Abstract
BackgroundAdvances in the management of retinal diseases have been fast-paced as new treatments become available, resulting in increasing numbers of patients receiving treatment in hospital retinal services. These patients require frequent and long-term follow-up and repeated treatments, resulting in increased pressure on clinical workloads. Due to limited clinic capacity, many National Health Service (NHS) clinics are failing to maintain recommended follow-up intervals for patients receiving care. As such, clear and robust, long term retinal service models are required to assess and respond to the needs of local populations, both currently and in the future.MethodsA discrete event simulation (DES) tool was developed to facilitate the improvement of retinal services by identifying efficiencies and cost savings within the pathway of care. For a mid-size hospital in England serving a population of over 500,000, we used 36 months of patient level data in conjunction with statistical forecasting and simulation to predict the impact of making changes within the service.ResultsA simulation of increased demand and a potential solution of the ‘Treat and Extend’ (T&E) regimen which is reported to result in better outcomes, in combination with virtual clinics which improve quality, effectiveness and productivity and thus increase capacity is presented. Without the virtual clinic, where T&E is implemented along with the current service, we notice a sharp increase in the number of follow-ups, number of Anti-VEGF injections, and utilisation of resources. In the case of combining T&E with virtual clinics, there is a negligible (almost 0%) impact on utilisation of resources.ConclusionsExpansion of services to accommodate increasing number of patients seen and treated in retinal services is feasible with service re-organisation. It is inevitable that some form of initial investment is required to implement service expansion through T&E and virtual clinics. However, modelling with DES indicates that such investment is outweighed by cost reductions in the long term as more patients receive optimal treatment and retain vision with better outcomes. The model also shows that the service will experience an average of 10% increase in surplus capacity.
Highlights
Advances in the management of retinal diseases have been fast-paced as new treatments become available, resulting in increasing numbers of patients receiving treatment in hospital retinal services
The aims of this study are : 1) to develop a discrete event simulation (DES) model, which captures the retinal service treatment pathways and service re-designs including virtual clinics; 2) Second, to determine possible and realistic policies, which could be implemented with regard to an increased use of virtual clinics combined with a new treatment regimen, and how these would affect hospital based treatment; 3) to evaluate the impact of the implementation of this service re-design on a number of operational and cost performance indicators relevant to the delivery of retinal services
The problem/hypothesis In order to address the issue of increasing patient numbers and to demonstrate how the model could be used to identify service efficiencies, we explored the impact on the service by adopting the Treat and Extend’ (T&E) regimen in combination with virtual clinics compared to the current regime of prn delivery as described in the SUSTAIN Study [4, 7,8,9,10, 18]
Summary
Advances in the management of retinal diseases have been fast-paced as new treatments become available, resulting in increasing numbers of patients receiving treatment in hospital retinal services These patients require frequent and long-term follow-up and repeated treatments, resulting in increased pressure on clinical workloads. Hospital Eye Services in the United Kingdom (UK) National Health Service (NHS) have consistently had a low profile, despite providing a high volume of work They account for nearly one in ten hospital outpatient appointments, as the second highest demand specialty with 5.95 million clinic attendances in 2009/10 in England and 7–8% of all surgical operations performed by the NHS. The three specific causes of such visual loss are age related macular degeneration (AMD), diabetic retinopathy (DR), and retinal vascular occlusions (RVO) These conditions are of particular interest as their prevalence is rising in an increasingly ageing population, as AMD and RVO are associated with increasing age, and diabetes mellitus, occurs more frequently.
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