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Ophthalmology services worldwide are facing a growing burden of chronic eye conditions. Age-related macular degeneration (AMD) is the most common cause of visual impairment in older adults in the developed nations, and New Zealand is no exception. Neovascular age-related macular degeneration (nAMD) results in rapid loss of central vision if left untreated. The advent of intravitreal anti-vascular endothelial growth factor (VEGF) therapy, such as bevacizumab (Avastin®) and aflibercept (Eylea®), has revolutionised the treatment of nAMD but comes at a considerable treatment burden and cost for the service provider and patient. Landmark trials, such as the Comparison of Age-related Macular Degeneration Treatments Trials (CATT) and VEGF Trap-Eye: Investigation of Efficacy and Safety in Wet AMD trial (VIEW1 and VIEW2), have demonstrated the safety and efficacy of bevacizumab and aflibercept.[[1,2]] Following a loading regimen of three monthly doses, the medication can continue to be administered pro-re-nata (PRN), or at gradually extending intervals (treat and extend) in order to maintain vision gained from treatment. Hence, successfully treated patients require long-term monitoring and treatment.

Delays in diagnosis and treatment can lead to irreversible scarring of the macula and permanent vision loss. Therefore, in 2019 the Ministry of Health (MOH) and the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) introduced national guidelines for the management of nAMD. The guidelines recommended that suspected nAMD patients be assessed within one week of referral and treated within one week of first assessment.[[3]]

Provincial ophthalmology centres in New Zealand have less staffing and less resource capacity compared with their urban counterparts and need to adopt creative strategies in order to meet the needs of an increasingly older population and a rising prevalence of AMD. Continuous review of key measures of performance is critical for focused planning around service delivery and to adapt to the needs of patients under our care.

Palmerston North Eye Department (PNED) operates under the MidCentral District Health Board (DHB) to deliver comprehensive ophthalmic care to the central North Island of New Zealand, servicing a population of 178,820 people during weekdays and 243,370 people during weekends (including Whanganui DHB).[[4]] Compared to other DHBs, MidCentral DHB caters to a population that is older and more socioeconomically deprived.

Several initiatives have been implemented by PNED in the past five years to improve outcomes for patients with nAMD. Collaborative care with optometrists and nurses was actively fostered and encouraged. The Acute Macula Clinic, introduced in 2019, prioritises nAMD referrals for review and initial treatment within two weeks and thus avoids the usual delays to first specialist appointments. In order to increase accuracy and facilitate timeliness of reviews, only optometrist referrals with supporting optical coherence topography (OCT) scans are accepted into this clinic.

The upskilling of nurse injectors to safely administer intravitreal injections increased clinicians’ capacity for more complex clinical duties and improved skill–task alignment. PNED nurse injectors run high-volume clinics in which patients are booked for injections only, streamlining the flow through clinic without the need for assessment. They also allow for same-day urgent injections. The nurse-led macular review clinic was introduced to facilitate the timely review of stable patients with a view to overseeing maintenance intravitreal therapy in 2016. In 2019, these were modified into ‘hybrid clinics’ to incorporate same-day injections. Under the remote supervision of an ophthalmologist, a trained nurse specialist reviews each patient’s medical chart, OCT macula scans and colour fundus photographs and formulates the patient’s ongoing treatment plan, as per the treat-and-extend protocol, before the patient receives their injection that day. The interval between injections is then adjusted according to their clinical response. The treat-and-extend protocol is associated with fewer patient visits, fewer injections and lower overall medical costs compared with fixed monthly injections or the pro-renata (PRN) protocol.[[5]]

This article describes the outcomes of patients with nAMD in PNED for the past two years. Outcome measures were selected according to the principles of the results-based accountability (RBA) framework.

Methods

A prospective, multi-user database was developed in 2017 to capture the treatment details and visual outcomes of patients with nAMD in Palmerston North. Dates, diagnoses, best corrected visual acuities (BCVA) and treatments were entered by the attending nurse or clinician into the database following each visit. Data for the newly diagnosed nAMD patients from January 2018 to December 2019 were extracted from the database. Patients’ medical charts and electronic records were also retrospectively reviewed to corroborate data. Visual acuity was entered in Snellen format but converted to Logarithm of the Minimum Angle of Resolution (LogMar) for analysis.

The primary outcomes were BCVA at baseline and at the last recorded visit. Secondary outcomes included the number of intravitreal injections administered over the treatment period and the time between the triage date and treatment initiation. Stabilisation of vision was defined as a drop of fewer than 15 letters on the Snellen chart during the treatment period, while improvement of vision was defined as a gain of more than 15 letters.

Statistical analysis was conducted on Microsoft Office Excel version 16.29.1 (19091700) and Apple Numbers (© Apple Inc. version 10.2 (7028.0.88)). Ethical approval was granted by the MidCentral DHB Research Office.

Results

Fifty-three patients were diagnosed and treated for nAMD in 2018, compared to 40 patients in 2019. Despite fewer patients, the total number of injections rose from 227 in 2018 to 301 in 2019. There was an increase in the percentage of patients achieving stabilisation (82.5% vs 93.2%) and improvement of vision (10.5% vs 31.8%) in 2019 compared to 2018. The percentage of patients that retained driving standard, defined as BCVA better than or equal to 6/12, was similar across both groups (58.3% vs 62.5%).

