When RANZCO and Specsavers announced a collaborative approach to producing guidelines for eye health in August, tongues began to wag. Questions were asked, among them, is there integrity in this resolve to establish new guidelines for eye care, will this pave the way for better patient outcomes, or is this just another Specsavers’ sortie aimed at gaining more control of the sector? mivision spoke to RANZCO, Specsavers and Optometry Australia to unpack the story.
There’s no arguing the current state of eye health services in Australia. Faced with an ageing population, the prevalence of eye disease is on the rise and there’s no turning back the clocks.
The number of ophthalmologists available to manage and treat these eye diseases is in a steady state of decline. Placements for medical graduates who want to specialise in ophthalmology are static due to availability of funding and, according to RANZCO, the number of specialist international graduates of ophthalmology applying to work in Australia has declined over the past 2 years.
Optometrists, on the other hand, have increasingly sophisticated tools at their fingertips that equip them in the process of disease diagnosis and management.
…we want to collaborate with everyone. Then the question became, how do we actually enable that rather than simply having a statement that does nothing?
And then there’s the issue of funding. Government, at federal and state level, continues to seek opportunities to reduce the cost of medical services, the demand for which continues to rise.
So what’s the answer?
According to the Royal Australian and New Zealand College of Ophthalmologists (RANZCO), at least part of it lies in building more efficient processes that enable timely referral from patients on from optometry to ophthalmology and facilitate effective collaborative care. That involves the development of specific, and easily referenced guidelines for the collaborative care of eye diseases such as glaucoma, age-related macular degeneration and diabetic retinopathy. It also involves measuring the outcomes of clinical practice in an effort to continuously implement improvements.
RANZCO has elected to start the process by working with Specsavers on a pilot program, and has already launched guidelines for the management of glaucoma and most recently, diabetic retinopathy. The College has made it clear that other optometrists are invited to make use of the guidelines and to provide their feedback on them.
David Andrews, Chief Executive Officer of RANZCO said this collaborative process is something the College has been considering for some time. “Last year RANZCO made a conscious decision to change our tagline to “collaborative eye care” because we want to collaborate with everyone. Then the question became, how do we actually enable that rather than simply having a statement that does nothing?
“One way is to make referral pathways clearer between all ophthalmologists and the professions – to get them working better together so that patients can move through the health system in the least invasive way possible – with the least amount of time – making sure they’re getting the right care and receiving the most appropriate treatment.”
Dr. Andrews said improved pathways would also reduce the number of false positive referrals that ophthalmologists receive, which in turn would reduce pressure on their services.
“I suggested to Peter Larsen (Specsavers’ Optometry Director) that RANZCO should work together with Specsavers to develop these more effective referral pathways,” said Dr. Andrews, adding, “we are not looking to endorse one optometry group over any other, rather we hope that the guidelines will become an opportunity to better improve patient care overall.”
Following initial discussions with Specsavers and the development of a Memorandum of Understanding to set out a mutual relationship, the concept was presented to RANZCO’s Council – which comprises over 40 ophthalmologists – who were overwhelmingly in favour. “They said this is what RANZCO should be doing,” said Dr. Andrews.
Mr. Larsen said Specsavers also embraced the opportunity. “We’ve always looked to ophthalmology for leadership in education of eye disease and clinical pathways. Specsavers is the holder of the biggest Medicare data under one roof – we perform circa three million examinations a year – so we, more than anybody understand the need for consistency and have a continued desire to derive consistent behavior through all our partners in their stores. Therefore, it made complete sense to investigate more efficient clinical pathways.”
“It’s inevitable that over time, with our ageing population, there will be greater incidence of eye disease,” said Mr. Larsen. “There are so few eye care specialists that optometrists will inevitably have to shoulder greater responsibility working in collaboration with ophthalmology to evolve greater clinical productivity for the benefit of the patient.”
First Guidelines Launched
RANZCO developed and launched its first guidelines – in collaboration with Specsavers – for the management of glaucoma in July 2016. Far from matching the dense 25-30 page guideline documents produced by the likes of the National Health and Medical Research Council (NHMRC) or Optometry Board of Australia (OBA), this is a simple flow chart that extracts the key points from existing guidelines and presents them graphically as an easy reference tool.
“The RANZCO guidelines are, we hope, a simplified way for health professionals to use the multiple guidelines now in place, including AHPRA and NHMRC. They don’t replace anything, they just bring it all together,” said Dr. Andrews.
“They are planned to provide a clear patient management pathway for the many variations of management possible for glaucoma, and other diseases in due course. Ideally they direct patients through their pathway of care with the most appropriate person for each step.”
Dr. Andrews conceded that the guidelines are prescriptive however, he said, “that’s what people are looking for… of course, as with all guidelines, there is some greyness around some aspects, but what we’re offering is something people can quickly refer to so they know they’re doing what they should be doing.”
