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Khanna S, Emerson GG, Shah GK. Role of physician extenders: more regulation is necessary before full integration into practice. Curr Opin Ophthalmol 2023; 34:386-389. [PMID: 37326218 DOI: 10.1097/icu.0000000000000971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
PURPOSE OF REVIEW To discuss the drawbacks and propose recommendations for integrating physician extenders in ophthalmologic practice. RECENT FINDINGS In this article, the role of utilizing physician extenders in ophthalmology is discussed. A role for physician extenders has been suggested as more and more patients will require ophthalmologic care. SUMMARY Guidance is needed on how to best integrate physician extenders into eye care. However, quality of care is of the highest importance, and unless there is reliable and consistent training of extenders, using physician extenders to administer invasive procedures (e.g., intravitreal injection) should be avoided due to safety concerns.
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Sivaprasad S, Ghanchi F, Kelly SP, Kotagiri A, Talks J, Scanlon P, McGoey H, Nolan A, Saddiq M, Napier J, Morgan-Warren P. Evaluation of standard-of-care intravitreal aflibercept treatment practices in patients with diabetic macular oedema in the UK: DRAKO study outcomes. Eye (Lond) 2023; 37:2527-2534. [PMID: 36653595 PMCID: PMC10397211 DOI: 10.1038/s41433-022-02367-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 11/30/2022] [Accepted: 12/12/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND/OBJECTIVES DRAKO (NCT02850263) was a 24-month, prospective, non-interventional, multi-centre cohort study enrolling patients with diabetic macular oedema (DMO) including central involvement. The study evaluated UK standard-of-care intravitreal aflibercept (IVT-AFL) treatment. This analysis describes the treatment pathway and service provision for the anti-vascular endothelial growth factor (VEGF) treatment-naïve (C1) and non-naïve patients (C2) who received prior anti-VEGF treatment for DMO other than IVT-AFL. METHODS Mean changes in best-corrected visual acuity and central subfield thickness were measured and stratified by baseline factors, including ethnicity and administration of five initial monthly injections within predefined windows. Clinic visits were classified as treatment only (T1), monitoring assessment only (T2), combined visits (T3) or post-injection visits with no treatment or assessment (T4). RESULTS Median time from decision to treat to treatment was 6 days. As a percentage of total visits, T1, T2, T3 and T4 were 7%, 42%, 48% and 3% for C1 and 11%, 39%, 48% and 2% for C2. Most IVT-AFL injections were administered by healthcare professionals (HCPs) other than doctors (C1, 57.4%; C2, 58.5%). The percentage of treatments associated with a procedure-related adverse event where at least 75% of injections were completed by the same injector role were similar for doctors and other HCPs (C1, 1.1% and 0.8%; C2, 0.7%, and 1.0%). CONCLUSIONS Results indicate that upon DMO diagnosis, patients were treated promptly, and most visits were combined (treatment and assessment) or monitoring only. Most IVT-AFL was administered by non-physicians with a similar treatment-related safety profile as IVT-AFL administered by physicians.
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Affiliation(s)
- Sobha Sivaprasad
- National Institute for Health Research, Moorfields Biomedical Research Centre, London, UK.
| | - Faruque Ghanchi
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | | | - Ajay Kotagiri
- South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - James Talks
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Peter Scanlon
- Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
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Bolme S, Austeng D, Morken TS, Follestad T, Halsteinli V. Cost consequences of task-shifting intravitreal injections from physicians to nurses in a tertiary hospital in Norway. BMC Health Serv Res 2023; 23:229. [PMID: 36890535 PMCID: PMC9996986 DOI: 10.1186/s12913-023-09186-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 02/15/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Anti-vascular endothelial growth factor is a medicine administered intravitreally by an injection to maintain visual acuity in patients with a variety of retinal diseases. The demand for this treatment has grown considerably in the westernized world the last two decades and will continue to increase due to an aging population. Because of the high volume, injections seize enormous resources and represent high costs for both hospitals and society. Task-shifting of injections from physicians to nurses may be a means to reduce such costs, however the magnitude of possible savings has been poorly investigated. To this end we investigated changes in the hospital costs per injection, six-year cost projections of physician- versus nurse-administered injections for a Norwegian tertiary hospital and we compared the societal costs per patient per year. METHODS Patients (n = 318) were randomized to either physician- or nurse administered injections, and data were prospectively collected. Hospital costs per injection were calculated as the sum of training costs, personnel time and running expenses. The number of injections for the years 2014 - 21 from a Norwegian tertiary hospital was combined with age group specific injection prevalence and population projections to calculate cost projections for 2022 - 27. Societal costs per patient were calculated as the sum of hospital costs, transport costs for patients, caregivers' use of time, costs of ophthalmology consultations and community-based homecare. RESULTS The hospital costs per injection were 5.5 € higher for physicians compared to nurses (281.6 € versus 276.1 €). Cost projections estimated an annual hospital saving of task-shifting of 48 921 € for 2022 - 27. Societal costs per patient did not differ significantly between the two groups (mean 4988 € vs 5418 €, p = 0.398). CONCLUSION Task-shifting of injections from physicians to nurses can reduce hospital costs and increase the flexibility of physician resources. The annual savings are modest, but increased demand for injections might increase future cost savings. To achieve future savings for society, organizing ophthalmology consultations and injections on the same day to reduce the number of visits might be a solution. TRIAL REGISTRATION ClinicalTrials.gov NCT02359149 (09/02/2015).
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Affiliation(s)
- Stine Bolme
- Department of Ophthalmology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway. .,Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, NTNU, Trondheim, Norway.
| | - Dordi Austeng
- Department of Ophthalmology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, NTNU, Trondheim, Norway
| | - Tora Sund Morken
- Department of Ophthalmology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, NTNU, Trondheim, Norway
| | - Turid Follestad
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, 7491, Trondheim, Norway
| | - Vidar Halsteinli
- Regional Centre for Health Care Improvement, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Emerson GG, Rahman MM, Kim DH, Stein JD, VanderBeek BL. Board Certification Is Associated With a Reduced Risk of Endophthalmitis After Intravitreal Injections. JOURNAL OF VITREORETINAL DISEASES 2022; 6:116-121. [PMID: 37008659 PMCID: PMC9976016 DOI: 10.1177/24741264211028519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: This work investigates associations between physician qualifications and the risk of postintravitreal injection endophthalmitis. Methods: This retrospective analysis of data from medical claims studied Medicare beneficiaries undergoing 1 or more intravitreal injections between January 1, 2013, and December 31, 2017. Logistic regression analysis was performed to assess whether board certification status or retina subspecialty training was associated with lower risk of postinjection endophthalmitis, controlling for patient's age, race, and sex, type of agent injected, diagnosis, and year of injection. The main outcome measure was odds ratio (OR) of receiving a diagnosis of endophthalmitis in the 14 days after intravitreal injection. Clinical outcome and quality of care were not evaluated in this study. Results: A total of 2 907 324 intravitreal injections were performed on 219 640 patients by 4315 ophthalmologists, 3196 (74%) of whom were retina specialists and 4021 (92%) of whom were certified by the American Board of Ophthalmology (ABO). Overall, there were 1088 (0.037%) cases of postinjection endophthalmitis, of which 1024 (0.037%) were injected by ABO-certified ophthalmologists and 64 (0.050%) by non–board-certified ophthalmologists. Injections by ABO-certified ophthalmologist had 28% reduced odds of endophthalmitis (OR = 0.72; 95% CI, 0.523-0.996, P = .05). Higher odds of endophthalmitis were observed for corticosteroid injections (OR = 3.91; 95% CI, 2.75-5.56, P < .001) and aflibercept injections (OR = 1.47; 95% CI, 1.19-1.80, P < .001). Patients' sex and race, the diagnosis associated with the injection, and providers' retina subspeciality training were not associated with the rate of endophthalmitis ( P < .20 for all comparisons). Conclusions: We found evidence that endophthalmitis may be reduced when ABO-certified physicians perform an intravitreal injection.