Although the average number of days between date of triage and date of first appointment is similar between both years, the difference between the average number of days between triage date and first injection reduced by approximately eight days in 2019 compared to 2018.

Table 1: Outcome measures of newly referred nAMD patients 2018–2019.

Discussion

The burden of chronic disease is an emerging health issue in developed countries with ageing populations. The proportion of the New Zealand population aged 65 years and over will double by the year 2040, and health expenditure as a percentage of gross domestic product is expected to increase from 6% to 9% within that timeframe.[[6]] Age-related macular degeneration is the leading cause of vision loss in people aged over 50 years old in New Zealand. A national study has projected that the prevalence of AMD will rise to 208,000 in 2026.[[7]] Early diagnosis and regular treatment in the form of intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections reduces vision loss but imposes a significant burden on healthcare resources.

Approximately 100 patients are seen daily in the Palmerston North Eye Department. The clinic faces increasing demands, an ongoing workforce shortage and finite resources. A collaborative, integrated team-care approach is undertaken to provide effective, comprehensive and coordinated care in the most efficient way, making the best use of technology and ‘lean-principle improvement methodology’ to continuously improve current systems and processes.

The outcome of this paper completes the audit cycle that began five years ago.[[8,9]] The number of new patients referred with wet AMD has increased. There was a total of 48 eyes commencing treatment for wet AMD in 2013 and 2014 combined, compared to 93 new patients in 2018 and 2019.[[9]] Despite this, the number of intravitreal injections administered for this cohort has not increased.[[8]] The number of patients achieving stabilisation and improvement of vision in the past two years has improved compared to 2013, during which time the stabilisation rate was 81.3% and improvement rate was 25%.[[9]] The rates in 2019 were similar to the Comparison of Age-related Macular Degeneration Treatments Trials, which showed a 95% rate of stabilisation and 34% rate of improvement with monthly injections.[[1]]

The Royal Australia and New Zealand College of Ophthalmologists best practice guidelines for management of neovascular AMD (nAMD) recommends that referred patients have their first appointment within one week and that they commence treatment within two weeks of referral. [[3]] Although our cohort received their first appointments more than one week after being referred, each patient still received their first treatment within the recommended timeframe because the Acute Macular Clinic combines their first appointment with treatment initiation. This initiative shortened the duration between the date of triage and the date of first injection in 2019 compared to the previous year. Other factors that lead to delays include a lack of awareness of AMD symptoms within the community and delays in the referral pathways. The latter aspect has been addressed by encouraging direct phone call referrals from optometrists for nAMD.

Palmerston North Eye Department, like many healthcare services, is a complex adaptive system. There has been a ‘paradigm shift’ in the methodological approach of improving healthcare service delivery and performance. There has been a transition from the traditional ‘empirical scientific (reductionist) approach’ to a more ‘systems approach’. Instead of breaking up the system into its components and performing an analysis of the individual parts, the systems approach emphasises the interactions between the component parts of the system. Each complex system is comprised of a collection of intersecting, interdependent networks with decentralised control and non-linear cause and effect relationships.[[10]] There exists leverage points or ‘sweet spots’ within such relationships where small changes can have disproportionately significant effects. The development of a robust database facilitates regular monitoring and reporting using advanced data analytics that can identify these leverage points in real time. Such health-information systems are required to support decision-making, as unfortunately even interventions supported by robust clinical trials do not always translate into similar clinical outcomes in the real-world clinical setting. This is due to the fact that the empirical reductionist approach (clinical trials) does not replicate the complex adaptive nature of contemporary healthcare delivery systems.

Results based accountability is a framework that has been adopted by various New Zealand organisations focusing on outcomes to make a positive change in their community.[[11]] Performance-accountability measures are centred around three key questions: How much did we do? How well did we do it? Is anyone better off? This approach acknowledges the complexity of the current system and provides real-time insights onto the added value and effectiveness of proposed quality-improvement strategies.

Variable compliance to data entry and inconsistent coding poses the greatest risk to the data quality. Robust data quality is essential for effective data-driven decision-making. Data integrity, quality of information and health information systems result in sound clinical decision-making and improved quality of healthcare. Poor data quality and health information systems contribute to inefficiencies, waste, variation and harm.[[12]] The two identifiable factors that affect data quality are the busy clinical environment and regular staff turnover. Hence current efforts are directed at making the database more user-friendly and less time-consuming.

In conclusion, the outcome measures generated by the AMD database and associated advanced data analytics allow for data driven, evidence-informed decision-making. This has resulted in service-improvement initiatives and strategies that have led to an improvement in visually significant outcomes for patients being treated for nAMD and the community.

