The outcomes of patients with newly diagnosed neovascular age-related macular degeneration in Palmerston North
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ARTICLE
The outcomes of patients
with newly diagnosed
neovascular age-related
macular degeneration in
Palmerston North
Aaron Yap, Adeline Kho, John Ah-Chan
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.
O
phthalmology services worldwide the service provider and patient. Landmark
are facing a growing burden of trials, such as the Comparison of Age-relat-
chronic eye conditions. Age-related ed Macular Degeneration Treatments Trials
macular degeneration (AMD) is the most (CATT) and VEGF Trap-Eye: Investigation of
common cause of visual impairment in Efficacy and Safety in Wet AMD trial (VIEW1
older adults in the developed nations, and and VIEW2), have demonstrated the safety
New Zealand is no exception. Neovascular and efficacy of bevacizumab and afliber-
age-related macular degeneration (nAMD) cept.1,2 Following a loading regimen of three
results in rapid loss of central vision if left monthly doses, the medication can continue
untreated. The advent of intravitreal an- to be administered pro-re-nata (PRN), or
ti-vascular endothelial growth factor (VEGF) at gradually extending intervals (treat and
therapy, such as bevacizumab (Avastin®) extend) in order to maintain vision gained
and aflibercept (Eylea®), has revolution- from treatment. Hence, successfully treated
ised the treatment of nAMD but comes at a patients require long-term monitoring and
considerable treatment burden and cost for treatment.
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NZMJ 30 April 2021, Vol 134 No 1534
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www.nzma.org.nz/journalARTICLE
Delays in diagnosis and treatment can flow through clinic without the need for
lead to irreversible scarring of the macula assessment. They also allow for same-day
and permanent vision loss. Therefore, in urgent injections. The nurse-led macular
2019 the Ministry of Health (MOH) and the review clinic was introduced to facilitate
Royal Australian and New Zealand College the timely review of stable patients with
of Ophthalmologists (RANZCO) introduced a view to overseeing maintenance intrav-
national guidelines for the management of itreal therapy in 2016. In 2019, these were
nAMD. The guidelines recommended that modified into ‘hybrid clinics’ to incorporate
suspected nAMD patients be assessed within same-day injections. Under the remote
one week of referral and treated within one supervision of an ophthalmologist, a trained
week of first assessment.3 nurse specialist reviews each patient’s
Provincial ophthalmology centres in New medical chart, OCT macula scans and colour
Zealand have less staffing and less resource fundus photographs and formulates the
capacity compared with their urban patient’s ongoing treatment plan, as per
counterparts and need to adopt creative the treat-and-extend protocol, before the
strategies in order to meet the needs of an patient receives their injection that day. The
increasingly older population and a rising interval between injections is then adjusted
prevalence of AMD. Continuous review of according to their clinical response. The
key measures of performance is critical for treat-and-extend protocol is associated with
focused planning around service delivery fewer patient visits, fewer injections and
and to adapt to the needs of patients under lower overall medical costs compared with
our care. fixed monthly injections or the pro-renata
(PRN) protocol.5
Palmerston North Eye Department (PNED)
operates under the MidCentral District This article describes the outcomes
Health Board (DHB) to deliver compre- of patients with nAMD in PNED for the
hensive ophthalmic care to the central North past two years. Outcome measures were
Island of New Zealand, servicing a popu- selected according to the principles of
lation of 178,820 people during weekdays the results-based accountability (RBA)
and 243,370 people during weekends framework.
