Injectionomics

Efficiencies in the era of high-volume intravitreal injections.

MICHAEL TOLENTINO, MD

Intravitreal injections have become an increasingly adopted procedure in retinal practices. While safety and efficacy are the most important factors dictating how we perform these procedures, systemic efficiencies must be considered that will allow us to deliver this service in ever-increasing volumes with the background of decreasing reimbursement. This article will discuss various strategies that can increase the efficiency of this procedure.

Intravitreal injections have recently become common-place in the office of retina specialists and will certainly increase in frequency. This exponential increase in a once infrequently used procedure can be attributed to novel treatments for conditions such as exudative macular degeneration, diabetic retinopathy, and vein occlusions. The large volume of intravitreal injections have demonstrated that intravitreal injections are safe, and tolerable. With the dramatic increase in procedural volume, there has been a parallel decrease in reimbursement. These changes have made the importance of efficient administration a key factor for the financial viability of both private and academic practices. Furthermore, the high cost of injected medicines requires examination of inventory management for these therapies.

The purpose of this paper is to review and discuss strategies to maximize cost and procedural efficiencies in regards to intravitreal injections and to describe how our practice has addressed the balancing act of maintaining the safety and efficacy of the procedure while maximizing procedural and patient flow. Patient flow can be enhanced by adjusting the process for evaluating and treating intravitreal injection patients, defining the caregivers' job description, streamlining the documentation process, providing checks and balances, and adjusting procedural variables.

INTRAVITREAL INJECTION PATIENT FLOW

■ Scheduling. Because of the recurrent nature of intravitreal injections, this procedure requires routine frequent scheduling which poses the challenge of continuously increasing procedural volume. To efficiently manage procedural flow, patients receiving injections can be scheduled on a given day of the week. This procedural day can enhance patient flow and potentially allow more procedures to be performed within a given hour. While potentially more efficient, if a practice covers more than 3 offices and the offices are far apart, this method is logistically impractical. Other downsides to this method include scheduling vacation times for physicians, the difficulty in accepting add-on patients or emergencies to the schedule, and potential hardship to patients' schedules.

Scheduling the injections in between other patients is a method that is applicable for all practices and may be streamlined to fit all practices irregardless of the number of satellite offices covered by the doctors. This method is advantageous for practices with multiple satellite offices where it would be impractical to schedule all injections on 1 day of the week.

A third method would be to schedule an injection block within a given day depending on the injection volumes seen in a particular office. If one can inject 6 patients per hour, then a 3-hour block can be reserved for 18 patients. The number of patients that can be scheduled per hour is a factor of injection procedure flow that will be discussed. In our practice, we schedule injection patients in between other types of patient visits. This method is efficient for our situation due to our multiple satellite offices and our stream lined injection process.

■ Check-in. Well trained technicians and front office staff are the key to an efficient intravitreal injection procedure. Identification of a patient as a possible intravitreal injection candidate is the first step in streamlining the process. This identification should originate from the scheduling. If a patient is a scheduled injection, this should appear on the schedule and should be visible to both front-desk staff and technicians. When the patient is checking- in, the insurance and payment method is examined and the chart is flagged if there are special requirements, for example, referral to use certain injectable drugs or the requirement of a large copay to cover the cost of the injection. The front desk can prime and warn the patient of these requirements before any physician-patient interaction. It also gives the staff ample time to ascertain if all referrals have been received, if payment will need to be collected, or if outstanding balances need to be collected.

■ Patient Work-up. Once the chart has been flagged, then the technician will call the patient back into the room and perform and obtain history, visual acuity, pressure, and dilation. At that time, the schedule will also note if the patient is returning for a routine injection or if the visit is for an examination and a possible injection. This situation can only be determined by the physician and needs to be entered into the scheduling process as a possible injection and a full exam. This determination is based on the injection strategy employed by the physician.

