Manpower Requirements in Ophthalmology

Ophthalmology manpower requirements estimates presented to the Graduate Medical Education National Advisory Committee (GMENAC) are explained and compared to previous estimates published by the American Academy of Ophthalmology. Both studies used similar methods but reached different conclusions; the reasons for this are explored and shown to be due principally to (1) differences in projected hours per week spent in patient care by ophthalmologists, and (2) differences in the medical workload traceable to differences in estimated visit time and needs for care in the area of systemic ophthalmology. The manpower implications of the principal contributors to the ophthalmology workload are examined, and differences between the two studies regarding these conditions are documented. Areas for further research are suggested.     

GMENAC Report on Ophthalmology

This paper determines how the GMENAC report was prepared and presents a perspective on the report. The Department of Health and Human Services mandated that the panel should have five ophthalmologists as well as five nonophthalmologists who were physicians, plus two optometrists to make 12 members. Of the five ophthalmologists, this author was the only one in full-time practice; the other four ophthalmologists were university based. A perspective on the report is that refractions will be approximately 60% of the work load of the ophthalmologist with cataract surgery being 6.5%, and other types of office procedures making up the rest of the working day. It is estimated that by 1990 we will have 14,688 ophthalmologists, and this will mean a surplus of 4,700. It is this author’s opinion that the ophthalmologists may well work more hours per week than the 41 hours estimated by the panel, as more hours will be needed to pay their overhead. The panel agreed that the medical school training programs must decrease the number of residents.     

Ophthalmology (eye physician and surgeon) manpower studies for the United States. Part IV: Ophthalmology manpower distribution 1983

Physician distribution continues to be important in health manpower planning. In 1980 the GMENAC Committee reported uneven geographic distribution of physicians and uneven rates of use of health services in the United States. This study uses zip code sectional areas as the geographical units to describe the geographic distribution of ophthalmologists. Ophthalmologists to population ratio was calculated for each of 532 zip code sectional areas in the US. Results indicate considerable variation in availability of ophthalmologic services. However, this variation is not necessarily indicative of a serious maldistribution problem since there are regional differences in need and supply. This study found that less than 1% of the population did not have convenient access to an ophthalmologist. Resulting data should be helpful to both ophthalmologists considering relocating and residents seeking practice opportunities. Ratios should be used in conjunction with other demographic information available for the sectional areas.     

Perceived barriers to the provision of low vision services among ophthalmologists in India

PURPOSE: To identify and report the perceived barriers to the provision of low vision services among ophthalmologists in India. METHODS: Seventy nine ophthalmologists responded to a structured self-administered questionnaire. Information was collected to understand the level of awareness and barriers/constraints to provision of low vision services. Significant factors associated with each barrier/constraint and perceptions on providing low vision care were investigated. RESULTS: Lack of training/knowledge [65 (82.3%)], lack of awareness [59 (74.7%)] and non-availability of low vision devices [57 (72.2%)] were perceived as the major constraints / barriers to providing low vision care. At least one significant factor was found for each of the above constraints/barriers in providing low vision care. The perception of lack of awareness as being one of the constraints/barriers was significantly higher [OR 3.97 (95% CI, 1.02 - 7.8)] among ophthalmologists from organisations providing low vision services. The perception of lack of motivation as constraint/barrier was significantly higher [OR 3.62 (95% CI, 1.3 - 10.3)] among ophthalmologists from organisations providing low vision services and/or those involved in VISION 2020: The Right to Sight programmes [OR 3.83 (95% CI, 1.4 - 10.4)]. The likelihood of responding that low vision care is time consuming was greater for those belonging to a teaching institute [OR 7.19 (95% CI, 2.0 - 26.1)], those involved in low vision services [OR 5.45 (95% CI, 1.8 - 16.5)] and those who knew that low vision is a priority in VISION 2020 [OR 15.1, 95% CI, 1.5 -155.4]. CONCLUSION: Ophthalmologists need more education about the benefits of low vision care in order to increase their level of awareness and knowledge.     

Present status of ophthalmological care for diabetic patients in Japan

PURPOSE: To investigate the present status of diabetic care provided by ophthalmologists working in hospitals and private clinics in Japan. METHODS: Questionnaires were mailed to 315 ophthalmologists. There was a return rate of 73%. RESULTS: Problems identified in the clinics were: (1) many diabetic patients who complain chiefly of ophthalmological symptoms voluntarily request their first ophthalmological examination; (2) appropriate cooperation between ophthalmologists and physicians is not established; (3) assessing the level of blood glucose control is difficult; and (4) scheduling of appointments is inadequate. Moreover, (1) inadequate handling of patients who discontinue their ophthalmological examinations, and (2) the lack of an established patient education program were seen as problems common to both hospitals and clinics. CONCLUSIONS: For the resolution of these problems, comprehensive countermeasures should be developed urgently by medical associations, medical administrators, and other relevant entities.     

