A Vision for Ontario. Strategic Recommendations for Ophthalmology in Ontario The Provincial Vision Strategy Task Force May 31, 2013

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1 A Vision for Ontario Strategic Recommendations for Ophthalmology in Ontario The Provincial Vision Strategy Task Force May 31, 2013

2 MESSAGE FROM THE CO-CHAIRS May 31, 2013 Susan Fitzpatrick Assistant Deputy Minister Negotiations and Accountability Management Division Ministry of Health and Long-Term Care Government of Ontario Dear Ms. Fitzpatrick, We are pleased to submit the Provincial Vision Strategy Task Force Report, Strategic Recommendations for Ophthalmology in Ontario. As requested by the Ministry, the Task Force conducted a thorough review of Ophthalmology services in Ontario including an assessment of the future patient needs. We brought together medical, clinical and academic experts, administrators and system leaders from ophthalmology, hospitals, independent health facility, LHIN and Ministry to look at current strengths and opportunities for improvement. A detailed analysis of emergency, general and specialty Ophthalmology services reveals a quality system that is well organized and responsive with strong collaborative referral patterns. We have found exemplary models of care in all settings that demonstrate best practice, clinical outcomes and operational efficiency. These models can serve to help others achieve increased efficiency in service delivery in their own communities. Our clinical review identified variation in practice across the province. We recommend both a new appropriateness measure for cataract surgery as well as adoption of a performance management framework in Ophthalmology. Additionally, an integrated Quality Based Procedure cluster for medical and surgical retinal procedures that also includes ODB coverage of intraocular injection drugs and OHIP covered diagnostic testing will provide an entirely new approach to quality based procedure design and implementation in Ontario. Ontario s aging population coupled with an increasing prevalence of eye disease among older adults will result in increased demand for Ophthalmology services over the next 5 years and more. We undertook a review of ophthalmologist availability to meet these volume demands. Surprisingly, we found that 1 in 5 Ontario ophthalmologists will reach the age of 70 within 3 years while new graduates are having difficulty securing positions to practice in Ontario. More rigorous physician planning is required and we have provided remedies to address this. 2 P a g e

3 Additional focus is also needed at the local LHIN level to plan for future volumes in medical and surgical treatment of eye diseases within the Provincial Ophthalmology Strategy provided here. In some cases, consolidation of Ophthalmology services especially specialty ophthalmology should be considered. In addition, our work confirms that wherever clinically feasible, the shift to ambulatory day surgery in adult ophthalmology should be encouraged. Many organizations are doing this and a variety of service delivery models have evolved which meet local needs, and in the case of teaching hospitals, provincial and academic roles. Consistent in all models however, is the need for a mix of hospital based Ophthalmology to ensure emergency and specialty ophthalmology services are available, along with appropriate and efficient ambulatory day surgery programs for lower risk eye procedures. Dedicated eye surgery suites, within broader day surgery programs in hospital or in offsite ambulatory care centres, can provide efficient use of shared resources and high patient satisfaction. Likewise independent health facility models like Toronto s Kensington Eye Institute, which works in partnership with hospital and university partners, also achieves excellent outcomes for low risk procedures. There is simply no one ideal model for adult ophthalmology services for all of Ontario. In children and neonatal Ophthalmology however, we endorse a hospital based model as the standard of care for Ontario. Specialization here requires unique focus that is best served in hospitals where pediatrics and ophthalmology are priorities. Lastly, we applaud the Ministry for its insight in looking for new ways to foster ambulatory eye surgery innovation. Our analysis shows that efficiency is not based on location but rather on an unrelenting desire to achieve high performing, lean ophthalmology services to meet patient needs with quality outcomes. We are confident that continued innovative models in Ophthalmology services will serve Ontarians well. We look forward to the Ministry s support of these recommendations and to working with you and others, on their implementation over the coming year. Sincerely, Robert Bell, MDCM, MSc, FRCSC, FACS President and Chief Executive Officer University Health Network Co-Chair Provincial Vision Strategy Task Force Phil Hooper, MD, FRCSC Assoc. Professor, Ophthalmology Western University Ministry Provincial Lead, Ophthalmology Co-Chair Provincial Vision Strategy Task Force 3 P a g e

4 TABLE OF CONTENTS Message from the Co-Chairs... 2 Table of Contents... 4 Executive Summary... 6 Introduction The Provincial Vision Strategy Task Force Impetus for Change Ophthalmology In Ontario Surgical Ophthalmology Medical and Diagnostic Ophthalmology Pediatric Ophthalmology Adult Ophthalmology Standardized Procedure Rates in Ontario Growth In Ophthalmology Services Distribution of Ophthalmology Services Special Topics in Ophthalmology Emergency and Urgent Services Access to Care Wait Times Eye Bank Of Ontario and Corneal Tissue for Transplantation Out-of-Country Services Emerging Technologies Academic Ophthalmology Ophthalmology in the North Local Health Integration Network Strategic Planning Summary of Key Findings Ophthalmology Volume Forecasting Health Human Resources Planning P a g e

5 Service Delivery and Low Volume Centres Cost Variation Quality Based Procedures in Ophthalmology Cataract Quality Based Procedure (Day Surgery) Integrated Retinal Quality Based Procedure Cluster Models of Ophthalmology Hospital-Based Model Ambulatory Model Within or Associated With a Hospital Independent Health Facilities and Private Hospitals Diagnostics In Ophthalmology Anesthesiology and Ophthalmology Models Of Organizational Efficiency Provincial Sourcing of Supplies Performance Management Framework Opportunities for System Improvement Conclusion Appendices: Provincial Vision Task Force Membership... Appendix 1 List of Non-Surgical Ophthalmology Procedures... Appendix 2 Methodology to Determine Procedure Levels for Analysis... Appendix 3 LHIN Initiatives in Ophthalmology... Appendix 4 Cataract Quality Based Procedure Methodology... Appendix 5 Vision Strategy Costing Methodology... Appendix 6 Patient Mapping... Appendix 7 5 P a g e

6 EXECUTIVE SUMMARY Visual impairment can have a profound effect on a person s independence, mental health, and ultimately their quality of life. It is for this reason that maintaining and enhancing Ontario s ophthalmology service delivery is critical for the patients in this province. With a growing population of seniors, the need for high quality, highly accessible and efficient ophthalmology services will continue to grow each year. Fortunately, ophthalmology services currently operate within a well-organized system that provides good quality care to patients. As such, the Task Force set forth to develop recommendations that would enhance the delivery of ophthalmology services to create a sustainable health care system that keeps patients healthy, happy, and independent. Ultimately, the vision is to create a system that is accountable for ensuring that Ontarians can access high quality ophthalmology services when they need them most. ACCESS Overall, access to most ophthalmology services is excellent in most areas of the province. The aggregate wait time of all ophthalmology services has always been within provincial wait time target. CritiCall volumes are low, suggesting that the system is well-organized with strong referral patterns. And there are very low volumes of patients needing to seek ophthalmology services outside of the country due to lack of services in Ontario. In order to ensure that access is maintained and enhanced the following recommendations have been developed. ACCESS R1 Ministry and LHIN funding for ophthalmology services should be sustained to address wait lists for adult and pediatric eye surgery. ACCESS R2 A provincial corneal transplant wait list registry should be developed by Trillium Gift of Life to assist in the prioritization of cases and the equitable distribution of corneal tissue. ACCESS R3 Eye Bank processes which incorporate the ability to provide precut tissue to end users should be implemented. ACCESS R4 Ministry should consider funding a Boston Scleral Lens/PROSE program in Ontario at a designated centre. NORTHERN ACCESS Northern Ontario has difficult challenges in the delivery of health care services due to its large geography which covers 87% of the province, while serving approximately 6% of population of Ontario. These factors combined with an older population, higher rates of diabetes and the barriers associated with providing services to remote aboriginal communities reflect the need for a robust plan for ophthalmology services for Northern Ontarians. 6 P a g e

7 ACCESS R5 Consideration should be given to establish a Pediatric Ophthalmology service in Sudbury in conjunction with other Pediatric services available there. ACCESS R6 The North West and North East LHINs should work together with specialty hospitals currently serving patients from the north to develop a Northern Ontario Vision Plan that would improve access to specialized ophthalmology services closer to home wherever possible. Furthermore, the Task Force recommends that consideration be given to planning for surgical retina services which our analysis suggests is a high-need program for the north. SYSTEM IMPROVEMENT QUALITY BASED PROCEDURES AND APPROPRIATENESS MEASURES One of the most noticeable opportunities for system improvement arose from the Task Force analysis around procedure rates. Wide variation exists in the medical management of vision-related diseases, with some LHINs performing up to 4 times more intraocular injections and 6 times more diagnostic tests per 100,000 population than other LHINs. Similarly, wide variation can also be found across LHINs in surgical procedure rates for cataracts, corneal transplants, glaucoma and retinal surgery. In an effort to ensure that patients receive equitable services regardless of where they live, the Task Force developed recommendations for the implementation of an Integrated Retinal Quality Based Procedure as well as the implementation of an appropriateness measure for cataract surgery. IMPROVE R1 IMPROVE R2 IMPROVE R3 IMPROVE R4 Task Force to work with the Ministry to develop an Integrated Quality Based Procedure (QBP) for medical and surgical retina procedures which incorporates associated intraocular injections and ODB coverage as well as OHIP covered diagnostic services such as OCT. Consideration should be made to review the day surgery Cataract QBP patient pathways and their associated costs. A multi-price QBP funding approach could be considered if appropriate. Cataract programs must collect and trend pre- and post-operative visual acuity ideally using an automated assessment system. All centres and LHINs that perform cataract surgery will report on this appropriateness measure. 7 P a g e

