Patient Preferences in the Treatment of Neovascular Age-Related Macular Degeneration: A Discrete Choice Experiment

Optimizing Visual Outcomes in Patients With Neovascular Age-Related Macular Degeneration: the Potential Value of Sustained Anti-VEGF Therapy

Neovascular age-related macular degeneration (nAMD) leads to irreversible central vision loss if untreated. Frequent administration of anti-vascular endothelial growth factor (anti-VEGF) injections inhibits disease activity with excellent functional and morphological benefits. However, these injections pose a heavy therapeutic burden, and treatment discontinuation is common. Although current anti-VEGF treatment paradigms, such as treat-and-extend, mitigate treatment burden while still leading to acceptable vision outcomes, they fail to sustain initial vision gains for many. Novel longer-acting anti-VEGF therapies may reduce the overall burden on nAMD patients. Gene therapy might offer a paradigm shift by providing continuous expression of anti-VEGF, potentially decreasing treatment requirements and improving long-term vision outcomes. [Ophthalmic Surg Lasers Imaging Retina 2023;54:654-659.].

Piloting a forced-choice task to elicit treatment preferences in geographic atrophy

OBJECTIVE

Geographic Atrophy (GA) is the advanced form of the non-neovascular ('dry') type of age-related macular degeneration (AMD) and responsible for one-quarter of legal blindness in the UK. New therapies delivered by intravitreal injection are in late-stage development, and two such therapies (pegcetacoplan (Syfovre) and avacincaptad pegol (Izervay)) have now been approved for clinical use by the US Food and Drug Administration. These therapies slow down, but do not stop or reverse, progression of GA and they may also increase the risk of developing the neovascular ('wet') type of AMD. Within a larger study exploring the acceptability of these new treatments to people living with GA, we developed a forced-choice exercise to evaluate how participants weigh up benefits and drawbacks of different treatment regimens. This research note reports quantitative and qualitative findings from this exercise.

RESULTS

Twenty-eight participants took part in this exercise. The exercise demonstrated that participants were generally, although not unanimously, in favour of less frequent treatment for GA that was slightly less efficacious in terms of preserving visual function but presented a lower risk of developing wet AMD. Even among a small sample, the exercise demonstrated the highly personal and idiosyncratic decision-making processes influencing participants' choices of preferred hypothetical GA treatment.

Understanding patient preferences in anti-VEGF treatment options for age-related macular degeneration

Purpose

(1) To investigate the relative importance of convenience (consultation frequency and injection frequency) against treatment outcomes (visual and anatomical outcomes) and out-of-pocket medical costs via a discrete choice experiment (DCE), and (2) to investigate how patient characteristics affect patient treatment preferences.

Methods

Eligibility criteria were: (1) receiving a neovascular age-related macular degeneration (nAMD) diagnosis; (2) receiving anti-VEGF treatment; (3) being ≥21 years old, and (4) being able to speak and understand English/Mandarin. Patients were presented with eight choice tasks and asked to choose between their current treatment and two hypothetical treatments that varied by six attributes: number of clinic visits in a year, number of injections in a year, vision quality, control of swelling in retina, drug labelling and out-of-pocket cost.

Results

This analysis involved 180 patients. Based on latent class logistic regressions, vision quality was the most important attribute (34%) followed by cost (24%). The frequency of total clinic visits (15%) was the third most-important attribute, closely followed by labelling (12%) and control of retina swelling (11%). Injection frequency was the least important attribute (4%).

Conclusions

Vision quality was the most important attribute followed by the out-of-pocket costs. Given the same outcomes, patients preferred treatment regimens which require fewer total clinic visits. In comparison, injection frequency alone did not influence patient preferences. With increasing treatment options for nAMD, understanding patients’ preferences can help clinicians in selecting agents and treatment regimen most preferred for each patient, which may lead to improved long-term adherence and outcomes.

Patient Preference and Treatment Satisfaction With a Port Delivery System for Ranibizumab vs Intravitreal Injections in Patients With Neovascular Age-Related Macular Degeneration: A Randomized Clinical Trial

Question

Do patients with neovascular age-related macular degeneration (nAMD) treated with a surgically implanted port delivery system (PDS) with ranibizumab prefer the PDS over intravitreal injections of anti–vascular endothelial growth factor agents?

Findings

This phase 3 randomized clinical trial found that treatment satisfaction was high with both PDS and intravitreal treatment, but almost all patients in the PDS arm preferred treatment delivered via the PDS at week 40 vs previous intravitreal injections.

Meaning

Although PDS treatment was preferred by most patients assigned to PDS over previous intravitreal injections, both delivery methods have high treatment satisfaction.

Importance

The port delivery system (PDS) with ranibizumab has demonstrated noninferior and equivalent efficacy compared with monthly intravitreal injections of ranibizumab, an anti–vascular endothelial growth factor (VEGF) agent, in patients with neovascular age-related macular degeneration (nAMD), but evaluating patient preference is important to help inform clinical decision-making.

Objective

Evaluate treatment satisfaction for ranibizumab delivered via PDS vs intravitreal injections as well as patient preference among those assigned to PDS.

Design, Setting, and Participants

Archway was a phase 3 randomized active-comparator open-label clinical trial conducted at 78 sites in the US. Patients 50 years and older with nAMD diagnosed within 9 months of screening with a documented response to anti-VEGF therapy were included. Of 619 patients screened, 418 were enrolled; 415 were included in the primary analysis and 234 were included in the secondary exploratory analysis. The Archway study ran from September 12, 2019, through primary readout on May 22, 2020.

Interventions

Patients were randomized 3:2 to PDS with ranibizumab, 100 mg/mL, with fixed refill exchanges every 24 weeks or intravitreal ranibizumab injections, 0.5 mg, every 4 weeks.

Main Outcomes and Measures

Treatment satisfaction was measured using the Macular Disease Treatment Satisfaction Questionnaire in the PDS and intravitreal injection arms at week 40. Patient preference was assessed using the content-validated PDS Patient Preference Questionnaire (PPPQ), which measured the proportion of patients in the PDS arm with monthly monitoring who preferred treatment with the PDS at week 40 over previous intravitreal injections or concurrent fellow-eye injections. Both outcomes were exploratory end points.

Results

The mean (SD) age of participants at baseline was 75.0 (7.9) years; 234 participants (59%) were women and 162 (41%) were men. At week 40, differences in overall treatment satisfaction scores were minimal for the PDS and intravitreal injection arms (mean, 68.0; 95% CI, 67.4-68.6; n = 237 and mean, 66.1; 95% CI, 64.9-67.3; n = 159, respectively; difference, 1.9; 95% CI, 0.7-3.1). A total of 234 of 248 patients (94.4%) in the PDS arm were included in the PPPQ analysis. At week 40, almost all patients in the PDS arm preferred treatment via PDS (218 of 234 [93.2%]) vs previous intravitreal injections (3 of 234 [1.3%]), including 172 of 234 (73.5%) with a very strong preference for the PDS. In patients who received concurrent fellow-eye injections (n = 78), 72 (92.3%) preferred the PDS.

Conclusions and Relevance

Although PDS treatment was preferred by almost all patients assigned to PDS over previous intravitreal injections, both delivery methods have high treatment satisfaction. These findings provide further evidence for the PDS as a meaningful alternative treatment option for patients with nAMD.

Trial Registration

ClinicalTrials.gov Identifier: NCT03677934

Covid-19 Impact on Macular Neovascularization and Retinal Vein Occlusion Treatment: Single-Center Experience

Purpose

The aim of this study was to evaluate whether the coronavirus disease 19 (COVID-19) pandemic resulted in undertreatment and subsequent loss of visual acuity (VA) in patients with macular neovascularization (MNV) or retinal vein occlusion (RVO) regularly treated with intravitreal antivascular endothelial growth factor injections.

Methods

Single-center, retrospective study of patients scheduled for treatment between March 19 and June 1, 2020, the national mandatory quarantine period. Patients' demographics, VA, and scheduled treatment during this period were reviewed via medical records. All patients were analyzed regarding treatment attendance rates. The visual impact of COVID-19 was assessed in patients who had been treated and presented a stable VA for >6 months before the beginning of the quarantine.

Results

This study included 927 eyes from 769 patients. The attendance rate increased throughout the study timeframe (p < 0.001) and correlated negatively with higher patient's age (r = -0.142; p = 0.005). Patients with age-related macular degeneration (67.6%) had lower attendance rates (p = 0.007) and were older (p < 0.001). The visual impact analysis included 400 eyes from 325 patients. The average VA variation throughout this period was -1.7 ± 8.4 ETDRS letters and was similar in different retinal pathologies (p = 0.334). VA variation did not correlate with the number of missed treatments per patient (r = 0.100; p = 0.150). The prevalence of subretinal fluid and intraretinal fluid, as well as central retinal thickness decreased significantly throughout the study period (p values of <0.001, <0.001, and 0.032, respectively).

Conclusion

The COVID-19 pandemic had a significant impact on the attendance rate of patients with MNV or RVO to their scheduled treatments, which was higher in the first week of mandatory quarantine. Nevertheless, VA did not decrease significantly during this period, with a limited VA variation regardless of primary retinal disorder and morphological parameters even improved in the eyes included in the visual impact analysis.