Summary

Abstract

AIM: To describe the outcomes of patients with newly diagnosed neovascular age-related macular degeneration (nAMD) treated in Palmerston North over the past two years. METHOD: A large prospective database was developed to capture the treatment and visual outcomes of patients with newly diagnosed nAMD. Data were subsequently extracted and analysed according to the result-based accountability (RBA) framework. RESULTS: Fifty-three patients in 2018 and 40 patients in 2019 were identified as having newly diagnosed nAMD. On average, there was an improvement in duration between the date of triage and the first intravitreal injection by eight days (22.7 vs 14.3 days), thus meeting national guidelines to assess and treat new referrals within 14 days. The total number of injections for the 2018 cohort was 227 compared to 301 in 2019. The percentage of patients achieving stabilisation of vision (≤15 letters vision loss, 82.5% vs 93.2%) and improvement in vision (≥15 letters gain, 10.5% vs 31.8%) was higher in 2019 compared to 2018. The percentage of patients that retained driving standard (ie, visual acuity of 6/12) was similar across both years (58.3% vs 62.5%). CONCLUSION: Patients receiving treatment for newly diagnosed nAMD in Palmerston North were achieving high rates of stabilisation and improvements in visual acuity, with more than half maintaining the national driving standard. The locally developed prospective database allows for real-time analysis of patient outcomes and the evaluation of the effectiveness of quality-improvement strategies.

Aim

Method

Results

Conclusion

Author Information

Aaron Yap, MBChB: Palmerston North Eye Department, MidCentral District Health Board. Adeline Kho, MBChB, PGDipBSOphth: Waikato Hospital Eye Clinic, Waikato District Health Board. John Ah-Chan, FRANZCO, AFRACMA: Palmerston North Eye Department, MidCentral District Health Board.

Acknowledgements

We thank Greg Bolton, Mike Yang, Paul Greatorex and Rahul Alate (Data Analytics and Business Advisory) and Dr Grieg Russell (Digital Services) for their help with the AMD database and data analytics. We thank the staff of the Palmerston North Eye Department for maintaining the database.

Correspondence

Aaron Yap, Palmerston North Eye Department, 50 Ruahine Street, Roslyn, Palmerston North 4414, 0211215528 (phone), 06-3508644 (fax)

Correspondence Email

Aaron.yap8@gmail.com

Competing Interests

Nil.

1. Group CR. Ranibizumab and bevacizumab for neovascular age-related macular degeneration. New England journal of medicine. 2011;364(20):1897-908.

2. Heier JS, Brown DM, Chong V, Korobelnik J-F, Kaiser PK, Nguyen QD, et al. Intravitreal aflibercept (VEGF trap-eye) in wet age-related macular degeneration. Ophthalmology. 2012;119(12):2537-48.

3. RANZCO. Referral Pathway for AMD Management 2020 [Available from: https://ranzco.edu/wp-content/uploads/2020/01/080120-RANZCO-Referral-pathway-for-AMD-management-revised.pdf.

4. Ministry of Health. Population of MidCentral DHB 2019 [Available from: https://www.health.govt.nz/new-zealand-health-system/my-dhb/midcentral-dhb/population-midcentral-dhb.

5. Gupta OP, Shienbaum G, Patel AH, Fecarotta C, Kaiser RS, Regillo CD. A treat and extend regimen using ranibizumab for neovascular age-related macular degeneration: clinical and economic impact. Ophthalmology. 2010;117(11):2134-40.

6. Frizelle F. Health expenditure and the ageing population. The New Zealand Medical Journal (Online). 2005;118(1208).

7. Worsley D, Worsley A. Prevalence predictions for age-related macular degeneration in New Zealand have implications for provision of healthcare services. The New Zealand Medical Journal (Online). 2015;128(1409):44.

8. Kim J, Ah-Chan J, Russell G. Improving Patient Access to Intravitreal Anti-Vascular Endothelial Growth Factor Treatment through an Integrated Collaborative Team Care Approach. Journal of Clinical & Experimental Ophthalmology. 2018;09.

9. Botha VE, Ah-Chan JJ, Ramachandran N. Improving accessibility to intravitreal anti-vascular endothelial growth factor treatment for ophthalmic patients in a peripheral centre. NZ Med J. 2016;129(1445):56-66.

10. Plsek PE, Wilson T. Complexity, leadership, and management in healthcare organisations. BMJ. 2001;323(7315):746-9.

11. Friedman M. Results-based Accountability: Producing Measurable Improvements for Customers and Communities: OECD; 2009.

12. Coiera E. Guide to health informatics: CRC press; 2015.

For the PDF of this article, contact
communications@nzma.org.nz

View Article PDF

Ophthalmology services worldwide are facing a growing burden of chronic eye conditions. Age-related macular degeneration (AMD) is the most common cause of visual impairment in older adults in the developed nations, and New Zealand is no exception. Neovascular age-related macular degeneration (nAMD) results in rapid loss of central vision if left untreated. The advent of intravitreal anti-vascular endothelial growth factor (VEGF) therapy, such as bevacizumab (Avastin®) and aflibercept (Eylea®), has revolutionised the treatment of nAMD but comes at a considerable treatment burden and cost for the service provider and patient. Landmark trials, such as the Comparison of Age-related Macular Degeneration Treatments Trials (CATT) and VEGF Trap-Eye: Investigation of Efficacy and Safety in Wet AMD trial (VIEW1 and VIEW2), have demonstrated the safety and efficacy of bevacizumab and aflibercept.[[1,2]] Following a loading regimen of three monthly doses, the medication can continue to be administered pro-re-nata (PRN), or at gradually extending intervals (treat and extend) in order to maintain vision gained from treatment. Hence, successfully treated patients require long-term monitoring and treatment.

