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

9.1 Program effectiveness and cost effectiveness

Page last updated: 28 February 2012

Stakeholder views


Within eye health there are some varying views of the effectiveness of VOS, in particular for Aboriginal and Torres Strait Islander people. Many stakeholders outside of the optometry profession or eye health care had little or no knowledge of VOS.

In the survey of VOS optometrists, the majority (89%) assessed the scheme as being very effective or reasonably effective in terms of improving access for rural populations to optometry services. The scheme is judged to be very effective in improving access for non-Indigenous people by 41% of VOS optometrists and very effective in improving access for Aboriginal and Torres Strait Islander people by 32% of VOS optometrists.

Table 84 VOS optometrists views on the effectiveness of VOS in improving access for people living in rural and remote Australia
  How effective is VOS in improving access to optometry services for:
  Indigenous Australians Non-Indigneous people
1. Very effective 32% 41%
2. Reasonably effective 57% 49%
3. Not effective 11% 11%


Source: HPA survey of VOS service providers, 2011. See also Table 3.5 in Volume 3.



Survey respondents made a range of suggestions for improving the effectiveness of the scheme (see Volume 3 Table 3.6). The main suggestions related to improved coordination in relation to Aboriginal and Torres Strait Islander people. Good coordination has a crucial impact on effectiveness as it can significantly increase the number of patients that are actually seen during a visit (e.g. minimising ‘did not attends’), ensure high risk patients are seen, improve the reach of the program to patients who have not previously been seen by an eye health practitioner, and reduce the possibility that there is duplication (e.g. the same patient being seen by optometrists when they were recently seen by an ophthalmologist). Suggestions about improving coordination included improved funding for eye health co-ordinators, enhancing their role in coordination, reducing rates of no shows, improved coordination with visiting specialist services, sharing information about schedules for visiting ophthalmologists and also other visiting optometrists, and funding and training of support staff in local community settings who can support visiting services. Increasing the frequency of optometry visits was also seen as a key way for improving effectiveness.

Coordination was identified principally as a challenge for services delivered in remote and very remote locations (see Table 85). As mentioned above, the availability of an eye health coordinator is considered one of the key areas which could improve coordination of outreach services.

Table 85 VOS optometrists views on coordination in selected locations
  Inner and Outer Regional Remote and Very Remote Total
If you receive coordination assistance, how well coordinated are the VOS outreach services?
1. Good coordination, problems occur only occasionally 75% 47% 54%
2. Adequate coordination, there are problems but these are to be expected 25% 41% 37%
3. Poor coordination, there are regular problems encountered 0% 12% 9%
       
If coordination is necessary for what would improve the coordination of outreach optometry services in this location?
1. Availability of eye health coordinator 33% 19% 21%
2. More assistance from local service 17% 19% 18%
3. Availability of a driver   4% 3%
4. Better coordination with Local Aboriginal stakeholders   4% 3%
5. Community awareness of eye health issues   4% 3%
6. Share information about visiting other eye health practitioners   4% 3%
7. Other 33% 26% 27%
8. System is working well 17% 22% 21%


Source: HPA survey of VOS service providers, 2011. See also Table 3.18 and Table 3.19 in Volume 3.



A common theme amongst stakeholders is that the role of eye health coordinators was crucial but under threat, principally because of the lack of specific funding for these roles and competing demands within AMSs. Organisations with a specific interest in servicing Aboriginal and Torres Strait Islander populations such as ICEE and the Fred Hollows Foundation, consider the program to be effective, but emphasise the need for collaboration between AMSs and eye health coordinators.

The Optometrists Association of Australia emphasise that optometry is a primary health service, not a specialist service (Optometrists Association of Australia 2011). Its principal objective is to assess eye health needs and meet these through prescribing spectacles. A secondary objective is screening for more serious eye health diseases, which may require medical treatment by a GP or an ophthalmologist. Optometrists can also detect other diseases such as diabetes earlier than some medical practitioners.

