of visual function. The VF-14 is a brief questionnaire designed to measure functional impairment for people with a cataract consisting of 18 questions covering 14 aspects of visual function. The VF-14 has a high internal consistency and is a reliable valid instrument providing information not conveyed by visual acuity or general health status measures. Further details and questions contained in the VF-14 assessment are provided in Appendix 13. The VF-14 is more often used in surgical audit or research activities than in routine clinical management. 12 http://bmj.bmjjournals.com/cgi/content/full/314/7074/131


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8.1.2 Utilisation Utilisation can be used as a measure of appropriateness of care. Utilisation of ophthalmology services is discussed in Section 4.

8.1.3 Complexity The relationship between the volume of procedures that a hospital or practitioner performs and the better outcomes for the patient have been documented for certain types of surgery and procedures (NHS Centre for Reviews and Dissemination, 1995; Institute of Medicine, 2000). As highlighted in Section 3 ophthalmology services are distributed over a range of service settings with a concentration of some patient types at the RVEEH. There is however no consistent definition of complex ophthalmology and where complex ophthalmic conditions should be treated. In the review of ophthalmology services in NSW, casemix definitions were used for categorising ophthalmology procedures considered ‘high cost complex’ (NSW Health, 2002). Such procedures included:

• Orbital procedures • Retinal procedures • Glaucoma procedures • Multiple eye procedures

It was found that 42% of high cost complex procedures performed in NSW were delivered in the private sector across a variety of facilities indicating that that not all high cost complex procedures require teaching hospital infrastructure. Review of these procedures with the RANZCO advisory committee concluded that those considered requiring tertiary care included:

• Orbital procedures and infections • Complex oculo-plastics • Complex retinal • Complex glaucoma • Complex squint procedures

It was concluded that the most important consideration in providing some types of surgery (ie. vitreoretinal, ocular plastics and orbital oncology) was seen as having sufficient referred volume to support teams of sub-specialists to promote safe, high quality services and undertake peer review. While this was done at a broad level no detail is available to differentiate complex from other glaucoma procedures for instance. Q24. Would prioritisation systems for ophthalmology surgery improve eye care services in Victoria? Q25. Is there a volume-outcome relationship for components of ophthalmology practice? - Is there a minimum volume of some procedures that should be performed by a health service or practitioner to ensure optimal outcomes for patients?


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8.2 Effectiveness Effectiveness of health care relates to the extent to which a treatment, intervention or service achieves the desired outcomes (VQC, 2003). There is debate about the effectiveness of some ophthalmology evidenced by the number of Cochrane reviews that have been performed or are underway that relate to the effectiveness of treatment of some common eye diseases and commonly performed ophthalmology interventions. Examples of reviews underway include:

• Radiotherapy for exudative age-related macular degenerations • Bilateral versus unilateral surgery for age related cataract • Interventions for preventing posterior capsule opacification • Medical versus surgical interventions for open angle glaucoma • Laser trabeculoplasty for open angle glaucoma • Surgical interventions for pterygium • Topical steroids versus placebo for allergic conjunctivitis

8.3 Acceptability Acceptability is the degree to which a service meets or exceeds the expectations of informed consumers (VQC, 2003). The Patient Satisfaction Monitor commenced in Victorian acute care hospitals in October 2000. It provides regular, ongoing monitoring and reporting of patient satisfaction in key areas of service delivery in Victoria. Recruitment for the survey is from patients who have been in-patients of a Victorian acute care hospital. There are currently 95 hospitals participating in Victoria. Results are reported at a state and hospitals level but not at a specialty level.

8.4 Safety As part of the department’s Clinical Risk Management program, hospitals and health services are required to monitor and manage adverse events internally. Serious adverse events, however, are to be reported to the department through the Sentinel Event program and a root cause analysis is to be undertaken (CRM, 2003). Sentinel events that have the greatest relevance to ophthalmology are, procedures involving the wrong patient or body part and other catastrophic event. A number of ACHS indicators are related to safety, such as readmissions, readmissions due to infections, anterior vitrectomy rates, long lengths of stay, revision and retreatment of procedures (Appendix 11). Q26. What key performance and outcome measures for ophthalmology services should be collected and reported by hospitals? Who should they be reported to? Q27. What mechanisms are required to be implemented to enable the collection and utilisation of these measures?


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9.0 Research

9.1 Ophthalmic research organisations in Victoria Ophthalmic research in Victoria is principally conducted by the Centre for Eye Research Australia (CERA). CERA was established in 1996 as a centre for excellence for eye research. CERA is a joint undertaking of the University of Melbourne, Royal Victorian Eye and Ear Hospital, Royal Australian and New Zealand College of Ophthalmologists, Ansell Ophthalmology Foundation, Lions Club of Victoria, Christian Blind Mission International, Royal Victorian Institute for the Blind, and Vision Australia Foundation. CERA is a higher education institution that incorporates the University of Melbourne Department of Ophthalmology and is a World Health Organisation Collaborating Centre. CERA has extensive research experience into causes, prevention and cure of eye disease, and in particular has undertaken large epidemiological studies, including the Visual Impairment Project. CERA is a core member of the Vision Cooperative Research Centre (CRC). Vision CRC is a collaboration of the world’s leading groups in eyecare and vision research, education and delivery. Vision CRC is a multinode centre, with its hub at dedicated premises at the University of New South Wales, Kensington Campus. Vision CRC participants comprise Core, Supporting and Industry members. Core members include:

• The Centre for Eye Research Australia • International Centre for Eyecare Education (Australia) • Institute for Eye Research (Australia) • LV Prasad Eye Institute (India)

Vision CRC was established in July 2003, having received a CRC grant of $32 million over seven years. The Centre will conduct major programs in the areas of myopia, presbyopia, vision care delivery, business growth, professional and academic education.

9.2 Research links with public hospitals A number of research groups are located at the RVEEH. These include:

• Centre for Eye Research Australia (CERA) • Department of Ophthalmology, University of Melbourne • Lions Eye Bank • W.H.O. Collaborating Centre for Prevention of Blindness • McComas Family Laboratory (Ophthalmology)

Q28. What is the role of the public and private hospitals in providing research opportunities? (ie. infrastructure, access to patients)? Q29. What are the advantages and disadvantages of collocation of research institutions with specialty hospitals (RVEEH)?


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Appendix 1: Statewide provision of public hospital eye services 2002-03 The VAED and VEMD do not identify the practitioner who delivered the eye service. Cataract separations have been included as an indicator of attendance by an ophthalmologist for inpatient services. VACS encounters indicate services provided by ophthalmologists in public hospital outpatient clinics.

Metropolitan Health Services

Inpatient separations (VAED)

Health Service and Hospital Total Cataract

Emergency presentations (VEMD)

Outpatient encounters (VACS)

Austin Health -

Austin Hospital 101 9 417 4,063*

Heidelberg Repatriation Hospital 542 415 - -

Bayside Health -

The Alfred 375 216 502 3,437 Sandringham & District Memorial Hospital 41 - 70 -

Caulfield General Medical Centre 2 - - -

Eastern Health -

Box Hill Hospital 55 - 368 -

Maroondah Hospital 347 279 625 -

Angliss Hospital 32 - 949 - The Peter James Centre 1 - - -

Melbourne Health

Royal Melbourne Hospital 541 333 506 4,689

Mercy Health and Aged Care

Mercy Public Hospitals Inc [Werribee] 41 - 819 -

Mercy Hospital for Women - 267 - Northern Health

The Northern Hospital 234 125 742 440

Broadmeadows Health Service 402 370 - -

Bundoora Extended Care Centre 1 - - -

Peninsula Health

Frankston Hospital 253 136 594 - Rosebud Hospital 31 - 354 -

Peter MacCallum Cancer Centre 56 - - 77

Royal Victorian Eye & Ear Hospital 9,322 5,394 17,192 62,306

Southern Health

Cranbourne Integrated Care Centre 1,800 1,473 - -

Dandenong Hospital 75 - 678 - Monash Medical Centre [Clayton] 90 - 648 4,620*

Monash Medical Centre [Moorabbin] 126 15 - -

St Vincent’s Health

St Vincent's Hospital Ltd 79 - 110 -

Caritas Christi Hospice 1 - - -

Western Health Sunshine Hospital 462 336 893 -

Western Hospital [Footscray] 305 224 403 -

Williamstown Hospital 10 7 544 -

Women’s & Children’s Health

Royal Children’s Hospital [Parkville] 731 33 720 5,266

Royal Women's Hospital 1 - 11 92 Other

Calvary Health Care Bethlehem 1 - - -

Kooweerup Regional Health Service 1 - - -

O'Connell Family Centre Inc. 1 - - -

Grand Total 38,663 9,365 27,412 76,307 * For VACS data Austin Hospital includes Heidelberg Repatriation Hospital and Monash Medical Centre Clayton includes Moorabbin.