Delays in diagnosis and treatment can lead to irreversible scarring of the macula and permanent vision loss. Therefore, in 2019 the Ministry of Health (MOH) and the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) introduced national guidelines for the management of nAMD. The guidelines recommended that suspected nAMD patients be assessed within one week of referral and treated within one week of first assessment.[[3]]

Provincial ophthalmology centres in New Zealand have less staffing and less resource capacity compared with their urban counterparts and need to adopt creative strategies in order to meet the needs of an increasingly older population and a rising prevalence of AMD. Continuous review of key measures of performance is critical for focused planning around service delivery and to adapt to the needs of patients under our care.

Palmerston North Eye Department (PNED) operates under the MidCentral District Health Board (DHB) to deliver comprehensive ophthalmic care to the central North Island of New Zealand, servicing a population of 178,820 people during weekdays and 243,370 people during weekends (including Whanganui DHB).[[4]] Compared to other DHBs, MidCentral DHB caters to a population that is older and more socioeconomically deprived.

Several initiatives have been implemented by PNED in the past five years to improve outcomes for patients with nAMD. Collaborative care with optometrists and nurses was actively fostered and encouraged. The Acute Macula Clinic, introduced in 2019, prioritises nAMD referrals for review and initial treatment within two weeks and thus avoids the usual delays to first specialist appointments. In order to increase accuracy and facilitate timeliness of reviews, only optometrist referrals with supporting optical coherence topography (OCT) scans are accepted into this clinic.

The upskilling of nurse injectors to safely administer intravitreal injections increased clinicians’ capacity for more complex clinical duties and improved skill–task alignment. PNED nurse injectors run high-volume clinics in which patients are booked for injections only, streamlining the flow through clinic without the need for assessment. They also allow for same-day urgent injections. The nurse-led macular review clinic was introduced to facilitate the timely review of stable patients with a view to overseeing maintenance intravitreal therapy in 2016. In 2019, these were modified into ‘hybrid clinics’ to incorporate same-day injections. Under the remote supervision of an ophthalmologist, a trained nurse specialist reviews each patient’s medical chart, OCT macula scans and colour fundus photographs and formulates the patient’s ongoing treatment plan, as per the treat-and-extend protocol, before the patient receives their injection that day. The interval between injections is then adjusted according to their clinical response. The treat-and-extend protocol is associated with fewer patient visits, fewer injections and lower overall medical costs compared with fixed monthly injections or the pro-renata (PRN) protocol.[[5]]

This article describes the outcomes of patients with nAMD in PNED for the past two years. Outcome measures were selected according to the principles of the results-based accountability (RBA) framework.

Methods

A prospective, multi-user database was developed in 2017 to capture the treatment details and visual outcomes of patients with nAMD in Palmerston North. Dates, diagnoses, best corrected visual acuities (BCVA) and treatments were entered by the attending nurse or clinician into the database following each visit. Data for the newly diagnosed nAMD patients from January 2018 to December 2019 were extracted from the database. Patients’ medical charts and electronic records were also retrospectively reviewed to corroborate data. Visual acuity was entered in Snellen format but converted to Logarithm of the Minimum Angle of Resolution (LogMar) for analysis.

The primary outcomes were BCVA at baseline and at the last recorded visit. Secondary outcomes included the number of intravitreal injections administered over the treatment period and the time between the triage date and treatment initiation. Stabilisation of vision was defined as a drop of fewer than 15 letters on the Snellen chart during the treatment period, while improvement of vision was defined as a gain of more than 15 letters.

Statistical analysis was conducted on Microsoft Office Excel version 16.29.1 (19091700) and Apple Numbers (© Apple Inc. version 10.2 (7028.0.88)). Ethical approval was granted by the MidCentral DHB Research Office.

Results

Fifty-three patients were diagnosed and treated for nAMD in 2018, compared to 40 patients in 2019. Despite fewer patients, the total number of injections rose from 227 in 2018 to 301 in 2019. There was an increase in the percentage of patients achieving stabilisation (82.5% vs 93.2%) and improvement of vision (10.5% vs 31.8%) in 2019 compared to 2018. The percentage of patients that retained driving standard, defined as BCVA better than or equal to 6/12, was similar across both groups (58.3% vs 62.5%).

Although the average number of days between date of triage and date of first appointment is similar between both years, the difference between the average number of days between triage date and first injection reduced by approximately eight days in 2019 compared to 2018.

Table 1: Outcome measures of newly referred nAMD patients 2018–2019.

Discussion

The burden of chronic disease is an emerging health issue in developed countries with ageing populations. The proportion of the New Zealand population aged 65 years and over will double by the year 2040, and health expenditure as a percentage of gross domestic product is expected to increase from 6% to 9% within that timeframe.[[6]] Age-related macular degeneration is the leading cause of vision loss in people aged over 50 years old in New Zealand. A national study has projected that the prevalence of AMD will rise to 208,000 in 2026.[[7]] Early diagnosis and regular treatment in the form of intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections reduces vision loss but imposes a significant burden on healthcare resources.

