Glaucoma Management among Individuals Enrolled in a Single Comprehensive Insurance Plan

doi:10.1016/j.ophtha.2005.02.030

Ophthalmology

Volume 112, Issue 9, September 2005, Pages 1500-1504

https://doi.org/10.1016/j.ophtha.2005.02.030 Get rights and content

Objective

To determine the management patterns for glaucoma and suspect glaucoma in a nationally representative sample of newly treated persons.

Design

Retrospective cohort study of persons enrolled in a large managed care organization.

Participants

One thousand seven hundred twelve diagnosed suspects and 3623 diagnosed glaucoma patients.

Methods

Linked pharmacy and patient care data were used to examine the glaucoma management and treatment patterns in this cohort of persons insured by a single managed care organization. Rates of monitoring and treatment were calculated for the 3 study groups.

Main Outcome Measures

Probability of monitoring (return visits, visual fields [VFs], and optic nerve head imaging or photography) and treatment (argon laser trabeculoplasty [ALT] and surgery) for newly treated persons with suspect and glaucoma diagnoses.

Results

After a median follow-up of 440 days, 83% of treated diagnosed suspects had had a billed follow-up office visit to either an optometrist or an ophthalmologist at any time during follow-up, 46% had had at least one billed VF, and 13% had had some form of optic nerve head imaging. Rates were slightly higher for those with diagnosed glaucoma (P>0.05). Surgery and ALT were performed rarely in this treated population (1%–6% at 2 years).

Conclusions

This study suggests that a large proportion of individuals felt to require treatment for glaucoma or suspect glaucoma are falling out of care and are being monitored at rates lower than expected from recommendations of published guidelines. More research is needed to confirm these findings and to determine the reasons for loss to follow-up and low monitoring rates.

Section snippets

Study Cohort Definition

All individuals enrolled in commercial health plans in the UnitedHealthcare Research Database between July 1, 1995 and December 31, 2001 were eligible for the current study. Individuals with a diagnosis of glaucoma or suspect glaucoma were eligible to be in the current study if they (1) had ≥365 days of continuous enrollment in UnitedHealthcare before their first recorded diagnosis of glaucoma or suspect glaucoma; (2) were >30 years old on the diagnosis date; (3) had not had a claim suggesting

Results

A total of 1712 diagnosed suspects and 3623 diagnosed glaucoma patients met enrollment criteria and filled at least one prescription for ocular hypotensive therapy during follow-up. The median follow-up for this group was 440 days. Among diagnosed suspects, 83% had a billed follow-up office visit to either an optometrist or an ophthalmologist at some point during follow-up, 46% had at least one billed VF, and 13% had some form of optic nerve head imaging (Table 1). Rates were slightly higher

Discussion

Using a large national insurance database of patients, this study suggests that >15% of those diagnosed as having glaucoma or as glaucoma suspects who filled at least one prescription for topical ocular hypotensive agents did not have a documented follow-up visit during the study period (median of about 440 days). The glaucoma suspect preferred practice pattern (PPP) guideline⁷ recommends that even glaucoma suspects with low levels of risk factors should be seen at least every 18 months. In

References (13)

L.H. Hertzog et al.
Glaucoma care and conformance with preferred practice patterns. Examination of the private, community-based ophthalmologist
Ophthalmology
(1996)
K.G. Albrecht et al.
Conformance with preferred practice patterns in caring for patients with glaucoma
Ophthalmology
(1994)
O. Kosoko et al.
Risk factors for noncompliance with glaucoma follow-up visits in a residents’ eye clinic
Ophthalmology
(1998)
L.S. Abrams et al.
Agreement among optometrists, ophthalmologists, and residents in evaluating the optic disc for glaucoma
Ophthalmology
(1994)
A.M. Fremont et al.
Patterns of care for open-angle glaucoma in managed care
Arch Ophthalmol
(2003)
M.A. Kass et al.
The Ocular Hypertension Treatment Studya randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma
Arch Ophthalmol
(2002)

There are more references available in the full text version of this article.