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Rural Hospitals

Inpatient separations (VAED)

Hospital Total Cataract

Emergency presentations (VEMD)

Outpatient encounters (VACS)

Alexandra District Hospital 2 - - -

Alpine Health [Mount Beauty] 2 - - -

Alpine Health [Myrtleford] 2 - - -

Bairnsdale Regional Health Service 273 244 - - Ballarat Health Services 479 323 1,314 858

Ballarat Health Services [Queen Elizabeth] 1 - - -

Barwon Health [Geelong] 985 714 827 2,831

Barwon Health [Grace McKellar] 2 - - -

Bass Coast Regional Health [Wonthaggi] 288 235 - -

Beechworth Health Service 1 - - - Benalla & District Memorial Hospital 222 214 - -

Bendigo Health Care Group 403 275 874 685

Bendigo Health Care Group [Anne Caudle] 1 - - -

Central Gippsland Health Service [Sale] 126 87 - -

Cobram District Hospital 4 - - -

Cohuna District Hospital 5 - - - Colac Area Health 20 11 - -

Coleraine District Health Services 1 - - -

Djerriwarrh Health Service [Bacchus Marsh] 2 - - -

Dunmunkle Health Services [Murtoa] 1 - - -

East Grampians Health Service [Ararat] 110 81 - -

East Wimmera Health Service [Birchip] 1 - - - East Wimmera Health Service [Donald] 3 - - -

East Wimmera Health Service [St Arnaud] 4 - - -

East Wimmera Health Service [Wycheproof] 1 - - -

Echuca Regional Health 146 67 390 -

Edenhope & District Hospital 2 - - -

Far East Gippsland Health & Support Service [Orbost] 1 - - - Gippsland Southern Health Service [Korumburra] 4 - - -

Gippsland Southern Health Service [Leongatha] 145 99 - -

Goulburn Valley Health [Shepparton] 31 - 699 -

Hepburn Health Service [Creswick] 1 - - -

Hepburn Health Service [Daylesford] 2 - - -

Inglewood & District Health Service 1 - - - Kerang District Health 38 28 - -

Kilmore & District Hospital 2 - - -

Kyabram & District Health Service 59 50 - -

Kyneton District Health Service 2 - - -

Latrobe Regional Hospital [Traralgon] 433 391 859 -

Mansfield District Hospital 6 - - - Maryborough District Health Service [Maryborough] 6 - - -

Mount Alexander Hospital [Castlemaine] 237 216 - -

Moyne Health Services [Port Fairy] 1 - - -

Nathalia District Hospital 1 - - -

New Mildura Base Hospital 422 239 885 -

Northeast Health Wangaratta 11 - 426 - Numurkah & District Health Service 4 - - -

Otway Health & Community Services [Apollo Bay] 1 - - -

Portland & District Hospital 174 159 - -

Robinvale District Health Services 5 - - -

Rochester & Elmore District Health Service 11 - - -

Rural Northwest Health [Hopetoun] 1 - - - Rural Northwest Health [Warracknabeal] 2 - - -

Seymour District Memorial Hospital 1 - - -


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South Gippsland Hospital [Foster] 2 - -

South West Healthcare [Camperdown] 4 - - -

South West Healthcare [Warrnambool] 198 141 739 -

Stawell Regional Health 81 70 - - Swan Hill District Hospital [Swan Hill] 224 183 - -

Terang & Mortlake Health Service [Terang] 2 - - -

Timboon & District Healthcare Service 1 - - -

Upper Murray Health & Community Services [Corryong] 2 - - -

West Gippsland Healthcare Group [Warragul] 29 19 - -

West Wimmera Health Service [Kaniva] 2 - - - West Wimmera Health Service [Nhill] 115 101 - -

Western District Health Service [Hamilton] 164 155 - -

Wimmera Base Hospital [Horsham] 225 174 576 -

Wodonga Regional Health Service 230 180 - -

Yarram & District Health Service 2 - - -

Yea & District Memorial Hospital 1 - - -

Grand Total 11,037 4,456 7,589 -


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Appendix 2: VEMD – Ophthalmology emergency presentations 1998-99 to 2002-03 Inner metropolitan hospitals

Presentations Hospital 98-99 99-00 00-01 01-02 02-03 % 02-03 Difference Growth Royal Victorian Eye & Ear Hospital 20,213 21,172 18,017 17,056 17,192 76% -3,021 -15% Sunshine Hospital 159 260 312 636 893 4% 734 462% Royal Children's Hospital 201 657 688 660 720 3% 519 258% Monash Medical Centre [Clayton] 353 783 698 657 648 3% 295 84% Williamstown Hospital 444 455 411 474 544 2% 100 23% Royal Melbourne Hospital 310 436 480 472 506 2% 196 63% The Alfred 386 476 439 479 502 2% 116 30% Austin Hospital 413 400 354 381 417 2% 4 1% Western Hospital [Footscray] 224 508 534 468 403 2% 179 80% Box Hill Hospital 418 400 360 359 368 2% -50 -12% Mercy Hospital for Women 327 255 283 305 267 1% -60 -18% St Vincent's Hospital Ltd 88 94 111 92 110 0% 22 25% Sandringham District Hospital 70 0% 70 Royal Women's Hospital 36 11 12 11 0% 11

Grand Total 23,536 25,932 22,698 22,051 22,651 100% -885 -4% Outer metropolitan hospitals

Presentations Hospital 98-99 99-00 00-01 01-02 02-03 % 02-03 Difference Growth Angliss Hospital 705 727 788 849 949 20% 244 35% Werribee Mercy Hospital 339 624 639 749 819 17% 480 142% The Northern Hospital 477 715 668 650 742 16% 265 56% Dandenong Hospital 593 520 531 627 678 14% 85 14% Maroondah Hospital 264 564 528 567 625 13% 361 137% Frankston Hospital 305 468 481 540 594 12% 289 95% Rosebud Hospital 119 318 354 7% 354

Grand Total 2,683 3,618 3,754 4,300 4,761 100% 2,078 77% Rural hospitals

Presentations Hospital 98-99 99-00 00-01 01-02 02-03 % 02-03 Difference Growth Ballarat Health Services 944 966 1,048 1,181 1,314 17% 370 39% New Mildura Base Hospital 364 735 751 814 885 12% 521 143% Bendigo Health Care Group 891 945 960 937 874 12% -17 -2% Latrobe Regional Hospital 811 941 962 867 859 11% 48 6% Barwon Health [Geelong] 878 911 854 833 827 11% -51 -6% South West Healthcare [Warrnambool] 541 867 936 1,027 739 10% 198 37% Goulburn Valley Health [Shepparton] 429 513 631 644 699 9% 270 63% Wimmera Base Hospital [Horsham] 379 482 616 607 576 8% 197 52% Northeast Health Wangaratta 518 607 514 436 426 6% -92 -18% Echuca Regional Health 425 423 429 438 390 5% -35 -8%

Total 6,180 7,390 7,701 7,784 7,589 100% 1,409 23% Total Victorian hospitals

Presentations 98-99 99-00 00-01 01-02 02-03 % 02-03 Difference Growth Inner metropolitan hospitals 23,536 25,932 22,698 22,051 22,651 65% -885 -4% Outer metropolitan hospitals 2,683 3,618 3,754 4,300 4,761 14% 2,078 77%

Total metropolitan hospitals 26,219 29,550 26,452 26,351 27,412 78% 1,193 5% Rural hospitals 6,180 7,390 7,701 7,784 7,589 22% 1,409 23%

Total Victorian hospitals 32,399 36,940 34,153 34,135 35,001 100% 2,602 8%


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Appendix 3: VEMD - Ophthalmology emergency diagnoses 1998-99 to 2002-03 Presentations Diagnosis 98-99 99-00 00-01 01-02 02-03 %02-03 Growth H578-Other specified disorders of eye and adnexa 11,724 11,087 9,161 8,609 8,926 26% -24% T159-Foreign body on external eye, part unspecified 5,865 7,670 7,731 7,695 8,462 24% 44% S059-Injury of eye and orbit, part unspecified 4,439 7,227 6,721 6,919 6,689 19% 51% H109-Conjunctivitis, unspecified 2,025 2,003 2,010 2,032 1,835 5% -9% H571-Ocular pain 1,516 1,300 1,405 1,519 1,477 4% -3% Z017-Laboratory examination 632 978 914 999 893 3% 41% H209-Iridocyclitis, unspecified 904 935 725 627 678 2% -25% H160-Corneal ulcer 238 242 442 571 669 2% 181% H101-Acute atopic conjunctivitis 600 625 667 658 655 2% 9% H169-Keratitis, unspecified 870 1,016 721 601 634 2% -27% H113-Conjunctival haemorrhage 563 589 581 583 628 2% 12% H000-Hordeolum & other deep inflammation of eyelid 367 449 423 515 548 2% 49% H100-Mucopurulent conjunctivitis 411 455 433 528 539 2% 31% H332-Serous retinal detachment 326 335 298 408 397 1% 22% H103-Acute conjunctivitis, unspecified 208 272 334 322 338 1% 63% H538-Other visual disturbances 184 250 246 275 284 1% 54% H409-Glaucoma, unspecified 346 372 287 248 240 1% -31% H110-Pterygium 210 186 155 165 208 1% -1% Z010-Examination of eyes and vision 108 145 223 277 187 1% 73% H269-Cataract, unspecified 139 178 154 144 182 1% 31% H045-Stenosis and insufficiency of lacrimal passages 107 113 146 138 173 0% 62% H050-Acute inflammation of orbit 16 64 84 101 0% H534-Visual field defects 20 34 33 38 59 0% 195% H532-Diplopia 35 32 46 55 57 0% 63% H518-Other spec disorders of binocular movement 42 52 54 38 42 0% 0% B005-Herpesviral ocular disease 62 49 62 35 42 0% -32% H210-Hyphaema 440 292 99 28 27 0% -94% H55-Nystagmus and other irregular eye movements 3 5 4 15 14 0% 367% H471-Papilloedema, unspecified 2 7 3 4 10 0% 400% H509-Strabismus, unspecified 12 26 11 5 7 0% -42% Grand Total 32,399 36,940 34,153 34,135 35,001 100% 8%


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Appendix 4: VEMD - RVEEH ophthalmology emergency presentations 2002-03 Proportion of emergency presentations treated at RVEEH by diagnosis (VEMD)

