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Meunier A, Opeifa O, Longworth L, Cox O, Bührer C, Durand-Zaleski I, Kelly SP, Gale RP. An eye on equity: faricimab-driven health equity improvements in diabetic macular oedema using a distributional cost-effectiveness analysis from a UK societal perspective. Eye (Lond) 2024; 38:1917-1925. [PMID: 38555401 PMCID: PMC11226444 DOI: 10.1038/s41433-024-03043-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 02/26/2024] [Accepted: 03/15/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND/OBJECTIVES Diabetic macular oedema (DMO) is a leading cause of blindness in developed countries, with significant disease burden associated with socio-economic deprivation. Distributional cost-effectiveness analysis (DCEA) allows evaluation of health equity impacts of interventions, estimation of how health outcomes and costs are distributed in the population, and assessments of potential trade-offs between health maximisation and equity. We conducted an aggregate DCEA to determine the equity impact of faricimab. METHODS Data on health outcomes and costs were derived from a cost-effectiveness model of faricimab compared with ranibizumab, aflibercept and off-label bevacizumab using a societal perspective in the base case and a healthcare payer perspective in scenario analysis. Health gains and health opportunity costs were distributed across socio-economic subgroups. Health and equity impacts, measured using the Atkinson inequality index, were assessed visually on an equity-efficiency impact plane and combined into a measure of societal welfare. RESULTS At an opportunity cost threshold of £20,000/quality-adjusted life year (QALY), faricimab displayed an increase in net health benefits against all comparators and was found to improve equity. The equity impact increased the greater the concerns for reducing health inequalities over maximising population health. Using a healthcare payer perspective, faricimab was equity improving in most scenarios. CONCLUSIONS Long-acting therapies with fewer injections, such as faricimab, may reduce costs, improve health outcomes and increase health equity. Extended economic evaluation frameworks capturing additional value elements, such as DCEA, enable a more comprehensive valuation of interventions, which is of relevance to decision-makers, healthcare professionals and patients.
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Affiliation(s)
| | | | | | - Oliver Cox
- F. Hoffmann-La Roche Ltd, Grenzacherstrasse, Basel, Switzerland
| | | | | | | | - Richard P Gale
- Hull York Medical School, York and Scarborough Teaching Hospitals NHS Foundation Trust, York, UK
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Bührer C, Paling T, Gale R, Paulo T, Bagijn M. Cost-Effectiveness of Faricimab in the Treatment of Diabetic Macular Oedema (DMO): A UK Analysis. PHARMACOECONOMICS - OPEN 2024; 8:445-457. [PMID: 38438829 PMCID: PMC11058163 DOI: 10.1007/s41669-023-00465-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/03/2023] [Indexed: 03/06/2024]
Abstract
AIM The aim of this work was to evaluate the cost-effectiveness of faricimab against relevant therapeutic alternatives used in clinical practice for the treatment of diabetic macular oedema (DMO) in the UK. METHODS A state-transition (Markov) model, with health states based on visual acuity scores and treatment pathways, was developed to conduct cost-utility analysis of faricimab treat and extend (T&E) regimen versus ranibizumab pro re nata (PRN) and aflibercept PRN over a time horizon of 25 years. Comparison against bevacizumab PRN was considered in scenario analysis. Effectiveness data for faricimab was sourced from the pivotal YOSEMITE and RHINE double-blind randomised controlled trials, and from a network meta-analysis for comparators. Costs and (dis)utilities were taken from nationally published sources or literature. The base case included indirect costs (productivity gains, informal care) given the wider impacts of DMO on society. Sensitivity analyses were conducted. RESULTS In the base case, faricimab T&E dominated ranibizumab PRN and aflibercept PRN, being more effective and resulting in cost savings (between 0.16 and 0.36 mean QALYs gained, and £5483-9655 mean cost savings). In scenario analysis, faricimab was more effective but costlier compared with bevacizumab, with an incremental cost-effectiveness ratio (ICER) of £8898 per QALY gained. Considering only healthcare payer costs, the ICER of faricimab compared with ranibizumab PRN was £7991 per QALY gained and faricimab dominated aflibercept PRN. CONCLUSIONS Faricimab T&E has the potential to reduce the burden of vision loss on society, giving people living with DMO greater independence and contributing to increased healthcare system capacity. At a threshold of £20,000, faricimab T&E is cost-effective compared with relevant comparators, and potentially cost saving.
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Affiliation(s)
- Christian Bührer
- F. Hoffmann-La Roche Ltd, Grenzacherstrasse, Basel, Switzerland.
| | - Thomas Paling
- Roche Products Ltd, 6 Falcon Way, Shire Park, Welwyn Garden City, UK
| | - Richard Gale
- York and Scarborough Teaching Hospital NHS Foundation Trust, York, UK
- Hull York Medical School, University of York, Heslington, York, UK
| | - Tatiana Paulo
- F. Hoffmann-La Roche Ltd, Grenzacherstrasse, Basel, Switzerland
| | - Marloes Bagijn
- F. Hoffmann-La Roche Ltd, Grenzacherstrasse, Basel, Switzerland
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Kyei S, Asare FA, Assan JK, Zaabaar E, Assiamah F, Obeng EO, Asiedu K. Efficacy of intravitreal bevacizumab on diabetic macular oedema in an African population. Ir J Med Sci 2023; 192:2777-2783. [PMID: 36988835 DOI: 10.1007/s11845-023-03348-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 03/19/2023] [Indexed: 03/30/2023]
Abstract
PURPOSE To evaluate the short-term effect of intravitreal bevacizumab (avastin) injection on visual outcomes of patients with diabetic macular oedema. METHODS A retrospective cross-sectional study was conducted to evaluate 39 eyes of thirty-nine patients (mean age ± SD: 61.4 ± 15.0 years) that received intravitreal bevacizumab injection (1.25 mg in 0.05 ml) as treatment for diabetic macular oedema between January 2014 and July 2019 in Ghana. Data on visual acuity and central macular thickness before treatment and 6 weeks post-treatment were collected and analysed using paired t-test. Ordinary least squares linear regression analysis was also conducted to determine the relationship between improvement in visual acuity and central macular thickness after treatment and other predictor variables. RESULTS The mean ± SD visual acuity (LogMAR-equivalent of Snellen) of patients with diabetic macular oedema significantly improved from 0.84 ± 0.58 LogMAR before treatment to 0.69 ± 0.58 LogMAR at 6 weeks post-treatment (mean difference: 0.15 ± 0.32 LogMAR; 95% CI: 0.04 to 0.25; p = 0.01). Mean macular thickness ± SD on the other hand, reduced significantly (p < 0.001) from 316.54 ± 75.35 μm before treatment to 275.54 ± 57.43 μm after treatment. While age and worse pre-treatment visual acuity predicted improvement in visual acuity after treatment, a higher central macular thickness before treatment predicted an improvement in central macular thickness after intravitreal bevacizumab injection. CONCLUSION Treatment with intravitreal bevacizumab injection produces short-term improvement in vision and reduction in central macular thickness in African patients with diabetic macular oedema.
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Affiliation(s)
- Samuel Kyei
- Department of Optometry and Vision Science, School of Allied Health Sciences, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana.
| | - Frederick Afum Asare
- Centre for Optometry and Vision Science, Biomedical Sciences Research Institute, Ulster University, Coleraine, UK
| | - John Kwesi Assan
- Department of Optometry and Vision Science, School of Allied Health Sciences, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Ebenezer Zaabaar
- Department of Optometry and Vision Science, School of Allied Health Sciences, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana
- Department of Ophthalmology and Visual Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Frank Assiamah
- Cell Biology and Human Anatomy Department, University of California, Davis, USA
| | - Eric Obour Obeng
- Department of Optometry and Vision Science, School of Allied Health Sciences, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Kofi Asiedu
- School of Optometry and Vision Science, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
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Mistry H, Maredza M, Campbell C, Lois N. Subthreshold micropulse laser versus standard laser for the treatment of central-involving diabetic macular oedema with central retinal thickness of <400µ: a cost-effectiveness analysis from the DIAMONDS trial. BMJ Open 2023; 13:e067684. [PMID: 37852765 PMCID: PMC10603454 DOI: 10.1136/bmjopen-2022-067684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 09/29/2023] [Indexed: 10/20/2023] Open
Abstract
OBJECTIVES To estimate the economic costs, health-related quality-of-life outcomes and cost-effectiveness of subthreshold micropulse laser (SML) versus standard laser (SL) for the treatment of diabetic macular oedema (DMO) with central retinal thickness (CRT) of <400µ. DESIGN An economic evaluation was conducted within a pragmatic, multicentre, randomised clinical trial, DIAbetic Macular Oedema aNd Diode Subthreshold. SETTING 18 UK Hospital Eye Services. PARTICIPANTS Adults with diabetes and centre involving DMO with CRT<400µ. INTERVENTIONS Participants (n=266) were randomised 1:1 to receive SML or SL. METHODS The base-case used an intention-to-treat approach conducted from a UK National Health Service (NHS) and personal social services (PSS) perspective. Costs (2019-2020 prices) were collected prospectively over the 2-year follow-up period. A bivariate regression of costs and quality-adjusted life-years (QALYs), with multiple imputation of missing data, was conducted to estimate the incremental cost per QALY gained and the incremental net monetary benefit of SML in comparison to SL. Sensitivity analyses explored uncertainty and heterogeneity in cost-effectiveness estimates. RESULTS One participant in the SL arm withdrew consent for data to be used; data from the remaining 265 participants were included in analyses. Mean (SE) NHS and PSS costs over 24 months were £735.09 (£111.85) in the SML arm vs £1099.70 (£195.40) in the SL arm (p=0.107). Mean (SE) QALY estimates were 1.493 (0.024) vs 1.485 (0.020), respectively (p=0.780), giving an insignificant difference of 0.008 QALYs. The probability SML is cost-effective at a threshold of £20 000 per QALY was 76%. CONCLUSIONS There were no statistically significant differences in EQ-5D-5L scores or costs between SML and SL. Given these findings and the fact that SML does not burn the retina, unlike SL and has equivalent efficacy to SL, it may be preferred for the treatment of people with DMO with CRT<400µ. TRIAL REGISTRATION NUMBERS ISRCTN17742985; NCT03690050.
