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Prospective validation of a virtual clinic pathway in the management of choroidal naevi: the NAEVUS study Report no. 1: safety assessment
  1. Lamis Al Harby1,
  2. Zaria Ali2,
  3. Azita Rajai2,3,
  4. Stephen A Roberts3,
  5. Tunde Peto4,
  6. Irene Leung5,
  7. Jane Gray2,
  8. Gordon Hay6,
  9. Amit K Arora1,
  10. Pearse A Keane5,6,
  11. Victoria M L Cohen7,
  12. Mandeep Sagoo5,8,
  13. Konstantinos Balaskas5,6
  1. 1Ocular Oncology, Moorfields Eye Hospital NHS Foundation Trust, London, UK
  2. 2Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester, UK
  3. 3Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester, UK
  4. 4Centre for Public Health, Blackwell’s Queen’s University Belfast, Belfast, UK
  5. 5Moorfields Ophthalmic Reading Centre, NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK
  6. 6Medical Retina, Moorfields Eye Hospital NHS Foundation Trust, London, UK
  7. 7Moorfields Eye Hospital, London, UK
  8. 8Barts Health NHS Trust, London, UK
  1. Correspondence to Mr Konstantinos Balaskas, Moorfields Eye Hospital, City Road, London EC1V 2PD, UK; k.balaskas{at}nhs.net

Abstract

Background Choroidal naevi are a common incidental finding prompting specialist referrals to ocular oncology. Rarely, such lesions have sufficient suspicious features to diagnose a small melanoma. The aim of the study is to show that ‘virtual’ imaging-based pathways are a safe and efficient option to manage such referrals.

Methods A prospective cohort study at the Manchester Royal Eye Hospital and Moorfields Eye Hospital between June 2016 and July 2017 of the management decision of 400 patients reviewed by an ophthalmologist in a face-to-face consultation (gold standard) supported by fundus photography, optical coherence tomography, autofluorescence (AF) and B-mode ultrasound. The images were also read independently by blinded graders (non-medical) and blinded ophthalmologists, and a management decision was made based on image review alone (virtual pathway). The two pathways were compared for safety.

Results The agreement for management decisions between face-to-face and virtual pathways was 83.1% (non-medical) and 82.6% (medical). There were more over-referrals in the virtual pathway (non-medical 24.3%, medical 23.3% of gold standard discharge) and only two under-referrals (10.5% of gold standard referrals), both borderline cases with minimal clinical risk. The agreement for risk factors of growth (orange pigment, subretinal fluid, hyper-AF) ranged between 82.3% and 97.3%.

Conclusions We prospectively validated a virtual clinic model for the safe management of choroidal naevi. Such a model of care is feasible with low rate of under-referral. An over-referral rate of almost 24% from the vitrual pathway needs to be factored into designing such pathways in conjunction with evidence on their cost-effectiveness.

  • Choroid
  • Diagnostic tests/Investigation
  • Imaging
  • Neoplasia
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Footnotes

  • MS and KB are joint senior authors.

  • Twitter Konstantinos Balaskas @konbalaskas.

  • Contributors LAH, MS, KB: substantial contribution to acquisition, analysis, interpretation of data for the work; drafting the work, revising it for critically important intellectual content; final approval of the version to be published; agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. ZA, AR, SAR, TP, IL, JG, GH, AKA, PAK, VMLC: drafting the work, revising it for critically important intellectual content; final approval of the version to be published; agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding The study was supported by a National Institute of Health Research/Research for Patient Benefit (PB-PG-0215-36081)—‘the NAEVUS study’ research grant and sponsored by Manchester University NHS Foundation Trust.

  • Competing interests None of the authors have any financial disclosures or conflicts of interest to declare.

  • Ethics statement The study had ethical approval (16/NW/0288) and adhered to the tenets of the Declaration of Helsinki.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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