Introduction of a nurse-led intravitreal injection service in ophthalmology

Integrating Nurse-Led Interventions in Ophthalmology Care: A Systematic Review

BACKGROUND

Nurse-led interventions in ophthalmology care can enhance the overall patient experience while optimizing health care system efficiency.

PURPOSE

The purpose of this study was to investigate the impact of nurse-led interventions in ophthalmology care.

METHODS

A comprehensive search was conducted across multiple databases for articles published from 2000 to 2023. Randomized controlled trials, quasi-experimental, and observational studies were included. Quality assessments were performed using the Cochrane Risk of Bias tool or Newcastle-Ottawa Scale, based on study design.

RESULTS

Nineteen studies were included. Nurse-led interventions positively impacted patient outcomes, improved efficiency and resource utilization, enhanced patient satisfaction and adherence, maintained safety and efficacy, and demonstrated notable diagnostic accuracy. Included studies originated from different countries and employed diverse methodologies, offering a global perspective on nurse-led interventions in ophthalmology care.

CONCLUSION

The findings advocate for the integration of nurse-led strategies in routine practice to realize equitable, efficient, and patient-centered eye care.

Save our Sight (SOS): a collective call-to-action for enhanced retinal care across health systems in high income countries

With a growing aging population, the prevalence of age-related eye disease and associated eye care is expected to increase. The anticipated growth in demand, coupled with recent medical advances that have transformed eye care for people living with retinal diseases, particularly neovascular age-related macular degeneration (nAMD) and diabetic eye disease, has presented an opportunity for health systems to proactively manage the expected burden of these diseases. To do so, we must take collective action to address existing and anticipated capacity limitations by designing and implementing sustainable strategies that enable health systems to provide an optimal standard of care. Sufficient capacity will enable us to streamline and personalize the patient experience, reduce treatment burden, enable more equitable access to care and ensure optimal health outcomes. Through a multi-modal approach that gathered unbiased perspectives from clinical experts and patient advocates from eight high-income countries, substantiated perspectives with evidence from the published literature and validated findings with the broader eye care community, we have exposed capacity challenges that are motivating the community to take action and advocate for change. Herein, we propose a collective call-to-action for the future management of retinal diseases and potential strategies to achieve better health outcomes for individuals at-risk of, or living with, retinal disease.

Diabetic Macular Edema and Diode Subthreshold Micropulse Laser: A Randomized Double-Masked Noninferiority Clinical Trial

PURPOSE

To determine clinical effectiveness, safety, and cost-effectiveness of subthreshold micropulse laser (SML), compared with standard laser (SL), for diabetic macular edema (DME) with central retinal thickness (CRT) < 400 μm.

DESIGN

Pragmatic, multicenter, allocation-concealed, double-masked, randomized, noninferiority trial.

PARTICIPANTS

Adults with center-involved DME < 400 μm and best-corrected visual acuity (BCVA) of > 24 Early Treatment Diabetic Retinopathy Study (ETDRS) letters in one/both eyes.

METHODS

Randomization 1:1 to 577 nm SML or SL treatment. Retreatments were allowed. Rescue with intravitreal anti-vascular endothelial growth factor therapies or steroids was permitted if 10 or more ETDRS letter loss occurred, CRT increased > 400 μm, or both.

MAIN OUTCOME MEASURES

Primary outcome was mean change in BCVA in the study eye at 24 months (noninferiority margin 5 ETDRS letters). Secondary outcomes were mean change from baseline to month 24 in binocular BCVA; CRT and mean deviation of Humphrey 10-2 visual field in the study eye; percentage meeting driving standards; EuroQoL EQ-5D-5L, 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25), and Vision and Quality of Life Index (VisQoL) scores; cost per quality-adjusted life-years (QALYs) gained; adverse effects; and number of laser and rescue treatments.

RESULTS

The study recruited fully (n = 266); 87% of SML-treated and 86% of SL-treated patients had primary outcome data. Mean ± standard deviation BCVA change from baseline to month 24 was -2.43 ± 8.20 letters and -0.45 ± 6.72 letters in the SML and SL groups, respectively. Subthreshold micropulse laser therapy was deemed not only noninferior but also equivalent to SL therapy because the 95% confidence interval (CI; -3.9 to -0.04 letters) lay wholly within both upper and lower margins of the permitted maximum difference (5 ETDRS letters). No statistically significant difference was found in binocular BCVA (0.32 ETDRS letters; 95% CI, -0.99 to 1.64 ETDRS letters; P = 0.63); CRT (-0.64 μm; 95% CI, -14.25 to 12.98 μm; P = 0.93); mean deviation of the visual field (0.39 decibels (dB); 95% CI, -0.23 to 1.02 dB; P = 0.21); meeting driving standards (percentage point difference, 1.6%; 95% CI, -25.3% to 28.5%; P = 0.91); adverse effects (risk ratio, 0.28; 95% CI, 0.06-1.34; P = 0.11); rescue treatments (percentage point difference, -2.8%; 95% CI, -13.1% to 7.5%; P = 0.59); or EQ-5D, NEI-VFQ-25, or VisQoL scores. Number of laser treatments was higher in the SML group (0.48; 95% CI, 0.18-0.79; P = 0.002). Base-case analysis indicated no differences in costs or QALYs.