8 PERFORMANCE MANAGEMENT AND ACCOUNTABILITY Ophthalmology in Ontario is remarkably safe and outcomes are consistently good. Continuously improving performance however requires new accountability measures that include both quality of care and patient satisfaction. IMPROVE R5 IMPROVE R6 IMPROVE R7 All ophthalmology programs must adopt the same patient satisfaction measurement tool that rates patients ease of access to care, wait times, patient improvement, staff and facility satisfaction. All centres and LHINs who perform ophthalmology procedures will implement the performance management framework, including all indicators li sted in Figure 38 of the report. Implement a performance indicator for Retinopathy of Prematurity (ROP) that measures the proportion of ROP infants at risk who receive follow up care within the recommended 6 to 9 months. SYSTEM PLANNING LHIN PLANNING The LHINs are leaders in system planning in Ontario. Their goal is to plan, fund and integrate health care services locally through collaborative solutions that are grounded in rich local knowledge. As such, there are no organizations within this province that are better equipped to evaluate and plan for local ophthalmology needs than the LHINs. PLAN R1 Each LHIN should develop a Local Vision Plans describing how they will provide for the current state and future needs of their communities, based on the Provincial Vision Strategy Task Force Report and its findings. HEALTH HUMAN RESOURCE PLANNING We have discovered that approximately one in five practicing ophthalmologists will be over the age of 70 years within the next three years. Over the next ten years, nearly half of all currently practicing ophthalmologists will reach that milestone. Paradoxically, new graduates are unable to secure positions to practice in Ontario. With the combination of retirements of ophthalmologists and an increase in demand for eye services associated with the aging population of Ontario, there may be a lack of ophthalmologists needed to meet service demands. 8 P a g e

9 The following recommendations will help address this issue by ensuring that new ophthalmology graduates in Ontario have access to adequate operating room/ day surgery time in order to enter a viable career in their trained profession in Ontario. PLAN R2 PLAN R3 PLAN R4 PLAN R5 At least 2-3 additional ophthalmology residents should be graduated each year in Ontario to address the imminent loss of ophthalmologist capacity due to upcoming retirements. A new graduate entering a career in Ophthalmology in Ontario needs to perform a reasonable number of cases. We recommend that they perform a minimum of 200 cataract surgeries, or 200 vitreo retinal surgeries, or 40 glaucoma/cornea surgeries per year. This will help to ensure adequate surgical skills are maintained and that new graduates can develop sustainable practices in Ontario. Ideally, general ophthalmologists should perform no more than a maximum of 600 adult cataract surgeries per year to ensure that patients also have access to medical vision care from a general ophthalmologist and that there is adequate operating room time made available to new graduates. Ideally, specialty ophthalmologists should perform no more than a maximum of 400 specialty procedures to ensure that patients also have access to medical vision care is maintained and that there is adequate operating room time made available to new graduates. COOPERATIVE OPHTHALMOLOGY & ANESTHESIA PLANNING Ophthalmology and anesthesiology have a strong history of working collaboratively to ensure planning for anesthesia results in optimal sedation and patient safety during ophthalmic surgery. There are many viable models of anesthesia including Anesthesia Care Teams and anesthesia assistants for the provision of low risk eye surgery. As such, it is important that Departments of Ophthalmology and Anesthesiology work together to determine which model(s) of anesthesia are best suited to meet the needs of the patients being served. PLAN R6 PLAN R7 PLAN R8 PLAN R9 Planning for ophthalmology services must be done in concert with planning for anesthesia to ensure that an appropriate eye surgery model is feasible, affordable, and safe. One-on-one anesthesiologist to patient services must be funded at a rate that matches low intensity general anesthesia services. Centers planning to use an Anesthesia Care Team model must ensure that there is sufficient volume and funding to make cost effective use of both the anesthe siologist and anesthesia assistants. Ophthalmologists are encouraged to liaise with a hospital Department of Anesthesiology to ensure the viability of the Anesthesia model of care. 9 P a g e

10 PLANNING FOR SYSTEM EFFICIENCY One of the most expensive inputs to the cost of ophthalmology surgeries is the cost of supplies (i.e. the intraocular lens and the Phaco packs). Additional cost reduction may be possible to achieve by taking a provincial approach to materials management of ophthalmology supplies. This would involve the nine (9) Hospital Shared Service Organizations in Ontario working collaboratively to further drive down supply costs for hospitals across the province. PLAN R10 Ontario s 9 Shared Services Organizations should coordinate efforts in developing a provincial sourcing model for ophthalmology supplies in order to maximize supply chain efficiencies. GENERAL CONSIDERATIONS FOR PLANNING There are also some recommendations that apply more broadly to system planning in ophthalmology. These recommendations are meant to ensure that those aspects of ophthalmology care that are currently operating effectively (i.e. emergency access, teaching and research, inpatient consultation, referral partnerships) are maintained as new models of service delivery evolve PLAN R11 PLAN R12 PLAN R13 PLAN R14 PLAN R15 PLAN R16 PLAN R17 PLAN R18 The shifting of routine low risk ophthalmology procedure volumes to ambulatory surgery models should be developed using a LHIN-led review of Ophthalmology needs and opportunities in their local environment. New ambulatory models must be contingent on Ophthalmologists maintaining inpatient consultation and emergency coverage at local hospitals, as well as maintaining a location for outpatient consultation and follow-up services geographically situated within affiliated communities. Planning for ambulatory models must also be contingent on maintenance of access to appropriately equipped and staffed eye suites/procedure rooms to deal with urgent and emergent cases on a 24/7 basis. Considerations for consolidation of specialty ophthalmology service delivery must follow a thorough LHIN-led review of low-volume centres and a local needs assessment. Patients need to cross LHIN boundaries to obtain specialty services in many i nstances. As such, specialty centres will develop strong referral partnerships both within and across LHINs. Specialty centres will explore and facilitate use of teleophthalmology to reduce travel for follow-up visits. Pediatric ophthalmology procedures should remain in a hospital setting where sufficient resources to provide adequate safety and medical back-up exist. System planning must ensure that education, basic and clinical research programs in ophthalmology are sustained and enhanced. 10 P a g e

11 NEXT STEPS In order to create the desired high quality, patient-centered outcomes within ophthalmology in Ontario a provincial perspective must be maintained throughout planning and implementation. The Task Force expertise and knowledge gained from developing this report will be an asset to the province as well as the LHINs in the implementation of these recommendations. NEXT R1 NEXT R2 NEXT R3 The findings of this report will be used to help guide the Ministry in their planning for new ambulatory surgery centres. The Task Force will continue to work with the Ministry to provide expertise and knowledge to implement the recommendations of the report. The Task Force will provide support to the LHINs in developing local LHIN vision care plans by utilizing the expertise and knowledge gained from developing this report. 11 P a g e

12 INTRODUCTION The people of Ontario, both patients and providers, want a high quality health care system that is accessible to everyone who needs care when they need it most. In January 2012, the Action Plan for Health was released by the Ministry of Health and Long-Term Care (the Ministry) to transform Ontario s health care system. The Action Plan emphasized the importance of improving patient care by gaining better value from Ontario s healthcare system. A key theme throughout the Action Plan is ensuring that, in all matters of health care, the patient always comes first. Ontario has a strong history in policy and planning for the improvement of patient access and quality of care in Ophthalmology. Some of these initiatives include: 2004 Ontario Wait Time Strategy was implemented for cataract procedures and the Ministry established the Expert Panel in Cataracts Ontario Wait Time Strategy was expanded to include all Ophthalmology procedures including pediatrics The report Evaluation of Anesthesia Care Teams in Ontario released, showing positive impact of anesthesia assistant in ophthalmology and other surgeries Ministry implemented the Cataract Quality Based Procedure (QBP) The Provincial Vision Strategy Task Force struck to review ophthalmology services in Ontario Cataract Surgery Clinical Pathway and Best Practices guideline released. On September 20, 2012, the Ministry furthered its commitment to ophthalmology patients by supporting the establishment of a provincial task force focused specifically on Ophthalmology services; the Provincial Vision Strategy Task Force (the Task Force). The Task Force set out to identify the outstanding system issues and develop an evidence-based provincial planning framework which would define criteria to maximize patient-centered care in ophthalmology for Ontarians. The following diagram outlines the core planning principles and strategic areas of focus which were applied towards the achievement of a patient-centered system in ophthalmology. 12 P a g e

13 The Terms of Reference for the Task Force are to examine and recommend ways to improve access to emergency and scheduled surgical, medical and diagnostic ophthalmology services for all Ontarians including adult and pediatric populations assess current and future population needs for ophthalmology using HBAM methodology optimize quality, cost efficiency and patient outcomes more specifically for ophthalmology surgery develop evidence based criteria for providing ophthalmology services in ambulatory day surgery centre or independent health facilities identify performance indicators for measuring local and provincial improvement in ophthalmology services. In this context, routine eye care, optometrist services, optical services and orthoptic services are excluded from the scope of the work of Task Force. Findings of the Task Force are based on thorough analysis and expert interpretation of ophthalmology data from CIHI including DAD and NACRS clinical data; costing data using OCDM and OCCI as well as OHIP provincial databases to identify key diagnostic tests. 13 P a g e

14 THE PROVINCIAL VISION STRATEGY TASK FORCE Dr. Robert Bell, President and Chief Executive Officer, University Health Network and Dr. Phil Hooper, Ministry Provincial Lead in Ophthalmology were appointed as co-chairs of the Provincial Vision Strategy Task Force. The Task Force representatives were chosen from across Ontario and consisted of a wide range of professionals with particular expertise in ophthalmology, anesthesia and health administration and planning. Membership included general and specialized ophthalmology, pediatric ophthalmology, anesthesiology, academic chairs in ophthalmology as well as ICES researchers in ophthalmology. Also included were administrators from hospitals, ambulatory centres and an Independent Health Facility, CritiCall Ontario and the Eye Bank of Ontario, as well as LHIN and Ministry officials (Appendix 1). The Task Force met nine times since September IMPETUS FOR CHANGE EXCELLENT CARE FOR ALL ACT On June 8, 2010 the Excellent Care for All Act, 2010 (ECFAA) received royal assent. The Act was put in place to ensure that health care organizations put patients first by creating accountability around the delivery of high quality of patient care. Specifically, the Act reads that the people of Ontario and their Government: Believe that the patient experience and the support of patients and their caregivers to realize their best health is a critical element of ensuring the future of our health care system. Share a vision for a Province where excellent health care services are available to all Ontarians, where professions work together, and where patients are confident that their health care system is providing them with excellent health care. Recognize that a high quality health care system is one that is accessible, appropriate, effective, efficient, equitable, integrated, patient centred, population health focused, and safe. Believe that quality is the goal of everyone involved in delivering health care in Ontario. Continued system level activities are needed to implement the goals of ECFAA. The Provincial Vision Strategy Task Force uses patient centered and evidence based approaches consistent with the principles of the Act. 14 P a g e