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2023, Ophthalmology Glaucoma
To report the outcomes of frontloaded visual field (VF) testing (2 tests per eye on the same visit) over 2 longitudinal, consecutive visits using SITA-Faster (SFR) in terms of global indices, reliability metrics, and test duration.
Prospective longitudinal study.
A total of 902 eyes of 463 subjects with normal, suspect, or manifest glaucoma.
Two intravisit SFR VF tests (T1 and T2) per eye at an initial (T_i) and follow-up (T_f) visit.
Intra- and intervisit global indices, reliability metrics, and test durations.
The mean age of the subjects was 63.6 years, and 58.3% were male. Seven hundred ninety eyes (87.4%) had a diagnosis of glaucoma or glaucoma suspicion. The mean duration between visits was 265.0 (standard deviation 98.8) days. In total, 3608 VF tests were analyzed, with the correlation of mean deviation (MD) values of the frontloaded tests at each visit high (T1/T2 MD correlation at initial visit r = 0.83, root mean squared error [RMSE] = 1.26, follow-up visit r = 0.83, RMSE = 1.25, P < 0.0001) and greater than the correlation of MD between visits (T_i1/T_f1 MD correlation r = 0.72, RMSE = 1.31). There was a significant intra-visit decrease in rates of abnormally high sensitivity in the glaucoma hemifield test (3.2% vs. 1.6%, P = 0.0023) and rates of unreliable test results (15.4% vs. 9.2%, P = 0.002) from T1 to T2 in both visits, with a corresponding significant decrease in MD (–1.28 dB vs. –1.68 dB, P < 0.0001) and VF index (P = 0.03). The mean duration of each SFR test was 132.6 (SD 27.2) seconds.
Frontloading VFs using SFR produced sets of repeatable perimetric data with significant improvement of reliability indices from the first to second test. This may help increase testing frequency at minimal time cost to meet recommended guidelines and for evaluating patients prone to high variability.
The author(s) have no proprietary or commercial interest in any materials discussed in this article.
An Analysis of the Quality, Reliability, and Popularity of YouTube Videos on Glaucoma
2022, Ophthalmology Glaucoma
To evaluate the quality, reliability, and popularity of videos relating to glaucoma on YouTube.
Retrospective, cross-sectional study of YouTube videos about glaucoma.
One hundred YouTube videos were analyzed for this study.
An online YouTube search for glaucoma videos was conducted simulating a user search using the keywords glaucoma, high eye pressure, and high intraocular pressure. The first 100 videos were analyzed, and each video was evaluated by 2 independent reviewers using the modified DISCERN (scale, 1–5), Journal of the American Medical Association (JAMA; scale, 0–4), and Global Quality (GQ; scale, 1–5) criteria to assess quality and reliability. Videos were categorized further into 3 groups depending on the source of their upload. Group 1 comprised videos uploaded by academic or government institutions, group 2 comprised videos uploaded by private medical practices, and group 3 comprised videos uploaded by independent users.
Modified DISCERN, JAMA, and GQ scores for quality and reliability of information and video power index (VPI) for video popularity.
No substantial difference in scoring was observed between the 2 independent reviewers. The overall mean ± standard error (SE) scores were modified DISCERN score, 3.81 ± 0.06; JAMA score, 2.93 ± 0.07; and GQ score, 3.98 ± 0.06. The overall mean ± SE VPI score was 9.9 ± 2.9. Significant positive correlations were found between video popularity and quality of information for all 3 criteria (P < 0.05). The videos in groups 1 and 2 showed higher modified DISCERN scores than those in group 3, but did not score higher with either the JAMA or GQ criteria. Videos in group 3 were the most popular when compared with videos in groups 1 or 2 (P < 0.01).
Overall, many of the videos had adequate quality and reliability scores. No difference was found among groups 1 through 3 for 2 of the 3 criteria used, suggesting a similar quality of information provided among academic, private, and independent sources.
Novel Eye Drop Delivery Aid Improves Outcomes and Satisfaction
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To compare a nose-pivoted drop delivery device (NPDD) with traditional eye drop delivery in glaucoma subjects.
Repeated-measures case series.
Fifty glaucoma subjects (100 eyes) who reported difficulty self-administering eye drops.
We compared eye drop delivery using a NPDD against traditional delivery techniques at baseline (baseline traditional) and after standardized teaching (post-teaching traditional). Subjects used a 1-to-10 scale (10 being easiest) to rate the ease of delivery with each technique and completed a satisfaction survey. Two graders used digital video to independently review eye drop delivery and recorded: (1) accurate placement: the eye drop reached the ocular surface; (2) no contact: no bottle tip contact against the ocular or periocular surface; and (3)number of eye drops dispensed. We defined primary success as accurate placement and no contact; secondary success as primary success with only 1 drop dispensed.
We used logistic-transformed generalized estimating equation (GEE) regression to compare technique satisfaction, accuracy, no contact, and primary and secondary success. Number of drops dispensed was compared using a Cox model.
Forty-seven of 50 subjects (94%) preferred the NPDD over traditional eye drop delivery. The mean score for ease of use was higher for the NPDD (8.9 ± 1.1) than baseline traditional (6.7 ± 2.1; P < 0.001) and post-teaching traditional (7.0 ± 2.0; P < 0.001). Forty-nine of 50 (98%) subjects thought the NPDD was comfortable to use and would recommend the device. The eye drop reached the ocular surface in a similar percentage of subjects (>90%) with each method. The bottle tip contacted fewer eyes with the NPDD (10 eyes) than baseline traditional (33 eyes; P < 0.001) and post-teaching traditional (25 eyes; P = 0.009). The number of drops dispensed was lower with the NPDD (1.7 ± 1.2) than baseline traditional (2.2 ± 1.6; P = 0.017) and post-teaching traditional (2.4 ± 1.8; P = 0.006). The NPDD increased primary and secondary success of eye drop delivery (86% and 54%, respectively) compared to baseline traditional (66% [P = 0.001] and 28% [P < 0.001]) and post-teaching traditional (70% [P = 0.005] and 40% [P = 0.018]).
