A teleconsultation network improves the efficacy of anti-VEGF therapy in retinal diseases

Introduction

Age-related macular degeneration (AMD) is the main cause of legal blindness in people over 50 years old in the industrialised world. ¹ The exudative form of the disease is characterized by the growth of abnormal neovessels beneath the macula, at the centre of the retina. Prompt intravitreal injection of antibody fragments of vascular endothelial growth factor (anti-VEGF) reduces new vessel growth, ² and has become the main therapy for this disease (Figure 1). Anti-VEGF therapy is also used in the treatment of Retinopathy of Prematurity. ³ OPEN IN VIEWER

Teleophthalmology has been used for patients in rural areas ⁴ and circumstances such as war ⁵ to speed up care delivery. Many programmes have been developed for eye care, disease screening, monitoring, diagnosis and management. ⁶ To our knowledge, there are no specific programmes using anti-VEGF therapy for AMD.

Methods

The study design was a longitudinal comparison of patient care in sites using the new telemedicine network. As a control group, we used consecutive patients undergoing usual care ^{12 – 14} (i.e. conventional in-person care procedures for diagnosis and treatment for AMD patients) during the three months before the use of the network began. Patient consent was obtained, and the study was approved by the appropriate ethics committee.

Eleven groups of ophthalmologists took part in the study. The groups were located in 10 cities across Italy (Figure 3). Each group was based on a Retina Centre located at a university or hospital, with one or two expert ophthalmologists (20 expert ophthalmologists in total). In each region containing a Retina Centre, 6-10 general ophthalmologists (94 ophthalmologists in total) referred patients via the network for a period of three months between June 2011 and December 2012. OPEN IN VIEWER

A four-hour meeting was held in each city. Two authors explained how the system worked, and the procedures for its use (network login, database search, insertion of new data and answers, reading of message notification, correct entering of the grading system once the disease was suspected).

A tablet computer (iPad) was given to each participant. Web consultation tests were carried out on site. After the initial meeting, the general ophthalmologists used the teleconsultation network for a trial period of 7-10 days to exchange clinical data with retina specialists from Retina Centres. After the trial period, the ophthalmologists began to exchange real data over the following three-month period.

At the end of the three-month period, the ophthalmologists at each site discussed the following results at a final audit meeting: degree of access to the network, acceptability of technology and medical efficacy in terms of whether better therapy had been delivered as a result of the use of the network. The supervision and coordination of all activities, together with the final report, were carried out by the Supervisory Centre in Milan (Figure 3). Each ophthalmologist completed a short questionnaire (Appendix 1) about the use of the app.

To compare network care to usual care, we evaluated the following variables: time between the first visit and the onset of treatment, and visual acuity at the first visit and after treatment. Statistical analysis was carried out using a spreadsheet (Excel 2007, Microsoft Corp., Redmond, WA).

Results

There were 360 network patients and 318 control patients, see Table 1. The referring general ophthalmologists submitted 360 EMRs via the network. The automatic grading system evaluated a high risk of disease progression in 310 of the cases (86%). Of these, the consultant at the Retina Centre made care recommendations (and anti-VEGF treatment with ranibizumab) in 276 patients (77%). The other 34 patients were sent back to the general ophthalmologist for clinical follow up, there being insufficient indication for treatment.

OPEN IN VIEWER

Table 1.

Demographic and clinical data at the time of the first visit in patients suspected of suffering from exudative AMD.

Telemedicine network	Usual care
Total patients with  suspected AMD	360	318
Patients with suspected  AMD and score <8	50	–
Patients with suspected  AMD and score ≥8	310	–
Mean age, years (range)	69 (52–85)	67 (54–88)
Male	174	144
Female	186	174
Mean LogMAR visual  acuity (range)	0.29 (0.23–0.34)	0.29 (0.24–0.35)
Symptom
visual blurring, %	65	68
central scotoma, %	73	71
AMD in the other eye, %	30	33

OPEN IN VIEWER

Table 2.

Responses (%) by the ophthalmologists (n = 114) during final audit meetings.

Poor	Good	Very good
Access to the teleconsultation  by computer or tablet	8	17	75
Acceptability of the network  procedures	8	10	82
Opinion about medical efficacy	2	6	92

Out of the 310 cases sent to a Retina Centre, 189 cases (61%) were updated with additional clinical data acquired at the Retina Centre for the benefit of the general ophthalmologists. The consulting ophthalmologists also inserted 115 images relating to 89 patients to keep the general ophthalmologists informed.