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Affiliation(s)
| | - Moshiur M. Rahman
- W. K. Kellogg Eye Center, University of Michigan, Ann Arbor, MI, USA
| | - Diana H. Kim
- Scheie Eye Institute, University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua D. Stein
- W. K. Kellogg Eye Center, University of Michigan, Ann Arbor, MI, USA
- Center for Eye Policy and Innovation, Ann Arbor, MI, USA
- University of Michigan School of Public Health, Ann Arbor, MI, USA
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Patel SV, Olsen TW, Hinchley RL, Whipple DC, Kor TM. Improving Patient Safety in a High-Volume Intravitreal Injection Clinic. Ophthalmol Retina 2022; 6:495-500. [PMID: 35151914 DOI: 10.1016/j.oret.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 02/04/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine root causes of patient safety events in a high-volume intravitreal injection clinic, and to assess the effect of interventions to reduce the rate of events. DESIGN Quality improvement study. SUBJECTS All cases of intravitreal injection in a designated injection clinic between January 1, 2016 and December 31, 2019. METHODS The injection clinic model involved an injecting physician who usually differed from a prescribing physician. The procedural injection area was also physically separate from the retina outpatient clinic. Root cause analysis was used to determine factors that contributed to possible patient safety events in an institutional quality improvement project. Specific interventions were implemented to address each specific root cause. The rates of patient safety events (never events and near misses), whether associated with patient harm or not, were compared before and after intervention. MAIN OUTCOME MEASURES Frequency (%) of patient safety-related intravitreal injection events before (January 1, 2016 to December 31, 2018) and after (January 1, 2019 to December 31, 2019) intervention. RESULTS Root cause analysis included complex treatment plans that could be difficult to interpret, insufficient time to adequately review designated treatment plans, and risk of human error given the pace and volume of scheduled injections. Quality improvement strategies included revision of the standardized treatment plan documentation template, scheduling block-time for injecting physicians to review treatment plans within 24 hours of the injection clinic, and requiring agreement between dual, independent, site and medication verifications of the treatment plan by the injecting physician and an allied health coordinator prior to site marking. The rate of events before intervention was 0.1% (28/27400, or 9.3 events per year) and decreased to 0.01% (1/9375, or 1 event per year) after intervention (p=0.01). Most events were classified as near misses and there were no instances of patient harm. CONCLUSIONS A high level of patient safety can be achieved in a complex, high-volume intravitreal injection practice by recognizing potential safety issues and root causes, and implementing relevant quality improvements. While most events were near misses and no patients were harmed, reducing near misses can reduce the likelihood of harm associated with never events.
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Affiliation(s)
- Sanjay V Patel
- Department of Ophthalmology, Mayo Clinic, Rochester, MN.
| | | | | | - Daniel C Whipple
- Department of Management Engineering and Consulting, Mayo Clinic, Rochester, MN
| | - Todd M Kor
- Department of Anesthesiology, Mayo Clinic, Rochester, MN
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Bolme S, Austeng D, Gjeilo KH. Task shifting of intravitreal injections from physicians to nurses: a qualitative study. BMC Health Serv Res 2021; 21:1185. [PMID: 34717603 PMCID: PMC8557571 DOI: 10.1186/s12913-021-07203-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 10/14/2021] [Indexed: 11/18/2022] Open
Abstract
Background Intravitreal injections of anti-vascular endothelial growth factor are high-volume procedures and represent a considerable workload on ophthalmology departments. Several departments have tried to meet this increase by shifting the task to nurses. To maintain high-quality patient care, we developed a training program for nurses that certifies them to administer injections. This qualitative study aimed to evaluate whether the nurses were confident and in control after participating in the training program and whether they were satisfied with the training and the new task. Methods Between 2014 and 2018, 12 registered nurses were trained in a tertiary hospital in central Norway. All the nurses were interviewed, either individually (n = 7) or in a group (n = 5). We analysed the interviews using Graneheim and Lundman’s qualitative content analysis. Results Eight subthemes were clustered within four main themes: 1) procedure and challenges, 2) motivation, 3) cooperation and confidence, and 4) evaluation. The nurses felt confident and in control when administering injections but experienced moments of insecurity. The new task gave the nurses a sense of achievement, and they highlighted improvement of patients’ lives as positive. A greater level of responsibility gave the nurses pride in their profession. They had suggestions that could improve training efficiency but were overall satisfied with the training program. Conclusions Our study showed that the nurses were satisfied with the training and that learning a new task led to higher self-esteem and increased respect from patients and colleagues. Suggestions to improve the training were identified; these should be considered before implementation by other departments.
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Affiliation(s)
- Stine Bolme
- Department of Ophthalmology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway. .,Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), N-7489, Trondheim, Norway.
| | - Dordi Austeng
- Department of Ophthalmology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), N-7489, Trondheim, Norway
| | - Kari Hanne Gjeilo
- Department of Public Health and Nursing, Faculty of Medicine, NTNU, Trondheim, Norway.,Clinic of Cardiology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Cardiothoracic Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Silpa-Archa S, Limwattanayingyong J, Tadarati M, Amphornphruet A, Ruamviboonsuk P. Capacity building in screening and treatment of diabetic retinopathy in Asia-Pacific region. Indian J Ophthalmol 2021; 69:2959-2967. [PMID: 34708730 PMCID: PMC8725108 DOI: 10.4103/ijo.ijo_1075_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The focus of capacity building for screening and treatment of diabetic retinopathy (DR) is on health professionals who are nonophthalmologists. Both physicians and nonphysicians are recruited for screening DR. Although there is no standardization of the course syllabus for the capacity building, it is generally accepted to keep their sensitivity >80%, specificity >95%, and clinical failure rate <5% for the nonophthalmologists, if possible. A systematic literature search was performed using the PubMed database and the following search terms: diabetic retinopathy, diabetic retinopathy screening, Asia, diabetic retinopathy treatment, age-related macular degeneration, capacity building, deep learning, artificial intelligence (AI), nurse-led clinic, and intravitreal injection (IVI). AI may be a tool for improving their capacity. Capacity building on IVIs of antivascular endothelial growth factors for DR is focused on nurses. There is evidence that, after a supervision of an average of 100 initial injections, the trained nurses can do the injections effectively and safely, the rate of endophthalmitis ranges from 0.03 to 0.07%, comparable to ophthalmologists. However, laws and regulations, which are different among countries, are challenges and barriers for nonophthalmologists, particularly for nonphysicians, for both screening and treatment of DR. Even if nonphysicians or physicians who are nonophthalmologists are legally approved for these tasks, sustainability of the capacity is another important challenge, this may be achieved if the capacity building can be part of their career development. Patient acceptability is another important barrier for initiating care provided by nonophthalmologists, particularly in Asia. There are also collaborations between national eye institutes of high-income countries, nongovernment organizations, and local eye institutes to improve both the quality and quantity of ophthalmologists and retinal specialists in low-income countries in Asia. This approach may require more labor, cost, and time consuming than training nonophthalmologists.
