Foot Barny, Foy Robbie, Chakravarthy Usha, Wormald Richard
The Royal College of Ophthalmologists, London.
J Public Health (Oxf). 2004 Mar;26(1):52-5. doi: 10.1093/pubmed/fdh112.
Photodynamic therapy (PDT) is a relatively new treatment for neovascular age-related macular degeneration. Trial evidence suggests that repeated treatments with PDT can decrease the relative risk of a reduction in visual acuity over 2 years. Concerns raised over the clinical and cost effectiveness of the treatment prompted a technology appraisal by the National Institute for Clinical Effectiveness (NICE). Difficulties in assessing the possible benefit or otherwise of PDT have led to delays in the publication of guidance. During this time the introduction of PDT into the UK National Health Service (NHS) has continued. Over three annual tracker surveys, we describe trends in the provision of PDT in the NHS and potential difficulties in the implementation of NICE guidance.
We undertook surveys in each October of 2000, 2001 and 2002 of clinical directors or lead consultants in all NHS eye units. These sought data on which (if any) patients were referred or treated with PDT and the thresholds of support for the use of PDT.
Response rates were 82 per cent, 79 per cent and 82 per cent. The proportion of units routinely providing PDT for patients with more than 50 per cent classic sub-foveal CNV increased from 8.5 per cent in 2000 to 31 per cent in 2002 (p <0.001). Units referring or treating no patients decreased from 35 per cent to 10 per cent between 2000 and 2002 (p <0.001). There was a significant fall in the proportion of units changing policies on provision between 2000-2001 and 2001-2002. The proportion of respondents requiring further evidence before supporting the use of PDT decreased from 33 per cent in 2000 to 20 per cent in 2002.
There is evidence of a continuing growth in access to PDT in the absence of NICE guidance. Although 90 per cent of units offer some pathway to treatment important variations in reported provision remain. Given that PDT services are becoming established, there is a risk that clinical policy is determined by local service development as much as by national guidance.
光动力疗法（PDT）是一种针对新生血管性年龄相关性黄斑变性的相对较新的治疗方法。试验证据表明，重复进行PDT治疗可降低两年内视力下降的相对风险。对该治疗的临床和成本效益的担忧促使英国国家临床优化研究所（NICE）进行了一项技术评估。评估PDT可能带来的益处或其他方面存在困难，导致相关指南的发布延迟。在此期间，PDT在英国国民健康服务体系（NHS）中的应用仍在继续。通过三次年度跟踪调查，我们描述了NHS中PDT的提供趋势以及实施NICE指南可能存在的困难。
我们在2000年、2001年和2002年的每年10月对所有NHS眼科单位的临床主任或首席顾问进行了调查。这些调查收集了哪些（如果有的话）患者被转诊或接受了PDT治疗的数据，以及支持使用PDT的标准。
回复率分别为82%、79%和82%。对于经典型中心凹下脉络膜新生血管（CNV）面积超过50%的患者，常规提供PDT治疗的单位比例从2000年的8.5%增至2002年的31%（p<0.001）。2000年至2002年间，未转诊或治疗任何患者的单位比例从35%降至10%（p<0.001）。2000 - 2001年至2001 - 2002年间，改变PDT提供政策的单位比例显著下降。在支持使用PDT之前需要进一步证据的受访者比例从2000年的33%降至2002年的20%。
有证据表明，在没有NICE指南的情况下，PDT的可及性持续增长。尽管90%的单位提供了某种治疗途径，但报告的提供情况仍存在重要差异。鉴于PDT服务正在确立，临床政策存在由地方服务发展而非国家指南决定的风险。
