Evaluation of the Medical Specialist Outreach Assistance Program and the Visiting Optometrists Scheme

4.2 Other and more recent comparative studies

Page last updated: 28 February 2012

Rankin et al. (2001) estimated the out of pocket costs of rural patients in Western Australia when accessing specialist services in a regional or metropolitan setting. The study was based on a random sample of 50 patients attending a visiting rural surgical service in 1998-99. Patients were surveyed to assess the cost of accessing these services including time lost from work, distance and travel expenses. The cost of attending a base metropolitan hospital was then modelled for the cohort. It was determined that 16 patients required an escort. It was estimated that for the patient attending a specialist consultation in a local rather than metropolitan location resulted in savings of AU$1,077. Savings were estimated to occur across all categories of costs (travel time, distance travelled, lost income, provision of an escort and waiting time).

In a subsequent study, Gruen et al. (2006) extended the original evaluation of outreach services in the Northern Territory to examine the effectiveness of regular surgical, ophthalmological, gynaecological, and ear, nose, and throat outreach visits, compared with hospital clinics alone. The evaluation examined the impact on access, referral practices, and outcomes for the populations of three remote Aboriginal and Torres Strait Islander communities in northern Australia over 11 years (from 1990 to 2001). The specific variable reviewed included the proportion of patients referred, the time from referral to initial specialist consultation, and the rates of community-based and hospital-based procedures. Over the time period examined there were 2,339 new surgical problems presented in 2,368 people. The provision of outreach clinics improved the rate of referral completion (i.e. patient referred getting to see the relevant specialist) by around 40%.

In addition, timeliness of referral was analysed by the urgency of referral, which improved by an estimated 30%. The study found that the outreach clinic had no effect on initiation of referrals (i.e. the overall number of referrals made). However there were an additional 156 opportunistic presentations on outreach clinic days. Specialist investigations and procedures in community clinics were found to remove the need for many patients to travel to hospital. Outreach consultations were associated with a reduced rate of procedures that needed hospital admission. The authors concluded that “specialist outreach visits to remote disadvantaged Aboriginal and Torres Strait Islander communities in Australia improves access to specialist consultations and procedures without increasing elective referrals or demands for hospital inpatient services” (Gruen et al. 2006).

McDermott and colleagues (McDermott, 2006 McDermott & Segal 2006; McDermott, 2003 McDermott et al. 2003; McDermott, 2004 McDermott, Tulip & Sinha 2004; McDermott et al. 2007; McDermott, 2004 McDermott, Tulip & Schmidt 2004) examined the impact of improved primary level diabetes care for Torres Strait Islander people, involving outreach specialist services. Outreach services were only one aspect of a complex intervention related to chronic disease management, in particular diabetes care in Torres Strait and other communities in Cape York. The intervention commenced in 1999 and involved:

    • a visiting diabetes outreach specialist team
    • evidence-based diabetes screening and referral and management protocols
    • registers and recall systems managed by local Aboriginal health workers
    • clear roles and responsibilities for health workers in chronic disease management, including orientation and regular professional updates
    • an information system integrating care plans for a range of common chronic conditions
    • an audit and feedback system for quality improvement (McDermott et al. 2007).
The approach combined a visiting specialist services with quality improvement processes at the local primary care level. Information systems evolved over time. From 2001 the state health department adapted and implemented a computerised health information system (Ferret) to be used in Aboriginal and Torres Strait Islander primary care settings across Queensland. McDermott et al. (2007) reported that by 2007 Ferret had been implemented in more than 50 community clinics in Queensland, predominantly in the northern areas.

Patient data is maintained on a central server and can be accessed in real-time from clinics. The system allows for information on people resident in the community to be captured. Patients requiring recall for chronic disease management can be identified through the system. From 2004 Ferret customised de-identified reports were produced by clinic, condition, age group, and sex. These are used by staff and management to monitor the performance of the primary care service for priority conditions (e.g. diabetes, renal, cardiovascular disease, rheumatic heart disease). As at 2006 12,765 ‘regular’ clients were registered on the system for the Torres Strait and Northern Peninsular district (McDermott et al. 2007).

McDermott and colleagues have been able to demonstrate that “much routine diabetes care can be done by non-physicians based in the community …[and] structured care in remote settings can improve control of blood pressure and reduce complications, especially infections, in high risk populations” (McDermott et al. 2003). They indicate that since 1999 “there have been significant improvements in systems for early detection and case management of people with diabetes and other chronic conditions…in line with current best practice in community level chronic care, although there remain problems with system and health staff support, and these require continuous attention” (McDermott et al. 2007).

Scrace & Margolis (2009) presented a study of a visiting skin cancer clinic provided by the Royal Flying Doctor Service (RFDS). The service is a fly-in fly-out based clinic which is run concurrently with the regular primary care medical service. The skin cancer skin clinic is exclusively focussed on skin cancer diagnosis and management. A total of 316 people were seen during the study period, 29% of whom were Aboriginal or Torres Strait Islander and 39% aged 50 years and older. Of the 316 people seen there was an average of 1.1 consultations per person. A procedure was performed in approximately one third of consultations. The number of lesions removed per year for the population services increased from 37 to 42 after the intervention, with no statistically significant change in the percentage of excised lesions that were malignant (44%). There was a four-fold rise in melanoma detection rate for males aged 50 years and older.