Demografischer Wandel

Background

Demographic change not only affects patients with ophthalmological diseases but also ophthalmologists.

Objectives

The aim of this article is to evaluate the consequences of an aging society on health care provision. How can these challenges be overcome?

Material and methods

Evaluation of publications from the German Federal Statistical Office about the current and projected population, analysis of own studies about health care provision, utilization, and delivery as well as the presentation and discussion of regulatory and organizational conditions.

Results

There is a continuous increase in chronic and age-related diseases. At the same time the prevalence of multimorbidity and the number of patients dependent on long-term care is rising, leading to an increase in the demand for ophthalmological care. Regarding health care providers we observed a cutback in qualified ophthalmological personnel, especially for remote areas thus causing difficulties in providing adequate eye care to the population.

Conclusion

To deliver health care to a growing number of patients with a decreasing number of medical professionals is the major challenge of demographic change. This will have an enormous impact on ophthalmological health care in terms of maintaining high quality health services covering a nationwide area.     

2007年云南省医疗机构眼科现状调查

目的了解截至2007年云南省的眼科医疗现状和服务能力。设计横断面问卷调查。研究对象云南省内165家医疗机构。方法采用卫生部统一设计的眼科机构现状调查表,于2007年10-12月对云南省内医疗机构的眼科现状进行问卷调查。收集整理并分析问卷结果。主要指标医护人员数量、年手术量、门诊量、可独立完成白内障手术的医生数量。结果参与调查的的165家医疗机构共有眼科医生735名,能独立完成白内障手术者392名,眼科护理人员771人。全省16个地州市中,昭通地区每百万人口拥有的眼科医生资源仅为7人,而昆明市为32人。2006年所有医疗机构共完成眼科各类手术58346例,包括白内障23833例。尚未开展白内障手术的医疗机构有27家。各级医疗机构仅29家（17．6％）拥有较好的眼科设备,6家（3．6％）没有任何眼科设备。结论云南省不同等级和不同地区之问的医疗机构眼科水平差异很大,人力资源分布不均,工作效率较低,需要进一步进行资源整合和优化利用,以满足群众对眼科医疗服务的需求。（跟科,2010,19：142—144）     

A comparison of charges by optometrists and ophthalmologists under the Medicare program.

Medicare data obtained from the Health Care Financing Administration was analyzed in relation to average allowed charges by optometrists and ophthalmologists. Optometric charges are considerably lower than ophthalmological charges for all services compared. The policy of different reimbursement levels is currently a major issue being considered by the Physician Payment Review Commission. Optometry must demonstrate that the procedure codes for which they submit Medicare claims are comparable and identical in service content to those provided by ophthalmologists.     

The European Glaucoma Society Glaucocard project: improved digital documentation of medical data for glaucoma patients based on standardized structured international datasets

Purpose  To evaluate existing international IT-based ophthalmological medical data projects, and to define a glaucoma data set based on existing international standards of medical and ophthalmological documentation. To develop the technical environment for easy data mining and data exchange in different countries in Europe. Methods  Existing clinical and IT-based projects for documentation of medical data in general medicine and ophthalmology were analyzed to create new data sets for medical documentation in glaucoma patients. Different types of data transfer methods were evaluated to find the best method of data exchange between ophthalmologists in different European countries. Results  Data sets from existing IT projects showed a wide variability in specifications, use of codes, terms and graphical data (perimetry, optic nerve analysis etc.) in glaucoma patients. New standardized digital datasets for glaucoma patients were defined, based on existing standards, which can be used by general ophthalmologists for follow-up examinations and for glaucoma specialists to perform teleconsultation, also across country borders. Datasets are available in different languages. Different types of data exchange methods using secure medical data transfer by internet, USB stick and smartcard were tested for different countries with regard to legal acceptance, practicability and technical realization (e.g. compatibility with EMR systems). Conclusion  By creating new standardized glaucoma specific cross-national datasets, it is now possible to develop an electronic glaucoma patient record system for data storage and transfer based on internet, smartcard or USB stick. The digital data can be used for referrals and for teleconsultation of glaucoma specialists in order to optimize glaucoma treatment. This should lead to an increase of quality in glaucoma care, and prevent expenses in health care costs by unnecessary repeated examinations. Presented in parts at the 105th meeting of the German Society of Ophthalmology (Deutsche Ophthalmologische Gesellschaft—DOG) 2007. Supported by an unrestricted grant from MSD/Chibret Europe.     