15 PREVALENCE OF EYE DISEASES Visual impairment has a fundamental impact on a person s quality of life and if unaddressed, can result in significant functional disability and poor and preventable outcomes. The National Coalition for Vision Health in 2011 reported that Canadians with vision loss experience: In addition, Double the incidence of difficulties in daily living and social dependence Double the incidence of falls Double the mortality rate Triple the incidence of depression Quadruple the incidence of hip fractures Earlier admission to long term care homes -- 3 years earlier than those without vision loss. 1 Annual cost of vision loss in Canada is $15.8 Billion (in 2007 dollars) Over 4 million Canadians have age-related blinding ocular disease 1 in 9 Canadians develop irreversible vision loss by age 65 1 in 3 Canadian ophthalmologists are over age 55 and due to retire in the next decade 200 Canadian workers suffer eye injuries daily 40% of Canadians in the workplace do not get needed visual aids 68% of adults with vision loss are unemployed 60% of Canadian children with reading difficulties have undetected or uncorrected vision problems. 1 With support and treatment, most patients with eye diseases and vision loss can remain safe, active and independent. The most common cause of visual impairment in Ontario of persons of working age is diabetic retinopathy. In older individuals, cataracts, macular degeneration and glaucoma are the most common types of eye disease. 2 Overall, 1 in 2 Ontarians will require clinical intervention to preserve visual function. However, with the proper support and management, patients with eye disease can remain safe, active and independent in their own homes with excellent quality of life. 1 The National Coalition for Vision Health. (2011). Vision Loss in Canada: Synopsis of Environmental Scan. Web. 2 Noertjojo K, et al. (2006). Awareness of eye diseases and risk factors: identifying needs for health education and promotion in Canada. Can J Ophthalmology, 41(5); P a g e

16 Cataracts will develop in most people at some point during their lifetime. The most common cause is related to aging and oxidation of the proteins in the lens of the eye. When enough damaged material builds up, the lens becomes cloudy (cataracts), vision is impaired and activities of daily living are reduced. Cataracts can be surgically removed and replaced with an artificial lens 3 which restores vision. Cataract surgery is very effective and is the most common surgery performed in Ontario. Glaucoma is characterized by a loss of the nerve fibers which carry the visual impulses from the retina to the brain. This results in a slow progressive loss of vision. Glaucoma is the second leading cause of blindness among people over the age of Treatments include medication in the earlier stages of the disease and surgical interventions in the later stages. Unfortunately, glaucoma cannot be cured by any intervention and requires ongoing monitoring and successive interventions over an individual s lifetime. Macular Degeneration results from damage to the photoreceptors in the macula, the small area at the center of the retina in the back of the eye that allows us to see fine details clearly and perform activities such as reading and driving. Macular Degeneration is the most common cause of legal blindness in persons aged 50 or older and accounts for 90% of new cases of legal blindness in Canada. 4 This disease has a major impact on the ability of people aged 50+ to live independently. Since 2007, ongoing regular intraocular injections of VEGF blocking medication have been shown to be effective in preventing 90% of the vision loss attributable to the most severe form of macular degeneration. Ontario provides coverage for Ranibizumab (trade name Lucentis ) to treat macular degeneration under the Ontario Drug Benefit (ODB) program. To be effective the patient must receive intraocular injections and monitoring tests such as optical coherence tomography (OCT) every 1-3 months for life. Although new drugs are in development, they are unlikely to reduce the burden of care for this disease over the next decade. Diabetic retinopathy will develop in 90% of people who develop Type 1 diabetes and in 60% of Type 2 diabetics. It is the most common cause of blindness in people under the age of 50. With appropriate and ongoing intervention, most of the visual loss attributable to this disease can be prevented. Management of this disease is currently undergoing an evidence-based paradigm shift from episodic and finite interventions such as laser treatments and surgery, to ongoing regular intraocular injection of VEGF blocking medication. As a result, in November 2012 ODB coverage for Lucentis therapy was extended to include diabetic retinopathy patients. This change in clinical treatment will increase the need for patients to have regular access to an ophthalmologist close to home as well as to be regularly assessed using OCT and Fluorescein angiography testing which are needed to treat diabetic retinopathy. 3 Canadian Ophthalmology Society evidence-based clinical practice guidelines for cataract surgery in the adult eye. Page 17. Vol 41: Suppl 1. October Age-Related Macular Degeneration (AMD). Canadian Society of Ophthalmology. Web. 14 Feb P a g e

17 OPHTHALMOLOGY IN ONTARIO SURGICAL OPHTHALMOLOGY In , there were 174,462 adult and pediatric surgical ophthalmology procedures performed in Ontario (Figure 1). The majority of these procedures (93%) are performed on a day surgery basis, while 7% of patients, particularly those who have complex eye diseases and/or multiple comorbidities, require inpatient surgery. A larger proportion of pediatric patients (25%) require inpatient ophthalmology surgery (1,121 of 4,494). FIGURE 1: DAY SURGERY AND INPATIENT SURGICAL VOLUMES FOR OPHTHALMOLOGY Day Surgery Volumes Inpatient Volumes TOTALS (2011/12) (2011/12) Adult Ophthalmology 158,959 11, ,968 Pediatric Ophthalmology 3,373 1,121 4, ,332 (93%) 12, ,462 Source: DAD and NACRS 2011/12 For the purposes of analysis, the Task Force divided adult ophthalmology procedure groups into four levels of specialization. Levels 1 and 2 by and large fall under the category of general ophthalmology while Levels 3 and 4 include more specialized ophthalmology procedures. Examples of procedures in each level are provided in Figure 2 below, while a more fulsome list can be found in Appendix 3. FIGURE 2: OPHTHALMOLOGY--LEVELS OF SPECIALIZATION- PROCEDURE EXAMPLES General Ophthalmology Level 1 Laser Capsulotomy Level 2 Cataract Extraction Specialty Ophthalmology Level 3 Corneal Repair, Refractive Surgery, Complex Intraocular, Non-major Orbital, Trabeculectomy Level 4 Corneal Transplant, Eyelid Lesion Excision/Reconstruction, Major Orbital Surgery, Retinal Surgery, Scleral Buckle, Vitrectomy, Aqueous drainage shunt implantation 17 P a g e

18 The complexity of the procedure, patient age and comorbidities plus anesthesia risk influences which type of the health care setting that the surgery occur (Figure 2). In adults, most procedures at level 1 and 2 are performed in community hospitals while the vast majority of level 4 eye procedures are performed in an Academic Health Sciences Centre. Only day surgery ASA 1-3 can be performed in an IHF. Most pediatric eye surgeries are performed in an Academic Health Sciences Centre. The anesthetic, pediatric and ophthalmology support services to provide general anesthetics to the young children who most frequently require these procedures are not commonly found outside of AHSCs. Figure 3 illustrates the percentage of pediatric and adult eye procedures performed in Academic Health Sciences Centres by procedure level. FIGURE 3: PROCEDURES PERFORMED IN ACADEMIC HEALTH SCIENCES CENTRES Pediatric Adult All Ages Level 1 routine 52% 10% 15% Level 2 39% 20% 21% Level 3 61% 45% 49% Level 4 complex 91% 82% 82% Source: DAD and NACRS 2011/12 MEDICAL AND DIAGNOSTIC OPHTHALMOLOGY It is estimated that 60 to 80% of an Ophthalmologist s time is spent in the medical management of eye disease which is treated with topical and systemic medication. Ophthalmologists perform many eye procedures in their offices or hospital eye clinics including injection of intra-ocular drugs and minor lid and corneal procedures. In addition, ophthalmologists oversee specialized ophthalmic diagnostic tests such as OCT, fluorescein angiography, and visual fields which are necessary for diagnosis, monitoring and follow-up care of patients. These tests measure treatment response and disease reoccurrence. The medical and diagnostic procedures performed by ophthalmologists are listed more fully in Appendix 2. Since medical and diagnostic eye procedures are not captured in DAD or NACRS databases, the OHIP database was used to assess OCT, visual field testing, and the use of intraocular injection. These analyses informed the task force about the management of glaucoma, diabetes and macular degeneration in Ontario. Repeat patient visits to ophthalmologist are required for effective medical and diagnostic eye care for a variety of eye diseases and conditions. Local access to regular medical treatments, monitoring and testing as well as geographic proximity helps ensure that appointments are not missed. This is 18 P a g e

19 important so that vision loss and disease progression are detected early and treated, and if necessary referred to specialist promptly. Figures 4 and 5 identify that there is regional variation in the medical and diagnostic ophthalmology procedure rates per 100,000 population across Ontario. This suggests opportunities to establish clinical guidelines to help define best practice, set a standard across the province, and improve patient access to care regardless of where they seek it. Intraocular Injections are currently performed in the ophthalmologist s office or a hospital eye clinic. Injection is the only way to treat macular degeneration and forms the mainstay of management for diabetic retinopathy. Effective October 1, 2009, a new OHIP billing code (E147A) was Local access to medical and diagnostic ophthalmology services is needed for effective non-surgical treatment of eye diseases introduced to separate the use of intraocular injection for treatment of macular degeneration (AMD) from other indications (E149A) such as diabetes and vein occlusion. The burden of care for these eye diseases is very large, accounting for over 100,000 visits for intraocular injections for macular degeneration and over 40,000 visits for other indications in 2011/2012. Treatment is available across all LHINs and most have similar age adjusted rates except for the Northwest LHIN, which is much lower and suggests a lack of access or availability to treatment in this LHIN. As noted in Figure 4 below, the rate of increase in intraocular injections for macular degeneration treatment has slowed though still increasing. The rate of increase in intraocular injection treatment for diabetic retinopathy is expected grow substantially in the coming years as this new treatment is incorporated more fully into practice. 19 P a g e

20 FIGURE 4: INTRAOCULAR INJECTIONS (AGE STANDARDIZED RATE PER 100,000 POPULATION) E149A Intraocular Injections E147A Intraocular Injection for AMD Age Standardized Rate (per 100,000 pop n) Age Standardized Rate (per 100,000 pop n) Patient Home LHIN 2009/ / / / / /12 Erie St. Clair ,695 3,067 South West ,761 2,635 Waterloo Wellington ,651 2,713 HNHB ,947 2,958 Central West ,369 2,078 Mississauga Halton ,390 1,896 Toronto Central ,893 2,622 Central ,513 2,189 Central East ,737 2,777 South East 1, ,062 4,341 Champlain ,142 2,959 North Simcoe Muskoka ,836 4,314 North East ,353 5,018 North West ,323 Provincial Average ,929 2,921 Source: OHIP Database Optical Coherence Tomography (OCT) is a relatively new diagnostic test which has come into widespread use over the last 5 years. OCT provides important data to improve the management of eye disease involving the central (high acuity) area of the retina as well as glaucoma progression. OCT is also used at most visits to follow progress of diabetes and macular degeneration regardless of whether an intraocular injection is provided. The test is office or clinic based requiring minutes to complete and is noninvasive. There was a 3 fold increase in OCT usage between 2009/10 and 2010/11 as medical treatment for macular disease became available. In 2011, OHIP coverage of OCT was capped to a limited number of tests per patient per year. This resulted in a 7% decrease in apparent utilization from 2010/11 to 2011/12 and as such, the OHIP data is thought to underestimate the actual need for OCT testing. As seen in Figure 5, utilization rates for OCT vary widely and do not follow the location of specialized services by LHIN. This suggests a significant variation in practice and usage. Access to OCT testing is high across the province with the exception of the Northwest LHIN where access appears much lower than expected. 20 P a g e