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Affiliation(s)
- Hema Mistry
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Mandy Maredza
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Noemi Lois
- Department of Ophthalmology, Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
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Sydnor S, Chatterjee S, Cooney P, Kaur S, Macmillan T, Stewart D, Munro I, Bandeiras C, Paine A, Felizzi F. Efficacy and Safety of Brolucizumab, Aflibercept, and Ranibizumab for the Treatment of Patients with Visual Impairment Due to Diabetic Macular Oedema: A Systematic Review and Network Meta-Analysis. Diabetes Ther 2023:10.1007/s13300-023-01410-8. [PMID: 37198521 DOI: 10.1007/s13300-023-01410-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 04/12/2023] [Indexed: 05/19/2023] Open
Abstract
INTRODUCTION Key clinical guidelines recommend anti-vascular endothelial growth factor (VEGF) therapy as first-line treatment for visual impairment due to diabetic macular oedema (DMO). A systematic literature review (SLR) and network meta-analysis (NMA) were conducted comparing the relative efficacy of the anti-VEGF brolucizumab with a focused network of the most relevant comparator dosing regimens approved in countries other than the USA (aflibercept, ranibizumab). The safety and tolerability of brolucizumab were also assessed. METHODS A broad SLR was conducted to identify randomised controlled trials to ensure all relevant potential comparators were captured. Identified studies were refined to those appropriate for inclusion in the NMA. A Bayesian NMA was conducted comparing brolucizumab 6 mg (every 12 [Q12W]/every 8 weeks [Q8W]) with relevant aflibercept 2 mg and ranibizumab 0.5 mg regimens. RESULTS Fourteen studies were included in the NMA. At 1-year follow-up, the various aflibercept 2 mg and ranibizumab 0.5 mg regimens were mostly comparable with brolucizumab 6 mg Q12W/Q8W across key visual and anatomical outcomes, except brolucizumab 6 mg was favoured over ranibizumab 0.5 mg every 4 weeks (Q4W) for the change from baseline (CFB) in best-corrected visual acuity (BCVA), and BCVA loss/gain of pre-specified numbers of letters, and over ranibizumab 0.5 mg pro re nata for CFB in diabetic retinopathy severity scale, and retinal thickness. At year 2, where data were available, brolucizumab 6 mg showed similar results across efficacy outcomes versus all other anti-VEGFs. In most cases, discontinuation rates (all cause, and due to adverse events [AE]) and serious and overall rates of AEs excluding ocular inflammatory events were similar (in unpooled and pooled-treatment analyses) versus comparators. CONCLUSION Brolucizumab 6 mg Q12W/Q8W was comparable or superior to aflibercept 2 mg and ranibizumab 0.5 mg regimens for various visual and anatomical efficacy outcomes and discontinuation rates.
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Affiliation(s)
- Shelby Sydnor
- Novartis Pharmaceuticals UK Ltd., London, England, UK
| | | | | | - Simarjeet Kaur
- CONEXTS, Novartis Healthcare Pvt. Ltd., Hyderabad, India
| | | | | | | | | | - Abby Paine
- Source Health Economics, Oxford, England, UK
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Cao X, Lu M, Xie RR, Song LN, Yang WL, Xin Z, Yang GR, Yang JK. A high TSH level is associated with diabetic macular edema: a cross-sectional study of patients with type 2 diabetes mellitus. Endocr Connect 2022; 11:EC-22-0122. [PMID: 35686715 PMCID: PMC9254322 DOI: 10.1530/ec-22-0122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 06/09/2022] [Indexed: 11/28/2022]
Abstract
AIMS In this study, we determined the association between thyroid-stimulating hormone (TSH) and diabetic macular edema (DME) by assessing the prevalence and risk factors for DME in type 2 diabetes mellitus (T2DM) patients with different thyroid dysfunctions. METHODS This was a retrospective cross-sectional study including 1003 euthyroid and 92 subclinical hypothyroidism (SCH) T2DM patients. DME status was detected by optical coherence tomography (OCT). The association between TSH and DME and the impact of TSH on DME were analyzed. RESULTS The DME prevalence was 28.3% in the SCH patients and 14.0% in the euthyroid population. The serum FT4 (P = 0.001) and FT3 (P < 0.001) levels were significantly higher in the non-DME group than in the DME group, and the TSH level (P < 0.001) was significantly lower. Four subgroups (G1-G4) were divided by TSH level, and the chi-square test indicated that even in the normal range, the TSH level was positively related to DME prevalence (P = 0.001). Subgroup data indicated that the association between TSH and DME detected by OCT (P = 0.001) was stronger than the correlation between TSH and diabetic retinopathy detected by digital retinal photographs (P = 0.027). The logistic regression model confirmed that elevated TSH was an independent risk factor for DME. The odds ratio was 1.53 (P = 0.02). CONCLUSIONS A high TSH level was an independent risk factor for DME. More attention should be given to the TSH level in T2DM patients due to its relationship with diabetic complications.
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Affiliation(s)
- Xi Cao
- Beijing Diabetes Institute, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Ming Lu
- Department of Endocrinology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Rong-Rong Xie
- Beijing Diabetes Institute, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Li-Ni Song
- Department of Endocrinology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Wei-Li Yang
- Beijing Diabetes Institute, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Correspondence should be addressed to J-K Yang:
| | - Zhong Xin
- Department of Endocrinology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Guang-Ran Yang
- Department of Endocrinology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Correspondence should be addressed to J-K Yang:
| | - Jin-Kui Yang
- Beijing Diabetes Institute, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Correspondence should be addressed to J-K Yang:
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Boyers D, Retat L, Jacobsen E, Avenell A, Aveyard P, Corbould E, Jaccard A, Cooper D, Robertson C, Aceves-Martins M, Xu B, Skea Z, de Bruin M. Cost-effectiveness of bariatric surgery and non-surgical weight management programmes for adults with severe obesity: a decision analysis model. Int J Obes (Lond) 2021; 45:2179-2190. [PMID: 34088970 PMCID: PMC8455321 DOI: 10.1038/s41366-021-00849-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 04/21/2021] [Accepted: 04/27/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To determine the most cost-effective weight management programmes (WMPs) for adults, in England with severe obesity (BMI ≥ 35 kg/m2), who are more at risk of obesity related diseases. METHODS An economic evaluation of five different WMPs: 1) low intensity (WMP1); 2) very low calorie diets (VLCD) added to WMP1; 3) moderate intensity (WMP2); 4) high intensity (Look AHEAD); and 5) Roux-en-Y gastric bypass (RYGB) surgery, all compared to a baseline scenario representing no WMP. We also compare a VLCD added to WMP1 vs. WMP1 alone. A microsimulation decision analysis model was used to extrapolate the impact of changes in BMI, obtained from a systematic review and meta-analysis of randomised controlled trials (RCTs) of WMPs and bariatric surgery, on long-term risks of obesity related disease, costs, quality adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) measured as incremental cost per QALY gained over a 30-year time horizon from a UK National Health Service (NHS) perspective. Sensitivity analyses explored the impact of long-term weight regain assumptions on results. RESULTS RYGB was the most costly intervention but also generated the lowest incidence of obesity related disease and hence the highest QALY gains. Base case ICERs for WMP1, a VLCD added to WMP1, WMP2, Look AHEAD, and RYGB compared to no WMP were £557, £6628, £1540, £23,725 and £10,126 per QALY gained respectively. Adding a VLCD to WMP1 generated an ICER of over £121,000 per QALY compared to WMP1 alone. Sensitivity analysis found that all ICERs were sensitive to the modelled base case, five year post intervention cessation, weight regain assumption. CONCLUSIONS RYGB surgery was the most effective and cost-effective use of scarce NHS funding resources. However, where fixed healthcare budgets or patient preferences exclude surgery as an option, a standard 12 week behavioural WMP (WMP1) was the next most cost-effective intervention.
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Affiliation(s)
- D Boyers
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK.
| | | | - E Jacobsen
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - A Avenell
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - P Aveyard
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
- NIHR Oxford Biomedical Research Centre (BRC) Obesity, Diet and Lifestyle Theme, Oxford, UK
- NIHR Applied Research Collaboration (ARC) Oxford and Thames Valley, Oxford, UK
| | | | | | - D Cooper
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - C Robertson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - M Aceves-Martins
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - B Xu
- UK Health Forum, London, UK
| | - Z Skea
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - M de Bruin
- Health Psychology, University of Aberdeen, Aberdeen, UK
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
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Haider S, Thayakaran R, Subramanian A, Toulis KA, Moore D, Price MJ, Nirantharakumar K. Disease burden of diabetes, diabetic retinopathy and their future projections in the UK: cross-sectional analyses of a primary care database. BMJ Open 2021; 11:e050058. [PMID: 34253675 PMCID: PMC8276304 DOI: 10.1136/bmjopen-2021-050058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES To estimate the current disease burden, trends and future projections for diabetes mellitus (DM) and diabetic retinopathy (DR) in the IQVIA Medical Research Data (IMRD). PARTICIPANTS/DESIGN/SETTING We performed a cross-sectional study of patients aged 12 and above to determine the prevalence of DM and DR from the IMRD database (primary care database) in January 2017, involving a total population of 1 80 824 patients with DM. We also carried out a series of cross-sectional studies to investigate prevalence trends, and then applied a double exponential smoothing model to forecast the future burden of DM and DR in the UK. RESULTS The crude DM prevalence in 2017 was 5.2%. The DR, sight-threatening retinopathy (STR) and diabetic maculopathy prevalence figures in 2017 were 33.78%, 12.28% and 7.86%, respectively, in our IMRD cross-sectional study. There were upward trends in the prevalence of DM, DR and STR, most marked and accelerating in STR in type 1 DM but slowing in type 2 DM, and in the overall prevalence of DR. CONCLUSION Our results suggest differential rising trends in the prevalence of DM and DR. Preventive strategies, as well as treatment services planning, can be based on these projected prevalence estimates. Improvements that are necessary for the optimisation of care pathways, and preparations to meet demand and capacity challenges, can also be based on this information. The limitations of the study can be overcome by a future collaborative study linking DR screening and hospital eye services data.
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Affiliation(s)
- Sajjad Haider
- Institute Of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Rasiah Thayakaran
- Institute Of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | | | - David Moore
- Institute Of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Malcolm James Price
- Institute Of Applied Health Research, University of Birmingham, Birmingham, UK
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Intravitreal injections: past trends and future projections within a UK tertiary hospital. Eye (Lond) 2021; 36:1373-1378. [PMID: 34172943 PMCID: PMC8227364 DOI: 10.1038/s41433-021-01646-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 05/30/2021] [Accepted: 06/14/2021] [Indexed: 11/08/2022] Open
Abstract
AIMS To describe past trends and future projections for the number of intravitreal injections being administered at a large tertiary hospital in London, United Kingdom. METHODS Retrospective data from Moorfields Eye Hospital were collected using the electronic medical record system. Descriptive statistics were used to visualise overall trends. Time series forecasting was used to predict the number of injections that will be administered up to and including the year 2029. RESULTS The number of injections has increased nearly 11-fold from 2009 to 2019, with a total of 44,924 injections delivered in 2019. The majority of injections were given for the treatment of neovascular age-related macular degeneration. Aflibercept formed 87% of injections administered in 2019. The number of injections is predicted to continue to increase every year, with nearly 83,000 injections forecasted in the year 2029. CONCLUSION The demand for intravitreal injections has increased substantially over the last decade and is predicted to further increase. Healthcare systems will need to adapt to accommodate the high demand. Other solutions may include longer-acting therapies to reduce the treatment burden.
