Hydroxychloroquine (HCQ) is widely used in the treatment of rheumatoid arthritis (RA) and connective tissue diseases (CTD) [1, 2]. A recent report estimated that the prevalence of retinal toxicity in patients on long-term HCQ was 7.5% [3]. The Royal College of Ophthalmologists (RCOphth) published a new guideline recommending all new patients on HCQ should undergo baseline retinopathy screening, ideally within six months of commencing HCQ but definitely within 12 months [4]. We conducted a quality improvement project in two NHS trusts to identify the number of patients starting HCQ and how to utilise retinopathy screening services optimally. Two NHS trusts contributed to this project: Salford Royal NHS Foundation Trust (SRFT) and Bolton NHS Foundation Trust (Bolton FT), representing tertiary care and district hospital services respectively. We identified patients commenced on HCQ and followed for 12 months using hospital and pharmacy records. We calculated attrition rates of HCQ use and explored cessation reasons. Mid-2017 population estimates for Salford and Bolton were extracted from the Office of National Statistics [5]. The number of patients commenced on HCQ at SRFT was higher compared to Bolton FT (Table 1). SRFT is a tertiary referral centre for CTD and patients living outside of Salford who commenced HCQ were included; thus raising the incidence of patients commenced on HCQ at SRFT artificially to 63 per 100,000 population compared to 40 per 100,000 in Bolton. A total of 272 patients were commenced on HCQ across both calendar years (median age 57 years, female preponderance and RA was the most common diagnosis). Of these, 69 patients (25%) had discontinued treatment before completing 6 months of treatment. By 12 months, 90 patients (33%) had discontinued HCQ. Upper gastrointestinal symptoms and inefficacy were the most common cessation reasons (17/90, 18.9% each). Pearce et al applied their estimates to the population of the United Kingdom and calculated that 36,444 patients were commenced on HCQ in 2016 [6]. This is a significant annual burden to local ophthalmology services to comply with RCOphth guidelines, not to mention the estimated 166,673 patients who are already on HCQ [6]. Many ophthalmology departments were aware of the creation of new guidelines for formal ophthalmology-based macular/fundal imaging for HCQ retinopathy screening in 2016/2017. It was perhaps only when the final guidance was in place in early 2018 that practicalities such as the funding/staffing of this new ophthalmology workload were considered at local levels. Our data provide an estimate of patient numbers starting HCQ treatment per annum per capita district general and tertiary hospital population and are in keeping with the estimates from Pearce et al. This information may help with local commissioning of services. With one in four patients stopping HCQ within 6 months of commencement, we suggest timing baseline retinopathy referrals for those still taking HCQ at 6 months. This model of referral will improve retinopathy screening efficiency and reduce commissioning costs.

中文翻译：

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羟氯喹基线视网膜病变筛查：何时转诊患者？优化资源利用的实用方法


羟氯喹（HCQ）广泛用于治疗类风湿性关节炎（RA）和结缔组织病（CTD）[1, 2]。最近的一份报告估计，长期服用 HCQ 的患者视网膜毒性发生率为 7.5% [3]。英国皇家眼科医师学会 (RCOphth) 发布了一项新指南，建议所有接受 HCQ 的新患者应接受基线视网膜病变筛查，最好在开始 HCQ 后 6 个月内进行，但绝对在 12 个月内进行 [4]。我们在两个 NHS 信托机构中开展了一项质量改进项目，以确定开始 HCQ 的患者数量以及如何最佳地利用视网膜病变筛查服务。两个 NHS 信托基金为本项目做出了贡献：索尔福德皇家 NHS 基金会信托基金 (SRFT) 和博尔顿 NHS 基金会信托基金 (Bolton FT)，分别代表三级护理和地区医院服务。我们根据医院和药房记录确定了开始接受 HCQ 并随访 12 个月的患者。我们计算了 HCQ 使用的流失率并探讨了停止使用的原因。索尔福德和博尔顿 2017 年中期的人口估计数据摘自国家统计局 [5]。与 Bolton FT 相比，SRFT 开始接受 HCQ 的患者数量较多（表 1）。 SRFT 是 CTD 的三级转诊中心，居住在索尔福德以外并开始 HCQ 的患者也包括在内；因此，在 SRFT 开始接受 HCQ 的患者的发病率人为地提高到每 100,000 人中有 63 人，而博尔顿的这一数字为每 100,000 人 40 人。这两个日历年共有 272 名患者开始接受 HCQ（中位年龄 57 岁，女性占多数，RA 是最常见的诊断）。其中，69 名患者 (25%) 在完成 6 个月的治疗之前就停止了治疗。到 12 个月时，90 名患者 (33%) 已停止使用 HCQ。 上消化道症状和无效是最常见的戒烟原因（17/90，各 18.9%）。 Pearce 等人将他们的估计应用于英国人口，计算出 2016 年有 36,444 名患者开始接受 HCQ [6]。对于当地眼科服务机构来说，遵守 RCOphth 指南是一个巨大的年度负担，更不用说估计有 166,673 名患者已经接受 HCQ [6]。许多眼科部门都意识到 2016/2017 年为 HCQ 视网膜病变筛查制定了基于眼科的正式黄斑/眼底成像新指南。也许直到 2018 年初最终指南出台后，地方层面才会考虑这一新眼科工作量的资金/人员配置等实际问题。我们的数据提供了地区综合医院和三级医院人均每年开始 HCQ 治疗的患者人数的估计，并且与 Pearce 等人的估计一致。此信息可能有助于本地调试服务。由于四分之一的患者在开始后 6 个月内停止 HCQ，我们建议为那些在 6 个月时仍在服用 HCQ 的患者安排基线视网膜病变转诊。这种转诊模式将提高视网膜病变筛查效率并降低调试成本。