An updated estimate of costs of endophthalmitis following cataract surgery among Medicare patients: 2010-2014.

BACKGROUND: Endophthalmitis, which can occur after ophthalmic surgery, is an inflammation of the intraocular cavity and causes temporary or permanent vision impairment. However, little is known about the cost of treatment. The objective of this analysis was to update and expand upon the results of a previously published report that estimated the direct medical cost of treatment for endophthalmitis. METHODS: Retrospective data analysis using 2010 through 2014 United States Medicare Limited Data Sets. Procedure codes were used to identify beneficiaries who underwent cataract surgery; demographic and clinical characteristics at the time of diagnosis were determined. Patients were stratified into cases (those who developed endophthalmitis) and controls (those who did not develop endophthalmitis) in the 3 months following surgery. Claims (ie, charges) and reimbursements (ie, costs) for cases and controls in the 6 months following cataract surgery were identified and compared. Results are presented in 2015 US dollars. RESULTS: Of a total of 153,860 cataract surgery patients, 181 were diagnosed with endophthalmitis following cataract surgery, at a rate of 1.2 per 1,000. Cases were more likely to be male and less likely to be white than controls; age was similar. Total medical claims and reimbursements as well as ophthalmic claims and reimbursements were significantly higher for cases compared with controls. Total reimbursements, adjusted for age, sex, and region, were $4,893 higher (83% greater) and adjusted ophthalmic reimbursements were $3,002 higher (156% greater) for cases than for controls. Claims and reimbursements were significantly higher across all types of Medicare cost components. CONCLUSION: Postcataract surgery endophthalmitis is associated with a substantial cost. Successful prophylaxis with antibiotic agents would reduce the significant costs associated with treating endophthalmitis.

Treatment costs of cystoid macular edema among patients following cataract surgery.

PURPOSE: The current costs of treating cystoid macular edema (CME), a complication that can follow cataract surgery, are largely unknown. This analysis estimates the treatment costs for CME based on the recently released US Medicare data. SETTING: Nationally representative database. DESIGN: Retrospective analysis of the 2011 through 2013 Medicare 5% Beneficiary Encrypted Files. METHODS: Beneficiaries who underwent cataract surgery were identified and stratified by diagnosis of CME (cases) or no diagnosis of CME (controls) within 6 months following surgery. Claims and reimbursements for ophthalmic care were identified. Subgroup analyses explored the rates of CME in beneficiaries based on the presence of selected comorbidities and by the type of procedure (standard vs complex). Total Medicare and ophthalmic costs for cases and controls are presented. The analysis explored the effect of considering diabetic macular edema (DME) and macular edema (ME) as exclusion criteria. RESULTS: Of 78,949 beneficiaries with cataract surgery, 2.54% (n=2,003) were diagnosed with CME. One-third of beneficiaries had one or more conditions affecting retinal health (including diabetes), 4.5% of whom developed CME. The rate of CME, at 22.5%, was much higher for those patients with preoperative DME or ME. Ophthalmic charges were almost twice as high for cases compared with controls (US$10,410 vs $5,950); payments averaged 85% higher ($2,720 vs $1,470) (both P<0.0001). CONCLUSION: Substantial costs can be associated with CME; beneficiaries whose retinas are already compromised before cataract surgery face higher risk. Cost savings could be realized with the use of therapies that reduce the risk of developing CME. Future analyses could identify whether and to what extent comorbidities influence costs.

Adjunctive therapy patterns in glaucoma patients using prostaglandin analogs.