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Lois N, Cook J, Wang A, Aldington S, Mistry H, Maredza M, McAuley D, Aslam T, Bailey C, Chong V, Ghanchi F, Scanlon P, Sivaprasad S, Steel D, Styles C, Azuara-Blanco A, Prior L, Waugh N. Multimodal imaging interpreted by graders to detect re-activation of diabetic eye disease in previously treated patients: the EMERALD diagnostic accuracy study. Health Technol Assess 2021; 25:1-104. [PMID: 34060440 DOI: 10.3310/hta25320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Owing to the increasing prevalence of diabetes, the workload related to diabetic macular oedema and proliferative diabetic retinopathy is rising, making it difficult for hospital eye services to meet demands. OBJECTIVE The objective was to evaluate the diagnostic performance, cost-effectiveness and acceptability of a new pathway using multimodal imaging interpreted by ophthalmic graders to detect reactivation of diabetic macular oedema/proliferative diabetic retinopathy in previously treated patients. DESIGN This was a prospective, case-referent, cross-sectional diagnostic study. SETTING The setting was ophthalmic clinics in 13 NHS hospitals. PARTICIPANTS Adults with type 1 or type 2 diabetes with previously successfully treated diabetic macular oedema/proliferative diabetic retinopathy in one/both eyes in whom, at the time of enrolment, diabetic macular oedema/proliferative diabetic retinopathy could be active or inactive. METHODS For the ophthalmic grader pathway, review of the spectral domain optical coherence tomography scans to detect diabetic macular oedema, and seven-field Early Treatment Diabetic Retinopathy Study/ultra-wide field fundus images to detect proliferative diabetic retinopathy, by trained ophthalmic graders. For the current standard care pathway (reference standard), ophthalmologists examined patients face to face by slit-lamp biomicroscopy for proliferative diabetic retinopathy and, in addition, spectral domain optical coherence tomography imaging for diabetic macular oedema. OUTCOME MEASURES The primary outcome measure was sensitivity of the ophthalmic grader pathway to detect active diabetic macular oedema/proliferative diabetic retinopathy. The secondary outcomes were specificity, agreement between pathways, cost-consequences, acceptability and the proportion of patients requiring subsequent ophthalmologist assessment, unable to undergo imaging and with inadequate quality images/indeterminate findings. It was assumed for the main analysis that all patients in whom graders diagnosed active disease or were 'unsure' or images were 'ungradable' required examination by an ophthalmologist. RESULTS Eligible participants with active and inactive diabetic macular oedema (152 and 120 participants, respectively) and active and inactive proliferative diabetic retinopathy (111 and 170 participants, respectively) were recruited. Under the main analysis, graders had a sensitivity of 97% (142/147) (95% confidence interval 92% to 99%) and specificity of 31% (35/113) (95% confidence interval 23% to 40%) to detect diabetic macular oedema. For proliferative diabetic retinopathy, graders had a similar sensitivity and specificity using seven-field Early Treatment Diabetic Retinopathy Study [sensitivity 85% (87/102), 95% confidence interval 77% to 91%; specificity 48% (77/160), 95% confidence interval 41% to 56%] or ultra-wide field imaging [sensitivity 83% (87/105), 95% confidence interval 75% to 89%; specificity 54% (86/160), 95% confidence interval 46% to 61%]. Participants attending focus groups expressed preference for face-to-face evaluations by ophthalmologists. In the ophthalmologists' absence, patients voiced the need for immediate feedback following grader's assessments, maintaining periodic evaluations by ophthalmologists. Graders and ophthalmologists were supportive of the new pathway. When compared with the reference standard (current standard pathway), the new grader pathway could save £1390 per 100 patients in the review of people with diabetic macular oedema and, depending on the imaging modality used, between £461 and £1189 per 100 patients in the review of people with proliferative diabetic retinopathy. CONCLUSIONS For people with diabetic macular oedema, the ophthalmic grader pathway appears safe and cost saving. The sensitivity of the new pathway to detect active proliferative diabetic retinopathy was lower, but may still be considered acceptable for patients with proliferative diabetic retinopathy previously treated with laser. Suggestions from focus group discussions should be taken into consideration if the new pathway is introduced to ensure its acceptability to users. LIMITATIONS Lack of fundus fluorescein angiography to confirm diagnosis of active proliferative diabetic retinopathy. FUTURE WORK Could refinement of the new pathway increase its sensitivity to detect proliferative diabetic retinopathy? Could artificial intelligence be used for automated reading of images in this previously treated population? TRIAL REGISTRATION Current Controlled Trials ISRCTN10856638 and ClinicalTrials.gov NCT03490318. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology AssessmentVol. 25, No. 32. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Noemi Lois
- The Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Jonathan Cook
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Ariel Wang
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | | | - Hema Mistry
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Mandy Maredza
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Danny McAuley
- The Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK.,The Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
| | - Tariq Aslam
- The Manchester Academic Health Science Centre, Manchester Royal Eye Hospital and Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | | | - Victor Chong
- Royal Free Hospital NHS Foundation Trust, London, UK
| | - Faruque Ghanchi
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford Royal Infirmary, Bradford, UK
| | - Peter Scanlon
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Sobha Sivaprasad
- National Institute for Health Research Moorfields Biomedical Research Centre, London, UK
| | - David Steel
- Sunderland Eye Infirmary, Sunderland, UK.,Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | | | | | - Lindsay Prior
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Norman Waugh
- Warwick Medical School, University of Warwick, Coventry, UK
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11
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Evaluation of a New Model of Care for People with Complications of Diabetic Retinopathy: The EMERALD Study. Ophthalmology 2020; 128:561-573. [PMID: 33130144 PMCID: PMC7980088 DOI: 10.1016/j.ophtha.2020.10.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/29/2020] [Accepted: 10/16/2020] [Indexed: 01/21/2023] Open
Abstract
Purpose The increasing diabetes prevalence and advent of new treatments for its major visual-threatening complications (diabetic macular edema [DME] and proliferative diabetic retinopathy [PDR]), which require frequent life-long follow-up, have increased hospital demands markedly. Subsequent delays in patient's evaluation and treatment are causing sight loss. Strategies to increase capacity are needed urgently. The retinopathy (EMERALD) study tested diagnostic accuracy, acceptability, and costs of a new health care pathway for people with previously treated DME or PDR. Design Prospective, multicenter, case-referent, cross-sectional, diagnostic accuracy study undertaken in 13 hospitals in the United Kingdom. Participants Adults with type 1 or 2 diabetes previously successfully treated DME or PDR who, at the time of enrollment, had active or inactive disease. Methods A new health care pathway entailing multimodal imaging (spectral-domain OCT for DME, and 7-field Early Treatment Diabetic Retinopathy Study [ETDRS] and ultra-widefield [UWF] fundus images for PDR) interpreted by trained nonmedical staff (ophthalmic graders) to detect reactivation of disease was compared with the current standard care (face-to-face examination by ophthalmologists). Main Outcome Measures Primary outcome: sensitivity of the new pathway. Secondary outcomes: specificity; agreement between pathways; costs; acceptability; proportions requiring subsequent ophthalmologist assessment, unable to undergo imaging, and with inadequate images or indeterminate findings. Results The new pathway showed sensitivity of 97% (95% confidence interval [CI], 92%–99%) and specificity of 31% (95% CI, 23%–40%) to detect DME. For PDR, sensitivity and specificity using 7-field ETDRS images (85% [95% CI, 77%–91%] and 48% [95% CI, 41%–56%], respectively) or UWF images (83% [95% CI, 75%–89%] and 54% [95% CI, 46%–61%], respectively) were comparable. For detection of high-risk PDR, sensitivity and specificity were higher when using UWF images (87% [95% CI, 78%–93%] and 49% [95% CI, 42%–56%], respectively, for UWF versus 80% [95% CI, 69–88%] and 40% [95% CI, 34%–47%], respectively, for 7-field ETDRS images). Participants preferred ophthalmologists’ assessments; in their absence, they preferred immediate feedback by graders, maintaining periodic ophthalmologist evaluations. When compared with the current standard of care, the new pathway could save £1390 per 100 DME visits and between £461 and £1189 per 100 PDR visits. Conclusions The new pathway has acceptable sensitivity and would release resources. Users’ suggestions should guide implementation.
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12
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Spatial Linear Mixed Effects Modelling for OCT Images: SLME Model. J Imaging 2020; 6:jimaging6060044. [PMID: 34460590 PMCID: PMC8321139 DOI: 10.3390/jimaging6060044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/27/2020] [Accepted: 05/30/2020] [Indexed: 11/22/2022] Open
Abstract
Much recent research focuses on how to make disease detection more accurate as well as “slimmer”, i.e., allowing analysis with smaller datasets. Explanatory models are a hot research topic because they explain how the data are generated. We propose a spatial explanatory modelling approach that combines Optical Coherence Tomography (OCT) retinal imaging data with clinical information. Our model consists of a spatial linear mixed effects inference framework, which innovatively models the spatial topography of key information via mixed effects and spatial error structures, thus effectively modelling the shape of the thickness map. We show that our spatial linear mixed effects (SLME) model outperforms traditional analysis-of-variance approaches in the analysis of Heidelberg OCT retinal thickness data from a prospective observational study, involving 300 participants with diabetes and 50 age-matched controls. Our SLME model has a higher power for detecting the difference between disease groups, and it shows where the shape of retinal thickness profiles differs between the eyes of participants with diabetes and the eyes of healthy controls. In simulated data, the SLME model demonstrates how incorporating spatial correlations can increase the accuracy of the statistical inferences. This model is crucial in the understanding of the progression of retinal thickness changes in diabetic maculopathy to aid clinicians for early planning of effective treatment. It can be extended to disease monitoring and prognosis in other diseases and with other imaging technologies.
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13
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Abu-Yaghi NE, Abed AM, Khlaifat DF, Nawaiseh MB, Emoush LO, AlHajjaj HZ, Abojaradeh AM, Hattar MN, Abusaleem SK, Sabbagh HM, Abu Gharbieh YA, Quaqazeh SA. Factors Affecting Compliance to Anti-Vascular Endothelial Growth Factor Treatment of Diabetic Macular Edema in a Cohort of Jordanian Patients. Clin Ophthalmol 2020; 14:921-929. [PMID: 32273676 PMCID: PMC7102883 DOI: 10.2147/opth.s248661] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 03/04/2020] [Indexed: 12/27/2022] Open
Abstract
Purpose To determine compliance rates and characteristics and to investigate factors affecting patients’ adherence to treatment with anti-vascular endothelial growth factors (anti-VEGFs) for diabetic macular edema (DME) in a cohort of Jordanian patients. Methods A retrospective case series wherein the files of DME patients treated with anti-VEGFs were reviewed and analyzed for factors affecting treatment compliance was undertaken. Demographic, clinical and ocular characteristics were recorded. All patients were also interviewed by phone using a structured questionnaire. Univariate and multivariate analyses were performed to determine factors associated with compliance. Results A total of 117 patients (65 males 52 females) were included in this study with a mean age of 62.93 years (±9.75). Approximately, 85% of patients were compliant to their treatment and follow-up plan during the first year of management. Subjective perception of visual improvement after receiving three loading doses was the only independent variable with a unique statistically significant contribution to compliance. All other studied factors in this group of patients were not significantly associated with patient compliance. Conclusion VEGF suppression via the intravitreal route to treat DME is a long-term process that requires caregiver dedication but also proper patient compliance. Addressing real-life barriers in those patients may help guide future strategies to improve the treatment experience, lower the financial burden and contribute to better outcomes. Patients' perceptions of possible treatment outcomes at the short term may influence their long-term commitment to therapy.
