Influence of Cost of Care and Adherence in Glaucoma Management: An Update

Predictors and long-term patterns of medication adherence to glaucoma treatment in Denmark-an observational registry study of 30 100 Danish patients with glaucoma

BACKGROUND

Self-treatment with glaucoma medication (eye drops) has been associated with adherence challenges. Poor adherence results in worse outcomes in terms of visual field loss.

OBJECTIVE

To investigate patterns in medication adherence among Danish patients with glaucoma in relation to selected predictors of adherence, long-term adherence patterns, and long-term societal economic consequences of poor adherence.

METHODS AND ANALYSIS

This register-based study included 30 100 glaucoma patients followed for 10 years between 2000 and 2018. Glaucoma was identified from the Danish national registers by diagnosis of Open Angle Glaucoma and/or by redeemed prescriptions of glaucoma medication. Logistic regression models were applied to estimate patient characteristics related to medical adherence. Diagnosis-related group fees were applied to estimate healthcare costs.

RESULTS

High adherence in the first year(s) of treatment was less likely among men (ORfirst year: 0.78, 95% CI: 0.75 to 0.82), younger individuals and among those with a positive Charlson Comorbidity Index (CCI) score (ORfirst year/CCI≥3: 0.71, 95% CI: 0.63 to 0.80). Adherence in the first year and in the first two years was associated with adherence in the fifth (ORfirst year: 4.55, 95% CI: 4.30 to 4.82/ORfirst two years: 6.47, 95% CI: 6.10 to 6.86) as with adherence in the 10th year with slightly lower estimates. Being medical adherent was related to higher costs related to glaucoma medication after 5 and 10 years comparing with poor adherence, whereas poor adherence was associated with a marked increase in long-term costs for hospital contacts.

CONCLUSION

Increasing age, female sex and low comorbidity score are correlated with better adherence to glaucoma treatment. Adherence in the first years of treatment may be a good predictor for future adherence. In the long term, patients with poor adherence are overall more expensive to society in terms of hospital contacts.

Factors affecting adherence to glaucoma medication: Patient perspective from North India

PURPOSE

Adherence to glaucoma medical therapy is a key factor in achieving target intraocular pressure to prevent glaucoma progression. To determine factors affecting medication adherence in glaucoma patients in an urban population belonging to poor socioeconomic status.

METHODS

A cross-sectional study was conducted on 200 patients attending glaucoma services in a tertiary referral hospital of North India. Adherence to medication was determined subjectively by questionnaire and objectively by counting the number of used bottles at the end of a month or during refill, whichever was earlier. Patient-related parameters in adherence toward glaucoma medication were studied based on demography, knowledge, attitudes, and practices (KAP). The statistical techniques of bivariate and multivariate logistic regression were adopted to test the objective.

RESULTS

The population was statistically homogeneous based on gender and income in both groups. A large proportion of patients had bilateral disease (87%) and were on two or more medications (62.5%). Adherence to glaucoma medical therapy was seen in 68% of patients, with knowledge about glaucoma present in 58% of patients. Deterrents to drug adherence were identified as forgetfulness (71%), unavailability of drugs (19%) or funds to purchase the same (26%), polypharmacy (21%), and side effects (5%). Dependence on an escort by 44% and dependence on hospital supply of medications by 60% emerged as the contextual factors requiring scrutiny while prescribing lifelong glaucoma medications. Disease misconceptions (53%) were prevalent and drug instillation practices were unsatisfactory (57%).

CONCLUSION

The study offers insight into patients' perspectives regarding the lifetime use of antiglaucoma medications and focuses on key issues linked to drug nonadherence.

Determinants of adherence to treatment in patients with ophthalmic conditions

BACKGROUND

The objective of this study was to identify and determine factors associated with patients' ophthalmic adherence in common ocular conditions from randomized clinical trials (RCT).