Presentations Vic RVEEH Diagnosis 2002-03 2002-03

% treated at RVEEH

H578-Other specified disorders of eye and adnexa 8,926 6,228 70% T159-Foreign body on external eye, part unspecified 8,462 2,819 33% S059-Injury of eye and orbit, part unspecified 6,689 3,009 45% H109-Conjunctivitis, unspecified 1,835 821 45% H571-Ocular pain 1,477 470 32% Z017-Laboratory examination 893 - 0% H209-Iridocyclitis, unspecified 678 634 94% H160-Corneal ulcer 669 322 48% H101-Acute atopic conjunctivitis 655 384 59% H169-Keratitis, unspecified 634 594 94% H113-Conjunctival haemorrhage 628 450 72% H000-Hordeolum & other deep inflammation of eyelid 548 16 3% H100-Mucopurulent conjunctivitis 539 317 59% H332-Serous retinal detachment 397 370 93% H103-Acute conjunctivitis, unspecified 338 - 0% H538-Other visual disturbances 284 63 22% H409-Glaucoma, unspecified 240 200 83% H110-Pterygium 208 195 94% Z010-Examination of eyes and vision 187 - 0% H269-Cataract, unspecified 182 164 90% H045-Stenosis and insufficiency of lacrimal passages 173 132 76% H050-Acute inflammation of orbit 101 - 0% H534-Visual field defects 59 - 0% H532-Diplopia 57 - 0% H518-Other spec disorders of binocular movement 42 - 0% B005-Herpesviral ocular disease 42 - 0% H210-Hyphaema 27 4 15% H55-Nystagmus and other irregular eye movements 14 - 0% H471-Papilloedema, unspecified 10 - 0% H509-Strabismus, unspecified 7 - 0% Grand Total 35,001 17,192 49%


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Appendix 5: VAED - Ophthalmology inpatient separations 1998-99 to 2002-03

Metropolitan hospitals

Separations

Metropolitan public hospitals 98-99 99-00 00-01 01-02 02-03 % 02-03 Growth The Royal Victorian Eye & Ear Hospital 8,814 8,850 8,798 9,194 9,322 19% 6% Cranbourne Integrated Care Centre - - 51 713 1,800 4% - Royal Children’s Hospital [Parkville] 847 892 829 797 731 1% -14% Heidelberg Repatriation Hospital 480 462 487 492 542 1% 13% Royal Melbourne Hospital 360 345 409 449 541 1% 50% Sunshine Hospital 13 24 24 57 462 1% 3454% Broadmeadows Health Service 32 93 242 295 402 1% 1156% The Alfred 300 312 298 345 375 1% 25% Maroondah Hospital 32 44 38 209 347 1% 984% Western Hospital [Footscray] 394 501 502 504 305 1% -23% Frankston Hospital 709 383 369 357 253 1% -64% The Northern Hospital 344 286 224 237 234 0% -32% Monash Medical Centre [Moorabbin] 598 580 549 221 126 0% -79% Austin Hospital 224 188 137 119 101 0% -55% Monash Medical Centre [Clayton] 682 683 630 465 90 0% -87% St Vincent's Hospital Ltd 49 91 86 78 79 0% 61% Dandenong Hospital 92 91 89 92 75 0% -18% Peter MacCallum Cancer Institute 40 44 49 42 56 0% 40% Box Hill Hospital 59 68 49 47 55 0% -7% Mercy Public Hospitals Inc [Werribee] 25 28 24 27 41 0% 64% Sandringham & District Memorial Hospital 21 29 18 22 41 0% 95% Angliss Hospital 24 25 23 34 32 0% 33% Rosebud Hospital 1 1 6 11 31 0% 3000% Williamstown Hospital 4 1 7 31 10 0% 150% Other (less than 10 separations) 26 4 18 10 9 0% -65%

Total metropolitan public hospitals 14,170 14,025 13,956 14,848 16,060 32% 13% Total metropolitan private hospitals 17,181 19,291 21,141 21,741 22,603 45% 32% Metropolitan Total 31,351 33,316 35,097 36,589 38,663 78% 23%


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Rural hospitals

Separations

Rural public hospitals 98-99 99-00 00-01 01-02 02-03 % 02-03 Growth Barwon Health [Geelong] 741 785 788 917 985 2% 33% Ballarat Health Services 695 670 588 589 479 1% -31% Latrobe Regional Hospital [Traralgon] 432 648 749 539 433 1% 0% New Mildura Base Hospital 479 410 356 374 422 1% -12% Bendigo Health Care Group 342 307 316 341 403 1% 18% Bass Coast Regional Health [Wonthaggi] 262 322 240 254 288 1% 10% Bairnsdale Regional Health Service 183 173 217 251 273 1% 49% Mount Alexander Hospital [Castlemaine] 208 211 240 216 237 0% 14% Wodonga Regional Health Service 228 202 249 231 230 0% 1% Wimmera Base Hospital [Horsham] 175 195 218 197 225 0% 29% Swan Hill District Hospital [Swan Hill] 40 136 184 182 224 0% 460% Benalla & District Memorial Hospital 162 213 254 317 222 0% 37% South West Healthcare [Warrnambool] 321 263 197 231 198 0% -38% Portland & District Hospital 15 28 109 165 174 0% 1060% Western District Health Service [Hamilton] 129 173 136 128 164 0% 27% Echuca Regional Health 73 111 109 115 146 0% 100% Gippsland Southern Health Service [Leongatha] 41 135 177 144 145 0% 254% Central Gippsland Health Service [Sale] 121 136 132 135 126 0% 4% West Wimmera Health Service [Nhill] 4 4 56 109 115 0% 2775% East Grampians Health Service [Ararat] 10 30 80 116 110 0% 1000% Stawell Regional Health 82 89 69 119 81 0% -1% Kyabram & District Health Service 41 60 53 55 59 0% 44% Kerang District Health 34 18 28 40 38 0% 12% Goulburn Valley Health [Shepparton] 19 0 17 29 31 0% 63% West Gippsland Healthcare Group [Warragul] 30 14 20 25 29 0% -3% Colac Area Health 5 9 10 7 20 0% 300% Northeast Health Wangaratta 19 12 34 6 11 0% -42% Rochester & Elmore District Health Service - 1 4 8 11 0% Other (less than 10 separations) 185 117 130 123 92 0% -50%

Total rural public hospitals 5,076 5,488 5,760 5,963 5,971 12% 18% Total rural private hospitals 3,073 3,649 4,468 4,400 5,066 10% 65% Rural Total 8,149 9,137 10,228 10,363 11,037 22% 35%

Victorian Total 39,500 42,453 45,325 46,952 49,700 100% 26%


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Appendix 6: VAED - Ophthalmology DRGs 1998-99 to 2002-03 All hospitals (public and private) Separations DRG 99-00 00-01 01-02 02-03 % 02-03 Growth C08Z-Major Lens Procedures 23,938 27,370 29,050 31,380 63% 31% C09Z-Other Lens Procedures 4,386 3,943 3,453 3,426 7% -22% C14Z-Other Eye Procedures 2,514 2,753 2,866 3,083 6% 23% C11Z-Eyelid Procedures 2,525 2,540 2,759 2,856 6% 13% C03Z-Retinal Procedures 1,708 1,692 1,858 1,919 4% 12% C12Z-Oth Corneal, Scleral & Conjunctival Procs 1,133 1,247 1,350 1,462 3% 29% C63B-Other Disorders of the Eye W/O CC 731 811 834 878 2% 20% C10Z-Strabismus Procedures 929 861 901 828 2% -11% C07Z-Other Glaucoma Procedures 954 945 748 778 2% -18% C62Z-Hyphema & Medically Mand Trauma to Eye636 714 804 722 1% 14% C05Z-Dacryocrystorhinostomy 542 504 564 626 1% 15% C13Z-Lacrimal Procedures 577 559 567 559 1% -3% C04Z-Maj Corneal, Scleral & Conjunctival Procs 622 431 255 264 1% -58% C02Z-Enucleations and Orbital Procedures 204 194 207 231 0% 13% C01Z-Procedures for Penetrating Eye Injury 181 176 155 166 0% -8% C60A-Acute and Major Eye Infections Age>54 123 145 137 159 0% 29% C63A-Other Disorders of the Eye W CC 243 166 163 133 0% -45% C06Z-Complex Glaucoma Procedures 206 158 155 132 0% -36% C60B-Acute and Major Eye Infections Age<55 102 113 126 98 0% -4% Other 199 3 - - 0% -100% Grand Total 42,453 45,325 46,952 49,700 100% 17% Public hospitals Separations DRG 99-00 00-01 01-02 02-03 % 02-03 Growth C08Z-Major Lens Procedures 9,490 10,375 11,481 12,653 57% 33% C14Z-Other Eye Procedures 1,210 1,229 1,166 1,326 6% 10% C03Z-Retinal Procedures 1,187 1,176 1,208 1,293 6% 9% C09Z-Other Lens Procedures 1,909 1,557 1,396 1,168 5% -39% C11Z-Eyelid Procedures 1,064 950 1,031 1,088 5% 2% C62Z-Hyphema & Medically Mand Trauma to Eye596 671 782 693 3% 16% C63B-Other Disorders of the Eye W/O CC 592 615 681 687 3% 16% C12Z-Oth Corneal, Scleral & Conjunctival Procs 519 491 539 607 3% 17% C10Z-Strabismus Procedures 679 600 573 533 2% -22% C07Z-Other Glaucoma Procedures 472 491 359 414 2% -12% C05Z-Dacryocrystorhinostomy 316 290 304 369 2% 17% C13Z-Lacrimal Procedures 379 349 349 323 1% -15% C02Z-Enucleations and Orbital Procedures 135 132 157 160 1% 19% C01Z-Procedures for Penetrating Eye Injury 158 160 142 156 1% -1% C04Z-Maj Corneal, Scleral & Conjunctival Procs 121 159 137 125 1% 3% C60A-Acute and Major Eye Infections Age>54 89 105 115 122 1% 37% C06Z-Complex Glaucoma Procedures 164 122 133 117 1% -29% C63A-Other Disorders of the Eye W CC 194 142 142 109 0% -44% C60B-Acute and Major Eye Infections Age<55 79 99 116 88 0% 11% Other 160 3 - - 0% -100% Total 19,513 19,716 20,811 22,031 100% 13%