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Affiliation(s)
- Nakhleh E Abu-Yaghi
- Department of Special Surgery, Ophthalmology Division, The University of Jordan, Amman, Jordan
| | - Alaa M Abed
- Department of Special Surgery, Ophthalmology Division, The University of Jordan, Amman, Jordan
| | | | | | - Laith O Emoush
- School of Medicine, The University of Jordan, Amman, Jordan
| | | | | | | | | | - Hashem M Sabbagh
- Department of Special Surgery, Ophthalmology Division, The University of Jordan, Amman, Jordan
| | - Yazan A Abu Gharbieh
- Department of Special Surgery, Ophthalmology Division, The University of Jordan, Amman, Jordan
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14
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Meng W, Chan BW, Ezeonwumelu C, Hébert HL, Campbell A, Soler V, Palmer CN. A genome-wide association study implicates that the TTC39C gene is associated with diabetic maculopathy with decreased visual acuity. Ophthalmic Genet 2019; 40:252-258. [PMID: 31264924 DOI: 10.1080/13816810.2019.1633549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Diabetic maculopathy is a form of diabetic retinopathy. The visual acuity of one third of patients with diabetic maculopathy will be affected. The purpose of this study was to identify genetic contributors of diabetic maculopathy with decreased visual acuity based on a genome-wide association approach using a well-defined Scottish diabetic cohort. Methods: We used linked e-health records of diabetic patients to define our cases and controls. The cases in this study were defined as type 2 diabetic patients who had ever been recorded in the linked e-health records as having maculopathy (observable or referable) in at least one eye and whose visual acuity of the eye was recorded to have decreased between the first and the last visual acuity record of that eye in the longitudinal e-health records. The controls were defined as a type 2 diabetic individual who had never been diagnosed with maculopathy or retinopathy in the linked e-health records. Anyone who had laser photocoagulation treatment was also excluded from the controls. A standard genome-wide association approach was applied. Results: Overall, we identified 469 cases and 1,374 controls within the Genetics of Diabetes Audit and Research in Tayside Scotland (GoDARTS) dataset. We found that the P value of rs9966620 in the TTC39C gene was 4.13x10-8, which reached genome-wide significance. Conclusions: We suggest that the TTC39C gene is associated with diabetic maculopathy with decreased visual acuity. This needs to be confirmed by further replication studies and functional studies.
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Affiliation(s)
- Weihua Meng
- a Division of Population Health and Genomics , Medical Research Institute, Ninewells Hospital and School of Medicine, University of Dundee , Dundee , UK
| | - Brian W Chan
- a Division of Population Health and Genomics , Medical Research Institute, Ninewells Hospital and School of Medicine, University of Dundee , Dundee , UK
| | - Chinenyenwa Ezeonwumelu
- a Division of Population Health and Genomics , Medical Research Institute, Ninewells Hospital and School of Medicine, University of Dundee , Dundee , UK
| | - Harry L Hébert
- a Division of Population Health and Genomics , Medical Research Institute, Ninewells Hospital and School of Medicine, University of Dundee , Dundee , UK
| | - Amy Campbell
- a Division of Population Health and Genomics , Medical Research Institute, Ninewells Hospital and School of Medicine, University of Dundee , Dundee , UK
| | - Vencent Soler
- b Retina unit, Ophthalmology department , Hôpital Pierre Paul Riquet, CHU Toulouse, 31059 Toulouse Cedex 9; Unité "Différenciation Epithéliale et Autoimmunité Rhumatoïde", UMR 1056 Inserm - Université de Toulouse , France
| | - Colin Na Palmer
- a Division of Population Health and Genomics , Medical Research Institute, Ninewells Hospital and School of Medicine, University of Dundee , Dundee , UK
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15
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Lois N, Cook J, Aldington S, Waugh N, Mistry H, Sones W, McAuley D, Aslam T, Bailey C, Chong V, Ghanchi F, Scanlon P, Sivaprasad S, Steel D, Styles C, McNally C, Rice R, Prior L, Azuara-Blanco A. Effectiveness of Multimodal imaging for the Evaluation of Retinal oedema And new vesseLs in Diabetic retinopathy (EMERALD). BMJ Open 2019; 9:e027795. [PMID: 31256030 PMCID: PMC6609061 DOI: 10.1136/bmjopen-2018-027795] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Diabetic macular oedema (DMO) and proliferative diabetic retinopathy (PDR) are the major causes of sight loss in people with diabetes. Due to the increased prevalence of diabetes, the workload related to these complications is increasing making it difficult for Hospital Eye Services (HSE) to meet demands. METHODS AND ANALYSIS Effectiveness of Multimodal imaging for the Evaluation of Retinal oedema And new vesseLs in Diabetic retinopathy (EMERALD) is a prospective, case-referent, cross-sectional diagnostic study. It aims at determining the diagnostic performance, cost-effectiveness and acceptability of a new form of surveillance for people with stable DMO and/or PDR, which entails multimodal imaging and image review by an ophthalmic grader, using the current standard of care (evaluation of patients in clinic by an ophthalmologist) as the reference standard. If safe, cost-effective and acceptable, this pathway could help HES by freeing ophthalmologist time. The primary outcome of EMERALD is sensitivity of the new surveillance pathway in detecting active DMO/PDR. Secondary outcomes include specificity, agreement between new and the standard care pathway, positive and negative likelihood ratios, cost-effectiveness, acceptability, proportion of patients requiring subsequent full clinical assessment, unable to undergo imaging, with inadequate quality images or indeterminate findings. ETHICS AND DISSEMINATION Ethical approval was obtained for this study from the Office for Research Ethics Committees Northern Ireland (reference 17/NI/0124). Study results will be published as a Health Technology Assessment monograph, in peer-reviewed national and international journals and presented at national/international conferences and to patient groups. TRIAL REGISTRATION NUMBER NCT03490318 and ISRCTN:10856638.
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Affiliation(s)
- Noemi Lois
- Ophthalmology, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
| | | | | | - Norman Waugh
- The Division of Health Sciences, University of Warwick, Warwick, UK
| | - Hema Mistry
- The Division of Health Sciences, University of Warwick, Warwick, UK
| | | | - Danny McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queens University, Belfast, UK
| | - Tariq Aslam
- The Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Claire Bailey
- Ophthalmology Department, Bristol Eye Hospital, Bristol, UK
| | - Victor Chong
- Ophthalmology, Royal Free Hospital NHS Foundation Trust, London, UK
| | - Faruque Ghanchi
- Ophthalmology, Bradford Royal Infirmary, Bradford, West Yorkshire, UK
| | - Peter Scanlon
- Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, Gloucestershire, UK
| | - Sobha Sivaprasad
- NIHR Moorfields Biomedical Research Centre, Moorfields Eye Hospital, London, London
| | - David Steel
- Sunderland Eye Infirmary, Sunderland, UK
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | | | | | - Rachael Rice
- Northern Ireland Clinical Trials Unit, Belfast, UK
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16
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Buchan JC, Norman P, Shickle D, Cassels-Brown A, MacEwen C. Failing to plan and planning to fail. Can we predict the future growth of demand on UK Eye Care Services? Eye (Lond) 2019; 33:1029-1031. [PMID: 30814654 DOI: 10.1038/s41433-019-0383-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 02/06/2019] [Accepted: 02/13/2019] [Indexed: 01/15/2023] Open
Affiliation(s)
- John Cameron Buchan
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Paul Norman
- School of Geography, University of Leeds, Leeds, UK
| | - Darren Shickle
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Carrie MacEwen
- Department of Ophthalmology, Ninewells Hospital, University of Dundee, Dundee, UK
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17
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Pochopien M, Beiderbeck A, McEwan P, Zur R, Toumi M, Aballéa S. Cost-effectiveness of fluocinolone acetonide implant (ILUVIEN®) in UK patients with chronic diabetic macular oedema considered insufficiently responsive to available therapies. BMC Health Serv Res 2019; 19:22. [PMID: 30626376 PMCID: PMC6327492 DOI: 10.1186/s12913-018-3804-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 12/10/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diabetic macular oedema (DMO) may lead to visual loss and blindness. Several pharmacological treatments are available on the National Health Service (NHS) to United Kingdom patients affected by this condition, including intravitreal vascular endothelial growth factor inhibitors (anti-VEGFs) and two types of intravitreal steroid implants, releasing dexamethasone or fluocinolone acetonide (FAc). This study aimed to assess the value for money (cost-effectiveness) of the FAc 0.2 μg/day implant (ILUVIEN®) in patients with chronic DMO considered insufficiently responsive to other therapies. METHODS We developed a Markov model with a 15-year time horizon to estimate the impact of changes in best-corrected visual acuity in DMO patients on costs and quality-adjusted life years. The model considered both eyes, designated as the "study eye", defined at model entry as phakic with an ongoing cataract formation or pseudophakic, and the "fellow eye". The model compared the FAc 0.2 μg/day implant with a 700 μg dexamethasone implant (pseudophakic patients only) or with usual care, defined as a mixture of laser photocoagulation and anti-VEGFs (phakic and pseudophakic patients). Costs were estimated from the perspective of the NHS and Personal Social Services; full NHS prices were used for drugs. RESULTS In patients who were pseudophakic at baseline, at 36 months, the FAc implant provided an additional gain of 4.01 and 3.64 Early Treatment Diabetic Retinopathy Study (ETDRS) letters compared with usual care and the dexamethasone implant, respectively. Over the 15-year time horizon, this translated into 0.185 additional quality-adjusted life years (QALYs) at an extra cost of £3066 compared with usual care, and 0.126 additional QALYs at an extra cost of £1777 compared with dexamethasone. Thus, incremental cost-effectiveness ratios (ICERs) were £16,609 and £14,070 per QALY gained vs. usual care and dexamethasone, respectively. In patients who were phakic at baseline, the FAc 0.2 μg/day implant provided an additional gain of 2.96 ETDRS letters at 36 months compared with usual care, which, over 15 years, corresponded to 0.11 additional QALYs at an extra cost of £3170, resulting in an ICER of £28,751 per QALY gained. CONCLUSION The FAc 0.2 μg/day implant provided good value for money compared with other established treatments, especially in pseudophakic patients.
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Affiliation(s)
| | - Annette Beiderbeck
- Alimera Sciences Ophthalmologie GmbH, Cicerostraße 21, Handelsregister Amtsgericht Berlin, (Charlottenburg) HRB 165580 B, 10709, Berlin, Germany.
