Supplements Managed Care Issues in Glaucoma: Emerging Trends and Treatment
Managed Care and the Impact of Glaucoma
Changes in the healthcare system, population demographics, and treatment alternatives have contributed to an emerging awareness of glaucoma among managed care organizations. Early diagnosis and treatment are essential to thwarting the personal and economic consequences of end-stage glaucoma. Despite recognition of the need for early intervention and therapy, the literature suggests a great need still exists for improvements in lowering intraocular pressure, managing appropriate follow-up, and improving adherence to current glaucoma medication regimens. As the elderly population continues to increase, these issues will intensify and present further problems for the healthcare system. The purpose of this introductory manuscript is to highlight the literature on the clinical and economic impact of glaucoma and its importance to the managed care community. The remainder of the supplement will focus on the current management of glaucoma and the potential role of neuroprotection in this patient population.
(Am J Manag Care. 2008;14:S5-S10)Managed care organizations (MCOs) continually encounter new challenges as novel therapies are developed, diseases become more treatable, and the structure of the healthcare system continues to evolve in terms of reimbursement and population demographics. One such case is in the area of ophthalmology, particularly in the treatment of glaucoma, where the addition of the prostaglandin analogues and alpha2 agonists to the armamentarium introduced more treatment options for glaucoma. In addition, the Health Plan Employer Data and Information Set (HEDIS®) requirements set forth by the National Committee for Quality Assurance (NCQA) were updated in 2005 to include glaucoma screenings. Moreover, the advent of Medicare Part D introduced managed care to a new population with more age-related conditions such as glaucoma. Appropriate management of this new population requires health plans to understand the consequences of disease and the benefits of available treatments for glaucoma.
Impact of Glaucoma
Glaucoma affects approximately 2.5 million persons in the United States older than age 55. Many of these cases are thought to be undiagnosed, with as many as half of these patients unaware that they have the disease.1,2 Moreover, the prevalence of glaucoma is increasing. It is estimated that by 2010, there will be 60.5 million people worldwide with open-angle glaucoma or angle closure glaucoma, with 79.6 million cases projected worldwide by 2020. Of these cases, approximately 74% will be open-angle glaucoma.3 In the United States, the number of individuals with potentially treatable openangle glaucoma is expected to reach 3 million by 2020.4 Left untreated, glaucoma leads to blindness. It is the second most common cause of legal blindness in the United States and the leading cause of legal blindness in African Americans.5 Moreover, glaucoma-related blindness is largely preventable with early detection and appropriate treatment regimens.6
Although there are several different types of glaucoma, the most common form is primary open-angle glaucoma (POAG), which accounts for more than 90% of cases in the United States.7 Risk factors associated with open-angle glaucoma include elevated intraocular eye pressure (IOP), older age, race (African American), diabetes, and a positive family history of glaucoma.5 Glaucoma usually affects both eyes, although each eye may be affected to a varying degree. In the early stages, glaucoma is rather insidious; patients with open-angle glaucoma rarely exhibit symptoms. Consequently, glaucoma is often an incidental finding during a routine eye examination or during an examination performed for other reasons. In patients who are symptomatic, glaucoma usually manifests itself as a gradual loss of peripheral vision. Unfortunately, this vision loss often occurs after 40% or more of the optic nerve fibers are damaged. Optic disc changes may be detected before patients experience symptoms of visual loss, further supporting the need for regular ophthalmic examinations that include glaucoma screenings.5 According to the American Academy of Ophthalmology (AAO), the most effective way to diagnose glaucoma early is to screen for elevated IOP or disc changes as part of a regular comprehensive eye examination.8
As a treatable risk factor, lowering IOP has been the primary target for glaucoma therapy. Patients are usually prescribed ophthalmic drops as the initial treatment of choice for glaucoma. The mechanism of action of these topical eyedrops is to reduce IOP by either decreasing aqueous production or increasing aqueous outflow. Several therapeutic classes of glaucoma agents are available; if one drop is found to be ineffective, the patient can be switched to a medication from a different class or have a second medication added to the regimen to adequately control the glaucoma. Without adequate control, irreversible vision loss can occur. Moreover, the consequences of poorly treated glaucoma are not limited to just the eye. Research has demonstrated that any degree of vision loss is associated with increased medical costs as well as an increased risk of depression, injury, skilled nursing facility utilization, and long-term care placement.9 In most cases, however, glaucoma can be controlled and vision loss prevented with early detection and effective treatment.6
Recommendations for Glaucoma Care and Patterns of Care
In 2005, the NCQA instituted glaucoma screening as a measure in its HEDIS requirements. The addition of this measure is significant because HEDIS measures are important quality assurance considerations for MCOs. The HEDIS glaucoma measure captures the percentage of Medicare members who received a glaucoma examination in the past 2 years by an eye-care professional.10 Under the current reimbursement system, Medicare pays for 1 comprehensive eye examination every 12 months for high-risk patients. To be considered at high risk, patients must have diabetes, a family history of glaucoma, or be an African American older than 50 years of age. Patients pay 20% of the Medicare deductible amount for the eye examination after the yearly Part B deductible is satisfied.11
The AAO has published a Preferred Practice Pattern (PPP) for the treatment of glaucoma. The PPP outlines the major recommendations for glaucoma care and provides guidelines concerning glaucoma screenings and follow-up intervals.8 To evaluate the effect of these recommendations, Fremont et al assessed conformance with the AAO practice patterns in a managed care population.12 A total of 395 patients, who were enrolled in 6 managed care plans, were assessed for processes of care at initial and follow-up visits; control of IOP; time intervals between visits; visual field tests; and adjustments in therapy. Overall, recommended processes of care were followed in 80% to 97% of follow-up visits. IOP was controlled in approximately 66% of follow-up visits for patients with mild glaucoma and in 52% of visits for patients with moderate-to-severe glaucoma.