21 FIGURE 5: AGE STANDARDIZED RATE PER 100,000 POPULATION FOR OCULAR COHERENCE TOMOGRAPHY (OCT) Age Standardized Rate (per 100,000 pop n) Patient Home LHIN 2009/ / /12 Erie St. Clair 1,893 15,457 11,509 South West 447 4,127 4,008 Waterloo Wellington 520 6,227 5,748 HNHB 799 9,677 9,301 Central West 1,424 14,060 9,633 Mississauga Halton 1,151 12,332 8,234 Toronto Central 866 8,728 7,817 Central 1,010 10,403 8,566 Central East 586 7,280 6,596 South East 827 9,616 7,281 Champlain 441 5,849 5,706 North Simcoe Muskoka 897 8,805 6,583 North East 879 9,647 9,048 North West 33 1,356 1,966 Provincial Average 841 8,826 7,285 Source: OHIP Database Visual Field Testing is used principally to monitor glaucoma patients for progression of the disease. It is an office or clinic based noninvasive test which takes minutes to complete. Generally the test is done twice a year for stable patients and more often if disease is unstable and progressing rapidly. As noted in Figure 6, visual field testing increased approximately 10% per year over the past 3 years and this is a good marker of the burden of care for glaucoma in Ontario. There is significant variation in use between LHINs. In some cases, this reflects the location of highly specialized glaucoma practitioners in that LHIN. In other circumstances, higher visual field testing use may be indicative of increasing prevalence of patients with glaucoma due to aging and/or immigration in a particular LHIN. Overall, routine glaucoma care is reasonably well distributed across the province but more complex patients require travel to specialty centres for advanced medical and surgical ophthalmology expertise. 21 P a g e

22 FIGURE 6: AGE STANDARDIZED RATE PER 100,000 POPULATION FOR VISUAL FIELD TESTING Age Standardized Rate (per 100,000 pop n) Patient s Home LHIN 2009/ / /12 Erie St. Clair 1,996 2,170 3,120 South West 1,287 1,498 1,730 Waterloo Wellington 1,594 1,627 1,791 HNHB 1,636 1,848 2,229 Central West 3,381 3,981 4,489 Mississauga Halton 2,085 2,321 2,754 Toronto Central 2,136 2,493 2,908 Central 2,537 2,944 3,431 Central East 1,946 2,297 2,738 South East 2,079 2,269 2,581 Champlain 3,089 3,327 3,681 North Simcoe Muskoka 2,064 2,374 2,667 North East 2,309 2,485 2,889 North West 2,118 2,198 2,321 Provincial Average 2,161 2,417 2,809 Source: OHIP Database PEDIATRIC OPHTHALMOLOGY In , there were 4,494 ophthalmology surgeries performed in children in Ontario. Strabismus Repair is the most common ophthalmology surgery in children. It is effective in correcting ocular misalignment and preventing permanent loss of vision resulting from unbalanced visual inputs to the developing brain (amblyopia). Strabismus occurs in about 3% of children. Left untreated, about 50% of children with strabismus will have some visual loss. 5 Another common pediatric ophthalmology procedure is Lacrimal duct probing. This procedure is required to eliminate tearing resulting from incomplete development of the ducts which drain tears from the eye to the nose. The procedure data from CIHI likely underrepresents the real volume of this surgery as much is now done in minor procedure suites which are not captured in DAD/NACRS databases. Due to the specialized nature of pediatric ophthalmology, the majority of cases are performed at Academic Health Sciences Centres namely, Hospital for Sick Children, the Children s Hospital of Eastern Ontario and London Health Sciences Centre. Credit Valley Hospital site in Mississauga and Toronto East General Hospital in Toronto also provide a large volume of pediatric ophthalmology day surgery procedures. 5 Fecarotta C, Huang WW. (2013). Eye Defects and Conditions in Children Strabismus. Retrieved from 22 P a g e

23 FIGURE 7: TOP PEDIATRIC OPTHALMOLOGY VOLUME SITES (2011/12) Strabismus Specialty Total Volumes Total Day Surgery Volumes Total Inpatient Volumes Prov. Rank Volume (Day Surg) Prov. Rank Volume (Day Surg) 1 TORONTO Hospital for Sick Children OTTAWA CHEO MISSISSAUGA Credit Valley LONDON Health Sciences TORONTO East General HAMILTON Health Sciences Corp BRAMPTON William Osler TORONTO Humber River Regional KINGSTON Hotel Dieu NEWMARKET Southlake Regional Source: CIHI DAD Pediatric ophthalmology patients have a high rate of comorbid conditions and the majority of cases require general anesthesia particularly in younger children. Along with increased risks for anesthesia, there is a post-operative risk of significant nausea, drowsiness, and other adverse effects that may require admission and general pediatric consultation. Hospitals remain the best location for children and youth to receive ophthalmology services, especially when there are concurrent medical, anesthesia and /or psychological concerns. As shown below in Figure 8, the vast majority of children from Toronto Central, South West, Champlain and South East LHINs who require ophthalmology services receive treatment in their home LHIN. This reflects the location of the pediatric ophthalmology programs in Toronto, London, Ottawa, and Kingston. In the remaining LHINs, pediatric patients must travel to these specialized pediatric ophthalmology hospitals. This can be a significant family burden when there are long distances to be covered for surgery and follow up care. 23 P a g e

24 FIGURE 8: PERCENTAGE OF ADULT AND PEDIATRIC PATIENTS TREATED WITHIN THEIR HOME LHIN Source: DAD, NACRS DS & ER, 2009/10 11/12 RETINOPATHY OF PREMATURITY - NEONATES Retinopathy of Prematurity (ROP) results from abnormal blood vessel development in the retina of the eye in a premature infant. 6 Infants born at or below 30 weeks gestation and/or under 1500 grams are at highest risk for developing ROP. The standard in Ontario is that these infants receive regular eye examinations for detection of ROP starting at 31 weeks corrected age or 4 weeks after birth, whichever is later. The examinations should continue until there is complete retinal vascularisation or clear evidence of regression of ROP. Evidence of progression of the disease requires immediate referral for treatment. Without examination and treatment, these infants are at high risk for serious permanent vision impairment. 7 ROP screening is mandatory at all level 3 and 2 maternal newborn hospitals in Ontario and is done either by an on-site ophthalmologist or remotely via the Provincial Council for Maternal and Child Health remote screening pilot. ROP treatment requires a specialized pediatric ophthalmologist and equipment found only at a pediatric ophthalmology hospital. Infants must be transferred within 72 hours of 6 Bustos DE, Zieve D. (2011). Retinopathy of Prematurity. Retrieved here 7 Provincial Council for Maternal and Child Health (2010). Final report of the Maternal-Newborn Advisory Committee Retinopathy of Prematurity Working Group. 24 P a g e

25 diagnosis of retinal disease requiring treatment. High quality ROP treatment also involves ensuring that infants receive adequate follow-up care for the recommended 6-9 months. RECOMMENDATIONS Pediatric ophthalmology procedures remain in a hospital setting where sufficient resources to provide adequate safety and medical back-up exist. Implement a performance indicator for Retinopathy of Prematurity (ROP) that measures the proportion of ROP infants at risk who receive follow up care within the recommended 6 to 9 months. Consideration should be given to establish a pediatric Ophthalmology service in Sudbury in conjunction with other pediatric services available there. ADULT OPHTHALMOLOGY Persons aged 65+ now account for 13.7% of Ontario s population and number over 1.9 million people. By age 65, approximately one third of Ontarians will have some form of vision-reducing eye disease. 8 With the influx of baby boomers into their senior years, Dr. Samir Sinha, the Ministry s Provincial Lead for Ontario s Seniors Care Strategy 9 reports that Ontario can anticipate that the 65+ population will more than double in the next 20 years. As evidenced by Figure 9, the need for general and specialty ophthalmology services in Ontario will continue to increase. FIGURE 9: AGE DISTRIBUTION OF EYE SURGERIES IN ONTARIO SPECIALTY OPHTHALMOLOGY CATARACTS (GENERAL OPHTHALMOLOGY) Source: DAD, NACRS DS & ER, 2009/10 11/12 8 Noertjojo K, et al. (2006). Awareness of eye diseases and risk factors: identifying needs for health education and promotion in Canada. Can J Ophthalmology, 41(5); Sinha, S. (2013) Living Longer, Living Well. Report Submitted to the Minister of Health and Long-Term Care. 25 P a g e

26 GENERAL OPHTHALMOLOGY (CATARACT) There are currently 67 hospitals and 1 independent health facility (Kensington Eye Institute) in Ontario that perform cataract surgery on adult patients. Figure 10 below identifies the 20 facilities that perform the greatest volumes of cataract surgery per year. These are primarily large community hospitals as well as Kensington Eye Institute. Some teaching hospitals with larger volume of cataract surgery have developed ambulatory eye surgery centres which allows them to meet the cataract demand without impairing access of higher acuity cases to the main operating room suites. FIGURE 10: TOP 20 ADULT DAY SURGERY FACILITIES CATARACT LHIN Name Facility Name Volume of Cataracts Champlain OTTAWA The Ottawa Hospital 10,384 Toronto Central Kensington Eye Institute 9,180 Central TORONTO North York General 8,122 Central East TORONTO Scarborough Hospital 6,619 HNHB ST CATHARINES Niagara Health System 5,600 Erie St. Clair WINDSOR Hotel Dieu Grace 5,341 HNHB HAMILTON St Joseph's 5,314 Central East OSHAWA Lakeridge Health Corp 5,298 Central NEWMARKET Southlake Regional 4,872 Central West BRAMPTON William Osler 4,599 South West LONDON St Joseph's 4,595 Mississauga Halton MISSISSAUGA Trillium Health Centre 3,993 Waterloo Wellington KITCHENER St Mary's 3,693 Toronto Central TORONTO East General 3,121 North East SUDBURY Regional De Sudbury 2,685 South East KINGSTON Hotel Dieu 2,564 HNHB BURLINGTON Joseph Brant Memorial 2,506 North East NORTH BAY REGIONAL HEALTH CENTRE 2,202 HNHB BRANTFORD Brant Community 2,198 Champlain OTTAWA Montfort 2,056 Source: NACRS SPECIALTY OPHTHALMOLOGY Figure 11 identifies the top ten hospitals that perform the highest volume of specialty ophthalmology day surgery procedures representing 78% of the total volume done in the province. Seven of these hospitals are Academic Health Sciences Centres. 26 P a g e

