The Effectiveness, cost-effectiveness and acceptability of Community versus Hospital Eye Service follow-up for patients with neovascular age-related macular degeneration with quiescent disease (ECHoES): a virtual randomised balanced incomplete block trial

Barnaby Reeves, Lauren Scott, Jodi Taylor, R Hogg, Chris Rogers, S Wordsworth, Daisy Townsend, A Muldrew, T Peto, M Violato, H Dakin , Heike Cappel-Porter, Nicola J Mills, D O'Reilly, Harding P , Usha Chakravarthy

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Abstract

Background
Patients with neovascular age-related macular degeneration (nAMD) usually attend regular reviews, even when the disease is quiescent. Reviews are burdensome to health services, patients and carers.
Objectives
To compare the proportion of correct lesion classifications made by community-based optometrists and ophthalmologists from vignettes of patients; to estimate the cost-effectiveness of community follow-up by optometrists compared to follow-up by ophthalmologists in the Hospital Eye Service (HES); to ascertain views of patients, their representatives, optometrists, ophthalmologists and clinical commissioners on the proposed shared care model.
Design
Community-based optometrists and ophthalmologists in the HES classified lesions from vignettes comprising clinical information, colour fundus (CF) and optical coherence tomography (OCT) images. Participants’ classifications were validated against experts’ classifications (reference standard).
Setting
Internet-based application.
Participants
Ophthalmologists had to have: ≥3 years’ post-registration experience in ophthalmology; part 1 of the Royal College of Ophthalmologists, Diploma in Ophthalmology or equivalent; experience in the AMD service. Optometrists had to be: fully qualified; registered with the General Optical Council for ≥3 years; not participating in nAMD shared care.
Interventions
The trial sought to emulate a conventional trial, comparing optometrists’ and ophthalmologists’ decision-making but vignettes, not patients, were assessed. Therefore, there were no interventions. Participants received training prior to assessing vignettes.
Main outcome measures
Primary outcome: correct classification of the activity status of a lesion based on a vignette, compared to a reference standard. Secondary outcomes: frequencies of potentially sight threatening errors; participants’ judgements about specific lesion components; participant-rated confidence in their decisions; cost-effectiveness of follow-up by community-based optometrists compared to HES ophthalmologists.
Results
155 participants registered for the trial; 96 (48 in each professional group) completed training and main assessments and formed the analysis population. Optometrists and ophthalmologists achieved 1702/2016 (84.4%) and 1722/2016 (85.4%) correct classifications, respectively (odds ratio [OR] 0.91, 95% confidence interval [CI] 0.66-1.25, p=0.543). Optometrists’ decision-making was non-inferior to ophthalmologists’ with respect to the pre-specified limit of 10% absolute difference (0.298 on the odds scale). Frequencies of sight-threatening errors were similar for optometrists and ophthalmologists (57/994 (5.7%) versus 62/994 (6.2%), OR 0.93, 95% CI 0.55-1.57, p=0.789). Ophthalmologists assessed lesion components as present less often than optometrists and were more confident about their lesion classifications than optometrists. The mean care pathway cost for assessment was very similar by group, namely £397.33 for ophthalmologists and £410.78 for optometrists. The optometrist led monitoring reviews were slightly more costly and less effective than ophthalmologist led reviews, although the differences were extremely small. There was consensus that optometrist-led monitoring has the potential to reduce clinical workload and be more patient-centred. However, potential barriers are: ophthalmologists’ perceptions of optometrists’ competence; the need for clinical training; the ability of the professions to work collaboratively; the financial feasibility of shared care for Clinical Commissioning Groups.
Conclusions
The ability of optometrists to make nAMD retreatment decisions from vignettes is non-inferior to that of ophthalmologists. Various barriers to implementing shared cared for nAMD were identified.
Study registration
ISRCTN07479761
Funding
The National Institute for Health Research Health Technology Assessment programme.
Original languageEnglish
Pages (from-to)1-120
Number of pages120
JournalHealth Technology Assessment
Volume20
Issue number80
DOIs
Publication statusPublished - 4 Nov 2016

Structured keywords

  • BTC (Bristol Trials Centre)
  • Centre for Surgical Research

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