Intervals between visits were consistent with preferred practice recommendations, but adjustments in therapy occurred in only half of visits where IOP was 30 mm Hg or higher (average IOP for the study was ~20 mm Hg). Patients with mild optic damage had IOP controlled in both eyes in less than half of follow-up visits, whereas patients with moderate-tosevere optic damage had IOP controlled in one third of follow-up visits. The probability of an adjustment in therapy for POAG at follow-up was a function of how well IOP was controlled at the visit, with medication increases occurring more often when the IOP was uncontrolled. However, the proportion of visits in which the therapy was increased was surprisingly low (44.6% of visits where the IOP was 26-29 mm Hg, and 49.3% of visits where the IOP was ≥30 mm Hg).12
A retrospective database study of patients enrolled in a large MCO found that 83% of patients with newly diagnosed glaucoma or suspected glaucoma had a claim for a follow-up office visit, and 46% had at least 1 claim filed for a visual field test during a median follow-up time of 440 days.13 According to recommended treatment patterns, even patients with suspected glaucoma whose risk factors are very low should be seen at a minimum of 18 months, whereas patients with diagnosed glaucoma should have a follow-up visit every 6 months.13 Among the managed care patients evaluated in this study, 10% to 20% (depending on the methodology used) did not receive a follow-up visit at the recommended frequency.
Treatment variations have also been observed in patients diagnosed with or suspected to have glaucoma. Friedman et al found that women were less likely than men to undergo treatment (topical ocular hypotensives, argon laser trabeculoplasty, or surgery) even though they were more likely to be diagnosed with glaucoma.14 Although women were less likely to be treated than men, they were monitored for glaucoma at comparable rates to men. Among all patients, individuals with a confirmed glaucoma diagnosis were 7.5 times more likely to receive topical medications and 9.4 times more likely to undergo surgery than patients with a suspected diagnosis. Factors other than gender and diagnosis associated with a greater likelihood of treatment were older age, geographic region, and longer follow- up periods. For example, patients older than 65 years were almost twice as likely to receive medication as those aged 50 to 59 years, while patients in the Northeast region had lower treatment rates than other parts of the country.14
Adherence and Persistence
For glaucoma therapy to be effective in lowering and controlling IOP, the proper regimen must be prescribed and used appropriately. Appropriate use involves compliance (adherence and persistence) with the regimen on the part of the patient, which can be problematic in those with glaucoma. As newly diagnosed patients are often asymptomatic, the use of medication does not provide the patient with immediately obvious benefits, such as pain relief or improved vision. This perceived benefit absence can lead to decreased patient compliance. Medication compliance in an elderly population is also affected by other factors, such as difficulty with self-administration of eyedrops, increased frequency of administration side effects (eg, irritation, burning, or blurred vision), unaffordable out-of-pocket expenses for medicines, or simply forgetting to administer the medication.15
Measuring adherence with ophthalmic medications is difficult in the elderly population. Assessments of medication adherence are often based on administrative paid claims databases rather than on more direct patient evaluation. Use of paid claims databases can be a potential problem for dosage forms such as eyedrops, where the quantitydispensed field may contain inaccuracies related to claims-filing procedures (eg, claims for a 2.5-mL bottle may be reported as 2 mL or 3 mL if a whole number must be entered into the field, or the number of bottles dispensed may be entered instead of the number of milliliters). Inconsistencies between the claim and actual medication use can also be related to variation in factors such as the number of drops per milliliter dispensed, vial overfill, and estimates of reported days’ supply. After adjusting for the influence of these factors on compliance, Wilensky et al found that patients considered to be new therapy starts and taking IOP-lowering prostaglandin/prostamide medications had an average adherence rate of 76%. Such a rate indicates that opportunities exist to improve adherence and decrease the long-term consequences of glaucoma.16
Costs Associated With Glaucoma
When direct medical costs and productivity costs are considered, the total financial burden of major adult visual disorders in the United States is estimated to be $35.4 billion, with more than $2.9 billion attributed to glaucoma alone. Outpatient medical and pharmaceutical costs accounted for the bulk of the glaucoma expenditure.17 When assessing the benefits and cost of glaucoma therapy, several factors should be considered, including disease progression (early detection requires screening and early treatment, increasing costs on the front end), costs of glaucoma medications, and adherence to treatment regimens.18