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Affiliation(s)
- Sukhum Silpa-Archa
- Department of Ophthalmology, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Jirawut Limwattanayingyong
- Department of Ophthalmology, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Mongkol Tadarati
- Department of Ophthalmology, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Atchara Amphornphruet
- Department of Ophthalmology, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Paisan Ruamviboonsuk
- Department of Ophthalmology, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
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Situational analysis of diabetic retinopathy treatment Services in Ghana. BMC Health Serv Res 2021; 21:584. [PMID: 34140000 PMCID: PMC8212523 DOI: 10.1186/s12913-021-06608-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 06/03/2021] [Indexed: 12/12/2022] Open
Abstract
Background Although the equitable distribution of diabetic retinopathy (DR) services across Ghana remains paramount, there is currently a poor understanding of nationwide DR treatment services. This study aims to conduct a situation analysis of DR treatment services in Ghana and provide evidence on the breadth, coverage, workload, and gaps in service delivery for DR treatment. Methods A cross-sectional study was designed to identify health facilities which treat DR in Ghana from June 2018 to August 2018. Data were obtained from the facilities using a semi-structured questionnaire which included questions identifying human resources involved in DR treatment, location of health facilities with laser, vitreoretinal surgery and Anti–vascular endothelial growth factor therapy (Anti-VEGF) for DR treatment, service utilisation and workload at these facilities, and the average price of DR treatment in these facilities. Results Fourteen facilities offer DR treatment in Ghana; four in the public sector, seven in the private sector and three in the Christian Health Association of Ghana (CHAG) centres. There was a huge disparity in the distribution of facilities offering DR services, the eye care cadre, workload, and DR treatment service (retinal laser, Anti-VEGF, and vitreoretinal surgery). The retinal laser treatment price was independent of all variables (facility type, settings, regions, and National Health Insurance Scheme coverage). However, settings (p = 0.028) and geographical regions (p = 0.010) were significantly associated with anti-VEGF treatment price per eye. Conclusion Our results suggest a disproportionate distribution of DR services in Ghana. Hence, there should be a strategic development and implementation of an eye care plan to ensure the widespread provision of DR services to the disadvantaged population as we aim towards a disadvantaged population as we aim towards a universal health coverage. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06608-9.
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Sundar D, Das T, Chhablani J, Kumar A, Sharma N. All India Ophthalmological Society members' survey: Practice pattern of intravitreal anti-vascular endothelial growth factor injection. Indian J Ophthalmol 2021; 68:1095-1098. [PMID: 32461437 PMCID: PMC7508122 DOI: 10.4103/ijo.ijo_1602_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose: The aim of this paper is to report the results of an on-line survey to evaluate the practice pattern of Indian retina specialists in administering intravitreal anti-vascular endothelial growth factor injection. Methods: A structured questionnaire on the intravitreal injection (IVI) procedure protocols was sent online to all members of the All India Ophthalmological Society (AIOS) with a request to the retina specialists to respond. A unique link that directed to the web-based questionnaire page allowed a single response only. Participating physicians were masked from each others' responses. The responses were categorized into pre-injection patient preparation, injection aliquoting, injection administration, and post-injection care. The results were compared with similar surveys in Europe, the UK, and the USA. Results: Response was received from 741 of 1016 (73%) retina specialists (of 16,000 AIOS ophthalmologists). The survey showed: 43.5% evaluated patient's cardiac risk factors, 60% used prophylactic topical antibiotic, 90.9% performed injection under topical anesthesia, 55% aliquoted from the bevacizumab vial at the eye care facility, 66.2% used a single puncture technique, 91.4% injected in the main operating room, 98% wore masks and sterile gloves during the procedure, 96% used lid speculum, and 89.3% advised topical antibiotic after the procedure. Peri procedure antibiotic use, injection in the min operating room, wearing of gloves and mask were higher than practices in other countries. Conclusion: Ophthalmologists in India practice asepsis in IVI procedure. There is no uniform protocol for aliquoting bevacizumab. Single use bevacizumab vial for exclusive ophthalmic use will further improve the safety of the procedure.
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Affiliation(s)
- Dheepak Sundar
- Dr. RP Centre for Ophthalmic Sciences, All India Institute of Ophthalmic Sciences, New Delhi, India
| | - Taraprasad Das
- L V Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, India
| | - Jay Chhablani
- University of Pittsburgh, UPMC Eye Center, Pittsburgh, United States of America
| | - Atul Kumar
- Dr. RP Centre for Ophthalmic Sciences, All India Institute of Ophthalmic Sciences, New Delhi, India
| | - Namrata Sharma
- Dr. RP Centre for Ophthalmic Sciences, All India Institute of Ophthalmic Sciences, New Delhi, India
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Trivizki O, Karp MR, Chawla A, Yamanuha J, Gregori G, Rosenfeld PJ. Eliminating Visual Acuity and Dilated Fundus Examinations Improves Cost Efficiency of Performing Optical Coherence Tomogrpahy-Guided Intravitreal Injections. Am J Ophthalmol 2020; 219:222-230. [PMID: 32621894 PMCID: PMC7329678 DOI: 10.1016/j.ajo.2020.06.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 01/22/2023]
Abstract
Purpose The clinic efficiency and cost savings achieved by eliminating formal visual acuity (VA) and dilated fundus examinations (DFEs) were assessed for established patients receiving optical coherence tomography (OCT)–guided intravitreal injections. Design Comparative cost analysis. Methods Two different treatment models were evaluated. The first model included patients undergoing routine VA assessment, DFEs, OCT imaging, and intravitreal injections. The second model eliminated the routine VA assessment and DFE while using OCT imaging through an undilated pupil followed by the intravitreal injection. The 2 models incorporated both bevacizumab and aflibercept. The number of patients per clinic day, the cost per visit, and the daily revenues were compared between the 2 models. Results Optimized schedules with and without VA assessments and DFEs allowed for 48 and 96 patients to be injected per day, respectively. Excluding drug costs, the cost per encounter for the visits with and without a DFE were $39.33 and $22.63, respectively. Including the drug costs, the costs per encounter for the visits with and without a DFE were $85.55 and $68.85 for bevacizumab and $1787.58 and $17770.88 for aflibercept, respectively. Once the reimbursements for each visit type were included, the clinics that eliminated the VA and DFEs were more cost efficient. Conclusion Eliminating both VA assessments and DFEs for patients undergoing OCT-guided retreatment with intravitreal injections resulted in decreased exposure times between patients and clinic staff, decreased cost per encounter, and increased patient volumes per clinic day, resulting in improved clinic efficiency and safety while seeing more patients in a clinic day.
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Affiliation(s)
- Omer Trivizki
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Michael R Karp
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Anuj Chawla
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Justin Yamanuha
- Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, Minnesota, USA
| | - Giovanni Gregori
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Philip J Rosenfeld
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA.