Patient and retina specialists' preferences in neovascular age-related macular degeneration treatment. A discrete choice experiment

INTRODUCTION AND OBJECTIVE

Neovascular age-related macular degeneration (nAMD) leads to severe and permanent visual impairment, significantly impacting patients' quality of life and functional independence. Although treatment with anti- vascular endothelial growth factor (VEGF) prevents and, in some cases, reverses visual damage, the need for frequent monitoring visits and intravitreal injections represents a significant burden on patients, caregivers and retina specialists.

OBJECTIVE

To elicit preferences for nAMD treatment characteristics from the perspectives of patients and retina specialists.

METHOD

A discrete choice experiment was conducted. Participants (patients > 50 years with nAMD receiving anti-VEGF drugs for at least 2 years and without previous experience with anti-VEGF and retina specialists working in the Spanish National Healthcare System) were asked to select one of two hypothetical treatments resulting from the combination of five attributes (effects on visual function, effects on retinal fluid, treatment regimen, monitoring frequency, and cost); their levels were identified by reviewing the literature and two focus groups. The relative importance (RI) given to each attribute was estimated using a mixed logit model. The marginal rates of substitution (MRS) were calculated taking cost as the risk attribute.

RESULTS

A total of 110 patients (P) [aged 79.0 (SD:7.4) years; 57.3% women; 2.3 (SD:0.7) years with nAMD; 2.1 years (SD:0.1) in treatment] and 66 retina specialists (RS) participated in the study. Participants gave greater RI to improvements in their visual function [60.0% (P); 52.7% (RS)], lower monitoring frequency [20.2% (P); 27.1% (RS)] and reduction in retinal fluid [9.8% (P); 13.0%(RS)]. Patients and retina specialists would agree to an increase in cost by 65.0% and 56.5%, respectively, in exchange for improvements of visual function; and 25.5% and 43.3% on delaying monitoring frequency by one month.

CONCLUSIONS

Efficacy of treatment, in terms of visual function improvements, is the main driver for treatment election for both patients and retina specialists. Treatment monitoring requirements are also considered, mainly from the retina specialist's perspective. These results suggest that the use of more efficacious anti-VEGF agents with a longer duration of action may contribute to aligning treatment characteristics with patients/specialists' preferences. A better alignment would facilitate better disease management, fulfilling the unmet needs of patients and retina specialists.

Patient Preferences in the Management of Wet Age-Related Macular Degeneration: A Conjoint Analysis

INTRODUCTION

To identify patient preference drivers related to the management of wet age-related macular degeneration (wet AMD).

METHODS

In this cross-sectional study, a self-explicated 'conjoint analysis' survey was administered online to eligible patients with wet AMD (receiving anti-vascular endothelial growth factor [VEGF] treatment for at least 12 months) from the USA, Canada, UK, France, Spain, Germany, Italy, Japan, Taiwan, and Australia. The survey consisted of six domains with 21 attributes, which were selected on the basis of a literature review, social media listening, and tele-interviews/discussions with patients, clinical experts, and patient groups. Utility and relative importance scores were generated for each attribute and utility difference significance testing was performed using 'unequal variances t tests'. The Patient Activation Measure (PAM-13) questionnaire was administered to assess patients' knowledge, skill, and confidence in self-management.

RESULTS

A total of 466 patients (mean age, 68 years; women, 54%; binocular wet AMD, 28%) with an average anti-VEGF treatment duration of 3.9 years completed the survey. The most important preference domains were 'treatment effects on vision' (non-significant) and 'vision-related symptom burdens' (p < 0.001), followed by 'treatment risk' (p < 0.05), 'impact on daily activities' (p < 0.05), 'burden of clinic/hospital visits' (p < 0.001), and 'impact on psychological well-being'. The five most important attributes in order of importance were clarity of vision, treatment effect on symptoms, quality of vision, time to treatment effect, and time to re-administration. The two most important attributes globally were also in the top three attributes across countries. The majority of participants in the study were level 3 or level 4 of the PAM-13 questionnaire.

CONCLUSIONS

This study identified the most important disease and treatment attributes to patients using patient-centred methods. The data showed the degree of harmonization of preferences across geographies and that participants actively adopt behaviours required for improved treatment outcomes. The identified preference drivers may inform future clinical development.

Drivers of and Barriers to Adherence to Neovascular Age-Related Macular Degeneration and Diabetic Macular Edema Treatment Management Plans: A Multi-National Qualitative Study

PURPOSE

Neovascular age-related macular degeneration (nAMD) and diabetic macular edema (DME) patients treated with intravitreally injected anti-vascular endothelial growth factor (anti-VEGF) monotherapies achieve lower vision improvements compared with patients in clinical trials. This qualitative research study aimed to better understand the real-world anti-VEGF treatment experience from nAMD and DME patients', caregivers', and retina specialists' perspectives.

METHODS

One-time, semi-structured, individual interviews were conducted with adult patients with nAMD or DME treated with anti-VEGF injections for ≥12 months, their caregivers, and experienced retina specialists. Interview transcripts were analyzed qualitatively using a thematic analysis approach.

RESULTS

A total of 49 nAMD and 46 DME patients, 47 nAMD and 33 DME caregivers, and 62 retina specialists were interviewed in the USA, Canada, France, Germany, Italy and Spain. Most (79%) patients and caregivers reported disruptions to their routine on the day before, the day of, or the day after anti-VEGF injection. Seven nAMD patients (14%) and 14 DME patients (30%) reported having missed an injection visit. The most frequently reported driver for adherence for patients was the doctor-patient relationship (n=66, 70%), whereas for caregivers, it was the ease of booking an appointment (n=25, 32%). Retina specialists reported patient education on the treatment (n=28, 45%) as the most important driver. Treatment barriers could be grouped into four categories: tolerability, clinical factors, logistical parameters and human factors. The most frequently reported barrier to adherence for patients and caregivers was related to side effects (pain/discomfort/irritation: n=63, 67% of patients; n=52, 66% of caregivers), whereas for retina specialists it was logistical parameters (travel logistics: n=44, 71%).

CONCLUSION

This study highlights the importance of the doctor-patient relationship and patient education as key drivers, and treatment tolerability and logistics as key barriers to treatment adherence. Improved doctor-patient relationship/communication and patient education together with new therapies offering convenience, long-acting effectiveness, and better tolerability may improve treatment adherence.

Management of neovascular age-related macular degeneration: Taiwan expert consensus

Neovascular age-related macular degeneration (nAMD) is a leading cause of irreversible vision loss. The present consensus provides suggestions on diagnosis, evaluation, treatment, and follow-up strategies for nAMD from a panel of 11 practicing ophthalmologists. The experts suggest that the baseline visit for nAMD management should include a comprehensive ophthalmologic examination via a multimodal approach consisting of visual and anatomical evaluation. Patients diagnosed with nAMD should be subjected to treatment with the goal of maintaining visual function while diminishing anatomical disease activity and minimizing treatment burden. Currently, anti-VEGF therapy is the main treatment strategy for nAMD, and evaluation involving comprehensive ophthalmologic examination within 1 month of completion of the loading phase comprising three monthly injections is recommended to guide subsequent management. Either a treat-and-extend or pro re nata regimen can be considered for the maintenance phase of anti-VEGF therapy, and the regimen should be chosen and adjusted according to disease activity, reimbursement criteria, financial burden, and patient preferences. In the event of inactive nAMD or poor treatment outcomes, after thorough evaluation and patient education, anti-VEGF therapy may be stopped. The consensus provides practical nAMD management guidelines for ophthalmologists and fellow healthcare professionals.

Treatment of Neovascular Age-Related Macular Degeneration: An Economic Cost-Risk Analysis of Anti-Vascular Endothelial Growth Factor Agents

PURPOSE

To find the best cost-effective neovascular age-related macular degeneration (nAMD) treatment to improve vision while avoiding complications. The model is based on a cost-risk tradeoff analysis from policymakers' perspective.

DESIGN

A powerful and flexible simulation modeled outcomes of 2 years of treatment with the 4 commonly used anti-vascular endothelial growth factor drugs (bevacizumab, ranibizumab, aflibercept, and brolucizumab) across 3 injection protocols, building on prior findings that these drugs are noninferior. The model incorporates blinding complications, their management, and associated costs to society. Each option and several what-if scenarios were simulated 1,000 times with 100,000 hypothetical patients.

PARTICIPANTS

One hundred thousand simulated patients using data from published clinical trials.

METHOD

Case- and eye-specific cost-risk economic analysis.

MAIN OUTCOME MEASURES

Costs of nAMD treatment per patient and number of eyes that become blind as a result of treatment over 2 years.

RESULTS

Using published prices and fees, the injection protocol that follows published clinical studies, results showed that the mean±standard deviation cost per patient were $16,859 ± $3.65, $32,949 ± $3.27, $39,831 ± $3.80, and $53,056 ± $2.99 for bevacizumab, brolucizumab, aflibercept, and ranibizumab, respectively. The numbers±standard deviations of treated eyes that became blind were 108 ± 10.18, 694 ± 26.66, 168 ± 12.83, and 108 ± 10.52, respectively. We further provide a lower bound (when all patients are maximally extended) and upper bound (when no patient is extended) to these numbers. For brolucizumab, the upper bound is the 2-month interval injection protocol.