In meeting the primary care goal of optometry, a key issue is whether patients are able to obtain spectacles. In 33% of locations identified through the optometrist survey, the optometrist believed there were problems in accessing the state/territory subsidised spectacle scheme (Table 86). In 70% of locations, optometrists reported that Aboriginal and Torres Strait Islander patients are usually able to obtain spectacles under a state subsidy scheme (84% in inner and outer regional areas, and 62% in remote and very remote areas). Separate arrangements are utilised for Aboriginal and Torres Strait Islander patients in 25% of locations, such as the scheme operated by the Fred Hollows Foundation in the Northern Territory. Comments on access to spectacles varied across jurisdictions (Table 87). Issues where eligibility criteria and administration differed between states were identified as problems for optometrists delivering outreach to locations near to state borders. Problems with the registration of Aboriginal and Torres Strait Islander people living in remote communities for state schemes were mentioned in the Northern Territory.
Table 86 VOS optometrists views on access to subsidies spectaclesTop of page
  Inner and Outer Regional Remote and Very Remote Total
Are there problems in eligible patients accessing the state/territory spectacle subsidy scheme?
1. Yes 30% 33% 33%
2. No 70% 67% 67%
 
When an Indigenous patient requires spectacles, what typically happens?
1. The patient will usually be able to obtain spectacles under a state spectacle subsidy scheme 84% 62% 69%
2. The local Aboriginal health service will be able to assist with purchase of spectacles 0% 8% 5%
3. A separate arrangement is in place through which spectacles can be supplied at no charge or low cost to the client 16% 31% 25%
4. Many patients are unable to obtain spectacles. 0% 0% 0%


Source: HPA survey of VOS service providers, 2011. See also Table 3.21 and Table 3.24 in Volume 3.



Some members of eye health teams consulted suggested that there were problems with the referral from optometrists to ophthalmologists. These views principally related to the role of optometrists in relation to outreach services for Aboriginal and Torres Strait Islander people.

Optometrists in general believed that referral to an ophthalmologist worked reasonably well where required. They recognised difficulties experienced by patients with gaining access to ophthalmologists, particularly in parts of the country. These included cultural and other barriers to access and in some areas poor relationships between optometry and ophthalmology providers. Optometrists consulted indicated they believed there was a professional duty to ensure referrals did occur. The responses to the survey of optometrists suggest they believed that, in most instances, patients referred to ophthalmologists were seen within a reasonable time (54%) or after a delay (40%). For remote and very remote locations, 8% of optometrists believed many patients will not have access to an ophthalmologist when required.
Table 88 VOS optometrists views on the referral pathway from optometrists to ophthalmologists
  Inner and Outer Regional Remote and Very Remote Total
How well does the referral pathway to an ophthalmologist work in this location?
1. Patients will almost always get to see an ophthalmologist in a reasonable time. 72% 47% 54%
2. In most instances patients will be seen by an ophthalmologist, although this is often delayed. 28% 45% 40%
3. Many patients will not be seen by an ophthalmologist. 0% 8% 5%
4. There is insufficient information to be able to assess this 0% 8% 5%


Source: HPA survey of VOS service providers, 2011. See also Table 3.27 in Volume 3.



Respondents to the optometrist survey made suggestions on how to improve VOS and visiting or local ophthalmology services. These include greater collaboration between visiting ophthalmologists and optometrists, ensuring outreach services are better coordinated, improved communication between optometrists and ophthalmologists, sharing information about patients who are being actively seen by ophthalmologists, and using optometrists to undertake follow up examinations for ophthalmologists.

Data Analysis - Effectiveness

The evidence presented in section 8.6 suggests that VOS has a material impact on access to optometry for selected inner regional locations and for many remote locations across Australia. The relative impact of VOS on access to optometry was estimated earlier at Table 83 and Figure 21. As discussed above, VOS has a very minor impact for inner regional areas, where access to optometry services is similar to that in major cities. The impact in outer regional areas is small, although in these areas, the impact of VOS is more likely to be focussed on populations with poor access to optometry. The impact of VOS is much more significant in remote and very remote areas.

