Ideas for Managing Intravitreal Injections
How do your processes compare with those of other practices of various sizes?
Dr. Singerman: Due to the widespread use of new treatments — anti-VEGF therapies for macular degeneration in particular — intravitreal injections occupy a significant portion of time in our offices. Certainly, there is much more to this than simply performing the injections. One of the key issues relates to properly setting patients' expectations, which directly affect how satisfied they are with their care and how they perceive the "treatment burden" placed on them. Again, "burden" may not be the best term, but I think we can agree that the frequency with which these treatments must be given is challenging for both patients and practices.
To help alleviate these challenges, we must inform patients that FDA studies indicate that monthly treatment, possibly lasting a year or more, is most effective. We risk scaring them away by recommending monthly injections for an extended period of time, but patients must be aware of the recommended dosing schedule.
Once I explain that to patients, I continue by saying that we may be able to increase the intervals between injections and we will do that as soon as possible. Taking the time to speak with patients about this is essential. In my case, I explain everything to them, but I also have a technician in the room who explains everything again. Of course, we must provide all of the legally appropriate consent forms, too, and those should be accompanied by appropriate educational materials, so patients truly understand that intravitreal injection is not a one-time event.
Dr. Gonzales: Discussions with patients at the outset, when we are initiating treatment, are critical. Anti-VEGF agents have generated a great deal of press, touting remarkable findings, and much of it is directed at the lay person. Patients hear news reports and think that regardless of the stage of disease, they can achieve these optimal benefits. I have spent a great deal of time counseling patients with end-stage macular degeneration, talking to them about the intricacies of the disease and the importance of early treatment. Tempering their expectations has taken a substantial amount of additional time compared with when patients did not have such high expectations.
Of course, it is wonderful to have the ability to attain improved results, but it takes extra time to explain to patients that not everyone will experience the same treatment response.
Dr. Lehr: With end-stage macular degeneration patients, I find it helpful to have these discussions in the angiography room or in front of one of our computer screens. I show them exactly what an early lesion looks like vs. what they have. It may have a shock effect, but they come away with a much clearer understanding of why not everyone will achieve a great outcome.
Dr. Brown: That is a great idea. If you look at the published data1 from the ANCHOR clinical trial of ranibizumab (Lucentis, Genentech), you see the average lesion size was a little more than 2 disc areas. The odds of an end-stage lesion being that size are zero. It is true that the difficult part is letting patients know what is going to happen.
Dr. Gonzales: This is where patient education forms and materials are useful in addition to having staff members who can communicate information to patients. We use education materials for all of our patients who have intravitreal injections.
They receive an education form for preinjection and for postinjection. We use antibiotics before and after the injections. The preinjection education form covers the frequency of the drops and what to expect when they come for the actual treatment. The postinjection education form covers potential symptoms they should be aware of with regard to infection, etc. It also lists the phone numbers to call if they experience eye pain or decreased vision, and we emphasize that it is important to call in with problems, even on evenings and weekends.
USING SEPARATE INJECTION DAYS
Dr. Brown: As far as reducing the treatment burden for the practice, we are constantly changing our flow patterns to find the best approach. In our latest iteration, we do not have separate injection days. We do most of the injections at the end of our morning and at the end of our afternoon. This is because technicians who have finished doing workups, by 10:45 or 11 a.m., then can be involved in prepping patients for intravitreal injections. The same applies at the end of the afternoon.
I am sure what works will be different for different practices, but continually thinking about how to schedule and how to improve patient flow is important for everyone.
Dr. Gonzales: I have adopted a similar system, performing my injections at the end of the clinic day. Clustering them has increased efficiency, improved patient flow and minimized the wait time for patients. We have a group of technicians who help run the injection sessions and facilitate the flow. I also have residents and fellows who help in that regard.
Macular degeneration patients often are elderly and have to rely on family members and friends to drive them to their appointments, so monthly injections can be difficult for them. Anything we can do to decrease the amount of time they spend in the office has a positive effect on their psyche, as well as how they do medically.
ADDING STAFF MEMBERS
Dr. Singerman: One thing we have done to increase efficiency is hire an additional registered nurse whose sole responsibilities are to prepare patients for physicianadministered intravitreal injections and perform fluorescein injections. In Ohio, where I practice, only doctors, physician assistants and registered nurses can inject intravenous drugs.
Some institutions may not be able to hire an RN specifically for this role, but I would recommend doing it if you can. It is expensive, but it is money well spent.