Approximately 100 patients are seen daily in the Palmerston North Eye Department. The clinic faces increasing demands, an ongoing workforce shortage and finite resources. A collaborative, integrated team-care approach is undertaken to provide effective, comprehensive and coordinated care in the most efficient way, making the best use of technology and ‘lean-principle improvement methodology’ to continuously improve current systems and processes.

The outcome of this paper completes the audit cycle that began five years ago.[[8,9]] The number of new patients referred with wet AMD has increased. There was a total of 48 eyes commencing treatment for wet AMD in 2013 and 2014 combined, compared to 93 new patients in 2018 and 2019.[[9]] Despite this, the number of intravitreal injections administered for this cohort has not increased.[[8]] The number of patients achieving stabilisation and improvement of vision in the past two years has improved compared to 2013, during which time the stabilisation rate was 81.3% and improvement rate was 25%.[[9]] The rates in 2019 were similar to the Comparison of Age-related Macular Degeneration Treatments Trials, which showed a 95% rate of stabilisation and 34% rate of improvement with monthly injections.[[1]]

The Royal Australia and New Zealand College of Ophthalmologists best practice guidelines for management of neovascular AMD (nAMD) recommends that referred patients have their first appointment within one week and that they commence treatment within two weeks of referral. [[3]] Although our cohort received their first appointments more than one week after being referred, each patient still received their first treatment within the recommended timeframe because the Acute Macular Clinic combines their first appointment with treatment initiation. This initiative shortened the duration between the date of triage and the date of first injection in 2019 compared to the previous year. Other factors that lead to delays include a lack of awareness of AMD symptoms within the community and delays in the referral pathways. The latter aspect has been addressed by encouraging direct phone call referrals from optometrists for nAMD.

Palmerston North Eye Department, like many healthcare services, is a complex adaptive system. There has been a ‘paradigm shift’ in the methodological approach of improving healthcare service delivery and performance. There has been a transition from the traditional ‘empirical scientific (reductionist) approach’ to a more ‘systems approach’. Instead of breaking up the system into its components and performing an analysis of the individual parts, the systems approach emphasises the interactions between the component parts of the system. Each complex system is comprised of a collection of intersecting, interdependent networks with decentralised control and non-linear cause and effect relationships.[[10]] There exists leverage points or ‘sweet spots’ within such relationships where small changes can have disproportionately significant effects. The development of a robust database facilitates regular monitoring and reporting using advanced data analytics that can identify these leverage points in real time. Such health-information systems are required to support decision-making, as unfortunately even interventions supported by robust clinical trials do not always translate into similar clinical outcomes in the real-world clinical setting. This is due to the fact that the empirical reductionist approach (clinical trials) does not replicate the complex adaptive nature of contemporary healthcare delivery systems.

Results based accountability is a framework that has been adopted by various New Zealand organisations focusing on outcomes to make a positive change in their community.[[11]] Performance-accountability measures are centred around three key questions: How much did we do? How well did we do it? Is anyone better off? This approach acknowledges the complexity of the current system and provides real-time insights onto the added value and effectiveness of proposed quality-improvement strategies.

Variable compliance to data entry and inconsistent coding poses the greatest risk to the data quality. Robust data quality is essential for effective data-driven decision-making. Data integrity, quality of information and health information systems result in sound clinical decision-making and improved quality of healthcare. Poor data quality and health information systems contribute to inefficiencies, waste, variation and harm.[[12]] The two identifiable factors that affect data quality are the busy clinical environment and regular staff turnover. Hence current efforts are directed at making the database more user-friendly and less time-consuming.

In conclusion, the outcome measures generated by the AMD database and associated advanced data analytics allow for data driven, evidence-informed decision-making. This has resulted in service-improvement initiatives and strategies that have led to an improvement in visually significant outcomes for patients being treated for nAMD and the community.

Summary

Abstract

AIM: To describe the outcomes of patients with newly diagnosed neovascular age-related macular degeneration (nAMD) treated in Palmerston North over the past two years. METHOD: A large prospective database was developed to capture the treatment and visual outcomes of patients with newly diagnosed nAMD. Data were subsequently extracted and analysed according to the result-based accountability (RBA) framework. RESULTS: Fifty-three patients in 2018 and 40 patients in 2019 were identified as having newly diagnosed nAMD. On average, there was an improvement in duration between the date of triage and the first intravitreal injection by eight days (22.7 vs 14.3 days), thus meeting national guidelines to assess and treat new referrals within 14 days. The total number of injections for the 2018 cohort was 227 compared to 301 in 2019. The percentage of patients achieving stabilisation of vision (≤15 letters vision loss, 82.5% vs 93.2%) and improvement in vision (≥15 letters gain, 10.5% vs 31.8%) was higher in 2019 compared to 2018. The percentage of patients that retained driving standard (ie, visual acuity of 6/12) was similar across both years (58.3% vs 62.5%). CONCLUSION: Patients receiving treatment for newly diagnosed nAMD in Palmerston North were achieving high rates of stabilisation and improvements in visual acuity, with more than half maintaining the national driving standard. The locally developed prospective database allows for real-time analysis of patient outcomes and the evaluation of the effectiveness of quality-improvement strategies.

