Lean approach to the management of patients undergoing intravitreal injections during COVID-19 pandemic

Comparative Study on Anti-VEGF in Wet Age-Related Macular Degeneration in the Setting Based on Lean Methodology from the Bari Intravitreal Injection Registry (BIVIR)

INTRODUCTION

Optimizing treatment protocols for wet age-related macular degeneration (wAMD) is an ongoing challenge, as it involves a delicate balance between achieving therapeutic efficacy and minimizing invasive procedures' frequency. This study aimed to apply the Lean methodology and evaluate the effectiveness of this new setting on intravitreal therapy for wAMD, employing different anti-vascular endothelial growth factors (VEGF) drugs (bevacizumab, brolucizumab, aflibercept, ranibizumab), drawing data from the Bari Intravitreal Injections Registry (BIVIR).

METHODS

This was a retrospective, monocentric, nonrandomized, comparative study. Lean methodology was employed to design the new setting and the BIVIR collected information from electronic medical records. Clinical data of four groups, stratified based on the first-line anti-VEGF agents used, were compared. Best-corrected visual acuity (BCVA) and central retinal thickness (CRT) changes were compared between the four groups at 3 and 12 months.

RESULTS

Out of 4990 eyes and 41,323 intravitreal injections (IVs) recorded in BIVIR, 1421 eyes of 1182 patients were included. The mean number of IVs in first year was 6.1 ± 2.5, with no significant differences among the four subgroups. The mean change in BCVA was + 6.2 letters [95% confidence interval (CI) 5.6-6.8] after two IVs, and + 5.9 (95% CI 5.1-6.8) letters after three IVs; at three months, brolucizumab was associated with a greater mean increase in BCVA than bevacizumab (p = 0.050); aflibercept (p = 0.044) and ranibizumab p = 0.047). At the 1-year follow-up, the mean change was + 6.3 letters (95% CI 5.4-7.2), brolucizumab and ranibizumab were associated with a superior improvement in BCVA compared to aflibercept (p = 0.033). Regarding the CRT, a significant reduction was observed in the subgroup treated with brolucizumab at the 3-month follow-up, compared to bevacizumab (p = 0.003), aflibercept (p = 0.015), and ranibizumab (p < 0.001); Aflibercept exhibited a superior effect than ranibizumab (p = 0.001). At 1-year follow-up, aflibercept resulted in a more significant reduction of macular thickness compared to ranibizumab (p = 0.016) while no significant differences were observed among the other drugs.

CONCLUSIONS

Our practical experience showed the effectiveness of the new setting in the treatment of wAMD. This comparative study at 1 year suggested a predominant brolucizumab efficacy on functional outcomes. In addition, brolucizumab and aflibercept appeared to have similar efficacy in fluid control.

Are intravitreal injections essential during the COVID-19 pandemic? Global preferred practice patterns and practical recommendations

Tertiary outpatient ophthalmology clinics are high-risk environments for COVID-19 transmission, especially retina clinics, where regular follow-up is needed for elderly patients with multiple comorbidities. Intravitreal injection therapy (IVT) for chronic macular diseases, is one of the most common procedures performed, associated with a significant burden of care because of the vigorous treatment regimen associated with multiple investigations. While minimizing the risk of COVID-19 infection transmission is a priority, this must be balanced against the continued provision of sight-saving ophthalmic care to patients at risk of permanent vision loss. This review aims to give evidence-based guidelines on managing IVT during the COVID-19 pandemic in common macular diseases such as age-related macular degeneration, diabetic macula edema and retinal vascular disease and to report on how the COVID-19 pandemic has affected IVT practices worldwide.

To illustrate some real-world examples, 18 participants in the International Retina Collaborative, from 15 countries and across four continents, were surveyed regarding pre- and during- COVID-19 pandemic IVT practices in tertiary ophthalmic centers. The majority of centers reported a reduction in the number of appointments to reduce the risk of the spread of COVID-19 with varying changes to their IVT regimen to treat various macula diseases. Due to the constantly evolving nature of the COVID-19 pandemic, and the uncertainty about the normal resumption of health services, we suggest that new solutions for eye healthcare provision, like telemedicine, may be adopted in the future when we consider new long-term adaptations required to cope with the COVID-19 pandemic.

The role of lean in healthcare during COVID-19 pandemic

Purpose

The impact of the COVID-19 pandemic on healthcare operations has raised questions about the applicability and capacity of the lean approach to respond to critical events. Thus, with a dearth of studies addressing this issue, this study aims to understand the role of lean in healthcare operations under the disruptive impact of the COVID-19 pandemic.

Design/methodology/approach

Drawing on a case study carried out in an emergency department in Brazil during the COVID-19 outbreak, the author presents results from semi-structured interviews and document analysis.

Findings

The results show three prominent themes that respond to this study's purpose: lean applicability during the pandemic, lean challenges during the pandemic and the pandemic impact on the lean processes. Furthermore, the study underscores that lean is not the panacea to operational problems caused by the pandemic in healthcare organisations, but it eases the impact on their operations. Finally, this study contributes to the discipline of operations management and highlights the need to rethink lean applications during disruptive events, focusing on flexibility, adaptability and patients' needs.

Research limitations/implications

The literature addressing the pandemic impact on healthcare operations is still new and emerging; therefore, it is possible that some of the studies that are under review and could contribute to this study were not considered.

Practical implications

The study provides a better understanding of the lessons learned from the real-world experiences gained during the pandemic, helping managers to make informed decisions when developing contingency plans to improve healthcare readiness and responsiveness under crisis conditions (e.g. untenable demand and constrained capacity).

Originality/value

Given the contemporary nature of this pandemic, only few emerging studies addressing the impact of the pandemic on lean healthcare operations are available and scholars are calling for more empirical studies. Furthermore, there is an increasing criticism and scepticism about the applicability of lean in healthcare during a pandemic. Thus, this research both provides original contributions by responding to scholars' calls for novel research in this area and further contributes towards filling the void in the literature.