CONCLUSIONS

Subthreshold micropulse laser therapy was equivalent to SL therapy, requiring slightly higher laser treatments.

Standard threshold laser versus subthreshold micropulse laser for adults with diabetic macular oedema: the DIAMONDS non-inferiority RCT

BACKGROUND

The National Institute for Health and Care Excellence recommends macular laser to treat diabetic macular oedema with a central retinal subfield thickness of < 400 µm on optical coherence tomography. The DIAMONDS (DIAbetic Macular Oedema aNd Diode Subthreshold micropulse laser) trial compared standard threshold macular laser with subthreshold micropulse laser to treat diabetic macular oedema suitable for macular laser.

OBJECTIVES

Determining the clinical effectiveness, safety and cost-effectiveness of subthreshold micropulse laser compared with standard threshold macular laser to treat diabetic macular oedema with a central retinal subfield thickness of < 400 µm.

DESIGN

A pragmatic, multicentre, allocation-concealed, double-masked, randomised, non-inferiority, clinical trial.

SETTING

Hospital eye services in the UK.

PARTICIPANTS

Adults with diabetes and centre-involving diabetic macular oedema with a central retinal subfield thickness of < 400 µm, and a visual acuity of > 24 Early Treatment Diabetic Retinopathy Study letters (Snellen equivalent > 20/320) in one/both eyes.

INTERVENTIONS

Participants were randomised 1 : 1 to receive 577 nm subthreshold micropulse laser or standard threshold macular laser (e.g. argon laser, frequency-doubled neodymium-doped yttrium aluminium garnet 532 nm laser); laser treatments could be repeated as needed. Rescue therapy with intravitreal anti-vascular endothelial growth factor therapies or steroids was allowed if a loss of ≥ 10 Early Treatment Diabetic Retinopathy Study letters between visits occurred and/or central retinal subfield thickness increased to > 400 µm.

MAIN OUTCOME MEASURES

The primary outcome was the mean change in best-corrected visual acuity in the study eye at 24 months (non-inferiority margin 5 Early Treatment Diabetic Retinopathy Study letters). Secondary outcomes included the mean change from baseline to 24 months in the following: binocular best-corrected visual acuity; central retinal subfield thickness; the mean deviation of the Humphrey 10-2 visual field in the study eye; the percentage of people meeting driving standards; and the EuroQol-5 Dimensions, five-level version, National Eye Institute Visual Function Questionnaire - 25 and Vision and Quality of Life Index scores. Other secondary outcomes were the cost per quality-adjusted life-years gained, adverse effects, number of laser treatments and additional rescue treatments.

RESULTS

The DIAMONDS trial recruited fully (n = 266); 87% of participants in the subthreshold micropulse laser group and 86% of participants in the standard threshold macular laser group had primary outcome data. Groups were balanced regarding baseline characteristics. Mean best-corrected visual acuity change in the study eye from baseline to month 24 was -2.43 letters (standard deviation 8.20 letters) in the subthreshold micropulse laser group and -0.45 letters (standard deviation 6.72 letters) in the standard threshold macular laser group. Subthreshold micropulse laser was deemed to be not only non-inferior but also equivalent to standard threshold macular laser as the 95% confidence interval (-3.9 to -0.04 letters) lay wholly within both the upper and lower margins of the permitted maximum difference (5 Early Treatment Diabetic Retinopathy Study letters). There was no statistically significant difference between groups in any of the secondary outcomes investigated with the exception of the number of laser treatments performed, which was slightly higher in the subthreshold micropulse laser group (mean difference 0.48, 95% confidence interval 0.18 to 0.79; p = 0.002). Base-case analysis indicated no significant difference in the cost per quality-adjusted life-years between groups.

FUTURE WORK

A trial in people with ≥ 400 µm diabetic macular oedema comparing anti-vascular endothelial growth factor therapy alone with anti-vascular endothelial growth factor therapy and macular laser applied at the time when central retinal subfield thickness has decreased to < 400 µm following anti-vascular endothelial growth factor injections would be of value because it could reduce the number of injections and, subsequently, costs and risks and inconvenience to patients.

LIMITATIONS

The majority of participants enrolled had poorly controlled diabetes.

CONCLUSIONS

Subthreshold micropulse laser was equivalent to standard threshold macular laser but required a slightly higher number of laser treatments.

TRIAL REGISTRATION

This trial is registered as EudraCT 2015-001940-12, ISRCTN17742985 and NCT03690050.

FUNDING

This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 50. See the NIHR Journals Library website for further project information.