CONCLUSIONS

Taking a policymaking perspective, this study suggested that bevacizumab is the preferred first-line therapy. Recommendation for second-line therapy depends on the extent of the policymaker's risk aversion because of the tradeoff between cost and risk of blindness as a result of treatment. If risk neutral, the least expensive option (brolucizumab) is preferred. But if policymakers are moderately to highly risk averse, then aflibercept or ranibizumab are preferred. Because medical advances and different costs may change our findings, we provide a free application (https://eye-inj.shinyapps.io/calc/) for readers who wish to use different cost structures. Simulating outcomes is an innovative approach, unique in ophthalmology, and presents a significant opportunity because it can be adapted easily to different settings (using different costs, risks, and protocols) and to other diseases (e.g., diabetic macular edema), to ultimately improve wide-scale decision-making and use of funds.

Treatment contentment and preference of patients undergoing intravitreal anti-VEGF therapy

Purpose

The aim of this study is to investigate patients´ treatment preference between the pro re nata (PRN) and treat and extend (T&E) regimens and their feelings and contentment undergoing intravitreal injections (IVI) with anti-vascular endothelial growth factor (anti-VEGF) agents.

Methods

Six months after the switch of the treatment regimen from PRN to T&E, answers of a 16-item questionnaire of 105 patients under IVI therapy regarding age, sex and treatment preference (T&E or PRN regimen), as well as burden and anxiety resulting from therapy, were evaluated. Analysis of associations between answers of the questionnaire was executed using Pearson’s Chi² test and Mann–Whitney U test. P values ≤ 0.05 were considered statistically significant.

Results

Nearly all patients (90.5%) felt well informed about disease and therapy. Comparing treatment regimen, 13.7% thought PRN was better and 23.3% felt T&E was better. The majority considered PRN and T&E to be equal (60.3%). No significant association between treatment regimen and age (p = 0.15), gender (p = 0.35) and duration of IVI therapy (p = 0.42) was seen. The examination results are associated with fear in the majority of patients (53.3%). Fear about the IVI was indicated by 47.6% of individuals and was significantly associated with pain during treatment (p = 0.0003), pain after treatment (p = 0.004) and fear about unfavourable examination results regarding disease activity (p = 7.94 × 10⁻⁷).

Conclusions

Most patients are satisfied with the IVI therapy and the treatment regimen. Fear of the IVI and particularly of unfavourable examination results demonstrate the high treatment burden for patients undergoing anti-VEGF therapy. These aspects should be taken into account by healthcare professionals.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00417-021-05324-8.

Acceptability of intravitreal injections in geographic atrophy: protocol for a mixed-methods pilot study

INTRODUCTION

Age-related macular degeneration (AMD) is a common cause of visual impairment, affecting central vision. Geographic atrophy (GA) is an advanced form of the non-neovascular (dry) type of AMD. Late-stage clinical trials suggest that intravitreal injections of novel therapeutics may slow down the rate of GA progression by up to 30% in 1 year, thus allowing people with GA to preserve central vision for a longer period. While intravitreal injections have become an established treatment modality for neovascular (wet) AMD, it is unknown whether patients with (more gradually progressing) GA would accept regular injections that slow down, but do not stop or reverse, vision loss. Therefore, this mixed-methods pilot study will aim to explore whether regular intravitreal injections will be acceptable as treatment for patients with GA, and the factors that may affect treatment acceptability.

METHODS AND ANALYSIS

A mixed-methods survey has been designed in collaboration with a GA patient advisory group. The survey comprises of structured questionnaires, semi-structured interview questions regarding patients' perceptions of intravitreal injections and the burden of treatment, and a task eliciting preferences between different potential treatments. Due to COVID-19 restrictions, this study will be conducted remotely by telephone. Thirty individuals will be recruited from NHS Medical Retina clinics at Central Middlesex Hospital, London. Half of the participants will be naïve to intravitreal injections, while half will have previous experience of intravitreal injections for neovascular (wet) AMD. Qualitative data analysis will be conducted using the Framework Method of analysis to identify key themes from participants' accounts.

ETHICS AND DISSEMINATION

The study received Health Research Authority approval on 23 March 2021 (IRAS Project ID: 287824). Findings will be disseminated through peer-reviewed publications and conference presentations to the medical retina community, as well as through dialogue with patients and macular disease charities.

Brolucizumab: a novel anti-VEGF humanized single-chain antibody fragment for treating w-AMD

INTRODUCTION

Wet age-related macular degeneration (w-AMD) represents the leading cause of visual impairment in the elderly in the developed countries. Intravitreal antivascular endothelial growth factor (VEGF) drugs are currently considered as the first-line treatment option for treating w-AMD; however, the frequent injection intervals have lit the way to investigate novel anti-VEGF agents allowing a more extended treatment regimen. Brolucizumab is a single-chain antibody fragment targeting all the isoforms of VEGF-A. Phase III HAWK and HARRIER trials have shown a longer durability and superior anatomical outcomes as compared with the standard of care by adopting a quarterly regimen for treating w-AMD. Brolucizumab has been approved in Europe, USA, and Japan for the management of w-AMD.

AREAS COVERED

This article presents an overview of w-AMD and investigates the progress of brolucizumab through clinical trials. It offers insights into where brolucizumab may be placed in the current market of anti-VEGF agents and its potential advantages over the previous molecules adopted for treating w-AMD.

EXPERT OPINION

The possibility of administering brolucizumab with more dilated treatment intervals represents an important advantage to decrease the treatment burden and improve patient compliance. Brolucizumab represents a possible drug switching option in non-responding patients to other anti-VEGF drugs.

Factors Associated With a Patient's Decision to Select a Cost-effective vs the Most Effective Therapy for Their Own Eye Disease

IMPORTANCE

Ten percent of the Medicare Part B budget is spent on aflibercept, used to treat a myriad of ocular neovascular diseases. A substantial portion of these costs can be attributed to a few hundred ophthalmologists, raising concerns regarding the influence of pharmaceutical companies on the choice of medication by a relatively small group of clinicians. One approach to protect patients' health care interests is to include them in deliberations on the choice of therapy for their eye disease.

OBJECTIVE

To examine factors associated with patients' choice between an effective and less expensive off-label drug or a more effective, but also more expensive, US Food and Drug Administration (FDA)-approved drug.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort analysis used data from the satellite office of a tertiary referral center from August 2, 2013, to April 9, 2018. Insured patients initiating treatment with anti-vascular endothelial growth factor were included in the analysis. Data were analyzed from March 26, 2018, to June 10, 2020.

INTERVENTIONS

Patients were asked to choose between bevacizumab (approximately $100 per dose), a chemotherapy that is effective, but not FDA approved, for the treatment of ocular vascular disease, or aflibercept (approximately $2000 per dose), an FDA-approved drug for ocular vascular disease that may be more effective than bevacizumab in some patients. Independent of this choice, patients were separately asked by a study coordinator to participate in an invasive clinical study for which they would not be compensated, there was a small risk for an adverse event, and they would not personally benefit from participating (a surrogate marker for altruism).

MAIN OUTCOMES AND MEASURES

Factors associated with patients' choice of medication, including age, sex, ocular disease, race, and participation in an invasive clinical study.

RESULTS

A total of 189 patients were included in the analysis (106 women [56%]; mean [SEM] age, 74.6 [0.8] years). Despite being told that it may not be as effective as aflibercept, 100 patients (53%) selected bevacizumab for their own eye care. An act of altruism (ie, participation in an invasive clinical study) when the patient was making a choice between the 2 drugs was associated with a patient's choice of bevacizumab (odds ratio [OR], 7.03; 95% CI, 2.27-21.80; P < .001); the OR for selecting bevacizumab for patients who never agreed to participate in the clinical study was 0.45 (95% CI, 0.25-0.83; P = .001). Age (OR, 1.00; 95% CI, 0.97-1.03; P = .86), race (OR, 0.70; 95% CI, 0.41-1.22; P = .21), sex (OR, 0.72; 95% CI, 0.39-1.35; P = .31), presence of diabetes (OR, 1.52; 95% CI, 0.59-3.93; P = .39), and type of eye disease (OR, 0.56; 95% CI, 0.30-1.04; P = .07) were not associated with choice of therapy.

CONCLUSIONS AND RELEVANCE

These findings suggest that clinicians must consider the ethical implications of the influence of altruism when patients participate in the decision between cost-effective vs the most effective medicines for their own health care.

Difference in treatment burden of neovascular age-related macular degeneration among different types of neovascularization

PURPOSE

To evaluate the difference in the treatment burden among different types of neovascular age-related macular degeneration (AMD).

METHODS

This retrospective, observational study included 431 patients who were diagnosed with neovascular AMD. Patients were divided into three groups: type 1 or 2 neovascularization group (n = 167), type 3 neovascularization group (n = 50), and polypoidal choroidal vasculopathy (PCV) group (n = 214). The number of hospital visits per year and the number of anti-vascular endothelial growth factor (VEGF) injections per year were compared among these groups. Furthermore, the incidence of bilateral involvement during the follow-up period was compared among the groups.