Ten years' experience in low vision practice

The Low Vision Clinic at the Palmerston North Hospital has now been operating for 10 years. Over the course of these ten years a number of factors have emerged which can be as readily applied to general ophthalmological practice as to low vision practice. The philosophy of low vision care is one of which all ophthalmologists should be aware and includes factors to be taken into account when dealing with children, people in the workplace, and everyday factors involved in daily living activities, all of which are equally relevant in routine ophthalmological practice. This paper endeavours to share some thoughts on these factors and also discusses means by which the visually handicapped can be helped in areas where specialist low vision services are not readily available.     

TEN YEARS' EXPERIENCE IN LOW VISION PRACTICE

The Low Vision Clinic at the Palmerston North Hospital has now been oerating for 70 years. Over the course of these ten years a number of factors have emerged which can be as readily applied to general ophthalmological practice as to low vision practice. The philosophy of low vision care is one of which all ophthalmologists should be aware and includes factors to be taken into account when dealing with children, people in the workplace, and everyday factors involved in daily living activities, all of which are equally relevant in routine ophthalmological practice. This paper endeavours to share some thoughts on these factors and also discusses means by which the visually handicapped can be helped in areas where specialist low vision services are not readily available.     

Indigenous access to cataract surgery: an assessment of the barriers and solutions within the Australian health system

Background: To identify barriers in the health systems that limit access to cataract surgery for Indigenous Australians and present strategies to overcome these barriers. Design: Interview and focus group‐based qualitative study. Participants: Five hundred thirty participants were consulted in semi‐structured interviews, focus group discussions and stakeholder workshops. Methods: Semi‐structured interviews with a cross‐section of health‐care professionals, eye care practitioners, primary health‐care workers, hospital staff and health department staff were conducted in 21 site locations. Focus group discussions with clients from seven Aboriginal Health Services in Victoria were conducted. Stakeholder workshops included Aboriginal Community Controlled Health sector, eye care sector, government departments and non‐government organizations. A total of 279 semi‐structured interviews were conducted in the Northern Territory, New South Wales, Queensland, South Australia, Victoria and Western Australia. Three stakeholder workshops were held. Main Outcome Measures: Barriers and solutions to increase access to cataract surgery for Indigenous Australians. Results: Analysis of the participant responses identified health system barriers at primary care, specialist care and hospital levels. These included: long waiting times, cost of surgery, complexity of the steps involved in treatment, lack of surgical capacity and low awareness of regional eye health needs. Strategies to overcome these barriers involve a system‐wide approach to increase provision and utilization of services. Conclusion: The need for surgery is real and services need to expand beyond current levels. The solutions for overcoming barriers to cataract surgery could be used as a model for other health interventions which rely on close interaction between primary and specialist care services.     

Utilization of eye care providers by Canadian adolescents: evidence from the Canadian Community Health Survey

ObjectiveTo examine whether different government-insured eye care coverage policies affect adolescents' access to eye care providers (ophthalmologists and optometrists) in Canada.DesignCross-sectional survey.Participants11 015 Canadian adolescents aged 12 to 17 participated in the Canadian Community Health Survey (CCHS) 2007-2008.MethodsSelf-reported use of eye care providers, was compared between adolescents with and without government-insured routine eye examinations. The association between the utilization and the government coverage was evaluated by using prevalence ratios (PR) and 95% confidence intervals (CI).ResultsAcross Canada, 45.6% of adolescents used eye care providers over a 12-month period. The utilization rate was highest (46.4%) in provinces with insured routine eye examinations, lower (35.9%) in provinces without insured routine eye examinations, and lowest (27.1%) in the 3 territories. Significantly lower utilization rates were also found in males (10% less likely than females); in those without dwelling ownership (19% less likely than those who owned); in those who read fewer than 3 hours weekly (13% less likely than in those who read 3 or more hours per week); and in nondiabetics. After adjusting for the confounding effects of these factors, we found that adolescents living in provinces with uninsured routine eye examinations were 24% less likely to utilize eye care services (PR = 0.76; 95% CI 0.67-0.85); whereas those in the 3 territories were nearly 40% less likely to use eye care providers (PR = 0.63; 95% CI 0.48-0.83) compared to adolescents in provinces with insured routine eye examinations.ConclusionsLack of eye care insurance for routine eye examinations has a negative impact on adolescents' access to eye care providers in Canada.     