Aim

Method

Results

Conclusion

Author Information

Aaron Yap, MBChB: Palmerston North Eye Department, MidCentral District Health Board. Adeline Kho, MBChB, PGDipBSOphth: Waikato Hospital Eye Clinic, Waikato District Health Board. John Ah-Chan, FRANZCO, AFRACMA: Palmerston North Eye Department, MidCentral District Health Board.

Acknowledgements

We thank Greg Bolton, Mike Yang, Paul Greatorex and Rahul Alate (Data Analytics and Business Advisory) and Dr Grieg Russell (Digital Services) for their help with the AMD database and data analytics. We thank the staff of the Palmerston North Eye Department for maintaining the database.

Correspondence

Aaron Yap, Palmerston North Eye Department, 50 Ruahine Street, Roslyn, Palmerston North 4414, 0211215528 (phone), 06-3508644 (fax)

Correspondence Email

Aaron.yap8@gmail.com

Competing Interests

Nil.

1. Group CR. Ranibizumab and bevacizumab for neovascular age-related macular degeneration. New England journal of medicine. 2011;364(20):1897-908.

2. Heier JS, Brown DM, Chong V, Korobelnik J-F, Kaiser PK, Nguyen QD, et al. Intravitreal aflibercept (VEGF trap-eye) in wet age-related macular degeneration. Ophthalmology. 2012;119(12):2537-48.

3. RANZCO. Referral Pathway for AMD Management 2020 [Available from: https://ranzco.edu/wp-content/uploads/2020/01/080120-RANZCO-Referral-pathway-for-AMD-management-revised.pdf.

4. Ministry of Health. Population of MidCentral DHB 2019 [Available from: https://www.health.govt.nz/new-zealand-health-system/my-dhb/midcentral-dhb/population-midcentral-dhb.

5. Gupta OP, Shienbaum G, Patel AH, Fecarotta C, Kaiser RS, Regillo CD. A treat and extend regimen using ranibizumab for neovascular age-related macular degeneration: clinical and economic impact. Ophthalmology. 2010;117(11):2134-40.

6. Frizelle F. Health expenditure and the ageing population. The New Zealand Medical Journal (Online). 2005;118(1208).

7. Worsley D, Worsley A. Prevalence predictions for age-related macular degeneration in New Zealand have implications for provision of healthcare services. The New Zealand Medical Journal (Online). 2015;128(1409):44.

8. Kim J, Ah-Chan J, Russell G. Improving Patient Access to Intravitreal Anti-Vascular Endothelial Growth Factor Treatment through an Integrated Collaborative Team Care Approach. Journal of Clinical & Experimental Ophthalmology. 2018;09.

9. Botha VE, Ah-Chan JJ, Ramachandran N. Improving accessibility to intravitreal anti-vascular endothelial growth factor treatment for ophthalmic patients in a peripheral centre. NZ Med J. 2016;129(1445):56-66.

10. Plsek PE, Wilson T. Complexity, leadership, and management in healthcare organisations. BMJ. 2001;323(7315):746-9.

11. Friedman M. Results-based Accountability: Producing Measurable Improvements for Customers and Communities: OECD; 2009.

12. Coiera E. Guide to health informatics: CRC press; 2015.

Contact diana@nzma.org.nz
for the PDF of this article

View Article PDF

Ophthalmology services worldwide are facing a growing burden of chronic eye conditions. Age-related macular degeneration (AMD) is the most common cause of visual impairment in older adults in the developed nations, and New Zealand is no exception. Neovascular age-related macular degeneration (nAMD) results in rapid loss of central vision if left untreated. The advent of intravitreal anti-vascular endothelial growth factor (VEGF) therapy, such as bevacizumab (Avastin®) and aflibercept (Eylea®), has revolutionised the treatment of nAMD but comes at a considerable treatment burden and cost for the service provider and patient. Landmark trials, such as the Comparison of Age-related Macular Degeneration Treatments Trials (CATT) and VEGF Trap-Eye: Investigation of Efficacy and Safety in Wet AMD trial (VIEW1 and VIEW2), have demonstrated the safety and efficacy of bevacizumab and aflibercept.[[1,2]] Following a loading regimen of three monthly doses, the medication can continue to be administered pro-re-nata (PRN), or at gradually extending intervals (treat and extend) in order to maintain vision gained from treatment. Hence, successfully treated patients require long-term monitoring and treatment.

Delays in diagnosis and treatment can lead to irreversible scarring of the macula and permanent vision loss. Therefore, in 2019 the Ministry of Health (MOH) and the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) introduced national guidelines for the management of nAMD. The guidelines recommended that suspected nAMD patients be assessed within one week of referral and treated within one week of first assessment.[[3]]

Provincial ophthalmology centres in New Zealand have less staffing and less resource capacity compared with their urban counterparts and need to adopt creative strategies in order to meet the needs of an increasingly older population and a rising prevalence of AMD. Continuous review of key measures of performance is critical for focused planning around service delivery and to adapt to the needs of patients under our care.

Palmerston North Eye Department (PNED) operates under the MidCentral District Health Board (DHB) to deliver comprehensive ophthalmic care to the central North Island of New Zealand, servicing a population of 178,820 people during weekdays and 243,370 people during weekends (including Whanganui DHB).[[4]] Compared to other DHBs, MidCentral DHB caters to a population that is older and more socioeconomically deprived.

