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Effectiveness of Community vs. Hospital Eye Service               NIHR Logo




Dates: 2014-2016
Collaborators: University of Bristol and Queen's Belfast University

Neovascular age-related macular degeneration (nAMD) is a common disorder of the ageing eye and may cause severe sight loss and blindness. After treatment with anti-VEGF therapy, patients are currently monitored regularly at the hospital eye service (HES) in case the disease reactivates, at which point further treatment is needed. Monitoring at the HES is burdensome to patients, their carers and the NHS.

The ECHoES trial was conducted jointly between the Universities of Bristol, Queen’s Belfast and Oxford and was funded by the Health Technology Assessment programme of the National Institute for Health Research (ref 11/129/195). The trial investigated whether high-street optometrists, after appropriate training, can make decisions about disease reactivation which are as accurate as those of hospital-based ophthalmologists and whether this innovative shared care delivery model between hospital ophthalmologists and community optometrists is cost-effective.

Forty-eight high-street optometrists with no prior experience of retina clinics and 48 ophthalmologists with prior experience were given the same short training. They were then asked to assess 42 real-life vignettes through a virtual internet-based application (rather than examining actual patients) to establish whether the disease had reactivated or not. Their answers were compared with the judgement of three medical retina experts, who acted as the reference standard.Resource use and cost information were attributed to these reactivation/retreatment decisions.

In the base-case analysis, the differences in mean cost per assessment (£14; £411 for community optometrists and £397 for hospital-based ophthalmologists) and the percentage of correct disease assessments (1%; 84% for optometrists and 85% for ophthalmologists) were not statistically significant. While the base-case analysis nominally favoured hospital-based ophthalmologist services, sensitivity analyses reflecting different practices across eye hospitals, suggested that a shared delivery model involving monitoring by community optometrists could be cost-effective. If delivered efficiently, shared care with community optometrists is a promising strategy to meet the challenges of shortage of ophthalmologists in the HES.


Reeves BC. et al, (2016), BMJ Open, 6

The cost-effectiveness of community versus hospital eye service follow-up for patients with quiescent treated age-related macular degeneration alongside the ECHoES randomised trial

Violato M. et al, (2016), BMJ Open

The Effectiveness, cost-effectiveness and acceptability of Community versus Hospital Eye Service follow-up for patients with neovascular age-related macular degeneration with quiescent disease (ECHoES): a virtual randomised balanced incomplete block trial.

Reeves BC. et al, (2016), Health Technol Assess, 20, 1 - 120