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Private hospitals Separations DRG 99-00 00-01 01-02 02-03 % 02-03 Growth C08Z-Major Lens Procedures 14,448 16,995 17,569 18,727 68% 30% C09Z-Other Lens Procedures 2,477 2,386 2,057 2,258 8% -9% C11Z-Eyelid Procedures 1,461 1,590 1,728 1,768 6% 21% C14Z-Other Eye Procedures 1,304 1,524 1,700 1,757 6% 35% C12Z-Oth Corneal, Scleral & Conjunctival Procs 614 756 811 855 3% 39% C03Z-Retinal Procedures 521 516 650 626 2% 20% C07Z-Other Glaucoma Procedures 482 454 389 364 1% -24% C10Z-Strabismus Procedures 250 261 328 295 1% 18% C05Z-Dacryocrystorhinostomy 226 214 260 257 1% 14% C13Z-Lacrimal Procedures 198 210 218 236 1% 19% C63B-Other Disorders of the Eye W/O CC 139 196 153 191 1% 37% C04Z-Maj Corneal, Scleral & Conjunctival Procs 501 272 118 139 1% -72% C02Z-Enucleations and Orbital Procedures 69 62 50 71 0% 3% C60A-Acute and Major Eye Infections Age>54 34 40 22 37 0% 9% C62Z-Hyphema & Medically Mand Trauma to Eye 40 43 22 29 0% -28% C63A-Other Disorders of the Eye W CC 49 24 21 24 0% -51% C06Z-Complex Glaucoma Procedures 42 36 22 15 0% -64% C01Z-Procedures for Penetrating Eye Injury 23 16 13 10 0% -57% C60B-Acute and Major Eye Infections Age<55 23 14 10 10 0% -57% Other 39 - - - 0% -100% Total 22,940 25,609 26,141 27,669 100% 21%


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Appendix 7: Ophthalmology DRGs and ESRGs

Enhanced Service Related Groups (ESRG) Diagnostic Related Groups (DRG)

079-Cataract Procedures C08, Major Lens Procs

C09, Other Lens Procs

080-Other Eye Procedures C01, Procs for Penetrating Eye Injury

C02, Enucleations & Orbital Procs

C03, Retinal Procs

C04, Major Corneal, Scleral & Conjunctival Procs

C05, Dacryocystorhinostomy

C06, Complex Glaucoma Procs

C07, Other Glaucoma Procs

C10, Strabismus Procs

C11, Eyelid Procs

C12, Other Corneal, Scleral & Conjunctival Procs

C13, Lacrimal Procs

C14, Other Eye Procs

081-Non-procedural Ophthalmology C60, Acute & Major Eye Infections

C62, Hyphema & Medically Managed Trauma to the Eye

C63, Other Dis of the Eye


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Appendix 8: Local Government Area: Age standardised ophthalmology separations per 1,000 people - 2002-03 Notes on standardisation method: The indirect standardisation method was used in this report as it is generally used when the rate information of a population of interest is unknown or subject to fluctuation due to small population sizes. The standardised rate ratio (SRR) is calculated by dividing the age-standardised separation rate for the LGA (observed rate) by the age-standardised separation rate for the total Victorian population (expected rate). Thus a SRR of 1 indicates that the LGA had a separation rate similar to that of the total Victorian population. A SRR of 1.2 indicates that the LGA had a rate that was 20% greater than that of the total Victorian population. This analysis by LGA is affected by the absence of interstate private hospital data. Cataract procedures:

• C08Z-Major Lens Procedures • C09Z-Other Lens Procedures

Actual Crude rate/1000 people SRR Standard Error SRR

Melton 182 3.10 0.43 0.66 Nillumbik 193 3.16 0.44 0.67 Yarra Ranges 525 3.65 0.51 0.72 Moorabool 98 3.86 0.54 0.73 Casey 748 3.90 0.55 0.74 Golden Plains 62 4.04 0.57 0.75 Hume 586 4.18 0.58 0.76 Whittlesea 520 4.30 0.60 0.78 Wyndham 400 4.32 0.60 0.78 Mitchell 129 4.40 0.62 0.78 Macedon Ranges 177 4.61 0.65 0.80 Cardinia 231 4.74 0.66 0.81 Melbourne 254 4.71 0.66 0.81 Knox 743 4.97 0.70 0.83 Yarra 364 5.24 0.73 0.86 Murrindindi 73 5.30 0.74 0.86 Brimbank 939 5.47 0.77 0.88 Port Phillip 449 5.49 0.77 0.88 Greater Shepparton 327 5.54 0.78 0.88 Wodonga 185 5.57 0.78 0.88 Maroondah 586 5.81 0.81 0.90 Wangaratta 166 6.22 0.87 0.93 Hepburn 94 6.45 0.90 0.95 Greater Dandenong 845 6.59 0.92 0.96 Ballarat 567 6.68 0.94 0.97 Colac-Otway 143 6.76 0.95 0.97 Surf Coast 146 6.75 0.95 0.97 Greater Bendigo 632 6.88 0.96 0.98 Frankston 800 6.90 0.97 0.98 Hobsons Bay 582 6.93 0.97 0.99 Northern Grampians 90 6.91 0.97 0.98 Glenelg 143 7.03 0.98 0.99 Delatite 149 7.07 0.99 0.99 Ararat 84 7.15 1.00 1.00 Loddon 61 7.11 1.00 1.00 Banyule 852 7.18 1.01 1.00


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Mount Alexander 126 7.34 1.03 1.01 Indigo 111 7.45 1.04 1.02 West Wimmera 36 7.45 1.04 1.02 La Trobe 528 7.48 1.05 1.02 South Gippsland 203 7.70 1.08 1.04 Swan Hill 165 7.70 1.08 1.04 Wellington 323 7.81 1.09 1.05 Campaspe 290 7.89 1.11 1.05 East Gippsland 322 8.09 1.13 1.06 Greater Geelong 1,603 8.09 1.13 1.06 Moira 217 8.04 1.13 1.06 Horsham 154 8.23 1.15 1.07 Mildura 413 8.18 1.15 1.07 Kingston 1,127 8.32 1.16 1.08 Manningham 949 8.29 1.16 1.08 Maribyrnong 513 8.33 1.17 1.08 Stonnington 760 8.40 1.18 1.08 Alpine 112 8.48 1.19 1.09 Gannawarra 103 8.58 1.20 1.10 Monash 1,431 8.78 1.23 1.11 Pyrenees 58 8.78 1.23 1.11 Glen Eira 1,129 9.15 1.28 1.13 Darebin 1,193 9.33 1.31 1.14 Strathbogie 90 9.34 1.31 1.14 Baw Baw 346 9.39 1.32 1.15 Central Goldfields 124 9.44 1.32 1.15 Mornington Peninsula 1,292 9.52 1.33 1.15 Moyne 152 9.60 1.34 1.16 Boroondara 1,536 9.72 1.36 1.17 Corangamite 172 9.81 1.37 1.17 Moreland 1,349 9.89 1.38 1.18 Whitehorse 1,452 9.89 1.39 1.18 Bass Coast 267 9.97 1.40 1.18 Bayside 917 10.26 1.44 1.20 Southern Grampians 178 10.43 1.46 1.21 Moonee Valley 1,159 10.51 1.47 1.21 Towong 70 11.14 1.56 1.25 Hindmarsh 75 11.42 1.60 1.26 Buloke 85 11.71 1.64 1.28 Warrnambool 381 12.65 1.77 1.33 Yarriambiack 119 14.45 2.02 1.42 Queenscliffe 52 15.94 2.23 1.49 Grand Total 34,807 7.14 1.00 1.00 Unincorporated Vic 422


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Other procedural ophthalmology • C01Z-Procedures for Penetrating Eye Injury • C02Z-Enucleations and Orbital Procedures • C03Z-Retinal Procedures • C04Z-Maj Corneal, Scleral & Conjunctival Procs • C05Z-Dacryocrystorhinostomy • C06Z-Complex Glaucoma Procedures • C07Z-Other Glaucoma Procedures

• C10Z-Strabismus Procedures • C11Z-Eyelid Procedures • C12Z-Oth Corneal, Scleral & Conjunctival Procs • C13Z-Lacrimal Procedures • C14Z-Other Eye Procedures