PURPOSE: To analyze patterns of use of adjunctive therapies among new initiators of topical prostaglandin analogs (PGAs) in a managed care population. METHODS: The study cohort included patients in a claims database who initiated PGA therapy between June 2007 and April 2011. Patients who had one or more adjunctive therapy prescriptions during 24 months of follow-up were included. Patterns of adjunctive therapy use were identified and compared between patients who had one or two fills of the initial adjunctive therapy and those who had three or more. RESULTS: There were 16,486 eligible beneficiaries. Of these, 5,933 (36%) had one or more adjunctive therapies within 24 months from the start of the PGA, 82% of whom started adjunctive therapy within 12 months. About 28% of patients started adjunctive therapy with a fixed-combination product; 45% of these patients started within the first 30 days. Overall, a large number of patients (42%) required adjunctive therapy within 30 days. Twenty-five percent of patients had only one or two prescriptions of their initial adjunctive therapy; of these patients, 74% discontinued adjunctive therapy altogether. CONCLUSION: Approximately 30% of patients starting glaucoma therapy will require adjunctive therapy within 1 year, and many receive a fixed-combination product as initial adjunctive therapy shortly after starting glaucoma therapy. This suggests a prescribing trend toward earlier, more aggressive drug therapy to control pressure and minimize disease progression. We found that compliance with adjunctive therapy continues to be a problem for patients, which could be attributed to a number of treatment burden and economic factors.

Medical service encounters and payments associated with topical adjunctive therapy use of timolol for glaucoma.

BACKGROUND: Topical ß-blockers are commonly prescribed for primary open-angle glaucoma. Existing research is limited regarding respiratory or cardiovascular events that may result from using these topical ß-blockers. OBJECTIVE: To evaluate inpatient and outpatient service encounters and payments associated with the topical adjunctive use of the ß-blocker timolol for glaucoma. STUDY DESIGN: Retrospective data analysis using 2004-2011 IMS Lifelink Health Plan Claims Database. PATIENTS: Beneficiaries were included if they had a diagnosis of glaucoma (International Classification of Diseases-Ninth Revision-Clinical Modification [ICD-9-CM] code 365.xx) and at least 4 years of continuous enrollment and glaucoma medication use (defined as at least one pharmacy claim each year). Beneficiaries who had 4 years of observation with no timolol use were categorized as "controls" and those with 2 years of non-timolol glaucoma medication use followed by consecutive years of adjunctive timolol use were considered "cases." Beneficiaries with 2 years of non-timolol glaucoma medication use followed by 1 year in which they used timolol adjunctively and then a year without timolol use were considered "discontinuers." MAIN OUTCOME MEASURE: The rates of respiratory and cardiovascular disease in year 2 of the observation period were compared to the rates in year 3, and healthcare encounters and payments were also compared. RESULTS: There were 24,271 glaucoma patients who did not receive timolol (controls), 1,406 beneficiaries who were prescribed timolol in addition to other glaucoma medications and continued its use (cases), and 299 beneficiaries who used adjunctive timolol for only a single year (discontinuers). More than half of each group was less than 65 years of age (58 % of controls, 53 % of cases, 54 % of discontinuers, p < 0.05). The rate of respiratory disease increased in all groups from year 2 to year 3 of the observation period, with increases of 1.0 %, 1.4 % and 5.0 % points among controls, cases and discontinuers, respectively (all between-group comparisons significant at p < 0.05). There were similar changes in the rate of cardiovascular disease, with increases of 1.3 %, 1.5 % and 4.7 % points among controls, cases and discontinuers, respectively (all between-group comparisons significant at p < 0.05). These increases were generally lower for younger beneficiaries and greater for those 65 years and older. Comparing years 2 and 3 of the observation period, discontinuers more than doubled their average rate of all-cause inpatient hospitalizations (0.35-0.83 encounters annually), while this rate remained steady for cases and controls (between-group comparisons significant at p < 0.05). There was little change in this rate among patients less than 65 years of age. Among those aged 65 years and older, there was a substantial increase for discontinuers, with a tripling of the average annual rate of inpatient hospitalizations from 0.45 to 1.48 (all between-group comparisons significant at p < 0.05). In this older group, both discontinuers and cases experienced more than a 20 % increase in outpatient service encounters compared to only 9 % for controls (all between-group comparisons significant at p < 0.05). Overall, discontinuers would be expected to have average annual medical payments US$3,600 greater than controls and US$3,200 greater than cases. CONCLUSION: Adjunctive use of timolol by patients with glaucoma may be associated with increased respiratory and/or cardiovascular disease, hospitalizations and payments among patients for whom timolol may be contraindicated or who have yet undiagnosed manifestations of conditions for which it would be contraindicated.

