Predictors of Nonadherence to Topical Intraocular Pressure Reduction Medications Among Medicare Members: A Claims-Based Retrospective Cohort Study

Review of glaucoma medication adherence monitoring in the digital health era

Current glaucoma treatments aim to lower intraocular pressure, often with topical ocular hypotensive medications. Unfortunately, the effectiveness of these medications depends on sustained patient adherence to regimens which may involve instilling multiple medications several times daily. Patient adherence to glaucoma medications is often low. Recent innovations in digital sensor technologies have been leveraged to confirm eyedrop medication usage in real-time and relay this information back to providers. Some sensors have also been designed to deliver medication reminders and notifications as well as assist with correct eyedrop administration technique. Here, we review recent innovations targeted at improving glaucoma medication adherence and discuss their limitations.

Association Between Open Payments-Reported Industry Transfers of Value and Prostaglandin Analog Prescribing in the US

Importance

Reported transfers of value (TOV) from pharmaceutical companies have been associated with greater use of branded anti-vascular endothelial growth factor agents by ophthalmologists, but payment under the Medicare Part B buy-and-bill model includes a financial incentive to choose costlier agents, potentially confounding analyses of pharmaceutical TOV and prescribing patterns. How these reported TOV are associated with prescribing patterns for prescription eye drops, not subject to the incentives created by Part B payments, should be considered.

Objective

To assess the association between prostaglandin analog (PGA) eye drop prescribing and reported nonresearch TOV by makers of branded PGAs to US vision care professionals.

Design, Setting, and Participants

This retrospective cohort analysis used a 20% nationally representative sample of 2018 Medicare Part D claims and industry TOV reported to the Open Payments program. Optometrists and ophthalmologists who had more than 10 claims for PGA drops in the 20% sample were analyzed. Analysis took place from June 2021 to February 2022.

Main Outcomes and Measures

Multivariable logistic regression assessing the association between membership in strata of reported TOV and branded PGA prescribing rate, controlling for prescriber demographic factors, local area practices, total PGA prescribing volume, and plan formularies involved.

Results

A total of 20 612 ophthalmologists and 5426 optometrists (7449 [29%] female and 18 589 [71%] male) prescribed PGA eye drops. Of these, 9685 (37%) were reported to have received TOV from manufacturers of branded PGAs in 2018, totaling $5 060 346. The median (IQR) reported TOV was $65 ($24-$147). Multivariable logistic regression showed that the predicted probability of primarily prescribing branded PGAs among prescribers who reported receiving no TOV was 12.9% (95% CI, 12.4%-13.4%). This figure increased to 19.6% (95% CI, 18.8%-20.4%) among prescribers receiving TOV, a 50% increase. There was a dose-response association, such that the top 10% of TOV recipients had a 29.2% probability (95% CI, 26.4%-31.9%) of preferential branded use.

Conclusions and Relevance

While the median reported TOV to a PGA prescriber was relatively low in this study, there was a positive association between amount of reported nonresearch TOV received from PGA makers and the frequency of branded PGA use. This shows that small reported TOV were associated with differences in prescribing. High rates of branded PGA prescribing may pose a cost burden to patients that affects adherence. Clinicians and policy makers should be aware of these associations.

Medication Adherence and Persistence of Open-Angle Glaucoma Patients in Korea: A Retrospective Study Using National Health Insurance Claims Data

This study aimed to analyze medication adherence and persistence among open-angle glaucoma patients in Korea. A retrospective study was conducted using the Korean National Health Insurance (NHI) claims database from 2016 to 2019. Newly diagnosed open-angle glaucoma patients who were prescribed with the intraocular pressure (IOP)-lowering eyedrops were included. Adherence was measured using the medication possession ratio (MPR), and persistence was measured using the duration of therapy during the 24 month follow-up period. During the study period, 14,648 open-angle glaucoma patients were identified, and 3118 (21.3%) and 4481 patients (30.6%) were adherent to and persistent with their glaucoma treatment, respectively. The mean MPR was 48.8%, and the mean duration of therapy was 357.2 days. Logistic regression analysis showed that patients who are older, female, using prostaglandins as the index medication, and visiting secondary or tertiary hospitals were significantly associated with greater rates of adherence (odds ratio (OR) = 1.21, 1.12, 1.27, and 1.73, respectively) and persistence (OR = 1.11, 1.17, 1.16, 1.17, and 1.36, respectively) during the study period. Patients with open-angle glaucoma in Korea had substandard medication adherence and discontinued their treatment. Ophthalmologists should pay more attention to younger, male patients to improve adherence.