RESULTS

The mean follow-up period was 50.6 ± 11.3 months. The number of hospital visits per year was significantly higher in the type 1 or 2 neovascularization group (mean: 6.1 ± 1.5) and type 3 neovascularization (6.6 ± 1.6) than in the PCV group (6.0 ± 1.5) (P < 0.001). The number of anti-VEGF injections per year was significantly higher in type 3 neovascularization group (3.1 ± 1.7) than in the type 1 or 2 neovascularization group (2.3 ± 1.5) or the PCV group (2.3 ± 1.2) (P = 0.042). There was a significant difference in the incidence of bilateral involvement among patients in type 1 or 2 neovascularization group (20.4%), type 3 neovascularization group (46.0%), and the PCV group (15.4%) (P < 0.001).

CONCLUSIONS

The high frequency of hospital visits and that of anti-VEGF injections in patients with type 3 neovascularization suggests high treatment burden in these patients. The high incidence of bilateral involvement could be one of the primary reasons for high treatment burden in patients with type 3 neovascularization.

Patient Preferences Associated with Anti-Vascular Endothelial Growth Factor Therapies for Neovascular Age-Related Macular Degeneration and Diabetic Macular Edema

Purpose

To evaluate treatment-related preferences among patients receiving intravitreal anti-vascular endothelial growth factor (VEGF) therapy for neovascular age-related macular degeneration (nAMD) or diabetic macular edema (DME).

Patients and Methods

We conducted a prospective survey of patients with nAMD or DME treated at one of three US-based retina clinics. Prior to survey development, small focus groups with anti-VEGF-treated patients identified five treatment-related “attributes” considered important to those with nAMD or DME: vision outcomes, cost to the insurance provider, cost to the patient, frequency of treatment, and drug label status. Attributes were described using two to three “levels”, and hypothetical treatment profiles were generated by assigning one level to each attribute. Surveyed patients were asked to indicate their preference between two given treatment profiles for a total of eight pairwise comparisons. Discrete choice conjoint analysis was performed to estimate the relative importance of each attribute for the overall patient cohort, and for subgroups stratified by age and highest education level.

Results

Among 300 respondents, 54% were female, 78% were aged ≥65 years, and 67% indicated that high school was their highest level of education. Achieving good vision was the most important factor associated with anti-VEGF therapy for nAMD or DME (relative importance, 40.4%), followed by low cost to the patient, on-label drug status, less frequent treatment intervals, and low cost to the insurance provider (23.1%, 21.3%, 12.2%, and 3.0%, respectively). When patients were stratified by age group or highest education level, preference trends across subgroups were generally comparable with the overall cohort.

Conclusion

Our data suggest that treatment decisions regarding anti-VEGF therapies for nAMD or DME are most likely driven by their efficacy, and that patients may be willing to accept less desirable treatment attributes, such as increased cost and/or injection frequency, in order to achieve superior vision outcomes.

Cost-Utility Analysis of VEGF Inhibitors for Treating Neovascular Age-Related Macular Degeneration

PURPOSE

To perform 11- and 2-year health care sector (ophthalmic) and societal cost perspective reference case, cost-utility analyses comparing bevacizumab, ranibizumab, and aflibercept monotherapies for neovascular age-related macular degeneration (NVAMD).

DESIGN

Cost-utility analysis.

METHODS

The authors performed 11-year and 2-year ophthalmic and societal cost perspective, cost-utility analyses comparing bevacizumab, ranibizumab, and aflibercept monotherapies for neovascular age-related macular degeneration (NVAMD). We employed patient utilities, bilateral outcomes, 2018 U.S. dollars, vision-related mortality, a Medicare fee schedule, and CATT (Comparison of Age-Related Macular Degeneration Treatments) study and VIEW (VEGF Trap-Eye: Investigation of Efficacy and Safety in Wet AMD) trial. Cochrane data were also used.

SETTING

Center for Value-Based Medicine. Patient/study population: patients with NVAMD.

INTERVENTION

Cost-utility analyses using published data. Data-modeled 10-year vision outcomes were modeled forward to year 11.

MAIN OUTCOME MEASUREMENT

These included cost-utility ratios (CURs), costs, and quality-adjusted life-years (QALYs) gained. $100,00/QALY was considered the US cost-effectiveness upper limit.

RESULTS

Bevacizumab and ranibizumab each conferred an 11-year, 1.339 QALY gain versus observation. Aflibercept conferred a 1.380 QALY gain. Aflibercept conferred greater QALY gain for less cost than ranibizumab but was not cost-effective compared to bevacizumab ($1,151,451/QALY incremental CUR). The average ophthalmic cost perspective CUR for bevacizumab was $11,033/QALY, $79,600/QALY for ranibizumab, and $44,801/QALY for aflibercept. Eleven-year therapies saved a 1.0 year-of-life loss without treatment from the 11.0-year life expectancy. Early treatment was 138%-149% more cost-effective than late treatment. Two-year therapy prevented a 1-month-of-life loss, and revealed bevacizumab, ranibizumab, and aflibercept conferred 0.141, 0.141, and 0.164 QALY gains, respectively, with corresponding average CURs of $40,371/QALY, $335,726/QALY, and $168,006/QALY, respectively.

CONCLUSIONS

From an ophthalmic (medical) cost perspective, bevacizumab, ranibizumab, and aflibercept NVAMD monotherapies were all cost-effective over 11 years, with bevacizumab 6.21× more cost-effective than ranibizumab and 3.06× more cost-effective than aflibercept. Two-year modeling revealed bevacizumab was cost-effective, whereas ranibizumab and aflibercept were not. Early treatment was critical for obtaining optimal vision and cost-effectiveness, as is long-term follow-up and adherence to treatment.

Systematic review: non-adherence and non-persistence in intravitreal treatment

Purpose

Intravitreal injection of VEGF inhibitors has become the standard of care for different macular diseases within the last years resulting in improved visual outcomes. Under real-life conditions, however, the necessity for frequent retreatments and reexaminations poses a burden for patients and treatment centers. Non-adherence and non-persistence to intravitreal treatment may lead to inferior clinical outcomes, and knowledge of contributing factors is crucial to improve adherence. This systematic review analyzes current literature for potential factors involved in non-adherence and non-persistence.

Methods

A systematic search was conducted in PubMed and Embase including three different aspects of intravitreal injection therapy: (1) diseases with intravitreal injections as treatment, (2) intravitreal injection, and (3) aspects of therapy adherence or therapy persistence. Data from identified quantitative studies were further extracted and grouped according to WHO criteria (condition, socio-economy, therapy, patient, and health system). The methodological quality of identified studies was graded. Identified qualitative studies (i.e., interviews) were descriptively analyzed and their findings narratively reported.

Results

Twenty-four publications were included. In 16 of those publications, a quantitative data analysis was conducted, analyzing factors associated with non-adherence. Worse visual acuity at baseline and unfavorable development of visual acuity, higher age, and greater distance to the treatment center were associated with non-adherence, while there was inconsistent evidence for an association of comorbidity. In qualitative studies, high follow-up/treatment burden, fear and anxiety, disappointed patient expectations, and lack of motivation to continue treatment were reported as reasons for non-persistence.

Conclusions

Knowledge of potential barriers in IVT treatment may improve adherence and potentially clinical results. Improvements can be achieved particularly in the healthcare complex (organizational improvements) and the “patient” complex by establishing realistic expectations. Recurrent education of the patient may be necessary.

Electronic supplementary material

The online version of this article (10.1007/s00417-020-04798-2) contains supplementary material, which is available to authorized users.

Decreased Periodicity of Reactivation Interval in Neovascular Age-Related Macular Degeneration in Patients with a Late First Reactivation After Initial Treatment

Purpose: To evaluate the periodicity of the intervals of lesion reactivation in patients with neovascular age-related macular degeneration (AMD). Methods: This retrospective study included 139 eyes diagnosed with treatment-naive neovascular AMD and treated with antivascular endothelial growth factor (VEGF) therapy. Patients were initially treated with 3 loading anti-VEGF injections using either ranibizumab or aflibercept. Additional treatment was administered only when lesion reactivation was noted. The difference between the time intervals to the first and the second reactivations was evaluated. The included eyes were divided into 2 groups according to the time interval to the first reactivation: the early reactivation group (≤6 months, n = 86) and the late reactivation group (>6 months, n = 53). The association between the time intervals to the first and the second reactivations was evaluated within each group. Results: The mean follow-up period was 52.7 ± 8.9 months. The first reactivation was noted at mean 9.4 ± 10.4 months after the loading injections. The second reactivation was noted at mean 6.2 ± 4.9 months after the treatment for the first reactivation. The time interval to the second reactivation was significantly shorter compared with the first reactivation (P = 0.018). The association between the time interval to the first and the second reactivations was significant only in the early reactivation group (P = 0.002). Conclusions: A short first reactivation interval suggests that there is a high likelihood that the second reactivation will also be short. However, a long first reactivation interval does not suggest that the second reactivation interval will be similarly long.