Patterns and costs associated with progression of age-related macular degeneration.

PURPOSE: To evaluate patterns of disease progression among individuals with age-related macular degeneration (AMD) and to compare costs over time. DESIGN: Retrospective data analysis using 5% Medicare claims data from 1997 through 2009. METHODS: Beneficiaries were included if they had no diagnosis of AMD in 1997, were 65 years of age or older, had data through 2009, and had no major ophthalmic conditions. Two cohorts were identified: those who had dry AMD in 1998 (cases) and matched controls who never had AMD. RESULTS: There were 52,607 beneficiaries who never had AMD and 1184 who were diagnosed with dry AMD in 1998. Among beneficiaries with dry AMD, the disease progressed in 20.4% to the wet form by 2009. From 1999 to 2009, average annual Medicare expenditures increased from $11,265 to $24,494 (cases whose disease did not progress) and from $11,712 to $34,308 (cases whose disease progressed). Among beneficiaries without AMD, expenditures also increased over time (from $4736 in 1999 to $17,473 in 2009), but consistently were lower than cases' expenditures. Considering ophthalmic expenditures, the pattern was more pronounced: beneficiaries without AMD had annual expenditures less than $100, those with dry AMD had expenditures at least 3 times more, and wet AMD beneficiaries' costs were at least 5-fold more than that of those with dry disease. A subgroup analysis of beneficiaries without hypertension revealed similar patterns, although expenditures were lower than in the general population. CONCLUSIONS: AMD progression seems to be associated with increased annual Medicare expenditures. Findings suggest that halting or slowing disease progression using proven treatment such as Age-Related Eye Disease Study-endorsed vitamins or novel technologies could have a substantial positive impact by lowering public health expenditures.

Persistence with prostaglandin agonist use with and without adjunctive therapy for glaucoma patients: a Canadian population-based analysis.

BACKGROUND: Glaucoma is one of the leading causes of blindness and visual disability. Few studies have examined persistence and adherence with topical medications in glaucoma patients. OBJECTIVE: The objective of this study was to compare patient persistence with prostaglandin agonist (PA) monotherapy versus with concomitant adjunctive therapy (AT) in Canada. METHODS: Data were obtained from the Québec prescription claims database. Persistence rates were determined for previously treated naive glaucoma patients at 1 year after their index date for use of any of the three available PAs (bimatoprost, latanoprost, and travoprost). Patients who had at least 334 days on their index PA were defined as being persistent during the analysis timeframe. Patient baseline demographics and persistence rates were reported. A logistic regression was used for comparing the PA and PA + AT groups, which incorporated baseline cofounders, such as age and sex, in the analyses. RESULTS: From an initial cohort of 28 534 patients, 14 893 were identified as naive to glaucoma therapy and had a PA as their index therapy. Of these, 11 197 (75.2%) continued to receive monotherapy and 3696 (24.8%) had an AT added to the PA; 59.0% were females, and the average age was 70.5 ± 11.3 years. Overall, at the end of the first year of therapy, 57.4% of patients were persistent on their index PA; however, a statistically significant difference was observed between the two subgroups, with 54.6% for those receiving PA monotherapy and 65.8% for those receiving PA + AT (p < 0.01) persistent with therapy. On average, 10.5 prescriptions per year were dispensed to persistent patients. CONCLUSIONS: In this Canadian population, persistence rates fall to approximately 60% at the end of the first year of therapy, with patients taking AT being more persistent. Similar persistence analyses are warranted on other populations, and would yield helpful data for conducting economic evaluations of non-persistence.

First-year treatment costs among new initiators of topical prostaglandin analog identified from November 2007 through April 2008.