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Blyth M, Innes W, Mohsin-Shaikh N, Talks J. A Comparison of Conventional Intravitreal Injection Method vs InVitria Intravitreal Injection Method. Clin Ophthalmol 2020; 14:2507-2513. [PMID: 32943833 PMCID: PMC7473978 DOI: 10.2147/opth.s238529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 01/29/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To compare use of the conventional intravitreal injection method to the InVitria intravitreal injection device. Three outcome measures were studied: patient comfort, speed of injection and cost-effectiveness. Patients and Methods A prospective review of 58 patients was undertaken. Patients scored their perceived pain for each part of the conventional injection method using visual analogue scales (VAS), which allows pain to be scored from 0 (no pain) to 100. The same 58 patients scored their perceived pain for each part of the injection process with the InVitria on their follow-up visit. The procedure was timed in both settings and cost to the Trust was analysed. Results Pain scores when the InVitria was used were lower than when the conventional method was used for all aspects of the intravitreal injection procedure, in particular, when comparing insertion of drape/speculum (mean score 57.56) to insertion the InVitria (mean score 16.50), needle entry (mean score 37.76 to 27.86) and removal of the drape/speculum (mean score 38.72) to removal of the InVitria (11.07). The reduction in pain scores was statistically significant for all aspects of the procedure, except the initial instillation of drops. The InVitria was an average of 1 minute and 32 seconds faster than the conventional method. Use of the InVitria in place of the conventional method provides an annual saving of £24,300 to the Trust based on the number of injections currently performed. Conclusion The introduction of the InVitria in the Newcastle Eye Centre has had a positive impact on patient comfort, time and cost to the Trust.
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Affiliation(s)
- Michelle Blyth
- Newcastle Eye Centre, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - William Innes
- Newcastle Eye Centre, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | | | - James Talks
- Newcastle Eye Centre, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
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Raman V, Triggol A, Cudrnak T, Konstantinos P. Safety of nurse-led intravitreal injection of dexamethasone (Ozurdex) implant service. Audit of first 1000 cases. Eye (Lond) 2020; 35:388-392. [PMID: 32728227 DOI: 10.1038/s41433-020-1114-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/07/2020] [Accepted: 07/16/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To assess the safety of nurse-led services of intravitreal injection of dexamethasone implant. METHODS An audit of intravitreal injection of dexamethasone implant service in our unit revealed a significant delay in the delivery of injection from the time a clinical decision was made. The limiting factors were an inadequate number of injectors and limited capacity. The constraint in capacity was addressed by moving the service from the theatre to the cleanroom in the outpatients setting. Two senior nurse practitioners in the existing pool of injectors, experienced in intravitreal anti-VEGF injection, were trained to deliver the intravitreal dexamethasone implant service. A safety audit was carried out after they had completed 1000 cases. RESULTS The nurse practitioners administered 1006 injections from February 2017 to October 2019. There was no case of endophthalmitis (0%) or other visually significant complications like retinal detachment, vitreous haemorrhage, hypotony or iatrogenic cataract. One patient had incomplete scleral penetration of the implant, but this resolved without any sequelae. The waiting time to inject the implant nearly halved from 29.5 to 15 days in the nurse-led service. A patient satisfaction survey was overwhelmingly positive, with the majority advocating for the continuation of the nurse-led service. CONCLUSION The current cohort of experienced nurses providing anti-VEGF injections can be trained under supervision to inject the intravitreal dexamethasone implant (Ozurdex). This is safe, additionally effective in streamlining the service and reducing the waiting time for delivery of the steroid implant.
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Affiliation(s)
- Vasant Raman
- Royal Eye Infirmary, University hospitals of Plymouth NHS Trust, Derriford, Plymouth, PL6 8DH, UK.
| | - Alison Triggol
- Royal Eye Infirmary, University hospitals of Plymouth NHS Trust, Derriford, Plymouth, PL6 8DH, UK
| | - Tomas Cudrnak
- Royal Eye Infirmary, University hospitals of Plymouth NHS Trust, Derriford, Plymouth, PL6 8DH, UK
| | - Papadedes Konstantinos
- Royal Eye Infirmary, University hospitals of Plymouth NHS Trust, Derriford, Plymouth, PL6 8DH, UK
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13
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Gale RP, Mahmood S, Devonport H, Patel PJ, Ross AH, Walters G, Downey L, El-Sherbiny S, Freeman M, Berry S, Jain N. Action on neovascular age-related macular degeneration (nAMD): recommendations for management and service provision in the UK hospital eye service. Eye (Lond) 2020; 33:1-21. [PMID: 30926932 PMCID: PMC6474281 DOI: 10.1038/s41433-018-0300-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
This publication and the expert roundtable meeting on which the article is based were sponsored by Bayer plc. Prescribing information for Eylea® (aflibercept solution for injection) can be found at the end of the article. This report by a group of UK retina specialists and health professionals considers best practice recommendations for the management of sight-threatening neovascular age-related macular degeneration (nAMD), based on collective experience and expertise in routine clinical practice. The authors provide an update for ophthalmologists, allied healthcare professionals and commissioners on practice principles for optimal patient care and service provision standards. Refinement of care pathways for nAMD has improved access to intravitreal anti-vascular endothelial growth factor therapy but there are still variations in care and reported outcomes between clinic centres. Innovative organisational models of service provision allow providers to better match capacity with increasing demand. The authors review the recent NICE guideline for diagnosis and management of AMD, considerations for switching therapies and stopping treatment and need for regular monitoring of non-affected fellow eyes in patients with unilateral nAMD. Actions for delivery of high-quality care and to improve long-term patient outcomes are discussed. Local pathways need to detail nAMD target time to treat, maintenance of review intervals to ensure proactive treatment regimens are delivered on time and appropriate discharge for patients deemed low risk or no longer benefiting from treatment. Actual visual acuity outcomes achieved and maintenance of the level of vision when disease stability is achieved are considered good measures for judging the quality of care in the treatment of patients with nAMD. Robust community referral pathways must be in place for suspected reactivation of choroidal neovascularisation and rapid referral for second eye involvement. Practical considerations for intravitreal injection therapy are outlined.
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Affiliation(s)
- Richard P Gale
- The Action on nAMD Group, Birmingham, UK. .,The York Hospital, York, UK.
| | - Sajjad Mahmood
- The Action on nAMD Group, Birmingham, UK.,Manchester Royal Eye Hospital, Manchester, UK
| | - Helen Devonport
- The Action on nAMD Group, Birmingham, UK.,Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Praveen J Patel
- The Action on nAMD Group, Birmingham, UK.,National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Adam H Ross
- The Action on nAMD Group, Birmingham, UK.,University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Gavin Walters
- The Action on nAMD Group, Birmingham, UK.,Harrogate and District NHS Foundation Trust, Harrogate, UK
| | - Louise Downey
- The Action on nAMD Group, Birmingham, UK.,Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - Samer El-Sherbiny
- The Action on nAMD Group, Birmingham, UK.,South Warwickshire NHS Foundation Trust, Warwickshire, UK
| | - Mary Freeman
- The Action on nAMD Group, Birmingham, UK.,Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Simon Berry
- The Action on nAMD Group, Birmingham, UK.,Simon Berry Optometrist, Durham, UK
| | - Nitin Jain
- The Action on nAMD Group, Birmingham, UK.,Bayer, Reading, UK
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14
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Amoaku W, Bailey C, Downey L, Gale RP, Ghanchi F, Hamilton R, Mahmood S, Menon G, Nosek J, Pearce I, Yang Y. Providing a Safe and Effective Intravitreal Treatment Service: Strategies for Service Delivery. Clin Ophthalmol 2020; 14:1315-1328. [PMID: 32546938 PMCID: PMC7239611 DOI: 10.2147/opth.s233061] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 04/03/2020] [Indexed: 11/23/2022] Open
Abstract
An aging population leads to increasing demand for medical retina services with chronic diseases being managed in long-term care pathways. Many hospital services struggle to deliver efficient and effective MR care due, at least in part, to infrastructure that does not expand responsively enough to meet the increased demand. A steering committee of retinal specialists from a variety of UK NHS hospital ophthalmology departments with experience of leading and managing NHS retinal services in the intravitreal era came together for the generation of this document to review and compile key aspects that should be considered when optimising intravitreal treatment capacity within MR services. This article aims to provide a useful collation and signposting of key published evidence, consensus and insights on aspects of delivering an intravitreal service, including treatment regimens, virtual clinics, staff training and governance, telemedicine and information technology, and data collection and key performance indicators. The objective is to equip ophthalmologic healthcare professionals with the necessary tools to develop and adapt their local service in the face of current and projected increased demand.