Eye drop users preferred the NPDD over traditional eye drop delivery. The NPDD improved eye drop delivery success, reduced bottle tip contact, and decreased the number of eye drops wasted.
Extraocular, periocular, and intraocular routes for sustained drug delivery for glaucoma
2021, Progress in Retinal and Eye Research
Although once daily anti-glaucoma drug therapy is a current clinical reality, most therapies require multiple dosing and there is an unmet need to develop convenient, safe, and effective sustained release drug delivery systems for long-term treatment to improve patient adherence and outcomes. One of the first sustained release drug delivery systems was approved for the reduction of intraocular pressure in glaucoma patients. It is a polymeric reservoir-type insert delivery system, Ocusert™, placed under the eyelid and on the ocular surface for zero-order drug release over one week. The insert, marketed in two strengths, released pilocarpine on the eye surface. While many clinicians appreciated this drug product, it was eventually discontinued. No similar sustained release non-invasive drug delivery system has made it to the market to date for treating glaucoma. Drug delivery systems under development include punctal plugs, ring-type systems, contact lenses, implants, microspheres, nanospheres, gels, and other depot systems placed in the extraocular, periocular, or intraocular regions including intracameral, supraciliary, and intravitreal spaces. This article discusses the advantages and disadvantages of the various routes of administration and delivery systems for sustained glaucoma therapy. It also provides the reader with some examples and discussion of drug delivery systems that could potentially be applied for glaucoma treatment. Interestingly, one intracamerally injected implant, Durysta™, was approved recently for sustained intraocular pressure reduction. However, long-term acceptance of such devices has yet to be established. The ultimate success of the delivery system will depend on efficacy relative to eye drop dosing, safety, reimbursement options, and patient acceptance. Cautious development efforts are warranted considering prior failed approaches for sustained glaucoma drug delivery. Neuroprotective approaches for glaucoma therapy including cell, gene, protein, and drug-combination therapies, mostly administered intravitreally, are also rapidly progressing towards assessment in humans.
Drug delivery devices for retinal diseases
2018, Advanced Drug Delivery Reviews
Citation Excerpt :
Still, lowering the intraocular pressure, the only proven treatable risk factor, is an effective initial approach for reducing the progression of the glaucoma, and there are five major classes of drugs used for lowering intraocular pressure, which are usually administered in combination as eye drops [8]. Poor patient compliance (e.g., due to forgetfulness) has limited the improvement of the disease states; less than half of the patients with glaucoma are said to maintain normal intraocular pressure [23–25]. Because retinal and vitreal bioavailability of drugs administered through this route is very low (about 0.001% or less) [26–28], delivering neuroprotective drugs to the posterior segment of the eye by topical instillation to reduce retinal degeneration is difficult [29].
Retinal degenerative diseases are a leading cause of irreversible blindness and visual impairment, affecting millions of people worldwide. Although intravitreal injection can directly deliver drugs to the posterior segment of the eye, it is invasive and associated with serious side effects. The design of drug delivery systems targeting the posterior segment of the eye in a less invasive manner has still been challenging because of various anatomical and physiological barriers. In this review, we provide an overview of the current implant device-based approaches used for treating retinal degenerative diseases. We then offer our perspectives on future directions and challenges that remain for developing more effective device-based therapies for retinal diseases.
Detecting Visual Field Progression
2017, Ophthalmology
Timely detection of glaucomatous progression is crucial in the delivery of glaucoma care. Clinical judgment may be used to make this assessment, but relatively modest agreement among practitioners supports the use of complementary methods. Event-based analyses take into account expected localized test–retest variabilities in sensitivity, and trend-based analyses are helpful for determining and predicting overall visual function. Landmark clinical trials have used various visual field progression criteria as end points with variable performances. Short- and long-term fluctuations as well as inadequate testing frequency are limitations in visual field analysis for glaucomatous progression. Ongoing improvements in statistical techniques as well as incorporation of functional and structural measures into a single model likely will lead to an enhanced ability to detect glaucomatous progression and will allow for more timely and appropriate therapy.

View all citing articles on Scopus

Manuscript no. 2004-230.

This work was supported by a contract between Ingenix Epidemiology and Pfizer Inc. Dr Friedman is the recipient of the Research to Prevent Blindness (New York, New York) Robert E. McCormick Scholarship and the American Geriatrics Society (New York, New York) Dennis Jahnigen Scholars Award. Drs Quigley and Friedman are paid consultants to Pfizer Inc.

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Original articleGlaucoma Management among Individuals Enrolled in a Single Comprehensive Insurance Plan

Objective

Design

Participants

Methods

Main Outcome Measures

Results

Conclusions

Section snippets

Study Cohort Definition

Results

Discussion

Ophthalmology

Ophthalmology

Ophthalmology

Ophthalmology

Patterns of care for open-angle glaucoma in managed care

Arch Ophthalmol

The Ocular Hypertension Treatment Studya randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma

Arch Ophthalmol

Original article
Glaucoma Management among Individuals Enrolled in a Single Comprehensive Insurance Plan