Health Inequalities May Impact Uptake of Home Monitoring for nAMD

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People of increasing age and worse socioeconomic status were more likely to be unwilling-in-principle to participate in home-monitoring vision tests.

Results from the MONARCH Study revealed notable inequalities in the uptake and use of digital applications for home monitoring of neovascular age-related macular degeneration (nAMD) in an elderly, visually impaired population.1

Across the MONARCH Study, only a minority of patients who were approached for study inclusion were willing-in-principle to participate in the trial. Patient factors, including increasing age and worse deprivation index for home address, were linked with being unwilling in principle to participate.

“It is likely that in future studies to address potential inequities, it will be important to ensure that remote monitoring devices are accessible to all older patients, regardless of their socioeconomic status, health literacy, language, or cultural background,” wrote the investigative team, led by Ruth E. Hogg, PhD, of the Centre for Public Health at Queen's University Belfast.

In ophthalmology, timely monitoring is crucial for patients receiving intravitreal injections of vascular endothelial growth factor (VEGF) inhibitors of retinal diseases, including nAMD.2 Appointments for monitoring often include an assessment of visual acuity, retina imaging, and clinical examination, to determine how future treatment will look for each patient.

On the other hand, self-monitoring with at-home monitoring tests could allow a clinical visit to occur only when a trigger threshold is met. The MONARCH study implemented tests to evaluate the effectiveness of home-based monitoring in nAMD, including one paper-and-pencil test and two software applications on an iPod touch device.3

The study's primary objective was the diagnostic accuracy of the chosen tests—Hogg and colleagues noted this implementation could cause inequality in the study cohort, particularly the effect of digital exclusion and low socioeconomic status exacerbating existing inequalities.1 As a secondary objective, MONARCH assessed the effect of inequalities, by age, sex, socioeconomic status, and visual acuity, on recruitment to the study and its impact on the ability of patients to accomplish and adhere to the weekly app-based tests.

Study participants were provided with the equipment and trained on how to use the device for the study, with weekly self-monitoring across all 3 tests. Any inequalities in the ability to do the tests and adherence to weekly testing were investigated separately for each test. Predictors of the outcomes were collected from hospital records, including patient sex, age, index of multiple deprivation (IMD), exposure to technology, strata of time since diagnosis, and baseline visual acuity at study entry.

Overall, the study recruited 297 (31.5%) participants from 943 potential individuals who were approached and met eligibility criteria. Among 936 individuals with complete data, only 291 (31.1%) were willing-in-principle to participate in the study.

Hogg and colleagues indicated age was a significant predictor of the willingness to participate in the study. Individuals aged ≥80 years had significantly decreased odds of being willing to participate, compared with patients aged <70 years (odds ratio [OR], 0.21; 95% CI, 0.13 - 0.35; P <.001).

They found no significant effect of time since the first treatment for nAMD on the likelihood of participating in the study. However, patients from the most deprived areas exhibited a 47% decreased likelihood of being willing compared with the middle quintile deprived area (OR, 0.53; 95% CI, 0.32 to 0.88).

Further analysis revealed no association between the participant's ability to perform home testing with time since the first treatment for nAMD, sex, age, IMD, or exposure to technology. In addition, there was no association between adherence to testing and time since the first treatment for nAMD, sex, age, or exposure to technology.

Based on these data, Hogg and colleagues noted a multi-faceted approach is required to address these challenges in remote monitoring, ranging from appropriate education and training to device design and patient support services.

“This would require healthcare providers, caregivers, and technology companies to work together to ensure that older patients can benefit from the advantages of remote monitoring technologies while overcoming these challenges,” they wrote.


  1. Hogg RE, Wickens R, O'Connor S, et al. Inequalities in Uptake and Use of Digital Applications for Home-Monitoring of Neovascular Age-Related Macular Degeneration in an Elderly Visually Impaired Population: The MONARCH Study. Transl Vis Sci Technol. 2024;13(3):2. doi:10.1167/tvst.13.3.2
  2. Miller JRC, Patel PJ, Hanumunthadu D. Perspectives on the Home Monitoring of Macular Disease. Ophthalmol Ther. 2023;12(1):1-6. doi:10.1007/s40123-022-00632-6
  3. Ward E, Wickens RA, O'Connell A, et al. Monitoring for neovascular age-related macular degeneration (AMD) reactivation at home: the MONARCH study. Eye (Lond). 2021;35(2):592-600. doi:10.1038/s41433-020-0910-4