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Helen Carter

 

A proposal to reimburse GPs and primary care staff under GP direction for fundus photography of diabetic patients is before the Medicare Services Advisory Committee. If recommended, Cabinet will decide whether to approve an item number, increasing diabetic retinopathy screening rates across the country.

The proposed fee is $50 and it would be for bilateral retinal photography with a non-mydriatic retinal camera for initial or repeat assessment for presence or absence of diabetic retinopathy in people with medically diagnosed diabetes.

The proposal stipulates that the images will be taken in clinics under the direction of a GP. Patients found to have reduced vision or abnormal results will be referred to eye-care professionals for follow-up.

Advocates say the aim is to dramatically boost the number of annual eye checks among diabetic patients. Currently, only half of non-Indigenous Australians with diabetes have annual checks and only one in five Indigenous Australians with diabetes has their recommended annual eye check. In most cases, monitoring diabetic retinopathy from diagnosis, and detecting and treating it sooner can avert vision loss.

More patients, less vision loss

Optometrist Mitchell Anjou, University of Melbourne senior research fellow in the Indigenous Eye Health Unit, is optimistic about the development.

‘Screening rates for diabetic retinopathy are 20 per cent for Aboriginal and Torres Strait Islander people with diabetes, and 50 to 60 per cent for non-Indigenous Australians with diabetes. It should be 100 per cent for everyone with diabetes and there is little evidence that screening rates are changing,’ Anjou said.

‘Optometrists doing more and better does not seem to be addressing this important public health issue,’ he said. ‘All people with diabetes need regular retinal examinations, and optometrists and ophthalmologists can’t do the screening at the rates required. We have not been able to get everyone who has diabetes into our practices to check their retinae.

‘This new item number would not be about replacing a comprehensive examination—it would be adding to screening options for people with diabetes so they are checked and those with problems will be referred.

‘If we can increase screening rates—because there is a measurement of visual acuity and a photo—the flow-on will be more patients into optometric services for comprehensive care and reduced vision loss from diabetic retinopathy,’ he said.

Mainstream screenings

Ophthalmologist Professor Hugh Taylor, the Harold Mitchell Chair of Indigenous Eye Health at the University of Melbourne, has been lobbying for the item for more than 20 years since first broaching the issue with politicians and medical committees in 1994.

Taylor recommended it in 1996 NHMRC Guidelines on Diabetic Retinopathy and Health Minister Michael Wooldridge was unsuccessful at securing funding. Further repeated attempts culminated two years ago when Taylor asked the Department of Health for help to write the submission by the Centre for Eye Research Australia to the Medicare Services Advisory Committee.

‘It will make a huge difference in the bush and cities too. It’s just as important for mainstream Australia. It is building [diabetic eye checks] into primary care. People will be able to have their photo taken at their GP practice, community health centre or diabetes clinic. It’s triage work for optometrists and ophthalmologists,’ Taylor said. ‘They will see all the people who need to be seen and not those who don’t.’

Anjou agrees, pointing out that after interpreting the photos, primary care staff would send patients with abnormal results to optometrists or ophthalmologists, and this would also help establish relationships between primary care and eye-care services.

‘The issue in remote areas is availability of services. This will allow clinics to build a viable service model and maybe employ someone to take photos, enabling opportunistic screening when a patient with diabetes visits the clinic for any reason and a staff member and camera are there, rather than waiting for a visiting eye-care practitioner,’ Anjou said.

‘The cameras are relatively simple to use once people have been trained and are non-mydriatic so no drops are required. It is basically point and shoot in a darkened room.

‘Staff can be trained to do simple grading of a photo under GP direction. If the vision is normal and the retina looks clear, there are no exudates or blood leakage, it is normal, but if there is exudation or haemorrhaging or it is questionable, they will be referred,’ he said.

‘The other part of screening is visual acuity testing and if VA is reduced that is another indicator for referral.’

Anjou said primary care staff who conducted annual health assessments in Indigenous people were already trained in visual acuity testing.

‘This will be a fantastic public health initiative which will increase screening rates and create opportunities for optometrists to engage with public health services,’ he said. ‘It will detect more cases of diabetic retinopathy and put more patients into the appropriate pathways of care.’

Optometry Australia CEO Genevieve Quilty said the organisation understood that an earlier version of the item being considered would have also supported primary care workers to take retinal photos for diabetic patients under the direction of an optometrist.

‘We’ve made clear to the government our disappointment that this has now been restricted to GPs. It would have meant greater benefit in numbers of patients screened,’ she said.

‘Maximising the potential public health benefit of this new item will mean we need clear referral protocols and established pathways at local levels to make sure all who need further assessment have ready access to an optometrist. We will be encouraging optometrists to make sure they connect with their local GPs and primary care services to ensure that these are in place.’

If approved, the item would complement Australian Government plans to release this year a new national diabetes strategy to reduce the growing diabetes burden.

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