In my practice, all patients undergo an optical coherence tomography in order to evaluate efficacy of the treatment. The OCT is performed prior to being seen by the physician. The technician prepares a consent for the eye and indication mentioned from prior notes. In addition, a timeout sheet with the correct eye, procedure, and drug to be administered, must be used and documented. We utilize a sticker system to mark the right or left eye. Prior to applying the sticker to the patient's forehead, the technician must reaffirm with the patient that the correct eye, drug, and procedure is being performed. While the patient is dilating, anesthetic gel or eyedrops can be administered by the technician. If subconjunctival lidocaine is administered, the physician must first see the patient.

■ Physician Review. If the patient is returning for a routine injection, then the physician can review the OCT prior to entering the room. The newer spectral-domain OCTs with high-resolution photographic abilities provide exceptional resolution for making clinical decisions such as the need for angiography.

At the time of OCT review, the physician can determine if an angiogram is necessary and can be ordered again prior to the physician actually examining the patient. By the time the physician enters the room to examine the patient, all testing has already been accomplished. The physician will have information to decide if an injection is needed and an idea of when the patient should return for a repeat injection.

■ Physician Exam. The physician can then enter the room, examine the patient, and reaffirm that the correct eye and drug are to be injected. At this time, patients' questions can be answered and followed by application of sub-conjunctival lidocaine. If only topical anesthetic is to be used, then the physican can check for adequate anesthesia. While the patient is being prepped by the technician, the physician can proceed to another patient.

■ Intravitreal Injection Procedure. When returning to perform the intravitreal injection, supplies for injection should be laid out for the physician. The patient should be prepped, and lid speculum, calipers, gloves, drapes, or supplies have been placed in the room by the technician. The patient should be draped appropriately per physician's preference. The injection can then be administered in a manner comfortable for the doctor. After the injection, a technician can administer post-injection antibiotics, undrape and clean the betadine, and check for loss of vision. Some offices check eye pressure after injection. We check vision, to make certain the patient has light perception. If light perception is documented, then a patch can be applied if desired. The post-injection care instructions can be given by the technician, and the patient can be escorted to the appointment desk. The process cycle comes full circle, and the patient must be scheduled either for a routine visit, or exam and possible injection.

THE INJECTION TEAM

The specific roles of the team members (the retinal physician, technicians, front-desk staff, scheduler, billing service, photographer, and practice administrator) must be well defined and the personnel well trained in their specific roles. Technicians in particular must be versed at all levels of the procedure so that they can enhance the ability of the retinal physician to see more patients and perform more injections. The primary role of the technician is to support the physician and to answer many of the routine questions asked by the patient.

The technician should act as a surgical scrub technician. They must be trained in surgical sterile technique and comprehend the flow of the procedure. The technician should also have defined preference sheets for the physician, which state clearly the supplies preferred by the physician, what preoperative and postoperative instructions are given by a particular physician, and the particular physician's routine. This preference sheet can also include the exact method of site preparation, the type of anesthetic used, and which antibiotic drops need to be prescribed. The more the procedure can be entrusted to the technicians, the more efficient the physician will be. The task amount entrusted to the technician should be directly correlated to the level of training and trust the physician has with the technician.

The physician's role should be to examine the patient, obtain proper informed consent by answering patient questions, document the procedure, reassure the patient, and perform the intravitreal injection. Minimizing the logistical, post- and pre-procedural tasks for the physician will maximize efficiency. Also performing as much diagnostic testing prior to the physicians encounter with the patient will also streamline patient flow and minimize idle waiting for the patient.

DOCUMENTATION

Streamlining documentation is simple if utilizing electronic medical records. In our office, we utilize a custom-designed EMR that requires only a few check boxes to fully document the procedure note. Without an EMR set procedure, forms can be used to efficiently document the procedure while adhering to compliance issues.