Turner at el. (2011a; 2011b) examined the models for service integration between ophthalmology and optometry in 10 case studies in rural and remote regions in Australia. The regions include Cape York, Longreach, Great Southern Western Australia, Pilbara, Kimberley, New South Wales Outback Eye Service (Bourke and other towns), Northern Territory Top End, Northern Territory Central Outreach, Northern Territory Central Alice Springs and SA IES. Semi-structured interviews were held with key stakeholders from nine eye health services (one service was responsible for two regions examined). Stakeholders included nurses, clinic clerical staff, Aboriginal health workers, hospital administrators, optometrists, ophthalmologists, eye health managers regional eye health coordinators (REHC).

Eye health services were assessed across a range of criteria including the quality and level of coordination, clarity and strength of communication channels for shared care and referrals, and a history of regional eye health coordinators facilitating systems between the two professions. Three models of coordination were recognised: scheduled, simultaneous, sequential. These are described in Table 27 below, together with examples of where these models are working well. In addition to service integration scores, clinical activity, waiting times and cost were compared across the 10 communities.

The service integration scores are shown in Table 28 and range from two out of 10 to 10 out of 10. Regions with higher service integration scores (greater than or equal to five) demonstrated higher levels of cataract operations per week (from 5.0 to 9.3), high levels of clinical examinations per week (61.8 to 88.9) and reduced average waiting times for clinics (8.8 months to 5.1 months). There was also a positive correlation found between surgical case rate (the % of surgical cases per clinic attendance for ophthalmologists) and service integration. Regions with higher levels of integration had slightly higher costs per clinic attendance ($605 to $694).
Table 27 – Service integration options as demonstrated in most efficient regionTop of page

Options for coordination

Demonstrated in most efficient regions

1 Informal

  • Optometry and ophthalmology not coordinated, but close communication at all times
  • Pilbara: close relationship between optometrists and ophthalmologists, including direct phone contact any time

2 Sequenced

  • Early optometry trips for screening purposes followed later by joint trips and postoperative optometry-only visits
  • Pros: improves efficiency and less duplication of screening roles
  • Cons: additional screening  appointments can result in patient fatigue
  • Cape York: optometrists play screening role for ophthalmologist in sequenced visits

3 Same day

  • Initial vision screening and refraction performed by optometrist and review and operation by ophthalmologist on same day if required
  • Pros: good communication between service providers
  • Cons: patients may have to wait for next ophthalmologist visit if busy schedule
  • Cape York & Longreach: trips are coordinated so optometrist/ophthalmologist visit at the same time and same site

Source: Turner et al. 2011b

Table 28 – Service integration scores for the ten regions
Region Rating Rationale
Cape York 10/10 10 years of REHC + assistant + sequenced and simultaneous clinics
Longreach 10/10 Run privately with co-located optometry and ophthalmology planned to visit simultaneously
Great Southern Western Australia 3/10 No coordinators or collaboration with local optometrists
Pilbara 8/10 Roving optometrist who coordinates remote community visits with good communication channels. No effective REHC
Kimberley 5/10 Roving optometrist coordinates, no effective REHC, but because of multiple clinicians, less effective communication than Pilbara
NSW Outback Eye Service(Bourke and other towns) 7/10 2 managers and simultaneous optometry clinics. But poor communication channels with ICEE optometry network
NT Top End 2/10 Multiple coordination agencies but poor communication between optometry and ophthalmology and REHC
NT Central Outreach 7/10 Effective REHC, simultaneous clinics
NT Central Alice Springs 4/10 Less collaboration of professions than on outreach
SA (IES) 9/10 Long-term REHC with simultaneous clinics and optometry pre-screening.

Source: Turner et al. 2011b

The authors discuss issues concerning the role of regional eye health coordinators (REHC). They point out coordination services provide multiple benefits including facilitating engagement with the local community, eye professions and health facilities. They recommend that the roles of eye health coordination need development, definition and appropriate funding. Several levels of involvement of REHC are observed across Australia including: workers at the primary care level undertaking examinations and managing straightforward eye health issues, providing local level coordination for visiting eye health teams (e.g. identifying people, interpretation, rounding people up who need to be seen or followed up), and regional coordination (e.g. scheduling visits across eye health and other visiting specialities.) They refer to this role as the ‘eye health manager’.

They also discuss the options and opinions related to clinical leadership of eye health services, for example, having a single consultant specialist responsible for coordination or locating responsibility in a public hospital when several consultants are involved. No specific conclusions were drawn.

In an extension of the first study, Turner et al (2011a) examine the impact of the funding model (private fee for service versus salaried practitioner) in levels of service provision. To place the analysis in context, the authors analysed the supply of ophthalmologists (full-time equivalent clinical staff per population), and found that in all 10 remote regions supply was below the national average (28,000 per ophthalmologist), ranging from 22,000 to 530,000 people per ophthalmologist. The supply of optometrists was also below the national average, but to the same extent ranging from 13,000 to 43,000 people per optometrist, with the national average of 5,400 per optometrist. Cataract surgery rates in the 10 regions were also below national averages, ranging from 904 per million people up to 6667 per million people, with the national average 9500 per million people.

Regions where ophthalmologists were paid on a fee-for-service basis had significantly higher levels of clinical activity (around three times more cataract operations per week, and double the number clinical examinations per week), shorter waiting times (4.4 months compared with 8.9 months) and lower costs per attendance ($549 per attendance compared with $846). Across the regions funding sources for eye health services varied but on average the mix was 37% federal (Medicare, MSOAP and REHCs), 44% state (clinical/surgical infrastructure and consumables, some travel/accommodation, local health services) and 19% other including NGOs, private funding and patient fees.Top of page