27 FIGURE 11: TOP 10 ADULT DAY SURGERY HOSPITALS SPECIALTY OPHTHALMOLOGY LHIN Name Facility Name Level 3 Level 4 Total Champlain OTTAWA The Ottawa Hospital 970 1,679 2,649 South West LONDON St Joseph's 471 2,247 2,718 Toronto Central TORONTO University Health Network 337 2,005 2,342 Toronto Central TORONTO St Michael's 166 1,346 1,512 Mississauga Halton MISSISSAUGA Credit Valley ,276 HNHB HAMILTON St Joseph's ,155 Toronto Central TORONTO Sunnybrook HSC South East KINGSTON Hotel Dieu Toronto Central TORONTO Mount Sinai Central East TORONTO Rouge Valley Source: NACRS Although the majority of specialty ophthalmology cases are done on a day surgery basis, there remains a small but significant proportion of patients who will require inpatient surgery. In addition, complex and/or comorbid conditions will also necessitate that for some high risk patients, simple eye procedures should also be done as inpatient surgery due to safety concerns. Figure 12 illustrates that 15 hospitals perform 89% of all inpatient adult ophthalmology procedures in Ontario. It is important that inpatient ophthalmology services are maintained to ensure that complex, comorbid patients receive care in the most appropriate setting FIGURE 12: TOP 15 ADULT INPATIENT OPHTHALMOLOGY SURGERY HOSPITALS (ALL PROCEDURE LEVELS) LHIN Name Facility Name Total Inpatient South West LONDON St Joseph's 257 Toronto Central TORONTO St Michael's 203 Toronto Central TORONTO University Health Network 140 Champlain OTTAWA The Ottawa Hospital 82 Toronto Central TORONTO Sunnybrook HSC 70 Toronto Central TORONTO Mount Sinai 52 South West LONDON Health Sciences 51 Central West BRAMPTON William Osler 37 HNHB HAMILTON St Joseph's 36 Central TORONTO Humber River Regional 27 North East TIMMINS & District General 27 Central TORONTO North York General 25 HNHB HAMILTON Health Sciences Corp 22 Mississauga Halton MISSISSAUGA Credit Valley 20 Central East TORONTO Scarborough Hospital 20 Source: DAD 2011/12 27 P a g e

28 Nevertheless, there an additional 46 hospitals that performed at least one inpatient ophthalmology procedures in 2011/12. We anticipate that in some circumstances this may be due to the need for immediate access to a bed, but certainly raises the question about cost and outcomes at hospitals with very low volumes of inpatient ophthalmology cases. STANDARDIZED PROCEDURE RATES IN ONTARIO The following maps illustrate the standardized procedure rate per 100,000 population for cataract extraction, corneal transplant, glaucoma and retinal surgery. Standardized procedure rates in figure 13 are calculated based on the residence postal code of the patient and not the location of the hospital where the procedure was done. FIGURE 13: PROCEDURE RATES PER 100,000 POPULATION CATARACT EXTRACTION CORNEAL TRANSPLANT GLAUCOMA SURGICAL RETINA 28 P age

29 There are high rates of cataract extractions in the Erie St. Clair and Champlain LHINs corneal transplant in the South East and Champlain LHINs glaucoma surgery in Central West and North East LHINs surgical retinal procedures in Erie St. Clair, South West, Hamilton Niagara Haldimand Brant and Champlain LHINs. Rates of specialty ophthalmology surgery in the North West LHIN are low. This is thought to be due to patients who travel to Winnipeg for specialty ophthalmology which is not captured in Ontario data as well as lower access due to remote populations. GROWTH IN OPHTHALMOLOGY SERVICES Figure 14 illustrates activity trends in selected ophthalmology procedure volumes in hospitals from 2007/08 to 2011/12. There has been significant growth in corneal transplants (31% growth) and lamellar keratoplasties (~90% growth). Glaucoma surgery volumes have decreased because of new medical treatments available for this disease. Medical retinal volumes in hospital have dropped significantly due to intraocular injection treatments now provided in ophthalmologist offices or eye clinics (which are not coded in CIHI). Cataract surgery volumes are stable as they are determined by MOHLTC wait time funded volumes which remained relatively constant over this time period. FIGURE 14: ACTIVITY TRENDS IN HOSPITAL OPHTHALMOLOGY VOLUMES Corneal Transplants Lamellar Corneal Transplants Surgical Retina Cataract Extraction Glaucoma Surgery Medical Retina Data Source: DAD, NACRS DS & ER, 2007/08 11/12 29 P a g e

30 DISTRIBUTION OF OPHTHALMOLOGY SERVICES The percentage of adults who are able to receive care in their home LHIN largely depends on the level of general or specialty ophthalmology expertise. Figure 15 illustrates that general (level 2) procedures such as cataract surgery, are more likely to be performed within the patients home LHIN. Adult specialty expertise (levels 3 and 4) are primarily centralized to South West (London), Toronto Central, Hamilton Niagara Haldimand Brant (Hamilton), South East (Kingston) and Champlain (Ottawa) LHINs. This reflects the locations of specialized ophthalmologists and equipment necessary to perform these procedures and their alignment with teaching hospitals. FIGURE 15: PERCENTAGE OF PATIENTS TREATED IN HOME LHIN BY PROCEDURE LEVEL Data Source: DAD, NACRS, KEI, 2009/10 11/12 Market share mapping analysis ( figures 16 and 17) further demonstrates that the main centres of ophthalmology specialization are Toronto, Ottawa, London, Hamilton, and Kingston. 30 P a g e

31 FIGURE 16: HOSPITAL SHARE OF TOTAL PROVINCIAL CASES: PROCEDURE LEVELS 1, 2, 3 Data Source: DAD, NACRS, KEI 2011/12 FIGURE 17: HOSPITAL SHARE OF TOTAL PROVINCIAL CASES PROCEDURE LEVEL 4 Data Source: DAD, NACRS, KEI 2011/12 31 P a g e

32 SPECIAL TOPICS IN OPHTHALMOLOGY EMERGENCY AND URGENT SERVICES Emergent ophthalmology services are available through emergency departments, specialized urgent eye clinics run by large ophthalmology departments, or by direct referral to the on-call ophthalmologist. Existing CIHI databases do not capture services provided in urgent eye clinics or direct referrals to ophthalmologist offices. In one Ontario Academic Health Science Centre, only 15% of the patients with urgent eye problems originated through the Emergency Department. The CIHI data available to the Task Force likely underestimates the amount of urgent eye care provided in Ontario by a significant degree. Emergency ophthalmology is provided at hospitals with surgical facilities available 24/7/365 supported by ophthalmology on call rosters. In larger centres, the Majority of referrals and transfers of emergency eye cases to hospital occur through direct referrals between physicians and specialty ophthalmologists ophthalmology on-call rota is unique to each hospital. In smaller communities, call may rotated through a number of local hospitals. The Task Force did not identify any issues related to emergency access to hospital ophthalmology services. Not surprisingly, ophthalmology makes up a relatively small portion of the cases that require CritiCall services. Of the 21,087 CritiCall cases in 2011/12, only 30 were ophthalmology cases (figures 18). Most referrals and transfers to hospital occur through well-established direct referrals and CritiCall has been rarely needed. FIGURE 18: NUMBER OF CRITICALL CASES FOR OPHTHALMOLOGY 2007/ / / / /12 Number of CritiCall Cases 14,246 15,319 16,491 18,073 21,087 Number of Referrals in Ophthalmology Number of Transfers in Ophthalmology Source: CritiCall Ontario 32 P a g e

33 LIFE AND LIMB POLICY The Ministry s Life and Limb Policy will be effective Spring The purpose of policy is to ensure positive outcomes for patients who are life and limb threatened through timely access to hospital acute services within 4 hours. The Ophthalmology diagnoses listed in Figure 19 are included on the Provincial Life and Limb Diagnoses Guideline List and these are consistent with current practice. FIGURE 19: OPHTHALMOLOGY DIAGNOSES ON PROVINCIAL LIFE AND LIMB LIST OPHTHALMOLOGY DIAGNOSES Acute Ocular Hypertension/Glaucoma Endophthalmitis Severe Orbital Cellulitis Ruptured Globe Vision Threatening Conditions (Orbital Abscess, Orbital Hematoma, Optic Nerve Compression) Source: MOHLTC Life and Limb Policy ACCESS TO CARE WAIT TIMES ADULT OPHTHALMIC SURGERY Ophthalmic surgery has the highest volumes of cases in the Provincial Access to Care Database for Surgical Wait Times. The aggregated wait time for ophthalmic surgery is within the overall provincial target of 182 days. 10 However access to pediatric and some adult specialty surgery remains problematic. The August 2012 cataract wait time is 127 days which is an improvement of 77 days (57%) from the 2005 baseline. The number of people on the cataract surgery waiting list has continued to grow however and as of February 2012, there were nearly 34,000 Ontarians waiting for cataract surgery. Cataract cases now make up 90% of the provincial ophthalmology wait list. 10 Corneal transplant has a very high wait time of 333 days. Though corneal transplant has shown some improvement recently, wait times are almost double the provincial target level and are 5% above baseline. Less than 75% of corneal transplant cases are completed on target. Key issues include access to specialists and availability of operating room time and corneal tissue. 10 In addition, cornea- other (220 days), adult strabismus (204 days) and combination of cataract and other eye procedures (214 days) now exceed provincial target wait time of 182 days. For these procedures, 10 Access To Care. (2012). Ophthalmology Surgery Update. Presentation to the Provincial Vision Strategy Task Force. 33 P a g e