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Affiliation(s)
- Winfried Amoaku
- Academic Ophthalmology, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Clare Bailey
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Louise Downey
- Hull and East Yorkshire Eye Hospital, Hull University Teaching Hospital, Hull, UK
| | | | - Faruque Ghanchi
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | | | - Sajjad Mahmood
- Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Geeta Menon
- Frimley Health NHS Foundation Trust, Frimley, UK
| | | | - Ian Pearce
- St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Yit Yang
- Wolverhampton Eye Infirmary, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
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15
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El-Khayat AR, Anzidei R, Konidaris V. Ophthalmic photographer virtual clinics in medical retina. Int J Ophthalmol 2020; 13:677-680. [PMID: 32399423 DOI: 10.18240/ijo.2020.04.23] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 02/12/2020] [Indexed: 11/23/2022] Open
Abstract
AIM To determine whether ophthalmic photographers (OPs) can conduct virtual clinics (VCs) in medical retina appropriately and whether this increases clinic capacity. METHODS Three OPs underwent a training programme to learn how to assess and manage macular edema secondary to diabetes or retinal vein occlusion. The 300 consecutive patients over a 7-month observation period in 2018 were assessed in VCs by both OPs and medical retina consultants. The degree of agreement in treatment decisions between doctors and photographers, as well as adverse events, was recorded. The change in number of patients seen in VCs over two years was also measured. RESULTS There was 100% agreement in management decisions between doctors and photographers during the 300-patient observation period. No adverse events were recorded. In 2017, 572 patients were seen in VCs by doctors. After OP clinics were introduced in 2018, this number increased by 24% to 709 patients seen by both photographers and doctors. There was a significant increase in mean number of patients seen per month between 2017 (47.7±11.7) and 2018 (59.1±14.4; P=0.045, 95%CI -22.5 to -0.296). CONCLUSION OPs can manage certain medical retina patients in VCs appropriately and can increase clinic capacity significantly for particular conditions.
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Affiliation(s)
- Abdul R El-Khayat
- Department of Ophthalmology, University Hospitals of Leicester NHS Trust, Leicestershire, LE1 5WW, United Kingdom
| | - Rossella Anzidei
- Department of Ophthalmology, University Hospitals of Leicester NHS Trust, Leicestershire, LE1 5WW, United Kingdom
| | - Vasileios Konidaris
- Department of Ophthalmology, University Hospitals of Leicester NHS Trust, Leicestershire, LE1 5WW, United Kingdom
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16
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Teo AWJ, Rim TH, Wong CW, Tsai ASH, Loh N, Jayabaskar T, Wong TY, Cheung CMG, Yeo IYS. Design, implementation, and evaluation of a nurse-led intravitreal injection programme for retinal diseases in Singapore. Eye (Lond) 2020; 34:2123-2130. [PMID: 32382144 DOI: 10.1038/s41433-020-0920-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 04/16/2020] [Accepted: 04/21/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND To describe the design, implementation, and evaluation of a nurse-led intravitreal injection (NL-IVT) programme in a Singapore tertiary eye hospital. METHODS Patients requiring anti-vascular endothelial growth factor (VEGF) IVT were recruited. Implementation and evaluation were done in the Singapore National Eye Centre, a tertiary centre. To assess safety, nurse injectors recorded details of procedures performed and complications for an 8-month period from February 2019. To evaluate patient experience, we used a modified patient questionnaire and recorded both patients' waiting time and IVT procedure duration. A retrospective audit of IVTs before and after the introduction of NL-IVT was performed from January 2017 to September 2019. Cost difference between NL-IVT and standard doctor-led (DL) IVT was evaluated. RESULTS A total of 8599 NL-IVTs were performed. No cases of severe complication were detected in the follow-up. A total of 135 patients who received NL-IVT and DL-IVT were surveyed. General satisfaction, interpersonal manner, financial aspect, time spent with injector, and staff competence were higher in NL-IVTs than in DL-IVTs (p < 0.05). There were no differences in terms of technical quality and communication. For 934 patients, waiting time was significantly shorter in NL-IVT (3.6 ± 10.3 min) compared with DL-IVTs (35.3 ± 32.3 min); on average, 19.7 min were saved through NL-IVT (p < 0.01). The cost difference per IVT between NL-IVT and DL-IVT is estimated at 286 SGD (163 GBP). CONCLUSION With a well-designed training programme, NL-IVT is a safe, acceptable, and cost savings procedure. With increasing demand for IVT, NL-IVT provides an alternative model of care for healthcare systems globally.
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Affiliation(s)
- Alvin Wei Jun Teo
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
| | - Tyler Hyungtaek Rim
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore.,Ophthalmology & Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore, Singapore
| | - Chee Wai Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
| | | | - Nazurah Loh
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
| | | | - Tien Yin Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore.,Ophthalmology & Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore, Singapore
| | - Chui Ming Gemmy Cheung
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore.,Ophthalmology & Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore, Singapore
| | - Ian Yew San Yeo
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore. .,Ophthalmology & Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore, Singapore.
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17
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Bolme S, Morken TS, Follestad T, Sørensen TL, Austeng D. Task shifting of intraocular injections from physicians to nurses: a randomized single-masked noninferiority study. Acta Ophthalmol 2020; 98:139-144. [PMID: 31267688 DOI: 10.1111/aos.14184] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 06/11/2019] [Indexed: 12/31/2022]
Abstract
PURPOSE To test if task shifting of intraocular injections to nurses in a real-world setting can result in similar visual function outcome with equal safety profile. METHOD All patients with either age-related macular degeneration, retinal vein occlusion or diabetic macular oedema remitted to intraocular injections at a tertiary ophthalmology department in Norway between March 2015 and May 2017, were asked to participate. The participants were randomized to either nurse- or physician-administered intraocular injections of anti-vascular endothelial growth factor. The primary outcome measure was change in best-corrected visual acuity from baseline to 1-year follow-up. The mean difference in the primary outcome between the groups was analysed by a noninferiority test with a margin of three letters in disfavour of the nurse group. Adverse events were recorded. RESULTS Three hundred and forty-two patients entered the study. Two hundred and fifty-nine completed the 1-year follow-up and were included in the study sample for the analysis of the primary outcome. Nurse-administered intraocular injections were noninferior to physician-administered injections with 0.7 and 1.6 letters gained, respectively (95% CI of the mean difference, -2.9 to 1.0; p = 0.019, one-sided t-test). Two thousand and seventy-seven injections and three ocular adverse events were recorded. CONCLUSION Task shifting of intraocular injections to nurses can be performed without increased risk to visual function. Such a task shift can alleviate the burden of performing intraocular injections in ophthalmology departments. To our knowledge, this is the first RCT on task shifting of a surgical procedure from physicians to nurses in a high-income country.
