Best-practice features of diabetic retinopathy treatment models for Indigenous Australians

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Diabetic retinopathy (DR) is a progressive eye disease that impacts the retina of the eye. The direct cause of DR is diabetes. In the early stages of DR there are no visual symptoms and the DR signs observed in the retina (back of the eye) are minimal. However, as the disease progresses, visual symptoms are noticeable and if left untreated it can cause permanent vision loss. Through early detection and timely treatment, almost all vision loss from DR is preventable.

In Australia, Aboriginal and Torres Strait Islander peoples (hereafter respectfully referred to as Indigenous Australians) are three times more likely to have diabetes than non-Indigenous Australians and have a higher rate of diabetes-related vision impairment (5.5%) compared to their non-Indigenous counterparts (1.5%). Despite this situation until now there has been limited evidence about suitable treatment models or clinical guidelines to provide appropriate and best-practice (best standard of care) to Indigenous Australians.

In February 2020, as part of my Masters of Public Health project, I conducted a six-month research project to identify what best-practice features are required to ensure that Indigenous Australians with DR have better treatment outcomes.

As the COVID-19 pandemic commenced during the time of my project, I was limited in what I could do. The best way forward was to interview ophthalmologists who were providing DR care to Indigenous Australians. A total of eight ophthalmologists were recruited that represented all geographic areas (urban, regional and remote) and jurisdictions in Australia. To facilitate my discussions with the ophthalmologists, I developed a semi-structured interview guide that used open-ended questions. All interviews were conducted over Zoom and had a duration of 45 to 60 minutes.

From the interviews, a thematic analysis was conducted in which the findings were themed. As a result, seven best-practice features were identified. These were:

Key features of best-practice models	Explanation and details
(1) Cultural safety	Services are provided within a culturally safe and appropriate environment, as considered by community
(2) Affordability and Accessibility	There are no cost or financial barriers to patients to receive care with services publicly funded or subsidised to a level that is effectively publicly funded
(3) Partnerships with key stakeholders	Relationships are important to support integrating and linking patients in the pathway of care and creating system changes/reforms (e.g., Aboriginal Medical Services, optometrist, ophthalmologist, hospital, Aboriginal Health Liaison Officers)
(4) Timeliness	Refers to; · Patients receiving DR screening on regular basis · Patients referred for DR treatment within appropriate time frame Travel time and distance to receive care is close to home as possible such that care is delivered locally
(5) Integration with primary care	Primary care providers understand and are engaged in the pathway of eye care (i.e. diabetic retinopathy screening) and referral pathways to secondary and tertiary care
(6) Clarity of guidelines	Clinicians refer to and follow the established guidelines so as to provide consistent and agreed standards of care
(7) Clinician attitude and motivation	Ophthalmologists involved are willing and committed to improving diabetic retinopathy outcomes for Indigenous client

Further research is still required to expand on these findings and should include Aboriginal Medical Service staff and community end-users (in particular, Indigenous patients with DR) in broadening this discussion.

In the meantime however, the best-practice features identified in this study have started to address a clear gap in the research on equity in DR treatment in Australia and can begin to inform improvements in the decisions of the eyecare sector on service delivery, funding and policy reforms for Indigenous Australians.