Mr. Larsen said the guidelines have offered a palpable level of surety to optometrist partners within the Specsavers group.
“When we took the flow chart out to show our optometrists, you could hear the relief in the room,” said Mr. Larsen.
Mr. Larsen continued: “Of course it is possible to leave decisions about diagnosis and management completely up to the individual, however that leaves more opportunity for error. The alternative is to provide guidelines. Yes, there are grey areas but overall, the new guidelines give a clear pathway – so our optometrists now have more surety around how to treat these conditions… From our perspective, with some 40 per cent of all patients having their primary eye care needs looked after by Specsavers, we need to offer a strong degree of consistency, which is what the guidelines will help us to achieve. That means patients will learn to expect the best levels of consistent care whichever ophthalmologist they are referred to and whichever Specsavers optometrist they may be a patient of.”
Measuring the Data
With the guidelines in place, RANZCO and Specsavers will work together to measure and assess their impact on patient referrals and disease management.
The two organisations are still determining exactly what data will be collected, but agree it will be big picture information as opposed to the minutiae of treatment protocols. “Ultimately we are looking to see if referrals have been made within appropriate timeframes, and that patients get the care they need,” said Dr. Andrews. “Are people being tested and referred when they should be, are things being missed? This is why the pilot program is so important – we want to work out whether the guidelines directing the patient through the most appropriate channels for treatment, and in the right way.”
Peter Larsen agreed. “That’s right. From our internal perspective, at Specsavers, we can build some very strong data of health outcomes that are derived from having hundreds and hundreds of optometrists taking a singular approach to a referral pathway.
Mr. Larsen said data collected from the pilot program would highlight areas of eye care management that need to be addressed, and going forward, both Specsavers and RANZCO would do this with targeted education. “We’re looking at some really simple measures to prove things but the power of the data collected is in the educational opportunities. There’s a revolution on CPD to go with this – once you can see individual responses and benchmark them against the group /industry / demographics, you should be able to build education to change behaviour and effect better outcomes as opposed to building education to get CPD points,” said Mr. Larsen. Already RANZCO has committed to providing optometrists with training at its annual Scientific Congress in Melbourne next month.
Is There Value in the Data?
Some may argue that Specsavers’s clinical approach and systems will differ from those of independent practice, meaning the data collected via the pilot project could not be applied to the eyecare profession as a whole. Both Dr. Andrews and Mr. Larsen agree that this is something that will be considered over time.
“Across Specsavers, we have consistency of equipment and pre-test processes but we’re very cognitive of the fact that our optometrists run their own consulting rooms; they’re totally independent in this regard and they have disparate ways of managing their clinics. There is no data available that analyses the appropriateness of Specsavers’ referrals versus referrals from other optometry practices and that’s something we’re hoping to learn more about – we want to be able to collect the data, to create a framework to be able to measure and prove effect,” said Mr. Larsen.
On a broader note, he said, “We know demographic data and the prevalence of eye disease, but there is no large study data in this environment to prove that optometrists and ophthalmologists work well together and that we’re actually effective. There are many people who say they’re very good, but we’d beg to suggest you don’t know until you start measuring,” said Mr. Larsen.
Asked whether optometrists outside the Specsavers group had concerns about whether data collected would be representative of the sector as a whole, Mr. Larsen said, “I am actually surprised at how little push-back we are seeing. There’s a bit of noise, much less than we expected, and that’s a great thing so I hope more optometrists will get on board. All of the optometrists we have heard directly from so far have been very supportive. This is day one of something exciting, so my message would be let’s take our political hats off and focus on the patient, rather than on brands and supposedly different styles of practice. When you talk about systems, ultimately whatever practice an optometrist works from, they can make a referral to an ophthalmologist. “When you consider varying approaches to patients, let’s remember, this hasn’t been designed around a Specsavers practice, it has been designed around optometry as a profession and we’ve taken the step of agreeing to adopt it. So we hope many others will get on board with RANZCO’s guidelines and give it a go. With piloting comes assessment, with assessment comes process review, and that leads to tweaks of pathways and guidelines so that we reach a better and better methodology for looking after patients.”
Dr. Andrews said some independent optometrists had expressed interest in contributing to the data however during the pilot stage of the project, RANZCO was restricted in its ability to collate and assess data from multiple difference sources. “Specsavers has a lot of technology that’s common across practices enabling individual optometrists to contribute their data to the pilot project. There will be hundreds of independent optometrists who will have other data that we’d like to assess as well. Right now we’re working with Specsavers because it’s a manageable way to facilitate the pilot program. In two years, if we find we are effecting behavioural change, we will need to give further consideration to engaging more optometrists in the process.” Dr. Andrews added that it was not necessary to have the Oculo system, developed by Centre for Eye Research Australia and supported by Specsavers, to contribute data. “A few ophthalmologists are using it but not everyone, so this program is not dependent on Oculo,” said Dr. Andrews. “Ultimately RANZCO hopes to collect data more widely, but the pilot program is our starting point”.