(including Whanganui DHB).4 Compared
to other DHBs, MidCentral DHB caters to a Methods
population that is older and more socioeco- A prospective, multi-user database was
nomically deprived. developed in 2017 to capture the treatment
Several initiatives have been implemented details and visual outcomes of patients
by PNED in the past five years to improve with nAMD in Palmerston North. Dates,
outcomes for patients with nAMD. Collab- diagnoses, best corrected visual acuities
orative care with optometrists and nurses (BCVA) and treatments were entered by
was actively fostered and encouraged. The the attending nurse or clinician into the
Acute Macula Clinic, introduced in 2019, database following each visit. Data for
prioritises nAMD referrals for review and the newly diagnosed nAMD patients from
initial treatment within two weeks and thus January 2018 to December 2019 were
avoids the usual delays to first specialist extracted from the database. Patients’
appointments. In order to increase accuracy medical charts and electronic records were
and facilitate timeliness of reviews, only also retrospectively reviewed to corroborate
optometrist referrals with supporting optical data. Visual acuity was entered in Snellen
coherence topography (OCT) scans are format but converted to Logarithm of the
accepted into this clinic. Minimum Angle of Resolution (LogMar) for
The upskilling of nurse injectors to analysis.
safely administer intravitreal injections The primary outcomes were BCVA at
increased clinicians’ capacity for more baseline and at the last recorded visit.
complex clinical duties and improved skill– Secondary outcomes included the number
task alignment. PNED nurse injectors run of intravitreal injections administered over
high-volume clinics in which patients are the treatment period and the time between
booked for injections only, streamlining the the triage date and treatment initiation.
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Stabilisation of vision was defined as a
drop of fewer than 15 letters on the Snellen
Discussion
chart during the treatment period, while The burden of chronic disease is an
improvement of vision was defined as a gain emerging health issue in developed
of more than 15 letters. countries with ageing populations. The
proportion of the New Zealand popu-
Statistical analysis was conducted on
lation aged 65 years and over will double
Microsoft Office Excel version 16.29.1
by the year 2040, and health expen-
(19091700) and Apple Numbers (© Apple
diture as a percentage of gross domestic
Inc. version 10.2 (7028.0.88)). Ethical
product is expected to increase from 6%
approval was granted by the MidCentral
to 9% within that timeframe.6 Age-related
DHB Research Office.
macular degeneration is the leading cause
Results of vision loss in people aged over 50 years
old in New Zealand. A national study has
Fifty-three patients were diagnosed and projected that the prevalence of AMD will
treated for nAMD in 2018, compared to 40 rise to 208,000 in 2026.7 Early diagnosis and
patients in 2019. Despite fewer patients, the regular treatment in the form of intrav-
total number of injections rose from 227 in itreal anti-vascular endothelial growth
2018 to 301 in 2019. There was an increase factor (anti-VEGF) injections reduces vision
in the percentage of patients achieving stabi- loss but imposes a significant burden on
lisation (82.5% vs 93.2%) and improvement healthcare resources.
of vision (10.5% vs 31.8%) in 2019 compared Approximately 100 patients are seen daily
to 2018. The percentage of patients that in the Palmerston North Eye Department.
retained driving standard, defined as BCVA The clinic faces increasing demands, an
better than or equal to 6/12, was similar ongoing workforce shortage and finite
across both groups (58.3% vs 62.5%). resources. A collaborative, integrated
Although the average number of days team-care approach is undertaken to
between date of triage and date of first provide effective, comprehensive and
appointment is similar between both years, coordinated care in the most efficient way,
the difference between the average number making the best use of technology and
of days between triage date and first ‘lean-principle improvement methodology’
injection reduced by approximately eight to continuously improve current systems
days in 2019 compared to 2018. and processes.
Table 1: Outcome measures of newly referred nAMD patients 2018–2019.
