Discussion
retinal diseases
MINOR, RETINAL DISEASES
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 [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 [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 [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 [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 [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 [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.