RESEARCH DESIGN METHODS

A univariate analysis with proportions, a bivariate analysis using polychoric correlations, and logistic regression (LR) models were used. The collected dataset was made up of records from RCT. Using three validated LR models, factors were identified and ranked based on their adjusted odds ratio and their statistical significance to adherence.

RESULTS

A total of 1,087 valid patients were included in this analysis, of which 88.96% presented adherence. All models were calibrated, had a good performance, were well specified and cost-effective using the Hosmer-Lemeshow test, metrics for class imbalance, link test approach and Akaike's criteriums, respectively.

CONCLUSION

We identified as determinants for encouraging good ophthalmic adherence the adverse events presented, duration of the study, female sex, and older age; other determinants such as medical condition, protocol treatment, type of treatment and disease are all risk factors for adherence. Improvements in ophthalmic adherence may be achieved by focused attention to young male patients with chronic degenerative diseases such as glaucoma or ocular hypertension (especially those who need combination therapy) and developing medications with reduced side effects.

A Randomized, Double-Masked, Active-Controlled, Crossover Phase III Equivalence Study of Generic Dorzolamide 2% versus Innovator Trusopt® Eye Drop Solution in Subjects with Open-Angle Glaucoma or Ocular Hypertension

Background

The aim of this study was to demonstrate the equivalence of generic dorzolamide 2% eye drops solution versus the innovator formulation (Trusopt® eye drops solution) in patients with open-angle glaucoma or ocular hypertension.

Methods

This prospective, monocentric, double-masked, active-controlled crossover phase III study included 32 patients. After washout, patients were randomized to reference product (Trusopt®) or test product (dorzolamide 2% eye drops, Rompharm Company SRL) for a 4-week period. Subsequent washout and crossover were performed. Drops were applied t.i.d. The primary efficacy endpoint was the difference in mean diurnal IOP. Goldmann applanation tonometry was performed at 8 am, 12 pm, and 4 pm at each visit, and safety was assessed by documentation of adverse events (AEs). Therapy adherence was documented by self-reporting and eye drop bottle weighing. An ANOVA with treatment, sequence, study period, and patient within the sequence as effects was performed and an additional post hoc ANCOVA including the baseline IOP was also performed.

Results

34 patients were randomized and analyzed in the safety population. The per-protocol population included 32 patients. According to the self-report, all patients were >80% compliant. Under the ANCOVA model, the 90% confidence interval for the average change of the IOP −0.27 mmHg (−1.17 mmHg–0.64 mmHg) is included by the acceptance range −1.5 mmHg to +1.5 mmHg after excluding 2 patients, which had falsely reported high therapy adherence. No clinically relevant difference was observed in frequency or severity of the AEs between both treatments.

Conclusions

This study showed the equivalence of the tested generic dorzolamide 2% eye drops solution to the reference product Trusopt® eye drops solution. Trial Registration. This trial is registered with (ClinicalTrials.gov (identifier: NCT00878917) on April 9, 2009).

Novel Osmoprotective DOPC-DMPC Liposomes Loaded with Antihypertensive Drugs as Potential Strategy for Glaucoma Treatment

Glaucoma is a group of chronic irreversible neuropathies that affect the retina and the optic nerve. It is considered one of the leading causes of blindness in the world. Although it can be due to various causes, the most important modifiable risk factor is the elevated intraocular pressure (IOP). In this case, the treatment of choice consists of instilling antihypertensive formulations on the ocular surface. The chronicity of the pathology, together with the low bioavailability of the drugs that are applied on the ocular surface, make it necessary to instill the formulations very frequently, which is associated, in many cases, with the appearance of dry eye disease (DED). The objective of this work is the design of topical ocular formulations capable of treating glaucoma and, at the same time, preventing DED. For this, two liposome formulations, loaded with brimonidine or with travoprost, were Tadeveloped using synthetic phospholipids and enriched by the addition of compounds with osmoprotective activity. The proposed formulations not only presented physicochemical characteristics (size, pH, osmolarity, surface tension, and viscosity) and encapsulation efficiency values (EE% of 24.78% and ≥99.01% for brimonidine and travoprost, respectively) suitable for ocular surface administration, but also showed good tolerance in human corneal and conjunctival cell cultures, as well as an in vitro osmoprotective activity. The hypotensive effect of both liposomal formulations was evaluated in normotensive albino New Zealand rabbits, showing a faster and longer lasting reduction of intraocular pressure in comparison to the corresponding commercialized products used as control. According to these results, the hypotensive liposomal formulations combined with osmoprotective agents would result in a very promising platform for the treatment of glaucoma and the simultaneous protection of the ocular surface.

