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Eyes on collaborative care in diabetic retinopathy: the Western Sydney Community Eye Care model

Diabetes is the world’s fastest growing chronic condition. In Australia, the number of people with diabetes has risen rapidly over the last 25 years, with the prevalence of diabetes now approximately 7.5% and diabetes set to become the disease that contributes most to the national burden of disability by 2017.
Consequently, diabetic retinopathy is becoming more common and this raises important public health considerations. How do ophthalmologists play a leading role in shaping the delivery of health services to meet demand and address the leading cause of vision loss and blindness in working age Australians?
In this three-part series, we explore our evolving roles in collaborative care for better diabetes management.
We do hope you find the first article of interest.

Prof Stephanie Watson, Chair, RANZCO Public Health Committee
A/Prof Anthony Kwan, Chair of the Australian and New Zealand Society of Retinal Specialists

Western Sydney is considered a diabetes hot spot as the numbers are higher than the New South Wales (NSW) average. Combined with the rising rates for diabetes and high glucose across the board (up 9.4% from 2002 in NSW), the staff at Westmead Hospital are feeling the impact and rethinking how to treat the wave of patients coming through their doors. An Australian first, the Community Eye Care Centre will open its doors for patients with diabetic retinopathy and glaucoma via a shop front clinic at West Point Shopping Centre in Blacktown. Expected to open mid-year, all low-risk referrals to Westmead will be sent on to the new Community Eye Care Centre where they will be assessed by optometrists employed by the Local Health District.

The trial program is being modelled from the Cambridge Optometry Glaucoma Scheme and has evolved from the Community Eye Care (C-Eye-C) project supported by the Agency for Clinical Innovation. Dr Andrew White, Consultant Ophthalmologist at Westmead and Chair of the C-Eye-C project was involved in the Cambridge program and has been instrumental in bringing a workable model to Western Sydney.

HOW DOES THE MODEL WORK?

Dr Gerald Liew works alongside Dr White as a hospital consultant ophthalmologist at Westmead and will oversee patients referred to the new centre with diabetic retinopathy. We interviewed Dr Liew and Dr White to better understand how the service will operate.

“Westmead Hospital Eye Clinic currently sees all referrals regardless of risk level and this has contributed to long waiting times. This project will triage referrals to high risk and low risk. When the new Community Eye Care Centre opens, they will receive the low-risk referrals while high-risk referrals will remain with Westmead.

“Optometrists reviewing patients at the Community Eye Care Centre will transmit colour retinal photographs and OCT scans as well as their recommendations to consultant ophthalmologists such as myself at Westmead Hospital Eye Clinic.

“This will enable specialist review and validation of the optometrist’s recommendation for follow-up, discharge back to the community or referral to the clinic. This is essentially a form of telemedicine to better utilise existing resources for the provision of eye care,” said Dr Liew.

WHAT ARE THE BENEFITS?

“Optometrists are well supported to manage low-risk cases, leaving capacity for ophthalmologists to manage high-risk cases. A model such as this supports an effective referral process and is underpinned by a multidisciplinary team that has the support of the consultant ophthalmologist,” said Dr Gerald Liew.

“The numbers of patients needing eye treatment is growing and is expected to grow by 150% in Western Sydney. This means we need to do things differently. By introducing a new model of care, we can become more efficient, see patients earlier and hopefully, prevent unnecessary and irreversible vision loss — which is life changing,” said Dr White

“Furthermore, having the Community Eye Care Centre at West Point Shopping Centre in Blacktown offers huge advantages for patients. They can be seen more quickly and the clinic is more accessible with easier access for those driving and parking or using public transport,” said Dr White.

WHAT ARE THE CHALLENGES?

“One of the key challenges is changing people’s thinking about how things are done. For each of the professions there is a shift in thinking and doing that needs to occur to increase our communication.

“For ophthalmologists, we need to focus more on the challenging aspects of diabetes retinopathy management and refer back to the optometrists for less severe cases. For optometrists, it’s about plugging patients back in to the broader health sector and closing that loop with general practice,” said Dr White.

“Under this initiative, our intention is that every patient and their health care team gets a letter back outlining our recommendations. We see this as important for communication with our patients but also with the providing optometrist. Through this process, we see an opportunity for upskilling and supporting appropriate referrals,” said Dr Liew.

WHY IS COLLABORATIVE CARE IMPORTANT?

“We are seeing collaborative care as an essential approach for addressing the demand for services in Western Sydney. It’s important we are all on the same page, that we can look after the patient in a more integrated way and then everyone gets seen.

“Crucial to the effectiveness of our eye clinic is the work occurring concurrently in primary care under the Western Sydney Community Eye Care Project,” said Dr White.

