Cost consequences of task-shifting intravitreal injections from physicians to nurses in a tertiary hospital in Norway

Injections with anti-vascular endothelial growth factor (anti-VEGF) have become the most common intraocular procedure worldwide due to its considerable effect on several retinal diseases such as age-related macular degeneration (AMD), retinal vein occlusion (RVO) and diabetic macular oedema (DMO) [1]. The chronic nature of these diseases results in repetitive, often life-long treatment. With an ageing population, managing this fast-growing patient pool will occupy an increased amount of physician resources and cause increased healthcare costs [2, 3]. A randomized controlled trial from Norway has reported that task-shifting injections from physicians to nurses resulted in similar visual function and safety profile [4]. However, the economic consequences of task-shifting were not investigated. This paper aimed to assess economic consequences from a Norwegian tertiary hospitals’ perspective with respect to hospital costs per injection and potential future cost savings, and in addition societal costs per patient. The hypothesis was that task-shifting would lower costs.

318 patients were recruited as part of a randomized controlled trial examining safety of task-shifting injections from physicians to nurses. Further description of the recruitment and randomization of patients has earlier been published [4]. The study was conducted at St. Olavs Hospital (StO-study), Trondheim University Hospital, serving 300.000 inhabitants in Central Norway, and data were prospectively collected from March 2015 to May 2017. Inclusion criteria were having either AMD, RVO or DMO eligible for anti-VEGF treatment. In both groups, the mean inclusion time in the StO-study was 50 weeks (SD_physician = 9.1, SD_nurse = 8.1). The patient baseline characteristics are shown in Table 1, in addition to service utilization in terms of number of eyecare consultations and injections. Patients received between one and 12 injections, according to their treating physician's discretion.

Detailed cost calculations were performed, which included the application of a range of unit costs (Table 2). The basic principle was first to identify the type and volume of cost elements and services and next multiply by the relevant unit cost. Of specific importance was the wage difference between physicians and nurses. Each personnel group’s mean annual gross income, including social expenses in 2017, was divided by the number of hours working that year (1748 h for physicians and 1725 h for nurses) to find the wage cost per hour. A detailed description of the costs is given below. Costs were measured in euros (€). Norwegian kroner (NOK) were converted using the rate 1 €²◦¹⁷ = 9.3295 NOK²◦¹⁷. All costs were adjusted to represent costs in 2017 [5].

In this study, the hospital cost per injection was estimated to be 5.5 € lower for nurses than physicians. Applying the estimated cost difference per injection and the projected number of injections, a potential hospital cost saving was found to be between 258 017 € and 293 527 € for the next six years if task-shifting the injections to nurses. We found no statistically significant difference in societal costs per patient between the two groups.

The hospital costs per injection were lower for nurses than physicians due to nurses’ lower wages. In St. Olavs Hospital, the wage of a certified nurse is 77% of the wage of a certified physician. The cost savings could be more substantial in countries where the wage gap is more prominent. For instance, in Singapore Teo et al. found a 61% reduction in cost per injection after task-shifting to nurses [11]. The cost categories that differed between physicians and nurses (training, injection- and support personnel costs) accounted for less than eight per cent of the total hospital costs per injection in the StO-study. This shows that the influence of time costs on the per injection cost was low, especially compared to the high medical costs, which account for over 70% of the total hospital costs. However, although anti-VEGF costs are high in Norway and other countries [12], it has been concluded that the improved vision associated with the treatment yields a substantial financial return on investment to patients and society [13].

The projected annual mean saving from task-shifting for St. Olavs Hospital from 2022–27 was between 43 003 and 48 921 € (two and four per cent growth). This amounts to half of the wage costs for a full-time nurse position per year. Hence, one can argue that the cost savings of task-shifting the injections to nurses are minor. However, more personnel trained equals more flexibility for the management and is also associated with higher treatment rates [14]. The physician resources can be reallocated to other urgent tasks, and a task shift like this is in line with WHOs recommendation to transfer tasks from a higher level of competence to a lower one [15]. It is also crucial for the visual outcome that patients receive treatment early after diagnosis and do not have to wait because of low capacity [16]. The Norwegian Ophthalmologic Society [17] has expressed concerns that the training and education of physicians do not meet the increasing demand. It is well known that in Norway, the rural areas have the most difficulties recruiting enough personnel. This highlights the need for a task shift that lowers costs and alleviates the injection burden. We have earlier reported that both experienced and less experienced nurses felt safe during training and treatment [18]. Several ophthalmology departments have task shifted injections from physicians to nurses with acceptable patient satisfaction [19‐22] and results from an RCT indicate that such task-shifting is safe [4].