Actual Crude rate/1000 people SRR SE SRR

Alpine 13 0.98 0.38 0.62

Indigo 19 1.28 0.49 0.70

Wodonga 43 1.30 0.50 0.71

Towong 9 1.43 0.55 0.74

Colac-Otway 31 1.47 0.57 0.75

Wangaratta 41 1.54 0.59 0.77

Surf Coast 34 1.57 0.61 0.78

West Wimmera 8 1.65 0.64 0.80

Golden Plains 26 1.69 0.65 0.81

Nillumbik 109 1.79 0.69 0.83

Moorabool 47 1.85 0.71 0.84

La Trobe 134 1.90 0.73 0.86

Casey 369 1.93 0.74 0.86

Macedon Ranges 74 1.93 0.74 0.86

Melton 113 1.92 0.74 0.86

Greater Geelong 389 1.96 0.76 0.87

Melbourne 107 1.98 0.76 0.87

Hepburn 29 1.99 0.77 0.88

Hume 286 2.04 0.79 0.89

Port Phillip 168 2.05 0.79 0.89

Corangamite 37 2.11 0.81 0.90

Ballarat 181 2.13 0.82 0.91

Delatite 45 2.13 0.82 0.91

Whittlesea 259 2.14 0.83 0.91

Yarra Ranges 311 2.16 0.83 0.91

Baw Baw 81 2.20 0.85 0.92

Cardinia 108 2.22 0.85 0.92

Glenelg 47 2.31 0.89 0.94

Wellington 97 2.34 0.90 0.95

Horsham 44 2.35 0.91 0.95

Mitchell 70 2.39 0.92 0.96

Wyndham 222 2.40 0.92 0.96

Greater Shepparton 142 2.41 0.93 0.96

Frankston 284 2.45 0.94 0.97

Moira 66 2.45 0.94 0.97

Mornington Peninsula 332 2.45 0.94 0.97

Yarriambiack 20 2.43 0.94 0.97

Greater Dandenong 315 2.46 0.95 0.97

Southern Grampians 42 2.46 0.95 0.97

Yarra 172 2.48 0.95 0.98

Banyule 295 2.49 0.96 0.98

East Gippsland 99 2.49 0.96 0.98

Central Goldfields 33 2.51 0.97 0.98

Monash 410 2.52 0.97 0.99

Moonee Valley 285 2.58 1.00 1.00


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Knox 392 2.62 1.01 1.01

Manningham 307 2.68 1.03 1.02

Greater Bendigo 248 2.70 1.04 1.02

Maroondah 272 2.69 1.04 1.02

South Gippsland 71 2.69 1.04 1.02

Darebin 348 2.72 1.05 1.02

Gannawarra 33 2.75 1.06 1.03

Moreland 384 2.81 1.08 1.04

Moyne 46 2.91 1.12 1.06

Northern Grampians 39 2.99 1.15 1.07

Warrnambool 90 2.99 1.15 1.07

Hobsons Bay 252 3.00 1.16 1.08

Kingston 410 3.03 1.17 1.08

Mount Alexander 52 3.03 1.17 1.08

Glen Eira 383 3.10 1.20 1.09

Loddon 27 3.15 1.21 1.10

Murrindindi 44 3.19 1.23 1.11

Brimbank 550 3.20 1.24 1.11

Strathbogie 31 3.22 1.24 1.11

Stonnington 295 3.26 1.26 1.12

Whitehorse 482 3.28 1.27 1.13

Queenscliffe 11 3.37 1.30 1.14

Bass Coast 93 3.47 1.34 1.16

Pyrenees 23 3.48 1.34 1.16

Boroondara 552 3.49 1.35 1.16

Swan Hill 76 3.54 1.37 1.17

Ararat 42 3.57 1.38 1.17

Bayside 319 3.57 1.38 1.17

Buloke 26 3.58 1.38 1.18

Campaspe 133 3.62 1.40 1.18

Hindmarsh 24 3.66 1.41 1.19

Mildura 239 4.74 1.83 1.35

Maribyrnong 298 4.84 1.86 1.37

Grand Total 12,638 2.59 1.00 1.00

Unincorporated 384


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Non-procedural ophthalmology: • C60A-Acute and Major Eye Infections Age>54 • C60B-Acute and Major Eye Infections Age<55 • C62Z-Hyphema & Med Man Trauma to Eye

• C63A-Other Disorders of the Eye W CC • C63B-Other Disorders of the Eye W/O C

Actual Crude rate/1000 people SRR SE SRR

Surf Coast 2 0.09 0.23 0.48

Loddon 1 0.12 0.29 0.54

Nillumbik 7 0.11 0.29 0.54

Golden Plains 2 0.13 0.33 0.57

Hepburn 2 0.14 0.35 0.59

Hindmarsh 1 0.15 0.38 0.62

Pyrenees 1 0.15 0.38 0.62

Manningham 20 0.17 0.44 0.66

Maroondah 21 0.21 0.52 0.72

Wangaratta 6 0.22 0.57 0.75

Northern Grampians 3 0.23 0.58 0.76

Moyne 4 0.25 0.64 0.80

Whittlesea 34 0.28 0.71 0.84

Cardinia 14 0.29 0.72 0.85

Casey 55 0.29 0.72 0.85

Corangamite 5 0.29 0.72 0.85

Greater Bendigo 27 0.29 0.74 0.86

Alpine 4 0.30 0.76 0.87

Wodonga 10 0.30 0.76 0.87

Queenscliffe 1 0.31 0.77 0.88

Knox 47 0.31 0.79 0.89

Banyule 38 0.32 0.80 0.90

Towong 2 0.32 0.80 0.89

Stonnington 29 0.32 0.81 0.90

Boroondara 53 0.34 0.84 0.92

Hume 47 0.33 0.84 0.92

Macedon Ranges 13 0.34 0.85 0.92

Ararat 4 0.34 0.86 0.92

Melton 20 0.34 0.86 0.92

Whitehorse 50 0.34 0.86 0.93

Yarra Ranges 50 0.35 0.87 0.93

Moorabool 9 0.35 0.89 0.94

Moreland 49 0.36 0.90 0.95

Monash 59 0.36 0.91 0.95

Hobsons Bay 31 0.37 0.93 0.96

Ballarat 32 0.38 0.95 0.97

Port Phillip 31 0.38 0.95 0.98

Kingston 53 0.39 0.98 0.99

Brimbank 69 0.40 1.01 1.01

Darebin 52 0.41 1.02 1.01

Melbourne 22 0.41 1.02 1.01

Moonee Valley 47 0.43 1.07 1.03

Warrnambool 13 0.43 1.08 1.04

Maribyrnong 27 0.44 1.10 1.05

Mildura 22 0.44 1.10 1.05

Mitchell 13 0.44 1.11 1.06

East Gippsland 18 0.45 1.14 1.07

Glen Eira 56 0.45 1.14 1.07

Central Goldfields 6 0.46 1.15 1.07


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Frankston 53 0.46 1.15 1.07

Mornington Peninsula 63 0.46 1.17 1.08

Wyndham 43 0.46 1.17 1.08

Greater Geelong 93 0.47 1.18 1.09

Indigo 7 0.47 1.18 1.09

Delatite 10 0.47 1.19 1.09

Campaspe 18 0.49 1.23 1.11

Greater Dandenong 64 0.50 1.25 1.12

Bass Coast 14 0.52 1.31 1.15

Moira 15 0.56 1.40 1.18

Greater Shepparton 34 0.58 1.45 1.20

Gannawarra 7 0.58 1.46 1.21

La Trobe 41 0.58 1.46 1.21

Murrindindi 8 0.58 1.46 1.21

Glenelg 12 0.59 1.48 1.22

Yarra 41 0.59 1.48 1.22

Colac-Otway 13 0.61 1.54 1.24

Bayside 56 0.63 1.57 1.25

Mount Alexander 11 0.64 1.61 1.27

Southern Grampians 11 0.64 1.62 1.27

Baw Baw 24 0.65 1.64 1.28

Wellington 28 0.68 1.70 1.30

Horsham 13 0.69 1.75 1.32

Buloke 6 0.83 2.08 1.44

Swan Hill 19 0.89 2.23 1.49

Strathbogie 9 0.93 2.35 1.53

South Gippsland 26 0.99 2.48 1.57

Yarriambiack 11 1.34 3.36 1.83

West Wimmera 7 1.45 3.64 1.91

Grand Total 1,939 0.40 1.00 1.00

Unincorporated VIC 54


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Appendix 9: Detailed ophthalmology forecasts

Forecast growth of public and private ophthalmology ESRGs: separations and bed days 2001-02 to 2016-17 - Victoria

ESRG_NAME STAY_TYPE 2001 2006 2011 2016 % pa growth

Cataract Procedures Day Only Separations 29,287 39,244 48,368 58,110 4.7%

Beddays 29,287 39,244 48,368 58,110 4.7%

Multiday Separations 3,900 3,812 3,597 3,523 -0.7%

Beddays 4,942 4,779 4,477 4,343 -0.9%

Cataract Procedures Separations 33,187 43,056 51,965 61,633 4.2%

Cataract Procedures Beddays 34,229 44,023 52,845 62,454 4.1%

Other Eye Procedures Day Only Separations 8,721 9,712 10,753 11,825 2.1%

Beddays 8,721 9,712 10,753 11,825 2.1%


Beddays 6,656 5,766 5,161 4,723 -2.3%

Other Eye Procedures Separations 12,589 13,238 14,031 14,931 1.1%

Other Eye Procedures Beddays 15,377 15,478 15,914 16,548 0.5%

Non-procedural Ophthalmology Day Only Separations 1,017 1,323 1,578 1,820 4.0%

Beddays 1,017 1,323 1,578 1,820 4.0%

Multiday Separations 1,051 984 969 961 -0.6%

Beddays 3,821 3,461 3,283 3,144 -1.3%

Non-procedural Ophthalmology Separations 2,068 2,308 2,547 2,781 2.0%

Non-procedural Ophthalmology Beddays 4,838 4,785 4,861 4,965 0.2%

Total Separations 47,844 58,602 68,543 79,345 3.4%

Total Beddays 54,444 64,286 73,619 83,967 2.9%

Total Multiday ALOS (days) 1.75 1.68 1.65 1.61 -0.6%


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Forecast growth of public ophthalmology ESRGs: separations and bed days 2001-02 to 2016-17 - Victoria