Dr. Brown: Each practice has to figure out for itself the return on investment and whether more patients can be injected per hour by hiring more staff. However, it is difficult to determine the point at which you get the best return. How many technicians do you use when you have a busy clinic?
Anti-VEGF agents have generated a great deal of press, touting remarkable findings, and much of it is directed at the lay person. … Tempering [patients'] expectations has taken a substantial amount of additional time.
— Christine R. Gonzales, MD
Dr. Singerman: Very early in my career, as soon as I was able to afford it, I began increasing my number of staff members on a regular basis. I found that it was not so much a return on investment as it was a different type of return. I was happier in my work having certain things taken care of by other people who could do them better than I could and for a fraction of the cost.
To address your question specifically, I usually work with two scribes or "followers" who are in the room with me, two photographers and two workup technicians. One technician, who is in the room, scribes and then stays after I leave to review with the patient and family what I have explained to them. I move on to the next room with the second scribe (or you may call that person a follower, patient facilitator, advocate or educator). Most of the time in my main office, I am alone. There are 3 hours every other week when one of my associates is with me. Several of the other doctors in our practice work alone for a significant part of their time also, although probably not as much as I do. I would guess that for most of them the staffing is similar.
So, in general I have two workup people, two photographers and two scribes for me personally. However, when I have a busy clinic, we usually add another person who floats. This person can either scribe or work up patients or possibly perform optical coherence tomography (OCT) to assist the photographers. They can alleviate the pressure in the OCT area if it gets backed up, which often happens. Photography, in fact, may be one of the biggest bottlenecks in the office.
We have a very strong photography staff of 10 or 12 people. Not all are designated, full-time photographers. About half of them are, but the other half spend some of their time doing technical work. All of the photographers do OCTs. In addition, many of the technicians have been trained to do OCTs.
Dr. Brown: The biggest backup for us lately has been OCT. Do you have one OCT instrument or two?
Dr. Singerman: We have two for whatever doctor is working in the main office. Occasionally, two doctors are working at once. One of our OCT instruments is a spectral domain technology prototype. We have another such prototype coming, as well.
EMPOWER STAFF TO MANAGE FLOW
Dr. Brown: Who directs your flow? Is it your scribe?
Dr. Singerman: Yes, the scribe directs where I go next.
Dr. Brown: On a related note, we feel that "scribe" is not a good term. It sounds demeaning to us. This has to be the most intuitive person on the team because he manages my movements and also plays a huge role in patient education. We use the term "administrative technician" to denote that these folks are my administrative assistants but also technicians. In our practice, as far as pay, the administrative technicians earn close to what photographers earn.
Dr. Singerman: That is a good point. We do not actually call them scribes, but we have tried different terms and have never come up with what we consider a good one.
Dr. Lehr: I have a similar setup as far as this position. My assistant is my scribe, but she also directs the flow and to a significant extent, oversees the entire retina clinic.
Dr. Singerman: We take the same approach. I could not agree more that the people in this position have a significant responsibility for educating patients. They do much more than put patients in rooms and scribe and take patients out of rooms. Their education role is critical to making the day go more smoothly for the doctors and the patients. After I go through my explanations with patients, I leave them there with the scribe, who offers further explanation, answers questions, clarifies the information and provides written literature.
Staff education should definitely include providing constructive criticism to the people who perform OCT. The more they know, the better data they capture and the faster they can do it.
— David M. Brown, MD
Dr. Brown: That is absolutely right. When I exit, I say, "Mary is going to teach you how to use the Amsler grid, what vitamins we recommend," etc. It saves me 5 minutes. The same applies to postoperative patients and explaining instructions, such as how to taper the steroids. Having someone else who can do that allows me to move on to the next patient or procedure.
Dr. Singerman: All of the people in these high-level positions are very involved in patient care. This becomes even more beneficial once they have gained substantial experience and thoroughly understand ophthalmology. Therefore, we strongly encourage our staff members to climb the ladder in terms of training and earning various certifications.
Dr. Brown: Staff education should definitely include providing constructive criticism to the people who perform OCT. The more they know, the better data they capture and the faster they can do it. For example, if a technician or photographer takes six OCT scans and the fovea only appears on two, we know there was a fovea on the other four. The technician simply did not capture it. Many times, staff members simply are not aware of those types of things. But the more we teach them, the more they can help us.
Dr. Singerman: That is so true, and it applies to all photography as well as angiography. If the photographers know what they are looking for, it is a tremendous help. You cannot have one standard approach to photography. Everyone should know the optimal sequencing and understand that it depends on each individual patient.
