Cost comparison of commonly used postoperative topical ophthalmic antibiotics

Fill levels, cost comparisons, and expulsion force requirements of commonly used topical ophthalmic nonsteroidal anti-inflammatory drugs

PURPOSE

To determine volume fill levels, estimated costs, and force expulsion requirements per bottle of topical ophthalmic nonsteroidal anti-inflammatory drugs (NSAIDs) commonly perioperatively in the United States.

SETTING

Tertiary care academic medical center.

DESIGN

Prospective laboratory investigation.

METHODS

8 commercially available NSAIDs (3 branded, 5 generic) were tested: branded bromfenac 0.07%, generic bromfenac 0.09%, diclofenac 0.1%, flurbiprofen 0.03%, generic ketorolac 0.5%, branded ketorolac 0.5%, ketorolac 0.47%, and branded nepafenac 0.3%. 10 bottles of each medication were tested, with an additional bottle tested for expulsion force requirements. A double-blinded method was used to measure the actual bottle fill volume and number of drops per bottle. The total cost per drop was calculated using published cash prices. Force requirements were measured using a customized force gauge apparatus. Formulations were compared using the Kruskal-Wallis test, followed by pairwise comparisons with the Dwass, Steel, Critchlow-Fligner Method.

RESULTS

2 branded NSAIDs (bromfenac and nepafenac) had slightly lower-than-sticker volumes while generics other than ketorolac had higher-than-sticker volumes. Diclofenac and branded bromfenac had the highest and lowest adjusted number of drops respectively. Generic bromfenac and generic ketorolac had the highest and lowest adjusted volume compared with sticker volume respectively. Branded bromfenac was the most expensive medication, while generic diclofenac was the least expensive. Force expulsion requirements varied significantly among generic and branded NSAIDs.

CONCLUSIONS

Volume fill levels, patient-incurred costs, and expulsion force requirements per bottle of topical NSAID medications vary significantly. Surgeons may wish to consider these factors when deciding how best to use these medications perioperatively.

Cost-Effectiveness of Preoperative Topical Antibiotic Prophylaxis for Endophthalmitis Following Cataract Surgery

PURPOSE

To determine the cost-effectiveness of preoperative topical antibiotic prophylaxis for the prevention of endophthalmitis following cataract surgery.

DESIGN

Cost-effectiveness analysis using a decision-analytic microsimulation model.

METHODS

Preoperative topical antibiotic prophylaxis vs no-prophylaxis costs and effects were projected over a life-time horizon for a simulated cohort of 500 000 adult patients (≥18 years old) requiring cataract surgery in theoretical surgical centers in the United States. Efficacy and cost (2021 US dollars) values were obtained from the literature and discounted at 3% per year.

RESULTS

Based on inputted parameters, the mean incidence of endophthalmitis following cataract surgery for preoperative topical antibiotic prophylaxis vs no-prophylaxis was 0.034% (95% CI 0%-0.2%) and 0.042% (95% CI 0%-0.3%), respectively-an absolute risk reduction of 0.008%. The mean life-time costs for cataract surgery with prophylaxis and no-prophylaxis were $2486.67 (95% CI $2193.61-$2802.44) and $2409.03 (95% CI $2129.94-$2706.69), respectively. The quality-adjusted life-years (QALYs) associated with prophylaxis and no-prophylaxis were 10.33495 (95% CI 7.81629-12.38158) and 10.33498 (95% CI 7.81284-12.38316), respectively. Assuming a cost-effectiveness criterion of ≤$50 000 per QALY gained, the threshold analyses indicated that prophylaxis would be cost-effective if the incidence of endophthalmitis after cataract surgery was greater than 5.5% or if the price of the preoperative topical antibiotic prophylaxis was less than $0.75.

CONCLUSIONS

General use of preoperative topical antibiotic prophylaxis is not cost-effective compared with no-prophylaxis for the prevention of endophthalmitis following cataract surgery. Preoperative topical antibiotic prophylaxis, however, would be cost-effective at a higher incidence of endophthalmitis and/or a substantially lower price for prophylaxis.

Fill levels, cost comparisons and expulsion force requirements of commonly used topical ophthalmic steroids

PURPOSE

To determine volume fill levels, estimated costs, and force expulsion requirements per bottle of topical ophthalmic steroids commonly used in the United States.

SETTING

Tertiary care academic referral center.

DESIGN

Prospective laboratory investigation.