| | - Phil McEwan
- Health Economics and Outcomes Research Ltd, 9 Oak Tree Court, Mulberry Drive, Cardiff Gate Business Park, Cardiff, CF23 8RS, UK
| | - Richard Zur
- Creativ-Ceutical, The Monadnock Building, Suite 73553 W Jackson, blvd Chicago, Chicago, IL, 60604, USA
| | - Mondher Toumi
- Creativ-Ceutical, 215, rue du Faubourg St Honoré, 75008, Paris, France.,Aix-Marseille University, Jardin du Pharo, 58 Boulevard Charles Livon, 13007, Marseille, France
| | - Samuel Aballéa
- Creativ-Ceutical, 215, rue du Faubourg St Honoré, 75008, Paris, France.,Aix-Marseille University, Jardin du Pharo, 58 Boulevard Charles Livon, 13007, Marseille, France
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18
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Avenell A, Robertson C, Skea Z, Jacobsen E, Boyers D, Cooper D, Aceves-Martins M, Retat L, Fraser C, Aveyard P, Stewart F, MacLennan G, Webber L, Corbould E, Xu B, Jaccard A, Boyle B, Duncan E, Shimonovich M, Bruin MD. Bariatric surgery, lifestyle interventions and orlistat for severe obesity: the REBALANCE mixed-methods systematic review and economic evaluation. Health Technol Assess 2018; 22:1-246. [PMID: 30511918 PMCID: PMC6296173 DOI: 10.3310/hta22680] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Adults with severe obesity [body mass index (BMI) of ≥ 35 kg/m2] have an increased risk of comorbidities and psychological, social and economic consequences. OBJECTIVES Systematically review bariatric surgery, weight-management programmes (WMPs) and orlistat pharmacotherapy for adults with severe obesity, and evaluate the feasibility, acceptability, clinical effectiveness and cost-effectiveness of treatment. DATA SOURCES Electronic databases including MEDLINE, EMBASE, PsycINFO, the Cochrane Central Register of Controlled Trials and the NHS Economic Evaluation Database were searched (last searched in May 2017). REVIEW METHODS Four systematic reviews evaluated clinical effectiveness, cost-effectiveness and qualitative evidence for adults with a BMI of ≥ 35 kg/m2. Data from meta-analyses populated a microsimulation model predicting costs, outcomes and cost-effectiveness of Roux-en-Y gastric bypass (RYGB) surgery and the most effective lifestyle WMPs over a 30-year time horizon from a NHS perspective, compared with current UK population obesity trends. Interventions were cost-effective if the additional cost of achieving a quality-adjusted life-year is < £20,000-30,000. RESULTS A total of 131 randomised controlled trials (RCTs), 26 UK studies, 33 qualitative studies and 46 cost-effectiveness studies were included. From RCTs, RYGB produced the greatest long-term weight change [-20.23 kg, 95% confidence interval (CI) -23.75 to -16.71 kg, at 60 months]. WMPs with very low-calorie diets (VLCDs) produced the greatest weight loss at 12 months compared with no WMPs. Adding a VLCD to a WMP gave an additional mean weight change of -4.41 kg (95% CI -5.93 to -2.88 kg) at 12 months. The intensive Look AHEAD WMP produced mean long-term weight loss of 6% in people with type 2 diabetes mellitus (at a median of 9.6 years). The microsimulation model found that WMPs were generally cost-effective compared with population obesity trends. Long-term WMP weight regain was very uncertain, apart from Look AHEAD. The addition of a VLCD to a WMP was not cost-effective compared with a WMP alone. RYGB was cost-effective compared with no surgery and WMPs, but the model did not replicate long-term cost savings found in previous studies. Qualitative data suggested that participants could be attracted to take part in WMPs through endorsement by their health-care provider or through perceiving innovative activities, with WMPs being delivered to groups. Features improving long-term weight loss included having group support, additional behavioural support, a physical activity programme to attend, a prescribed calorie diet or a calorie deficit. LIMITATIONS Reviewed studies often lacked generalisability to UK settings in terms of participants and resources for implementation, and usually lacked long-term follow-up (particularly for complications for surgery), leading to unrealistic weight regain assumptions. The views of potential and actual users of services were rarely reported to contribute to service design. This study may have failed to identify unpublished UK evaluations. Dual, blinded numerical data extraction was not undertaken. CONCLUSIONS Roux-en-Y gastric bypass was costly to deliver, but it was the most cost-effective intervention. Adding a VLCD to a WMP was not cost-effective compared with a WMP alone. Most WMPs were cost-effective compared with current population obesity trends. FUTURE WORK Improved reporting of WMPs is needed to allow replication, translation and further research. Qualitative research is needed with adults who are potential users of, or who fail to engage with or drop out from, WMPs. RCTs and economic evaluations in UK settings (e.g. Tier 3, commercial programmes or primary care) should evaluate VLCDs with long-term follow-up (≥ 5 years). Decision models should incorporate relevant costs, disease states and evidence-based weight regain assumptions. STUDY REGISTRATION This study is registered as PROSPERO CRD42016040190. FUNDING The National Institute for Health Research Health Technology Assessment programme. The Health Services Research Unit and Health Economics Research Unit are core funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorate.
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Affiliation(s)
- Alison Avenell
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Clare Robertson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Zoë Skea
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Elisabet Jacobsen
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Dwayne Boyers
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - David Cooper
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | | | - Cynthia Fraser
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Fiona Stewart
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | | | | | | | - Bonnie Boyle
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Eilidh Duncan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Raman V. A cost analysis comparing continued 3-year aflibercept monotherapy versus a switch from aflibercept to the fluocinolone acetonide intravitreal implant in phakic patients with chronic diabetic macular edema. EXPERT REVIEW OF OPHTHALMOLOGY 2018. [DOI: 10.1080/17469899.2018.1523720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Vasant Raman
- Royal Eye Infirmary, University Hospitals Plymouth NHS Trust, Plymouth, UK
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Li J, Wang P, Chen Z, Yu S, Xu H. Fenofibrate Ameliorates Oxidative Stress-Induced Retinal Microvascular Dysfunction in Diabetic Rats. Curr Eye Res 2018; 43:1395-1403. [PMID: 30024319 DOI: 10.1080/02713683.2018.1501072] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Jun Li
- Department of Ophthalmology, Lishui Municipal Central Hospital, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, PR China
- Department of Ophthalmology, Lishui Hospital, Zhejiang University School of Medicine, Lishui, PR China
| | - Peipei Wang
- Department of Ophthalmology, Lishui Municipal Central Hospital, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, PR China
- Department of Ophthalmology, Lishui Hospital, Zhejiang University School of Medicine, Lishui, PR China
- Department of Stomatology, Lishui Hospital, Zhejiang University School of Medicine, Lishui, PR China
| | - Zhen Chen
- Department of Ophthalmology, Lishui Municipal Central Hospital, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, PR China
- Department of Ophthalmology, Lishui Hospital, Zhejiang University School of Medicine, Lishui, PR China
| | - Songping Yu
- Department of Ophthalmology, Lishui Municipal Central Hospital, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, PR China
- Department of Ophthalmology, Lishui Hospital, Zhejiang University School of Medicine, Lishui, PR China
| | - Huiwen Xu
- Department of Ophthalmology, Lishui Municipal Central Hospital, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, PR China
- Department of Ophthalmology, Lishui Hospital, Zhejiang University School of Medicine, Lishui, PR China
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Frampton GK, Kalita N, Payne L, Colquitt J, Loveman E. Accuracy of fundus autofluorescence imaging for the diagnosis and monitoring of retinal conditions: a systematic review. Health Technol Assess 2018; 20:1-108. [PMID: 27115052 DOI: 10.3310/hta20310] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Natural fluorescence in the eye may be increased or decreased by diseases that affect the retina. Imaging methods based on confocal scanning laser ophthalmoscopy (cSLO) can detect this 'fundus autofluorescence' (FAF) by illuminating the retina using a specific light 'excitation wavelength'. FAF imaging could assist the diagnosis or monitoring of retinal conditions. However, the accuracy of the method for diagnosis or monitoring is unclear. OBJECTIVE To conduct a systematic review to determine the accuracy of FAF imaging using cSLO for the diagnosis or monitoring of retinal conditions, including monitoring of response to therapy. DATA SOURCES Electronic bibliographic databases; scrutiny of reference lists of included studies and relevant systematic reviews; and searches of internet pages of relevant organisations, meetings and trial registries. Databases included MEDLINE, EMBASE, The Cochrane Library, Web of Science and the Medion database of diagnostic accuracy studies. Searches covered 1990 to November 2014 and were limited to the English language. REVIEW METHODS References were screened for relevance using prespecified inclusion criteria to capture a broad range of retinal conditions. Two reviewers assessed titles and abstracts independently. Full-text versions of relevant records were retrieved and screened by one reviewer and checked by a second. Data were extracted and critically appraised using the Quality Assessment of Diagnostic Accuracy Studies criteria (QUADAS) for assessing risk of bias in test accuracy studies by one reviewer and checked by a second. At all stages any reviewer disagreement was resolved through discussion or arbitration by a third reviewer. RESULTS Eight primary research studies have investigated the diagnostic accuracy of FAF imaging in retinal conditions: choroidal neovascularisation (one study), reticular pseudodrusen (three studies), cystoid macular oedema (two studies) and diabetic macular oedema (two studies). Sensitivity of FAF imaging using an excitation wavelength of 488 nm was generally high (range 81-100%), but was lower (55% and 32%) in two studies using longer excitation wavelengths (514 nm and 790 nm, respectively). Specificity ranged from 34% to 100%. However, owing to limitations of the data, none of the studies provide conclusive evidence of the diagnostic accuracy of FAF imaging. LIMITATIONS No studies on the accuracy of FAF imaging for monitoring the progression of retinal conditions or response to therapy were identified. Owing to study heterogeneity, pooling of diagnostic outcomes in meta-analysis was not conducted. All included studies had high risk of bias. In most studies the patient spectrum was not reflective of those who would present in clinical practice and no studies adequately reported how FAF images were interpreted. CONCLUSIONS Although already in use in clinical practice, it is unclear whether or not FAF imaging is accurate, and whether or not it is applied and interpreted consistently for the diagnosis and/or monitoring of retinal conditions. Well-designed prospective primary research studies, which conform to the paradigm of diagnostic test accuracy assessment, are required to investigate the accuracy of FAF imaging in diagnosis and monitoring of inherited retinal dystrophies, early age-related macular degeneration, geographic atrophy and central serous chorioretinopathy. STUDY REGISTRATION This study is registered as PROSPERO CRD42014014997. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Geoff K Frampton
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Neelam Kalita
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Liz Payne
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
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Action on diabetic macular oedema: achieving optimal patient management in treating visual impairment due to diabetic eye disease. Eye (Lond) 2017; 31:S1-S20. [PMID: 28490797 PMCID: PMC5437340 DOI: 10.1038/eye.2017.53] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
This paper identifies best practice recommendations for managing diabetes and sight-threatening diabetic eye disease. The authors provide an update for ophthalmologists and allied healthcare professionals on key aspects of diabetes management, supported by a review of the pertinent literature, and recommend practice principles for optimal patient management in treating visual impairment due to diabetic eye disease. In people with diabetes, early optimal glycaemic control reduces the long-term risk of both microvascular and macrovascular complications. The authors propose more can and should be done to maximise metabolic control, promote appropriate behavioural modifications and encourage timely treatment intensification when indicated to ameliorate diabetes-related complications. All people with diabetes should be screened for sight-threatening diabetic retinopathy promptly and regularly. It is shown that attitudes towards treatment adherence in diabetic macular oedema appear to mirror patients' views and health behaviours towards the management of their own diabetes. Awareness of diabetic macular oedema remains low among people with diabetes, who need access to education early in their disease about how to manage their diabetes to delay progression and possibly avoid eye-related complications. Ophthalmologists and allied healthcare professionals play a vital role in multidisciplinary diabetes management and establishment of dedicated diabetic macular oedema clinics is proposed. A broader understanding of the role of the diabetes specialist nurse may strengthen the case for comprehensive integrated care in ophthalmic practice. The recommendations are based on round table presentations and discussions held in London, UK, September 2016.
