The NOD audit provides data and insights for the management for neovascular age-related macular degeneration
Researchers compile data from around 18,000 patients to provide a comprehensive understanding of the current state of nAMD treatment in the UK.
Researchers compile data from around 18,000 patients to provide a comprehensive understanding of the current state of nAMD treatment in the UK. (Image Credit: Adobe Stock/tonefotografia)
Researchers in the UK conducted the first large scale audit of hospital eye care services for patients with neovascular age-related macular degeneration (nAMD) who received treatment. This significant effort provides new insights to understand the effectiveness of treatment, disease management, and the progress made in nAMD treatments.1
Data contributed from over 20,000 eyes from about 18,000 patients was submitted to the database (NOD) audit, providing a snapshot of 12-month outcomes from over 75 centers throughout the UK for patients who commenced treatment for nAMD with VEGF inhibitors from 2020 to 2021. The key findings can be divided into visual outcomes, care processes, and safety outcomes.
The investigators found that overall, 90% of patients had stable vision, 20% experienced a ≥ 15 letter gain, and 40% had good vision (defined as close to driving standard) after 1 year of treatment. The overall median VA change was a gain in 3 letters for the entire cohort. This gain is comparable to the results reported by the Fight retinal blindness registry 12-month outcome report which found a gain in 4.7 letters for patients from Australia. To contextualize the perceived difference in vision gain, the baseline visual acuity from the NOD audit was higher (60 letters) as compared to the baseline VA in the FRB registry at 57 letters. The vision gain reported here is also comparatively better than other real world cohort studies which reported either a maintenance of vision from baseline or a much lower improvement over 12 months.
According to the data, the driver of good vision gains appears to be the number of treatments administered. Similar to the FRB cohort, the NOD audit cohort also received a median number of 7 injections over 12 months, numerically identical to that reported in the FRB registry. This is in comparison to 3–5 injections reported elsewhere.
The second key finding from this report was the time to first injection which assessed the care processes for nAMD. About a quarter of patients received their first injection within 2 weeks of referral from primary care and about half the patients received their first injection within 1 month of referral. This suggest that there are still improvements to be made in the delivery of the 1st injection in the majority of patients to meet the Royal College of Ophthalmology guidelines for first injection within 2 weeks of presentation. While a majority of patients did not manage to meet the desired first treatment window, the overall median presenting visual acuity was still reasonable, at 60 letters, just at the limit of the definition of impaired vision. Compared to prior cohort studies conducted in the UK in 2014 of 55 letters, and 50–55 letters in the early registration trials for anti VEGF therapies this level of presenting vision is at least 1 line better. This implies that patients are probably presenting with early symptoms as compared to previously.
Also assessed within the care process paradigm was the completion of the loading phase. Almost 70% of the patients completed their 3 loading injections within 10 weeks of the first treatment. This proportion suggests a high level of service provision and emphasis on early treatment to maximize outcomes. Taken together, early and intensive treatment has been shown to provide optimal outcomes and these measures of access care processes should continue to be tracked in this audit.
Lastly, almost 90% of patients completed the first year of treatment. This is substantially higher than that reported in other real-world studies. The AURA study (2012), which reported the real-world outcomes using anti-VEGF therapy for nAMD in 8 countries, only showed that about 75% completed 1 year of follow up. This again could be due to increased awareness of the condition as the therapy matures, patient profiles, or the effective management of nAMD in the participating sites.
The results presented appear to buck the trend of prior real world reports proving that appropriate treatment delivered in clinical settings can indeed provide excellent outcomes at a large population level. This could also represent the current state of affairs with more efficacious treatments, better treatment regimens and more informed physicians and patients.
The continued use of this audit will facilitate the benchmarking for nAMD management for years to come as it continues to evolve and is not only useful for establishing local standards of care but also for international comparisons.