OBJECTIVE: Ocular surface disease (OSD) is a common side effect of ophthalmic medications containing the preservative benzalkonium chloride (BAK). Little is known whether and how glaucoma treatment patterns and annual costs vary based on the presence of BAK. The objective of this analysis was to estimate first-year treatment costs among new initiators of topical prostaglandin analogs in a managed care population. RESEARCH DESIGN AND METHODS: A model was developed to estimate first-year direct medical costs associated with glaucoma prescriptions and outpatient ophthalmic care. Patients were identified from a pharmacy claims database, covering more than 75 million individuals, if they initiated therapy with one of three prostaglandin analog products between November 1, 2007 and April 30, 2008. Patients needed to have at least 6 months of prior claims data in which there were no glaucoma therapy claims and at least 12 months of follow-up data available after the initial claim. Patients were excluded if they were not continuously eligible for pharmacy benefits throughout this 18-month period. Published studies were used to estimate outpatient visit-related health care resource use, and costs for prescription medications and health care resource use were derived from standard, published benchmarks. RESULTS: The database analysis identified 9398 patients meeting study criteria, 45% (n = 4230) of whom remained on their initial prostaglandin therapy for 12 months after initiation. Adjunctive intraocular pressure lowering therapy was needed in 23.6%, 18.5%, and 13.3% of bimatoprost, latanoprost, and BAK-free travoprost patients, respectively. Median numbers of days to the first prescription filled for adjunctive therapy (if required) were 72.5, 74.0, and 125.0 for patients initiating on bimatoprost, latanoprost, and BAK-free travoprost. Total estimated first-year costs were $1973, $1807, and $1739 for patients initiating therapy with bimatoprost, latanoprost, and BAK-free travoprost. Findings were consistent through sensitivity analysis. CONCLUSIONS: A BAK-free prostaglandin analog may permit longer duration of monotherapy and be associated with lower first-year direct treatment costs. Use of a claims database and the selection of new initiators of prostaglandin analogs limit projecting findings to all glaucoma patients.

Two-year treatment patterns and costs in glaucoma patients initiating treatment with prostaglandin analogs.

OBJECTIVE: To determine treatment patterns and costs over a two-year period among new initiators of topical prostaglandin analogs in a managed care population by retrospective cohort analysis of an insurance claims database. METHODS: Patients who initiated therapy with a prostaglandin analog between September 2006 and March 2007 were identified. The use of monotherapy and adjunctive therapies were compared by index prostaglandin. Days to initiation of adjunctive therapy and rates of glaucoma surgical procedures were also calculated. Medical costs (antiglaucoma medications and ophthalmic visits) over the two-year period were estimated. RESULTS: The analysis identified 5018 patients with at least one prostaglandin analog prescription (bimatoprost, n = 747; latanoprost, n = 1651; benzalkonium chloride (BAK)-free travoprost, n = 203). The majority (51%-54%) had repeat prescriptions. Among those with repeat prescriptions, 52% were female (not significant) and mean age was 64 years (P < 0.01). Rates of adjunctive therapy use varied across groups (bimatoprost 51%, latanoprost 37%, and BAK- free travoprost 35%, P < 0.0001). Median and mean days to initiation of adjunctive therapy were 83 and 140 for bimatoprost, 101 and 181 for latanoprost, and 113 and 221 for BAK- free travoprost. Two-year medical costs were $3147, $2843, and $2557 for patients initiating treatment with bimatoprost, latanoprost, and BAK-free travoprost, respectively. Use of glaucoma surgical procedures across the treatment groups was similar over the two-year period. CONCLUSIONS: Over a two-year period, the rate and time to initiation of adjunctive therapy use, as well as medical costs, varied between index prostaglandins. However, the rate of glaucoma surgical interventions did not vary significantly across index medications.

First-year treatment costs among new initiators of topical prostaglandin analogs: pooled results.