Fuelling the Medicare Review
As well as clarifying and improving patient pathways, both RANZCO and Specsavers hope the data gathered will provide solid evidence of the positive impact optometrists and ophthalmologists have on eye health in Australia. This in turn may assist with securing reasonable patient reimbursements for treatments by Government, which are currently being examined as part of the Medicare review.
“The Medicare review is taking a very long time,” said Dr. Andrews. “At this time we don’t see how the relationship (between RANZCO and Specsavers) impacts the Medicare review other than both parties would like to see patients continue to be reimbursed appropriately for their treatments,” he said.
Mr. Larsen agreed. “We know the Medicare review is a big task and we know that it will be taking an evidence-based look at every item number across all the health professions.
“We know this review is part of what will be an ongoing process of review – and we want to be able to gather rock-solid evidence that the work optometrists are funded to undertake is valuable and can demonstrate a public health outcome – as a profession, we need to be able to give more detail than item number ‘x’ being billed 3 million times. We actually need to be able to show what the outcomes of that work was, for example, the outcomes of the glaucoma referrals we make. In short, we need to be able to demonstrate value to the public purse… we’re very aware that the health budget is challenged and so we need to go on the journey of
The Review taskforce has also made clear that it expects co-professionals to work together and collaborate. Our arrangement with RANZCO provides a clear signal that optometry and ophthalmology will work together for the public health benefit. It’s an important indicator of our shared willingness and desire to work together and that this is all about patients, nothing more, nothing less.
Will there be savings?
When new, more efficient systems are put in place as a result of review process, there is often an expectation that costs will decrease, however in this case, Dr. Andrews expects the upfront costs may rise.
“From our perspective this pilot program will show whether the referrals being received are the right sort of referrals as opposed to reducing the number of referrals. I actually believe that referrals will go up significantly in the next few years because the diseases we’re talking about are diseases of ageing.
“In a different setting, RANZO is talking to government agencies and organisations such as Vision 2020 about health promotion activities that will increase public awareness of the need to undergo testing for various diseases such as diabetes and glaucoma. Once this happens, costs to government will rise, which will make it increasingly important for both professions – optometrists and ophthalmologists – to have evidence of people being appropriately treated and referred on. We will need to be able to demonstrate that we’re not just doing more tests for the sake of it.
“We believe optometry and ophthalmology are well placed to do this and that there is a mountain of work to do in the future, but we need to gather data to prove that.
“Of course in the end, a more proactive approach to managing eye health will generate savings at the other end by preventing blindness,” Dr. Andrews concluded.
Optometry Australia Speaks Out
Optometry Australia re-convened its Glaucoma Clinical Practice Guide Working Group in response to the release of new guidelines on glaucoma management by RANZCO in collaboration with Specsavers.
Made up of nine practitioners with expertise in the area of glaucoma assessment and management, the working group was charged with determining the clinical implications and reviewing the RANZCO Referral Pathway guidelines.
“We note that these guidelines appear to be modelled on the UK system where optometric scope of practice is not at the same level as it is in Australia,” Ms. Quilty told mivision. “We note there is no comment about intra-professional referrals either. There will be other matters raised in addition to these points when our review is complete.”
Ms. Quilty said the Referral Pathways were discussed at a meeting of Presidents of our Federation on Saturday 3 September and final discussions were to take place at the National Board meeting on 23 September. Optometry Australia had also met with the Optometry Board of Australia to discuss the RANZCO Referral Pathway guidelines and any possible impact on the existing regulatory guidelines, a concern Ms. Quilty said members had raised with Optometry Australia.
“We note that the Optometry Board of Australia has previously endorsed the recommendation from the NHRMC Guidelines that ‘the professional roles, responsibilities and referral pathways are best determined in individual cases based on location, resources, skill-base of local health care practitioners and patient choice’. We appreciate the complexities of glaucoma management and continue to provide assistance and clarification in this area with the recent publication of the Optometry Australia Clinical Practice Guide for the Diagnosis, Treatment and Management of Glaucoma developed through the input of the above mentioned Working Group.
“Optometry Australia notes that all optometrists in clinical practice have as their central concern, the clinical care of the patient,” said Ms. Quilty.
OBA Code of Conduct
Ms. Quilty referred to the Optometry Board of Australia’s Code of Conduct, which states that providing good care includes:
Ms. Quilty said Optometry Australia would provide views about the Pathway following the National Board’s review of the Glaucoma Working Group’s advice and response from the OBA.