Ophthalmology

Michèle Beaconsfield, FRCS, FRCOphth, FEBO, president of the UEMS ophthalmology section, noted the wide variation in the numbers of ophthalmologists throughout Europe. Image: Beaconsfield M

The population profile of Europe is projected to become older in the coming decades, with an uneven growth rate expected in the various countries. The percentage of the total population age 65 years or older is predicted to increase from 17% in 2008 to 23.5% in 2030.

The graying of Europe will have an impact on disease distribution and the overall growing demand for health care services. At the same time, a consistent decrease in the number of specialist physicians is expected, creating concern about whether the diminished workforce will be able to cope with an even larger medical workload.

Age-related diseases will be main challenge

The main challenge for eye care professionals will be in age-related diseases, such as age-related macular degeneration, diabetic retinopathy and glaucoma.

According to the EUREYE study, 3.3% of the European population age 65 years or older has AMD. The prevalence is 40% higher in women than men and rises steeply with age. This would indicate approximately 2.5 million AMD cases within the 27 EU nations.

In addition, the number of diabetic retinopathy cases is expected to rise, due to the increasing prevalence and earlier onset of diabetes.

Data from the International Diabetes Federation show that there are currently 55 million adults and 112,000 children with diabetes in Europe; 10 million to 12 million more cases are expected by 2030.

“The increasing rate of diabetes is connected with the aging of the population, but also dietary and other lifestyle factors have an impact. They explain the earlier onset of the disease and the increasing prevalence of type 2 diabetes in children,” Pascale G. Massin, MD, head of a large clinical practice at Lariboisière Hospital in Paris, said.

As demonstrated by several studies, almost all patients with a 15-year history of type 1 diabetes develop retinopathy. The disease also affects patients with type 2 diabetes: 50% to 80% will develop retinopathy after 20 years of their diabetes diagnosis. The European Diabetes Study investigated patients from 31 centers in 16 European countries. The overall mean prevalence of diabetic retinopathy in 3,250 type 1 diabetes patients was 35.9%, while the mean prevalence rate for proliferative diabetic retinopathy was 10.8%.

With people living longer, glaucoma will also become more common. Currently, the number of people bilaterally blind from glaucoma is approximately 8.4 million worldwide. By 2020, this number is estimated to rise to 11 million.

“Europe is witnessing a fast rising incidence of glaucoma, from 5% in 2000 to 10% to 11% in 2010 in people older than 75,” Julian Garcia-Feijoo, MD, PhD, professor of ophthalmology at Universidad Complutense and head of the glaucoma department at San Carlos University Hospital in Madrid, said.

Higher demand for refractive procedures

Ophthalmologists also expect a higher demand for refractive procedures in the coming years.

With the aging of the population, presbyopia will become a fast-growing problem, resulting in a large demand for refractive surgeons.

Thomas Kohnen

“In Germany, 17 million people are currently over 65 years of age, and in the next few years, there will be an estimated increase of 4 million,” Thomas Kohnen, MD, deputy chairman of the ophthalmology department at Goethe University in Frankfurt, said.

“Besides the growing number of people who will require surgical treatment for presbyopia, we expect an increase in the demand for other refractive procedures. Looking at the distribution of refractive errors, we can see that there is only a very small group of ametropic people. About half of the European population are hyperopic, and 25%, more than 100 million now, are myopic, 64% of which is mild, 32% moderate and 4% high,” he said.

Europe is a composite territory

Europe is small geographically, but it is densely populated, with an uneven distribution between countries.

Data from the European Union of Medical Specialists (UEMS) show that there are 40,000 ophthalmologists in Europe to care for a total population of 500 million — an average of eight ophthalmologists for every 100,000 people.

“Also from this point of view, Europe is a composite territory. The number of ophthalmologists varies enormously from country to country,” Michèle Beaconsfield, FRCS, FRCOphth, FEBO, president of the UEMS Ophthalmology Section, said.

“At the bottom of the scale there is the U.K., where the aggressive numerus clausus and the strongly centralized national health system have traditionally imposed limitations. We are about two ophthalmologists per 100,000 population,” she said. “At the opposite end there is Greece, with no numerus clausus and more than 14 ophthalmologists per 100,000 population. France and Germany are somewhere in the middle.”

The investment in health care is also unevenly distributed. Data show a positive correlation with gross domestic product, although differences exist within countries such as Italy, where the rich areas of the north are better served than the poorer southern regions.

“Generally speaking, if you put the number of ophthalmologists against the ability to spend on health care, you see that where there are insufficient ophthalmologists there is also insufficient money to invest in more,” Dr. Beaconsfield said.

Causes behind workforce decrease

Experts agree that the numerus clausus, implemented by an increasing number of medical faculties in Europe to address overcrowding and to meet governmental workforce planning, may be responsible for the shortage of specialists in the coming years. In addition, in countries where the balance between number of patients and number of specialists is positive at present, there will soon be an insufficient number of physicians to replace those who will be retiring.

Jean-Bernard Rottier

“In France, in the next 10 years, we will have lost 1,500 ophthalmologists due to the too strict numerus clausus implemented in 1990. We are now 5,500 to manage 35 million medical acts. In 2020, we will be 4,000 dealing with 45 million,” Jean-Bernard Rottier, MD, president of the Trade Union of French Ophthalmologists, said.