Impact of nurse-surgeons on patient-centred outcomes: A systematic review

Background

Nurse-surgeons have been performing surgeries for decades. Yet, their impact on perioperative clinical outcomes has not been explored in detail.

Objective

To investigate the impact of nurse-surgeons on patient-centred outcomes.

Design

Systematic review.

Method

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram and checklist for systematic reviews were used as the screening and reporting guideline. CINAHL, Cochrane Library, MEDLINE, and PubMed databases were searched for articles that fit the review's eligibility criteria. A combination of Medical Subject Headings, keywords and filters for each database were used. Following screening and full text review, the Mixed Methods Appraisal Tool was used for quality assessment and the Grading of Recommendations, Assessment, Development and Evaluations framework for certainty and confidence assessment. Narrative synthesis was used to report the findings due to the design heterogeneity of the included studies.

Results

Forty-eight (n = 48) patient-centred outcomes were identified from 25 included studies. These outcomes were grouped into four categories: patient satisfaction and experience; waiting list; perioperative complications; and quality of surgical care. Patient satisfaction and experience was rated high to very high in 16 studies; none reported patient dissatisfaction. Waiting lists improved in eight studies. Perioperative complications were none to very low in nine studies. Mortality rates in the nurse-surgeon group were better than the physician group in three studies. The quality of care in the performance of surgeries by nurse-surgeons was either similar or better than physicians in ten studies.

Conclusions

Nurse-surgeons performed safe, satisfactory, and high-quality surgeries with minimal perioperative complications similar to physicians. The use of nurse-surgeons has significantly reduced waiting lists regardless of surgical speciality. Policies around nurse-surgeon practice needs to be developed at national and international levels to streamline the delivery of much needed surgical services amidst the coronavirus pandemic in the areas of cancer diagnostic surgeries, emergency surgeries, minor surgeries, and remote and rural health.

Capacity building in screening and treatment of diabetic retinopathy in Asia-Pacific region

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.

Characterising the outcomes, impacts and implementation challenges of advanced clinical practice roles in the UK: a scoping review

OBJECTIVES

In response to demographic and health system pressures, the development of non-medical advanced clinical practice (ACP) roles is a key component of National Health Service workforce transformation policy in the UK. This review was undertaken to establish a baseline of evidence on ACP roles and their outcomes, impacts and implementation challenges across the UK.

DESIGN

A scoping review was undertaken following JBI methodological guidance.

METHODS

13 online databases (Medline, CINAHL, ASSIA, Embase, HMIC, AMED, Amber, OT seeker, PsycINFO, PEDro, SportDiscus, Osteopathic Research and PenNutrition) and grey literature sources were searched from 2005 to 2020. Data extraction, charting and summary was guided by the PEPPA-Plus framework. The review was undertaken by a multi-professional team that included an expert lay representative.

RESULTS

191 papers met the inclusion criteria (any type of UK evidence, any sector/setting and any profession meeting the Health Education England definition of ACP). Most papers were small-scale descriptive studies, service evaluations or audits. The papers reported mainly on clinical aspects of the ACP role. Most papers related to nursing, pharmacy, physiotherapy and radiography roles and these were referred to by a plethora of different titles. ACP roles were reported to be achieving beneficial impacts across a range of clinical and health system outcomes. They were highly acceptable to patients and staff. No significant adverse events were reported. There was a lack of cost-effectiveness evidence. Implementation challenges included a lack of role clarity and an ambivalent role identity, lack of mentorship, lack of continuing professional development and an unclear career pathway.

CONCLUSION

This review suggests a need for educational and role standardisation and a supported career pathway for advanced clinical practitioners (ACPs) in the UK. Future research should: (i) adopt more robust study designs, (ii) investigate the full scope of the ACP role and (iii) include a wider range of professions and sectors.

Need for Nurse Practitioner Fellowships in Ophthalmology in the USA

Medical attention to vision impairment and associated eye care complications are a vital component of daily living and overall well-being. In the United States today, the physician to patient deficit places great strain on the availability of medical attention tenable to patients nationwide; in terms of specialty medicine, this deficit is even more widespread. The field of ophthalmology faced the same physician to patient deficit in 2020, a grim reality that has left many states void of ophthalmic care, rending millions of aging individuals without domestic eye care. The implementation of trained, ophthalmic nurse practitioners (NPs) can fill the needs of this deficit; however, efficient, accredited, and board-approved American ophthalmic fellowships and residencies that secure proper ophthalmic NP transitions from academia to clinical practice are non-existent. Though scant, evidence-based literature presents sound findings that support the efficacy and benefit for superior patient outcomes with care provided by ophthalmic-trained NPs, offering a viable, long-term solution to the need for ophthalmic medical providers across all states without mitigating patient care, emphasizing the great need for the implementation of ophthalmic NP residencies and fellowships to ensure the continuity of impeccable ophthalmic care for all populations.

Design, implementation, and evaluation of a nurse-led intravitreal injection programme for retinal diseases in Singapore

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.