Original article
Treatment Patterns for Neovascular Age-Related Macular Degeneration: Analysis of 284 380 Medicare Beneficiaries

https://doi.org/10.1016/j.ajo.2011.11.032Get rights and content

Purpose

To examine trends in the treatment of newly diagnosed neovascular age-related macular degeneration (AMD).

Methods

Among 284 380 Medicare beneficiaries with a new diagnosis between 2006 and 2008, we used the cumulative incidence function to estimate procedure rates and the mean frequency function to estimate the cumulative mean number of intravitreous injections. We used Cox log-binomial regression to estimate predictors of the use of vascular endothelial growth factor (VEGF) antagonists within 1 year after diagnosis. Discontinuation of anti-VEGF therapy was defined by absence of treatment for 12 months. Discontinuation rates were calculated using the Kaplan-Meier method.

Results

The proportion of patients receiving anti-VEGF therapy increased from 60.3% to 72.7%, photodynamic therapy decreased from 12.8% to 5.3%, and thermal laser treatment decreased from 5.5% to 3.2%. Black patients (hazard ratio, 0.77; 95% confidence interval, 0.75–0.79) and patients of other/unknown race (0.83; 0.81–0.84) were less likely than white patients to receive anti-VEGF therapy. Patients with dementia were less likely to receive anti-VEGF therapy (0.88; 0.88-0.89). Among patients who received anti-VEGF therapy, the mean number of injections within 1 year of the first injection was 4.3 per treated eye. Anti-VEGF therapy was discontinued in 53.6% of eyes within 1 year, and in 61.7% of eyes within 18 months.

Conclusions

Treatment of new neovascular AMD changed significantly between 2006 and 2008, most notably in the increasing use of anti-VEGF therapies. However, few patients treated with anti-VEGF medications received monthly injections, and discontinuation rates were high.

Section snippets

Data Sources

We obtained outpatient and carrier standard analytic files and the corresponding denominator files from the US Centers for Medicare & Medicaid Services for January 1, 2004, through December 31, 2009, for all Medicare beneficiaries having any claim with a diagnosis for neovascular AMD (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] diagnosis code 362.52). This time frame allowed for a 3-year study period with 1 year of history and 1 year of follow-up.

Results

Between January 1, 2005, and December 31, 2008, nearly 1 million Medicare beneficiaries had a diagnosis of AMD (Figure 1). More than 60% of these beneficiaries had a second diagnosis of AMD within 1 year, and approximately 60% of these had no neovascular AMD diagnosis in the previous year. Therefore, the study population included 284 380 Medicare beneficiaries with a diagnosis of neovascular AMD between January 1, 2006, and December 31, 2008. The source population from which the study

Discussion

In this analysis of a nationally representative cohort of 284 380 Medicare beneficiaries with newly diagnosed AMD, we observed an increase in the proportion of patients who received any treatment, as well as shifts in the types of treatments used between 2006 and 2008. During the 3-year study period, the proportion of patients receiving treatment increased from 68% to 75%, driven primarily by an increase in the proportion of patients receiving anti-VEGF injections. In tandem with the use of

Lesley H. Curtis, PhD, is an associate professor in medicine at the Duke University, Durham, North Carolina, and works primarily in the Duke Clinical Research Institute. A health services researcher by training, Dr Curtis oversees a portfolio of projects that use observational data to address questions related to clinical and comparative effectiveness, pharmacoepidemiology, health care delivery, and epidemiological trends. Her clinical areas of interest include heart failure, atrial

References (35)

  • Photodynamic therapy of subfoveal choroidal neovascularization in age-related macular degeneration with verteporfin: one-year results of 2 randomized clinical trials—TAP report

    Arch Ophthalmol

    (1999)
  • E.S. Gragoudas et al.

    Pegaptanib for neovascular age-related macular degeneration

    N Engl J Med

    (2004)
  • P. Mitchell et al.

    Ranibizumab (Lucentis) in neovascular age-related macular degeneration: evidence from clinical trials

    Br J Ophthalmol

    (2010)
  • D.F. Martin et al.

    Ranibizumab and bevacizumab for neovascular age-related macular degeneration

    N Engl J Med

    (2011)
  • Comparison of Age-Related Macular Degeneration Treatments Trials: Lucentis-Avastin Trial

  • Clinical Assessment of Age-Related Macular Degeneration Patients After Early Diagnosis and Treatment With Ranibizumab (COMPASS)

  • Lucentis in Advanced Macular Degeneration

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    Lesley H. Curtis, PhD, is an associate professor in medicine at the Duke University, Durham, North Carolina, and works primarily in the Duke Clinical Research Institute. A health services researcher by training, Dr Curtis oversees a portfolio of projects that use observational data to address questions related to clinical and comparative effectiveness, pharmacoepidemiology, health care delivery, and epidemiological trends. Her clinical areas of interest include heart failure, atrial fibrillation, eye diseases in older patients, and cancer.

    Lisa D. DiMartino is currently with the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

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