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Affiliation(s)
- Stine Bolme
- Department of Ophthalmology St. Olavs Hospital Trondheim University Hospital Trondheim Norway
- Department of Neuromedicine and Movement Science Norwegian University of Science and Technology Trondheim Norway
| | - Tora Sund Morken
- Department of Ophthalmology St. Olavs Hospital Trondheim University Hospital Trondheim Norway
- Department of Neuromedicine and Movement Science Norwegian University of Science and Technology Trondheim Norway
| | - Turid Follestad
- Department of Public Health and Nursing Norwegian University of Science and Technology Trondheim Norway
| | - Torben Lykke Sørensen
- Department of Ophthalmology Zealand University Hospital Roskilde Denmark
- Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
| | - Dordi Austeng
- Department of Ophthalmology St. Olavs Hospital Trondheim University Hospital Trondheim Norway
- Department of Neuromedicine and Movement Science Norwegian University of Science and Technology Trondheim Norway
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18
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Intravitreal Injections with Vascular Endothelial Growth Factor Inhibitors: A Practical Approach. Ophthalmol Ther 2020; 9:191-203. [PMID: 32034689 PMCID: PMC7054499 DOI: 10.1007/s40123-020-00230-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Indexed: 01/01/2023] Open
Abstract
Intravitreal injections with vascular endothelial growth factor inhibitors constitute the most prevalent ophthalmic procedure in developed countries. Historically, there has been steady growth in the number of treatments performed of this kind, and projection studies estimate further growth in such treatments in the future. We provide a practical approach to intravitreal injections and discuss important aspects relating to the setting, the patient, the procedure, and the information given to the patient.
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19
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Flaxel CJ, Adelman RA, Bailey ST, Fawzi A, Lim JI, Vemulakonda GA, Ying GS. Retinal Vein Occlusions Preferred Practice Pattern®. Ophthalmology 2020; 127:P288-P320. [DOI: 10.1016/j.ophtha.2019.09.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 09/20/2019] [Indexed: 12/18/2022] Open
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20
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Essex RW, Nguyen V, Daien V, Steinmann S, Walton R, Gillies MC, Barthelmes D. Trainee-led versus specialist-led management of neovascular age-related macular degeneration: a registry-based study. Br J Ophthalmol 2018; 103:1158-1162. [PMID: 30385435 DOI: 10.1136/bjophthalmol-2018-311852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 08/09/2018] [Accepted: 09/13/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare the outcomes of trainee-led and specialist-led management of neovascular age-related macular degeneration. DESIGN Prospective multicentre registry-based observational study. SETTING Ophthalmology training centres in Australia and Europe where both trainee-led and specialist-led models of care coexist. PARTICIPANTS Treatment-naïve eyes with neovascular age-related macular degeneration and at least 12 months follow-up. 726 eyes were included in the study from two centres, 534 receiving trainee-led treatment and 192 specialist-led treatment. INTERVENTIONS The management and outcomes of patients receiving trainee-led care were compared with those receiving specialist-led care. MAIN OUTCOMES MEASURES The primary outcome was the mean change in visual acuity at 12 months from first injection. Outcomes were also presented at 36 months where available. RESULTS The mean age of participants was 79 years and 65% were female. The adjusted change in acuity at 12 months in trainee-led vs specialist-led eyes was +3.2 letters vs +4.1 letters (difference -0.9 letters, 95% CI -3.4 to 1.5, p=0.473). The mean adjusted change in acuity at 36 months was -0.9 letters in trainees vs +0.2 letters for specialists (difference -1.1 letters, 95% CI -5.1 to 2.9, p=0.596). Eyes treated by trainees received fewer injections on average to 36 months (15.0 vs 19.0, p=0.004), although this trend was observed at one centre only. CONCLUSIONS No significant differences in outcome between eyes managed by trainees and eyes managed by specialists were observed. Appropriately structured trainee-led management of neovascular age-related macular degeneration is a reasonable approach where regulatory and practical considerations allow it.
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Affiliation(s)
- Rohan W Essex
- Academic Unit of Ophthalmology, Australian National University, Acton, Australian Capital Territory, Australia .,Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia
| | - Vuong Nguyen
- The Save Sight Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Vincent Daien
- The Save Sight Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Department of Ophthalmology, Gui De Chauliac Hospital, Montpellier, France.,Inserm, U1061, Montpellier, France
| | - Sarah Steinmann
- Department of Ophthalmology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Richard Walton
- The Save Sight Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Mark C Gillies
- The Save Sight Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Daniel Barthelmes
- The Save Sight Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Department of Ophthalmology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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21
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De Bruijn-Geraets DP, van Eijk-Hustings YJL, Bessems-Beks MCM, Essers BAB, Dirksen CD, Vrijhoef HJM. National mixed methods evaluation of the effects of removing legal barriers to full practice authority of Dutch nurse practitioners and physician assistants. BMJ Open 2018; 8:e019962. [PMID: 29934382 PMCID: PMC6020970 DOI: 10.1136/bmjopen-2017-019962] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To evaluate the effects of granting legal full practice authority (FPA) to nurse practitioners (NP) and physician assistants (PA) regarding the performance of specified reserved medical procedures and to support governmental decision-making. DESIGN Nationwide mixed methods design with triangulation of quantitative (Pre-post test design) and qualitative data (expert interviews and focus groups). METHODS Surveys focused on the performance of the procedures (monthly number, authorisation mode, consultations and procedural time) and legal cross-compliance requirements (adherence with protocols, competence). Interviews focused on competence, knowledge, skills, responsibilities, routine behaviour, NP/PA role, acceptance, organisational structure, collaboration, consultation, NP/PA positioning, adherence with protocols and resources. Data collection took place between 2011 and 2015. RESULTS Quantitative data included 1251 NPs, 798 PAs and 504 physicians. Besides, expert interviews with 33 healthcare providers and 28 key stakeholders, and 5 focus groups (31 healthcare providers) were held.After obtaining FPA, the proportion of NPs and PAs performing reserved procedures increased from 77% to 85% and from 86% to 93%, respectively; the proportion of procedures performed on own authority increased from 63% to 76% for NPs and from 67% to 71% for PAs. The mean number of monthly contacts between NPs/PAs and physicians about procedures decreased (from 81 to 49 and from 107 to 54, respectively), as did the mean duration in minutes (from 9.9 to 8.6 and from 8.8 to 7.4, respectively). Utilisation of FPA was dependent on the setting, as scepticism of physicians and medical boards hampered full implementation. Legal cross-compliance requirements were mostly fulfilled. CONCLUSIONS Informal practice was legalised. The opportunities to independently perform catheterisations, injections, prescribing, punctures and small surgical procedures were highly used. Care processes were organised more efficiently, services were performed by the most appropriate healthcare provider and conditions were met. This led to the recommendation to continue with FPA.
