Determining Patient Preferences in the Management of Neovascular Age-Related Macular Degeneration

A Conjoint Analysis

JM Baxter; AJ Fotheringham; AJE Foss


Eye. 2016;30(5):698-704. 

In This Article

Abstract and Introduction


Purpose To determine the opinions from a patient perspective on relevant variables in the delivery of treatment for neovascular age-related macular degeneration (nAMD).

Methods Pilot interviews with patients and doctors were conducted to identify what variables in the provision of a nAMD service were important. This led to the generation of two sets of scenario options. Subsequently 100 patients undergoing active treatment for nAMD in the National Health Service University Hospital, United Kingdom underwent interview assessment. They were asked to rank their preferences for provision of their care with reference to these two sets of scenario options. Using conjoint analysis, percentage preferences, and utility scores for each variable in each scenario design were calculated.

Results Ninety-five patients completed the preference ranking for both scenarios. Eight patients ranked worse vision as preferable to better vision and were excluded on the basis that they had not understood the task. The results of the remaining 87 patients are presented. The most important factor to patients was having good vision, followed by a one-stop service and less frequent follow up. The least important factors were label status of the drug, cost to the health service, and grade of the injector.

Conclusion Patients regard good vision and minimal visits to the hospital above the status of injector, label status of drug, or cost to the NHS.


Age-related macular degeneration (AMD) is the commonest cause of blindness among elderly people in the developed world. In the United Kingdom, the prevalence of neovascular AMD (nAMD) was estimated to be 245 000[1] in 2003 and it is estimated that it will increase to 700 000 by 2020.[2]

The introduction of the ranibizumab[3,4] has been a major advance for the management of this condition but has also bought its own problems as the assessment and administration of anti-VEGF agents is a major workload for many ophthalmology units and is a major item of expenditure for the healthcare budget. A cheaper option, bevacizumab has been shown to be as effective as ranibizumab[5–7] but has proven controversial as it is not licensed for intraocular use. This has not prevented bevacizumab been used widely for this condition.

More recently aflibercept has been introduced and this seems to be effective when used on a two monthly rather than a one monthly regimen.[8]

In addition to the issue of cost, there is the issue of workload with an increasing number of units turning to the use of nursing staff to perform the intraocular injections[9] and issues as to whether it is appropriate to inject patients on the same day as their assessment clinic.

Patient-centred care is ever more important and was a key theme in the report by Robert Francis QC, making sure that patients' voices are heard and used to deliver better services.[10] One way of ascertaining a patients' preference for a product or service is by assessing 'trade off' using conjoint analysis (CA). Briefly, CA is a technique that has recently been used in healthcare research particularly to determine patients preferences for service development[11,12] and in ophthalmology to determine patients preferences for treatment of various ophthalmic conditions.[13–15] The full concept method of analysis generates a number of profiles or scenarios with the attributes of interest for the service package or product represented. The subject has to evaluate the scenarios and had to make trade-offs to rank the scenarios. Two additional scenarios, termed holdouts, were also generated in order to assess the validity. These holdouts are generated from another random plan and not the experimental orthogonal plan. The analysis allowed us to discover the relative importance of each factor for individuals but also more importantly help to identify trends in a group. CA generates a 'utility score', which is a numeric value of how desirable or undesirable a patient values the aspects presented in the scenario. A mean 'utility score' will then show which factors the whole group finds desirable.

The aim of this study was to elucidate the factors that are important to the patients attending our department with nAMD that affects how their treatment is delivered. This information provides insights into aspects of our management that are considered important by patients and to help guide local service improvements. We were interested also in views on whether a one-stop or two-stop service (assessment and treatment occurring at either the same visit or different visit) and whether they would accept off-label medication or a nurse, rather than a doctor lead injection service.