Outcome measures 2018 2019
Number of patients receiving treatment 53 patients (57 eyes) 40 patients (44 eyes)
for wet macular degeneration
Number of injections administered 227 injections 301 injections
Number of days between triage and ap- 12.7 days 14.6 days
pointment date
Number of days between triage and date 22.7 days 14.3 days
of first injection
Percentage of patients achieving stabilisa- 82.5% 93.2%
tion of vision
Percentage of patients achieving improve- 10.5% 31.8%
ment of vision
Percentage of patients that maintained 58.3% 62.5%
driving standard (BCVA 6/12)
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The outcome of this paper completes the interdependent networks with decen-
audit cycle that began five years ago.8,9 The tralised control and non-linear cause and
number of new patients referred with wet effect relationships.10 There exists leverage
AMD has increased. There was a total of 48 points or ‘sweet spots’ within such rela-
eyes commencing treatment for wet AMD tionships where small changes can have
in 2013 and 2014 combined, compared to 93 disproportionately significant effects. The
new patients in 2018 and 2019.9 Despite this, development of a robust database facilitates
the number of intravitreal injections admin- regular monitoring and reporting using
istered for this cohort has not increased.8 advanced data analytics that can identify
The number of patients achieving stabili- these leverage points in real time. Such
sation and improvement of vision in the past health-information systems are required to
two years has improved compared to 2013, support decision-making, as unfortunately
during which time the stabilisation rate was even interventions supported by robust
81.3% and improvement rate was 25%.9 The clinical trials do not always translate into
rates in 2019 were similar to the Comparison similar clinical outcomes in the real-world
of Age-related Macular Degeneration Treat- clinical setting. This is due to the fact that
ments Trials, which showed a 95% rate of the empirical reductionist approach (clinical
stabilisation and 34% rate of improvement trials) does not replicate the complex
with monthly injections.1 adaptive nature of contemporary healthcare
The Royal Australia and New Zealand delivery systems.
College of Ophthalmologists best practice Results based accountability is a
guidelines for management of neovascular framework that has been adopted by various
AMD (nAMD) recommends that referred New Zealand organisations focusing on
patients have their first appointment within outcomes to make a positive change in their
one week and that they commence treatment community.11 Performance-accountability
within two weeks of referral. 3 Although measures are centred around three key ques-
our cohort received their first appoint- tions: How much did we do? How well did
ments more than one week after being we do it? Is anyone better off? This approach
referred, each patient still received their acknowledges the complexity of the current
first treatment within the recommended system and provides real-time insights
timeframe because the Acute Macular Clinic onto the added value and effectiveness of
combines their first appointment with proposed quality-improvement strategies.
treatment initiation. This initiative shortened Variable compliance to data entry and
the duration between the date of triage and inconsistent coding poses the greatest risk
the date of first injection in 2019 compared to the data quality. Robust data quality is
to the previous year. Other factors that lead essential for effective data-driven deci-
to delays include a lack of awareness of AMD sion-making. Data integrity, quality of
symptoms within the community and delays information and health information systems
in the referral pathways. The latter aspect result in sound clinical decision-making
has been addressed by encouraging direct and improved quality of healthcare. Poor
phone call referrals from optometrists for data quality and health information systems
nAMD. contribute to inefficiencies, waste, variation
Palmerston North Eye Department, like and harm.12 The two identifiable factors
many healthcare services, is a complex that affect data quality are the busy clinical
adaptive system. There has been a environment and regular staff turnover.
‘paradigm shift’ in the methodological Hence current efforts are directed at making
approach of improving healthcare service the database more user-friendly and less
delivery and performance. There has been time-consuming.
a transition from the traditional ‘empirical In conclusion, the outcome measures
scientific (reductionist) approach’ to a more generated by the AMD database and asso-
‘systems approach’. Instead of breaking ciated advanced data analytics allow
up the system into its components and for data driven, evidence-informed
performing an analysis of the individual decision-making. This has resulted in
parts, the systems approach emphasises service-improvement initiatives and strat-
the interactions between the component egies that have led to an improvement in
parts of the system. Each complex system visually significant outcomes for patients
is comprised of a collection of intersecting, being treated for nAMD and the community.
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NZMJ 30 April 2021, Vol 134 No 1534
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Competing interests:
Nil.
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.
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.
Corresponding author:
Aaron Yap, Palmerston North Eye Department, 50 Ruahine Street, Roslyn,
Palmerston North 4414, 0211215528 (phone), 06-3508644 (fax)
Aaron.yap8@gmail.com
URL:
www.nzma.org.nz/journal-articles/the-outcomes-of-patients-with-newly-diagnosed-neovas-
cular-age-related-macular-degeneration-in-palmerston-north
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