Beddays 11,302 15,458 19,303 23,380 5.0%


Beddays 2,285 2,207 2,067 2,003 -0.9%





Beddays 4,682 3,943 3,540 3,242 -2.4%

Other Eye Procs Seps (Total) 6,098 6,243 6,459 6,737 0.7%

Other Eye Procs Beddays (Total) 8,367 7,980 7,942 8,030 -0.3%

Other Eye Procs Multiday ALOS (days) 1.94 1.79 1.72 1.66 -1.0%

Non-procedural Ophthalmology Day Only Separations 864 1,127 1,347 1,558 4.0%

Multiday Separations 959 900 886 878 -0.6%

Beddays 3,339 3,065 2,917 2,800 -1.2%

Non-proc. Ophth. Seps (Total) 1,823 2,026 2,234 2,436 2.0%

Non-proc. Ophth. beddays (Total) 4,203 4,192 4,264 4,358 0.2%

Non-proc. Ophth. Multiday ALOS (days) 3.48 3.41 3.29 3.19 -0.6%

Total Sameday Separations 15,851 20,622 25,053 29,725 4.3%

Total Multiday Separations 4,946 4,669 4,419 4,273 -1.0%

Total Multiday Beddays 10,306 9,215 8,524 8,045 -1.6%


Total Separations 20,797 25,291 29,472 33,999 3.3%

Total Beddays 26,157 29,837 33,577 37,771 2.5%


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Forecast growth of private ophthalmology ESRGs - separations and bed days by SRG 2001-02-2016-17 - Victoria



Beddays 17,985 23,786 29,064 34,730 4.5%


Beddays 2,657 2,573 2,410 2,340 -0.8%




Beddays 5,036 5,675 6,350 7,038 2.3%


Beddays 1,974 1,823 1,621 1,481 -1.9%

Other Eye Procedures Separations 6,491 6,995 7,571 8,194 1.6%

Other Eye Procedures Beddays 7,010 7,498 7,971 8,519 1.3% Non-procedural Ophthalmology Day Only Separations 153 197 231 263 3.7%

Beddays 153 197 231 263 3.7%

Multiday Separations 92 85 83 82 -0.7%

Beddays 482 396 366 344 -2.2%

Non-procedural Ophthalmology Separations 245 281 314 345 2.3%

Non-procedural Ophthalmology Beddays 635 593 597 607 -0.3%

TOTAL Separations 27,047 33,311 39,071 45,347 3.5%

TOTAL Beddays 28,287 34,449 40,042 46,196 3.3%



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Appendix 10: Proposed Clinical Pathways, UK First report of the National Eye Care Services Steering Group (DOH, 2003) http://www.info.doh.gov.uk/doh/point.nsf/page/5FCE36DEB485D2E680256DA5002933F7?OpenDocument Cataract Care Pathway For most people, cataract surgery can significantly improve their vision, however the pathway for accessing treatment has often involved multiple visits to different people, and a long wait. ‘Action on Cataracts – Good Practice Guidance’ (Department of Health, 2000) estimated that annually 3.2% of those aged 65 and over would benefit from cataract surgery. This implies a planning assumption of a 47% increase in provision. The proposed pathway aims to provide a patient-centred, cost-effective service, to a high clinical standard, making the best use of the professional staff available.

Proposed Pathway • Patient attends optometrist/ Optometrists and Ophthalmic Medical Practitioners (OMP’s) for sight

test, cataract diagnosed and discussed, general risks & benefits of surgery explained, current medication listed, patient information given, and appointment made for Hospital Eye Service (HES).

• Patient attends HES for pre-op assessment • Patient attends HES for day case surgery • Patient attends HES/optometrist/OMP for 24/48 hr check OR is phoned by cataract nurse to check

progress (agreed locally) • Patient attends optometrist/OMP for final check and sight test, 2nd eye discussed.

Glaucoma Care Pathway The pathways aims to present patient-centred options utilising increased activity of OMP’s in an attempt to reduce the burden of glaucoma and its associated conditions on HES ophthalmologists.

Proposed pathway (Community based care) • Community optometrists work to nationally agreed screening protocols which permit refinement

of tests prior to referral • Glaucoma suspects and stable glaucoma patients managed in the community by COs and OMPs

with interaction of community and HES teams where appropriate. Low Vision Care Pathway Emphasis on low vision services, not provision of low vision, aids led by Primary or Social Care involving a Partnership Approach.

This pathway involves providing services which promote: • Awareness • Timeliness • Accessible

Age-Related Macular Degeneration Care Pathway (ARMD) The pathway aims to consider the current options for managing patients suffering ARMD and to develop a novel, patient-cantered model of service delivery that will fully utilise the community optometrist resource and ensure prompt, effective and appropriate care for all patients.

Proposed Pathway • Patient presents with a visual problem • Attends optometrist for precise differential diagnosis • Direct referral to HES if appropriate • Exudative (wet) ARMD detected and treated promptly • Non-exudative (dry) ARMD detected promptly and patient offered • Appropriate optical or Low Vision services • Registration, Social Service & Rehabilitation support provided promptly for patient.


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Appendix 11: Australian Council on Healthcare Standards - Clinical Indicators

Ophthalmology & Excimer Laser - Version 3

Indicator Area 1: Cataract Surgery CI. 1.1 Numerator The total number of re-admissions (related to the operated eye) within 28 days of discharge following cataract surgery, during the time period under study. Denominator The total number of patients having cataract surgery during the time period under study. CI. 1.2 Numerator The total number of patients having a re-admission within 28 days of discharge following cataract surgery, due to infection in the operated eye, during the time period under study. Denominator The total number of patients having cataract surgery during the time period under study. CI. 1.3 Numerator The total number of patients having a discharge intention of one day, who had an overnight admission following cataract surgery, during the time period under study. Denominator The total number of patients having cataract surgery, during the time period under study. CI. 1.4 Numerator The total number of patients having an anterior vitrectomy at the time of cataract surgery, during the time period under study. Denominator The total number of patients having cataract surgery, during the time period under study. Indicator Area 2: Glaucoma Surgery CI. 2.1 Numerator The total number of re-admissions (related to the operated eye) within 28 days of discharge following glaucoma surgery, during the time period under study. Denominator The total number of patients having glaucoma surgery during the time period under study. CI. 2.2 Numerator The total number of patients having a re-admission within 28 days of discharge following glaucoma surgery, due to infection in the operated eye, during the time period under study. Denominator The total number of patients having glaucoma surgery during the time period under study CI. 2.3 Numerator The total number of patients with a LOS greater than 3 days following glaucoma surgery, during the time period under study. Denominator The total number of patients having glaucoma surgery during the time period under study Indicator area 3: Retinal detachment surgery CI. 3.1 Numerator The total number of unplanned re-admissions within 28 days of discharge following retinal detachment surgery, during the time period under study. Denominator The total number of patients having retinal detachment surgery during the time period under study. CI. 3.2 Numerator The total number of patients having an unplanned readmissions within 28 days of discharge following retinal detachment surgery, due to infection in the operated eye, during the time period under study. Denominator The total number of patients having retinal detachment surgery during the time period under study. CI. 3.3 Numerator The total number of patients with a LOS greater than 4 days, following retinal detachment surgery, during the time period under study. Denominator The total number of patients having retinal detachment surgery, during the time period under study. CI. 3.4 Numerator The total number of patients having a revision of the operated eye (ACHI code 42779-00 [213] Revision of previous retinal detachment procedure) within 28 days, following retinal detachment surgery, during the time period under study. Denominator The total number of patients having retinal detachment surgery, during the time period under study.


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Indicator area 4: treatment adequacy CI. 4.1 Numerator The total number of patients with a history of surface ablation who has re-treatment, as defined above, during the study period. Denominator The total number of patients having surface ablation during the study period. CI. 4.2 Numerator The total number of patients with a history of non-surface ablation who have re-treatment, as defined above, during the study period Denominator The total number of patients having non-surface ablation during the study period. Indicator area 5: post- operative complication CI. 5.1 Numerator The total number of patients having excimer laser surgery who receive treatment due to infection in the operated eye/s within 28 days of surgery, during the time period under study. Denominator The total number of patients having excimer laser surgery during the time period under study.


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Appendix 12: Western Canada Waiting List Project - Cataract Surgery Priority Criteria (Version 1.0 revised 2 October 2000) http://www.wcwl.org/tools/cataract_surgery/


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Appendix 13: VF-14

General Functioning

1 Do you have any difficulty even with glasses reading small print such as labels on medicine bottles a telephone book food labels?

2 Do you have any difficulty even with glasses reading a newspaper or a book?

3 Do you have any difficulty even with glasses reading a large-print book or large-print newspaper or numbers on a telephone?

4 Do you have any difficulty even with glasses recognizing people when they are close to you?

5 Do you have any difficulty even with glasses seeing steps stairs or curbs?

6 Do you have any difficulty even with glasses reading traffic signs street signs or store signs?

7 Do you have any difficulty even with glasses doing find handwork like sewing knitting crocheting carpentry?

8 Do you have any difficulty even with glasses writing checks or filling out forms?

9 Do you have any difficulty even with glasses playing games such as bingo dominos card games mahjong?

10 Do you have any difficulty even with glasses taking part in sports like bowling handball tennis golf?

11 Do you have any difficulty even with glasses cooking?

12 Do you have any difficulty even with glasses watching television?

Response Points

not applicable

no 4

yes with a little difficulty 3

yes with a moderate amount of difficulty 2

yes with a great deal of difficulty 1

yes and am unable to do the activity 0

Driving

(13) Do you currently drive a car? • if Yes go to 14 • if No go to 16

(14) How much difficulty do you have driving during the day because of your vision?

