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Norwegian ophthalmologists face changing demographics, workforce shortage
An increase in intravitreal injection treatments is having an effect on all areas of ophthalmology.
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Norway has a well-balanced health care system, with excellent standards and efficient delivery of services to citizens throughout the country.
However, the aging of the Norwegian population and the consequent changes in the country’s demographics are raising concern over the ability to meet future demands.
“The needs for eye care were well covered up to the biennium 2007 to 2008, but in the past 3 years, we have seen increasing problems with our capacity. We are going to face an enormous challenge in the upcoming 10 years to 20 years,” Alexander Skau, MD, president of the Norwegian Ophthalmological Society, said.
Alexander Skau
A recent survey showed that the age of consultancy for age-related macular degeneration, cataract and glaucoma is between 71 and 75 years. This population group is estimated to increase by 76% in the next 18 years.
“We are at the limits of our capacity now. If in 2030 we’ll have to take on 76% more, it’s going to be an unsustainable burden,” Dr. Skau said.
The needs created by the rapid growth of the elderly population may not be met because there is not an equal increase in the number of ophthalmologists. The educational capacity of university departments has lowered in recent years, and there are too few residents to serve upcoming demands. In addition, the ministry of health is not creating new positions in either hospitals or ambulatory practices.
“In the past 3 years, we have been putting together facts and figures about the current status and future projections. The national ophthalmological society has done a great deal of work, and we are nearly ready to present our data to the health authorities. We are confident that this will lead to increased investment in human resources and to a more efficient health planning able to manage future changes,” Dr. Skau said.
Intravitreal injection treatments are the area of ophthalmology in which the pressure from increasing demand is most noticeable. Intravitreal injections are widely used for a number of pathologies, such as age-related maculopathies, retinal vein occlusions and diabetic retinopathy. The prevalence of these conditions is dramatically on the rise.
“In 2007, Lucentis (ranibizumab, Genentech/Novartis) was introduced in our country. In 2008, we performed about 11,000 injections. In 2010, we performed 24,000, which is 120% more in only 2 years. This has had a great impact on our work amount and workflow. It has taken away time from other groups of patients, so that now we have waiting lists for other conditions. Our capacity for cataract surgery has lowered because we have shifted our workforce to intravitreal. And we haven’t seen the top yet,” Dr. Skau said.
Ophthalmic care distribution
There are 19 ophthalmology departments in Norway. Five of them are university clinics, located in the country’s largest cities, and 14 are smaller city hospital departments. Outside hospitals, there is a large number of single or group practices that provide NHS-funded care. There are only three or four private clinics, where the patients pay for themselves, in the country. One of them is a retina clinic, and the others are for general ophthalmology.
There are 359 ophthalmologists; 247 are men and 112 are women. In addition, there are 82 residents.
“It’s interesting to note that among young residents, the proportion of men to women is significantly different, with 48 women [and] 34 men. There’s a definite trend toward women surpassing men in all medical specialties,” Dr. Skau said.
Ophthalmologists are more or less equally distributed between hospitals and clinics outside hospitals, and services are equally available and evenly distributed throughout the country.
Optometrists
There are about 1,200 optometrists in Norway. Discussion on whether their role should be expanded beyond vision testing and the prescription of spectacles and contact lenses has been ongoing for years. Although optometrists could help compensate for the shortage of ophthalmologists in the coming years, ophthalmologists have a cautious attitude regarding the delegation of medical tasks and responsibilities.
“At the moment, optometrists are not allowed to do medical screenings, glaucoma follow-up visits or anything that is traditionally done by doctors. However, their study curriculum has changed. They are getting more and more medically educated. They are looking at the U.K. and the U.S. and want to be more involved in eye care. That’s the border where we’ll have to meet them eventually,” Dr. Skau said.
Co-payment and reimbursement
In Norway, all medical procedures are almost entirely covered by tax-funded national health insurance, with the exception of refractive surgery. Co-payment is allowed for premium IOLs.
“A group within the national society is working at setting up reference prices and rules for co-payment. There is ongoing discussion about potential reimbursement of premium IOLs, but [as] they would represent … much higher costs for the NHS, I don’t think we’ll be getting any national funding for them. Most of us agree that co-payment is probably the best solution,” Dr. Skau said.
Reimbursement for intravitreal ranibizumab is provided by the government, on the condition that split doses are used to treat two patients with one vial instead of one patient with one vial.
“This is questionable, of course, but the same is done all over the word with Avastin (bevacizumab, Genentech/Roche). One vial of Avastin is split in 20 doses,” Dr. Skau said.
Both drugs are used in Norway, in the proportion of two-to-one in favor of bevacizumab. The choice depends on the budget of individual centers and on established habits because it took some time before ranibizumab was reimbursed by the government.
“On the whole, our system is good, and we have always been able to balance affordability and value, care capacity and care demand. We have faced problems and found solutions to overcome them. However, the upcoming workload is a challenge that appears much greater than anything we have met before,” Dr. Skau said. – by Michela Cimberle
For more information:
- Alexander Skau, MD, is president of the Norwegian Ophthalmological Society and eye consultant at the Ophthalmology Department of the City Hospital of Bodø, Norway. He can be reached at +47-75-53-43-15; email: ale-skau@online.no.
- Disclosure: Dr. Skau has no relevant financial disclosures.