OBJECTIVE: To estimate first-year treatment costs among new initiators of topical prostaglandin analogs in a managed care population. RESEARCH DESIGN AND METHODS: A model was developed to estimate first-year medical costs. Model inputs were based on weighted results from three previous studies. Treatment patterns were derived from a claims database analysis. Published studies were used to estimate visit-related resource use. Costs were obtained from standard sources. RESULTS: Across studies, 27,809 patients met study criteria, 44.2% of whom remained on their index therapy for 12 months. Adjunctive therapy was needed in 22.5%, 18.5%, and 11.9% of bimatoprost, latanoprost, and benzalkonium chloride (BAK)-free travoprost patients, respectively. Median days to initiating adjunctive therapy were 64, 67, and 127 for bimatoprost, latanoprost, and BAK-free travoprost patients. Estimated first-year medical costs were $1,945, $1,803, and $1,730 for patients initiating therapy with bimatoprost, latanoprost, and BAK-free travoprost. Findings were consistent through sensitivity analysis. CONCLUSIONS: A BAK-free prostaglandin analog may permit longer duration of monotherapy and be associated with lower first-year treatment costs. Use of a claims database and the selection of new initiators of prostaglandin analogs limit the ability to project findings to all glaucoma patients.

First-year treatment costs among new initiators of topical prostaglandin analogs.

OBJECTIVE: To estimate first-year costs among new initiators of topical prostaglandin analogs in a managed care population. RESEARCH DESIGN AND METHODS: We developed a model to estimate first-year direct medical costs. We derived treatment patterns from a claims database analysis. Published studies were used to estimate visit-related resource use. Costs were obtained from standard sources. RESULTS: The database analysis identified 9,063 patients meeting study criteria, 41% (n = 3,672) of whom remained on their initial prostaglandin therapy for 12 months after initiation. Adjunctive intraocular pressure lowering therapy was needed in 20.7%, 16.5%, 13.9%, and 8.9% of bimatoprost, latanoprost, travoprost, and BAK-free travoprost patients, respectively. Median numbers of days to the first prescription filled for adjunctive therapy (if required) were 69.5, 67.0, 123.0, and 158.5 for patients initiating on bimatoprost, latanoprost, travoprost, and BAK-free travoprost. Total estimated first-year costs were $1,457, $1,360, $1,278, and $1,307 for patients initiating therapy with bimatoprost, latanoprost, travoprost, and BAK-free travoprost. Findings were consistent through sensitivity analysis. CONCLUSIONS: A BAK-free prostaglandin analog may permit longer duration of monotherapy and be associated with lower first-year direct medical costs. Use of a claims database and the selection of new initiators of prostaglandin analogs limit projecting findings to all glaucoma patients.

Characteristics of respondents with glaucoma and dry eye in a national panel survey.

BACKGROUND: There is an increasing body of evidence strongly suggesting that glaucoma medications may contribute to ocular surface disease and development of dry eye. OBJECTIVE: To identify glaucoma patients with dry eye, using a nationally representative sample, and to compare clinical and treatment characteristics with controls without dry eye. METHODS: Patients taking intraocular pressure-lowering medications were identified from the Medical Expenditure Panel Survey. A matched cohort without glaucoma served as controls. Dry eye was identified by diagnosis or use of prescription or over-the-counter medications. Demographic and clinical characteristics and medication use patterns were compared. RESULTS: The analysis identified 629 respondents with glaucoma and 6,934 controls without glaucoma. Dry eye was more common among glaucoma respondents than nonglaucoma controls (16.5% vs 5.6%, P < 0.0001). There was a nonsignificant trend for respondents with dry eye to report higher rates of glaucoma adjunctive therapy use compared to those without dry eye (44.2% vs 35.0%, P < 0.076). Prostaglandin analogs were the most common glaucoma medication. CONCLUSIONS: This analysis found that the rate of dry eye was higher in patients with glaucoma than in controls. The use of glaucoma adjunctive therapies may increase the rate of dry eye in glaucoma patients.

Trends in annual medicare expenditures for glaucoma surgical procedures from 1997 to 2006.

OBJECTIVE: To identify payments and changes in payments for glaucoma surgical procedures among Medicare beneficiaries in the United States and to evaluate trends in costs based on the types of procedures being performed. DESIGN: Retrospective analysis using 1997 through 2006 Part B Medicare Beneficiary Encrypted Files. The annual number of claims and payments for glaucoma surgical procedures were calculated, as were the rates per 100 000 beneficiaries. RESULTS: Overall, there were decreases in both the number of glaucoma surgical procedures and the amount of annual payments from 1997 to 2001 but an increase in the number of procedures in the following years. Trends in claims and payments vary according to procedure. Average payments for trabeculectomies decreased over time, while annual payments for cyclophotocoagulation and shunt-related procedures have increased. After an initial decline, there was a substantial increase in the number of trabeculoplasties in conjunction with advancements in technology and a change in the global period for reimbursement. Patterns of surgery rates were similar to volume of surgical procedures. CONCLUSIONS: Findings suggest that while the overall number of glaucoma surgical procedures is increasing, payments have been decreasing. Clinical and technological advancements and reimbursement decisions may influence surgeons' preferences and, therefore, costs to Medicare.

