September 2014 - North East LHIN
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September 2014
Acknowledgements This plan is built on the valuable information and insights provided by ophthalmologists, optometrists and health care providers across the region. In addition, individuals such as David Tanner and Kalen Paulson of Hamilton, Niagara Halidmand Brant Local Health Integration Network (LHIN) provided valuable advice and prepared the table of ophthalmic day procedures for this report. Heather Gray, Heli Mehta and Lori Marshall of the North West LHIN collaborated in planning and reviewing the results of the plan. Thank you must go as well to Claudine Wathier-Doucett, Client Relations Manager at CritiCall Ontario, who provided details regarding the calls made from the NE LHIN hospitals and the tables included in Appendix G. The North East LHIN acknowledges and thanks Mary Ellen Szadkowski for her research, writing as well as work engaging practitioners and health care providers in compiling this report.
NE LHIN Vision Care Plan
Table of Contents
Executive Summary .................................................................................................................................. i
Introduction .................................................................................................................................................. 1
Vision Care Overview .............................................................................................................................. 4
Common Eye Diseases and Conditions.................................................................................. 4
Vision loss and Diabetes ............................................................................................................... 5
Eye Care Providers ........................................................................................................................... 6
Screening ............................................................................................................................................... 8
Current State of Vision Care in the NE LHIN .............................................................................. 9
Vision Care in the North East...................................................................................................... 9
Where do Patients Go for Cataract Surgery? ................................................................... 14
Vision Care in Hub Areas..................................................................................................................... 18
First Nations ....................................................................................................................................... 18
Algoma Hub......................................................................................................................................... 18
Cochrane .............................................................................................................................................. 20
James and Hudson Bay Coasts................................................................................................ 22
Nipissing – Temiskaming Hub ................................................................................................... 24
Sudbury/Manitoulin/Parry Sound Hub .................................................................................... 28
NE LHIN Regional Summary of Vision Care .............................................................................. 33
Future Needs for Vision Care in the NE LHIN .......................................................................... 39
Recommendations .................................................................................................................................. 41
Appendices ................................................................................................................................................. 43
Endnotes ...................................................................................................................................................... 57
Executive Summary
North East LHIN Plan for Vision Care
Executive Summary
The Ministry of Health and Long Term Care (MOHLTC) released A Vision for Ontario: Strategic
Recommendations for Ophthalmology in Ontario in 2013. Among the recommendations of this report is
that Local Health Integration Networks develop vision plans describing how they will provide for the
vision care needs of their communities. In January 2014 the North East Local Health Integration Network
(NE LHIN) embarked on a review of the current state of vision care across the region and developed
recommendations to provide for current and future eye care needs of the people in the North East.
The NE LHIN Vision Care Plan was developed within the context of the MOHLTC Action Plan, the
Provincial Vision Strategy and the NE LHIN Priorities. It included an examination of current services,
needs and issues across the region. Discussions were held with eye care specialists, hospitals, Aboriginal
Health Access Centres, diabetes care specialists, Canadian National Institute for the Blind, and the
Ontario Telemedicine Network. Quantitative data regarding cataract surgery and other vision care
services were also gathered. This report is intended as a baseline and first step in the planning process.
At the same time as the vision care planning was initiated, the Northeastern Ontario Clinical Services
Review was completed and it included recommendations regarding delivery of cataract surgery in the NE
LHIN.
Since the NE LHIN and the North West LHIN (NW LHIN) have similar issues related to our shared
geography, similar population demographics and a large shared border, planning for these two areas was
conducted in collaboration with each other. Throughout the planning process staff of both LHINs
discussed the issues and proposed plans for meeting those needs.
Vision care is a broad spectrum of services that crosses the lifespan from health and wellness to disease
and loss of vision. For many older adults poor vision is the cause of falls and injuries and for younger
adults the consequences could include diminished job prospects, functional ability, and quality of life,
along with anxiety and depression.
Cataracts, retinopathy, glaucoma and macular degeneration are common diseases and conditions of the
eye that are addressed in this report.
Medical and surgical care of the eyes is provided primarily by ophthalmologists. The CNIB Eye Van
provides ophthalmology care to remote communities in Northern Ontario and teleophthalmology
provides diabetic retinal screening in a few rural and remote areas of the region. Optometrists also
provide screening and eye care services.
The geographic area of the northeast region covers 400,000 square kilometres and is home to 564,400
people. The health needs of the people in this region are somewhat different from other parts of
Ontario, with a higher prevalence of diabetes and a greater percentage of people over age 65. Residents
often have to travel significant distances to access health services and public transportation is limited or
not available.
Highlights of Vision Care in the NE LHIN
Most patients in the region have their cataract surgery done at hospitals in the NE LHIN and in 2012-13
363 patients went to hospitals outside the NE LHIN for this surgery. Repatriating patients to their home
hub hospitals for surgery could result in redistribution of volumes, which could create opportunities for
new ophthalmologists.
NE LHIN Vision Care Plan September 2014 | i
Executive Summary
Eye care in the North East is provided by teams of experienced professionals who work well together and
report high patient satisfaction.
Fifteen ophthalmologists live and work in the NE LHIN and 33% have 29 or more years of experience. In
addition, two surgeons from outside the NE LHIN provide ophthalmology care in Temiskaming and Parry
Sound areas. In 2012-2013 the average number of cataracts performed by the surgeons ranged from 315
to 647 per year.
The provincial Vision Strategy Task Force identified several performance indicators for ophthalmology.
However,he only indicator currently being measured is wait time. Other indicators recommended by the
task force are related to quality, access, appropriateness, efficiency and patient satisfaction. In the NE
LHIN, the average wait time for cataract surgery is less than the provincial average, yet Health Sciences
North wait time is higher than the regional and provincial averages. To ensure consistency of the data
collected for the other indicators tools and processes will need to be developed.
Eye care for infants and children is provided in some hub hospitals and many children are referred to
specialists in Southern Ontario. An ophthalmologist with a sub specialty in pediatrics would be a benefit
to patients across the NE LHIN, improve their access to care, and reduce the cost of Northern Travel
Grants.