Several initiatives have been implemented by PNED in the past five years to improve outcomes for patients with nAMD. Collaborative care with optometrists and nurses was actively fostered and encouraged. The Acute Macula Clinic, introduced in 2019, prioritises nAMD referrals for review and initial treatment within two weeks and thus avoids the usual delays to first specialist appointments. In order to increase accuracy and facilitate timeliness of reviews, only optometrist referrals with supporting optical coherence topography (OCT) scans are accepted into this clinic.

The upskilling of nurse injectors to safely administer intravitreal injections increased clinicians’ capacity for more complex clinical duties and improved skill–task alignment. PNED nurse injectors run high-volume clinics in which patients are booked for injections only, streamlining the flow through clinic without the need for assessment. They also allow for same-day urgent injections. The nurse-led macular review clinic was introduced to facilitate the timely review of stable patients with a view to overseeing maintenance intravitreal therapy in 2016. In 2019, these were modified into ‘hybrid clinics’ to incorporate same-day injections. Under the remote supervision of an ophthalmologist, a trained nurse specialist reviews each patient’s medical chart, OCT macula scans and colour fundus photographs and formulates the patient’s ongoing treatment plan, as per the treat-and-extend protocol, before the patient receives their injection that day. The interval between injections is then adjusted according to their clinical response. The treat-and-extend protocol is associated with fewer patient visits, fewer injections and lower overall medical costs compared with fixed monthly injections or the pro-renata (PRN) protocol.[[5]]

This article describes the outcomes of patients with nAMD in PNED for the past two years. Outcome measures were selected according to the principles of the results-based accountability (RBA) framework.

Methods

A prospective, multi-user database was developed in 2017 to capture the treatment details and visual outcomes of patients with nAMD in Palmerston North. Dates, diagnoses, best corrected visual acuities (BCVA) and treatments were entered by the attending nurse or clinician into the database following each visit. Data for the newly diagnosed nAMD patients from January 2018 to December 2019 were extracted from the database. Patients’ medical charts and electronic records were also retrospectively reviewed to corroborate data. Visual acuity was entered in Snellen format but converted to Logarithm of the Minimum Angle of Resolution (LogMar) for analysis.

The primary outcomes were BCVA at baseline and at the last recorded visit. Secondary outcomes included the number of intravitreal injections administered over the treatment period and the time between the triage date and treatment initiation. Stabilisation of vision was defined as a drop of fewer than 15 letters on the Snellen chart during the treatment period, while improvement of vision was defined as a gain of more than 15 letters.

Statistical analysis was conducted on Microsoft Office Excel version 16.29.1 (19091700) and Apple Numbers (© Apple Inc. version 10.2 (7028.0.88)). Ethical approval was granted by the MidCentral DHB Research Office.

Results

Fifty-three patients were diagnosed and treated for nAMD in 2018, compared to 40 patients in 2019. Despite fewer patients, the total number of injections rose from 227 in 2018 to 301 in 2019. There was an increase in the percentage of patients achieving stabilisation (82.5% vs 93.2%) and improvement of vision (10.5% vs 31.8%) in 2019 compared to 2018. The percentage of patients that retained driving standard, defined as BCVA better than or equal to 6/12, was similar across both groups (58.3% vs 62.5%).

Although the average number of days between date of triage and date of first appointment is similar between both years, the difference between the average number of days between triage date and first injection reduced by approximately eight days in 2019 compared to 2018.

Table 1: Outcome measures of newly referred nAMD patients 2018–2019.

Discussion

The burden of chronic disease is an emerging health issue in developed countries with ageing populations. The proportion of the New Zealand population aged 65 years and over will double by the year 2040, and health expenditure as a percentage of gross domestic product is expected to increase from 6% to 9% within that timeframe.[[6]] Age-related macular degeneration is the leading cause of vision loss in people aged over 50 years old in New Zealand. A national study has projected that the prevalence of AMD will rise to 208,000 in 2026.[[7]] Early diagnosis and regular treatment in the form of intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections reduces vision loss but imposes a significant burden on healthcare resources.

Approximately 100 patients are seen daily in the Palmerston North Eye Department. The clinic faces increasing demands, an ongoing workforce shortage and finite resources. A collaborative, integrated team-care approach is undertaken to provide effective, comprehensive and coordinated care in the most efficient way, making the best use of technology and ‘lean-principle improvement methodology’ to continuously improve current systems and processes.

