In both the first- and second-year reports of the UK AMD Audit, performance in Leeds Teaching Hospitals NHS Trust against the aggregate benchmark was good for data quality around recording of visual acuity and the proportion of eyes with visual acuity ≥ 70 ETDSRS letters at the start of treatment. When compared to aggregate results and the available quality markers, performance was less good for the proportion of eyes treated within 14 days of referral from primary care, although there were data quality concerns for this measure, completing the initial 3 monthly injections within 10 weeks and with good visual acuity after 12 months. In order to try to improve local treatment outcomes, a decision was taken to focus on the loading phase of treatment as the service’s “Just one thing” to change and, where possible, to improve recording of the date of referral from primary care for eyes starting treatment for neovascular AMD. 

Traditionally all patients in the Leeds injection service have been assessed and treated within the same clinic, either by medical staff or trained, non-medical practitioners. This information was recorded - visual acuity, OCT imaging and a face-to-face discussion for all patients with additional slit lamp examination or ultra-widefield retinal imaging for a selection. We realised that this model of care delivery was appropriate for patients on either a treat and extend or a PRN regime but not for those patients receiving fixed, monthly treatment during the loading phase. To create a new pathway for these patients and to provide additional capacity, two band 6 nurses were recruited and trained to give intra-vitreal injections of licensed products in a new INJLOAD clinic. Patients attending for initial assessment, diagnosis and treatment were booked into this clinic after their first injection. Visual acuity was recorded into the electronic medical records and patients asked if they had experienced any new problems since their last visit but neither OCT imaging not any clinical examination were done. Paper copies of the consent form and a signed, annual prescription chart were available at the time of INJLOAD clinic attendance. The maximum number of patients booked into these clinic was 10 per session. 

In the latter half of 2023, a 4th year medical student reviewed the impact of the new INJLOAD clinics on the Leeds eye clinic’s performance against the 2 chosen elements of the care pathway. Looking at the available data for a sample of 100 eyes referred into an urgent assessment clinic from primary care, it was found that the proportion of eyes starting treatment within 14 days of referral from primary care rose to 52%, exceeding the aggregate benchmark in both reports and the acceptable quality marker in the year 2 report. Similarly the proportion of eyes completing the initial 3 injections within 10 weeks rose to 87%, exceeding not only the aggregate benchmarks  in both reports but also both the acceptable and desirable quality markers in the year 2 report. Although these results are only for a proportion of all the eyes starting treatment in Leeds in 2023, it is hoped that they will be replicated in the third annual report of the AMD audit which will focus on all the eyes starting treatment in 2022/23.

In the year 2 report of the UK AMD Audit, statistical modelling of “good” (≥70 ETDRS letters) and “poor” (≤35 ETDRS letters) visual acuity outcomes after 12 months of treatment found that “good” visual acuity outcomes are almost 40% more likely when the initial 3 injections are given within 10 weeks. As the initial treatment in Leeds has become more efficient as a result of the new INJLOAD clinics, it is anticipated that this change in the care pathway will also improve visual acuity outcomes. 

22 JULY 2024