Ontario Telemedicine Network teleophthalmology and the CNIB Eye Van provide screening and
treatment for vision loss in several communities across the region.
The NE LHIN had more ophthalmology calls to the provincial CritiCall system than all other LHINs.
CritiCall is a system that provides a 24 hour emergency referral service for physicians across Ontario. The
limited access to regional ophthalmologists has been an issue in the past.
The Northeastern Ontario Clinical Services Review Report (2014) identified cataract surgery as one of the
clinical services that will use the new Quality Based Procedure (QBP) funding formula. Traditionally,
collaboration between the hub hospitals and their small hospitals has been limited but the responsibility
to ensure that the practice guidelines for cataracts are implemented in their hub areas will enhance
collaborative service delivery. Collaboration among service providers could also identify additional
strategies to improve care.
Other common issues identified by stakeholders were: the need to travel, when public transportation is
limited or not available; collaboration and coordination among regional eye care providers; and, the
need for health promotion to enhance the knowledge of residents of the NE LHIN about the modifiable
risks associated with vision loss.
The future needs for eye treatment and the distribution of the workload among ophthalmologists is an
issue that requires ongoing planning and consultation with the doctors and the hospitals in order to
ensure that appropriate services available to all residents. Other concerns include:
a. Access to full time surgical retinal specialist and pediatric ophthalmologist for the region
b. Adequate retinal screening, especially for those with diabetes and at risk for glaucoma and Age
Related Macular Degeneration (AMD)
c. Eye health promotion to reduce the risk of vision loss and to promote healthy eye care
d. Increased use of teleophthalmology in isolated and remote communities, including First Nations,
to increase retinal screening
e. Stronger links to eye health services for the people of the James Bay and Hudson Bay Coasts
f. Use of QBPs, clinical guidelines and order sets for ophthalmology across the NE LHIN
g. Replacement of aging equipment
NE LHIN Vision Care Plan September 2014 | ii
Executive Summary
Recommendations
The NE LHIN Vision Care Plan provides an overview of ophthalmology services across the NE LHIN and a
view to the future needs of the residents. Vision care and the promotion of eye health is a complex
process that involves many health care providers and organizations. The next step is the formation of the
NE LHIN Ophthalmology Working Group with ophthalmologists and hospital administrators to guide the
planning for and implementation of improved ophthalmology services. In time, it is possible that this
group would expand to include other eye care professionals such as optometrists, operating room
nurses, opticians and others as indicated. In collaboration with the Provincial Vision Strategy Task Force
the NE LHIN group will work to implement the recommendations of the NE LHIN Vision Report and
continue to plan and implement quality improvements to these services in order to best meet the needs
of the residents for the right ophthalmology care, at the right time and in the right place.
Recommendation 1
That the NE LHIN form a working group of clinical leaders in ophthalmology from across the
region (Ophthalmology Working Group) to ensure the implementation of the recommendations
of the Clinical Services Review and the NE LHIN Vision Care Plan recommendations.
Recommendation 2
That all cataract surgery be provided through the hub hospitals in the NE LHIN and where
indicated, in some of the smaller hospitals within the hub areas. The cataract surgery in the small
hospitals be supported by the hub hospitals.
Recommendation 3
That the Ophthalmology Working Group lead the integration of best practices, as set out in the
Quality Based Procedures, across the region. Initially this may include support and education to
ophthalmologists and hospital staff on the cataracts clinical guidelines and order sets to facilitate
the implementation of these resources across the region.
That the Ophthalmology Working Group collaborate with the Provincial Vision Strategy Task
Force to develop processes and tools to gather and report on the ophthalmology performance
indicators identified in A Vision for Ontario.
Recommendation 4
That the Ophthalmology Working Group:
a. Develop a strong network among eye care professionals across the region
b. Develop plans to repatriate referrals outside of LHIN and hub areas
c. Support the expansion of retinal screening to people with diabetes and those living in First
Nation Communities
d. Support delivery of services to patients of the James Bay and Hudson Bay Coasts both on
site and in other areas of the NE LHIN
e. Collaborate with Ontario Telemedicine Network to explore options to expand
teleophthalmology to remote communities across the region
f. Explore with optometry professionals reporting of screening data for patients with diabetes
g. Explore opportunities for cost saving in the purchase of expensive supplies, such as lenses,
and equipment; collaborate with the Ophthalmology Working Group for potential
purchasing of ophthalmology equipment and supplies for the NE LHIN.
NE LHIN Vision Care Plan September 2014 | iii
Executive Summary
h. Collaborate with local primary care and public health groups to develop a health promotion
strategy for eye health.
i. Develop a process for continuing education in ophthalmology and meet with Northern
Ontario School of Medicine and other ophthalmology schools to discuss potential placement
opportunities for students.
Recommendation 5
That the Ophthalmology Working Group collaborate with the hub hospitals to recruit and retain
a new generalist ophthalmologist for Timmins, in addition toa new pediatric ophthalmologist,
and a second surgical retinal specialist for the region.
Recommendation 6
That the Ophthalmology Working Group monitor and adjust volumes of cataract and other
ophthalmology procedures including intraocular injections for AMD, to ensure the right care at
the right time and in the right place.
Recommendation 7
That each hub hospital create an interdisciplinary ophthalmology team to:
a. Develop strong links with the smaller hospitals in order to support and ensure quality in the
delivery of ophthalmology services in all areas of the NE LHIN.
b. Ensure 24/7 on-call support for the Emergency Departments of the small hospitals in their
hub area, providing advice and referrals as indicated.
NE LHIN Vision Care Plan September 2014 | iv
Introduction
NE LHIN Plan for Vision Care
Introduction
The Ministry of Health and Long Term Care released A Vision for Ontario: Strategic Recommendations for
Ophthalmology in Ontario in 2013. Among the recommendations of this report is that Local Health
Integration Networks should develop vision plans describing how they will provide for the vision care
needs of their communities.1
The Provincial Vision Strategy Task Force conducted a comprehensive review of ophthalmology services
in Ontario identifying system issues and developing an evidence-based planning framework to enhance
patient-centred vision care. The Task Force developed strategies to “improve access to emergency and
scheduled surgical, medical and diagnostic ophthalmology services for all Ontarians,” “optimize quality,
cost efficiency and patient outcomes more specifically for ophthalmology surgery,” and “identify
performance indicators for measuring local and provincial improvement in ophthalmology services.”2 A
complete list of the recommendations is included in Appendix A.