The analysis highlights the value of VOS, but it is clear from consultations and other evidence, that the impact of VOS is patchy and that significant gaps in access to optometry remain. This is particularly the case for remote and very remote areas where rates of use of optometry services are about three quarters of those for major cities.

Data Analysis – Cost effectiveness

As discussed above, the average VOS subsidy cost per patient is $146 across the program. This varies by remoteness area, from $87 in inner regional to $101 in outer regional, $212 in remote and $254 in very remote areas. When DoHA administrative costs are included, the total cost per patient seen ($168) is approximately 3.5 times the cost of the underlying MBS benefits. VOS costs could be reduced through strategies designed to improve the effectiveness of the program and administrative costs.

In assessing the cost effectiveness of VOS, the current arrangements should be compared with alternatives. While telehealth options for eye screening are feasible (e.g. using a primary health practitioner to take retinal photographs), telehealth is generally not feasible for optometric eye examinations which required specialised equipment and accurate measurement.

Another alternative to outreach optometry is to assist patients to travel to centres to receive optometry examinations. Patient assisted travel for optometry has generally not been included within the eligibility criteria for state patient assisted travel schemes. Average claims for patient assisted travel (estimated at $200 per trip) are likely to be more than the average cost under VOS, particularly in more remote areas.

A further alternative would be to offer direct financial incentives for optometrists to relocate to rural and remote locations that do not currently have an optometrists. While we have not prepared estimates of this approach, we believe that this is likely to be significantly more costly that the current VOS scheme, for two reasons. Firstly, optometrists already located in rural areas may be eligible for assistance which involves expenditure without any increase in access. Secondly, the scheme would support arrangements that were relatively unproductive, and still leave significant gaps in service provision.

We conclude that the current approach of supporting outreach optometry is likely to represent the most cost effective approach to address access gaps, but that cost effectiveness could be significantly improved through some of the recommendations set out in this report.

Evaluation findings

Top of pageOne of the primary benefits of optometry services is the provision of eye examinations and the prescribing of spectacles where required. Access to these services is a significant issue for Australians living in rural and remote Australia, particularly Aboriginal and Torres Strait Islander people. As discussed earlier, refractive error remains the single most common cause of vision loss in Aboriginal and Torres Strait Islander people (Taylor et al. 2009). However, it was estimated that 35% of Indigenous adults had never had an eye examinations, and only 20% wear glasses compared with 56% of other Australians (Taylor et al. 2009). For people with vision loss, access to spectacles can have a profound impact on the quality of life and capacity to engage in activities of daily living.

VOS is addressing the deficiencies in access to eye examinations. However, the evidence from stakeholders interviewed suggests access to spectacles is mixed across Australia with a variety of schemes offered by states, territories and NGOs. Outreach optometrists typically develop processes to minimise the problems in accessing subsidised spectacles. However some schemes, because of their design and eligibility, are difficult to navigate for optometrists and patients. For patients who are ineligible for these schemes, out-of-pocket costs remain a barrier, particularly for Aboriginal and Torres Strait Islander people.