Comparison of adherence between fixed and unfixed topical combination glaucoma therapies using Japanese healthcare/pharmacy claims database: a retrospective non-interventional cohort study

Background

Adherence to chronic therapies is crucial to prevent the progression of disease, such as glaucoma. However, only a limited number of studies have investigated them using real-world data in Japan. This study aimed to evaluate Japanese patients’ adherence to fixed- and unfixed-combination eye drops as a second-line therapy for glaucoma in real-world practice.

Methods

This retrospective, non-interventional cohort study utilized a commercially available Japanese healthcare database (MinaCare database). Medical/pharmacy claims data were collected from 2011 to 2016. The primary endpoint was adherence to medications, assessed by proportion of days covered (PDC) with medication during a 12-month post-index period. Meanwhile, the secondary endpoints included the persistence rate.

Results

A total of 738 patients were included in this study: 309 and 329 in the fixed- and unfixed-combination cohorts, respectively. Prostaglandin analog (PG)/β-blocker (BB) was most commonly claimed in 241/309 (78.0%) patients in the fixed-combination cohort. In the unfixed-combination cohort, PG and BB were claimed in 130/329 (39.5%) patients, whereas PG and α2-agonist were claimed in 87/329 (26.4%) patients. Patients were more adherent to the fixed-combination than the unfixed-combinations (mean PDCs [SD], 79.1% [32.1] vs. 62.2% [38.0]; P < 0.0001). The proportion of patients with good adherence (PDC ≥ 80%) was also higher in the fixed-combination cohort (69.6%) than in the unfixed-combination cohort (48.6%) (P < 0.0001). During the 12-month post-index period, the persistence rate was higher in the fixed-combination cohort than in the unfixed-combination cohort (47.6% [95% confidence intervals (CI): 41.9–53.0] vs. 24.9% [95% CI: 20.4–29.7], P < 0.0001).

Conclusions

Japanese patients with glaucoma preferred the fixed-combination therapies over the unfixed-combination therapies. Hence, fixed-combination therapies would contribute to the improvement of adherence.

Level of Glaucoma Drug Adherence and Its Associated Factors Among Adult Glaucoma Patients Attending Felege Hiwot Specialized Hospital, Bahir Dar City, Northwest Ethiopia

BACKGROUND

Glaucoma is a chronic optic nerve disease, often asymptomatic in an early stage, which is usually associated with elevated intraocular pressure. Good adherence to ocular hypotensive agents is essential to control the intraocular pressure and optic nerve damage. There is limited information on glaucoma drug adherence and associated factors in Ethiopia, particularly in the study area.

OBJECTIVE

To determine the level of glaucoma drug adherence and associated factors among adult glaucoma patients attending Felege Hiwot Specialized Hospital, Northwest Ethiopia, 2019.

MATERIALS AND METHODS

A hospital-based cross-sectional study was conducted at Felege Hiwot specialized Hospital from March 2019 to May 2019. A systematic random sampling method was used to select 402 study participants. A structured questionnaire was prepared, and adherence was assessed by using self-report questions. The collected data were entered into Epi data version 4.2.2.1 and exported into Statistical Package for Social Science version 23 for analysis. Tables, graphs, frequency, mean, and standard deviation were used for descriptive statistics. Variables with a p-value of <0.2 in the bivariable logistic regression were entered in the multivariable logistic regression, and variables with a p-value of <0.05 under multivariable analysis were taken as statistically significant factors for glaucoma drug adherence.

RESULTS

Among a total of 390 study participants, 212 (56.2%) were adherent to their topical medication. Early glaucoma (AOR=2.8: 95% CI =1.29-5.91), normal vision (AOR=1.9: 95% CI=1.15-3.09), urban residence (AOR=1.6: 95% CI=1.03-2.51), family support (AOR=1.7: 95% CI=1.06-2.76) and information from pharmacist (AOR=1.8: 95% CI=1.11-2.99) were significantly associated with adherence.