In January 2014 the North East Local Health Integration Network (NE LHIN) embarked on a review of the
current state of vision care across the region and developed recommendations to provide for current
and future eye care needs of the people in the North East.
This report describes the planning process for the project, an overview of vision care in the NE LHIN, and
recommendations for increasing access to and coordination of vision care services for people of the
region. It is intended to serve as a baseline and first step in future planning.
Ministry of Health and Long Term Care
The Ontario Ministry of Health and Long Term Care (MOHLTC) sets the overall framework that guides
health planning by the LHINS. Ontario’s Action Plan for Health Care identifies three focus areas:
1) Keeping Ontario Healthy. “Helping people stay healthy must be our primary goal and it requires
partnership. As a government, we’re increasingly putting our efforts into promoting healthy habits
and behaviours, supporting lifestyle changes and better management of chronic conditions.”3
2) Faster Access and a Stronger Link to Family Health Care. “When patients have faster access to
family health care that serves as the hub of our health care system, they stay healthier, get
connected to the right care and are less likely to require treatment in hospital.”4
3) Right Care, Right Time, Right Place. “At the heart of our action plan is a commitment to ensure
that patients receive timely access to the most appropriate care in the most appropriate place. It’s
about getting the greatest value for patients from the system, allowing evidence to inform how our
scarce health care dollars are best invested and ensuring”5
NE LHIN
The NE LHIN released its three-year Integrated Health Services Plan (IHSP), in 2013 after engaging with
more than 4,000 Northerners. With a mission “to advance the integration of health care services across
Northeastern Ontario by engaging our local communities”6 it has been focusing on the following four
priorities:
Priority 1: Increase Primary Care Coordination
Priority 2: Enhance Care Coordination and Transitions to Improve the Patient Experience
Priority 3: Make Mental Health and Substance Abuse Treatment Services More accessible.
NE LHIN Vision Care Plan September 2014 | 1
Introduction
Priority 4: Target the Needs of Culturally Diverse Population Groups (including
Francophone and First Nations).7
For each of these priorities the IHSP identified goals, actions, patient outcomes and metrics that
are guiding the NE LHIN’s work (see Appendix B).
These priorities are additionally supported by three enablers:
Electronic Health Record Opportunities
Realignment and System Transformation
Recruitment and Retention of Health Human Resources.
The NE LHIN Vision Care Plan was developed within the context of the MOHLTC Action Plan, the
provincial vision strategy and the NE LHIN’s IHSP. It includes an examination of current services, needs,
issues across the region and projections for future needs. Discussions were held with eye care specialists,
hospital staffs, Aboriginal Health Access Centres, and a number of organizations concerned with vision
care. Qualitative data regarding cataract surgery and other vision care services were gathered.
While vision care was not identified as a priority for the NE LHIN, it was recognized as an important
opportunity in reaching the overall mission “to advance the integration of health care services across
Northeastern Ontario by engaging our local communities.”
At the same time as the vision care planning was initiated, the Northeastern Ontario Clinical Services
Review was completed. The purpose of the Clinical Services Review was to identify the best approach to
configuring clinical services related to several medical and surgical services including cataracts. These
services are funded through the Quality Based Procedure (QBP) model, in which “evidence-based best-
practices have been established by clinical consensus alongside the evidence-based cost of the best-
practice.”8 In 2013, the MOHLTC released the Quality-Based Procedures Clinical Handbook for Cataract
Surgery, which is intended to inform providers of evidence-based best practice pathways.
The Clinical Services Review recommends that cataract surgery be consolidated at the hub hospitals—
Sault Area Hospital, Timmins and District Hospital, Health Sciences North, and North Bay Regional Health
Centre—with diagnostic and follow up, as well as some procedures at local hospitals. Oversight by the
hub hospitals will support a consistent model of care and standard order sets across the region. The
report also recommends that all cataract surgery be performed in the hub where the patients live.9
NE LHIN Approach to Vision Care Planning
In January 2014 the NE LHIN began consultations for the regional vision care plan. Information was
gathered about cataract surgeries, eye injections, vision screening and other treatments involved in eye
care. Hospital staff, ophthalmologists, and optometrists were interviewed. Representatives from
Ontario Telemedicine Network, the Canadian National Institute for the Blind, the Diabetes Regional
Coordinating Centre and Aboriginal Health Access Centres were also consulted. Appendix C includes a list
of the people who contributed to the plan. The results of these consultations are contained in the
following sections of the report.
Once the draft report was completed highlights and the recommendations were shared via
teleconference with those who participated in the consultations and their suggestions were
incorporated into the report. NE LHIN staff also met with the Provincial Vision Task Force to discuss their
suggestions for the NE LHIN plan.