[IVOM quality assurance in Westfalen-Lippe : Structure of quality assurance and results of the pilot study Q-VERA]

BACKGROUND

The KVWL-QS assists ophthalmologists in the transfer for good clinical praxis into real life. In addition the QS-commission initiated a pilotstudy "Qualitäts-Versorgung bei AMD" (Q‑VERA) in order to test new instruments for improvements. It was analized, if Reading Center (RC) based controls in combination with specific case-management modules can improve the results of IVOM treatment.

PATIENTS AND METHODS

In 5 treatment centers 878 consecutive patients with newly diagnosed AMD (Neu-Patienten) were included, who were treated with the IVAN-scheme. Initial FA and OCT images were transferred electronically to the RC. Also 781 retreatment patients (mean 20.7 IVOM before) with retreatment due to lesion activity were observed.

RESULTS

In 5% of the 878 newly treated patients a discrepancy between RC and treatment center was recorded. In this group the 481 patients, who finished up to the analysis date the 12-month follow-up, the visual function (increase in BCVA) and SD-OCT (reduction in central retinal thickness) results were comparable with large prospective cohorts. This was achieved with 6.5 injections and 10.6 visits over 12 months. In the group of 781 patients with repeated injections the number of injections over 12 months was 7.7 and the number of visits 11.6.

CONCLUSION

Quality assessment can improve the efficacy of IVOM therapy for AMD patients in real life. In addition to existing structures, electronical exchange by a RC assisted evaluation can further improve the quality by reducing the number of unnecessary treatment visits. The case-management with adherence control, re-call-system and specific information for patients and relatives can specifically increase the long-term adherence and thus the success of the therapy.

Long-term switching between ranibizumab and aflibercept in neovascular age-related macular degeneration and polypoidal choroidal vasculopathy

PURPOSE

To investigate the rate and timing of switching between ranibizumab and aflibercept and to evaluate the difference in the switching rates among the different subtypes of neovascularization.

METHODS

This retrospective study included 386 patients (386 eyes) who had been diagnosed with neovascular age-related macular degeneration (AMD) or polypoidal choroidal vasculopathy (PCV) and treated with ranibizumab (ranibizumab group, n = 260) or aflibercept (aflibercept group, n = 126). The rate and timing of switching from ranibizumab to aflibercept or vice versa were evaluated. Within the ranibizumab and the aflibercept groups, the switching rates were compared among the 3 subtypes of neovascularization: PCV, type 1 or 2 neovascularization, and type 3 neovascularization.

RESULTS

During the mean 44.9 ± 15.9 months of follow-up period, switching rate was significantly higher in the ranibizumab group (28.8%, 75 patients) than in the aflibercept group (9.5%, 12 patients) (P < 0.001). No difference was observed in the mean duration between the diagnosis and switching among the ranibizumab (18.7 ± 14.6 months) and the aflibercept groups (14.8 ± 14.5 months) (P = 0.379). In the ranibizumab group, the switching rate was markedly higher in PCV (39.6%) than in type 1 or 2 neovascularization (17.6%) or in type 3 neovascularization (13.3%) (P < 0.001). In the aflibercept group, there was no significant difference in the switching rates among the subtypes of neovascularization (P = 0.811).

CONCLUSIONS

Although the timings of switching were similar, switching rate was higher in patients undergoing ranibizumab therapy than in those undergoing aflibercept therapy. The switching rate was especially higher in PCV patients undergoing ranibizumab therapy.

Patient Preferences for Anti-Vascular Endothelial Growth Factor Treatment for Wet Age-Related Macular Degeneration in Japan: A Discrete Choice Experiment

BACKGROUND

In Japan, intravitreal anti-vascular endothelial growth factor (anti-VEGF) dosing regimens for wet age-related macular degeneration (wAMD) include pro re nata, every 2 months, and treat-and-extend, resulting in different outcomes and patient burden. Although reflecting patient preferences in treatment decision-making is desirable, few studies have examined this in Japan. This study assessed the patients willingness to trade-off between different dosing regimens.

PATIENTS AND METHODS

Patients with wAMD were recruited from four Japanese university hospitals to complete a face-to-face cross-sectional survey. In a discrete choice experiment, patients were asked to choose their preferred option from two anti-VEGF treatment profiles shown side-by-side across a series of choice tasks. The profiles varied on four attributes: number of injections in 12 months, number of physician consultations in 12 months, chance of 1-year visual acuity (VA) improvement, and chance of 2-year VA maintenance. Preference weights were estimated using hierarchical Bayes' models.

RESULTS

Overall, 120 patients (30 treatment naïve and 90 anti-VEGF experienced) completed the survey. Patients were willing to accept an increase from three to approximately eight injections in 12 months to increase the chance of 1-year VA improvement from 25% to 40%. They would be willing to accept 11 injections in 12 months if the chance of 2-year VA maintenance increased from 80% to 96%. The most valued attributes were increasing the chance of 2-year VA maintenance and reducing the number of injections in 12 months, which were each about twice as important as decreasing physician consultations in 12 months and increasing the chance of 1-year VA improvement (p<0.001). Among the dosing regimens, patients most preferred treat-and-extend because of its higher chance of 2-year VA maintenance.

CONCLUSION

Informing patients with wAMD about the likelihood of long-term VA maintenance when selecting treatment may increase the acceptance of an optimal treatment regimen and number of injections.

Methods to Assess Patient Preferences in Old Age Pharmacotherapy - A Systematic Review

PURPOSE

The aim of this systematic review was to identify methods used to assess medication preferences in older adults and evaluate their advantages and disadvantages with respect to their applicability to the context of multimorbidity and polypharmacy.

MATERIAL AND METHODS

Three electronic databases (PubMed, Web of Science, PsycINFO) were searched. Eligible studies elicited individual treatment or outcome preferences in a context that involved long-term pharmacological treatment options. We included studies with a study population aged ≥ 65 years and/or with a mean or median age of ≥ 75 years. Qualitative studies, studies assessing preferences for only two different treatments, and studies targeting preferences for life-sustaining treatments were excluded. The identified preference measurement methods were evaluated based on four criteria (time budget, cognitive demand, variety of pharmacological aspects, and link with treatment strategies) judged to be relevant for the elicitation of patient preferences in polypharmacy.

RESULTS

Sixty articles met the eligibility criteria and were included in the narrative synthesis. Fifty-five different instruments to assess patient preferences, based on 24 different elicitation methods, were identified. The most commonly applied preference measurement techniques were "medication willingness" (description of a specific medication with inquiry of the participant's willingness to take it), discrete choice experiments, Likert scale-based questionnaires, and rank prioritization. The majority of the instruments were created for disease-specific or context-specific settings. Only three instruments (Outcome Prioritization Tool, a complex intervention, "MediMol" questionnaire) dealt with the broader issue of geriatric multimorbidity. Only seven of the identified tools showed somewhat favorable characteristics for a potential use of the respective method in the context of polypharmacy.

CONCLUSION

Up to now, few instruments have been specifically designed for the assessment of medication preferences in older patients with multimorbidity. To facilitate valid preference elicitation in the context of geriatric polypharmacy, future research should focus on suitable characteristics of existing techniques to develop new measurement approaches for this increasingly relevant population.

Brolucizumab: Evolution through Preclinical and Clinical Studies and the Implications for the Management of Neovascular Age-Related Macular Degeneration

Improving or maintaining visual acuity is the main goal for the treatment of neovascular age-related macular degeneration (nAMD). Current nAMD standard of care dictates frequent intravitreal (IVT) anti-vascular endothelial growth factor (VEGF) injections, which places a substantial burden on patients, caregivers, and physicians. Brolucizumab, a newly developed anti-VEGF molecule for nAMD treatment, has demonstrated longer durability and improvement in visual and anatomic outcomes in clinical studies in a q12-week regimen, indicating its potential to reduce treatment burden as an important therapeutic tool in nAMD management. This review focuses on the development of brolucizumab and the preclinical and clinical studies evaluating its efficacy, tolerability, and safety. Brolucizumab (also known as "RTH258" and "ESBA1008") is a humanized, single-chain variable fragment (scFv) antibody with a molecular mass of approximately 26 kDa that inhibits VEGF-A. Preclinical studies show that brolucizumab readily penetrates the retina to reach the retinal pigment epithelium (RPE)/choroid with minimal subsequent systemic exposure. The safety, tolerability, and efficacy of a single IVT brolucizumab administration in patients with treatment-naïve nAMD were first demonstrated in the SEE Phase 1/2 study. The OSPREY Phase 2 study showed brolucizumab to be as efficacious as aflibercept in a q8-week regimen with regard to best-corrected visual acuity (BCVA) and brolucizumab achieving greater fluid resolution. Brolucizumab-treated patients in the OSPREY study were subsequently challenged with a q12-week dosing interval, and the outcomes provided key information for the study design and end points of the Phase 3 studies. In the HAWK and HARRIER Phase 3 studies, after 3 monthly loading injections, brolucizumab treatment regimen (q12-week or q8-week) was guided by individual disease activity assessment using functional and anatomic parameters (central subfield thickness [CST], intraretinal fluid [IRF], or subretinal fluid [SRF]) versus aflibercept (q8-week). Fewer brolucizumab 6-mg treated eyes had disease activity versus aflibercept, and anatomic outcome results at weeks 16 and 48 demonstrate brolucizumab as a potent drying agent. Moreover, of patients treated with 6 mg brolucizumab, 55.6% and 51.0% maintained a q12-week dosing interval immediately after the loading phase until week 48 in HAWK and HARRIER, respectively. These Phase 3 studies demonstrated that the brolucizumab q12-week regimen maintains efficacy and safety while reducing treatment burden associated with regular IVT injections for patients with nAMD.

