Effectiveness of Community versus Hospital Eye Service follow-up for patients with neovascular age-related macular degeneration with quiescent disease (ECHoES): a virtual non-inferiority trial

OBJECTIVES: To compare the ability of ophthalmologists versus optometrists to correctly classify retinal lesions due to neovascular age-related macular degeneration (nAMD).

DESIGN: Randomised balanced incomplete block trial. Optometrists in the community and ophthalmologists in the Hospital Eye Service classified lesions from vignettes comprising clinical information, colour fundus photographs and optical coherence tomographic images. Participants' classifications were validated against experts' classifications (reference standard).

SETTING: Internet-based application.

PARTICIPANTS: Ophthalmologists with experience in the age-related macular degeneration service; fully qualified optometrists not participating in nAMD shared care.

INTERVENTIONS: The trial emulated a conventional trial comparing optometrists' and ophthalmologists' decision-making, but vignettes, not patients, were assessed. Therefore, there were no interventions and the trial was virtual. Participants received training before assessing vignettes.

MAIN OUTCOME MEASURES: Primary outcome-correct classification of the activity status of a lesion based on a vignette, compared with a reference standard. Secondary outcomes-potentially sight-threatening errors, judgements about specific lesion components and participants' confidence in their decisions.

RESULTS: In total, 155 participants registered for the trial; 96 (48 in each group) completed all assessments and formed the analysis population. Optometrists and ophthalmologists achieved 1702/2016 (84.4%) and 1722/2016 (85.4%) correct classifications, respectively (OR 0.91, 95% CI 0.66 to 1.25; p=0.543). Optometrists' decision-making was non-inferior to ophthalmologists' with respect to the prespecified limit of 10% absolute difference (0.298 on the odds scale). Optometrists and ophthalmologists made similar numbers of sight-threatening errors (57/994 (5.7%) vs 62/994 (6.2%), OR 0.93, 95% CI 0.55 to 1.57; p=0.789). Ophthalmologists assessed lesion components as present less often than optometrists and were more confident about their classifications than optometrists.

CONCLUSIONS: Optometrists' ability to make nAMD retreatment decisions from vignettes is not inferior to ophthalmologists' ability. Shared care with optometrists monitoring quiescent nAMD lesions has the potential to reduce workload in hospitals.

TRIAL REGISTRATION NUMBER: ISRCTN07479761; pre-results registration.

National incomes and economic growth in pre-industrial Europe: insights from recent research

Pessimistic Malthusian verdicts on the capacity of pre-industrial European economies to sustain a degree of real economic growth under conditions of population growth are challenged using current reconstructions of urbanisation ratios, the real wage rates of building and agricultural labourers, and GDP per capita estimated by a range of methods. Economic growth is shown to have outpaced population growth and raised GDP per capita to in excess of $1,500 (1990 $ international at PPP) in Italy during its twelfth- and thirteenth-century commercial revolution, Holland during its fifteenth- and sixteenth-century golden age, and England during the seventeenth- and eighteenth-century runup to its industrial revolution. During each of these Smithian growth episodes expanding trade and commerce sustained significant output and employment growth in the manufacturing and service sectors. These positive developments were not necessarily reflected by trends in real wage rates for the latter were powerfully influenced by associated changes in relative factor prices and the per capita supply of labour as workers varied the length of the working year in order to consume either more leisure or more goods. The scale of the divergence between trends in real wage rates and GDP per capita nevertheless varied a great deal between countries for reasons which have yet to be adequately explained.