Since the NE LHIN and the North West LHIN (NW LHIN) share many of the issues related to our shared
geography, similar population demographics and a large shared border, planning for these two areas was
NE LHIN Vision Care Plan September 2014 | 2
Introduction conducted in collaboration with each other. Throughout the planning process staff of both LHINs discussed the issues and proposed plans for meeting those needs. Although both NE LHIN and NW LHIN share the geography of Northern Ontario, many differences exist in the delivery of vision care. All resident ophthalmologists in North West Ontario are located in Thunder Bay and itinerant ophthalmologists perform surgery in Kenora and Marathon areas. In the North East, 15 ophthalmologists live and work in the four hub areas, while two itinerant surgeons operate in three small hospitals. Both regions have poor public transportation and access to tertiary health care requires significant travel for many residents. Northern Ontario is home to many First Nations, most of which are in remote locations. Succession planning, travel, and access to specialist services were common to both NE and NW LHINs. For both regions, the most efficient access is to Southern Ontario or in the case of areas in the NW LHIN, to Winnipeg. Even though sub-specialists work in the North East, access to Sudbury or Timmins from Thunder Bay is by road or by air: road travel is 780 kilometres one way from Thunder Bay to Timmins and 3.5 hours by air at a cost of about $500; to Sudbury road travel is 1,000 kilometres or two hours by air at about $500 one way. As the vision plans develop in both regions collaboration between the working groups may identify future opportunities for collaboration. NE LHIN Vision Care Plan September 2014 | 3
Vision Care Overview Vision Care Overview Vision care is a broad spectrum of services that crosses the lifespan from health and wellness to disease and loss of vision. Vision is the “special sense by which the qualities of an object (as colour, luminosity, shape, and size)” are seen “through a process in which light rays entering the eye are transformed by the retina into electrical signals that are transmitted to the brain through the optic nerve.”10 The ability to see is fundamental to quality of life and is often taken for granted. When vision is lost or changed, it presents a significant challenge to individuals and their families. The personal impacts include suffering, loss of employment, inability to perform everyday tasks, depression and grief. Especially among the elderly, loss of sight often leads to falls and injuries such as fractures that require medical intervention.11 Vision loss is most common in older adults, however, premature infants are also at risk and monitoring of their eye changes is required to minimize the risk of vision loss. As we age, our eyes are subject to changes. Presbyopia usually develops between ages 40 and 50 and is treated with corrective lens. Other age related conditions include cataracts, glaucoma and macular degeneration. Diabetic retinopathy has been identified as a common condition among those living with diabetes.12 Eye disease is often the result of exposure to risk factors such as poor nutrition and co-morbid chronic disease. Cigarette smoking is a significant risk factor for Age Related Macular Degeneration (AMD). Smokers are twice as likely to develop AMD as people who have quit or never smoked. As much as 20% of vision loss from AMD could be avoided through smoking cessation.13 The Canadian National Institute for the Blind (CNIB) reports that “every 12 minutes someone in Canada begins to lose their eyesight” and most of this loss can be prevented. 14 The CNIB estimates that vision loss will affect more individuals in the next 25 years than today. This is a result of the growing number of people over 65 likely to experience age-related vision loss. Part of the solution to minimizing these risks is through health promotion and education about eye care and regular screening for early diagnosis.15 The National Coalition for Vision Health in a 2011 report predicts a crisis in eye health care due to the increasing number of older persons, special needs among First Nations people, shortages of specialists and preventive programs and lack of planning and coordination. Among the recommendations of the report were “eye health care for special populations, including seniors, indigenous populations and people with diabetes” and “equitable and timely access to treatment, particularly among those living in rural and remote areas.”16 When vision is at risk or lost (temporarily or permanently) quality of life is impacted. Vision loss can affect the health and safety of individuals, and for many older adults, poor vision is the cause of falls and injuries. For younger adults who experience vision loss, the consequences could include decreases in productivity, functional ability and quality of life along with anxiety and depression.17 Common Eye Diseases and Conditions Cataracts, retinopathy, glaucoma and macular degeneration are common diseases and conditions of the eye. Cataracts are conditions where the lens of the eye becomes clouded resulting in vision loss. It is a condition related to aging and is corrected by the removal and replacement of the lens. Risk factors for cataracts include family history, having diabetes, and smoking.18 Cataract surgery is performed in an operating room usually under local anaesthesia or conscious sedation with the administration of a combination of sedative and analgesic medications. Conscious NE LHIN Vision Care Plan September 2014 | 4
Vision Care Overview sedation is short acting and patients recover quickly. On occasion the patient’s condition might require use of general anaesthesia. Before the procedure, the patient must have a pre-operative assessment by the ophthalmologist. During the 12-20 minute procedure the ophthalmologist removes the deteriorated lens and replaces it with an artificial one. Following the procedure patients are moved to a recovery room until they are ready to return home. A visit with the ophthalmologist takes place following the surgery and patients are referred to optometrists or primary care providers for ongoing follow up. The ophthalmologists bill Ontario Health Insurance Plan (OHIP) for their cataract procedures and the hospitals receive funding from the NE LHIN to cover the cost of operating room time, equipment, including the replacement lenses, nursing staff and overhead. OHIP subsidizes the cost for standard lenses and those who require specialized lenses may be required to pay the difference in price to the hospital. Each hospital is given a quota for annual cataract surgeries and funding per case. 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 50. 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.19 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. This disease has a major impact on the ability of people aged 50 plus 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 one to three 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.20 Retinopathy is a disease of the blood vessels at the back of the eye (retina). In premature infants it is called Retinopathy of Prematurity (ROP). In people who have diabetes it is known as diabetic retinopathy. Vision loss due to diabetic retinopathy can be minimized by maintaining blood sugar levels recommended by the Canadian Diabetes Association (CDA) and regular vision screening. Research has shown that regular intraocular injections are effective in treating retinopathy and reducing vision loss.21 Lucentis injections are administered in a clinic or office setting. The drug decreases the growth of certain eye cells and keeps the blood vessels from leaking. The medication is injected into the vitreous humour, the clear jelly-like substance behind the lens of the eye. These injections are usually administered monthly and are effective at minimizing vision loss for the patients. OHIP covers the cost of the medication, which is approximately $1,600 per injection. Vision loss and Diabetes The Canadian Diabetes Association (CDA) reports that diabetes is the “single largest cause of blindness in Canada.” High blood sugar levels cause changes to the microcirculation of the retina that result in loss of vision. In addition, people with diabetes often develop glaucoma and may develop cataracts at younger ages than those who do not have diabetes. Early detection and treatment reduces the impact of vision NE LHIN Vision Care Plan September 2014 | 5
Vision Care Overview
loss and may prevent or delay complications.22 In Northeastern Ontario approximately 14.3% of the
population has diabetes.23
The 2013 Clinical Practice Guidelines for diabetes recommend that annual screening for retinopathy be
conducted through assessment of retinal photographs for the following people:
Any individual older than 15 with type 1 diabetes should be screened annually beginning five
years after the onset of diabetes.
All individuals with type 2 diabetes should be screened at the time of diagnosis and annually.