How to Implement Adherence-Promoting Programs in Clinical Practice? A Discrete Choice Experiment on Physicians' Preferences

INTRODUCTION

The aim of this study was to examine physicians' preferences regarding adherence-promoting programs (APPs), and to investigate which APP characteristics influence the willingness of physicians to implement these in daily practice.

MATERIALS AND METHODS

A discrete choice experiment was conducted among general practitioners, cardiologists, neurologists and ophthalmologists in Germany. The design considered five attributes with two or three attribute levels each: validation status of the APP; possibility for physicians to receive a certificate; type of intervention; time commitment per patient and quarter of the year to carry out the APP; reimbursement for APP participation, per included patient and quarter of the year.A multinomial logit model was run to estimate physicians' utility for each attribute and to evaluate the influence of different levels on the probability of choosing a specific APP. The relative importance of the attributes was compared between different pre-defined subgroups.

RESULTS

In total, 222 physicians were included in the analysis. The most important characteristics of APPs were time commitment to carry out the program (34.8% importance), reimbursement (33.3%), and validation status of the program (23.7%). The remaining attributes (type of intervention: 3.6%; possibility to receive a certificate: 4.7%) were proven to be less important for a physician's decision to participate in an APP. Physicians on average preferred APP alternatives characterized by little time commitment (β=1.456, p<0.001), high reimbursement for work (β=1.392, p<0.001), "positive validation status" (β=0.990, p<0.001), the "possibility to get a certificate" (β=0.197, p<0.001), and the provision of "tools for both physicians and patients" (β=0.150, p<0.001).

CONCLUSION

For the majority of the physicians participating in this survey, the willingness to implement an APP is determined by the associated time commitment and reimbursement. Considering physicians' preferences regarding different APP features in the promoting process of these programs may enhance physicians' participation and engagement.

Preferences of Patients with Chronic Hepatitis B - A Discrete Choice Experiment on the Acceptability of Functional Cure

BACKGROUND

Current antiviral therapies for chronic hepatitis B (CHB) rarely achieve functional cure, thus often requiring lifelong therapy. A therapy achieving functional cure in a significant percentage of patients could change the treatment landscape substantially. However, the acceptability of functional cure by patients is unknown, especially if associated with additional treatment burden.

METHODS

A Discrete Choice Experiment (DCE) including patients with CHB was performed between 2018 and 2019 in Germany. Patient inclusion criteria were confirmed CHB; age of at least 18 years; no history of hepatocellular carcinoma; no HIV or HCV/HDV co-infection. The final DCE included the following attributes: route of administration (oral administration by tablets; subcutaneous injection + tablets; intramuscular electroporation + tablets), side effect frequency (0/1/3 days per month), functional cure (1%/30%/50% of patients), frequency of physician visits (monthly, half-yearly) and travel time to treating physician (15/45 min).

RESULTS

The main analysis sample consisted of 108 patients with CHB (mean age: 49.1 years, female: 37.0%, average time since CHB diagnosis: 14.0 years, 52.8% with Hepatitis B surface antigen (HBsAg) chronic HBV infection). High efficacy was found to be the main driver of decisions for/against the presented treatment options (impacted 57% of patients' decisions), followed by therapy regimen (17%), safety profile (12%) and number of physician visits (11%). Latent class analysis revealed first insights into different decision patterns, with age, gender and previous side-effect experience affecting patients' decisions.

CONCLUSION

In comparison to all other treatment-related attributes such as therapy regimen or safety profile, patients with CHB showed a strong preference towards a scenario where a substantial number of patients benefit from sustained disease remission, which mimics functional cure.

Undertreatment of Neovascular Age-Related Macular Degeneration after 10 Years of Anti-Vascular Endothelial Growth Factor Therapy in the Real World: The Need for A Change of Mindset

PURPOSE

To assess the gap between visual acuity (VA) outcomes with anti-vascular endothelial growth factor (anti-VEGF) therapies in clinical trials and real-world practice, and explore the reasons for this gap.

METHODS

The literature was searched from January 1, 2013, to June 30, 2018, for studies reporting VA gains and injection frequencies in clinical trials and real-world practice.

RESULTS

Clinical trials of anti-VEGF agents and their extension studies demonstrated initial VA gains maintained at 4 years and beyond (up to 7 years) with continuous proactive treatment. Visual outcomes correlated with injection frequency. In real-world practice, patients are usually undertreated, accounting for the VA decline over time. Reasons for undertreatment include the burden of injections and monitoring visits imposed on patients/caregivers. However, another primary reason is the general mindset in the ophthalmological community that sustained benefits with treatment are not possible, leading to poor compliance and creating a vicious circle.

CONCLUSIONS

Initial VA gains can be maintained with more intensive/proactive approaches. Promising new treatments requiring less frequent injections/monitoring will help in the near future; meanwhile, better results could be achieved by changing the community mindset that contributes to undertreatment.

Patient experience of treatment decision making for wet age-related macular degeneration disease: a qualitative study in China

OBJECTIVES

This study aimed to investigate the experience of patients with wet age-related macular degeneration (wAMD) in treatment decision-making process.

DESIGN

A descriptive qualitative study was designed by using semistructured interviews, and the data analysis was conducted with the thematic analysis approach.

PARTICIPANTS AND SETTING

A convenient and purposive sample of 21 participants diagnosed with wAMD was recruited from May 2018 to September 2018. The study was conducted in the Eye Clinic of Southwest Hospital of Army Medical University in Chongqing located in the southwest of China.

RESULTS

The mean age of the participants was 64.48 years (ranging 50-81 years), and the duration of the disease ranged from 6 months to 48 months. Four major themes were identified from the original data analysis. These themes included facing the darkness (choosing from light and darkness and living in pain), constraints on decision making (doctor-oriented decision making, inadequacy of options and time), weighing alternatives (family influence, financial burden and maintaining social function) and decision-making support (professional decision-making assistance and peer support).

CONCLUSION

This is a qualitative study attempting to explore the patient experience of treatment decision making for wAMD disease in China. Previous literature has focused on treatment effect and symptoms, rather than the individual experience and the wide contexts from a sociocultural perspective. Further studies, such as cross-sectional studies, can be used to describe the status and determine the influencing factors of decision0making process, so as to develop an impact factor model of decision making and to formulate an intervention for patients with wAMD.

Determining patient preferences in a glaucoma service: A discrete choice experiment

IMPORTANCE

Patient perspectives are crucial in informing design of acceptable services.

BACKGROUND

This study determined patient preferences in glaucoma care.

DESIGN

A discrete choice experiment was used to evaluate the relative importance of out-of-pocket costs, waiting time, continuity of care, service location and expertise.

PARTICIPANTS

Ninety-eight glaucoma suspects or glaucoma patients were recruited from one public and two private clinics in Sydney.

METHODS

Twelve choice-tasks were presented in random order and forced-choice preferences were elicited. Choice data were analysed using a multinominal logit model (NLOGIT 4.0).

MAIN OUTCOME MEASURES

The relative importance and the likelihood of choosing services with each attribute were determined. Willingness-to-pay and willingness-to-wait were calculated. Analyses were stratified by whether the patient attended a public or private glaucoma clinic and other demographic features.

RESULTS

Choice was influenced by four or five attributes: greater clinician expertise, the same clinician each visit, lower out-of-pocket costs and shorter wait times (all P < .05). Respondents were willing to pay an additional (Australian dollars) $325 (95% confidence interval [CI] 188-389) to see a senior eye doctor, and $87 (95% CI 60-116) to see the same clinician each visit. Respondents were willing to wait for these attributes; however, the estimates had wide confidence intervals and were beyond the range tested. Private patients had a stronger preference for expertise and continuity of care compared to public patients.

CONCLUSIONS AND RELEVANCE

Expertise and continuity of care were important to glaucoma patients in this setting, and they were willing to pay out-of-pocket and concede longer waiting times to secure these preferences.

COMPLIANCE AND ADHERENCE OF PATIENTS WITH DIABETIC MACULAR EDEMA TO INTRAVITREAL ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY IN DAILY PRACTICE

PURPOSE

We assessed differences in compliance and adherence (lateness of patients, visual acuity, reasons for abstaining) between patients with diabetic macular edema (DME) and patients with age-related macular degeneration (AMD), both under anti-vascular endothelial growth factor therapy.

METHODS

We included 136 patients with DME (36% women, 65 years, 22 visits, 13.9 injections, and 29.9 months of follow-up) and 109 patients with AMD (59% women, 76 years, 20 visits, 14.7 injections, and 22.3 months of follow-up) (minimum follow-up of 12 months and at least 5 injections). We assessed missed appointments (lateness >14 days) and therapy break-offs (lateness >100 days). All delayed patients were called and interviewed for abstaining reasons.

