[Patient's Knowledge after Informed Consent for Intravitreal Injections]

See clearer: survey on the subjective and objective information levels as well as perception and information transfer using virtual reality headsets in patients with diabetic macular edema receiving anti-VEGF treatment

PURPOSE

The purpose of this study is to investigate the use of a VR Headset in routine clinical practice as an additional source of information for patients with diabetic macular edema (DME) and their companions.

METHODS

Survey including 121 patients with DME, 22 companions, and 14 healthcare professionals from 8 ophthalmology centers in Germany. Patients' and their companions' health literacy was assessed by questionnaires including knowledge statements before and after watching a VR-based 3-D educational video. HCPs' perspectives on the usability of a VR Headset were also assessed.

RESULTS

Patients' mean age was 63.4 ± 12.2 years, 64.5% were men, and 76% (92/121) had previous anti-VEGF (VEGF, vascular endothelial growth factor) injections. After using the VR Headset, over 85% of patients and companions felt better informed about DME and its treatment. Patients' mean (± SD) number of correct answers to knowledge statements increased from 13.2 ± 3.7 before to 15.5 ± 2.3 after using the VR Headset. Over 95% of patients and companions rated content and ease of understanding of the video as "very good" or "good." Most patients and all companions considered the use of a VR Headset as a positive experience, most wishing to obtain information via VR Headset in the future. Most physicians and all medical assistants rated the effect of the VR Headset on patient satisfaction as positive and suggested further VR modules.

CONCLUSION

After using the VR Headset, patients with DME and their companions demonstrated knowledge gains that may be meaningful individually and contribute to better adherence. This may offer an additional opportunity for knowledge transfer.

[Patient education before ocular surgery]

Particular importance and diligence must be attached to patient information prior to ocular surgery. A surgical intervention performed without error according to the state of the art in medicine remains exempt from punishment according to § 228 German Criminal Code (StGB) only if effective consent to the treatment is given and only then is there no liability if a risk inherent to the intervention materializes. The patient's consent is only effective if the patient has been properly informed beforehand. In medical malpractice proceedings, a breach of the duty to inform is regularly alleged. From the outset, the physician bears the burden of proof that he has obtained consent in accordance with Section 630d of the German Civil Code (BGB) and provided information in accordance with the requirements of Section 630e of the BGB. The provisions of the Patients' Rights Act also contain formulations that regularly lead to a very detailed individual review of possible errors of disclosure in medical liability proceedings. Apart from the indispensable requirement of an oral clarification discussion by a physician qualified to do so, who informs about "all essential circumstances" of the planned eye operation, the adherence to formal requirements for the clarification discussion and a written documentation with the individual discussion contents are of decisive importance in a lawsuit in order to reduce possible liability risks from the outset. On the one hand, case law sets high requirements for information and on the other hand, every ophthalmologist should also be aware that this effectively counteracts a depersonalization of the physician-patient relationship.

[Adherence to anti-VEGF treatment-Considerations and practical recommendations]

BACKGROUND

Numerous studies have identified a lack of treatment adherence as an important factor that often conflicts with the necessary number of anti-VEGF injections and therefore a better functional result.

OBJECTIVE

This article discusses approaches and possible measures to reduce the risk of late and infrequent intravitreal injections leading to the major issue of undertreatment.

MATERIAL AND METHOD

In the course of an expert dialogue, relevant parameters of treatment adherence and variables were identified. Meaningful processes were structured and assigned to organizational areas.

RESULTS

The compilation of meaningful measures enables practitioners to optimize their own implementation in different areas. Regular monitoring measures can identify the extent of treatment interruption and discontinuation. For specific indicators (treatments per time interval, longest pause interval, minimum coverage per unit time, delay) an effect on the development of visual function was demonstrated. Organizational measures, training of teams and referring physicians, redundant and iterative information transfer to patients have been proven in the experience of experts. The firm integration of these processes into the structures is facilitated by working with checklists.

CONCLUSION

An optimization of the processes is possible to improve the adherence and the functional results; however, interventional studies showing how adherence and persistence can be increased in the German treatment setting are still lacking.

Systematic review: non-adherence and non-persistence in intravitreal treatment

Purpose

Intravitreal injection of VEGF inhibitors has become the standard of care for different macular diseases within the last years resulting in improved visual outcomes. Under real-life conditions, however, the necessity for frequent retreatments and reexaminations poses a burden for patients and treatment centers. Non-adherence and non-persistence to intravitreal treatment may lead to inferior clinical outcomes, and knowledge of contributing factors is crucial to improve adherence. This systematic review analyzes current literature for potential factors involved in non-adherence and non-persistence.

Methods

A systematic search was conducted in PubMed and Embase including three different aspects of intravitreal injection therapy: (1) diseases with intravitreal injections as treatment, (2) intravitreal injection, and (3) aspects of therapy adherence or therapy persistence. Data from identified quantitative studies were further extracted and grouped according to WHO criteria (condition, socio-economy, therapy, patient, and health system). The methodological quality of identified studies was graded. Identified qualitative studies (i.e., interviews) were descriptively analyzed and their findings narratively reported.

Results

Twenty-four publications were included. In 16 of those publications, a quantitative data analysis was conducted, analyzing factors associated with non-adherence. Worse visual acuity at baseline and unfavorable development of visual acuity, higher age, and greater distance to the treatment center were associated with non-adherence, while there was inconsistent evidence for an association of comorbidity. In qualitative studies, high follow-up/treatment burden, fear and anxiety, disappointed patient expectations, and lack of motivation to continue treatment were reported as reasons for non-persistence.

Conclusions

Knowledge of potential barriers in IVT treatment may improve adherence and potentially clinical results. Improvements can be achieved particularly in the healthcare complex (organizational improvements) and the “patient” complex by establishing realistic expectations. Recurrent education of the patient may be necessary.

Electronic supplementary material

The online version of this article (10.1007/s00417-020-04798-2) contains supplementary material, which is available to authorized users.

Intravitreal Injections with Vascular Endothelial Growth Factor Inhibitors: A Practical Approach

Intravitreal injections with vascular endothelial growth factor inhibitors constitute the most prevalent ophthalmic procedure in developed countries. Historically, there has been steady growth in the number of treatments performed of this kind, and projection studies estimate further growth in such treatments in the future. We provide a practical approach to intravitreal injections and discuss important aspects relating to the setting, the patient, the procedure, and the information given to the patient.