• no difficulty (4 points) • a little difficulty (3 points) • a moderate amount of difficulty (2 points) • a great deal of difficulty (1 point)

(15) How much difficulty do you have driving at night because of your vision?

• no difficulty (4 points) • a little difficulty (3 points) • a moderate amount of difficulty (2 points) • a great deal of difficulty (1 point)


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(16) Have you ever driven a car? • if Yes go to 17 • if No stop

(17) When did you stop driving?

• less than 6 months ago • 6-12 months ago • more than 12 months ago

(18) Why did you stop driving?

• vision • other illness • other reason

Scoring An item is not included in scoring if the person does not do the activity for some reason other than their vision. Scores on all activities that the person performed or did not perform because of vision were then averaged yielding a value from 0 to 4. This value was multiplied by 25 giving a final score from 0 to 100. • a score of 100 indicates able to do all applicable activities; and • a score of 0 indicates unable to do all applicable activities because of vision.


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Folland S, Goodman AC, and Stano M., 1997, The Economics of Health and Health Care 2nd Edition, Prentice Hall, pp. 213-228. Hurst, J. & Siciliani, L., 2003, Tackling Excessive Waiting Times for Elective Surgery: A Comparison of Policies in Twelve OECD Countries, OEDC Heath Working Papers No. 6, http://ww.oecd.org. Institute of Medicine, 2000, Interpreting the Volume-Outcome Relationship in the Context of Health Care Quality - Workshop Summary. http://www.nap.edu/catalog/10005.html Last accessed 23/01/2004 Keeffe, J.E., LeAnn, M.W., McCarty, C.A. & Taylor, H.R., 2002, Utilisation of Eye Care Services by Urban and Rural Australians, British Journal of Ophthalmology, Vol 86, pp. 24-27. Keeffe, J.E., 2003, Screening for Diabetic Retinopathy: A Planning and Resource Guide, Centre for Eye Research, University of Melbourne. Lee, P. P. & Asch, S, 2000, Cataracts, In Chapter 5, Kerr, E. A., Asch S. M., Hamilton, E.G. & McGlynn, E. A. (eds) Quality of Care for General Medical Conditions: A Review of the Literature and Quality Indicators, RAND, MR-1280-AHRQ. Liou, H, McCarty, C., Jin, C., & Taylor, H. R., 1999, Prevalence and Predictors of Undercorrected Refractive Errors in the Victorian Population, Vol 127, no 5, pp. 590-596. Madden, A.C. Simmons, D, McCarty, C.A., Khan, M.A. Taylor, H.R, 2002, Eye Health in Rural Australia, Clinical and Experimental Ophthalmology, Vol 30, pp. 316-321. McCarty, C.A., 2002, Cataract In The 21st Century: Lessons From Previous Epidemiologic Research, Clinical and Experimental Optometry, Vol 85, no 2, pp. 91-96. McCarty, C.A., Nanjan, M. B. & Taylor, H. R., 2000, Operated and Non-operated Cataract in Australia, Clinical and Experimental Ophthalmology, Vol 28, pp. 77-82. McCarty, C.A., Keeffe, J.E. & Taylor, H.R., 1999a, The Need For Cataract Surgery: Projections Based On Lens Opacity, Visual Acuity and Personal Concern, British Journal of Ophthalmology, Vol 83, pp. 62-65. McCarty, C. A., Mukesh, B.N., Cara, L. & Taylor, H.R. (1999b), The Epidemiology of Cataract in Australia, American Journal of Ophthalmology, Vol 128, no 4, pp. 446 – 465. McKay, R., McCarty, C.A. & Taylor, H.R., 2000, Diabetic Retinopathy in Victoria, Australia: The Visual Impairment Project, British Journal of Ophthalmology, Vol 84, no 8, pp. 865-870. Mitchell, P., Smith, W., Attebo, K. & Wang, J.J., 1995, Prevalence of Age-related Maculopathy in Australia, The Blue Mountains Eye Study, Ophthalmology, Oct; Vol 102, no 10, pp. 1450-60. Mitchell, P., Smith, W., Attebo, K., & Healey, P.R., 1996, Prevalence of Open-angle Glaucoma in Australia, The Blue Mountains Eye Study, Ophthalmology, Oct; Vol 103, no 10, pp. 1661-9. Mitchell, P., Smith, W., Chey, T. & Healey, P.R., 1997, Open-angle Glaucoma and Diabetes: the Blue Mountains Eye Study, Ophthalmology, Apr; Vol 104, no 4, pp. 712-8. Mooney G. & Scotton R., 1999, Economics and Australian Health Policy, Allen & Unwin. ISBN 1 86448 749 6, pp.197-200. National Health Service, 2000a, The NHS Plan: A Plan for Investment A Plan for Reform. National Health Service, 2000b, Action on Cataracts: Good Practice Guidance. National Rural and Remote Allied Health Advisory Service, 2003, Orthoptics (Workforce) (Draft). NSW Health, 2002, Ophthalmology Clinical Service Plan for NSW, Boyd Health Management (September). Nurse Policy Branch, 2003, Policy and Strategic Projects Division, Department of Human Services. Qing, Y., Flanagan, S. & McCarty, D, 2001, Trends in Health Service Delivery for Cataract Surgery at a Large Australian Ophthalmic Teaching Hospital, Clinical & Experimental Ophthalmology, Vol 29, pp. 291-95. Queensland Health, 1994, Guide to the Role Delineation of Health Services, Queensland Health, December. Robertson I, Richardson J and Hobbs, 1998, The Impact of New Technology on the Treatment and Cost of Acute Myocardial Infarction in Australia, Centre for Health Program Evaluation, Technical Report 10. http://chpe.buseco.monash.edu.au/pubs/tr10.pdf (Last accessed 14 Jan 2004).


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Rochtchina, E., Mukesh, B.N., Wang, J.J. McCarty, C.A. Taylor, H.R & Mitchell, P., 2003, Projected Prevalence Of Age-Related Cataract And Cataract Surgery In Australia For The Years 2001 And 2021: Pooled Data From Two Population-Based Surveys. Clinical and Experimental Ophthalmology, Vol 31, no 3, pp. 233-236. Royal College of Ophthalmologists (RCO), 2001, Cataract Surgery Guidelines, February. http://www.rcophth.ac.uk/publications/guidelines/cataract_surgery.html. RANZCO, 2004, http://ranzco.edu/member/intraocular.php. Sharwood, P. & O’Connell, B., 2001, Assessing the Relationship Between Inpatient and Outpatient Activity: A Clinical Specialty Analysis, Australian Health Review, Vol 23, no 3, pp. 137-144. Tan, J.H., Newman, D. K., Klunker, C. Watts, S. and Burton, R., 2000. Phacoemulsification Cataract Surgery: Is Routine Review Necessary on the First Post-operative Day? Eye, Vol 14, pp. 53-55. Taylor, H.R., 2000, Cataract: How Much Surgery Do We Have To Do? British Journal of Ophthalmology, Vol 84, pp. 1-2. Taylor, H.R., 2001, Trachoma in Australia, Medical Journal of Australia, Vol 175, pp. 371-372. Taylor, H.R. & Keeffe, J. E., 2002, Updates in Medicine - Ophthalmology, MJA, Vol 176, p. 29. Thiagalingam, S., Cumming, R.G. & Mitchell, P., 2002, Factors Associated with Undercorrected Refractive Errors in an Older Population: Blue Mountains Study, British Journal of Ophthalmology, Vol 86, no 9, pp. 1041-45. Tinley, C.G., Frost, A., Hakin, K.N. McDermott, W. & Ewings, P., 2003, Is Visual Outcome Compromised When Next Day Review Is Omitted After Phacoemulsification Surgery? A Randomised Controlled Trial, British Journal of Ophthalmology, Vol 87, pp. 1350-1355. University of York, NHS Centre for Reviews and Dissemination, 1995, Relationship Between Volume and Quality of Health Care: A Review of the Literature, pp. 1-34. York: University of York, NHS Centre for Reviews and Dissemination. VanNewkirk, M.R., Nanjan, M.B., Wang, J.J., Mitchell, P., Taylor, H.R. & McCarty, C.A., 2000, The Prevalence of Age-related Maculopathy: The Visual Impairment Project, Ophthalmology, Vol 107(Aug), no 8, pp. 1593-1600. Victorian Quality Council (VQC), 2003, Better Quality, Better Health - A Safety and Quality Improvement Framework for Victorian Health Services, Department of Human Services http://qualitycouncil.health.vic.gov.au. Vision 2020, 2003, National Eye Health Strategy, – The Right to Sight Australia. www.v2020australia.org/Publications/documents/ NationalEyeHealthStrategyFinal8Feb02.pdf - Weih, L.M., Nanjan, M., McCarty, C.A., & Taylor, H.R., 2001, Prevalence and Predictors of Open-Angle Glaucoma: Results from the Visual Impairment Project, Ophthalmology, Vol 108, no 11, pp. 1966-72. Western Canada Waiting List Project (WCWL), (2001), From Chaos to Order: Making Sense of Waiting Lists in Canada, Final Report, Health Transition Fund, Health Canada. Wright, C. J. & Robens-Paradise, Y., 2001, Evaluation of Indications and Outcomes in Elective Surgery; A Feasibility Study in the Acute Care Hospitals of the Vancouver/Richmond Health Region, Web address: www.resio.org. Wu, G. and Morrell, A., 2001, A Nationwide Survey of Post-operative Instructions Following Uncomplicated Phacoemulsification Cataract Surgery, Eye, Vol 15: pp. 723-727.