The outcome of this paper completes the audit cycle that began five years ago.[[8,9]] The number of new patients referred with wet AMD has increased. There was a total of 48 eyes commencing treatment for wet AMD in 2013 and 2014 combined, compared to 93 new patients in 2018 and 2019.[[9]] Despite this, the number of intravitreal injections administered for this cohort has not increased.[[8]] The number of patients achieving stabilisation and improvement of vision in the past two years has improved compared to 2013, during which time the stabilisation rate was 81.3% and improvement rate was 25%.[[9]] The rates in 2019 were similar to the Comparison of Age-related Macular Degeneration Treatments Trials, which showed a 95% rate of stabilisation and 34% rate of improvement with monthly injections.[[1]]

The Royal Australia and New Zealand College of Ophthalmologists best practice guidelines for management of neovascular AMD (nAMD) recommends that referred patients have their first appointment within one week and that they commence treatment within two weeks of referral. [[3]] Although our cohort received their first appointments more than one week after being referred, each patient still received their first treatment within the recommended timeframe because the Acute Macular Clinic combines their first appointment with treatment initiation. This initiative shortened the duration between the date of triage and the date of first injection in 2019 compared to the previous year. Other factors that lead to delays include a lack of awareness of AMD symptoms within the community and delays in the referral pathways. The latter aspect has been addressed by encouraging direct phone call referrals from optometrists for nAMD.

Palmerston North Eye Department, like many healthcare services, is a complex adaptive system. There has been a ‘paradigm shift’ in the methodological approach of improving healthcare service delivery and performance. There has been a transition from the traditional ‘empirical scientific (reductionist) approach’ to a more ‘systems approach’. Instead of breaking up the system into its components and performing an analysis of the individual parts, the systems approach emphasises the interactions between the component parts of the system. Each complex system is comprised of a collection of intersecting, interdependent networks with decentralised control and non-linear cause and effect relationships.[[10]] There exists leverage points or ‘sweet spots’ within such relationships where small changes can have disproportionately significant effects. The development of a robust database facilitates regular monitoring and reporting using advanced data analytics that can identify these leverage points in real time. Such health-information systems are required to support decision-making, as unfortunately even interventions supported by robust clinical trials do not always translate into similar clinical outcomes in the real-world clinical setting. This is due to the fact that the empirical reductionist approach (clinical trials) does not replicate the complex adaptive nature of contemporary healthcare delivery systems.

Results based accountability is a framework that has been adopted by various New Zealand organisations focusing on outcomes to make a positive change in their community.[[11]] Performance-accountability measures are centred around three key questions: How much did we do? How well did we do it? Is anyone better off? This approach acknowledges the complexity of the current system and provides real-time insights onto the added value and effectiveness of proposed quality-improvement strategies.

Variable compliance to data entry and inconsistent coding poses the greatest risk to the data quality. Robust data quality is essential for effective data-driven decision-making. Data integrity, quality of information and health information systems result in sound clinical decision-making and improved quality of healthcare. Poor data quality and health information systems contribute to inefficiencies, waste, variation and harm.[[12]] The two identifiable factors that affect data quality are the busy clinical environment and regular staff turnover. Hence current efforts are directed at making the database more user-friendly and less time-consuming.

In conclusion, the outcome measures generated by the AMD database and associated advanced data analytics allow for data driven, evidence-informed decision-making. This has resulted in service-improvement initiatives and strategies that have led to an improvement in visually significant outcomes for patients being treated for nAMD and the community.

Summary

Abstract

AIM: To describe the outcomes of patients with newly diagnosed neovascular age-related macular degeneration (nAMD) treated in Palmerston North over the past two years. METHOD: A large prospective database was developed to capture the treatment and visual outcomes of patients with newly diagnosed nAMD. Data were subsequently extracted and analysed according to the result-based accountability (RBA) framework. RESULTS: Fifty-three patients in 2018 and 40 patients in 2019 were identified as having newly diagnosed nAMD. On average, there was an improvement in duration between the date of triage and the first intravitreal injection by eight days (22.7 vs 14.3 days), thus meeting national guidelines to assess and treat new referrals within 14 days. The total number of injections for the 2018 cohort was 227 compared to 301 in 2019. The percentage of patients achieving stabilisation of vision (≤15 letters vision loss, 82.5% vs 93.2%) and improvement in vision (≥15 letters gain, 10.5% vs 31.8%) was higher in 2019 compared to 2018. The percentage of patients that retained driving standard (ie, visual acuity of 6/12) was similar across both years (58.3% vs 62.5%). CONCLUSION: Patients receiving treatment for newly diagnosed nAMD in Palmerston North were achieving high rates of stabilisation and improvements in visual acuity, with more than half maintaining the national driving standard. The locally developed prospective database allows for real-time analysis of patient outcomes and the evaluation of the effectiveness of quality-improvement strategies.

Aim

Method

Results

Conclusion

Author Information

Aaron Yap, MBChB: Palmerston North Eye Department, MidCentral District Health Board. Adeline Kho, MBChB, PGDipBSOphth: Waikato Hospital Eye Clinic, Waikato District Health Board. John Ah-Chan, FRANZCO, AFRACMA: Palmerston North Eye Department, MidCentral District Health Board.

Acknowledgements

We thank Greg Bolton, Mike Yang, Paul Greatorex and Rahul Alate (Data Analytics and Business Advisory) and Dr Grieg Russell (Digital Services) for their help with the AMD database and data analytics. We thank the staff of the Palmerston North Eye Department for maintaining the database.

Correspondence

Aaron Yap, Palmerston North Eye Department, 50 Ruahine Street, Roslyn, Palmerston North 4414, 0211215528 (phone), 06-3508644 (fax)

Correspondence Email

Aaron.yap8@gmail.com

Competing Interests

Nil.

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