The growing number of medical lawsuits is also having a significant impact on the number of students who choose surgical specialties in which the risk of medical error and malpractice claims is high. In countries such as Italy, where physicians who commit medical errors can be — and usually are — charged with a criminal act, the decrease in the number of practitioners is dramatic, approximating 30% compared with the previous decade.

“Although 80% of medical lawsuits in Italy end with a favorable verdict, the high risk and disproportionate potential consequences are a strong deterrent. As a further consequence, premiums for liability insurance are becoming prohibitive,” Costantino Bianchi, MD, senior vice president of the UEMS Ophthalmology Section, said.

Costantino Bianchi

“In absence of a more favorable legislation, we will face a dramatic shortage of surgeons, increased by massive migration to countries that offer better protection and more favorable working conditions,” he said.

Cross-border mobility

The European Union is conceptually based on the free movement of people, goods and services. In the field of health care, a concerted European strategy is being developed to facilitate the movement of patients and professionals.

However, in the current situation, cross-board mobility raises more questions than answers, according to Dr. Beaconsfield.

Countries with fewer resources, such as Eastern European countries, see their already insufficient workforce migrating to where better working conditions are offered. On the other hand, richer countries offer incentives to Eastern European professionals because the richer countries lack qualified workers. This trend is having dramatic consequences in some places: Clinics and medical institutions are forced to close as standards of care can no longer be guaranteed.

As far as patients are concerned, cross-border mobility is likely to be the response by some consumers due to health care system overload. But behind the apparent advantages, there are challenges that need to be considered.

“With patients increasingly seeking abroad what they cannot get in their own country, uncertainty exists about the application of rights to reimbursement and over how the necessary frameworks for quality and safety should be ensured for cross-border health care. Who ultimately carries medicolegal responsibility when things go wrong has yet to be clarified,” Dr. Beaconsfield said.

Moving toward shared care

Ophthalmologists from different countries agree that task delegation is one way future challenges can be met without sacrificing quality of care.

“Paramedics, like orthoptists, can share the consultation with the ophthalmologist. By dealing with patient history, refraction, ocular motility and tonometry, they will save 30% of medical time,” Dr. Rottier said.

The overall monitoring and care of specific eye diseases such as glaucoma and diabetic retinopathy can also be rescheduled within shared care programs, he suggested.

“In the U.K., we have a long tradition of shared care programs and have significantly expanded the role of paramedics in recent years. Properly constructed training for paramedics and the publication of professional practice guidelines ensure that these specific extended roles are delivered to a high standard,” he said.

There are a number of medical, technical and possibly even surgical acts that can potentially be transferred to ophthalmic paramedics. The role of the ophthalmologist, however, remains central and essential in selecting suitable candidates, providing the appropriate training, supervising the procedures and assessing the outcomes.

“Controlled delegation is the key, and the UEMS definition of a medical act is what protects us all from role confusion, by shaping boundaries and responsibilities,” Dr. Beaconsfield said.

According to this definition, stated in an official document issued by the UEMS council: “The medical act encompasses all the professional actions, eg scientific, teaching, training and educational, organisational, clinical and medico-technical steps, performed to promote health and functioning, prevent diseases, provide diagnostic or therapeutic and rehabilitative care to patients, individuals, groups or communities in the framework of the respect of ethical and deontological values. It is the responsibility of, and must always be performed by a registered medical doctor/physician or under his or her direct supervision and/or prescription.”

The extent and modalities of task delegation are currently being discussed within individual countries.

“There is no need to be uniform, as long as provisions are made in the interest of the patient,” Dr. Beaconsfield said. – by Michela Cimberle

Should paramedical staff be entitled to perform surgical procedures such as YAG laser capsulotomy?

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• Michèle Beaconsfield, FRCS, FRCOphth, FEBO, can be reached at Moorfields Eye Hospital, 162 City Road, EC1V 2PD London, United Kingdom; +44-20-75662010; fax: +44-20-75662019; e-mail: mb@consultansee.co.uk.
• Costantino Bianchi, MD, can be reached at Via Ciro Menotti 1/A, 20129 Milano, Italy; +39-02-740793; fax: +39-02-7386612; e-mail: biankeye@fastwebnet.it.
• Julian Garcia-Feijoo, MD, PhD, can be reached at Departamento de Glaucoma, Hospital Clinico San Carlos, Martin Lagos sn, 28040 Madrid, Spain; +34-91-3303977; e-mail: jgarciafeijoo@hotmail.com.
• Thomas Kohnen, MD, can be reached at Goethe Universitat, Klinik fur Augenheilkunde, Theodor-Stern-Kai, Frankfurt/Main, Germany; +49-69-63016739; fax: +49-69-63013893; e-mail: kohnen@em.uni-frankfurt.de.
• Pascale G. Massin, MD, can be reached at Department of Ophthalmology, Hôpital Lariboisière, Université Paris 7, Paris, France; +33-1-49956488; fax: +33-1-49956483; e-mail: p.massin@lrb.aphp.fr.
• Jean-Bernard Rottier, MD, can be reached at 37 avenue du Gal Leclerc, 72000 Les Mans, France; +33-2-43391767; e-mail: jbr@ophtalmo.net.