34 only % of cases are completed within provincial target. Glaucoma- filtering procedures and retina- vitrectomy are completed 88% and 87% of the time within provincial targets. 11 Ophthalmic Cancer has a slightly higher wait time at 61 days than the aggregate cancer surgery wait time of 56 days in a similar time period. 11 The volume of ophthalmic cancer surgery is extremely small and subject to significant variation on a case by case basis as a result. The majority of ocular cancer surgical volume is localized to the eyelids and is generally performed in a procedure room rather than in an operating room setting. These are not captured by the Access to Care wait time database. Erie St. Clair LHIN has consistently lower wait times, while Mississauga-Halton and Central West have the longest wait times for all ophthalmic surgery. 11 PEDIATRIC OPHTHALMIC SURGERY Pediatric Ophthalmic surgery is over the 90th percentile wait time P4 baseline of 153 days. In August 2012, the average pediatric ophthalmic surgery wait time was 223 days, which represents an increase of 70 days or 46% over 3 years. Completion within priority 4 target is 84%. In children, the longest wait lists are for strabismus. RECOMMENDATION Ministry and LHIN funding for ophthalmology services should be sustained to address wait lists for adult and pediatric eye surgery. EYE BANK OF ONTARIO AND CORNEAL TISSUE FOR TRANSPLANTATION Corneal transplantation is the most commonly performed transplant. It can successfully restore vision, reduce pain and improve the appearance of a damaged or diseased cornea. Most corneal transplant procedures are typically performed as a day surgery procedure which takes 1-3 hours to complete depending on the type of procedure used and other ocular comorbidities. Fewer than 3.5% of patients reject corneal tissue. Recent advances are such that it is now possible to transplant only a part of the cornea which makes the procedure faster and speeds visual recovery and the predictability of outcome. As a result, indications for corneal transplantation have expanded. The Eye Bank of Canada, Ontario Division receives all donor corneas from across Ontario. On average 1,100 usable corneas are obtained per year from deceased donors. Corneas must be transplanted within 9 days. Approximately 90% of corneal tissue is used within Ontario and 10% is sent out-ofprovince or out-of- country. 11 Access To Care. (2012). Ophthalmology Surgery Update. Presentation to the Provincial Vision Strategy Task Force. 34 P a g e

35 Wait times for patients in Ontario for corneal transplants vary depending on the surgeon and/or hospital. Since 2008/09, Ontarians wait on average 407 days for corneal transplants. Toronto and London have the longest wait times at 827 days and 519 days respectively. The number of patients on the wait list for corneal transplant at any time is approximately 500. In Q1 2011/12, the largest waiting lists for corneal transplant were in Toronto Central LHIN (333 patients: Sunnybrook, TEGH and UHN), Champlain LHIN (67 patients) and South West LHIN (46 patients). St. Joseph s in London, St. Mary s in Waterloo and UHN have the highest number of unmet requests (30%) for eye bank tissue. The longest wait times for corneal transplant are 827 days in Toronto and 519 days in London There are new approaches for corneal tissue preparation prior to lamellar surgery that would increase the utilization of donated tissue. The use of precut tissue would reduce waste and allow more cases to be done within the same amount of operating room time. It is recommended that these be introduced in Ontario soon. Approximately 74% of patients on the waitlist are between the ages of Unfortunately, without a provincial corneal transplant registry there is no way of measuring disability or prioritizing Ontarians on the various corneal transplant lists maintained by ophthalmologists and hospitals. The absence of a transplant registry also hampers the implementation of strategic improvements to the system of distributing corneal tissue to those patients who need it most. Recently, Kensington Eye Institute was funded to provide 400 corneal transplants to help address waiting lists. RECOMMENDATION A provincial corneal transplant wait list registry should be developed by Trillium Gift of Life to assist in the prioritization of cases and the equitable distribution of corneal tissue. Eye Bank processes which incorporate the ability to provide precut tissue to end users should be implemented. 35 P a g e

36 OUT-OF-COUNTRY SERVICES There are occasional circumstances when a patient requires an ophthalmology service that is not available in Ontario. In 2012/13 from April 1-December 31, there have been 19 out of country ophthalmology cases funded by the Ministry. Of the 15 ophthalmology cases funded in 11/12, the majority (11 cases) were for the Boston Scleral Lens/PROSE procedure, which is not currently available in Ontario. FIGURE 20: OUT-OF-COUNTRY OPHTHALMOLOGY CASES 2009/ / / /13 (Q3) Boston Scleral Lens/PROSE Cataract Surgery Cornea Transplant Cytophotocoagulation Eyelid Spring Repair Limbal Stem Cell Transplant Mucus Membrane Graft to Eyelid Shunt for Glaucoma Take down of Tarsorrhaphy and pars plana vitrectomy Victrectomy YAG Laser Capsulotomy S o S Source: Ministry of Health and Long-Term Care RECOMMENDATIONS Ministry should consider funding a Boston Scleral Lens/PROSE program in Ontario at a designated centre. EMERGING TECHNOLOGIES Innovations in the field of ophthalmology are continuingly providing opportunities for procedures to be done more efficiently, safely and at a higher quality. There are five emerging technologies that were identified by the Task Force as either being imminent within the next 1-5 years or having a real positive impact on the delivery of vision care in the Ontario. EYLEA (AFLIBERCEPT) EYLEA is an anti-vegf molecule, similar to Lucentis, which is the only drug currently covered by the ODB program for treatment of macular degeneration and diabetic retinopathy. It has a longer action than Lucentis. This may result in up to a doubling of current follow up intervals with a consequent reduction in injection and OCT testing volumes. EYLEA is anticipated to gain approval in Canada in P a g e

37 OCRIPLASMIN Ocriplasmin is an intravitreal injection designed to induce the vitreous gel to separate from the retina. This new procedure offers medical treatment for conditions that would otherwise require surgery to create this separation (i.e. Vitreomacular Traction Syndrome, stage 2 macular hole). Macular hole is one of the conditions that require a vitrectomy to repair (incidence 7.8/100,000 population) 12 so removal of some of these cases from the surgical mix has the potential for cost and resource savings. Overall about 1/3 of cases should respond. The impact of this treatment will depend on the drug cost as failed cases will still require vitrectomy. FEMPTOSECOND LASER The femtosecond laser is an automated technique to produce high quality incisions during some anterior segment surgery (i.e. corneal incisions, the creation of the capsulotomy and the initial fragmenting of the lens during cataract surgery, as well as flap creation in corneal refractive surgery, and incisions in corneal transplant surgery). Evidence suggests that it may increase reproducibility, safety, and speed of some aspects of surgery; however, it is an expensive technology with application to a limited subset of patients at present. ELECTRONIC MEDICAL RECORDS VISION CARE There is currently no provincial Electronic Medical Record (EMR) system for ophthalmology and vision care. Few existing EMRs adapt readily to the specialized ophthalmology information collected during patient assessments. Developing one consistent information-sharing system across the province has the potential to allow information about surgical outcomes to be monitored as well as providing a more uniform platform for information sharing between general and specialized ophthalmologists, and other care providers. TELE-OPHTHALMOLOGY Teleophthalmology provides patients with the opportunity to access some aspects of vision care with face-to-face distance visit with the ophthalmologist. With the use of this technology there is potential to expand diabetic screening to at risk individuals who are not being screened and reduce travel for patients in small communities with chronic eye conditions who need ongoing monitoring. However patients undergoing active treatment (eg: most macular degeneration and diabetic maculopathy patients) will still need to travel to have treatment administered. TECHNOLOGIES IN DEVELOPMENT There are a number of technologies that are currently in development in ophthalmology which will require review as they mature. This would include retinal prosthesis, artificial cornea, stem cell 12 McCannel, C.A. et al. (2009) Population-based Incidence of Macular Holes. J. Ophthalmology, 116(7): P a g e

38 transplants for retinal regeneration as well as regeneration of the corneal endothelium, gene therapy and nerve growth factor. ACADEMIC OPHTHALMOLOGY Ontario s academic ophthalmology departments provide advanced clinical care, research and education, and are the home for leaders in research and education in Ontario. This is achieved through the concentration of high level subspecialty experts, whose skills are honed with research and teaching activities, and who provide care for complex patients with difficult eye diseases. As the major referral centers, academic departments attract patients from a wide catchment area and allow trainees to have first-hand experience in handling the treatment of more complex eye cases. Academic eye programs in teaching hospitals are a critical component for the delivery ophthalmology services. As these organizations incur costs not found in non-teaching centres, specific considerations are needed to ensure that ongoing investments are made in Ontario to maintain and improve the supporting infrastructure that enables these research and education programs to exist. The five academic ophthalmology centres in Ontario are: Toronto (University of Toronto), London (Western University), Ottawa (University of Ottawa), Kingston (Queen s University) and Hamilton (McMaster University). OPHTHALMOLOGY EDUCATION Ophthalmologic education ranges from undergraduate medical student education through to residency and fellowship. Each of these aspects of education is vital to ensuring the comprehensiveness and sustainability of Ontario s eye-care system. While much internal expertise in education exists within academic departments of ophthalmology, collaborations with education experts at the affiliated universities also contribute to the development of pedagogically sound curricula in ophthalmology. Furthermore, by drawing on some of the best medical school graduates from Canada and internationally, ophthalmology residents and international fellows provide breadth of experience which also helps advance ophthalmology in Ontario. The following table outlines the academically affiliated ophthalmology sites, number of ophthalmology fellows and number of ophthalmology graduates in Ontario per year. It should be noted that many of the subspecialty fellows are foreign and return home at the completion of their training. 38 P a g e

39 FIGURE 21: ACADEMIC OPHTHALMOLOGY DEPARTMENTS IN ONTARIO ACADEMIC DEPARTMENTS AFFILIATED HEALTH SCIENCES CENTRE(S) FELLOWS/ YEAR RESIDENTS GRADUATING/ YEAR University of Toronto Western University University of Ottawa Queen s University McMaster University Toronto Western Hospital Kensington Eye Institute St. Michael s Hospital Sunnybrook Hospital Hospital for Sick Children Mount Sinai Hospital Ivey Eye Institute (St. Joseph s Health Centre) London Health Sciences Centre The Ottawa Hospital - University of Ottawa Eye Institute The Ottawa Hospital - Riverside Eye Care Center Children s Hospital of Eastern Ontario Hotel Dieu Hospital Kingston General Hospital part-time only St. Joseph s Ambulatory Care Centre HHSC McMaster Children s Hospital Source: Academic Chairs RESEARCH IN OPHTHALMOLOGY Ophthalmology research in Ontario includes biomedical, clinical, health services and policy research. The biomedical sciences form the foundation of modern ophthalmologic care and are a source of innovation in care. Most biomedical eye research is led by PhD-trained researchers who are affiliated with academic departments of ophthalmology in Toronto, Ottawa or London. Clinical research informs best practices and encourages the use of the most effective types of care, which helps drive efficiencies in the eye care system in Ontario. It focused on a wide range of clinical issues such as disease prevalence, risk factor identification, diagnostic testing and surgical and medical treatment. In addition to investigator-initiated studies, industry-driven clinical trials often incorporate sites in Ontario. Clinical research is generally led by clinician ophthalmology researchers partnering with research methodology experts. Resident trainees are often included in these studies in order to provide 39 P a g e

