Breaking down barriers …. alliances to improve access to specialty services

1. A case for vision care in Nova Scotia and Canada Breaking down barriers ….alliances  to improve access to specialty services Royal College NSS Summit Ottawa 2018 Ottawa, March 2018

2. The case of Ophthalmology G. R. La Roche MD FRCSC PROFESSOR AND DIVISION CHIEF PEDIATRIC OPHTHALMOLOGY AND ADULT STRABISMUS DEPARTMENT OF OPHTHALMOLOGY AND VISUAL SCIENCES DALHOUSIE UNIVERSITY

3. Know the players and potential allies • Ophthalmology • Optometry • Family Medicine • Technology, Megadata, AI • Government Public Health • NGOs like CNIB, Fight for Blindness etc

4. Two main routes of Referral to Ophthalmology • Optometrists: Many Surgical cases • Physicians: Family Doctors, Other specialists (Medical specialties) • Medical Referral routes for ophthalmology are failing • Lacking Family Docs (see NS as example .. 10% without) • Lacking competent Family Docs for Eye Care (Curriculum issue) • Silent blinding conditions (D. Retinopathy, Mac. Degeneration, Amblyopia)

5. Know some issues of access • Vision restoration - Cataract surgery wait time: increasing again • Distant, and indigenous populations: neglected • Referral routes: deficient and changing • Evolving practices: insufficient in Ped. Ophth, Neuro-ophth • Pediatric vision primary care: under-utilized at 30% • Diabetic retinopathy screening and treatment: under-utilized at 40%

6. Increases (4 provinces) Looking through the lens of cataract surgery… Proportion of patient’s accessing care within wait time benchmarks (2012-2016) Declines (6 provinces) Source: CIHI, 2017, Wait Times for Priority Procedures in Canada, http://waittimes.cihi.ca/All#year

7. Nova Scotia – Pediatric Strab. surgery Case Example: Strabismus surgery adults – Wait Times Data

8. Patient/family need for access Overarching value trumps care-givers’ turfs

9. Alliances to improve access • Scope of competence • Ophthalmology complemented by Optometry • Education and participation • Target population, Family Medicine, Optometry, Nursing • Government • Quality and access at predictable costs

10. Ophthalmology solutions to improve access • COS Provincial Alliances (Eye Health Councils) • Glaucoma • Diabetic Retinopathy • Pediatric ophthalmology • Many Telemedicine programs include First Nations • Senior Vision Rehabilitation Recommendations • Re-allocations of $$ to sub-specialty fees • Pediatric and Neuro-ophthalmology

11. < 6months EVSP vision screening program: failure (+) on screening, or failure to be screened Teacher’s suspicion of Vision problem Figure 1 NovaSPPEC Treatment Initiation Protocol For Optometrists Figure 2 NovaSPPEC Access Stream Protocol Entry to NovaSPPEC via Access Stream Protocol Red eye reflex at birth Red eye reflex at Abnormal Vision As per NovaSPPEC Normative Standards Start Refractive Rx Control Visit 3/12 after Initiation of refractive Rx Normal VA Normal Alignment As per NovaSPPEC Normative Standards Yearly Follow up To age 12 b birth < 1 week No Red Reflex Refer to Ophthalmologist Normal Refraction As per NovaSPPEC Normative Standard Red eye reflex at each vaccination AND History to identify Children at risk Abnormal VA Abnormal alignment Normal VA Abnormal Alignment Abnormal VA Normal Alignment Refer to Optometrist or Ophthalmologist For NovaSPPEC Standard examination Positive History Of Risk Initiation of full time occlusion Refer to OMD < 2 months Continue with Refractive Tx Refer to OMD < 2months Refer to Optometrist or Ophthalmologist For NovaSPPEC Confirmatory Standard examination Initiation of full time occlusion Follow up after 1 cycle* < 6months Development of abnormal alignment Normal Alignment + NI or recurrence in abnormal VA Normal Alignment + improvement in VA Follow-ups x 2 cycles Children sent by parents for one (x1) eye exam Before age 12 years Routine Optometric or Ophthalmologic Eye examination Continue with Tx Refer to OMD < 1 Month Continue with Tx Refer to OMD < 1 Month Normal Alignment & Normal VA** Follow-up for recurrence q 1/12 x 2 Then q 4/12 x 2 then q 6/12 until age 12 < 12months

12. Future access Problems &Reliefs P1: Aging population increases ophthalmology demand - Cataracts - Glaucoma - Retinal degenerative diseases - Acquired Strabismus with diplopia P2: Aged Ophthalmologists of 2018 x2 > 65y/o --- x1 < 35y/o 2028 : 1/3 > 65y/o Cataract patients = from 21% to 32 % New graduates/year : flat 40 R1: Technology - Imaging - 5G communications - A.I. / VR - Robotics R2: Expanded Team - Fam.Docs - Optoms - Orthoptists

13. However … financial limitations • COS • Yearly membership $500 • One time vonluntary “gift” $700 • Doctors Nova Scotia • Ophthal. Section : $250 • Volunteers, time, dedication Priceless

14. Thank you Shanna DiMillo, Royal College Jennifer Brunet-Colvey, Canadian Ophthalmological Society Ken Rogers, Ophthalmologist, Fredericton, New Brunswick