Women with type 1 or type 2 diabetes or women who hope to become pregnant should be
screened before conception, during the first trimester, as needed during pregnancy, and within
the first year post-partum. 24
Eye Care Providers
Medical and surgical care of the eyes is provided primarily by ophthalmologists. The CNIB Eye Van
provides ophthalmology care to remote communities in Northern Ontario and teleophthalmology
provides diabetic retinal screening in a few rural and remote areas of the region. Teleophthalmology is
also provided for premature infants in Sudbury, with links to a pediatric ophthalmologist in Toronto.
Optometrists
Optometrists are regulated health professionals in Ontario who use skill and instruments to examine
eyes, screen for changes, prescribe corrective lenses and apply treatments to eyes. Optometrists operate
in private practices and often have a range of screening equipment in their offices and are located in
most towns and cities across the region. In 2004, routine eye examinations for adults aged 20 to 64 were
no longer insured services through Ontario Health Insurance Plan (OHIP).
Coverage is available for those residents receiving social assistance benefits and for people younger than
20 or over age 65. Patients of any age who have diabetes or eye disease qualify for insured eye
examinations every year. Fees for eye care examinations and tests, such as photographs of the retina are
not regulated by MOHLTC. When optometrists complete screening for the patients with diabetes or
those over age 65 they may, but are not required to, send results to the patients’ primary care providers
or to MOHLTC. Digital photographs are not funded through OHIP.
Other members of the optometrist’s team may include ophthalmic assistants and technicians.
Family physicians receive an incentive payment when their patients with diabetes complete annual
retinal screening as reported through the diabetes education centres or optometrists.
The Canadian Association of Optometrists suggests that an average optometric practice handles about
2,800 patient consultations per year.25
Ophthalmologists
Ophthalmologists are medical doctors who are specialized in the diagnosis and treatment of eye
conditions and diseases. Approximately 330 unique procedures were identified by the Provincial Vision
Strategy Task Force.26 Family physicians, optometrists and emergency room physicians may refer
patients who demonstrate vision changes to ophthalmologists for treatment. The ophthalmologists
conduct assessments, perform treatments and follow up. Once the eye condition is stabilized, the
patients are referred back to primary care providers or optometrists for ongoing monitoring.
Many ophthalmologists are considered generalists and they provide medical and surgical care to their
patients. Sub-specialists are ophthalmologists who are fellowship trained and certified in their specialty
NE LHIN Vision Care Plan September 2014 | 6Vision Care Overview such as retinal surgery, cornea, glaucoma, ophthalmic plastic surgery, pediatrics, and neuro- ophthalmology. While sub specialists focus on their area of expertise, they are also required to perform other general ophthalmology surgery such as cataracts. Orthoptists Orthoptists are allied health professionals who work closely with ophthalmologists to provide measurements used in the diagnosis of visual dysfunctions. They are often the first step in the assessment and diagnosis of eye movement, eye alignment and binocularity and they work with pediatric ophthalmologists in formulating and implementing treatment plans. Opticians Opticians are regulated health professional who are registered with the College of Opticians of Ontario. They are trained to supply, prepare and dispense optical appliances, interpret prescriptions from optometrists and ophthalmologists, fit, adjust and adapt optical appliances. Independent Health Facilities A Vision Strategy for Ontario includes recommendations that routine low risk ophthalmology procedures could be shifted to independent health facilities if agreed to by the hospitals and LHIN. These facilities are governed by the Independent Health Facilities Act and the College of Physician and Surgeons of Ontario (CPSO) has developed Out-of-Hospital Premises Standards for the use of anesthesia and provision of medical and surgical procedures in out-of-hospital premises. None of these facilities currently exist in Northeastern Ontario for ophthalmology and all cataract surgeries are performed in public hospitals. CNIB The CNIB has operated the Eye Van in Northern Ontario for 42 years, providing primary eye care services with a team of ophthalmologists and ophthalmic technicians in remote communities without access to eye care specialists. It is a fully-equipped, medical eye care clinic that travels to 30 communities in Northeastern and Northwestern Ontario every year. Staff of the eye van includes an ophthalmologists and two CNIB ophthalmic assistants. Twenty-five ophthalmologists take turns working with the van. The team works closely with local partners, such as the diabetes education centres, to see patients and conduct vision testing, treat eye conditions and perform minor surgery. Appointments are booked in advance by local appointment coordinators for new as well as recall patients and services supported by the local hospitals, where they exist. In 2013, approximately 500 volunteers assisted the CNIB team to serve an average of 35 patients per day. The eye health services included complete examinations of ocular health (vision screening, eye pressures, field of vision, and eye movement); minor surgical procedures and laser treatments; and follow up after cataract surgery. Each year the CNIB Eye Van travels more than 6,000 kilometres and treats more than 5,000 patients. 27 In addition to the eye van, CNIB works in prevention of vision loss and provides a number of programs and services throughout the NE LHIN to support those people affected by vision loss. These include the rehabilitation program, orientation mobility and independent living support. The CNIB provides support to children and families and helps with applications for assistive devices and travel grants. Teams of specialists also visit patients throughout the region. NE LHIN Vision Care Plan September 2014 | 7