40 them with the research experience mandated by the Royal College of Physicians and Surgeons of Canada. Ontario s leading ophthalmology research programs are at the Toronto Western Hospital, SickKids, St. Michael s Hospital, The Ottawa Hospital, Kingston s Hotel Dieu Hospital Eye Care Centre and the Ivey Eye Institute at St. Joseph s in London. UNIVERSITY OF TORONTO UNIVERSITY HEALTH NETWORK VISION SCIENCE RESEARCH PROGRAM The largest academic research program in ophthalmology is at UHN. Clinical and basic science researchers in the Vision Sciences Research Program focus on: Molecular genetics of blinding eye diseases and brain disorders Treatment, biophysics and psychophysics of glaucoma Eye movement control mechanisms Neuronal damage Retinal degeneration and diabetic retinopathy The Vision Science Research Program at UHN also offers a comprehensive fellowship program which is unique in North America. In addition, UHN Vision Endowment Funds support graduate student research in Ophthalmology at the University of Toronto. THE HOSPITAL FOR SICK CHILDREN The Hospital for Sick Children houses Canada s largest pediatric vision research program which receives more that $2 million in research grants per year. Vision research in pediatrics is focused on: Molecular genetics of inherited retinal dystrophies Electrophysiology of the retina and visual pathway Prosopagnosia and other agnosias Visual development in neonates with cataract ST. MICHAEL S HOSPITAL KEENAN RESEARCH CENTRE Ophthalmology is one of 24 research priorities at the Keenan Research Centre at St. Michael s Hospital. Areas of clinical and translational research include glaucoma, diabetic retinopathy, retinal detachment and age-related macular degeneration. Beyond leading an internationally-recognized glaucoma and nerve protection unit, St. Michael s has developed the National Ocular Trauma database. 40 P a g e

41 SUNNYBROOK HEALTH SCIENCES CENTRE DIXON FAMILY CHAIR IN OPHTHALMOLOGY Sunnybrook Health Sciences Centre is working with the University of Toronto to establish the new Dixon Family Chair in Ophthalmology Research at the Sunnybrook Research Institute. The Chair is expected to establish a program of research excellence in vision sciences. UNIVERSITY OF OTTAWA The Ottawa Hospital Research Institute Vision Program which is located at the General Campus of the hospital, is the research arm of the University of Ottawa Eye Institute. Investigators focus on a wide variety of vision disorders. Research efforts within the program have grown steadily through recruitment and through construction of the new Centre for Research on Age-Related Blindness. Well-established research programs in cellular and molecular biology, biomedical instrumentation, electrophysiology, optics, psychophysics, and visual performance have been developed. In addition, there is a strong clinical science expertise in many areas including epidemiology, ocular pathology, ocular genetics, neuro-ophthalmology, cornea, uveitis, and glaucoma. WESTERN UNIVERSITY The Department of Ophthalmology conducts basic and clinical research at the Ivey Eye Institute and has a dedicated basic science laboratory located in the Lawson Health Research Institute (LHRI) at St. Joseph s Health Centre. Clinical research includes health economics of eye diseases, knowledge synthesis studies, and large population based cohort studies. The department also has one of the most active groups in the Canadian retina clinical trials network. They hope to expand clinical research into the area of health technology assessment. QUEEN S UNIVERSITY The Department of Ophthalmology at Queen s University has a strong research focus centered at the Hotel Dieu Hospital Eye Care Centre. The department has internationally recognized research programs in eye and vision health services and policy research and knowledge translation. The department was also recognized for starting Canada s first multi-centered randomized clinical trial evaluating the efficacy of different wavelengths for the treatment of macular degeneration. RECOMMENDATION System planning must ensure that education, basic and clinical research programs in ophthalmology are sustained and enhanced. OPHTHALMOLOGY IN THE NORTH Northern Ontario has challenges in the planning and delivery of health care services due to its unique geography, low population density, and widely dispersed communities. The North West and North East 41 P a g e

42 LHINs have the two largest geographies of any LHIN, together covering 87% of the province s landmass though a population of only 781,000 people (approximately 6% of the entire population of Ontario). This result in health service delivery challenges including access to care, adequate health human resources, 13, 14 the need for extensive travel, and higher costs of care per capita. Compared to the rest of the province, Northern Ontario has a higher prevalence of chronic disease. For example 8% of people in the North East LHIN have diabetes compared to the provincial average of 6.8%. In addition, 16.9% and 14.1% of the populations in North East and North West LHINs (respectively) are 13, 14 over the age of 65, compared to provincial average of 13.7%. The north also has special populations including very large aboriginal and francophone communities. Specifically, in the North West and North East LHINs, 19% and 10% of their populations identify as Aboriginal, respectively. Access to health care services for Aboriginal people living in First Nation communities continues to be a challenge due to geography, remoteness, language, and 13, 14 federal/provincial issues. Together, these impact on ophthalmology services in the north as follows: An older population increases the prevalence of age-related ocular diseases Higher rates of diabetes increased the risk of diabetic retinopathy Remote communities coupled with language barriers make the on-going regular medical management of ocular diseases much more challenging. Solutions that are appropriate for the north must be developed locally in partnership with others who are providing services there. Opportunities may include more tele-ophthalmology, evaluating the location, and availability of specialty ophthalmologists in the region or developing specialist outreach programs. Specific issues identified by the Task Force related to pediatric and retinal ophthalmology. There may also be opportunities to leverage the Northern Ontario School of Medicine as an hub for ophthalmology in the north. RECOMMENDATION The North West and North East LHINs should work together with specialty hospitals currently serving patients from the north to develop a Northern Ontario Vision Plan that would improve access to specialty ophthalmology services closer to home wherever possible. LOCAL HEALTH INTEGRATION NETWORK STRATEGIC PLANNING The Local Health Integration Networks (LHINs) are system leaders in strategic planning for local health care services. The main roles of the LHINs are to plan, fund and integrate health care services locally. Their goal is to develop innovative, collaborative solutions leading to more timely access to high quality 13 North West Local Health Integration Network (LHIN). Integrated Health Services Plan III ( ) 14 North East Local Health Integration Network (LHIN). Integrated Health Services Plan ( ) 42 P a g e

43 services. The LHINs provided the following planning principles related to developing provincial strategic recommendations for ophthalmology in Ontario. The unique features of each LHIN must be considered in determining which model of service delivery is most appropriate as there is not a one-size-fits-all model for ophthalmology. The geography of LHINs and how that geography relates to patient travel and access to care are key consideration in any service delivery model. The allocation of volumes and funding should be determined based on a reliable demand/need forecasts. Historical service levels may not reflect the actual needs of the population. Strategic planning should consider access for special populations such as aboriginal populations with a higher prevalence of diabetes, and older population with high prevalence of eye disease. Three key existing LHIN initiatives in ophthalmology can be found in detail in Appendix 4. For planning purposes, it is important to recognize that provision of pediatric and adult specialty ophthalmology services requires coordination across LHINs because of their provincial specialized nature. RECOMMENDATION Each LHIN should develop a Local Vision Plan describing how they will provide for the current state and future needs of their communities, based on the Provincial Vision Task Force Report. SUMMARY OF KEY FINDINGS OPHTHALMOLOGY VOLUME FORECASTING The Provincial Vision Strategy Task Force developed year ophthalmology volume forecasts for adult and pediatric populations based on population demographics using Ministry of Finance projections and adjusted for clinical trends and utilization patterns. In this way, the Task Force was able to identify ophthalmology service gaps in short and longer term horizons. ADULT VOLUMES FORECAST For the next 15 years, the average annual growth in adult ophthalmology is projected to be 2.6% per year, with a more significant growth rate of % per year for specialty procedures (figure 22). 43 P a g e

44 FIGURE 22: ANNUAL GROWTH IN ADULT OPHTHALMOLOGY CASES OVER THE NEXT 15 YEARS General Ophthalmology Specialty Ophthalmology Level 2 (Cataracts Only) Actual Forecast 2011/ / / /27 Average Annual Change 137, , , ,262 2% Level 2 (Other) 15,777 14, , % Level 3 9,441 10,596 12,241 13, % Level 4 14,378 16,227 18,639 21, % TOTAL 177, , , , % Source: DAD and NACRS 2011/12 Figure 23 (general) and figure 24 (specialty) show the additional ophthalmology procedure volumes expected by 2021 for each LHIN. From these tables we see that the greatest growth in cataract volumes, will be in North Simcoe Muskoka, Central West, Mississauga Halton, Waterloo Wellington and South West LHINs. FIGURE 23: PROJECTED GAPS IN ADULT CASE VOLUMES BY LHIN GENERAL OPHTHALMOLOGY Level 2 - Cataracts Level 2 - Other Patient LHIN 2011/ /22 % 2011/ /22 % Actual Add'l Change Actual Add'l Change Erie St. Clair 9,241 1, % % South West 9,968 3, % 1, % Waterloo Wellington 6,214 2, % % HNHB 16,301 3, % 1, % Central West 6,475 2, % % Mississauga Halton 8,793 4, % % Toronto Central 9,206 2, % % Central 16,975 4, % % Central East (Pickering, Ajax, Oshawa) 10,600 2, % % Central East (Other) 6,920 1, % % South East 6,681 1, % % Champlain 15,116 3, % 1, % North Simcoe Muskoka 4,669 2, % % North East and North West 10,614 1, % 2, % All Ontario 137,773 36, % 13,459 1, % Source: DAD and NACRS 2011/12 44 P a g e

