Home-monitoring for neovascular age-related macular degeneration in older adults within the UK: the MONARCH diagnostic accuracy study
Authors: Hogg Ruth E , Wickens Robin , O’Connor Sean , Gidman Eleanor , Ward Elizabeth , Treanor Charlene , Peto Tunde , Burton Ben , Knox Paul , Lotery Andrew J , Sivaprasad Sobha , Donnelly Michael , Rogers Chris A , Reeves Barnaby C 
Published: February 2023

Background
Most neovascular age-related macular degeneration treatments involve long-term follow-up of disease activity. Home monitoring would reduce the burden on patients and those they depend on for transport, and release clinic appointments for other patients. The study aimed to evaluate three home-monitoring tests for patients to use to detect active neovascular age-related macular degeneration compared with diagnosing active neovascular age-related macular degeneration by hospital follow-up.

Objectives
There were five objectives:

Estimate the accuracy of three home-monitoring tests to detect active neovascular age-related macular degeneration.
Determine the acceptability of home monitoring to patients and carers and adherence to home monitoring.
Explore whether inequalities exist in recruitment, participants’ ability to self-test and their adherence to weekly testing during follow-up.
Provide pilot data about the accuracy of home monitoring to detect conversion to neovascular age-related macular degeneration in fellow eyes of patients with unilateral neovascular age-related macular degeneration.
Describe challenges experienced when implementing home-monitoring tests.

Design
Diagnostic test accuracy cohort study, stratified by time since starting treatment.

Setting
Six United Kingdom Hospital Eye Service macular clinics (Belfast, Liverpool, Moorfields, James Paget, Southampton, Gloucester).

Participants
Patients with at least one study eye being monitored by hospital follow-up.

Reference standard
Detection of active neovascular age-related macular degeneration by an ophthalmologist at hospital follow-up.

Index tests

KeepSight Journal: paper-based near-vision tests presented as word puzzles.
MyVisionTrack®: electronic test, viewed on a tablet device.
MultiBit: electronic test, viewed on a tablet device.

Participants provided test scores weekly. Raw scores between hospital follow-ups were summarised as averages.

Results
Two hundred and ninety-seven patients (mean age 74.9 years) took part. At least one hospital follow-up was available for 317 study eyes, including 9 second eyes that became eligible during follow-up, in 261 participants (1549 complete visits). Median testing frequency was three times/month. Estimated areas under receiver operating curves were < 0.6 for all index tests, and only KeepSight Journal summary score was significantly associated with the lesion activity (odds ratio = 3.48, 95% confidence interval 1.09 to 11.13, p = 0.036). Older age and worse deprivation for home address were associated with lower participation (χ2 = 50.5 and 24.3, respectively, p < 0.001) but not ability or adherence to self-testing. Areas under receiver operating curves appeared higher for conversion of fellow eyes to neovascular age-related macular degeneration (0.85 for KeepSight Journal) but were estimated with less precision. Almost half of participants called a study helpline, most often due to inability to test electronically.

Limitations
Pre-specified sample size not met; participants’ difficulties using the devices; electronic tests not always available.

Conclusions
No index test provided adequate test accuracy to identify lesion diagnosed as active in follow-up clinics. If used to detect conversion, patients would still need to be monitored at hospital. Associations of older age and worse deprivation with study participation highlight the potential for inequities with such interventions. Provision of reliable electronic testing was challenging.

Future work
Future studies evaluating similar technologies should consider:

Independent monitoring with clear stopping rules based on test performance.
Deployment of apps on patients’ own devices since providing devices did not reduce inequalities in participation and complicated home testing.
Alternative methods to summarise multiple scores over the period preceding a follow-up.

Trial registration
This trial is registered as ISRCTN79058224.

Funding
This award was funded by the National Institute of Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 15/97/02) and is published in full in Health Technology Assessment; Vol. 28, No. 32. See the NIHR Funding and Awards website for further award information.