RESULTS

Forty-six percent of patients with DME and 22% of patients with AMD had at least one break-off. Thirty-five percent of patients with DME and 50% of patients with AMD were always on schedule. In patients with DME, there was significant correlation (P = 0.017) between the number of break-offs and change of visual acuity. In 60% DME and 38% AMD of break-off cases, visual acuity was worse than the before break-off. The most common reason for abstaining was comorbidities (33% AMD and 20% DME).

CONCLUSION

There are significant differences between patients with AMD and DME regarding compliance and adherence, which also affects outcome. Strategies to tie patients with DME to costly intravitreal therapy need to be developed to improve outcomes and efficacy.

Analysis of Anti-Vascular Endothelial Growth Factor Injection Claims Data in US Medicare Part B Beneficiaries From 2012 to 2015

Importance

The frequency of anti-vascular endothelial growth factor (VEGF) injections has grown exponentially with the introduction of bevacizumab, ranibizumab, and most recently aflibercept. The cost associated with these medications has garnered significant national attention, warranting a granular analysis of their use.

Objective

To analyze trends in anti-VEGF injections for US Medicare Part B beneficiaries from 2012 to 2015.

Design, Setting, and Participants

This observational cohort study used 2012-2015 data from the Centers for Medicare & Medicaid Services Medicare Part B Provider Utilization Files to analyze trends in intravitreal injections of anti-VEGF medications among Medicare Part B beneficiaries and their health care professionals.

Main Outcomes and Measures

The primary outcome measure was distribution of and change over time in the number of anti-VEGF injections performed for ranibizumab, aflibercept, and bevacizumab.

Results

A total of 2 574 124 intravitreal injections were performed by 3348 ophthalmologists in the outpatient setting for Medicare Part B beneficiaries during the 2015 calendar year; 100 ophthalmologists (3.0%) performed the highest volume of intravitreal injections. The total number of intravitreal injections administered in 2015 was 870 843 for aflibercept, 697 412 for ranibizumab, and 1 147 432 for bevacizumab. Ranibizumab injections decreased by 7.1% from 2012 to 2015 and bevacizumab injections decreased by 17.1%. From 2013 to 2015, aflibercept injections increased by 69.4%. The 100 ophthalmologists performing the highest volume of ranibizumab injections, as gauged by number of injections administered, accounted for 31.0% (95% CI, 30.994%-30.997%) of all ranibizumab injections nationally. The 100 ophthalmologists performing the highest volume of aflibercept injections accounted for 17.6% (95% CI, 17.638%-17.641%) of all aflibercept injections and the 100 ophthalmologists performing the highest volume of bevacizumab injections accounted for 19.6% (95% CI, 19.649%-19.653%) of all bevacizumab injections administered nationally to Medicare Part B beneficiaries. The highest number of injections per 1000 Medicare Part B beneficiaries occurred in Nebraska (aflibercept), Tennessee (ranibizumab), and South Dakota (bevacizumab).

Conclusions and Relevance

A total of 3.0% of ophthalmologists account for 17.6% to 31.0% of the total number of anti-VEGF injections administered nationally in the Medicare Part B population. Overall, bevacizumab and ranibizumab injections have decreased, coinciding with a 69.4% increase in aflibercept injections.

INFLUENCE OF FELLOW-EYE EXAMINATION INTERVAL ON VISUAL ACUITY AT FELLOW-EYE NEOVASCULARIZATION IN UNILATERAL TYPE 3 NEOVASCULARIZATION

PURPOSE

To evaluate the influence of the fellow-eye examination interval on visual acuity at fellow-eye neovascularization in unilateral Type 3 neovascularization.

METHODS

This retrospective, observational study included 55 patients who were initially diagnosed with unilateral Type 3 neovascularization and subsequently developed fellow-eye neovascularization during the follow-up period. The fellow-eye examination interval was defined as the hospital visit interval between fellow-eye neovascularization detection and immediately before neovascularization detection. The primary outcome measures were the associations between the fellow-eye examination interval and fellow-eye best-corrected visual acuity (BCVA) at fellow-eye neovascularization detection and degree of deterioration in fellow-eye BCVA.

RESULTS

After the initial diagnosis of the first-involved eye, fellow-eye neovascularization was noted after a period of 22.7 ± 17.5 months. The mean fellow-eye examination interval was 4.8 ± 2.2 months (range, 2-10 months). The mean logarithm of the minimum angle of resolution BCVA in the fellow eye was 0.22 ± 0.18 (Snellen equivalents, 20/33) immediately before neovascularization and 0.52 ± 0.26 (20/66) at neovascularization. There were significant associations between the fellow-eye examination interval and fellow-eye BCVA when neovascularization was detected (P = 0.005, r = 0.371) and at degree of deterioration in fellow-eye BCVA (P = 0.001, r = 0.428).

CONCLUSION

A longer fellow-eye examination interval was associated with poor visual acuity and greater visual deterioration of the fellow eye at neovascularization. These results suggest the need for frequent fellow-eye examination in patients with unilateral Type 3 neovascularization.

LONG-TERM VISUAL CHANGES IN INITIALLY STRONGER FELLOW EYES IN PATIENTS WITH UNILATERAL TYPE 3 NEOVASCULARIZATION

PURPOSE

To evaluate long-term visual changes in initially stronger fellow eyes in patients with unilateral Type 3 neovascularization.

METHODS

This retrospective study included 102 patients who were newly diagnosed with unilateral Type 3 neovascularization and in whom the best-corrected visual acuity (BCVA) of the fellow eye was initially better than that of the involved eye. All patients were treated with intravitreal anti-vascular endothelial growth factor injections. The BCVAs were compared at diagnosis, 12 months, 24 months, and the final visit. In patients who experienced ≥3 lines of visual deterioration in the BCVA of the fellow eye, the reason for visual deterioration was also verified.

RESULTS

The patients were followed for 45.9 ± 18.5 months after diagnosis. At diagnosis, the fellow-eye BCVA was better than that of the initially involved eye in all 102 patients. However, the fellow-eye visual acuity was the same or worse than that of the initially involved eye in 13 patients (12.7%) at 12 months, in 20 patients (19.6%) at 24 months, and in 24 patients (23.5%) at the final visit. At the final visit, 53 patients (51.9%) had experienced ≥3 lines of deterioration in the BCVA of the fellow eye. Fellow-eye neovascularization occurred in 42 patients, and geographic atrophy involving the fovea was noted in the remaining 11 patients.

CONCLUSION

Deterioration of the visual acuity of the fellow eye is frequently noted in unilateral Type 3 neovascularization. As a result of this deterioration, the initially stronger fellow eye did not remain stronger in 23.5% of the patients, suggesting the need for long-term strict treatment of the initially involved eye even when the visual acuity of the fellow eye is good.

TREATMENT OF NEOVASCULAR AGE-RELATED MACULAR DEGENERATION PATIENTS WITH VASCULAR ENDOTHELIAL GROWTH FACTOR INHIBITORS IN EVERYDAY PRACTICE: Identification of Health Care Constraints in Germany-The PONS Study

PURPOSE

The PONS study was conceived to analyze the extent of nonpersistence (NP) and nonadherence (NA) in the treatment of patients with neovascular age-related macular degeneration in everyday clinical practice in Germany. Further objectives were to identify factors that can affect NP and NA and to analyze clinical outcomes under everyday conditions.

METHODS

Nonpersistence (no contact with doctor for at least 3 months) and NA (no treatment or follow-up for at least 6 weeks) as well as clinical data were analyzed up to 24 months retrospectively and 12 months prospectively in 480 patients with neovascular age-related macular degeneration in 23 treatment centers. Patients were interviewed for factors possibly affecting NP and NA.

RESULTS

One third of patients fulfilled criteria of NA in the first 3 months and two thirds after 6 months. The NP was 18.8% after 12 months. Treatment exclusively at one center, a higher number of patients with neovascular age-related macular degeneration at the treating center, and fixed appointments were associated with a lower risk for NP. An initial gain in visual acuity after upload was not preserved after 12 months (mean change -0.5 Early Treatment Diabetic Retinopathy Study letters). Whereas visual acuity declined by 7.5 Early Treatment Diabetic Retinopathy Study letters in patients with good baseline visual acuity >20/40, visual acuity improved by 8.5 letters in patients with baseline visual acuity of ≤20/200. Only 7.5% of patients underwent an optical coherence tomography scan after 3 upload injections, and only 2.0 optical coherence tomographies were performed in the first 12 months.

CONCLUSION

The NP and NA were high in our study population and are likely to have contributed to a suboptimal clinical outcome compared with randomized clinical trials. Shortcomings in the management of patients with neovascular age-related macular degeneration, including restrictions in the timely and adequate follow-up (including optical coherence tomography) and retreatment, appear to be constraining factors in Germany.

Subjective evaluation of visual acuity is not reliable to detect disease activity in different exudative maculopathies

BACKGROUND

Patients with exudative maculopathies (neovascular age-related macular degeneration (nAMD), diabetic macular edema (DME), and retinal vein occlusion (RVO)) are faced with a high burden of examinations and treatments. This study was conceived to analyze the accuracy of a subjective evaluation of visual acuity (VA) and metamorphopsia to detect disease reactivation, compared to morphological signs of reactivation assessed by means of SD-OCT.