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Affiliation(s)
- Daisy P De Bruijn-Geraets
- Department of Patient and Care, Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
- School CAPHRI, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Yvonne J L van Eijk-Hustings
- Department of Patient and Care, Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
- School CAPHRI, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Monique C M Bessems-Beks
- Department of Patient and Care, Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Brigitte A B Essers
- Department of Patient and Care, Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
- School CAPHRI, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Carmen D Dirksen
- Department of Patient and Care, Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
- School CAPHRI, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Hubertus Johannes Maria Vrijhoef
- Department of Patient and Care, Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
- Panaxea, Amsterdam, The Netherlands
- Department of Primary Care, Vrije Universiteit Brussel, Brussels, Belgium
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22
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Thun S, Halsteinli V, Løvseth L. A study of unreasonable illegitimate tasks, administrative tasks, and sickness presenteeism amongst Norwegian physicians: an everyday struggle? BMC Health Serv Res 2018; 18:407. [PMID: 29871623 PMCID: PMC5989409 DOI: 10.1186/s12913-018-3229-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 05/23/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It has been shown that a recently defined stressor, 'illegitimate tasks', has negative effects on employees' work motivation and health. Better understanding of the illegitimate tasks undertaken by physicians might contribute to a more resource-efficient division of labour within the health care system, with beneficial effects on organisational economics and employee performance. We aimed to investigate the prevalence of unreasonable illegitimate tasks, their associations with workplace variables and their impact on health, in particular sickness presenteeism. METHODS Cross-sectional data were collected in 2012. A sample of 545 Norwegian physicians answered an online questionnaire. The response rate was high (71.8%). The data were analysed using independent-samples t-tests, ANOVA and logistic regression. RESULTS About 50.2% of physicians in all clinical positions reported that at least 11% of their everyday tasks could have been done by other hospital personnel. Seven percent of the physicians reported that at least 31% of their daily workload consisted of unreasonable illegitimate tasks. There were no significant differences in unreasonable illegitimate tasks according to clinical position, age or gender. Administrative task load and role conflict were positively associated with unreasonable illegitimate tasks that physicians reported could be reallocated to non-medical professionals. Moreover, unreasonable illegitimate task was associated with a higher probability of sickness presenteeism after controlling for age, gender, role conflict, control over work pace, exhaustion and administrative tasks. CONCLUSIONS The results confirm that physicians' workload includes a high proportion of unreasonable illegitimate tasks and that this can contribute to sickness presenteeism. Investigation of work environmental factors can provide insight into the mechanisms behind unreasonable illegitimate tasks. Decreasing the amount of administrative tasks and role conflicts faced by physicians should be a priority. These findings could be used to make hospital task management more resource-efficient. Our results indicate that a substantial proportion of physicians' work capacity could be re-allocated to core tasks. Further research is needed into the specific type and content of unreasonable illegitimate tasks undertaken by physicians in order to determine to whom they should be allocated to ensure a healthy and motivated workforce and provision of high quality, resource-efficient health care services.
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Affiliation(s)
- Sylvi Thun
- Department of Research and Development, Division of Psychiatry, St. Olavs Trondheim University Hospital, Trondheim, Norway
| | - Vidar Halsteinli
- Regional Centre for Health Care Development, St Olavs Trondheim University Hospital, Trondheim, Norway
| | - Lise Løvseth
- Department of Research and Development, Division of Psychiatry, St. Olavs Trondheim University Hospital, Trondheim, Norway.
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23
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Mohamed R, Ramcharan D, Srikaran S, Mensch E. A model of clinical practice: a randomised clinical study evaluating patient satisfaction of nurse-led vs consultant-led intravitreal injection. Eye (Lond) 2018; 32:1148-1149. [DOI: 10.1038/s41433-017-0008-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 12/01/2017] [Indexed: 11/09/2022] Open
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24
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Kortuem K, Fasler K, Charnley A, Khambati H, Fasolo S, Katz M, Balaskas K, Rajendram R, Hamilton R, Keane PA, Sim DA. Implementation of medical retina virtual clinics in a tertiary eye care referral centre. Br J Ophthalmol 2018; 102:1391-1395. [PMID: 29306863 DOI: 10.1136/bjophthalmol-2017-311494] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 11/29/2017] [Accepted: 12/19/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND The increasing incidence of medical retinal diseases has created capacity issues across UK. In this study, we describe the implementation and outcomes of virtual medical retina clinics (VMRCs) at Moorfields Eye Hospital, South Division, London. It represents a promising solution to ensure that patients are seen and treated in a timely fashion METHODS: First attendances in the VMRC (September 2016-May 2017) were included. It was open to non-urgent external referrals and to existing patients in a face-to-face clinic (F2FC). All patients received visual acuity testing, dilated fundus photography and optical coherence tomography scans. Grading was performed by consultants, fellows and allied healthcare professionals. Outcomes of these virtual consultations and reasons for F2FC referrals were assessed. RESULTS A total number of 1729 patients were included (1543 were internal and 186 external referrals). The majority were diagnosed with diabetic retinopathy (75.1% of internal and 46.8% of external referrals). Of the internal referrals, 14.6% were discharged, 54.5% continued in VMRC and 30.9% were brought to a F2FC. Of the external referrals, 45.5% were discharged, 37.1% continued in VMRC and 17.4% were brought to a F2FC. The main reason for F2FC referrals was image quality (34.7%), followed by detection of potentially treatable disease (20.2%). CONCLUSION VMRC can be implemented successfully using existing resources within a hospital eye service. It may also serve as a first-line rapid-access clinic for low-risk referrals. This would enable medical retinal services to cope with increasing demand and efficiently allocate resources to those who require treatment.
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Affiliation(s)
- Karsten Kortuem
- Medical Retina Department, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Medical Retina Department, University Eye Hospital, Munich, Germany
| | - Katrin Fasler
- Medical Retina Department, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Department of Ophthalmology, University Hospital Zurich, Zurich, Switzerland
| | - Amanda Charnley
- Medical Retina Department, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Hussain Khambati
- Medical Retina Department, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Sandro Fasolo
- Medical Retina Department, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Menachem Katz
- Medical Retina Department, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Konstantinos Balaskas
- Medical Retina Department, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,School of Biological Sciences, University of Manchester, Manchester, UK
| | - Ranjan Rajendram
- Medical Retina Department, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,National Institute for Health and Research (NIHR) Biomedical Center, Moorfields Eye Hospital, London, UK.,Institute of Ophthalmology, University College of London (UCL), London, UK
| | - Robin Hamilton
- Medical Retina Department, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,National Institute for Health and Research (NIHR) Biomedical Center, Moorfields Eye Hospital, London, UK.,Institute of Ophthalmology, University College of London (UCL), London, UK
| | - Pearse A Keane
- Medical Retina Department, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,National Institute for Health and Research (NIHR) Biomedical Center, Moorfields Eye Hospital, London, UK.,Institute of Ophthalmology, University College of London (UCL), London, UK
| | - Dawn A Sim
- Medical Retina Department, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,National Institute for Health and Research (NIHR) Biomedical Center, Moorfields Eye Hospital, London, UK.,Institute of Ophthalmology, University College of London (UCL), London, UK
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Gallagher MJ. Introduction of a nurse-led intravitreal injection service in ophthalmology. ACTA ACUST UNITED AC 2017; 26:800-803. [PMID: 28745964 DOI: 10.12968/bjon.2017.26.14.800] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Anti-VEGF (anti-vascular endothelial growth factor) agents are useful for a variety of previously untreatable eye conditions; indications for their use are increasing. As this treatment evolved from cutting-edge to mainstream NHS practice, it resulted in a significant increase in appointments for intravitreal (IVT) injections, clinical assessment and follow-up, and hence an increasing challenge to ensure its timely availability to all who needed it. In addressing that challenge, NHS Lothian successfully initiated an advanced nurse practitioner IVT service in addition to its medical IVT service, which has increased its capacity to provide the requisite high-quality care to this patient group.
