Solutions depend on practice setting, available resources and physicians' preferences.
Along with a new treatment paradigm for patients with exudative AMD, a new scheduling paradigm would not have been unexpected. In some practices, however, attempts to manage patient flow through creative scheduling have come full circle, while in others, the traditional scheduling approach has been revised and refined.
None of the physicians to whom we spoke schedule injection-only days for patients receiving anti-VEGF therapy, although in one practice, a former associate did so with some success. Some retina specialists see these patients throughout the day, while others cluster them during certain times of day, depending on the doctor's preference and the practice's resources.
At Ophthalmic Consultants of Boston, patients of Jeffrey S. Heier, MD, who are receiving treatment with ranibizumab (Lucentis, Genentech) are scheduled for injections throughout the clinic day. This is the approach that was used when Dr. Heier was investigating ranibizumab during clinical trials, and it's the approach he uses today for current patients who are enrolled in studies.
"When I started working with Dr. Heier in 2003, the team had already begun incorporating a fair volume of intravitreal injections into our clinic flow each day," says Alison Nowak, research director for Dr. Heier and two other physicians in the practice. " We were accustomed to having these patients interspersed throughout our clinic day, so that works well for us."
Developing a workable schedule has a lot to do with a practice's resources: the number of clinic lanes and how a physician follows patients diagnostically. "Dr. Heier follows wet AMD patients at most visits with OCT and less frequently with fluorescein angiography," Ms. Nowak explains. "So we must consider the availability of the OCT machines and diagnostic staff. If we tried to block-schedule — that is, consecutively group together his patients receiving intravitreal injections — availability of OCT machines and diagnostic staff could be rate-limiting factors, since they're also servicing the patients of other retina specialists in the clinic at that time. Likewise, Dr. Heier takes less time to perform an injection than it takes clinical staff to prepare the injection, so the availability of clinical lanes and the pace of prepping patients could also result in the doctor being idle while patients were being photographed and prepped."
Rather than develop a complicated formula based on patients' diagnoses and the possibility that they may need treatment, Ms. Nowak uses a traditional scheduling method based on the average number of patients a doctor can see in an hour. If there are six slots in an hour, for example, one is reserved for a new patient, while the remaining five accommodate a variety of established, follow-up and urgent patients.
"Dr. Heier is seeing wet AMD patients, some of whom will receive an injection, some of whom will not, but we often do not know that until they are examined," Ms. Nowak says. "He may also see emergent retinal tear or detachment patients, some of whom will need a procedure or surgery urgently, sometimes same-day, some of whom may be counseled for future surgery. Then we may have diabetic patients whom we are counseling on treatment options, and we also may be having discussions with patients about enrolling studies."
Those are only a few of the factors that can affect how much time a doctor will spend with each patient. In addition, the availability of resources, such as examination lanes, technicians, OCT technicians and nurses, contribute to how the flow of each day. " We know we can schedule a certain number of patients per hour, regardless of their diagnosis," Ms. Nowak says. "Usually, everything evens out by the end of the day. It's definitely a fast-paced environment."
Some practices have found a middle ground between seeing patients who will receive anti-VEGF therapy throughout the day and designating an injection-only day.
|Treat-and-Extend vs PRN vs Monthly Anti-VEGF Therapy|
|Basically, there are three approaches to managing exudative AMD with anti-VEGF therapy:|
1) Monthly injections, as dictated by the clinical trials."Treat-and-extend has obvious advantages for the patient, who receives fewer injections, and, theoretically, for the vision because the macula remains dry," Dr. Slakter says. "It assumes, however, that the patient remains stable and the fluid-free interval is the same over time, which may or may not be true in every person. In fact, for some patients, treat-and-extend is essentially monthly therapy."
2) PRN therapy (also called treat-and-follow), in which patients receive an injection once a month for 3 months, then monthly follow-up and treatment when leakage is detected.
3) Treat-and-extend, whereby patients are treated once a month for 3 months. If no leakage is detected at 1 month after the third injection, their next visit may be scheduled for 6 weeks instead of 4. If no leakage is detected at the 6-week visit, they receive treatment, and their next appointment is scheduled for 8 weeks. The idea is to establish how long between injections an individual will maintain a dry macula.
There's also a possibility with the PRN approach and with treat-and-extend that a patient will show no leakage at his evaluation but begin leaking days later. "If a patient isn't seen for another month, he could have a month of reaccumulation of fluid," Dr. Slakter says. "There have been some suggestions and reports that the intermittent reaccumulation of fluid, at least on a regular basis, is detrimental to vision over time. So we must keep that in mind."
As Dr. Heier notes, "After the introduction of ranibizumab, some physicians tried to find ways to minimize the number of injections while still achieving the maximum benefit. I think many of us have fallen away from that approach, and in many cases now, we're treating more frequently rather than less frequently, particularly in patients who have only one eye affected by AMD."