CONCLUSION

The level of glaucoma drug adherence was 56.2% among patients attending Felege Hiwot Specialized Hospital. Early glaucoma, normal visual acuity, family support, information on medication from the pharmacist, and urban residence were positively associated with adherence.

Prostaglandin Coverage and Costs to Medicare and Medicare Beneficiaries, 2009-2017

BACKGROUND

Prostaglandin analogs are the most effective treatment for glaucoma, a common condition among older adults. Despite the availability of generic drugs, the costs associated with these prescription drugs are rising.

OBJECTIVE

To characterize Medicare prescription drug plan (PDP) formulary coverage and beneficiary out-of-pocket cost for prostaglandin analogs from 2009 to 2017 and Medicare spending on prostaglandin analogs from 2013 to 2017.

METHODS

This study was a retrospective analysis. We used 2009, 2013, and 2017 Medicare PDP formulary, beneficiary cost, and pricing files to determine beneficiary first-prescription out-of-pocket costs and plan coverage (unrestricted, restricted, or not covered) of branded latanoprost 0.005%, travoprost 0.004%, bimatoprost 0.03% and 0.01%, and tafluprost 0.0015% and of generic latanoprost 0.005% and generic bimatoprost 0.03%. We also used Medicare Part D spending data to determine aggregate spend in 2013 and 2017.

RESULTS

In 2009, 92% of plans covered branded latanoprost, 83% covered branded bimatoprost; and 49% covered branded travoprost, whereas in 2017, 6% of plans covered branded latanoprost; 95% covered branded bimatoprost; and 96% covered branded travoprost. Although generic latanoprost was universally covered, generic bimatoprost was only covered by 35% of plans in 2017. Median out-of-pocket cost of branded prostaglandins without generic equivalents was $35 (IQR = $29-$40) in 2009, $45 (IQR = $42-$101) in 2013, and $90 (IQR = $45-$159) in 2017. Median out-of-pocket cost of all available generic prostaglandins was $10 (IQR = $5-$33) in 2013 and $10 (IQR = $4-$15) in 2017. In 2013, Medicare spent $733 million on prostaglandin analogs; in 2017, this increased to $1.09 billion, with $943 million (86%) spent on branded prostaglandins and $148 million (14%) spent on generics.

CONCLUSIONS

Medicare PDP coverage of branded prostaglandins remained stable from 2009 to 2017. While median beneficiary out-of-pocket costs associated with generic prostaglandins remained stable, those associated with branded prostaglandins increased nearly 3-fold.

DISCLOSURES

Research reported in this publication was supported by National Heart, Lung and Blood Institute of the National Institutes of Health under Award Number T35HL007649. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute or the National Institutes of Health. Shah has received research support through Mayo Clinic from the U.S. Food and Drug Administration (FDA) to establish Yale-Mayo Clinic Center for Excellence in Regulatory Science and Innovation (CERSI) program (U01FD005938); the Centers of Medicare and Medicaid Innovation under the Transforming Clinical Practice Initiative (TCPI); the Agency for Healthcare Research and Quality (U19HS024075, R01HS025164, R01HS025402, R03HS025517); and the National Heart, Lung and Blood Institute of the National Institutes of Health (NIH) (R56HL130496, R01HL131535), National Science Foundation, and the Patient Centered Outcomes Research Institute to develop a clinical data research network. Ross has received research support through Yale University from Johnson & Johnson to develop methods of clinical trial data sharing; Medtronic and the FDA to develop methods for postmarket surveillance of medical devices (U01FD004585); the FDA to establish Yale-Mayo Clinic Center for Excellence in Regulatory Science and Innovation program (U01FD005938); the Blue Cross Blue Shield Association to better understand medical technology evaluation; the Centers of Medicare & Medicaid Services to develop and maintain performance measures that are used for public reporting (HHSM-500-2013-13018I); the Agency for Healthcare Research and Quality (R01HS022882); the National Heart, Lung and Blood Institute of the NIH (R01HS025164); and the Laura and John Arnold Foundation to establish the Good Pharma Scorecard at Bioethics International and the Collaboration on Research Integrity and Transparency at Yale. The other authors have nothing to disclose.

The Association between Medication Adherence and Visual Field Progression in the Collaborative Initial Glaucoma Treatment Study

PURPOSE

To evaluate the relationship between medication adherence and visual field progression in participants randomized to the medication arm of the Collaborative Initial Glaucoma Treatment Study (CIGTS).

