title: Effectiveness of Community versus Hospital Eye Service follow-up for patients with neovascular age-related macular degeneration with quiescent disease (ECHoES): a virtual non-inferiority trial.
abstract: To compare the ability of ophthalmologists versus optometrists to correctly classify retinal lesions due to neovascular age-related macular degeneration (nAMD).
  
  
  
  Randomised balanced incomplete block trial. Optometrists in the community and ophthalmologists in the Hospital Eye Service classified lesions from vignettes comprising clinical information, colour fundus photographs and optical coherence tomographic images. Participants' classifications were validated against experts' classifications (reference standard).
  
  
  
  Internet-based application.
  
  
  
  Ophthalmologists with experience in the age-related macular degeneration service; fully qualified optometrists not participating in nAMD shared care.
  
  
  
  The trial emulated a conventional trial comparing optometrists' and ophthalmologists' decision-making, but vignettes, not patients, were assessed. Therefore, there were no interventions and the trial was virtual. Participants received training before assessing vignettes.
  
  
  
  Primary outcome-correct classification of the activity status of a lesion based on a vignette, compared with a reference standard. Secondary outcomes-potentially sight-threatening errors, judgements about specific lesion components and participants' confidence in their decisions.
  
  
  
  In total, 155 participants registered for the trial; 96 (48 in each group) completed all assessments and formed the analysis population. Optometrists and ophthalmologists achieved 1702/2016 (84.4%) and 1722/2016 (85.4%) correct classifications, respectively (OR 0.91, 95% CI 0.66 to 1.25; p=0.543). Optometrists' decision-making was non-inferior to ophthalmologists' with respect to the prespecified limit of 10% absolute difference (0.298 on the odds scale). Optometrists and ophthalmologists made similar numbers of sight-threatening errors (57/994 (5.7%) vs 62/994 (6.2%), OR 0.93, 95% CI 0.55 to 1.57; p=0.789). Ophthalmologists assessed lesion components as present less often than optometrists and were more confident about their classifications than optometrists.
  
  
  
  Optometrists' ability to make nAMD retreatment decisions from vignettes is not inferior to ophthalmologists' ability. Shared care with optometrists monitoring quiescent nAMD lesions has the potential to reduce workload in hospitals.
  
  
  
  ISRCTN07479761; pre-results registration.
authors.affiliation: Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK.
authors.forename: Barnaby C
authors.initials: BC
authors.lastname: Reeves
authors.affiliation: Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK.
authors.forename: Lauren J
authors.initials: LJ
authors.lastname: Scott
authors.affiliation: Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK.
authors.forename: Jodi
authors.initials: J
authors.lastname: Taylor
authors.affiliation: Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK.
authors.forename: Simon P
authors.initials: SP
authors.lastname: Harding
authors.affiliation: NIHR BMRC at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK.
authors.forename: Tunde
authors.initials: T
authors.lastname: Peto
authors.affiliation: Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK.
authors.forename: Alyson
authors.initials: A
authors.lastname: Muldrew
authors.affiliation: Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK.
authors.forename: Ruth E
authors.initials: RE
authors.lastname: Hogg
authors.affiliation: Health Economic Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
authors.forename: Sarah
authors.initials: S
authors.lastname: Wordsworth
authors.affiliation: School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors.forename: Nicola
authors.initials: N
authors.lastname: Mills
authors.affiliation: Centre for Public Health, Queen's University Belfast, Belfast, UK.
authors.forename: Dermot
authors.initials: D
authors.lastname: O'Reilly
authors.affiliation: Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK.
authors.forename: Chris A
authors.initials: CA
authors.lastname: Rogers
authors.affiliation: Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK.
authors.forename: Usha
authors.initials: U
authors.lastname: Chakravarthy
mesh_terms: D000328:Adult; D000359:Aftercare; D000066491:Clinical Decision-Making; D003153:Community Health Services; D019468:Disease Management; D000074099:Equivalence Trials as Topic; D005260:Female; D005654:Fundus Oculi; D006761:Hospitals; D006801:Humans; D008297:Male; D008875:Middle Aged; D009885:Ophthalmology; D009907:Optometry; D010781:Photography; D041623:Tomography, Optical Coherence; D057135:Wet Macular Degeneration / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000628:therapy
keywords: AMD; Optical Coherence Tomography; Wet AMD Reactivation