Vision Care Overview Screening Vision screening is completed primarily by optometrists who make referrals to ophthalmologists or primary care providers for treatment as needed. Effective screening and monitoring of eye changes over time are helpful in the detection, early diagnosis and treatment of eye conditions and may reduce or delay vision loss. Digital fundus photography, visual field testing and optical coherence tomography (OCT) are screening tests that provide detailed information about eye health. Screening is conducted in offices, clinics and through teleophthalmology. CDA recommends that people with diabetes have retinal eye exams every year.28 The diabetes education and care programs throughout the region collect data regarding patient self-reports of eye exams and these indicate that 69% of people with diabetes had eye exams from 2012-2013.29 Screening for retinopathy in premature infants is recommended and conducted by general ophthalmologists. Infants who require treatment for retinopathy are referred to specialized pediatric ophthalmologists in Southern Ontario. Teleophthalmology The Ontario Telemedicine Network (OTN) provides teleophthalmology service in 12 rural locations across Ontario. Teleophthalmology is a store-and-forward service currently used for screening retinopathy and macular edema in patients with diabetes, as well as forwith premature infants at risk for retinopathy. A trained health care professional uses the special equipment to take images of the retina, which are securely stored for subsequent review by a participating ophthalmologist. The purpose of teleophthalmology is to increase access to retinal screening for those people who live in rural and remote locations, especially those at risk of developing eye disease. Teleophthalmology for ROP at Health Sciences North was introduced as a pilot project several years ago and it continues today. The nurses in the neonatal intensive care unit take images that are reviewed by a pediatric ophthalmologist at SickKids Hospital in Toronto. In 2009, another pilot project was conducted at Sensenbrenner Hospital in Kapuskasing and at the Manitoulin Central Family Health Team in Mindemoya, Manitoulin Island. The goal of this project was to increase vision screening services in remote communities, in particular for adults with diabetes. OTN provided the equipment and staff members were trained to complete a patient history and take the retinal photographs. An ophthalmologist in Sudbury reviewed the images and sent reports back to the primary care providers or the diabetes education centres. When the project was completed in 2013, the equipment was gifted to the centres but funding for the technical staff was eliminated. The NE LHIN provided the Manitoulin Health Centre with three year funding to support continuation of the services in Mindemoya, as well as expansion across the entire island. In Kapuskasing a local optometrist agreed to do the screening out of his office. A third teleophthalmology site opened in conjunction with the Weeneebayko Area Health Authority (WAHA) in Moose Factory. This service expanded to other communities along the coast in the summer of 2014. OTN reports that between 2009 and 2013, 757 screens were completed at the hospital in Kapuskasing and since October 2013, 69 screens have been completed at the optometrist’s office for a total of 826 screens for 644 patients. The Manitoulin Central Family Health Team has completed 1,501 screens in seven different locations since 2009. This included 1,116 unique patients, with 285 having two or more screens. NE LHIN Vision Care Plan September 2014 | 8
Current State of Vision Care in NE LHIN
Current State of Vision Care in the NE LHIN
The geographic area of the northeast region is divided into five distinct districts and highlights of the
region include:30
400,000 square kilometres and home to 564,400 people
19% of people or 109,494 are aged 65+, compared to provincial average of 15%. (2014
MOHLTC projections)
11% are First Nations people
23% are Francophone
30% of the population live in rural and small communities compared to 14% provincially
60% of adults are overweight or obese compared to provincial average of 53%
45% of the population are living with chronic disease compared to 37% in Ontario.
Table 1 – Demographics of NE LHIN for 2011
District Total Population % of NE LHIN % over age 65
Algoma 118,127 21 20%
Cochrane 81,246 14 15%
James Bay & Hudson 6,922 1 6%
Bay Coasts
Manitoulin-Parry 218,798 39 17%
Sound-Sudbury
Nipissing-Temiskaming 139,335 25 18%
Grand Total 564,428 100 1%
31
Source: Ministry of Finance Estimates
Vision Care in the North East
Two risk factors that affect vision are smoking and diabetes. In the North East, 25% of residents smoke
compared to 19% in Ontario and the prevalence of diabetes is 14.3% compared to the provincial rate of
11.9% (Health Analytics Branch). As illustrated in Table 2, 68.6% of people with diabetes in NE LHIN
received retinal exams between April 2011 and March 2013.32
Table 2 –NE LHIN Ontarians with diabetes (age 18+) with retinal eye exam during a two‐year period
Apr 2008–Mar 31 2010 Apr 2009–Mar 31 2011 Apr 2010–Mar 2012 Apr 2011–Mar 2013
Rate per 100,000 Rate per 100,000 Rate per 100,000 Rate per 100,000
Number % Number % Number % Number %
40,167 67.3 42,703 68.4 44,488 68.8 45,327 68.6
Source: Key Performance Measures for the Ontario Diabetes Strategy (2014). Health Analytics Branch
As identified in the Provincial Vision Task Force report, health services in Northeastern Ontario are
affected by the vast geography and low population density and the health needs of the people in this
region are somewhat different from other parts of Ontario with a higher prevalence of diabetes and a
greater percentage of people over age 65. Residents often have to travel significant distances to access
health services and public transportation is limited or not available.
The impact of these factors on ophthalmology services include:
An older population increases the prevalence of age-related ocular diseases
Higher rates of diabetes increases the risk of diabetic retinopathy
NE LHIN Vision Care Plan September 2014 | 9Current State of Vision Care in NE LHIN
Remote communities coupled with language barriers make the on-going regular medical
management of ocular diseases much more challenging.33
The large and growing population of people over age 65 and the high rates of diabetes place over
100,000 in the North East at risk for vision loss, and many of these people live in small rural communities
with limited or no access to eye care specialists and screening.
Ophthalmologists
Altogether 17ophthalmologists currently work in the NE LHIN, of that number 15 reside in the region
(Table 3): 14 generalists and three sub specialists. Itinerant surgeons from outside the NE LHIN provide
care a Temiskaming Hospital, Kirkland District Hospital and West Parry Sound Health Centre. The
average length of service of the ophthalmologists is 22 years, with 33% of resident ophthalmologists
having more than 29 years of service (see Appendix F). The two sub-specialists in Sudbury joined the
group in January 2014 and the hospital has required that the new surgeons share a single practice for
cataract operating room time.
Many pediatric patients and adults requiring ophthalmology specialties are referred to centres in
Southern Ontario for treatment. Among the general ophthalmologists in NE LHIN, one in Sault Ste.
Marie, one in North Bay, and one in Sudbury provide only medical services.
Table 3 – Ophthalmologists in NE LHIN
Number of General Average Years
Hospital Sub Specialist 34
Ophthalmologists of Service
Sault Area Hospital
4 18
Timmins and District Hospital
1 Retinal Specialist 6
Kirkland and District & Temiskaming Hospitals
1 part time (0.2 FTE) 30
North Bay Regional Health Centre
3 36
Health Sciences North
5 1-Ocular-plastics
17
1 Neuro-ophthalmology
West Parry Sound Health Centre
1 part time (0.1 FTE) 27
TOTAL 12.3 3 22
Bellen and Buske predicted that the ratio of ophthalmologists to population would increase from
1:29,589 in 2006 to 1:31,654 in 2014. They also noted that since the elderly are high users of
ophthalmology services, the ratio of ophthalmologists to those over age 65 is expected to increase from
1:4,301 in 2006 to 1:7,576 in 2021.35 The current ratio of ophthalmologists to population in the NE LHIN
is 1:36,890.