Several factors influence the future need for injections and thus the calculation of six-year cost projections. Increased awareness of retinal diseases in the population and increased use of advanced diagnostic imaging tools could increase the demand to some extent. Furthermore, novel drugs licensed for other retinal diseases [23, 24] like dry AMD [25] could increase the numbers substantially. On the other hand, development of longer-acting anti-VEGF injected as implants could lower the demand for injections [26]. We estimated that in 2027 the number of injections at St. Olavs Hospital will be between 9374 and 10 602. The upper estimate is calculated with a growth factor of four per cent, matching the mean of the last five years’ growth factor. We could have used a larger growth factor of seven per cent, matching the growth factor in 2021 at St. Olavs Hospital and used in an article from a UK tertiary hospital [27]. However, we chose to use the more modest estimate of two per cent because the UK hospital [27] reported that the growth factor appeared to be declining. They report a nearly 11-fold increase between 2009–19, which is more than double the increase at St. Olavs Hospital in the corresponding years. While the UK hospital used historical data to predict the number of future injections, we added population predictions to our model, making it more sensitive to age differences in the future.

The difference in societal costs per patient between the physician and nurse group was not statistically significant. Patients randomized to nurses travelled more often with a caregiver. However, the use of a caregiver decreased in the nurse group and increased in the physician group. There are more women in the nurse group, and there are reports that women more often utilize healthcare services and travel more with caregivers [28, 29]. This could be an explanation to the higher use of a caregiver in this group.

The mean travel cost per patient per year of all study patients was 1093 €, nurse and physician groups combined, a sum that is equivalent to 1/5 of the total societal cost per patient. The large number of patients receiving injection results in high travel costs for hospitals and society. For instance, in 2016 St. Olavs Hospital treated around 900 patients annually, with the estimated travel costs from the present study amounting to over 1 million euros. A study from Portugal found that the injection rates were negatively associated with travelling distances from home to hospital, meaning that patients that live farther off from the hospital are less likely to receive injections [14]. A Norwegian study observed the same geographical variation with higher injection rates in urban counties compared to rural ones [30] and suggested that travel distances to treatment may be one of the reasons why they observe geographical variations. The number of injections per 100 000 inhabitants in Portugal was 560 in 2018 [14]. In the population in Central Norway covered by St. Olavs Hospital, the corresponding number was 1818 (in the age range 0 – 105 + years), more than three times as many as in Portugal. However, even though St. Olavs Hospital is a university hospital in Norway’s third-largest city, the population distribution has a rural pattern, and many patients travel long distances for treatment (mean 57 km). This can explain the high travel costs that are reported in the present study.

The cost calculations had some limitations. We used a mean medical cost in the calculations since the actual medical costs of the three different medicines, are classified information. A further examination of medicine costs would have been of interest since the cost of various anti-VEGF-agents differ considerably and therefore choice of anti-VEGF-agent will likely affect hospital costs as such. However, when we compared injections by nurses versus physicians, we assumed equal distribution of anti-VEGF agents in both groups in accordance with randomization. It follows that a different choice will not affect the difference between nurses and physicians, only the level of hospital costs. We calculated time costs and clinical support costs for injections for the two groups, but available data did not enable the calculation of such costs for individual patients. Hence variation within groups remained unknown. A third limitation was the uncertainty when projecting the future number of injections. Pharmaceuticals are developing new long-acting anti-VEGF medicines [31], and alternative administration of anti-VEGF is also under construction [32] making the future projections less predictable. Since most eyecare consultations happened outside the hospital on different days than the injections, we might have overestimated the transport costs. In addition, we lacked detailed information on type of transport. Home-care costs will vary according to the patient population as a younger patient with unilateral diabetic macular edema or vein occlusion most likely need less help than an elderly patient with bilateral AMD. Our data mainly consisted of the latter patient category and hence the home care costs in this study might be high.

The strength of our study was the comprehensive calculation of hospital costs, covering most relevant cost categories. Moreover, the detailed calculation of injection costs like training, time costs and clinical support where data collected in the StO-study.

To the best of our knowledge, the present study is the first to compare costs of physician- versus nurse-administered injections in a Nordic setting. Task-shifting the treatment to nurses provided a modest cost saving per injection for the hospital in addition to increased flexibility when reallocating physician resources from injections to other tasks. The societal cost per patient was not significantly different for physician- and nurse-administered injections. However, transport costs are high because of the long travel distances for patients in central Norway. Reducing transport costs by minimizing the number of clinical visits and organizing consultations and injections on the same day, may be a solution to reduce costs for society in the future.