“Led by endocrinologist, Dr Mani Manoharan from Blacktown Hospital, this project is raising awareness of diabetic retinopathy, aiming to reach the 63% of people with diabetes in Western Sydney who are not being screened. They are teaming up optometrists with large general practitioner (GP) practices and introducing standardised referrals and electronic transfer of reports to streamline communication between providers.

“Standardised reporting is enhancing the quality of referrals to the Eye Clinic, plus those discharged from the Community Eye Centre are then plugged back into their GP-led care,” said Dr White.

WHERE TO FROM HERE?

The clinic will operate as a 3- to 5-year trial and will be evaluated by The George Institute to assess cost effectiveness and clinical accuracy. This includes measuring impact on waiting times and patient safety,” said Dr Liew.

“We wait to see the results but we envisage this as a flagship model that has the potential for broader roll out”, said Dr White

Diabetic retinopathy remains an important cause of decreased vision in our community, despite the existence of effective treatments for retinopathy and the sophistication of our health system.

Screening rates for diabetic retinopathy are poor with fewer than 50% of patients with diabetes being screened according to National Health and Medical Research Council (NHMRC) guidelines. In addition, the demand for treatment of diabetic retinopathy is increasing, and is not being met.

These failures mean that opportunities to prevent or minimise vision loss due to diabetic retinopathy are being missed.

The presence of diabetic retinopathy is a red flag for GPs and endocrinologists, indicating an urgent need for improved diabetic control in order to minimise both the progression of diabetic retinopathy and the development of other diabetic complications. If retinopathy is undetected, this important signal is lost.

The option of continuing with the status quo for diabetic eye disease is not tenable for Western Sydney, or the rest of Australia. I applaud Andrew and Gerald for their leadership in developing the Community Eye Care Centre model at Westmead.

Staffing the Community Eye Care Centre with optometrists might be confronting for some ophthalmologists. However, it is a way for Westmead Hospital Eye Clinic to cope with the demand for its services by devolving screening, and follow-up of low risk diabetic retinopathy, to a supervised, lower resource centre. Doing so, will hopefully free ophthalmologists and resources at the main clinic to review and treat more patients with sight threatening diabetic retinopathy, in a more timely fashion.

Ophthalmologists, as medical eye specialists and leaders in collaborative eye care, need to be at the forefront of developing a response to the unmet eye health needs of patients with diabetes. This will involve increased engagement with local optometrists, GPs, and endocrinologists, and probably a suite of other measures to cement functional management pathways.

The ‘whole of area response’ that is being undertaken by the Western Sydney Diabetes Prevention and Management Initiative, of which the Westmead Eye Clinic and the Community Eye Centre at Blacktown are a part, is an effective example of this approach.

Future articles in this series will deal with the issues of poor screening rates for diabetic retinopathy, and the delivery of diabetic retinopathy care in rural and remote areas.

DR JOHN DOWNIE, MEMBER OF THE RANZCO PUBLIC HEALTH COMMITTEE

Diabetic retinopathy is the most common cause of blindness in patients of working age in the Western world. In the anti-VEGF era, the treatment burden of sight threatening diabetic retinopathy can be immense if early diabetic retinopathy is not identified promptly so that preventative measures can be put in place.

This eye care model in Western Sydney can potentially provide valuable education to patients and identify diabetic retinopathy in their early stage so that appropriate advice and management can be given.

By liaising with other stakeholders, like endocrinologists and GPs, this exciting model can provide holistic care to diabetic patients in a local and convenient environment and, if successful, may provide a platform for similar projects around the country.

A/Prof Anthony Kwan, Chair of the Australian and New Zealand Society of Retinal Specialists

ACKNOWLEDGEMENT

There were many stakeholders involved in making the Community Eye Care Centre a reality, in particular, Dr White would like to thank Western Sydney Local Health District, Western Sydney Diabetes Initiative, NSW Agency for Clinical Innovation, Glaucoma Australia, Diabetes NSW, Optometry Australia and RANZCO NSW.

Part 2 in the next issue of Eye2Eye
In part 2 of this series, we interview Dr Peter van Wijngaarden, Principal Investigator at the Centre for Eye Research Australia (CERA) regarding diabetic retinopathy screening and the proposal for the National Blindness Prevention Program.

Visit our 5 question poll to share your views on diabetes management and collaborative care. The survey will take less than 1 minute to complete, results will be de-identified and shared with you via the RANZCO E-news.
Link to poll: https://www.surveymonkey.com/r/K63T93R

Click here if you would like to read this article in Eye2Eye.

Last updated: November 29, 2018

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