Title: Comparing the cost-effectiveness, barriers and facilitators to the adoption of alternative surgical techniques for the management of retinal detachment in the National Health Service.
Funder: Department of Health and Social Care

Abstract: Background RRD is an acute sight threatening condition which requires urgent surgical treatment. There are three techniques available for RRD repair: scleral buckling (SB), pars plana vitrectomy (PPV) and the pneumatic retinopexy (PnR). A recent clinical trial suggested that PnR may offer better clinical outcomes than PPV, and it is hypothesised that PnR may offer reduced healthcare costs. However, there is currently a lack of understanding regarding the cost-effectiveness of the three techniques from an NHS perspective. Furthermore, there is wide variation between countries and surgeons in which technique is utilised. For example, PnR is carried out routinely in North America but rarely in the UK. The reasons for this variation are poorly understood. Aims and objectives 1. To evaluate the costs and effectiveness of the available techniques for RRD repair. 2. To understand how decisions are made regarding choice of surgery, and what the barriers and facilitators to the adoption of each technique are. Methods The study aims will be met during two distinct but complementary workstreams. The first will synthesise the existing evidence and utilise this in an economic decision model. Existing systematic reviews comparing surgical techniques will be updated to include newer RCTs, with the evidence brought together using meta-analytic techniques. The decision model will utilise this synthesised evidence to assess the costs and benefits both in the shorter (1 year) and longer time horizon (lifetime) to fully understand the clinical and cost effectiveness of each technique. The second will be a pragmatic qualitative study of stakeholder perspectives on the selection of surgical technique. Three main stakeholder groups are defined: (i) Patients and carers, (ii) NHS managers, and (iii) Surgeons. One-to-one interviews and focus groups will be conducted. Thematic Analysis will be applied; data coding will utilise inductive and deductive techniques, drawing on relevant theoretical evidence-based practice and implementation frameworks. This will provide data on the barriers and facilitators of the key groups involved in the provision of care for RRD. Anticipated impact and dissemination The economic and qualitative components will be drawn together to generate evidence about how scarce healthcare resources should be used and inform future guidelines for RRD surgery. The embedded qualitative work will ensure that the clinical and cost effectiveness data is firmly situated in a practical NHS context, with the potential to impact on practice. This study has the potential to offer significant cost savings for the NHS over a short time-frame of 2-5 years (estimated crude cost savings of &pound;8,250,000 per year). Dissemination will include publication of results in peer reviewed academic journals and conferences, production of patient information materials, notification to NICE for consideration of Interventional Procedures Guidance , and presentations to groups of key stakeholders such as patients and surgeons.

Lay abstract: Background: The retina is a delicate film at the back of the eye which is responsible for seeing. Retinal detachment affects at least 1 in 10,000 people per year, and results in blindness without surgery. There are three different ways to treat a detached retina, with broadly similar outcomes and safety. The most common way used in the UK is a keyhole surgery ( vitrectomy ), which involves removal of the jelly from inside the eye and its replacement with a large gas bubble. A second technique ( scleral buckling ) involves placement of a silicone band around the eye, and is less often used. A third technique ( pneumatic retinopexy ), involves injection of a small gas bubble without removal of the jelly. There is currently wide variation in the use of each technique between countries and between surgeons. The reasons for this are unclear. For example, a recent study found that pneumatic retinopexy offers better visual results than vitrectomy. As it requires less equipment, its use may reduce NHS costs, although this has not been researched yet. Although pneumatic retinopexy is well established in North America, it is carried out very rarely in the UK. Aims: (i) To evaluate the cost-effectiveness of the available techniques for retinal detachment repair. (ii) To understand how decisions about surgical technique choice are made, and the barriers and facilitators to the use of alternative techniques. Methods: (i) A cost-effectiveness analysis will weigh up the costs (e.g. healthcare resources) and benefits for patients (e.g. visual outcomes) of each technique, using existing clinical trial data. (ii) Interviews and focus groups will collect views from key stakeholders (patients and carers, surgeons and NHS managers) about surgical decision-making. Patient and Public Involvement (PPI): A lay panel and patients were consulted during the design of this proposal. Their suggestions have informed our study methods and plans to draw upon patient experiences and opinions throughout the research. Our PPI Panel will consist of our PPI Lead (a research team member) and 5 lay members (three patients and two carers). The Panel will meet at scheduled intervals throughout the study, and their recommendations will be sought by and feed into the Study Management Group (a lay member will attend each meeting). Dissemination: The PPI Panel will advise on appropriate dissemination of the research findings to the public (e.g. share them with relevant societies that represent patients and devise patient information material). The research findings will be presented at conferences and published in peer-reviewed journals. We will build on the provision of educational resources (online material, courses and book chapters) to facilitate evidence-based adoption of retinal detachment surgery techniques. Our data will inform national guidance on retinal surgery for the benefit of patients and the NHS.

Research activity codes: 8.2 HEALTH AND WELFARE ECONOMICS;7.3 MANAGEMENT AND DECISION MAKING
Health categories: EYE