I have been helped tremendously by one of our technician/photographers who has been with us for 30 years. She is not interested so much in her job security as she is in teaching everything she knows to the rest of the staff. That is a quality we all should seek out in employees.
ISSUES IN IMAGING
Dr. Singerman: Previously, we discussed facilities and office layout and utilization as a powerful tool for mitigating the challenges we face with delivering some of our new treatments. Does anyone have any comments about facilities specific to intravitreal injections?
Dr. Brown: The biggest limitation we face in our practice is not a lack of space but a lack of sufficient Internet access bandwidth. This prevents us from being able to see pictures on computers in every room in multiple clinics where we need them. When I have to move back and forth to view OCT scans, for example, it hurts our flow. If I were designing our facility from the ground up, I would have the best Internet connection in each room so that we would be "future-proof " and could adopt improvements easily.
Dr. Singerman: We have had issues with this in the past, but finally we have the ability to view images in every exam room. When each patient is assigned to a room, the staff members get the previous angiogram and the OCT, if I request it, up on the screen.
More often than not, however, we look at the printed OCT scans. Dr. Brown, have you considered using the printouts to circumvent your bandwidth problems?
Dr. Brown: Do you print all 12 cuts on every patient?
Dr. Singerman: We print several different OCT sheets, depending on the case. In some cases, we need to look at all of the information, but in others we do not. With some, we simply are looking at a big pigment epithelial detachment or a serous detachment of the sensory retina, or the fact that the sensory retina is 100 μm thinner than it was at the last visit.
We have initiated a new system whereby the charts contain a special flap just for OCT scans. I can flip directly to that flap and not go through all of the paperwork in the chart. In that section, the technicians place that day's OCT side-by-side with the previous OCT so I can compare them. When I do the comparison, I can decide if I need more information. The room where I would go for that is not so remote that I cannot go and look in more detail at the whole case.
Dr. Lehr: In addition to what Dr. Singerman described, we use a flow sheet. The OCT is done before I see the patient. Key parameters such as central macular thickness from that and the previous test are put onto the flow sheet. We then can ascertain if there is a major difference and go back and pull up all of the images if necessary.
Dr. Brown: I like to look at all of the scans for every case. Unfortunately, it is prohibitive to have easy access to all of the test data. I think OCT is like MRI in that you have to look at every scan, and the more scans you can look at, the more you will detect subtle changes that are likely to lead you to treat more.
Dr. Singerman: Good point. We heard much talk a few years ago about the possibility that OCT would replace fluorescein angiography, but we know the truth is that we do not have a solid understanding of the correlation between anatomic treatment success and patient functioning. The new spectral domain instruments should provide us with more information, but it remains to be seen how we might be able to get that data into an exam room. For practices with multiple offices, it also makes delivering care more efficient when we have the ability to pull up any image in any office.
EFFICIENCY, BUT NOT BEFORE EFFICACY
Dr. Brown: I am concerned, as many retinal physicians are, about how much potential vision gain we are sacrificing or how much loss we are allowing when we decrease injection frequency. Most of us are not doing monthly injections in every case, and we have to wonder if we are affecting patients in terms of vision gains or losses by using "treat and extend" or "treat and observe" strategies instead.
Getting clinical trial results on this issue is so important. We certainly do not want to be "treating our waiting rooms," giving patients fewer injections in an attempt to decrease our office congestion. Learning what is truly happening is of the utmost importance for the future.
Dr. Singerman: That is a critically important point. I am reminded of it every time I present the results of the major ranibizumab clinical trials. My most common approach, too, is to treat and extend. Sometimes patients do not like that strategy. They feel that if they are better, they should skip treatment until they feel worse. That is their choice. However, for us to choose something other than monthly injections, we have to keep in mind that the data show that monthly injections for 2 years produce the best outcomes. We have not yet seen high-quality data that beat those outcomes.
SEEKING NEW SOLUTIONS
Dr. Singerman: Are there any final comments on the issues associated with managing intravitreal injections?
Dr. Brown: I hope better ways to deliver treatment eventually emerge.
Dr. Singerman: Yes, we are all hoping for something better. Many therapeutic options are being considered as ways to decrease the number of treatments while achieving optimal visual results. I think we certainly will find ways to accomplish that. It used to be that we thought performing photodynamic therapy every 3 months was taxing. That seems relatively easy compared with what we do now with intravitreal injections.
Many good ideas for handling the challenges have emerged from this discussion. We have learned a great deal and shared our thoughts with colleagues, and we will continue to collectively improve how the retinal community functions. RP