45 In specialty ophthalmology, the largest percentage growth is for people from North Simcoe Muskoka, Waterloo Wellington, Central, Central East, Mississauga Halton, and North East and North West LHINs seeking specialty services. FIGURE 24: PROJECTED GAPS IN ADULT CASE VOLUMES BY LHIN SPECIALTY OPHTHALMOLOGY Level 3 Level 4 Patient LHIN 2011/ /22 % 2011/ /22 % Actual Add'l Change Actual Add'l Change Erie St. Clair % % South West % 1, % Waterloo Wellington % % HNHB % 1, % Central West % % Mississauga Halton % % Toronto Central % % Central 1, % % Central East (Pickering, Ajax, Oshawa) % % Central East (Other) % % South East % % Champlain 1, % 1, % North Simcoe Muskoka % % North East and North West % % All Ontario 8,764 3, % 13,270 5, % Source: DAD and NACRS 2011/12 PEDIATRIC VOLUMES FORECAST In pediatrics, a more modest 1.3% annual growth in volumes is expected over the next 15 years mostly in strabismus repair. The annual negative change in Lacrimal Duct Probing is due to the fact that these procedures are now being performed in minor procedure suites and no longer being captured in the CIHI databases. FIGURE 25: FORECASTED CHANGE IN PEDIATRIC CASE VOLUMES BY PROCEDURE GROUP Actual Forecast 2011/ / / /27 Annual Change Strabismus Repair 1,863 1,959 2,136 2, % Lacrimal Duct Probing % Pediatric - Other 2,135 2,223 2,407 2, % TOTAL 4,458 4,571 4,914 5, % Source: DAD and NACRS 2011/12 45 P a g e

46 In pediatric ophthalmology, the greatest growth over the next ten years is in children from North Simcoe Muskoka, Erie St. Clair, Hamilton Niagara Haldimand Brant, Waterloo Wellington, Central West and Mississauga Halton LHINs. FIGURE 26: PROJECTED GAPS IN PEDIATRIC CASE VOLUMES BY LHIN Strabismus Other Patient LHIN 2011/ /22 % 2011/ /22 % Actual Add'l Change Actual Add'l Change Erie St. Clair % % South West % % Waterloo Wellington % % HNHB % % Central West % % Mississauga Halton % % Toronto Central % % Central % % Central East-Pickering/Ajax/Oshawa % % Central East-Other % % South East % % Champlain % % North Simcoe Muskoka % % North East and North West % % All Ontario 1, % 2, % Source: DAD and NACRS 2011/12 HEALTH HUMAN RESOURCES PLANNING There are 391 ophthalmologists currently practicing in Ontario (figure 27). Given their large general, pediatric and specialty Ophthalmology programs, Toronto and Ottawa are home to the largest number of ophthalmologists. FIGURE 27: NUMBER OF OPHTHALMOLOGISTS CURRENTLY PRACTICING IN ONTARIO 46 P a g e Source: CPSO

47 A forecast of physician human resource trends was undertaken using data from both the Ontario Medical Association and the College of Physicians and Surgeons of Ontario. Of the ophthalmologists currently practicing in Ontario, there are 60 who are currently over the age of 70. It is anticipated that over the next three years, 16 more ophthalmologists will reach this milestone. This represents nearly one in five ophthalmologists in Ontario at or near retirement. FIGURE 28: NUMBER OF OPHTHALMOLOGISTS REACHING THE AGE OF 70 Total Ophthalmologist % Currently > % % % % % Source: OMA and CPSO data We undertook to model the impact of retirements and new ophthalmology graduates. Figure 29 illustrates the anticipated number of general and specialist ophthalmologist who will be practicing in Ontario over the next 15 years assuming that no new human resources strategy measures are taken. The assumptions used in the calculations are as follows: Of the approximately 16 ophthalmology graduates in Ontario, 13 choose to stay in Ontario and practice here. The current mix of general (65%) and specialty (35%) ophthalmologists remains constant over time. FIG. 29: 25 YEAR FORECAST--NUMBER OF GENERAL AND SPECIALTY OPHTHALMOLOGISTS ONTARIO Source: OMA, CPSO, Academic Departments of Ophthalmology 47 P a g e

48 We then compared the anticipated number of ophthalmologists in 2021/22 to the forecasted volumes for the same period (figure 30). To meet demand, general ophthalmology case load per ophthalmologist would need to increase 34% from 609 to 815 surgeries per year. Specialist ophthalmology caseloads would need to increase 44% from 171 to 246 cases per ophthalmologist per year. This is not realistic from a patient safety or physician workload perspective and new human resources strategies for ophthalmology are required. FIGURE 30: ADDITIONAL SURGEON PRODUCTIVITY NEEDED TO MEET FUTURE VOLUMES # Level 2 (General) Cases per General Ophthalmologist # Level 3/4 (Specialty) Cases per Specialty Ophthalmologist IDEAL WORK LOAD For some interventions, surgeon experience with the procedure is essential for patient safety and surgeons must perform a critical annual volume to maintain a requisite skill level and achieve low surgical complication rate. Studies on critical mass and quality relationships focus largely on cataract surgery where it has been shown that complication rates increase as surgeon volume decreases. However, even in the highest incidence group (those who perform under 200 cataract cases/year), a recent Ontario study showed surgical complication rate were still extremely low at 0.8%. 48 P a g e

49 Furthermore, it has been shown that the specialty surgeons who perform lower case volumes appear to operate on a higher proportion of complicated eyes which artificially increases complication rates. 15 The numbers needed to maintain competence in specialty ophthalmology surgery have not been well studied. In one British study the rate of complication in glaucoma surgery increased only in those performing less than 10 cases per year. 16 There is little clinically significant evidence to suggest that there are diminishing returns on quality when surgeons perform too many cases per year, however there are other system disadvantages associated with very high volumes per surgeon. Based on current projections, in 10 years Ontario could have a shortfall of approximately 68 general ophthalmologists One concern is that new graduates are not receiving enough operating room time and are therefore unable to offer their patients appropriate surgical treatment. This often forces them to practice outside of Ontario or to abandon ophthalmology all together. A second concern is that, if ophthalmologists focus only on providing surgical services, their contribution to medical aspects of vision care may be insufficient to meet the local population needs for medical eye care. Consequently, the task force recommends that the annual volume of adult cataract surgery performed by a single surgeon should fall within the following range; Cataract Surgery Cataract surgeries per year For adult specialty surgery the average surgical volumes vary significantly between subspecialties with the highest volumes of procedures being done by vitreoretinal surgeons. Given the limited amount of evidence, the task force relied on expert consensus to arrive at the following recommended ranges: Specialty Surgery Vitreoretinal surgeries per year Glaucoma/Cornea surgeries per year As the forecast in Figure 30 illustrates, a projected surgical volume of 246 cases per year for specialty ophthalmologists is unlikely to produce major workload pressures. However, reevaluating the physician requirements using 600 as the maximum volume of general ophthalmology procedures per ophthalmologist per year, we find that in 10 years Ontario could have a shortfall of approximately 68 general ophthalmologists. Despite this, the task force felt that, given the aging demographic in Ophthalmology and the projected increases in medical Ophthalmology and office and treatment room procedures required, the benefits of placing a limit on the number of cataract procedures/surgeon far 15 Habib M.S., Bunce C.V., Fraser S.G. (2005). The role of case mix in the relation of volume and outcome in phacoemulsification. Br J Ophthalmol. Sep, 89(9): Wu G., Hildreth T., Phelan P.S., Fraser S.G. (2007). The relation of volume and outcome in trabeculectomy. Eye (Lond). Jul, 21(7): P a g e

50 outweigh any increase in the number of general ophthalmologists needed to do cataract surgery if a higher cap were imposed. RECOMMENDATIONS At least 2-3 additional ophthalmology students must be graduated each year to ease the impending physician human resource pressures in ophthalmology in Ontario. To ensure each new graduate is retained to enter a career in Ophthalmology in Ontario- we recommend that access to facilities be granted such that a minimum of 200 cataract surgeries per year, or 200 vitreo retinal surgeries, or 40 glaucoma/cornea surgeries are performed by each surgeon respectively so that adequate skills are maintained and that new graduates can develop sustainable practices. General ophthalmologists should ideally perform a maximum of 600 adult cataract extraction per year to ensure that access to medical vision care is maintained and that there is adequate OR time available for new graduates. Subspecialty ophthalmologists should ideally perform a maximum of 400 adult specialty procedures to ensure that access to medical vision care is maintained and that there is adequate OR time available for new graduates. SERVICE DELIVERY AND LOW VOLUME CENTRES The tables below outline the number of facilities located in each LHIN providing low, moderate or high volumes of ophthalmology surgeries per year. LHIN with multiple hospitals performing low volumes of eye procedures should review service delivery models to see if there are new ways of achieving critical mass to enhance services perhaps with increased efficiency. In some circumstances, low volume eye centers create much needed local access to services especially in remote areas, and remain a key element in a LHIN based regional plan for vision services. In other communities, low volume hospitals may be open to consolidation of eye services in order to create larger more comprehensive centres for eye care. Figure 31 on Cataract Surgery shows that 15 hospitals perform cataract surgeries a year, 14 hospitals provide cataracts per year, 28 hospitals provide cataract surgeries and 11 facilities (including KEI) perform over 4000 cataract surgeries per year. Figure 32 on Specialty Surgery reveals that 67 hospitals provide 0-50 specialty level 3 procedures and 46 hospitals provide 0-50 specialty level 4 procedures per year. These groupings also capture complicated cataract surgery and ocular trauma. Further analysis at the local LHIN level is necessary to interpret these findings and determine if opportunities for consolidation or different models of general and specialty ophthalmology services given geographical, patient, provider and growth considerations. 50 P a g e

51 FIGURE 31: NUMBER OF FACILITIES PERFORMING CATARACT SURGERIES IN THE VOLUME RANGES SPECIFIED Annual Volume Ranges Cataracts/yr Cataracts/yr Cataracts/yr Cataract/yr Erie St. Clair South West Waterloo Wellington HNHB Mississauga Halton Central West Toronto Central * Central Central East South East Champlain North Simcoe Muskoka North East North West TOTAL # of *KENSINGTON EYE INSTITUTE FIGURE 32: NUMBER OF HOSPITALS PERFORMING SPECIALTY SURGERY IN THE VOLUME RANGES SPECIFIED LEVEL Specialty Cases/yr Specialty Cases/Yr Specialty Cases/Yr 800+ Specialty Cases/Yr Erie St. Clair South West Waterloo Well HNHB Mississauga Halton Central West Toronto Central Central Central East South East Champlain North Simcoe Musk North East North West TOTAL LEVEL Specialty Cases/yr Specialty Cases/Yr Specialty Cases/Yr 800+ Specialty Cases/Yr Erie St. Clair South West Waterloo Well HNHB Mississauga Halton Central West Toronto Central Central Central East South East Champlain North Simcoe Musk North East North West TOTAL P a g e

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