Based on the current population of the NE LHIN and using the ratio of ophthalmologists to population
suggested by Bellen and Buske of 1:32,000, the estimate of current need is 18.2 as shown in Table 5.
With retirements expected in the next couple of years, the need to increase human resources is
imminent.
NE LHIN Vision Care Plan September 2014 | 10Current State of Vision Care in NE LHIN
Table 5 - Estimated Current Need for Ophthalmologists (1:32,000) by NE LHIN Hub Area
Hub Area Required Ophthalmologists Current NE LHIN Ophthalmologists
Algoma 4 4
Cochrane 2.5 1
Hudson and James Bay Coast 0.2 0
Manitoulin-Parry Sound- Sudbury 7 7
Temiskaming & Nipissing 4.5 3
Total 18.2 15
Ophthalmologists, optometrists, the CNIB Eye Van, teleophthalmology services and diabetes education
programs monitor the eye health of people living in the northeast region. Table 6 shows the summary by
hub areas and more detailed information is included in Appendix D.
Table 6 – Eye Services & Diabetes Education Programs by Hub Areas
CNIB Eye Diabetes
Van* Optometrists Ophthalmologists Teleophthalmology Programs
Algoma District
5 25 4 5
Cochrane District
6 16 1 1 5
James & Hudson Bay Coasts
1 1
Manitoulin-Parry Sound-Sudbury
4 45 6 1 8
Nipissing-Temiskaming
1 28 4 5
Total 16 114 15 3 24
*Number of sites visited
Wait Times
The NE LHIN Annual Report for 2012-2013 showed that wait times for cataract surgeries improved and at
Q4 were below target.36 As shown in Table 7, the average wait time for cataract surgery is 141 days,
compared to the provincial target of 182 days. The exception is Health Sciences North at 256 days. The
2012-2013 report of cataract surgery in the North East showed that eight hospitals performed between
127 and 2,453 cataract surgeries. The hospitals in smaller centres rely on expertise from outside their
communities: an ophthalmologist at Health Science North performs the cataract surgery for St. Joseph
General Hospital Elliot Lake; an ophthalmologist from Rouyan-Noranda works at Kirkland and District and
Temiskaming Hospitals; and, an ophthalmologist from Orillia/Barrie performs the cataracts in West Parry
Sound Health Centre.
NE LHIN Vision Care Plan September 2014 | 11Current State of Vision Care in NE LHIN
Table 7 – Cataracts performed by hospital in 2012-2013
th
Hospital Cataracts Average / month 90 percentile
i ii
2012-2013 Wait (Days)
Health Sciences North (HSN) 2,453 204 256
North Bay Regional Health Centre (NBRHC) 1,940 162 83
Sault Area Hospital (SAH) 1,262 105 86
Timmins and District Hospital (TADH) 503 42 137
St. Joseph General Hospital Elliot Lake (SJGH) 218 18 n/a
West Parry Sound Health Centre (WPSHC) 195 16 124
Kirkland & District Hospital (KDH) 178 15 n/a
Temiskaming Hospital (TH) 127 11 160
Total 6,876 Average- 141
i Data pulled based on October 2013 QBP definition for Cataracts (CACS grouper C060 – cataract removal/lens insertion
with relevant exclusions)
ii. Source: Cancer Care Ontario, iPORT
In addition to cataract surgeries, ophthalmologists performed other day surgery procedures as shown in
Table 8. A total of 2,797 other eye procedures were performed with 52% at HSN and 25% at NBRHC. At
NBRHC, 490 corneal procedures were performed; this represents 95% of all corneal procedures in the
region. TADH had 72% of surgical retina cases. HSN had 549 ‘other’ procedures (63%), while NBRHC had
156 (18%). Most of the glaucoma surgery (71%) was performed at HSN and 19% at KDH. A Vision for
Ontario noted that the rate of glaucoma surgery was high in the NE LHIN compared to the rest of the
province.37
Table 8 – NE LHIN Ophthalmic Day Surgery Procedures: Cases by Facility, Adults (FY 12-13)
Cataracts Corneal Glaucoma Surgical Medical Other Not Total
Surgery Retina Retina Classified
Algoma
SAH 1,273 9 10Current State of Vision Care in NE LHIN
The rates for intraocular injections for AMD in the NE LHIN were much higher than the provincial average
and in 2011-2012 it was the highest rate in the province.
Table 9 – Rates for Intraocular Injections and Intraocular Injections for AMD
Intraocular Injections (E149A) Age standardized Rate (per 100 000 population)
2009-2010 2010-2011 2011-2012
NE LHIN Rate 543 83 179
Provincial Average 125 119 216
Variance 4.3 0.7 0.8
Intraocular injections for AMD E147A Age standardized rate (per 100,000 population)
2009-2010 2010-2011 2011-2012
NE LHIN Rate 343 3,353 5,018
Provincial Average 214 1,929 2,921
Variance 1.6 1.7 1.7
Source – A Vision for Ontario, 2013.
The raw data for intraocular injections for age-related macular degeneration (AMD) in 2012-2013 show
that most of the intraocular injections were administered in one community where 27 patients received
more than 12 injections per year (Table 10). The two most common diagnoses for the patients receiving
these injections were hypertensive retinopathy and other retinal disease and purpura,
thrombocytopenia and other hemorrhagic conditions (Table 11). These data require further investigation
by the NE LHIN Ophthalmology Working Group to determine the factors that contribute to these
anomalies.
Table 10 –Intraocular Injections for AMD (E147A) by Provider Municipality in Fiscal Year 2012-2013
Provider Municipality Number of Number of Number of patients with more
patients Procedures than 12 procedures/year
North Bay 712 3,377 27
Greater Sudbury 818 2,992Current State of Vision Care in NE LHIN
Where do Patients Go for Cataract Surgery?