Telemedicine for Retinopathy of Prematurity Diagnosis: Evaluation and Challenges

Retinopathy of prematurity (ROP) is a vasoproliferative disorder affecting low birth weight infants. Although timely diagnosis and treatment can significantly reduce the risk of severe complications, ROP remains a leading cause of childhood blindness worldwide. Limitations of current disease management strategies include extensive travel and logistical coordination requirements for ophthalmologists and neonatologists, decreasing availability of adequately trained ophthalmologists at the point of care, variability in how retinal findings are diagnosed and documented, and a growing need for ROP care worldwide. Store-and-forward telemedicine is an emerging technology by which medical data are captured for subsequent interpretation by a remote expert. This has potential to improve accessibility, quality, and cost of ROP management. In this article, we summarize the current evaluation data on applications of telemedicine for ROP, particularly involving the diagnostic accuracy and reliability of remote image interpretation by experts. We also address challenges such as the cost-effectiveness of telemedicine, and highlight potential barriers to implementation of these systems. Understanding these principles is essential to determine future directions in research and development of telemedicine systems for ROP, as well as for other ophthalmic diseases.     

Post-lockdown challenges for ophthalmologists during COVID-19 pandemic in India: A survey-based analysis

Purpose:The purpose of this study is to evaluate the post-lockdown challenges during Coronavirus disease 2019 (COVID-19) pandemic amongst the ophthalmologists in India.Methods:An online survey was sent to the practicing ophthalmologists across India. Data were collected from the responding ophthalmologists and analysed using Medcalc 16.4 software.Results:A total of 794 responses were obtained. Most respondents (51%) were in the age group 30–50 years and were in independent practice (40.05%). Almost three-fourth of ophthalmologists resumed their surgical services after a gap of more than a month post-lockdown. Almost a third of the respondents had significant reduction in their surgical workload during this period. Significant fear of contracting COVID-19 infection in the operation theatres was reported while moderate difficulty was found in procuring protective gear during immediate post-national lockdown period.Conclusion:The pandemic has changed the ophthalmic practice significantly, with patient and staff safety becoming areas of major concern. Both financial and psychological concerns affecting healthcare workers need addressing for continued patient care.     

The need and total cost of Finnish eyecare services: a simulation model for 2005–2040

Purpose: The aims of this study were: (i) to create a structural simulation model capable of predicting the future need and cost of eyecare services in Finland; and (ii) to test and rank different policy alternatives for access to care and the required physician workforce. Methods: Using the system dynamics approach, the number and cost of patients with cataract, glaucoma, diabetic retinopathy and age‐related macular degeneration (AMD) were described with causal‐loop diagrams and were then translated into a set of mathematical equations to build a computer simulation model. Mathematically, the problem was formulated as a set of differential equations that were solved numerically with specialized software. The validity of the model was tested against prevalence and administrative historical data. The costs covered by the public sector in Finland were obtained from 2003 from the Finnish Hospital Discharge Register (including outpatient care), the Finnish Social Insurance Institution and a survey of hospital price lists. Different levels of access to public care were then simulated in four eye diseases, for which the model estimated the need for services and resources and their costs in the years 2005–2040. Results: The model forecasted that the adoption of the 2005 national ‘access to care’ criteria for cataract surgery would shorten waiting lists. If the workload of Finnish ophthalmologists were kept at the 2003 level, the graduation rate of new ophthalmologists would have to increase by 75% from the current level. If all glaucoma patients were followed in the public sector in future, even this increase in training would not meet the demand for physician workforce. The current model indicated that the screening frequency of diabetes can be increased without large sacrifices in terms of costs. AMD therapy has a significant role in the allocation of future resources in eyecare. The modelling study predicted that ageing alone will increase the costs of eyecare during the next four decades in Finland by about 1% per year in real terms (undiscounted and without inflation of unit costs). The increases in total yearly costs were on average 8.6% between 2001 and 2003. Conclusions: The results of this modelling study indicate that policy initiatives, such as defining criteria for access to care, can have substantial implications on the demand for care and waiting times whereas the effect of ageing alone was relatively small. Measures to control several other factors – such as the adoption and price level of new technologies, treatments and practice patterns – will be at least equally important in order to restrain healthcare costs effectively.     

Professor Jules Fran?ois Memorial Lecture. Code of ethics and its practice in ophthalmology

Several Articles are shown from the code of ophthalmological ethics written by late Professor Jules Fran?ois. Some examples found in the history of ophthalmological practice that complied with these articles are demonstrated. In the modern society with aging population, ophthalmic surgery must be done with great care; long-term prognosis should always be taken into consideration for the patients to be able to maintain high quality of life throughout their life-span. To achieve this, meticulous and continuous care of patients by means of best possible noninvasive techniques must be exercised and this is a conscience of ophthalmologists.