Informed consent documents should include the potential for systemic toxicity as well as potential procedural side effects. While informed consent should be administered by the physician, it is beneficial to educate technicians and staff so that they can reinforce the potential risks and strengthen the informed consent process. The physical acquisition of signatures for the informed consent should be obtained by the technician.

CHECKS AND BALANCES

■ Pharmaceutical Appropriation and Reimbursement. The major fixed costs originate from the cost of the injectable. While this is usually a pass-through cost, it can pose a financial risk. It is imperative that charges and collections are at their highest rate. Loss of reimbursement due to poor accounting or failure to collect from insurance or patient could be financially devastating to any practice.

Currently FDA-approved intravitreally injectable drug prices are largely non-adjustable. The cost of these drugs are predetermined. Only the individual practice is able to determine what level of collections on drug costs allows for financial viability. While 100% of collections from insurance and patient copayments is virtually impossible, an organization should strive for 100% collection rates. I reinforce this to my patients and staff. If our practice is bankrupt, then no one can receive the appropriate care.

The supply method for pharmaceuticals is important to minimize financial loss. If the pharmaceuticals are purchased by the practice and then reimbursed after the injections, then efficient inventory and accounting methods are important. The advantage of this method is the ability to treat patients without delay — immediately after financial approval is obtained. The disadvantage is that the practice pays for the drug first and then needs to collect for reimbursement. Practices with streamlined operations will benefit from this approach, but it should be avoided by those with historically inefficient collection practices.

Another method calls for the pharmaceutical agent to be supplied directly to a patient. This only allows an injection to be administered after the patient has been diagnosed, approved by a payor, and the pharmaceutical has been ordered for that individual. In some cases, the insurance company or supplier is responsible for collecting for all the costs of the medicines, including the co-pay and payor portion of the charge. While this method decreases economic risks, it does affect patient flow. This method negates the ability of seeing the patient and treating on the day of diagnosis. Furthermore, this may pose logistical problems with practices that have multiple offices. This method is the most cost efficient method for practices with suboptimal collection histories.

■ Wrong Site Prevention. There should never be a wrong eye procedure performed. To prevent this, there should be several layers of checks and balances. Each staff member who encounters the patient should have an opportunity to check which eye will have a procedure. We utilize a sticker that is placed by the technician or the physician onto the patient. The physician and technician also must sign a timeout form that documents the correct eye and drug administered. If at any time there is a discrepancy between the patient and the caregiver, the physician will decide the eye to be treated. This is particularly difficult when patients have bilateral disease and the treatment regimen is not in unison for both eyes. In those cases, the physician needs to decide which eye is being treated in a given session.

INTRAVITREAL INJECTION FACTORS

The intravitreal injection procedure and the pre- and post-injection procedures should be based on clinical factors that maximize patient safety and efficacy. There is no uniform consensus on how these injections are to be performed. Several factors that can be adjusted include the use of subconjunctival vs topical anesthesia, the use of a sterile drape, the use of a lid speculum, the method for site preparation with betadine wash vs povidone-iodine drops, the use of sterile gloves, the use of injectable medicines, and the prescription of post-procedural antibiotic drops. All of these injection-related decisions must be based on the retinal physician's clinical opinion and the physician's interpretation of the available evidence.

My routine for intravitreal injections is to use subconjunctival lidocaine, no drape, and a povidone-iodine drop with skin prep. I use an alcohol hand scrub, but no sterile gloves. I electively use lid speculums, no longer use a caliper, and I prescribe postoperative antibiotics. This routine is based mainly on my opinion of the clinical evidence and my experience. While some of these procedures are more efficient, safety and efficacy are the primary goals for our patients and this should not be compromised for the sake of improved patient flow.

CONCLUSION

Intravitreal injections have become an integral part of the retinal physicians' practice. While the increased volume of patients may be intimidating, a few adjustments in the patient flow, documentation, scheduling, and training of staff should allow your practice to accommodate and effectively treat your patients for conditions that previously would relegate them to blindness. RP