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Hasan H, Flockhart S, Qureshi W, Khan S, Ahmed S, Shah N. Intravitreal injections service: a patient experience evaluation. ACTA ACUST UNITED AC 2017. [PMID: 28640723 DOI: 10.12968/bjon.2017.26.12.678] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
INTRODUCTION This survey has been conducted following the introduction of nurse-led intravitreal injections clinics at the Great Western Hospital. A team of 5 nurses regularly carry out an average of 90 injections per week. METHODS A series of 169 consecutive injection patients have been offered the study questionnaire between 28 January 2016 and 28 February 2016; patients with no previous experience with a nurse injector were excluded. RESULTS 76.9% strongly agree that the nurse is more friendly and sensitive to their needs. Only 12.4% strongly agree that a doctor will be more suitable to deliver the injections. Seventy-five percent stated that they were very happy with the care, while 0.4% thought a nurse would be unsafe; 69.2% feel more comfortable asking questions when with a nurse injector. Anxiety and nervousness were found to be the main two symptoms experienced by patients around the time of injections (27.8% and 34.9%, respectively). DISCUSSION The questionnaire was designed based on the feedback from the local friends and family test. A clear majority of patients gave highly positive feedback about nurse injectors. Considering patients' individual needs at the time of injections, such as allergies or points that needs clarification, helps in overcoming some of the psychological complications of treatment.
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Affiliation(s)
- Hani Hasan
- Specialty Doctor in Ophthalmology, Department of Ophthalmology, Great Western Hospital, Marlborough Road
| | | | - Waseem Qureshi
- Specialty Doctor, Great Western Hospital, Marlborough Road
| | - Selina Khan
- Specialty Trainee Doctor (Year 2) in Ophthalmology, Great Western Hospital, Marlborough Road
| | - Shahina Ahmed
- Specialty Doctor, Great Western Hospital, Marlborough Road
| | - Nimish Shah
- Consultant Ophthalmologist, Great Western Hospital, Marlborough Road
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Marahrens L, Ziemssen F, Fritsche A, Ziemssen T, Kern R, Martus P, Roeck D. Limited Time from the Diabetes Patients' Perspective: Need for Conversation with the Eye Specialist. Ophthalmologica 2016; 236:154-158. [PMID: 27701169 DOI: 10.1159/000450708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 09/02/2016] [Indexed: 11/19/2022]
Abstract
PURPOSE Facing the lack of time, busy retina consultants should be aware of how the patients would prefer that time is spent and whether they wish the specialist to talk more at the expense of other medical activities. METHODS 810 persons with diabetes were asked to divide the time of 10 min between examination, consultation and treatment when envisioning a real-life scenario of diabetic retinopathy (NCT02311504). RESULTS With the increasing duration of diabetes, patients wanted significantly more time for diagnostics (p = 0.028), while age was found to be associated with less time for treatment (p = 0.009). Female subjects tended to prefer only little more time for talking (p = 0.051) in comparison with males, who slightly favored therapy (p = 0.025). CONCLUSIONS The large majority recognized the need for diagnostics in their allocation of time. If individual patients are confronted with the health care perspective of time constraints, this might improve the understanding of prioritization.
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Affiliation(s)
- Lydia Marahrens
- Center for Ophthalmology, Eberhard Karl University of Tuebingen, Tuebingen, Germany
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Nurse-administered intravitreal injections of anti-VEGF: study protocol for noninferiority randomized controlled trial of safety, cost and patient satisfaction. BMC Ophthalmol 2016; 16:169. [PMID: 27716253 PMCID: PMC5045663 DOI: 10.1186/s12886-016-0348-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 06/24/2016] [Indexed: 12/03/2022] Open
Abstract
Background Intravitreal injections (IVI) of anti-vascular endothelial growth factor (anti-VEGF) now improve or stabilize visual acuity in a number of previously untreatable eye diseases, of which the main are age-related macular degeneration, retinal vein occlusion and diabetic macular edema. Most patients require multiple injections over lengthy periods of time and the prevalence of treatable conditions is increasing. Anti-VEGF IVI normally administered by physicians, therefore represent a considerable workload on ophthalmologic clinics and will continue to do so in the near future. Nurse-administered IVI may relieve this workload, but the safety, cost and patient satisfaction of such an extended role for nurses in ophthalmologic clinics has not earlier been investigated. To investigate these outcomes following independent anti-VEGF IVI by trained nurses, a noninferiority randomized controlled trial is being conducted. Methods/Design Patients eligible for anti-VEGF treatment, minimum 304, are recruited and randomized to IVI administration by either trained nurses or physicians. The primary outcome is safety, measured by difference in mean change in visual acuity between the two groups during an observation period of 12 months. Secondary outcomes are incidence of ocular adverse events, cost per patient and patient satisfaction. Discussion This study protocol describes the design of the first randomized controlled trial of nurse-administered IVI of anti-VEGF. The study is designed to examine safety, cost and patient satisfaction during 12 months follow-up. Trial registration ClinicalTrials.gov NCT02359149. Registered February 4, 2015. Electronic supplementary material The online version of this article (doi:10.1186/s12886-016-0348-4) contains supplementary material, which is available to authorized users.
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Lee AY, Day AC, Egan C, Bailey C, Johnston RL, Tsaloumas MD, Denniston AK, Tufail A, Akerele T, Al-Husainy S, Brand C, Chakravarthy U, Downey L, Fitt A, Khan R, Kumar V, Lobo A, Mahmood S, Mandal K, McKibbin M, Menon G, Natha S, Ong JM, Varma A, Wilkinson E. Previous Intravitreal Therapy Is Associated with Increased Risk of Posterior Capsule Rupture during Cataract Surgery. Ophthalmology 2016; 123:1252-6. [DOI: 10.1016/j.ophtha.2016.02.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 02/03/2016] [Accepted: 02/04/2016] [Indexed: 12/19/2022] Open
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Samia-Aly E, Cassels-Brown A, Morris DS, Stancliffe R, Somner JEA. A survey of UK practice patterns in the delivery of intravitreal injections. Ophthalmic Physiol Opt 2016; 35:450-4. [PMID: 26094833 DOI: 10.1111/opo.12217] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 04/24/2015] [Indexed: 12/01/2022]
Abstract
PURPOSE To assess UK practice patterns related to the prescription of antibiotics before, during and after intravitreal injections, the location where injections are carried out and the qualifications of those administering the injections. METHODS Every ophthalmology unit featured in the Royal College of Ophthalmologists (UK) training directory was contacted. A healthcare professional involved in giving intravitreal injections at each institution completed a questionnaire regarding local practice patterns. RESULTS A response rate of 85% (115/136) was achieved. Seventy four percent of hospitals (85/115) gave take home antibiotics post intravitreal injection. Twenty three percent (26/115) of hospitals employed non-medical healthcare professionals to administer injections and 83% (96/115) administered intravitreal injections in a dedicated clean room as opposed to an operating theatre. CONCLUSION Practice patterns for intravitreal injection vary considerably. Guidelines alone do not appear to be effective in reducing practices which are considered wasteful and other approaches need to be developed.
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Affiliation(s)
| | | | - Daniel S Morris
- Cardiff Eye Unit, University Hospital of Wales, Cardiff, Wales, UK
| | | | - John E A Somner
- Vision and Eye Research Unit, Postgraduate Medical Institute, Anglia Ruskin University, Cambridge, UK
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Li E, Greenberg PB, Krzystolik MG. Nurse-administered intravitreal injections: a systematic review. Graefes Arch Clin Exp Ophthalmol 2015; 253:1619-21. [DOI: 10.1007/s00417-014-2921-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 12/27/2014] [Indexed: 10/24/2022] Open
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Bloch SB, Larsen M. Translational public health care perspective: intravitreal treatment of neovascular age-related macular degeneration has revolutionized clinical ophthalmology. Acta Ophthalmol 2015; 93:103-4. [PMID: 25688486 DOI: 10.1111/aos.12680] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Utilisation of orthoptists to give intravitreal injections-a multidisciplinary approach. Eye (Lond) 2014; 29:290. [PMID: 25412714 DOI: 10.1038/eye.2014.234] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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