METHODS

Retrospective study of 888 patients treated for nAMD (n = 638), DME (84), BRVO (110), and CRVO (56) was conducted. Subjective evaluation of the patient at an examination (i.e., change of VA and/or metamorphopsia) was compared to clinical evaluation of disease activity as assessed by SD-OCT. Sensitivity and specificity, negative and positive predictive values (PPV/NPV) for detection of active disease were calculated. Factors associated with false-negative subjective evaluation were analyzed by regression analysis.

RESULTS

The sensitivity of the subjective evaluation to detect disease reactivation was < 0.50 in all exudative maculopathies. Sensitivity was increased to ≥ 0.60 by combining subjective worsening with loss of 1 line in the VA test in RVO, but not in DME and nAMD. The specificity was > 0.85 in all patients. PPV was > 0.85 in patients with RVO. Regression analysis did not reveal any factors that could reliably identify patient subgroups in which OCT could be omitted, though CRVO patients with a visual acuity of < 0.3 logMAR had an odds ratio of 0.20 for false-negative subjective evaluation (p = 0.009).

CONCLUSION

The accuracy of subjective evaluation to discriminate disease activity in patients with different exudative maculopathies was low and cannot substitute for frequent SD-OCT exams. Routinely assessed clinical parameters such as age, visual acuity, or treatment experience were of no use to predict the validity of subjective evaluation of disease activity.

TRIAL REGISTRATION

This trial was registered at the DRKS (Deutsches Register Klinischer Studien, drks.de; No 00006851) prior to the inclusion of the first patient.

Association of treatment adherence with real-life VA outcomes in AMD, DME, and BRVO patients

Purpose

Real-life clinical outcomes of patients treated with anti-VEGF drugs for neovascular age-related macular degeneration (nAMD), diabetic macular edema (DME), or macular edema secondary to branch retinal vein occlusion (BRVO) are often inferior to results from randomized clinical trials. This observational cohort study investigates treatment adherence and real-life clinical outcomes within the first year of treatment.

Patients and methods

A total of 708 treatment-naïve patients (466 nAMD, 134 DME, and 108 BRVO) were included. Patients were followed with a PRN treatment protocol with three intravitreal injections (IVIs) and a series of 3 monthly injections in case of persistent or recurrent disease activity, as determined by monthly follow-up exams including optical coherence tomographies. Occurrence of gaps of >56 days between treatments or follow-up (nonadherence [NA]) and the reasons for NA (patient- or center-associated) as well as disease activity within the first 12 months of treatment were analyzed. Visual acuity (VA) as well as numbers and dates of optical coherence tomography and IVI were extracted from medical records.

Results

NA occurred significantly more often in patients with DME (44%) than nAMD (32%) or BRVO (25%, p<0.01 between groups). NA was mainly patient-associated (nAMD: 80.0%, DME: 83.1%, BRVO: 70.4%, p=0.38 between groups). Patients with nAMD and DME and appropriate treatment/follow-up adherence had a better chance of significantly gaining or maintaining VA, respectively (19.9% vs 12.0% with 3-line-gain in nAMD and 1.3% vs 15.3% 3-line loss in DME; each p<0.05). NA did not correlate with VA outcomes in BRVO (3-line gain 30.9% vs 48.1% and 3-line loss 8.6% vs 7.4%; p>0.05).

Conclusion

NA to treatment and follow-up regimens is a common problem in the management of patients with AMD and DME and limits clinical treatment outcomes under real-life conditions. Patients with DME have the highest risk of patient-associated NA, associated with a higher risk for significant VA loss.

Effects of Aflibercept for Neovascular Age-Related Macular Degeneration: A Systematic Review and Meta-Analysis of Observational Comparative Studies

Purposes

To compare the effects of aflibercept and other anti-vascular endothelial growth factor (anti-VEGF) medications on both functional and anatomical outcomes for treatment-naïve neovascular age-related macular degeneration (nAMD) in the real world.

Methods

A systematic review and meta-analysis of observational comparative studies.

Results

A total of 18 studies remained after literature selection and quality assessment of 1697 studies. The most common aflibercept treatment regimen was three monthly injections followed by pro re nata (PRN). Aflibercept and ranibizumab had similar effects in 2-year treatment. At 3, 6, 12, and 24 months, the differences in the logarithm of minimum angle of resolution (logMAR) decrease in aflibercept and ranibizumab groups were 0.00 (95% confidence interval [CI]: −0.03 to 0.02); 0.01 (95% CI: −0.02 to 0.05); −0.03 (95% CI: −0.07 to 0.01); and –0.06 (95% CI: −0.30 to 0.17), respectively; the differences in decrease of central retinal thickness (CRT) were 3.25 μm (95% CI: −15.03 to 21.53); 7.89 μm (95% CI: −31.91 to 47.69); 2.89 μm (95% CI: −18.33 to 24.11); and −2.42 μm (95% CI: −77.87 to 73.03), respectively. However, aflibercept was significantly more effective in patients with initial reduced visual acuity (logMAR >0.6 or <55 letters; P = 0.001). In the first year, treatment frequency was not significantly different for aflibercept and ranibizumab, but aflibercept required fewer injections than ranibizumab with PRN regimen (mean −0.90; 95% CI: −1.80 to 0.00).

Conclusions

Aflibercept has comparable effects with ranibizumab for treatment-naïve nAMD in the real world, and may be more effective for patients with initial lower visual acuity.

Treatment of age-related neovascular macular degeneration: the patient's perspective

OBJECTIVES

The aim of this study was to assess patients' views and expectations with regard to neovascular age-related macular degeneration (nAMD) and intravitreal anti-VEGF therapy (IVT).

METHODS

We conducted a multicenter, non-interventional, prospective cohort study including nAMD patients treated with IVT in Germany. Patients with at least one IVT before study enrollment and aged ≥50 years were included. Three telephone interviews were conducted during a 12-month observational period. Here, patient's beliefs/expectations with regard to the nAMD disease and the IVT treatment were discussed. Only patients who completed all three phone interviews were included in the analyses. We used a two-step cluster analysis to identify patient clusters regarding specific patient attitudes towards nAMD and its treatment.

RESULTS

Three hundred and thirty-two patients completed all interviews (mean age of 76.4 ± 7.2 years, 59.0% women). Out of these, 57.8% acknowledged that they needed general assistance in daily life, while 77.4% stated being able to attend general medical appointments on their own. However, 64.7% needed a driver or an accompanying person to attend their IVT appointments. In addition, 3.9% of the patients were afraid of IVT side effects. Also, 87.3% and 43.1% of the patients could name their disease or the anti-VEGF drug administered, respectively. More than three-quarters of the patients (83.1%) were aware of possible consequences of nAMD by stating vision loss or blindness, but only 16.6% knew that nAMD is a chronic disease. Generally, patients were optimistic: 70.2%, 5.1% and 13.0% of them expected stable visual acuity (VA), a significant improvement or expected worsening of VA in the next year, respectively. Almost two thirds of patients who provided their therapy expectations (47.0%) anticipated fewer injections/discontinuation of IVT. We identified five patient clusters differing significantly from each other with regard to four variables: being afraid of IVT, nAMD disease awareness, optimism with regard to effectiveness of IVT, and nAMD disease and treatment knowledge.

CONCLUSIONS

Only a minority of patients is aware of the chronic nature of nAMD. To motivate patients to accept a life-long IVT treatment, physicians and caregivers must know that there exist different patient types with significant differences in communication needs.

Comparing Analytic Hierarchy Process and Discrete-Choice Experiment to Elicit Patient Preferences for Treatment Characteristics in Age-Related Macular Degeneration

BACKGROUND

In this study, we conducted an analytic hierarchy process (AHP) and a discrete choice experiment (DCE) to elicit the preferences of patients with age-related macular degeneration using identical attributes and levels.

OBJECTIVES

To compare preference-based weights for age-related macular degeneration treatment attributes and levels generated by two elicitation methods. The properties of both methods were assessed, including ease of instrument use.

METHODS

A DCE and an AHP experiment were designed on the basis of five attributes. Preference-based weights were generated using the matrix multiplication method for attributes and levels in AHP and a mixed multinomial logit model for levels in the DCE. Attribute importance was further compared using coefficient (DCE) and weight (AHP) level ranges. The questionnaire difficulty was rated on a qualitative scale. Patients were asked to think aloud while providing their judgments.

RESULTS

AHP and DCE generated similar results regarding levels, stressing a preference for visual improvement, frequent monitoring, on-demand and less frequent injection schemes, approved drugs, and mild side effects. Attribute weights derived on the basis of level ranges led to a ranking that was opposite to the AHP directly calculated attribute weights. For example, visual function ranked first in the AHP and last on the basis of level ranges.

CONCLUSIONS

The results across the methods were similar, with one exception: the directly measured AHP attribute weights were different from the level-based interpretation of attribute importance in both DCE and AHP. The dependence/independence of attribute importance on level ranges in DCE and AHP, respectively, should be taken into account when choosing a method to support decision making.