Managed Care Approaches for Treating Eye Diseases

Cincinnati—As adults age, there is an increased risk of abnormal eye functions and even blinding disorders. Diseases such as glaucoma, diabetic retinopathy, and macular edema are sometimes overlooked by managed care professionals; however, according to speakers at the AMCP meeting, healthcare providers and pharmacists need to understand the severity of these disorders as well as the treatment options available.

The topic was presented at a satellite symposium titled Managed Care and the Aging Eye: Pharmacy Implications for Improving Treatment and Quality of Life.

Michelle Hessen, OD, instructor of ophthalmology at the Johns Hopkins Hospital in Baltimore, Maryland, defined glaucoma as chronic, progressive optic neuropathy resulting in characteristic optic nerve changes and visual field loss. Glaucoma is the second leading cause of blindness in the world. Among the groups of people more likely to have glaucoma are African Americans, people whose first-degree relatives have the disease, and the elderly.

Before diagnosing glaucoma, healthcare professionals are advised to check for patient risk factors such as race, age, and family history as well as evaluate for intraocular pressure (IOP), anterior chamber/gonioscopy/central corneal thickness, optic nerve, nerve fiber layer, and visual field.

Dr. Hessen said trials have indicated lowering the IOP impedes glaucoma progression, with an ideal IOP of <21 mm Hg, although it is not a definitive threshold.

“It is a gray zone,” she said. “Elevated pressure for one person is not the same for another person.”

There are several options for glaucoma, according to Dr. Hessen. Medical treatments include prostaglandin analogs, beta blockers, alpha agonists, and carbonic anhydrase inhibitors; surgical treatments include laser therapy, trabeculectomy, and filter/tube implants.

Another common eye disease is diabetic retinopathy, the most common cause of legal blindness for people between 20 and 65 years of age. Dr. Hessen said the most important risk factor for the disease is duration of diabetes. She added the disease is likely to increase rapidly as the global prevalence of diabetes is expected to grow from 171 million in 2000 to 366 million in 2030.

Dr. Hessen said treating diabetic retinopathy depends on whether it is nonproliferative, proliferative, or clinically significant macular edema. For nonproliferative diabetic retinopathy, clinicians should monitor with dilated fundus examinations and educate patients on the importance of blood glucose and blood pressure control. For proliferative disease, options include pan retinal photocoagulation, anti-vascular endothelial growth factor (anti-VEGF), kenalog, and vitrectomy. For clinically significant macular edema, options include focal or grid laser, intravitreal anti-VEGF, and kenalog.

Behind diabetic retinopathy, retinal vein occlusion (RVO) is the second most common cause of visual loss because of retinal vascular disease. Branch RVO typically begins between 60 and 70 years of age and is 3 times more common than central RVO. Dr. Hessen said risk factors for branch RVO are hypertension, cardiovascular disease, obesity, and glaucoma.

In developed countries, age-related macular degeneration is the most common cause of blindness in patients >50 years of age, according to Dr. Hessen. It affects an estimated 10 million people in the United States and is characterized as the gradual or rapid loss of central vision and the distortion of the central visual field.

Meanwhile, dry eye disease is characterized by symptoms of discomfort, visual disturbance, tear film instability, sensitivity to light, pain, mucous discharge, and crusting of the eyelids. Treatments include lubricants such as artificial tears, topical corticosteroids, and cyclosporine A.

Role of Managed Care Pharmacy

Sheldon J. Rich, RPh, PhD, adjunct assistant professor at the University of Michigan and Wayne State University in Detroit, noted there has not been enough research on managed care’s role in ophthalmology. He said he conducted a literature search for the past 15 years and found only 1 article on managing ophthalmology.

“There is a lot going on that we do not pay enough attention to,” Dr. Rich said.

According to research from the American Health Assistance Foundation website that Dr. Rich cited, total healthcare expenditures in the United States for low vision (including macular degeneration and glaucoma) are $51 billion per year, while the direct cost for vision loss in North America is $512.8 billion and the indirect cost is $179 billion. Glaucoma itself costs $2.86 billion per year in the United States based on direct costs and productivity losses.

Adherence to therapy is a major concern, according to Dr. Rich, noting that a study found  that 44% of patients regularly missed their eyes when attempting to apply eye drops. In the same study, approximately 31% of patients adhered to their IOP-lowering treatments 12 months after beginning therapy.

Dr. Rich also discussed the costs of diabetic macular edema (DME). In a study, the cost of treating diabetes and DME was $28,606 compared with $16,363 for patients with diabetes alone. Another analysis found the presence of DME led to 31% higher 1-year costs and 29% higher 3-year costs.

RVO is also expensive to treat: branch RVO costs $4.5 billion per year and central RVO costs $1.3 billion per year, according to a 2010 study that Dr. Rich cited. He added that it is important that patients and healthcare leaders understand RVO is associated with atherosclerosis, diabetes, hypertension, and other eye conditions such as glaucoma, macular edema, and vitreous hemorrhage.

For patients with age-related macular degeneration, Dr. Rich said there has been a debate between treating with on-label ranibizumab (costing $2000 per injection) or off-label bevacizumab (costing $50 per injection). A recent option is aflibercept, which the FDA approved in September 2012 and costs $1850 per injection, according to Dr. Rich.

Although 40% of patients do not seek medical care for dry eye disease, a 2010 study found it is associated with $3.84 billion in direct costs and $55.4 billion in indirect costs, mainly attributable to lost work days. Dr. Rich said dry eye disease should be considered a chronic condition, should be known to cause other comorbid conditions, and should be treated with treatments such as tears, gels, prescription medications, and omega-3 fatty acids. He added that the clinical diagnosis could minimize the effect of dry eye disease and such symptoms as significant ocular discomfort, a decrease in vision-related quality of life, and an inability to work.

In 2011, the release of the Healthcare Effectiveness Data and Information Set ophthalmology measures recommended annual glaucoma screening for all people ≥65 years of age plus a comprehensive diabetes screening every 2 years for those without diabetic retinopathy and once per year for those who have diabetic retinopathy.

Dr. Rich said that since ophthalmic agents are not the most costly products, managed care organizations typically overlook them, which means they do not get much attention from pharmacy and therapeutics committees.