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Dang S, Parke DW, Sodhi GS, Eichenbaum D, Nielsen J, Danzig C, Lalwani G, Moinfar N, London N, Kimura A, Jumper JM, Lord K, Sheth V, Pieramici D, Orlin A, Madson A, Horton M, Blim J, Cao JA, Thompson J, Khanna S, Wykoff CC, Shah AR. Anti-VEGF Pharmaceutical Prior Authorization in Retina Practices. JAMA Ophthalmol 2024; 142:716-721. [PMID: 38935350 PMCID: PMC11211988 DOI: 10.1001/jamaophthalmol.2024.2217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 04/28/2024] [Indexed: 06/28/2024]
Abstract
Importance Anti-vascular endothelial growth factor (VEGF) intravitreal injections, a mainstay of treatment for many retinal diseases to optimize visual outcomes, have been included in prior authorization (PA) initiatives. However, if clinicians are extremely accurate in their use of anti-VEGF medications, such administrative burdens may need reconsideration. Objective To quantify PA for anti-VEGF medications (aflibercept, ranibizumab, and bevacizumab) that were approved and determine associated administrative burdens experienced by retina practices. Design, Setting, and Participants Prospective multicenter quality improvement study conducted from January 2022 through June 2022, and participants were 9 private retina practices across the US. Main Outcomes and Measures Overall rate of approval of PA requests, reasons for requesting PA, and overall rate of delay of care resulting from PA procedures. Results In total, 2365 PA requests were recorded, 2225 of which met inclusion criteria. Overall, 2140 (96.2%) requests were approved. The most common reason for requesting PA, at 64% (1423 of 2225 requests), was reauthorization for a previously utilized medication. Of the 2140 approvals, 59.6% (1277) resulted in a delay in care greater than 24 hours, and 40% (863) were given on the date of service. In a granular analysis of a subset of delayed approvals, 23.9% (173 of 725) were approved within 1 day, 15.9% (115 of 725) were approved within 2 to 3 days, 21.5% (156 of 725) were approved within 4 to 7 days, 26.3% (191 of 725) were approved within 8 to 31 days, and 12.4% (90 of 725) were approved within more than 31 days. Overall, PA denial for step therapy was 2.9% (65 of 2225) of requests and uncovered diagnoses was 0.9% (20 of 2225) of requests. The median staff time spent to obtain a single PA was 100 (range, 0-200) minutes. Conclusions and Relevance In this study, PA requests were almost always approved but led to a delay in patient care in most patients. The current study suggests that the PA process may not be effective for retina specialists if these results can be generalized to other practices in the US and if less burdensome and less costly approaches could result in similar approval rates. Potential short-term solutions may include eliminating the PA process for bevacizumab and reauthorizations for established patients.
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Affiliation(s)
- Sabin Dang
- The Retina Institute, St Louis, Missouri
| | | | | | | | | | - Carl Danzig
- Rand Eye Institute, Deerfield Beach, Florida
| | | | | | | | | | | | - Ken Lord
- Retina Associates of Southern Utah, St George
| | | | | | | | - Allison Madson
- American Society of Retina Specialists, Chicago, Illinois
| | - Monica Horton
- American Society of Retina Specialists, Chicago, Illinois
| | - Jill Blim
- American Society of Retina Specialists, Chicago, Illinois
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Begaj T, Jeong D, Park JG, Runner MM, Capone A, Dass AB, Drenser KA, Faia LJ, Farley ND, Garretson BR, Hassan TS, Mahmoud TH, Margherio A, Raphaelian PV, Randhawa S, Ruby AJ, Sneed S, Rao P, Wolfe JD, Williams GA. LONG-TERM USE OF ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY FOR NEOVASCULAR AGE-RELATED MACULAR DEGENERATION. Retina 2024; 44:222-229. [PMID: 37903288 DOI: 10.1097/iae.0000000000003961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2023]
Abstract
PURPOSE Although pivotal trials have demonstrated efficacy of anti-vascular endothelial growth factor therapy in neovascular age-related macular degeneration, there is a paucity of clinical data about the long-term (>5 years) treatment. METHODS Retrospective analysis of all patients with neovascular age-related macular degeneration who were actively treated, had received >40 anti-vascular endothelial growth factor injections, and were followed for ≥5 years. Snellen-corrected visual acuity, initial drug choice, and times elapsed between treatments were collected. Rates of endophthalmitis and outcomes of submacular hemorrhage were also evaluated. RESULTS A total of 88 patients (162 eyes) met the inclusion criteria: the average patient age was 86.3 years with an average follow-up period of 7.6 years. The average total number of injections per eye was 69 (18.0 SD); a total of 11,208 injections were given throughout the study period, and 6 cases (0.05%) of endophthalmitis were observed. Overall, there was a clinical and statistical difference in average Snellen-corrected visual acuity at Injections #2,#3, #4, #5, #6, #10, and #20, as compared with baseline ( P = 0.03, P < 0.01, P = 0.02, P < 0.01, P = 0.01, P = 0.01, P < 0.01, respectively). Patients in the Snellen-corrected visual acuity subgroup 20/20 to 20/40 maintained vision until injection #30. Seven eyes experienced a visually significant submacular hemorrhage. CONCLUSION This neovascular age-related macular degeneration cohort received on average eight anti-vascular endothelial growth factor injections per year for approximately 8 years; eyes with good (≥20/40) initial baseline vision maintained their visual acuity, whereas those with worse Snellen-corrected visual acuity (≤20/50) had a robust initial improvement that diminished with time. Most patients were maintained on the same initial drug of choice and the rate of endophthalmitis was low.
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Affiliation(s)
- Tedi Begaj
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - Daeun Jeong
- Oakland University William Beaumont, Rochester, Michigan
| | - Jong G Park
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - Margaret M Runner
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - Antonio Capone
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - A Bawa Dass
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - Kimberly A Drenser
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - Lisa J Faia
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - Nathan D Farley
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
| | - Bruce R Garretson
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - Tarek S Hassan
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - Tamer H Mahmoud
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - Alan Margherio
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
| | | | - Sandeep Randhawa
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - Alan J Ruby
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - Scott Sneed
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - Prethy Rao
- Retina and Vitreous of Texas, Houston, Texas
| | - Jeremy D Wolfe
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - George A Williams
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
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