A second benefit of optometry eye examinations is the opportunity to screen patients for more serious eye and other diseases. When identified, optometrists are required to submit a referral for medical and/or a specialist ophthalmology consultation. In considering the effectiveness of optometry with respect to its role in eye health screening, issues to be considered include:
    • The level of participation in eye examinations and regularity of eye examinations, particularly for people with high risks (e.g. people with diabetes and older people): The available VOS data only provides information on the number of patients seen. This includes patients seen on repeat occasions, and does not provide a basis for identifying how many people within a community have had an eye examination within a set period of time. The Taylor et al. (2009) study estimates that 35% of Aboriginal and Torres Strait Islander adults had never had an eye examination. The evidence from Turner et al. (2011b) suggests levels of participation vary depending on the organisation and coordination of eye health services. Levels of participation cannot be easily estimated without a population register or a disease register (e.g. a diabetes register), both of which would be typically maintained by primary health care services in a community rather than visiting services. Systems to record that a patient has been examined by an optometrist or ophthalmologist would also be required. The active involvement of eye health coordinators has been identified as a contributor to effective outreach services, particularly in identifying patients requiring an eye examination and notifying patients and other staff prior to an outreach visit. For patients with higher risks (e.g. people with diabetes and older people) eye examinations need to be undertaken on a sufficiently regular basis to be able to detect emerging problems. However, it is difficult to determine the extent to which clinical guidelines in these areas are met. While there are data systems for identifying patients requiring follow-up maintained by primary care services, optometrists, ophthalmologists and eye health coordinators, there is no comprehensive mechanism for monitoring the overall performance of the eye health system on these issues.
    • The referral process from the optometrist to the GP and/or ophthalmologist: There is recognition that in some systems the referral process is problematic. There is evidence that better coordinated systems are working well, where there is good communication and coordination or an explicit team. In these systems, access to ophthalmologists can be as good as what occurs in metropolitan Australia. However, this does not apply in many parts of Australia. Also, for a variety of reasons referrals may not result in a patient been seen by an ophthalmologist. The logistical, financial and cultural issues that impact the referral process are exacerbated in remote Australia. Despite these issues, it is important to emphasise that outreach optometrists reported that in 95% of locations visited, patients requiring referral to an ophthalmologist usually saw an ophthalmologist, even if this was delayed.
Overall, VOS is vital in providing financial support for outreach optometry services. VOS by itself cannot address all the issues in eye health, particularly the many challenges for the eye health of Aboriginal and Torres Strait Islander people. We conclude that at this point in time the scheme should continue as a discrete scheme and not be absorbed into the Rural Outreach Fund. The principal areas VOS can improve its effectiveness are through:
    • A more comprehensive and open approach to planning and developing services (see next section). One of the most important contributions that VOS can make is to ensure that services are developed and funding allocated to localities and communities with the poorest level of access.
    • Ongoing monitoring of VOS effectiveness through the creation of a small set of performance indicators for the program.
    • Creating greater flexibility to support the most cost effective outreach services for particular communities.
    • Improved sharing of information between outreach eye health providers (VOS optometrists, ophthalmologists and others), primary care health services and communities.
    • Contributing funds, along with MSOAP, to research options for improving the effectiveness of outreach services. For example, input might be on how the concept of eye health registers might be developed to ensure services are well targeted, how information can be better shared between optometrists and ophthalmologists, how rates of ‘did not attend’ can be reduced, or the role optometrists can play in eye health awareness and education (see next chapter).
Outside the program, the key issues to emerge for governments are:
    • The need for clearer and ongoing support for the regional eye health coordinator role.
    • The need for state/territory level coordination of eye health services.
    • Improved and more consistent access to subsidised spectacles for people living in rural and remote Australia.

Recommendations


35. VOS remain a discrete program with a separate budget allocation.
36. New funding under Core VOS and VOS IA should be targeted at regions and communities with the highest levels of need. Better mechanisms are required to assess levels of need and gaps in access, taking into account the cost of service delivery in more remote locations and align optometry outreach with other outreach eye health services.
37. To improve the effectiveness and cost effectiveness of outreach services, the types of service eligible for support should be extended to include support for local optometrists willing to provide optometry services in local AMSs, where this is supported by the AMS. In this situation support for the optometrist should be based on an estimate of the cost to the business associated with this arrangement.
38. DoHA implement an approach for sharing comprehensive information about outreach optometry services available in all rural and remote communities across Australia. The following steps are required:
    a. Funding agreements with VOS optometrists should stipulate that information about the visiting service they have agreed to provide (the schedule of visits, where the service will be provided, details of how to contact the optometrists to make an appointment) will be made available to the public and shared for planning and coordination purposes. The funding agreements should provide a requirement to update this information when it changes.
    b. Comprehensive information on visiting services should be openly available to the public and health service providers through a web site and/or interactive map.Top of page