An objective evaluation of eyedrop instillation in patients with glaucoma.

OBJECTIVES: To evaluate the performance of patients with ocular hypertension and glaucoma who are experienced in the instillation of topical ocular hypotensive medications. METHODS: We conducted a prospective, open-label study at a single private practice site. We enrolled 139 patients with a diagnosis of glaucoma or ocular hypertension who used 1 or more topical ocular hypotensive medications for at least 6 months and who instilled their own medications. Patients were questioned regarding their use of topical ocular hypotensive medications, and we used a video recording to evaluate patient performance of eyedrop instillation with 2 bottle designs. RESULTS: Patients reported relatively good performance on eyedrop instillation. One hundred twenty-nine of 139 patients (92.8%) reported no problem putting in their eyedrops, and 86 of 139 (61.9%) believed that they never missed their eye when administering the drops. The proportions of patients who were able to instill a single drop into the eye without touching the bottle to the eye were 14 of 64 (21.9%) with a 15-mL bottle and 36 of 117 (30.8%) with a 2.5-mL bottle. CONCLUSIONS: Under a single direct observation, patients experienced in the use of topical ocular hypotensive agents performed relatively poorly when instilling a single eyedrop into the eye without touching the bottle tip to the eye or the ocular adnexae. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00522600.

First-year treatment patterns among new initiators of topical prostaglandin analogs.

OBJECTIVE: To evaluate treatment patterns and costs among new initiators of topical prostaglandin analogs in a managed-care population. RESEARCH DESIGN AND METHODS: Annual costs were modeled using multiple inputs. A retrospective cohort design was used to identify treatment patterns for pharmacotherapy. The study population was identified from pharmacy claims for patients who met study inclusion criteria (patients initiating prostaglandin analog monotherapy). Published studies were used to estimate visit-related resource use and costs were obtained from published and standard sources. RESULTS: In the cohort analysis, a total of 12 202 patients met study criteria: 2275 received bimatoprost, 7347 received latanoprost and 2580 received travoprost (1808 used the original formulation and 772 used the newer preservative formulation). Of patients meeting study criteria, 50% stopped all glaucoma therapy, 6% switched from their initial prostaglandin therapy, and the remaining 44% stayed on their initial prostaglandin for 1 year. Of patients remaining on prostaglandin analog monotherapy for 1 year, 22.7% of bimatoprost patients, 19.8% of latanoprost patients and 17.9% of travoprost patients (19.7% for the original formulation and 13.7% for the new formulation) required adjunctive therapy. Of those requiring adjunctive therapy, the median number of days until starting adjunctive therapy was 53 days for bimatoprost patients, 63 days for latanoprost patients and 83 days for travoprost patients (70.5 days for the original formulation and 109 days for the new formulation). The resources used at each visit were estimated at $424 for an initial visit and $70 for follow-up visits. Estimated first-year costs were $1294, $1199, and $1186 for patients initiating therapy with bimatoprost, latanoprost, and travoprost, respectively. Estimated travoprost costs were higher for the original formulation ($1203) than for the new formulation ($1160). Sensitivity analyses suggested that the cost estimates are robust to changes in costs and use of adjunctive therapies. LIMITATIONS: The use of a claims database without compliance data or clinical outcomes and the selection of new initiators of topical prostaglandin analogs limits the findings and does not allow projecting outcomes to all glaucoma patients. CONCLUSIONS: Use of adjunctive therapy in glaucoma is an important driver of glaucoma management costs. Based on the results of this study, it is possible that longer duration of monotherapy with prostaglandin analogs may be associated with lower annual costs. Further study should be conducted to validate these findings.