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Holden SE, Currie CJ, Owens DR. Health-economic evaluation of fluocinolone acetonide 190 µg implant in people with diabetic macular edema. Curr Med Res Opin 2017; 33:45-52. [PMID: 28881146 DOI: 10.1080/03007995.2017.1366663] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To assess healthcare resource use and costs of treating people with clinically significant diabetic macular edema (DME) with fluocinolone acetonide (FAc) 190 µg intravitreal implant in routine clinical practice. METHODS The retrospective Iluvien Clinical Evidence (ICE-UK) study collected data on people prescribed the FAc implant in any one of 13 ophthalmology centers between April 1, 2013 and April 15, 2015. Data were collected for 12 months before and after implantation. Standard UK costs were attributed to healthcare resource use. RESULTS In total, 208 people contributing 233 FAc-treated eyes were selected. Mean age was 68.1 years and 62% were male. The mean (standard deviation, SD) number of anti-vascular endothelial growth factor (anti-VEGF) injections per FAc treated eye in the 12 months prior to implant was 2.8 (2.5), decreasing to 0.6 (1.4) for the same period after implant (p < .001). The corresponding figures for other steroid injections (dexamethasone and triamcinolone) were 0.14 (0.4) before and 0.08 (0.4) after implant (p = .016). There was no statistically significant difference in the number of laser therapies required in the 12 months before and after FAc implant (mean = 0.12 vs 0.11, respectively; p = .626). Overall, mean (SD) healthcare costs were £2,691 (£1,850) before and £1,239 (£1,203) after FAc implant (p < .001). The unit drug and administration cost per FAc implant was £5,680. CONCLUSIONS Excluding the cost of the FAc implant, healthcare costs were significantly reduced in the 12 months post-implant. FAc implant has a duration of 3 years. This needs to be considered when interpreting the cost associated with the FAc implant.
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Affiliation(s)
| | - Craig J Currie
- a Pharmatelligence , Cardiff , UK
- b Cardiff University , Cardiff , UK
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The Status of Maculopathy in Diabetes and Prediabetes Patients in a Population-Based Study Detected by Optical Coherence Tomography: The 2011 Health Examination Survey in Beijing. BIOMED RESEARCH INTERNATIONAL 2017; 2017:6513076. [PMID: 28808662 PMCID: PMC5541794 DOI: 10.1155/2017/6513076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 06/12/2017] [Accepted: 06/27/2017] [Indexed: 11/27/2022]
Abstract
Objective The aim of the study was to investigate the prevalence and the risk factors of maculopathy detected by optical coherence tomography (OCT) in a Chinese population with diabetes or prediabetes. Methods. 8,155 people were randomly selected to participate in the 2011 annual Health Examination Survey in Beijing. A 75 g oral glucose tolerance test (OGTT) was tested in 3760 subjects with fasting plasma glucose (FPG) ≥ 5.6 mmol/L. Of 3,760 subjects, 583 were also randomly selected to take OCT. Results In this study population, 21 (3.95%) patients had maculopathy. Eight patients had diabetes macular edema (DME) and the prevalence was 6.72% in diabetes patients and 1.51% in all subjects. Eleven patients had age-related macular degeneration (AMD) and the prevalence was 3.36% in diabetes patients and 2.07% in all subjects. Logistic regression model confirmed that elevated HbA1c (p < 0.001) and systolic pressure (p < 0.05) made significant contributions to DME. Stepwise regression analysis revealed that HbA1c and blood creatinine were significantly independent influence factors for central subfield thickness (CST) (p = 0.01, p < 0.001). Conclusions High prevalence of maculopathy was found in patients with diabetes in a Chinese population. Maculopathy poses a significant public health problem in China with rapid rising trend of diabetes.
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Schirr-Bonnans S, Costa N, Derumeaux-Burel H, Bos J, Lepage B, Garnault V, Martini J, Hanaire H, Turnin MC, Molinier L. Cost of diabetic eye, renal and foot complications: a methodological review. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2017; 18:293-312. [PMID: 26975444 DOI: 10.1007/s10198-016-0773-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 02/16/2016] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Diabetic retinopathy (DR), diabetic kidney disease (DKD) and diabetic foot ulcer (DFU) represent a public health and economic concern that may be assessed with cost-of-illness (COI) studies. OBJECTIVES (1) To review COI studies published between 2000 and 2015, about DR, DKD and DFU; (2) to analyse methods used. METHODS Disease definition, epidemiological approach, perspective, type of costs, activity data sources, cost valuation, sensitivity analysis, cost discounting and presentation of costs may be described in COI studies. Each reviewed study was assessed with a methodological grid including these nine items. RESULTS The five following items have been detailed in the reviewed studies: epidemiological approach (59 % of studies described it), perspective (75 %), type of costs (98 %), activity data sources (91 %) and cost valuation (59 %). The disease definition and the presentation of results were detailed in fewer studies (respectively 50 and 46 %). In contrast, sensitivity analysis was only performed in 14 % of studies and cost discounting in 7 %. Considering the studies showing an average cost per patient and per year with a societal perspective, DR cost estimates were US $2297 (range 5-67,486), DKD cost ranged from US $1095 to US $16,384, and DFU cost was US $10,604 (range 1444-85,718). DISCUSSION This review reinforces the need to adequately describe the method to facilitate literature comparisons and projections. It also recalls that COI studies represent complementary tools to cost-effectiveness studies to help decision makers in the allocation of economic resources for the management of DR, DKD and DFU.
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Affiliation(s)
- Solène Schirr-Bonnans
- Unité Inserm 1027, Faculté de Médecine, National Institute for Health and Medical Research (Inserm), Research Unit 1027, 37 allées Jules Guesde, 31073, Toulouse, France.
- University of Science of Toulouse III, Université Paul Sabatier Toulouse III, Bâtiment 1R1, 31062, Toulouse Cedex 9, France.
- Diabetology Metabolic Disease and Nutrition Department, Service de Diabétologie, Maladies Métaboliques et Nutrition, Hôpital Rangueil, University Hospital of Toulouse, 1 avenue Jean Poulhès, TSA 50032, 31059, Toulouse Cedex 9, France.
| | - Nadège Costa
- Unité Inserm 1027, Faculté de Médecine, National Institute for Health and Medical Research (Inserm), Research Unit 1027, 37 allées Jules Guesde, 31073, Toulouse, France
- Medical Information Department, University Hospital of Toulouse, Hôtel-Dieu Saint-Jacques, 2, rue viguerie, 31059, Toulouse Cedex 9, France
| | - Hélène Derumeaux-Burel
- Medical Information Department, University Hospital of Toulouse, Hôtel-Dieu Saint-Jacques, 2, rue viguerie, 31059, Toulouse Cedex 9, France
| | - Jérémy Bos
- Medical Information Department, University Hospital of Toulouse, Hôtel-Dieu Saint-Jacques, 2, rue viguerie, 31059, Toulouse Cedex 9, France
| | - Benoît Lepage
- Unité Inserm 1027, Faculté de Médecine, National Institute for Health and Medical Research (Inserm), Research Unit 1027, 37 allées Jules Guesde, 31073, Toulouse, France
- University of Science of Toulouse III, Université Paul Sabatier Toulouse III, Bâtiment 1R1, 31062, Toulouse Cedex 9, France
- Methodological Support Unit, Faculté de Médecine, University Hospital of Toulouse, USMR, 37 allées Jules Guesde, 31073, Toulouse, France
| | - Valérie Garnault
- Medical Information Department, University Hospital of Toulouse, Hôtel-Dieu Saint-Jacques, 2, rue viguerie, 31059, Toulouse Cedex 9, France
| | - Jacques Martini
- Diabetology Metabolic Disease and Nutrition Department, Service de Diabétologie, Maladies Métaboliques et Nutrition, Hôpital Rangueil, University Hospital of Toulouse, 1 avenue Jean Poulhès, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Hélène Hanaire
- University of Science of Toulouse III, Université Paul Sabatier Toulouse III, Bâtiment 1R1, 31062, Toulouse Cedex 9, France
- Diabetology Metabolic Disease and Nutrition Department, Service de Diabétologie, Maladies Métaboliques et Nutrition, Hôpital Rangueil, University Hospital of Toulouse, 1 avenue Jean Poulhès, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Marie-Christine Turnin
- Diabetology Metabolic Disease and Nutrition Department, Service de Diabétologie, Maladies Métaboliques et Nutrition, Hôpital Rangueil, University Hospital of Toulouse, 1 avenue Jean Poulhès, TSA 50032, 31059, Toulouse Cedex 9, France
- Medical Information Department, University Hospital of Toulouse, Hôtel-Dieu Saint-Jacques, 2, rue viguerie, 31059, Toulouse Cedex 9, France
| | - Laurent Molinier
- Unité Inserm 1027, Faculté de Médecine, National Institute for Health and Medical Research (Inserm), Research Unit 1027, 37 allées Jules Guesde, 31073, Toulouse, France
- University of Science of Toulouse III, Université Paul Sabatier Toulouse III, Bâtiment 1R1, 31062, Toulouse Cedex 9, France
- Medical Information Department, University Hospital of Toulouse, Hôtel-Dieu Saint-Jacques, 2, rue viguerie, 31059, Toulouse Cedex 9, France
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Strain WD, Cos X, Prünte C. Considerations for management of patients with diabetic macular edema: Optimizing treatment outcomes and minimizing safety concerns through interdisciplinary collaboration. Diabetes Res Clin Pract 2017; 126:1-9. [PMID: 28189948 DOI: 10.1016/j.diabres.2017.01.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 01/20/2017] [Indexed: 10/20/2022]
Abstract
Diabetes is a growing worldwide epidemic and a leading cause of blindness in working-age people around the world. Diabetic retinopathy (DR) and diabetic macular edema (DME) are common causes of visual impairment in people with diabetes and often indicate the presence of diabetes-associated preclinical micro- and macrovascular complications. As such, patients with DR and DME often display complex, highly comorbid profiles. Several treatments are currently available for the treatment of DME, including anti-vascular endothelial growth factor (VEGF) agents, which are administered via intravitreal injection. While the safety profiles of approved ocular anti-VEGF therapies have been reassuring, the high-risk nature of the DME patient population means that treatment must be carefully considered and a holistic approach to disease management should be taken. This requires multidisciplinary, collaborative care involving all relevant specialties to ensure that patients not only receive prompt treatment for DME but also appropriate consideration is taken of any systemic comorbidities to evaluate and minimize potentially serious safety issues.
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Affiliation(s)
- W David Strain
- Diabetes and Vascular Research Centre, University of Exeter Medical School, Exeter, UK.
| | - Xavier Cos
- Sant Marti de Provençals Primary Care Centres, Institut Català de la Salut, Barcelona, Spain; University Research Institute in Primary Care (IDIAP Jordi Gol), Barcelona, Spain
| | - Christian Prünte
- Kantonsspital Baselland, Eye Clinic, Liestal, Switzerland; University of Basel, Basel, Switzerland
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Cost Advantage of Fluocinolone Acetonide Implant (ILUVIEN®) versus Ranibizumab in the Treatment of Chronic Diabetic Macular Oedema. GLOBAL & REGIONAL HEALTH TECHNOLOGY ASSESSMENT 2017. [DOI: 10.5301/grhta.5000268] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Massin P, Erginay A, Dupas B, Couturier A, Tadayoni R. Efficacy and safety of sustained-delivery fluocinolone acetonide intravitreal implant in patients with chronic diabetic macular edema insufficiently responsive to available therapies: a real-life study. Clin Ophthalmol 2016; 10:1257-64. [PMID: 27468222 PMCID: PMC4944911 DOI: 10.2147/opth.s105385] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose To evaluate the efficacy and safety of sustained-delivery fluocinolone acetonide (FAc) intravitreal implant for diabetic macular edema (DME). Patients and methods Prospective study in patients with DME insufficiently responsive to laser and anti-vascular endothelial growth factor (anti-VEGF). Patients with history of rise of intraocular pressure after intravitreal corticosteroids were excluded. Results The macular edema rapidly decreased both in group 1 (prior laser only; n=7 eyes) and group 2 (prior laser and ≥3 monthly anti-VEGF therapy; n=10 eyes) and central subfield thickness was reduced by −299 μm (P=0.008) and −251 μm (P=0.016) at 12 months, respectively. Mean area under the curve from baseline to last value for pseudophakic eyes was +4.2 letters in group 1 and +9.5 letters in group 2. Overall, the FAc implant was well tolerated. Conclusion This prospective study confirms the efficacy of the FAc implant in DME patients insufficiently responsive to laser and anti-VEGF. Moreover, with a careful patient selection, our safety results would support an earlier use of FAc in the DME treatment pathway.