Anterior segment imaging in minimally invasive glaucoma surgery - A systematic review

Minimally invasive glaucoma surgery (MIGS) has grown in popularity over the past decade. This systematic review explores the peri-operative and intraoperative application of anterior segment imaging to maximize the efficacy and safety of MIGS. A review of the PubMed, EMBASE and CINAHL databases was conducted, with inclusion criteria restricted to MIGS that had received United States Food and Drug Administration (FDA) premarket approval, FDA 510(K) premarket notification, or were listed as a class 1 device exempt from FDA approval or notification. 21 manuscripts from 21 unique studies were identified pertaining to MIGS devices including the XEN Gel Stent, Trabectome, iStent Inject, 1st-generation iStent and the Kahook Dual Blade (KDB). Anterior segment imaging modalities included anterior segment optical coherence tomography (AS-OCT), ultrasound biomicroscopy (UBM), aqueous angiography, OCT volumetric scans and in vivo confocal microscopy. Identification and evaluation of aqueous outflow pathways before and after MIGS have potential for improving patient preoperative patient selection and postoperative outcomes. Intraoperative imaging potentially provides the resolution needed for good visualization of angle anatomy and accurate evaluation of surgical endpoints in angle-based MIGS. Anterior segment imaging has been used to identify procedural complications, provide objective information on implant location in relation to surrounding anatomy, assess the post-implantation structural impact of MIGS devices and manage bleb failure and scarring. Technical difficulties in incorporating imaging modalities into the surgical microscope, variable quality of images and optical interference from ocular structures or surgical instruments are remaining barriers, which discourage the widespread clinical use of this technology.

Racial and Ethnic Disparities in Cost-Related Barriers to Medication Adherence Among Patients With Glaucoma Enrolled in the National Institutes of Health All of Us Research Program

IMPORTANCE

Ability to afford medication is a major determinate of medication adherence among patients.

OBJECTIVE

To determine cost-related barriers to medication adherence by race and ethnicity in a nationwide cohort of patients with glaucoma.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included patients with glaucoma enrolled in the National Institutes of Health All of Us Research Program, a nationwide longitudinal cohort of US adults, with more than 300 000 currently enrolled. Individuals with a diagnosis of glaucoma based on electronic health record diagnosis codes who participated in the Health Care Access and Utilization survey and had complete data on all covariates were studied. Data were collected from June 2016 to March 2021, and data were analyzed from August to November 2021.

EXPOSURES

Race and ethnicity defined as non-Hispanic African American, non-Hispanic Asian, Hispanic, and non-Hispanic White.

MAIN OUTCOMES AND MEASURES

Logistic regression was used to evaluate the association between reported cost-related barriers to medication adherence (could not afford prescription medication, skipped medication doses to save money, took less medication to save money, delayed filling a prescription to save money, asked for lower-cost medication to save money, bought prescriptions from another country to save money, and used alternative therapies to save money) and race and ethnicity, adjusting multivariable models by age, gender, health insurance status, education, and income. Odds ratios of these barriers were obtained by race and ethnicity, with non-Hispanic White race as the reference group.