METHODS

Eight commercially available medications were tested: loteprednol 0.5%, loteprednol gel 0.5%, loteprednol gel 0.38%, difluprednate 0.05%, generic fluorometholone 0.1%, branded fluorometholone 0.1%, generic prednisolone 1.0%, and branded prednisolone 1.0%. Ten bottles of each medication were tested. A double-blinded method was used to measure actual bottle-fill volume and number of drops dispensed per bottle. The total perioperative cost per drop was calculated for each medication using average cash price. Force requirements were measured using a customized force gauge apparatus. Formulations were compared using Kruskal-Wallis one-way ANOVAs.

RESULTS

All formulations were able to cover postoperative periods commensurate with commonly used dosing regimens for cataract surgery. All medications had greater than sticker volume. Loteprednol 0.5% suspension and branded fluorometholone had the highest and lowest number of drops among the medications tested, respectively. Loteprednol 0.38% gel was the most expensive medication, while generic prednisolone 1.0% was the least expensive. Gel and branded formulations of ophthalmic steroids required less expulsion force compared to other tested formulations.

CONCLUSIONS

Volume fill levels, patient-incurred costs and expulsion force requirements per bottle of topical steroid medications vary widely. Clinicians may wish to consider these findings when determining their perioperative prescribing regimens.

Trends in Outpatient Prescribing Patterns for Ocular Topical Anti-Infectives in Six Major Areas of China, 2013-2019

Topical anti-infectives are important in the management of ocular infections, but little is known about their current status and trends in their use in China. Thus, we carried out a prescription-based, cross-sectional study using the database of Hospital Prescription Analysis Projection of China, and aimed to analyze the trend in the use of ocular topical anti-infectives for outpatients of the ophthalmology department from 2013 to 2019. A total of 2,341,719 prescriptions from 61 hospitals located in six major areas written by ophthalmologists for outpatients were identified, and 1,002,254 of the prescriptions contained at least one anti-infective. The yearly anti-infective prescriptions increased continuously from 126,828 prescriptions in 2013 to 163,434 prescriptions in 2019. The cost also increased from 4,503,711 Chinese Yuan (CNY) in 2013 to CNY 5,860,945 in 2019. However, the use rate of anti-infectives decreased slightly from 46.5% in 2013 to 41.1% in 2019. Patients aged between 19 and 45 years old had the highest anti-infective use rate. Levofloxacin was the most frequently used anti-infective and kept on increasing among all age groups, occupying 67.1% of the total cost at the end of the study. Tobramycin was more frequently used in pediatric patients than in adults, but the use still decreased. Ganciclovir was the preferred anti-viral drug over acyclovir. In conclusion, the prescriptions and cost of ocular topical anti-infectives for outpatients both increased progressively. The increasingly widespread use of levofloxacin raised concerns regarding safety in pediatrics and resistance development. The observed trends can lead to the more efficient management of ocular anti-topical anti-infectives in China.

Cataract surgery practice patterns worldwide: a survey

Objective

To report the results of a global survey on cataract practice patterns related to preoperative, intraoperative and postoperative care, surgical setting and personnel allocation.

Methods and analysis

An online 28 questions survey was sent to 240 ophthalmologists asking to describe prevailing trends in their institutions across 38 countries and 5 continents. Questions inquired country, institution, surgical volume and setting, anaesthesia, preoperative and intraoperative examination and postsurgical care. Statistical analysis used crosstabs lambda statistics for non-parametric nominal variables. P value less than 0.05 was considered statistically significant.

Results

209/240 (87%) ophthalmologists responded: 38% representing public hospitals, 36% private practices and 26% academic sites; overall surgical volume was between 241 700 and 410 500 cataracts per year. There was a significant correlation between type of institution and surgical volume. Complete results available in online (https://freeonlinesurveys.com/r/W6BcLLxy).

Conclusion

Cataract surgery related patterns of perioperative care showed significant difference among respondents, regardless to type of institution, surgical volume and country. Many evidence-based procedures are unevenly practiced around the world and some widespread and expensive habits lack solid scientific evidence while consuming enormous amount of resources both monetary and human. There is a need to reach consensus and share evidence-based practice patterns.

Drop-free approaches for cataract surgery

PURPOSE OF REVIEW

Routine prophylaxis for adverse events following cataract surgery is evolving. Prior reliance on topical eyedrop instillation by patients is giving way to surgeon directed injections at the time of cataract surgery. The benefit of this new approach is assured delivery of drugs in standardized doses which should optimize the healing process and reduce the incidence of untoward events with higher confidence.

RECENT FINDINGS

Adoption rates of intracameral antibiotic injection amongst European and American cataract surgeons is increasing. Techniques to inject periocular corticosteroid for routine inflammation prophylaxis are also in development. In combination with intraoperative pharmacologic dilation, a drop-free modality can be achieved.

SUMMARY

Intraoperative injections offer the patient and surgeon assured drug delivery and hold promise to avoid the pitfalls of patient adherence, incorrect topical instillation, and topical drop-associated corneal issues.