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Affiliation(s)
- Pascale Massin
- Ophthalmology Department, Lariboisière Hospital, Paris, France
| | - Ali Erginay
- Ophthalmology Department, Lariboisière Hospital, Paris, France
| | - Bénédicte Dupas
- Ophthalmology Department, Lariboisière Hospital, Paris, France
| | - Aude Couturier
- Ophthalmology Department, Lariboisière Hospital, Paris, France
| | - Ramin Tadayoni
- Ophthalmology Department, Lariboisière Hospital, Paris, France
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Sabanayagam C, Yip W, Ting DSW, Tan G, Wong TY. Ten Emerging Trends in the Epidemiology of Diabetic Retinopathy. Ophthalmic Epidemiol 2016; 23:209-22. [PMID: 27355693 DOI: 10.1080/09286586.2016.1193618] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE Diabetes is a major public health problem affecting 415 million people worldwide. With the increasing prevalence of diabetes, diabetic retinopathy (DR) is emerging as the leading cause of avoidable blindness worldwide. METHODS We reviewed previous and recent literature to provide an overview of emerging trends on the burden, epidemiology, risk factors, and prevention of DR. RESULTS First, there is clear evidence of a global increase in the prevalence of diabetes. Second, there is a decline in the incidence of blindness due to DR, particularly in developed countries. Third, diabetic macular edema (DME) rather than proliferative diabetic retinopathy (PDR) is the increasingly common cause of visual impairment. Fourth, DR awareness remains patchy and low in most populations. Fifth, hyperglycemia remains the most consistent risk factor for DR in type 1 diabetes across different studies and populations. Sixth, in contrast, blood pressure is an important risk factor for DR in type 2 diabetes. Seventh, the relationship between dyslipidemia and DR remains unclear, with inconsistent results from different studies and trials. Eighth, the utility of predictive models incorporating multiple risk factors for assessing DR risk requires evaluation. Ninth, photographic screening of DR using tele-ophthalmology platforms is increasingly recognized as being feasible and cost-effective. Finally, DR prevention in low-resource settings cannot follow models developed in high-resource countries and requires different strategies. CONCLUSIONS The ten trends we observed in the current review may guide planning of public healthcare strategies for the management of DR and prevention of blindness.
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Affiliation(s)
- Charumathi Sabanayagam
- a Singapore Eye Research Institute, Singapore National Eye Centre , Singapore.,b Center for Quantitative Medicine, Duke-NUS Medical School , Singapore.,c Yong Loo Lin School of Medicine , National University of Singapore , Singapore
| | - WanFen Yip
- a Singapore Eye Research Institute, Singapore National Eye Centre , Singapore
| | - Daniel S W Ting
- a Singapore Eye Research Institute, Singapore National Eye Centre , Singapore
| | - Gavin Tan
- a Singapore Eye Research Institute, Singapore National Eye Centre , Singapore
| | - Tien Y Wong
- a Singapore Eye Research Institute, Singapore National Eye Centre , Singapore.,c Yong Loo Lin School of Medicine , National University of Singapore , Singapore.,d Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School , Singapore
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Sivaprasad S, Oyetunde S. Impact of injection therapy on retinal patients with diabetic macular edema or retinal vein occlusion. Clin Ophthalmol 2016; 10:939-46. [PMID: 27307696 PMCID: PMC4888735 DOI: 10.2147/opth.s100168] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Purpose An important factor in the choice of therapy is the impact it has on the patient’s quality of life. This survey aimed to understand treatment burden, treatment-related anxiety and worry, and practical issues such as appointment attendance and work absence in patients receiving injection therapy for diabetic macular edema (DME) or retinal vein occlusion (RVO). Patients and methods A European sample of 131 retinal patients completed a detailed questionnaire to elucidate the impact of injection therapy on individuals with DME or RVO. Results RVO and DME greatly impact a patient’s quality of life. An intensive injection regimen and the requirements for multiple hospital visits place a large practical burden on the patient. Each intravitreal injection appointment (including travel time) was reported to take an average of 4.5 hours, with a total appointment burden over 6 months of 13.5 hours and 20 hours for RVO and DME patients, respectively. This creates a significant burden on patient time and may make appointment attendance difficult. Indeed, 53% of working patients needed to take at least 1 day off work per appointment and 71% of patients required a carer’s assistance at the time of the injection appointment, ~6.3 hours per injection. In addition to practical issues, three-quarters of patients reported experiencing anxiety about their most recent injection treatment, with 54% of patients reporting that they were anxious for at least 2 days prior to the injection. Patients’ most desired improvement to their treatment regimen was to have fewer injections and to require fewer appointments, to achieve the same visual results. Conclusion Patients’ quality of life is clearly very affected by having to manage an intensive intravitreal injection regimen, with a considerable treatment burden having a large negative effect. Reducing the appointment burden to achieve the same visual outcomes and the provision of additional support for patients to attend appointments would greatly benefit those receiving intravitreal injection therapies for DME and RVO.
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Affiliation(s)
- Sobha Sivaprasad
- NIHR Biomedical Research Centre, Moorfields Eye Hospital, London, UK
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Abraldes MJ, Pareja A, Roura M. Analysis of costs associated with the management and morbidity of diabetic macular oedema and macular oedema secondary to retinal vein occlusion. ACTA ACUST UNITED AC 2016; 91:273-80. [PMID: 26810908 DOI: 10.1016/j.oftal.2015.11.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 11/20/2015] [Accepted: 11/28/2015] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To analyse the disease burden in patients with diabetic macular oedema (DMO) or with retinal vein occlusion macular oedema (RVOMO) from a societal perspective. METHODS Observational, cross-sectional, multicentre study conducted on patients >18 years old diagnosed with uni- or bilateral DMO or unilateral RVOMO. Data on the use of health resources from diagnosis was collected, and the impact of disease on work life was assessed. Costs were annualised (euros, January 2014). Differences were contrasted using Chi-squared test (or Fisher Exact test), Mann Whitney-U test or Kruskal-Wallis test (Dunn contrast). RESULTS A total of 448 patients were included (DMO 255; RVOMO 193). There were significant differences in costs of diagnosis: RVOMO €1856, bilateral DMO €1661, and unilateral DMO €1401 (P<.001) and the aggregate medical costs: RVOMO €4639, bilateral DMO 6275€ and unilateral DMO 6269€ (P<.001). Cost by permanent time off work was higher in bilateral DMO €11712, than in unilateral DMO €4284€, and than in RVOMO €1052 (P<.05). Linear regression analysis showed that variables associated with direct health costs were: Diagnosis (bilateral DMO was associated with higher cost), as well as number of days in hospital, number of visits, time of observation, and number of days of time off work. CONCLUSIONS Patients with bilateral DMO are associated with a higher direct health cost, as well as a higher indirect cost by impact of the disease on work life.
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Affiliation(s)
- M J Abraldes
- Complexo Hospitalario Universitario de Santiago de Compostela, Universidad de Santiago de Compostela, Santiago de Compostela, (La Coruña), España; Red Temática de Investigación Cooperativa en Salud (RETICS), Instituto de Salud Carlos III, Madrid, España.
| | - A Pareja
- Hospital Universitario de Canarias, Tenerife, España
| | - M Roura
- Novartis Farmacéutica, S. A. , Barcelona, España
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Kotecha A, Baldwin A, Brookes J, Foster PJ. Experiences with developing and implementing a virtual clinic for glaucoma care in an NHS setting. Clin Ophthalmol 2015; 9:1915-23. [PMID: 26508830 PMCID: PMC4610880 DOI: 10.2147/opth.s92409] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background This article describes the development of a virtual glaucoma clinic, whereby technicians collect information for remote review by a consultant specialist. Design and Methods This was a hospital-based service evaluation study. Patients suitable for the stable monitoring service (SMS) were low-risk patients with “suspect”, “early”-to-“moderate” glaucoma who were deemed stable by their consultant care team. Three technicians and one health care assistant ran the service. Patients underwent tests in a streamlined manner in a dedicated clinical facility, with virtual review of data by a consultant specialist through an electronic patient record. Main outcome measure Feasibility of developing a novel service within a UK National Health Service setting and improvement of patient journey time within the service were studied. Results Challenges to implementation of virtual clinic include staffing issues and use of information technology. Patient journey time within the SMS averaged 51 minutes, compared with 92 minutes in the glaucoma outpatient department. Patient satisfaction with the new service was high. Conclusion Implementing innovation into existing services of the National Health Service is challenging. However, the virtual clinic showed an improved patient journey time compared with that experienced within the general glaucoma outpatient department. There exists a discrepancy between patient management decisions of reviewers, suggesting that some may be more risk averse than others when managing patients seen within this model. Future work will assess the ability to detect progression of disease in this model compared with the general outpatient model of care.
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Affiliation(s)
- Aachal Kotecha
- Glaucoma Service, Moorfields Eye Hospital National Health Service Foundation Trust ; NIHR BRC, Moorfields Eye Hospital, NHS Foundation Trust and UCL Institute of Ophthalmology, University College London, London, UK
| | - Alex Baldwin
- Glaucoma Service, Moorfields Eye Hospital National Health Service Foundation Trust
| | - John Brookes
- Glaucoma Service, Moorfields Eye Hospital National Health Service Foundation Trust
| | - Paul J Foster
- Glaucoma Service, Moorfields Eye Hospital National Health Service Foundation Trust ; NIHR BRC, Moorfields Eye Hospital, NHS Foundation Trust and UCL Institute of Ophthalmology, University College London, London, UK
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The progress in understanding and treatment of diabetic retinopathy. Prog Retin Eye Res 2015; 51:156-86. [PMID: 26297071 DOI: 10.1016/j.preteyeres.2015.08.001] [Citation(s) in RCA: 630] [Impact Index Per Article: 70.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 08/12/2015] [Accepted: 08/13/2015] [Indexed: 12/15/2022]
Abstract
Diabetic retinopathy is the most frequently occurring complication of diabetes mellitus and remains a leading cause of vision loss globally. Its aetiology and pathology have been extensively studied for half a century, yet there are disappointingly few therapeutic options. Although some new treatments have been introduced for diabetic macular oedema (DMO) (e.g. intravitreal vascular endothelial growth factor inhibitors ('anti-VEGFs') and new steroids), up to 50% of patients fail to respond. Furthermore, for people with proliferative diabetic retinopathy (PDR), laser photocoagulation remains a mainstay therapy, even though it is an inherently destructive procedure. This review summarises the clinical features of diabetic retinopathy and its risk factors. It describes details of retinal pathology and how advances in our understanding of pathogenesis have led to identification of new therapeutic targets. We emphasise that although there have been significant advances, there is still a pressing need for a better understanding basic mechanisms enable development of reliable and robust means to identify patients at highest risk, and to intervene effectively before vision loss occurs.
