First Author: B.C.Gonglore UK
Co Author(s): W. Fusi-Rubiano K.M. Darrad A. Bhatnagar 0 0 0 0 0 0 0 0 0
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Currently a two-stop service delivery model for intravitreal treatments is widely practiced in the UK with separate dedicated “assessment” and “injection” clinics. This often results in extension of treatment intervals. A one-stop model would not only reduce number of hospital visits for the patients but also ensure adherence to the four weekly follow-up regime described in clinical trials. However, the unpredictability regarding number of patients needing injections following each assessment creates difficulty estimating the activity levels for such clinics. We present an innovative model for delivering intravitreal treatment for DMO in a one-stop setting.
We describe the service model adopted in an NHS secondary-care ophthalmology department serving over 26,000 registered diabetic patients. Patients with sight threatening retinopathy are referred to the hospital and are seen by an ophthalmologist with special interest in diabetic retinopathy supported by a team of junior doctors, optometrists and nurses
All patients with DMO suitable for intravitreal treatment are booked into one-stop clinics. Best corrected visual acuity (logmar) is measured at every visit. Patients are divided into 5 categories depending on additional estimated/planned activity. Category A: New patients - Optical Coherence Tomography (OCT), slit lamp biomicroscopy and intravitreal injection. Category B: follow-ups (second and third visit) - intravitreal injection only. Category C: OCT and are likely to need intravitreal treatment. Category D: Stable DMO – OCT but less likely to need intravitreal treatment at this visit. Category E: In addition to any of the above, if a patient will require full biomicroscopy to assess a co-existing proliferative DR (PDR). All patients will have this at least once every 6 months. . Clinics are booked using a points system (A=2, B=0.5, C=1, D=1, E=2 points) with a maximum of 20 points/20 patients per clinic. Dedicated DMO clinics using this pathway were set up in July 2013. After allowing 3 months for this new system to get embedded we audited our activity levels over the following three months (12 consecutive clinics). We also reviewed the interval between hospital visits for all patients who had completed a minimum of 6 months follow-up.
109 patients were enrolled in the DMO clinics between July 2013 and Feb 2014. Review of the activity levels of 12 consecutive 4-hour sessions (Dec’13-Feb’14) shows an average of 19.5 (range 16-25) patients booked for each clinic. On the points based system for booking each clinic, 2 clinics scored 13.5 points, 1 scored 23 points. All others scored between 19-21 points. Each of these clinics was staffed by 2 doctors (1 examining the patients and making treatment decisions and the other performing the intravitreal injection) and 3 nurses. The number of patients needing an intravitreal injection averaged 16.7 (range 14-21). If both eyes needed treatment, they were both injected at the same visit. 20 patients have completed a 6 month follow-up so far. 2 patients missed several appointments so are excluded for calculating intervals between follow-up visits. For the other 18 patients the interval between visits averages 5 weeks (median and mode – 4 weeks).
Our model for providing a one-stop service for intravitreal treatment for DMO allows for optimum numbers of patients to be booked into each clinic. It provides a good balance of new and review patients. Subdividing “review patients” into categories ensures optimal utilisation of capacity for intravitreal injections. It also ensures that patients will have fundus biomicroscopy at regular intervals thereby reducing the risk of missing co-existing proliferative disease in the same or the opposite eye. This model ensures adherence to the follow-up regime for treating DMO with anti-VEGF drugs as described in various landmark clinical trials. It reduces the total number of hospital visits for patients and ensures better compliance with treatment.