Impact of visual impairment on service and device use by individuals with diabetic retinopathy.

PURPOSE: This study was performed to assess the use of devices and caregiving among individuals with diabetic retinopathy and to evaluate the impact of visual acuity on use. METHODS: Data were collected using a questionnaire that included items on demographic and clinical characteristics and on the use of services, assistive devices, and caregiving. The study was approved by an institutional review board. Two ophthalmologists identified and invited patients with diabetic retinopathy and provided best corrected visual acuity (BCVA). Patients provided informed consent. De-identified data were analysed in SAS(R). RESULTS: Of the 806 respondents, 55% were women; mean age was 65 years. Respondents were classified into five categories based on BCVA. Few respondents used services such as transportation and counseling, but there was wide use of assistive devices. More than 20% of respondents used a cane, a hand-held magnifier, and/or special glasses. The mean number of devices used increased significantly as BCVA deteriorated, as did hours of caregiving. Annual costs for services, devices, and caregiving increased as BCVA deteriorated. CONCLUSIONS: There are substantial differences in the use and costs of assistive devices and caregiving among individuals with diabetic retinopathy with varying BCVA.

Medicare expenditures associated with diabetes and diabetic retinopathy.

BACKGROUND: To estimate the expenditures for diabetic retinopathy in the United States by Medicare. METHODS: Retrospective data analysis using the 1997 through 2004 5% Medicare claims data. A case control design was used; eligible beneficiaries were 65 or older and without major ophthalmic conditions (cataract, cataract surgery, and macular degeneration) during the study period. Controls had diabetes but no evidence of diabetic retinopathy. There were two diabetic retinopathy case groups: beneficiaries with nonproliferative diabetic retinopathy (NPDR) and beneficiaries with proliferative diabetic retinopathy (PDR). Analyses quantified annual Medicare payments for case and control groups. RESULTS: A total of 178,383 controls, 33,735 NPDR cases, and 6,138 PDR cases were identified. After adjusting for age, sex, and race, annual average Medicare payments for all care were significantly higher for case groups compared to the control group, as were average payments for ophthalmic care only (all P < 0.0001). In addition, average payments for all care and for ophthalmic care were substantially higher for PDR cases compared to NPDR cases. CONCLUSION: These findings demonstrate substantial expenditures associated with diabetic retinopathy, and with PDR in particular, only part of which is due to ophthalmic care. Delaying progression may be associated with decreased Medicare expenditures.

Anterior juxtascleral delivery of anecortave acetate in eyes with primary open-angle glaucoma: a pilot investigation.

PURPOSE: To describe the intraocular pressure (IOP)-lowering effects in eyes with open-angle glaucoma (OAG) after treatment with an anterior juxtascleral depot of anecortave acetate. DESIGN: Prospective, interventional case series. METHODS: Seven eyes of six subjects with OAG, with uncontrolled IOP while being administered one or more topical medications, received 24 mg anecortave acetate delivered by anterior juxtascleral depot. IOP was assessed at baseline and regularly after treatment for up to 24 months. RESULTS: Mean IOP before anecortave acetate treatment was 31.3 +/- 11.3 mm Hg and dropped by 9.5 +/- 4.5 mm Hg (32.7% +/- 16.8%) within one week after treatment. This IOP reduction was sustained through six months (8.4 +/- 5.4 mm Hg [29.6% +/- 12.4%]) and 12 months (9.5 +/- 5.7 mm Hg [34.0% +/- 15.9%]) after a single anecortave acetate treatment. The injection process was well tolerated, and no eyes experienced any injection-related or drug-related serious adverse events. CONCLUSIONS: Both the anterior juxtascleral depot of a drug and anecortave acetate may be promising candidates for IOP reduction in eyes with OAG. Additional studies are required to establish better their efficacy and safety, optimal dosing frequency, mechanism of action, and potential additivity to other IOP-lowering therapies.

Estimated first-year costs of prostaglandin analogs with/without adjunctive therapy for glaucoma management: a United States perspective.