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Heng LZ, Pefianaki M, Hykin P, Patel PJ. Interobserver agreement in detecting spectral-domain optical coherence tomography features of diabetic macular edema. PLoS One 2015; 10:e0126557. [PMID: 25996150 PMCID: PMC4440774 DOI: 10.1371/journal.pone.0126557] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 04/02/2015] [Indexed: 12/02/2022] Open
Abstract
Purpose To evaluate interobserver agreement for the detection of spectral-domain optical coherence tomography (SDOCT) features of diabetic macular edema (DME). Method Cross-sectional study in which 2 retinal specialists evaluated SDOCT scans from eyes receiving treatment for DME. Scans from 50 eyes with DME of 39 patients were graded for features of DME including intra-retinal fluid (IRF), diffuse retinal oedema (DRE), hyper-reflective foci (HRF), subretinal fluid (SRF), macular fluid and vitreomacular traction (VMT). Features were graded as present or absent at zones involving the fovea, 1mm from the fovea and the whole scan of 49 line scans. Analysis was performed using cross-tabulations for percentage concordance and kappa values (κ). Results In the 2950 line scans analysed, there was an increase in percentage concordance for DRE and HRF when moving from a foveal line scan, 1mm zone and then to a whole scan analysis (88% vs 94% vs 96%) and (88% vs 94% vs 94%) respectively with κ ranging from substantial to almost perfect. Percentage concordance for SRF was 96% at all 3 regions analysed, whilst IRF was 96% at fovea and 98% at higher number of line-scans analysed. Concordance for MF was 100% at fovea and 98% at 1mm zone and whole scan with almost perfect and substantial κ respectively. κ agreement was substantial for VMT at all regions analysed. Conclusion We report a high level of interobserver agreement in the detection of SDOCT features of DME. This finding is important as detection of macular fluid is used to guide retreatment with anti-angiogenic agents.
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Affiliation(s)
- Ling Zhi Heng
- NIHR Moorfields Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - Maria Pefianaki
- NIHR Moorfields Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - Philip Hykin
- NIHR Moorfields Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - Praveen J. Patel
- NIHR Moorfields Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
- * E-mail:
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Schwartz SG, Flynn HW, Scott IU. Emerging drugs for diabetic macular edema. Expert Opin Emerg Drugs 2014; 19:397-405. [PMID: 25141904 DOI: 10.1517/14728214.2014.938048] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Diabetic macular edema (DME) is the most common cause of visual impairment due to diabetic retinopathy. The treatment of DME has recently undergone a paradigm shift. Traditionally, photocoagulation was standard treatment, but pharmacologic therapies are becoming increasingly used for this purpose. All currently available drug therapies for DME are either anti-VEGF agents or corticosteroids. AREAS COVERED The pathogenesis of DME involves angiogenesis, inflammation and oxidative stress. The scientific rationale to treat DME through the pharmacologic blockade of VEGF and other pro-angiogenic factors is discussed. The fluocinolone insert is approved for the treatment of DME in several European countries, but not in the US at this time. Some medications that are already approved for other retinal diseases, most prominently aflibercept and the dexamethasone delivery system, have recently obtained approval for DME in the US. Other compounds are being studied in earlier-phase clinical trials. EXPERT OPINION Pharmacologic treatment of DME will likely become increasingly used, especially for patients with edema involving the fovea. At this time, the two main classes of medication for treatment of DME are anti-VEGF agents and corticosteroids. As we continue to collect clinical trials data, the precise role of individual agents, and the continuing role for photocoagulation, will become more clear.
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Affiliation(s)
- Stephen G Schwartz
- University of Miami Miller School of Medicine, Bascom Palmer Eye Institute , 311 9th Street North, #100, Naples, FL 34102 , USA
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Abstract
Vascular endothelial growth factor (VEGF) plays a pivotal role in the development of diabetic macular edema (DME), the leading cause of vision loss among working-aged individuals. A decade of clinical trials demonstrated that drugs that bind soluble VEGF restore the integrity of the blood-retinal barrier, resolve macular edema, and improve vision in most patients with DME. Four drugs (pegaptanib, ranibizumab, bevacizumab, and aflibercept) effectively treat DME when administered by intravitreal injections. Only ranibizumab has received U.S. Food and Drug Administration (FDA) approval for DME, but bevacizumab is commonly used off-label, and an FDA application for aflibercept is pending. Effective treatment requires repeated injections, although recent data suggest that the treatment burden diminishes after 1 year. Intravitreal therapy is generally safe, although the incidence of systemic thromboembolic events varies among trials.
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Affiliation(s)
- Michael W Stewart
- Department Of Ophthalmology, Mayo Clinic Florida, Jacksonville, FL, 32224, USA,
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Kotecha A, Turner S, Vasilakis C, Utley M, Fulop N, Azuara-Blanco A, Foster PJ. Improving care and increasing efficiency-challenges in the care of chronic eye diseases. Eye (Lond) 2014; 28:779-83. [PMID: 25008575 PMCID: PMC4094808 DOI: 10.1038/eye.2014.135] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- A Kotecha
- NIHR Biomedical Research Centre, Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK
| | - S Turner
- Department of Applied Health Research, University College London, London, UK
| | - C Vasilakis
- IDO Group, School of Management, University of Bath, Bath, UK
| | - M Utley
- Clinical Operational Research Unit, University College London, London, UK
| | - N Fulop
- Department of Applied Health Research, University College London, London, UK
| | - A Azuara-Blanco
- Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - P J Foster
- NIHR Biomedical Research Centre, Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK
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Stitt AW, Lois N, Medina RJ, Adamson P, Curtis TM. Advances in our understanding of diabetic retinopathy. Clin Sci (Lond) 2013; 125:1-17. [PMID: 23485060 DOI: 10.1042/cs20120588] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Diabetic retinopathy remains the most common complication of diabetes mellitus and is a leading cause of visual loss in industrialized nations. The clinicopathology of the diabetic retina has been extensively studied, although the precise pathogenesis and cellular and molecular defects that lead to retinal vascular, neural and glial cell dysfunction remain somewhat elusive. This lack of understanding has seriously limited the therapeutic options available for the ophthalmologist and there is a need to identify the definitive pathways that initiate retinal cell damage and drive progression to overt retinopathy. The present review begins by outlining the natural history of diabetic retinopathy, the clinical features and risk factors. Reviewing the histopathological data from clinical specimens and animal models, the recent paradigm that neuroretinal dysfunction may play an important role in the early development of the disease is discussed. The review then focuses on the molecular pathogenesis of diabetic retinopathy with perspective provided on new advances that have furthered our understanding of the key mechanisms underlying early changes in the diabetic retina. Studies have also emerged in the past year suggesting that defective repair of injured retinal vessels by endothelial progenitor cells may contribute to the pathogenesis of diabetic retinopathy. We assess these findings and discuss how they could eventually lead to new therapeutic options for diabetic retinopathy.
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Affiliation(s)
- Alan W Stitt
- Centre for Vision and Vascular Science, Queen's University of Belfast, The Royal Victoria Hospital, Belfast BT12 6BA, UK.
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Ford JA, Lois N, Royle P, Clar C, Shyangdan D, Waugh N. Current treatments in diabetic macular oedema: systematic review and meta-analysis. BMJ Open 2013; 3:e002269. [PMID: 23457327 PMCID: PMC3612765 DOI: 10.1136/bmjopen-2012-002269] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 02/01/2013] [Accepted: 02/01/2013] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVES The aim of this systematic review is to appraise the evidence for the use of anti-VEGF drugs and steroids in diabetic macular oedema (DMO) as assessed by change in best corrected visual acuity (BCVA), central macular thickness and adverse events DATA SOURCE MEDLINE, EMBASE, Web of Science with Conference Proceedings and the Cochrane Library (inception to July 2012). Certain conference abstracts and drug regulatory web sites were also searched. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS Randomised controlled trials were used to assess clinical effectiveness and observational trials were used for safety. Trials which assessed triamcinolone, dexamethasone, fluocinolone, bevacizumab, ranibizumab, pegaptanib or aflibercept in patients with DMO were included. STUDY APPRAISAL AND SYNTHESIS METHODS Risk of bias was assessed using the Cochrane risk of bias tool. Study results are narratively described and, where appropriate, data were pooled using random effects meta-analysis. RESULTS Anti-VEGF drugs are effective compared to both laser and placebo and seem to be more effective than steroids in improving BCVA. They have been shown to be safe in the short term but require frequent injections. Studies assessing steroids (triamcinolone, dexamethasone and fluocinolone) have reported mixed results when compared with laser or placebo. Steroids have been associated with increased incidence of cataracts and intraocular pressure rise but require fewer injections, especially when steroid implants are used. LIMITATIONS The quality of included studies varied considerably. Five of 14 meta-analyses had moderate or high statistical heterogeneity. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS The anti-VEGFs ranibizumab and bevacizumab have consistently shown good clinical effectiveness without major unwanted side effects. Steroid results have been mixed and are usually associated with cataract formation and intraocular pressure increase. Despite the current wider spectrum of treatments for DMO, only a small proportion of patients recover good vision (≥20/40), and thus the search for new therapies needs to continue.
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Affiliation(s)
- John Alexander Ford
- Department of Population Health and Primary Care, Faculty of Medicine and Health Sciences,Norwich Medical School, University of East Anglia, Norwich,UK
| | - Noemi Lois
- Centre for Vascular and Visual Sciences, Queens University, Belfast, UK
| | - Pamela Royle
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, Coventry, UK
| | | | - Deepson Shyangdan
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, Coventry, UK
| | - Norman Waugh
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, Coventry, UK
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Mitchell P, Annemans L, Gallagher M, Hasan R, Thomas S, Gairy K, Knudsen M, Onwordi H. Cost-effectiveness of ranibizumab in treatment of diabetic macular oedema (DME) causing visual impairment: evidence from the RESTORE trial. Br J Ophthalmol 2012; 96:688-93. [PMID: 22399690 PMCID: PMC3329632 DOI: 10.1136/bjophthalmol-2011-300726] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background/aims To evaluate the cost-effectiveness of ranibizumab as either monotherapy or combined with laser therapy, compared with laser monotherapy, in the treatment of diabetic macular oedema (DME) causing visual impairment from a UK healthcare payer perspective. Methods A Markov model simulated long-term outcomes and costs of treating DME in one eye (BCVA ≤75 letters) based on data from the RESTORE Phase III trial. Outcomes measured in quality-adjusted life-years (QALYs) were simulated for a 15-year time horizon based on 12-month follow-up from RESTORE and published long-term data. Costs included treatment, disease monitoring, visual impairment and blindness (at 2010 price levels). Results Ranibizumab monotherapy resulted in a 0.17 QALY gain at an incremental cost of £4191 relative to laser monotherapy, yielding an incremental cost-effectiveness ratio (ICER) of £24 028. Probabilistic sensitivity analysis showed a 64% probability of being cost-effective at a threshold of £30 000 per QALY. Combined ranibizumab and laser therapy resulted in a 0.13 QALY gain at an incremental cost of £4695 relative to laser monotherapy (ICER £36 106; 42% probability of ICER <£30 000). Conclusions Based on RESTORE 1-year follow-up data, ranibizumab monotherapy appears to be cost-effective relative to laser monotherapy, the current standard of care. Cost-effectiveness of combination therapy is less certain. Ongoing studies will further inform on disease progression and the need for additional ranibizumab treatment.
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Affiliation(s)
- Paul Mitchell
- Centre for Vision Research, Westmead Millennium Institute, Westmead Hospital, Hawkesbury Rd, Westmead, 2145 Australia.
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