The time delay before therapy was significantly shorter in the network patients (mean 5.5 days) compared with the usual care patients (mean 28.7 days; P < 0.0001), see Table 3. There was a significant improvement in visual acuity in the network patients after treatment (first visit = 0.29 logMAR; after treatment = 0.22 logMAR; P < 0.05). In contrast, there was a non-significant improvement in the usual care patients (first visit = 0.29 logMAR; after treatment = 0.27 logMAR; P > 0.05), see Table 4.

OPEN IN VIEWER

Table 3.

Interval (days) from the patient's first visit to the general ophthalmologist to therapy delivered at the Retina Centre.

Region	Usual care	Telemedicine network
Torino	33	7
Cuneo	29	5
Alessandria	26	4
Desenzano	30	5
Roma SE	35	6
Roma SG	33	8
Tivoli	23	4
Ostia	29	6
Brindisi	30	7
Milazzo	23	4
Cagliari	26	5
Mean (SD)	28.7 (4.0)	5.5 (1.4)

OPEN IN VIEWER

Table 4.

Mean visual acuity in the study patients. Values shown are mean LogMAR visual acuity (range). Lower scores represent better acuity.

First visit	Post-treatment	P-value
Usual care	0.29 (0.24–0.35)	0.27 (0.23–0.32)	>0.05
Telemedicine  network	0.29 (0.23–0.34)	0.22 (0.18–0.25)	<0.05

Access to the teleconsultation network, acceptability of network procedures and medical efficacy were judged good or very good by all the general ophthalmologists (Table 2).

Discussion

Patients suffering a decrease in visual acuity usually make an appointment with their local general ophthalmologist. If the ophthalmologist suspects AMD, the patient has to make further appointments at a specialized public or private Retina Centre for additional testing and for anti-VEGF therapy when indicated. The majority of these patients are elderly people, who require organization and self-commitment, so the start of treatment is often delayed.

Our telemedicine network allows general referring ophthalmologists, who first identify AMD patients, to complete an EMR. The grading system then automatically indicates the risk of exudative AMD. If the score is high, the referring ophthalmologist can directly book an appointment for the patient at the appropriate Retina Centre. EMRs are visible to the Centre’s consulting ophthalmologist via the web, and SMS messages sent to both physicians and patients facilitate the booking process.

An important advantage of the network is the significant time reduction before treatment begins (Table 3). Any delay between initial diagnosis and treatment causes a significant decrease in final visual acuity recovery after treatment. Treatment procedures should be expedited, and delay should not exceed two weeks for the sake of vision preservation in individual patients. ¹⁵ The network, which reduces the time between visits and allows prompt therapy, has clear benefits for both patients and society as a whole.

Another advantage of the network is the interaction between general ophthalmologists and those working in ophthalmology centres to reduce the number of trips made (and money spent) by patients and their companions. This is particularly burdensome in anti-VEGF treatment, where therapy may need to be carried out for many years. We estimated that each of our 310 patients, sent directly to the relevant Retina Centre, avoided 1-2 visits, as well as the accompanying trips by their companions, during the three-month study.

The automatic grading system helped general ophthalmologists decide to send patients to the Retina Centre. The grading system has limitations, but takes into consideration the fact that general ophthalmologists do not have the facilities for carrying out detailed instrumental analyses.

Another important function allows a general ophthalmologist, who is the first doctor seen by the patient, to make a direct appointment with the Retina Centre. A calendar function allows the general ophthalmologists to make the appointment and also allows consulting ophthalmologists to indicate their availability (Figure 2c,d). Wasted appointments can be avoided, and SMS and email notifications are sent to both ophthalmologists and patients, indicating the time and place of the visit.

We believe that the success of the teleconsultation work was due to the involvement of interested groups of ophthalmologists, and to useful software functions, such as the grading system and the online appointments calendar. The use of portable devices, the high number of CME credits (20 credits) and the remote help-desk service for assistance, advice and news were also important.

The present study had certain limitations. The cohort of patients studied was not randomized, and simply represents a before and after trial. Ophthalmologists possess differing levels of skill regarding information technology, the ability to use the network and interact with the help-desk when necessary, which might introduce bias. The aim of the preliminary training phase was to limit this possible bias as much as possible.

In conclusion, delay plays a key role in the final outcome of exudative AMD, where abnormal new vessels grow rapidly at the centre of the retina. Treatment delay results in a permanent loss of final visual acuity. The telemedicine network allows regional ophthalmologists to quantify the risk of disease progression, and to send patients to the Retina Centre quickly and easily, when required. The treatment process using anti-VEGF therapy was accelerated, and final outcome improved. This is an example of how clinical telemedicine can benefit both patients and the healthcare system, and we believe that the same model might be applicable in many other medical specialties.