RESULTS

Of 3826 included patients with glaucoma, 481 (12.6%) were African American, 119 (3.1%) were non-Hispanic Asian, 351 (9.2%) were Hispanic, and 2875 (75.1%) were non-Hispanic White. The median (IQR) age was 69 (60-75) years, and 2307 (60.3%) were female. After adjusting for confounders, non-Hispanic African American individuals (odds ratio, 1.82; 95% CI, 1.34-2.44) and Hispanic individuals (odds ratio, 1.77; 95% CI, 1.25-2.49) were more likely than non-Hispanic White individuals to report not being able to afford medications. Further, despite having the lowest rate of endorsing difficulty affording medications, non-Hispanic White individuals were equally likely to ask for lower-cost medication from their clinicians as individuals of racial and ethnic minority groups.

CONCLUSIONS AND RELEVANCE

In this study, there was significantly higher odds of self-reported difficulty affording medications among non-Hispanic African American and Hispanic individuals compared with non-Hispanic White individuals. Clinicians should be proactive and initiate discussions about costs in an effort to promote medication adherence and health equity among patients.

Topical Treatment of Elevated Intraocular Pressure in Patients with Graves' Orbitopathy

Purpose: In this study, we evaluated the efficacy of topical hypotensive treatment and/or systemic corticosteroids therapy in patients with elevated intraocular pressure and Graves’ orbitopathy (GO). Methods: We included 172 eyes in 86 individuals with duration of GO ≥ 3 months, intraocular pressure in either eye ≥ 25.0 mmHg, and GO ranked ≥ 3 at least in one eye in modified CAS form. The study subjects were divided into three treatment subgroups: subgroup I was administered latanoprost once a day; subgroup II was administered a combined preparation of brimonidine and timolol BID; subgroup III was the control group, not receiving any topical hypotensive treatment. All the study participants received systemic treatment, intravenous corticosteroid therapy at the same dose, according to the European Group of Graves’ Orbitopathy (EUGOGO) guideline. Results: On the final visit, the mean IOP value was significantly lower in all treatment subgroups compared to the initial values. In both subgroups receiving topical treatment, the IOP reduction was higher than in the control group receiving systemic corticosteroids only. However, the latanoprost eye drops decreased intraocular pressure more effectively than drops containing brimonidine and timolol. Conclusion: Topical ocular hypotensive treatment is effective in reducing intraocular pressure in GO and decreases intraocular pressure more effectively than systemic corticosteroid therapy alone.

Quality of Life After Combined Cataract and Minimally Invasive Glaucoma Surgery in Glaucoma Patients

Purpose

To determine the quality of life (QOL) in glaucoma patients undergoing combined cataract and minimally invasive glaucoma surgery from various perspectives ranging from personal, social, occupational life, and economic status.

Settings and Design

A cross-sectional study design at King Fahd Hospital of the University, Khobar, Saudi Arabia.

Methods

Patients undergoing phacoemulsification in conjunction with various forms of minimally invasive glaucoma surgery (MIGS) for each patient, including either Kahook Dual Blade (KDB) goniotomy, iStent, iStent inject and gonioscopy-assisted transluminal trabeculotomy (GATT), were included in the study between 2018 and 2019. Data were collected through a self-administered questionnaire based on the Visual Function Questionnaire (VFQ-25) for the 25-item National Eye Institute.

Results

The study included 93 eyes of 78 patients (40 males and 38 females) who had MIGS: 50 KDB, 13 iStent, 23 iStent inject, and 7 GATT. An overall reduction in the number of anti-glaucoma medications (p<0.001) was statistically significant. In the study, 36.6% of patients had a better social life, but 85.2% had no change in occupational life. Eventually, 86% were satisfied with the operation’s outcome, and 79% confirmed that the overall quality of life improved after the procedure.

Conclusion

Evaluating QOL is a crucial component of glaucoma treatment. More research is needed on MIGS and their relationship to QOL. In the future, MIGS may provide the desired outcomes in controlling glaucoma and improving the QOL.