Transferable Mechanisms of Quinolone Resistance from 1998 Onward

While the description of resistance to quinolones is almost as old as these antimicrobial agents themselves, transferable mechanisms of quinolone resistance (TMQR) remained absent from the scenario for more than 36 years, appearing first as sporadic events and afterward as epidemics. In 1998, the first TMQR was soundly described, that is, QnrA. The presence of QnrA was almost anecdotal for years, but in the middle of the first decade of the 21st century, there was an explosion of TMQR descriptions, which definitively changed the epidemiology of quinolone resistance. Currently, 3 different clinically relevant mechanisms of quinolone resistance are encoded within mobile elements: (i) target protection, which is mediated by 7 different families of Qnr (QnrA, QnrB, QnrC, QnrD, QnrE, QnrS, and QnrVC), which overall account for more than 100 recognized alleles; (ii) antibiotic efflux, which is mediated by 2 main transferable efflux pumps (QepA and OqxAB), which together account for more than 30 alleles, and a series of other efflux pumps (e.g., QacBIII), which at present have been sporadically described; and (iii) antibiotic modification, which is mediated by the enzymes AAC(6')Ib-cr, from which different alleles have been claimed, as well as CrpP, a newly described phosphorylase.

Comparison of United States and International Ophthalmic Drug Pricing

PURPOSE

To compare United States and international drug pricing for commonly prescribed intravitreal and topical ophthalmic medications.

DESIGN

Cross-sectional observational study.

METHODS

For 25 commonly used ophthalmic medications (3 intravitreal, 22 topical), we obtained 2017 third quarter United States average wholesale price (AWP), drug acquisition cost, or consumer pricing through United States government health insurance plans (Veterans Affairs [VA], Medicaid, Medicare Part B, and Medicare Part D) and commercial drug plans (CVS Caremark and Navitus Health Solutions), online pricing without insurance through a large United States warehouse retailer (Costco), and international drug pricing through government-sponsored health plans in Italy, Spain, Turkey, Canada, and Japan.

MAIN OUTCOME MEASURES

Drug acquisition costs and consumer pricing of ophthalmic drugs through various payment systems. All prices were converted to United States dollars.

RESULTS

For intravitreal medications in the United States, aflibercept and ranibizumab were priced similarly to each other and were more expensive than dexamethasone implants. Pricing of aflibercept and ranibizumab through government health insurance plans in Italy, Spain, Turkey, Canada, and Japan were less expensive by as much as 84.3% compared with the United States. For topical medications in the United States, pricing varied significantly both across different classes of medications and also between nonbranded and branded medications. Drug acquisition costs through the VA and Medicaid were inexpensive on average, but pricing through a hospital-employee drug insurance plan offered the smallest range (between $2.35 and $60.00). In all 5 non-United States countries studied, each topical medication with the exceptions of cyclosporine emulsion and difluprednate was less than $100, and 94.4% of topical medications in these countries had a nonbranded or branded option that was less than $50.

CONCLUSIONS

In the United States, for topical more than intravitreal medications, significant price variation exists across both different drug pricing systems and different medications. Price differentials between nonbranded and branded medications can be significant. Internationally, topical medications exhibited a more limited and lower price range compared with drug pricing in the United States.

The Routine Use of Intracameral Antibiotics to Prevent Endophthalmitis After Cataract Surgery: How Good is the Evidence?

Post-operative endophthalmitis (POE) following cataract surgery is an uncommon, vision-threatening complication that has been reported to occur at rates of between approximately 0.03% and 0.2%. Prompt diagnosis and treatment of endophthalmitis is critical for minimizing vision loss, but most recent efforts have focused on the prophylactic administration of antibiotics to prevent the development of endophthalmitis. Surgeons from around the world have different topical and intracameral antibiotic usage patterns to prevent endophthalmitis, and to date no general consensus regarding best practice has emerged. Several studies have reported on the routine use of intracameral cefuroxime, moxifloxacin, and vancomycin, including a single randomized clinical trial by the European Society of Cataract and Refractive Surgery (ESCRS) in 2007. These studies have notable shortcomings, but many authors suggest that intracameral cefuroxime together with topical antibiotics probably decreases the risk of endophthalmitis. However, the deleterious effects of routine prophylactic antibiotics, which include toxicity, cost, and increasing antimicrobial resistance, among others, are noteworthy. In contrast, aseptic technique with pre-operative instillation of povidone-iodine remains the only technique supported by level I evidence to reduce the incidence of endophthalmitis. Although the routine use of intracameral antibiotics continues to increase throughout the world, data from multicenter, randomized, prospective trials is needed to provide better guidance regarding the prophylactic use of antibiotics.