Tag: British Medical Journal

Clinical trial provides new approach for people with eye disease to increase NHS capacity

A UK-wide study, led by Queen’s University Belfast, has shown how a new surveillance pathway for people with stable diabetic eye disease is safe and cost-saving, freeing up ophthalmologists to evaluate and treat people requiring urgent care. 

The new health care surveillance pathway may help ophthalmic units across the world to improve their capacity whilst saving patient’s sight. It is already having a positive impact on the re-design of NHS services across the UK, having been implemented successfully in several hospitals. 

The research, funded by the National Institute for Health Research (NIHR), has been published in leading journals including Ophthalmology, BMJ and NIHR’s Health Technology Assessment. 

The EMERALD (the Effectiveness of Multimodal imaging for the Evaluation of Retinal oedemA and new VesseLs in Diabetic retinopathy) diagnostic accuracy study tested a new “ophthalmic grader” pathway. Rather than ophthalmologists, this pathway involves trained graders monitoring people with previously treated and stable complications of diabetic eye disease, namely diabetic macular oedema (DMO) and proliferative diabetic retinopathy (PDR), based on the reading of images and scans of the back of their eyes.  

The grader’s pathway can save £1390 per 100 patients, and the real savings are the ophthalmologist’s time, which can then be redirected to the evaluation of people at high risk of visual loss. 

Professor Noemi Lois, lead researcher and Clinical Professor of Ophthalmology from the Wellcome-Wolfson Institute for Experimental Medicine at Queen’s University Belfast, explains: “Diabetic macular oedema and proliferative diabetic retinopathy, the main sight-threatening complications of diabetic retinopathy can cause blindness if left untreated. It is therefore important to diagnose them and to treat them timely.

“NHS hospitals eye units are under significant pressure given the extremely high number of people that need to be examined and treated and given the insufficient number of ophthalmologists in the UK. Currently, ophthalmologists need to evaluate all patients, even those that are stable after treatment and who are doing well.” 

In EMERALD, trained ophthalmic graders were found to achieve satisfactory results when compared to standard care (i.e., ophthalmologists evaluating patients in clinic) while releasing ophthalmologist’s time. 

Professor Lois added: “EMERALD showed trained ophthalmic graders are able to determine whether patients with diabetic macular oedema or proliferative diabetic retinopathy previously successfully treated remain stable or if on them the disease has reactivated.  

“Thus, they would be able to follow people that have been already treated, releasing ophthalmologists’ time. Ophthalmologists could then use this time to treat timely other patients, for example, those who have indeed diabetic macular oedema or active proliferative diabetic retinopathy and who have not yet received treatment saving their sight.” 

Dr Clare Bailey, consultant ophthalmologist at the Bristol Eye Hospital, said: “The important data from the EMERALD study has helped us to significantly increase the numbers of people with diabetic retinopathy being seen in ‘imaging/grading’ pathways.

“This has hugely increased our follow-up capacity, whilst allowing ophthalmologists’ time to be directed to the people with diabetic retinopathy who need treatment or further assessment. 

“This has helped us to deal with the capacity pressures as a result of Covid -19 as well as the longer-term capacity demands due to the increasing prevalence of diabetic retinopathy.” 

Dr Caroline Styles, Consultant Ophthalmologist with NHS Fife, added: “Emerald provided us in NHS Fife with the relevant evidence that allowed us to redesign our pathways for people with diabetic eye disease.

“The involvement of people with diabetes in this study reassures our population that these are safe and appropriate changes, and not just based on cost.” 

The EMERALD study was set in 13 National Health Service (NHS) hospitals across the UK and is a large multicentric, UK-wide, National Institute for Health Research (NIHR)-funded diagnostic accuracy study. 

Health leaders call for urgent review: “Second wave a real risk”

This open letter, signed by the Presidents of the Royal Colleges of Surgeons, Nursing, Physicians, and GPs, appears in today’s British Medical Journal.

It comes the day after Boris Johnson announced a major relaxation to lockdown measures in England.

Dear leaders of UK political parties,

Several countries are now experiencing covid-19 flare-ups. While the future shape of the pandemic in the UK is hard to predict, the available evidence indicates that local flare-ups are increasingly likely and a second wave a real risk.

Many elements of the infrastructure needed to contain the virus are beginning to be put in place, but substantial challenges remain. The job now is not only to deal urgently with the wide ranging impacts of the first phase of the pandemic, but to ensure that the country is adequately prepared to contain a second phase.

You may have seen the recent editorial in The BMJ calling for a transparent rapid review of where we are and what needs to be done to prevent and prepare for a second wave.1 We believe that such a review is crucial and needs to happen soon if the public is to have confidence that the virus can be contained.

The review should not be about looking back or attributing blame. Rather it should be a rapid and forward looking assessment of national preparedness, based on an examination of the complex and inter-related policy areas listed below. These are too broad for any one of the existing select committees.

That is why a cross party commission was suggested, establishing a constructive, non-partisan, four nations approach that could rapidly produce practical recommendations for action, based on what we have all learnt, and without itself becoming a distraction for those at the front line or in government.

These recommendations should not require primary legislation or major organisational change. The approach would also help the public understand how and by whom they will be implemented. We believe this will be essential if the UK is to get ahead of the curve.

We are aware of YouGov polls showing that a majority of the public now support an “inquiry.” We also know that the prime minister and secretary of state for health and social care have received a petition from the Covid-19 Bereaved Families for Justice group, requesting a full public inquiry.

The group has also called for an urgent interim inquiry, which shares the same fundamental approach and objective as our suggested rapid review: that it should be forward looking, practical, responsive to what the public at large want to see happen, and focused on evaluating national preparedness in the lead up to winter, with the aim of saving lives.

We are not wedded to any particular design of inquiry or review, but as outlined in the editorial, we believe it should be quick, broad, ambitious, able to command widespread public and stakeholder trust, and needs to happen now.

It should focus on those areas of weakness where action is needed urgently to prevent further loss of life and restore the economy as fully and as quickly as possible. We believe the list below includes those areas.

As stakeholders and leaders of the UK’s medical, nursing, and public health professions, we urge you to establish such a review.

We think there’s a strong case for an immediate assessment of national preparedness, with the first results available no later than August, and that all its work should be completed by the end of October.

We don’t underestimate the complexities of establishing this in the required timeframe. We stand by ready to help in whatever way we can.

Policy areas needing rapid attention:

  • Governance including parliamentary scrutiny and involvement of regional and local structures and leaders

  • Procurement of goods and services

  • Coordination of existing structures, in a way designed to optimise the establishment of effective public health and communicable disease control infrastructure, the resilience of the NHS as a whole, and the shielding of vulnerable individuals and communities

  • The disproportionate burden on black, Asian, and minority ethnic individuals and communities

  • International collaboration, especially to mitigate any new difficulties in pandemic management due to Brexit.