The physicians to whom we spoke all agreed monthly treatment is the gold standard, but most are tailoring therapy to individual patients, and they're awaiting the results of the Comparison of AMD Treatments Trials (CATT) study for further guidance. The CATT study is designed to evaluate the relative safety and efficacy of ranibizumab and bevacizumab (Avastin, Genentech) and to evaluate how frequently the drugs should be administered.
"The CATT study is evaluating as-needed treatment, and we think as-needed treatment is pretty good," Dr. Kaiser says, "but the problem is that you still need to see patients on a monthly basis. It's not as if we can reduce the frequency of visits, so as-needed versus monthly therapy is not a significant time-saver."
Several of the retina specialists we interviewed have found the most efficient scheduling approach is to cluster appointments for patients whom they expect will require anti-VEGF therapy. Where in the schedule these patients are grouped depends upon the availability of resources and the tempo of the practice and the doctor.
For David S. Boyer, MD, Retina-Vitreous Associates Medical Group in Southern California, the early morning and early afternoon time slots are best. "We've tried to streamline our routines to improve our patients' waiting time while still obtaining good visual results," he says. "When patients arrive for injections, our technicians check their vision and IOPs, dilate their eyes, take OCT scans and instill anesthetic drops. I examine the patients briefly to rule out signs of external infection or hemorrhage, and then I inject. I may do four or five injections in the first hour, and I may see one new patient or a couple of follow-up patients in between. I don't designate one day for injections, but even if I wanted to do that, the limiting factors would be the OCT and the number of technicians available to instill the anesthetic."
David M. Brown, MD, of Retina Consultants of Houston, prefers to group his injection patients toward the end of the morning and the end of the afternoon. "We try to avoid injections in the mid-morning when I'm more likely to be off schedule," he says. "The injection patients are relatively routine in terms of what needs to be done for them, and we don't want to make them wait 2 hours for their injection. An advantage to having injections at the end of the clinic is that the workup techs, who are busy at the beginning of the clinic, are free to assist patients receiving injections."
Although this is the routine that works best now, Dr. Brown says he relies on his staff to continually assess the system and try different approaches to scheduling. "It really takes a team effort, including the technicians working with the front desk people, to get the most efficient clinic scheduling and throughput," he says.
Peter K. Kaiser, MD, who practices at the Cole Eye Institute in Cleveland, Ohio, also prefers to group appointments for injection patients. He has found his staff — and even the patients — tend to adopt a mindset of efficiency with this schedule. Patients are dilated, imaged and injected quickly, without interrupting the flow of the clinic. Dr. Kaiser has seen another benefit for patients who are grouped together for anti-VEGF injections: "It's nice for patients to be able to talk to someone else who's receiving the same therapy. It's almost like a mini-support group in my waiting area."
|Simple Time-saving Tool|
|If you follow the treat-and-extend philosophy for anti-VEGF therapy, this scenario may be familiar. Your patient didn't show leakage at 5 weeks, so you decide to extend him to 6 weeks. In 6 weeks, however, you'll be out of the office on vacation or attending a professional meeting. So when your patient arrives at the front desk ready to make his follow-up appointment, the scheduler has to find you and remind you that you'll be out of the office in 6 weeks. Then you must decide if you'll see the patient at 5 weeks or 7 weeks.|
"To avoid this scenario, at the beginning of every clinic day, my staff gives me a list of the dates when I'll be in the office and when I'll be out of the office (and why) over the next 3 months," says David M. Brown, MD, Retina Consultants of Houston. "I refer to this list while the patient is still with me, and I make the medical decision when to see him. Often, I actually give the patient the date of his next appointment. That's a simple thing we've done that's really helpful. It save the patient's time, and it saves my time."
According to Ms. Nowak, another scheduling model used by some physicians is to schedule a full or partial day of intravitreal injections of anti-VEGF therapy. "The physician examines the patient and then has the patient schedule an appointment for imaging only," she explains. "After the physician reviews the images, the staff calls the patient to schedule an appointment for treatment, if indicated. No examination is performed and no pictures are taken on the day of the injection."
The upside of injection-only days for the physician and his patients, Ms. Nowak says, is that visits are relatively quick and usually on time. The downside for patients, particularly those who don't drive, is the need to return to the practice three times before receiving treatment.
KEEP THE DOOR OPEN
Whether you see patients with exudative AMD throughout the day or in groups, there's one important caveat to remember, Dr. Kaiser says: "Be sure to keep appointment slots open for new patients. On any given clinic day, we block out time for consults and new referrals," he says. "New patients are the lifeblood of any practice." RP
Retinal Physician, Issue: October 2010