Violato M, Dakin H, Chakravarthy U, Reeves B C, Peto T, Hogg R E, Harding S P, Scott L J, Taylor J, Cappel-Porter H, Mills N, O'Reilly D, Rogers C A, Wordsworth S
Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK.
Health Protection Research Unit in Gastrointestinal Infections, National Institute for Health Research, University of Oxford, Oxford, UK.
BMJ Open. 2016 Oct 24;6(10):e011121. doi: 10.1136/bmjopen-2016-011121.
To assess the cost-effectiveness of optometrist-led follow-up monitoring reviews for patients with quiescent neovascular age-related macular degeneration (nAMD) in community settings (including high street opticians) compared with ophthalmologist-led reviews in hospitals.
A model-based cost-effectiveness analysis with a 4-week time horizon, based on a 'virtual' non-inferiority randomised trial designed to emulate a parallel group design.
A virtual internet-based clinical assessment, conducted at community optometry practices, and hospital ophthalmology clinics.
Ophthalmologists with experience in the age-related macular degeneration service; fully qualified optometrists not participating in nAMD shared care schemes.
The participating optometrists and ophthalmologists classified lesions from vignettes and were asked to judge whether any retreatment was required. Vignettes comprised clinical information, colour fundus photographs and optical coherence tomography images. Participants' classifications were validated against experts' classifications (reference standard). Resource use and cost information were attributed to these retreatment decisions.
Correct classification of whether further treatment is needed, compared with a reference standard.
The mean cost per assessment, including the subsequent care pathway, was £411 for optometrists and £397 for ophthalmologists: a cost difference of £13 (95% CI -£18 to £45). Optometrists were non-inferior to ophthalmologists with respect to the overall percentage of lesions correctly assessed (difference -1.0%; 95% CI -4.5% to 2.5%).
In the base case analysis, the slightly larger number of incorrect retreatment decisions by optometrists led to marginally and non-significantly higher costs. Sensitivity analyses that reflected different practices across eye hospitals indicate that shared care pathways between optometrists and ophthalmologists can be identified which may reduce demands on scant hospital resources, although in light of the uncertainty around differences in outcome and cost it remains unclear whether the differences between the 2 care pathways are significant in economic terms.
ISRCTN07479761; Pre-results.
评估在社区环境（包括商业街验光配镜店）中由验光师主导的对静止性新生血管性年龄相关性黄斑变性（nAMD）患者的随访监测评估与在医院由眼科医生主导的评估相比的成本效益。
基于一项为期4周的基于模型的成本效益分析，该分析基于一项“虚拟”非劣效性随机试验，旨在模拟平行组设计。
在社区验光配镜诊所和医院眼科诊所进行基于互联网的虚拟临床评估。
有年龄相关性黄斑变性服务经验的眼科医生；未参与nAMD共享护理计划的完全合格的验光师。
参与的验光师和眼科医生对病例 vignettes 中的病变进行分类，并被要求判断是否需要再次治疗。病例 vignettes 包括临床信息、彩色眼底照片和光学相干断层扫描图像。参与者的分类与专家分类（参考标准）进行验证。资源使用和成本信息归因于这些再次治疗决策。
与参考标准相比，正确分类是否需要进一步治疗。
每次评估的平均成本，包括后续护理路径，验光师为411英镑，眼科医生为397英镑：成本差异为13英镑（95%CI -18英镑至45英镑）。在正确评估的病变总体百分比方面，验光师不劣于眼科医生（差异 -1.0%；95%CI -4.5%至2.5%）。
在基础病例分析中，验光师做出的错误再次治疗决策数量略多，导致成本略有增加但无统计学意义。反映不同眼科医院不同做法的敏感性分析表明，可以确定验光师和眼科医生之间的共享护理路径，这可能会减少对稀缺医院资源的需求，尽管鉴于结果和成本差异的不确定性，尚不清楚这两种护理路径在经济方面的差异是否显著。
ISRCTN07479761；预结果。
