Prescription of Ocular ??-Blockers in??Patients with Obstructive Pulmonary Disease

Resource Utilization Among Glaucoma Patients in the UK Treated with Beta-Blocker and Non-Beta-Blocker Adjunctive Therapy: A Retrospective Cohort Analysis

Introduction

Few studies have examined outcomes and potential complications among glaucoma patients who are prescribed topical beta-blockers. This study examined resource usage (number of GP visits and hospitalizations) and diagnoses of respiratory or cardiovascular conditions among glaucoma patients prescribed beta-blockers compared to patients not prescribed beta-blockers.

Methods

A retrospective cohort analysis was conducted using data from the UK Clinical Practice Research Datalink (CPRD) database over the period January 1, 2006 to March 31, 2014. Adult patients with at least one diagnosis of glaucoma were categorized into beta-blocker users and non-beta-blocker users. Beta-blocker users were further separated into patients that maintained beta-blocker therapy and patients that discontinued beta-blocker treatment in year 2 of the post-index period. The CPRD data was queried directly to obtain the number of GP visits, and hospitalizations were extracted by linking the CPRD and Hospital Episode Statistics (HES) patient-level data.

Results

In the 12 months after being prescribed beta-blockers, patients that later discontinued beta-blocker treatment had a significantly higher average number of hospitalizations than patients that maintained beta-blocker therapy and the non-beta-blocker users (p < 0.05). In the year after beta-blocker initiation, there was a statistically significant within-group difference pre- and post-beta-blocker initiation for all groups, but the greatest number of GP visits occurred in the patients that subsequently discontinued beta-blocker treatment (mean 19.27). Patients that discontinued beta-blocker treatment were significantly more likely to have cardiovascular events than non-beta-blocker users in the post-index period (p < 0.05).

Conclusion

This study suggests that the introduction of beta-blockers in a certain group of patients who later discontinue their use is associated with increased use of medical resources (higher number of GP visits and hospitalizations) in glaucoma patients in the UK, which may be indicative of a potential relationship between use of topical beta-blockers in glaucoma therapy and adverse outcomes.

Electronic supplementary material

The online version of this article (doi:10.1007/s12325-017-0541-8) contains supplementary material, which is available to authorized users.

Randomized trial of brinzolamide/brimonidine versus brinzolamide plus brimonidine for open-angle glaucoma or ocular hypertension

INTRODUCTION

Fixed-combination intraocular pressure (IOP)-lowering medications simplify treatment regimens for patients requiring 2 ocular hypotensive agents to maintain sufficiently low IOP. The aim of this study was to evaluate the safety and efficacy of fixed-combination brinzolamide 1%/brimonidine 0.2% (BBFC) versus concomitant administration of brinzolamide 1% plus brimonidine 0.2% (BRINZ + BRIM) in patients with open-angle glaucoma or ocular hypertension.

METHODS

This was a prospective, phase 3, multicenter, double-masked, 6-month trial. Patients who had insufficient IOP control with monotherapy or who were receiving 2 IOP-lowering medications were randomized 1:1 to receive twice-daily BBFC or BRINZ + BRIM. IOP was assessed at 9 a.m. and 11 a.m. during week 2, week 6, month 3, and month 6 visits. The primary efficacy endpoint was mean diurnal IOP change from baseline to month 3; noninferiority was concluded if the upper limit of the 95% CI of the between-group difference was <1.5 mmHg. Supportive endpoints included mean IOP, IOP change from baseline, and percentage of patients with IOP <18 mmHg. Adverse events were recorded.

RESULTS

The mean diurnal IOP change from baseline with BBFC (least squares mean ± standard error -8.5 ± 0.16 mmHg) was noninferior to that with BRINZ + BRIM (-8.3 ± 0.16 mmHg; mean difference -0.1 mmHg; 95% CI -0.5 to 0.2 mmHg). The upper limits of the 95% CIs were <1.5 mmHg at all time points. Decreases from baseline >8 mmHg were observed for least squares mean diurnal IOP in both groups as early as week 2 and continued to the end of the study. The results of all other supportive endpoints were similar to the primary efficacy endpoint. The most common ocular adverse drug reactions were hyperemia of the eye (reported as ocular or conjunctival hyperemia), visual disturbances, ocular allergic reactions, and ocular discomfort. Common systemic adverse drug reactions included dysgeusia, oral dryness, and fatigue/drowsiness.

CONCLUSION

Brinzolamide 1%/brimonidine 0.2% fixed combination was as well tolerated and effective as concomitant therapy with its components. BBFC reduces treatment burden in patients who require multiple IOP-lowering medications.

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.

User experiences with different regional health information exchange systems in Finland

PURPOSE

The interest in cross-organizational Health Information Exchange (HIE) is increasing at regional, national and cross-European levels. The purpose of our study was to compare user experiences (usability) of different regional health information exchange system (RHIE) types as well as the factors related to the experienced level of success of different RHIE system types.

