Author: Robin Hamilton (United Kingdom)
Co-authors: Konstantinos Balaskas, Sesan Oyetunde, Kuldip Grewal, Fiona Glen, Luke Saunders, Louise Downey
Purpose
Age-related macular degeneration (AMD) is the leading cause of blindness in the United Kingdom (UK) and is associated with a significant cost to the healthcare system. In the UK, standard care for the treatment of neovascular AMD (nAMD) is intravitreal injection of anti–vascular endothelial growth factor inhibitors (anti-VEGF). Treatment success, in terms of the ability to achieve disease control and preserve visual function, relies on early diagnosis of nAMD followed by prompt initiation and continued timely maintenance of therapy. Due to the chronic nature of nAMD, ongoing follow-up and review of treatment requires patients to regularly attend retinal clinics for many years. As such, clinical service-related considerations including capacity, staffing, service structure and operational delivery are key to minimising delays and optimising patient outcomes. There are, however, limited studies describing real-world practices for the management of patients within the UK. The overall aim of the RATE Study in nAMD was to describe the current landscape of nAMD treatments and clinical outcomes during the first 24 months after initiating anti-VEGF treatment. As part of this study, we aimed to understand the structure of current clinical services utilised for the management of nAMD patients treated with anti-VEGF therapy in the UK.
Setting/Venue
The RATE study involved the collection of pseudonymised patient and service-level data about current treatment practices and outcomes for patients newly initiated on licensed anti-VEGF therapy at eighteen hospitals within the UK National Health Service. Participating centres were from a diverse setting of teaching and district general hospitals known to routinely treat patients with nAMD with licensed anti-VEGF treatments and were spread geographically across England and Wales. As part of this study, a bespoke cross-sectional survey was completed by nominated healthcare professionals at each centre: initial survey results are reported here.
Methods
A clinical staff member from each participating study centre was nominated by their principal investigator to complete a survey about the structure of current services used for the management of nAMD patients treated with anti-VEGF therapy at their centre. This person was required to (i) be a healthcare professional who was routinely involved in the treatment and management of patients with nAMD receiving anti-VEGF treatment; (ii) be able to provide accurate information about clinical practice over the past two years at that centre and (iii) give their consent to take part. The completing clinician was asked questions for two timepoints; the end of December 2017 and current service at the time of survey completion. All surveys were completed between November 2020 and February 2021. The self-reported data received for each question were pooled across all study centres and summarised using descriptive statistics (the denominators for the analyses, based on the total number of evaluable responses received for each question, are also provided in the results).
Results
At the time of survey completion, a median (interquartile range [IQR]) of 1810 (900–2625) patients with nAMD per centre were estimated to be receiving anti-VEGF treatment (based on estimates provided by 16 centres). 71% (n=12/17) of centres used ‘one stop’ clinics for the management of patients while 29% (n=5/17) used a combination of ‘one stop’ and ‘two stop’ clinics. 65% (n=11/17) of centres currently used virtual clinics for the management of patients with nAMD who are receiving anti-VEGF treatment (at the end of 2017, 35% [n=6/17] of centres used virtual clinics). Anti-VEGF injections could currently be administered by non-physicians at all centres (n=17), with a median (IQR) of 1050 (465–1850) patients per centre estimated to receive injections from non-physicians. All respondents (n=17) reported that their centre provided specific guidance about the type of treatment regimen used to administer anti-VEGF (i.e. that their centre had a preference that is communicated to physicians). Specific guidance about fixed treatment regimens was given at 41% (n=7/17) of centres, while 59% (n=10/17) of centres provided guidance on pro re nata (PRN) treatment regimens and 76% (n=13/17) on treat-and-extend (T&E) regimens.
Conlusions
Early results from the RATE study provide insight into the current structure of nAMD services in the UK, including the adoption of different approaches for improving care delivery which may reflect strategies to alleviate burden in light of high patient caseloads and/or adaptations made in light of the COVID-19 pandemic. At the time of survey completion (which occurred during the pandemic), three quarters of the centres surveyed used one stop clinics for the management of patients and all centres allowed non-physicians to administer injections. Virtual clinics were used for the management of patients with nAMD at approximately two-thirds of centres, with usage appearing to have increased from 2017 when approximately one-third of centres used virtual clinics. Guidance on alternative treatment regimens that allow for longer intervals between injections were available at over half of centres (76% of centres provided guidance on T&E and 59% on PRN regimens, respectively). These data may serve as a benchmark for evaluating future retinal services and for planning for changes to the management of nAMD in the post COVID-19 era.
Financial Disclosure
Robin Hamilton: Consultant for Allergan, Bayer Healthcare, Novartis Pharmaceuticals, and Roche; Receives grants from Bayer Healthcare, Novartis Pharmaceuticals and Roche; Receives lecture fees from Allergan, Roche, Bayer Healthcare, and Novartis Pharmaceuticals. Sesan Oyetunde: Employee of Novartis Pharmaceuticals UK. Kuldip Grewal: Employee of Novartis Pharmaceuticals UK. Fiona Glen: Employee of Open Health, who have received funding from Novartis Pharmaceuticals UK. Luke Saunders: Employee of Open Health, who have received funding from Novartis Pharmaceuticals UK. Konstantinos Balaskas: Consultant for Novartis and Roche; Research grants from Bayer Healthcare, Novartis Pharmaceuticals, Roche, Apellis; Speaker fees from Roche, Bayer, Novartis, Alimera, Heidelberg engineering. Louise Downey: Consultant for Alimera, Allergan, Bayer Healthcare, Novartis Pharmaceuticals, and Roche; Receives grants from Allergan, Bayer Healthcare and Novartis Pharmaceuticals; Receives lecture fees from Alimera, Allergan, Bausch and Lomb, Bayer Healthcare, Novartis Pharmaceuticals and Roche.
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