Most patients in the region have their surgery done at hospitals in the NE LHIN. Table 12 illustrates which
hospitals are used by patients across the region. The hub hospitals were the most common choice of all
residents: 97% in Algoma; 91% in Sudbury; 96% in Cochrane; and 72% in Nipissing-Temiskaming. HSN
had patients from all but the Coastal area and NBRHC had patients from all areas except Algoma. Forty-
nine (49) patients came from outside NE LHIN.
Table 12 – Patients’ home district by provider hospital
District SAH SJEL HSN TDH NBRHC KDH TH WPS Total
Algoma Patients 1,231 216 43 1,490
Cochrane Patients 8 94 483 390 71 1,046
James & Hudson Bay Coast 7 7 14
Nipissing –Temiskaming 64 11 1,401 106 124 1,706
Patients
Sudbury Manitoulin Parry 1 2 2,233 2 107 174 2,514
Sound Patients
Other – outside LHIN 13 11 11 14 2 14 49
Other 11 8 21 1 1 7 54
Hospital Totals 1,262 218 2,453 503 1,940 178 127 195 6,876
Data source: MOHLTC IntelliHEALTH, DAD
Cataract Surgery outside NE LHIN
In 2012-2013, 363 patients from NE LHIN had cataract surgery in hospitals in other regions. Of these 40%
were treated in North Simcoe Muskoka LHIN, 20% in Champlain LHIN (Ottawa) and 14% in the NW LHIN
(Thunder Bay). Of the 144 treated in North Simcoe Muskoka LHIN, 47% or 67 came from the Parry Sound
area.
The following maps illustrate the home municipality of patients and the hub hospitals where they had
cataract surgery. Figure 1 shows that most patients treated in NE LHIN lived in the region and there were
several from North Simcoe Muskoka and North West LHIN.
Figure 1: Distribution of Cataract Patients in NE LHIN by home location, 2012-2013
NE LHIN Vision Care Plan September 2014 | 14Current State of Vision Care in NE LHIN As shown in Figure 2, most of SAH patients live in Algoma District. Each circle on the map represents 100 kilometres from Sault Ste. Marie. While most patients live close to Sault Ste. Marie, many travel more than 100 kilometres to the hospital for care. Figure 2 – Distribution of SAH Cataract Patients by home location, 2012-2013 Cataract patients at TADH live primarily in the Cochrane District with some travelling from Temiskaming District. Many of these patients travel more than 100 kilometres to the hospital. Figure 3 – Distribution of TADH Patients by home location, 2012-2013 NE LHIN Vision Care Plan September 2014 | 15
Current State of Vision Care in NE LHIN NBRHC has patients who come from all areas except Algoma. While most of their patients live near North Bay, many travel from more than 300 kilometres north and several from North Simcoe Muskoka LHIN also have surgery in North Bay (Figure 4). Figure 4 – Distribution of NBRHC Patients by home location, 2012-2013 HSN has the highest number of cataract patients among the hub hospitals and Figure 5 illustrates that these patients travel from across the NE LHIN, many travelling more than 100 kilometres to the hospital. Figure 5 – Distribution of HSN Patients, 2012-2013 NE LHIN Vision Care Plan September 2014 | 16
Current State of Vision Care in NE LHIN The southern area of NE LHIN borders on the North Simcoe Muskoka LHIN and there are approximately 140 patients from NE LHIN who have cataract surgery in five hospitals in the North Simcoe Muskoka LHIN. As shown in Figure 6, most patients of West Parry Sound Health Centre live within 100 kilometres of the hospital, including a few from the North Simcoe Muskoka LHIN. Figure 6 – Distribution of WPSHC Patients, 2012-2013 . NE LHIN Vision Care Plan September 2014 | 17
Vision Care in Hub Areas Vision Care in Hub Areas This section of the report describes the current state of vision care in the First Nations and in each of the five hubs within the NE LHIN: Algoma, Cochrane, James Bay and Hudson Bay Coasts, Nipissing Temiskaming, and Sudbury, Manitoulin Parry Sound. First Nations The 28 First Nations health service providers funded by the NE LHIN are located throughout the region, from Peawanuk in the north to Parry Sound in the south. Many of these communities are located in remote sites, isolated from the range of health care providers found in urban settings. Among the First Nation people, chronic diseases such as diabetes and hypertension are common and many people live with more than one chronic disease. When facing life-threatening illnesses, poor vision becomes a lower priority and as a result, many people do not have regular vision screening. The barriers to accessing care include lack of transportation, the complicated planning involved in making a trip to the city, feeling that they will not be comfortable and long waits for care. The health centre staff of one First Nation noticed that their members were not attending the diabetes education centre in the city and they were managing their diabetes inappropriately. When a diabetes program was introduced at the health centre attendance increased and better patient outcomes were noted. This experience reinforces the effectiveness of having health care close to home—the right care in the right place at the right time. Teleophthalmology service is available to First Nation communities on Manitoulin Island and in Moose Factory through OTN. Telemedicine is an effective way to bring health services, in particular retinal screening to remote communities. The First Nations of the North Shore Tribal Council recently purchased teleophthalmology equipment and are hoping to arrange for this service to their communities. Another eye care need identified in recent community consultations was the lack of optician service. When glasses break people sometimes have to wait for weeks before they can get the glasses to an optician for repair. The CNIB Eye Van visits several First Nations in the summer and this is a valuable service to the residents. Vision care would be strengthened with the addition of additional screening and optician services provided through the local health centres. Algoma Hub Algoma District stretches along the North shores of Lake Huron and Lake Superior and is home to 118,127people. It borders on Thunder Bay District to the west, Cochrane to the north and east, and Sudbury on the southeast. Sault Ste. Marie, an industrial city located centrally in the district, is the second largest city in the North East Region located 300 km from the next largest centre (Sudbury). It is the major health centre for the District of Algoma, supporting smaller hospitals in Hornepayne, Wawa, Thessalon, St. Joseph Island, and Blind River. The large geography of the district (48,811 km) and small population present challenges in meeting the health needs of the residents. Although St. Joseph’s General Hospital Elliot Lake is geographically located in Algoma District, the referral patterns are primarily to Health Sciences North, so in this report it is included with the Sudbury Manitoulin Algoma District Parry Sound area. Seven First Nations are located in Algoma District. NE LHIN Vision Care Plan September 2014 | 18
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