References http://www.rvib.org.au/aboutus/aboutus_work.shtml http://www.visionaustralia.org.au/ http://www.guidedogs.asn.au/guide.asp http://www.rvib.org.au/nexus/index.shtml http://www.health.vic.gov.au/electivesurgery/esas/index.htm http://www.dhs.vic.gov.au/rrhacs/ruralbranch/rpi_guidelines_2003.doc http:/www.health.vic.gov.au/electivesurgery/about.htm http://www.visioncrc.org.au/the_centre/participants.asp http://www.health.vic.gov.au/clinrisk/sentin.htm http://www.health.vic.gov.au/patsat/ http://www.hic.gov.au/providers/health_statistics/statistical_reporting/medicare.htm


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Glossary of terms Diagnosis Related Group (DRG) The Diagnosis Related Group (DRG) classification system clusters patients into groups that are clinically meaningful and resource-use homogenous. The concept of clinical coherence requires that patient characteristics included in the definition of each DRG relate to a common organ system or aetiology (disease cause), and that a specific medical specialty should typically provide care to the patients in that DRG. Emergency Department Presentation Emergency Department Presentation is the reporting unit of the Victorian Emergency Minimum Dataset (VEMD). An Emergency Department Presentation should be reported for every patient who is triaged to one of the VEMD triage categories. Arrival Date/Time indicates the commencement of an Emergency Department Presentation, which concludes when the patient physically leaves the Emergency Department (Departure Date/Time). Encounter The encounter is defined as an outpatient clinic visit, plus all ancillary services (pathology, radiology and pharmacy) provided within the 30 days either side of the clinic visit. The 30-day window has been chosen to encompass the majority of services associated with a particular visit and to enable a reasonable and practical time period for reporting and funding. There are 47 clinical categories, all of which are weighted except for allied health and emergency services. Hub and Spoke A model of service delivery where highly specialised services are maintained at one or two locations (hubs), while high volume or lower complexity same day services will be provided by staff from the hub in distant locations, called spokes. The hub supplies the staff and pays the spoke only for the hire of facilities. Length of Stay The Length of Stay (LOS) of an admitted patient is measured in patient days. A same day patient should be allocated a length of stay of one patient day. The length of stay of an overnight or multi-day stay patient is calculated by subtracting the Admission Date from the Separation Date and deducting total [normal] leave days. Total contracted patient days are included in length of stay. Metropolitan Health Service Metropolitan health service is a term used in the Health Services Act 1988 to refer to a public hospital, which is listed in Schedule 5 of the Act. A metropolitan health service may consist of a number of campuses. Guide for Use Refer to: http://www.health.vic.gov.au/hospitals/index. Non-Admitted Patient A patient who does not undergo a hospital’s formal admission process. There are three categories of non-admitted patient: Emergency Department patient, outpatient, and other non-admitted patient (treated by hospital employees off the hospital site —includes community/outreach services). Overnight or Multi-day Stay Patient: A patient who, following a clinical decision, receives hospital treatment for a minimum of one night. That is, who is admitted to and separated from the hospital on different dates. Principal Diagnosis: The diagnosis established after study to be chiefly responsible for occasioning the patient’s episode of care in hospital (or attendance at the health care facility). Separation: The process by which an episode of care for an admitted patient ceases. A separation may be a discharge from the hospital (patient transferred, goes home or dies) or a transfer of care type within the one hospital stay (episode changes from acute care to mental health or aged care). For this reason the number of separations do not equal the number of patients. Statistical Local Area (SLA) The Statistical Local Area (SLA) of the patient’s usual residence. Stay type A clinical-complexity grading of DRGs (derived from DRGs): Primary Secondary Tertiary It must be noted that this is a complexity grading of the DRG not the hospital, so that the same coding can occur at a small rural hospital or a tertiary referral hospital.


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The forecasting model has two options: “multi-day non-tertiary” which consists of Primary and Secondary “multi-day tertiary” which consists of Tertiary. For simplicity, the “multi-day tertiary” and “multi-day non-tertiary” stay types are usually combined to form one “multiday” field. Victorian Admitted Episodes Dataset (VAED) The Department of Human Services collects morbidity data on all admitted patients from Victorian public and private acute hospitals including rehabilitation centres, extended care facilities and day procedure centres. This data forms the Victorian Admitted Episodes Dataset (VAED, formerly VIMD). Among other things, VAED data are used for; health services planning, policy formulation, casemix funding and epidemiological research. The VAED data collection also enables the Department of Human Services to meet the requirements of the Victorian Health Act 1958, which includes maintaining a comprehensive information system on:

• the causes, effects and nature of illness among Victorians • the determinants of good health and ill health and • the utilisation of health services in Victoria.

Victorian Ambulatory Classification and Funding System (VACS) The Victorian Ambulatory Classification and Funding System (VACS) is a casemix based funding system for public outpatient services where hospitals are funded on the basis of patient encounters for medical and surgical services. WIES Weighted Inlier Equivalent Separation (WIES) is calculated using a formula of the weight assigned to each DRG, together with any co-payments or adjustments relevant to the episode. Hospitals are provided with acute service targets and actual acute throughput is measured in both separations and WIES. The WIES unit is used within the Acute program to assign monetary value to each separation. Waiting List A register that contains essential details about patients who require admission for elective care. Patients on waiting lists for elective care can be ‘ready for care’ or ‘not ready for care’.

Privacy declaration:

Your information is being sought for the sole purpose of developing a framework for the delivery of ophthalmology services in Victoria. Information gathered will be stored securely by the Department of Human Services and will not be disclosed to anyone outside of the Project without your consent. Contact details will only be used to inform you of information pertinent to the Project.

Victorian Ophthalmology Service Planning Framework

Discussion Paper: Response Submission Form

This response form is available in electronic format at http://www.health.vic.gov.au/ophthalmology/

Name:

Title:

Organisation:

Address:

Suburb:

Postcode:

Phone:

Email:

What is your interest in the project? (please tick the appropriate box)

Professional Business

Personal Other (please specify) ……………………………..

If you do not want your details to be published in the Framework document please indicate this by ticking the following box.

I do not agree to my name and organisation being published in the Framework document, as participating in the consultation?

Q1. What are the barriers to people obtaining correction to refractive error?

Q2. How can these barriers be addressed?

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Q3. How can it be ensured that appropriate patients attend specialist ophthalmology emergency departments and that appropriate treatment is available at other emergency departments?

Q4. How can appropriate ophthalmic expertise be available in non-specialist emergency departments?

Q5. How can ophthalmology outpatient services be optimised?

Q6. What ophthalmology outpatient services should be provided in the following settings –

• Specialist tertiary hospital (RVEEH) • General hospitals • Community settings

o Ophthalmologists o Optometrists o Other

Q7. What are the specific issues of rural Victorians in accessing ophthalmology outpatient services?

Q8. To what extent should the public system treat private ophthalmology patients (insured or uninsured)?

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Q9. What types of ophthalmology services (emergency, outpatient, surgical, non-surgical) should be available to patients at general hospitals?

Q10. How could ophthalmology services be coordinated more effectively with non-ophthalmology specialties such as trauma, diabetes, and immunology?

Q11. What is an acceptable waiting time for non-urgent outpatient and inpatient ophthalmology care?

Q 12. What strategies are required to ensure timely provision of ophthalmic surgical services?

Q13. What are the cost and funding issues in ophthalmology that require action (inpatient, outpatient, emergency, Commonwealth, state)?

Q14. What strategies should be developed and implemented to manage demand for treatment of eye disease such as cataract surgery, glaucoma, diabetic retinopathy and ARM?

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Q15. What innovations in clinical practice, models of care, technology and health promotion will change treatment patterns over the next decade?

Q16. What service configuration and models of care for ophthalmology services in Victoria would best meet the needs of stakeholders (consumers, providers, teaching and research), including:

• Primary care (screening and prevention) • Community care • Hospital based services (emergency, outpatient and inpatient) • Public and private collaboration

Q17. What are the barriers to achieving optimal service configuration?

Q18. What support services, staff skills, minimum safety standards and other requirements are needed to ensure that ophthalmology services are provided safely and appropriately across a variety of settings?

Q19. Does Victoria have an adequate eye care workforce across metropolitan and rural settings?

Q20. Is current training adequate to meet future demand for services in Victoria?

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Q21. What service configurations are required to support training requirements in order to meet future demand for health care professionals in the delivery of ophthalmology services in metropolitan and rural settings?

Q22. Can other health professionals be integrated into the delivery of ophthalmology services (ie. Optometrists are having a greater role in chronic disease management)? What enablers are required to implement these changes?

Q23. What is the role of the private health care sector in providing training opportunities?

Q24. Would prioritisation systems for ophthalmology surgery improve eye care services in Victoria?

Q25. Is there a volume-outcome relationship for components of ophthalmology practice? - Is there a minimum volume of some procedures that should be performed by a health service or practitioner to ensure optimal outcomes for patients?

Q26. What key performance and outcome measures for ophthalmology services should be collected and reported by hospitals? Who should they be reported to?

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Q27. What mechanisms are required to be implemented to enable the collection and utilisation of these measures?

Q28. What is the role of the public and private hospitals in providing research opportunities? (ie. infrastructure, access to patients)?

Q29. What are the advantages and disadvantages of collocation of research institutions with specialty hospitals (RVEEH)?

Return this document to:

Ophthalmology Service Planning Framework c/o Kerri Martin, Senior Project Officer Metropolitan Health and Aged Care Services Division Department of Human Services Level 10, 589 Collins St Melbourne VIC 3000 Email: [email protected] Ph: 03 9616 1394 Fax: 03 9616 2880 Further information can be found at: http://www.health.vic.gov.au/ophthalmology

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