OBJECTIVE: To evaluate costs associated with prostaglandin analogs among newly-diagnosed glaucoma patients in a managed-care population. RESEARCH DESIGN AND METHODS: A cost minimization model compared annual costs for patients initiating therapy with one of the three prostaglandin analogs (bimatoprost, latanoprost, travoprost). The study cohort was identified from pharmacy claims and eligibility files of patients who met study inclusion criteria. Annual costs were estimated for patients initiating therapy with each prostaglandin based on treatment patterns and medication use over the year. Costs for outpatient physician visits and medications were estimated from standard sources. RESULTS: A total of 4444 patients met study criteria: 674 received travoprost, 729 received bimatoprost, and 3041 received latanoprost. More than 80% stayed on monotherapy for 1 year (82.9% of travoprost patients, 82.8% of bimatoprost patients, and 80.5% of latanoprost patients). Of those who required adjunctive therapy, the average number of days until starting adjunctive therapy was 130 days for travoprost patients, 94 days for bimatoprost patients, and 104 days for latanoprost patients. Average annual costs were $1198, $1290, and $1217 for patients treated with travoprost, bimatoprost, and latanoprost, respectively. CONCLUSIONS: The use of adjunctive therapy in glaucoma is an important driver of glaucoma management costs. This study demonstrates that the longer duration of monotherapy and the likelihood to use single rather than combination adjunctive agents contribute to lower annual costs among patients starting on travoprost compared with the other available prostaglandin analogs. Study limitations include the lack of clinical indicators in the study database; further, results may not be generalizable to patients who discontinue prostaglandin analogs or to the population of patients with glaucoma as a whole. Future studies with clinical and compliance indicators would further identify distinctions among treatment regimens.

Adherence in glaucoma: objective measurements of once-daily and adjunctive medication use.

PURPOSE: To determine with electronic monitoring an objective measurement of adherence in two populations of subjects: those using once-daily prostaglandin analogs as sole ocular hypotensive therapy (one-drug group) and those requiring an adjunctive medicine to the prostaglandin analog (two-drug group). DESIGN: Single-site, open-label, nonrandomized, parallel design of 60 days. METHODS: Sixty-two consecutive adult subjects with a diagnosis of open-angle glaucoma (OAG) or ocular hypertension: 31 were taking one drug and 31 were taking two drugs. An electronic event medication monitoring device was used to record each bottle opening. The main outcome measures were dosing errors (number of under-adherence or over-adherence events) and coverage (proportion of pharmacologic duration covered by dosing) relative to the ophthalmologist-prescribed regimen. RESULTS: Adherence to the prostaglandins once daily was good in both groups by all measures (

Evaluation of costs for cystoid macular edema among patients after cataract surgery.

PURPOSE: Little is known about the costs of cystoid macular edema (CME), an important complication associated with cataract surgery. The purpose of this analysis was to estimate the cost of treatment for CME in the United States. METHODS: Data were analyzed from the 1997 through 2001 Medicare 5% Beneficiary Encrypted Files. Beneficiaries who underwent cataract surgery were identified and stratified by diagnosis of CME (cases) or no diagnosis of CME (controls) within 1 year after surgery. Claims and reimbursements for ophthalmic care were identified. Subgroup analyses explored CME costs among beneficiaries with diabetes versus those without diabetes. RESULTS: Of 139,759 beneficiaries with cataract surgery, 1.95% (2,720) were diagnosed with CME. Annual total ophthalmic claims were 41% ($3,298) higher for cases than for controls; payments were 47% ($1,092) higher (both P < 0.0001). Approximately 16% (23,122) of cataract patients had diabetes. The rate of CME diagnosis was significantly higher for diabetics than for nondiabetics (3.05% vs. 1.73%, respectively). Differences in claims and payments between cases and controls were similar for diabetic and nondiabetic subgroups. CONCLUSION: CME is associated with substantial costs. Therapies that prevent or decrease CME severity are likely to result in cost savings, particularly among diabetic beneficiaries. Further analyses should explore the relationship of comorbidities to costs among CME patients.