METHODS

A web-based questionnaire was sent to 95% of Finnish physicians aged between 25 and 65 years of age. RHIE systems were mainly available in the public sector and only in certain regions. Those 1693 physicians were selected from the 3929 respondents of the original study, who met these criteria. The preferred means (paper/fax vs. electronic) of cross-organizational HIE, and replies to the 11 questions measuring RHIE success were used as the main dependent variables.

RESULTS

Two thirds (73%) of the primary care physicians and one third (33%) of the specialized care physicians replied using an electronic RHIE system rather than paper or fax as a primary means of cross-organizational HIE. Respondents from regions where a regional virtual EHR (type 3) RHIE system was employed had used electronic means rather than paper HIE to a larger extend compared to their colleagues in regions where a master patient index-type (type 1) or web distribution model (type 2) RHIE system was used. Users of three local EHR systems preferred electronic HIE to paper to a larger extend than users of other EHR systems. Experiences with an integrated RHIE system (type 3) were more positive than those with other types or RHIE systems.

CONCLUSIONS

The study revealed User preferences for the integrated virtual RHIE-system (type 3) over the master index model (type 1) or web distribution model (type 2). Success of individual HIE tasks of writing, sending and reading were impacted by the way these functionalities were realized in the EHR systems. To meet the expectations of increased efficiency, continuity, safety and quality of care, designers of HIE systems also need to take into account the different HIE needs of primary care clinicians and their secondary care colleagues in hospitals. Both national legislation and local interpretations of data protection possibly hinder the full use of any RHIE systems. These findings should be taken into account when designing usable HIE systems. More qualitative research is needed on specific features of those local systems that are associated with positive or negative user experience.

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

BACKGROUND

Topical β-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 β-blockers.

OBJECTIVE

To evaluate inpatient and outpatient service encounters and payments associated with the topical adjunctive use of the β-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.

Use of glaucoma medications: state of the science and directions for observational research

PURPOSE

To summarize observational studies that focus on the use of glaucoma medications and to identify gaps in knowledge to guide future investigation.

DESIGN

Literature study.

METHODS

We searched the electronic databases MEDLINE, EMBASE, and PubMed for English language articles published through December 2009 using the search terms physician's practice patterns, drug prescriptions, pharmaceutical services, medication adherence, ophthalmology, glaucoma, and ophthalmic solutions. We categorized studies by areas of focus and extracted and summarized key features: study population, data sources, and main findings.

RESULTS

We identified 2224 articles by the search. Fifty-five described glaucoma medication use using large databases. Predominant areas of focus were: trends in prescription choices (n = 13); adherence, persistence, or both (n = 31); rational use of medications (n = 9); and policy-related issues (n = 2). Over the last decade, use of β-blockers and miotics has decreased substantially, whereas new agents, particularly prostaglandin analogs, have become more popular. Nonadherence was an issue in more than 25% of patients. A significant proportion of patients with comorbidities, contraindications, or both had received topical β-blockers.

CONCLUSIONS

To date, most studies have focused on adherence to glaucoma medications and changes in treatment choices. Major gaps in knowledge include prescribing patterns by prescriber specialty (ophthalmologists, primary care physicians, and optometrists), medication-related problems, and subsequent adverse health outcomes. Well-designed longitudinal observational studies addressing these gaps are warranted to improve patient safety.

Topical beta blockers in asthmatic patients-is it safe?

PURPOSE

To investigate the use of topical ocular anti-glaucoma medications by glaucomatous patients with obstructive pulmonary disease and their effect on related hospitalizations and emergency room visits.

PARTICIPANTS

We followed the electronic medical records of all the members in a district of the largest health maintenance organization in Israel (the "central district" of Clalit Health Services) older than 20 years (317,469 members); 6597 of them were on chronic topical anti-glaucoma treatment of which 693 (10.5%) suffered from obstructive pulmonary disease (OPD).

METHODS

In a historical cohort study, we documented all anti-glaucoma prescriptions filled in the district between January 1, 2001, and December 31, 2003, and all emergency room (ER) visits and hospitalizations in internal medicine, geriatric, or pulmonology departments.

MAIN OUTCOME MEASURES

The rate of hospitalization and emergency room visits during treatment with each anti-glaucoma medication.

RESULTS

Five hundred forty-four glaucomatous OPD patients (78.5%) were treated with topical beta-blockers, but only 169 (31.1%) of them received a cardio-selective beta-blocker (betaxolol). Patients treated with betaxolol each received more prescriptions per year than patients treated with timolol (p < 0.0001). Patients on topical betaxolol or timolol had 23.1 and 20.7 hospitalization days as well as 7.3 and 6.1 emergency room visits per 100 treatments per year, respectively, compared to a mean of 10 hospitalization days (p < 0.0001) and 5.0 ER visits for patients on non-beta-blocker anti-glaucoma medications.

CONCLUSIONS

A majority of glaucomatous patients with obstructive pulmonary disease were treated with topical beta-blockers, mostly non-cardioselective (timolol). Those patients were more prone to be hospitalized or visit the emergency room while on the medication.