DESIGN

The CIGTS was a randomized, multicenter clinical trial comparing initial treatment with topical medications to trabeculectomy for 607 participants with newly diagnosed glaucoma.

PARTICIPANTS

Three hundred seven participants randomized to the medication arm of the CIGTS.

METHODS

Participants were followed up at 6-month intervals for up to 10 years. Self-reported medication adherence and visual fields were measured. Medication adherence was assessed by telephone from responses to the question, "Did you happen to miss any dose of your medication yesterday?" The impact of medication adherence on mean deviation (MD) over time was assessed with a linear mixed regression model adjusting for the effects of baseline MD and age, cataract extraction, interactions, and time (through year 8, excluding time after crossover to surgery). Medication adherence was modeled as a cumulative sum of the number of prior visits where a missed dose of medication was reported.

MAIN OUTCOME MEASURE

Mean deviation over time.

RESULTS

Three hundred seven subjects (306 with adherence data) were randomized to treatment with topical medications and followed up for an average of 7.3 years (standard deviation, 2.3 years). One hundred forty-two subjects (46%) reported never missing a dose of medication over all available follow-up, 112 patients (37%) reported missing medication at up to one third of visits, 31 patients (10%) reported missing medication at one third to two thirds of visits, and 21 patients (7%) reported missing medication at more than two thirds of visits. Worse medication adherence was associated with loss of MD over time (P = 0.005). For subjects who reported never missing a dose of medication, the average predicted MD loss over 8 years was 0.62 dB, consistent with age-related loss (95% confidence interval [CI], 0.17-1.06; P = 0.007); subjects who reported missing medication doses at one third of visits had a loss of 1.42 dB (95% CI, 0.86-1.98; P < 0.0001); and subjects who reported missing medication doses at two thirds of visits showed a loss of 2.23 dB (95% CI, 1.19-3.26; P < 0.0001).

CONCLUSIONS

This longitudinal assessment demonstrated a statistically and clinically significant association between medication nonadherence and glaucomatous vision loss.

Adherence to Medical Treatment and Its Determinants Among Adult Saudi Glaucoma Patients in Riyadh City

Background

Glaucoma in adults is a leading eye disease that causes blindness. Its management is life long and both surgical and medical treatment options are available to manage this ailment. Patients and their caregiver’s cooperation in instilling timely eye drops is crucial for the effective reduction of intraocular pressure (IOP) and by halting/delaying the progression of visual disabilities due to glaucoma. Periodic assessment and strict adherence to medical treatment has been found to be less than desired. It is influenced by the severity of the disease, the duration of the ailment, the number of eye drops being used, the literacy level, and the cost of medication. We present the adherence rate of topical medications and its determinants among adult Saudi glaucoma patients getting treated in 2017 in a tertiary eye center in Saudi Arabia.

Methodology

This cross-sectional survey was carried out from January to March 2017 at a tertiary eye hospital in Riyadh, Saudi Arabia. To undertake a cross-sectional study, we assumed that among 1300 patients visiting the eye department of a tertiary eye hospital, the level of non-adherence to glaucoma medication would be in 27% of glaucoma patients. To achieve a 95% confidence interval and an acceptable error margin of 5% for a survey, we needed to interview at least 253 participants.

Results

We interviewed 263 randomly selected glaucoma patients among 1236 patients visiting the eye department of the tertiary eye hospital in Riyadh, Saudi Arabia. Two-thirds of participants were school graduates, Saudi nationals, and had undergone surgery for glaucoma in the past; perhaps only YAG laser peripheral iridotomy (PI). Less than half of the participants (43%) had less than a one-year duration of glaucoma. The client-perceived subjective adherence rate to glaucoma medication was noted in 191/263 = 72.6% (95% Confidence Interval 67.2 -78.0). Of the 263 glaucoma patients, 229 judiciously abided with their follow-up appointments with ophthalmologists. Thus, the compliance to follow-up for glaucoma treatment was 87.1% (95% CI 83.0 - 91.1).

Conclusion

Our study with a large sample is perhaps the first one to assess compliance with medical treatment among adult Saudi glaucoma patients. The adherence rate for topical glaucoma medication measured using the subjective method was 72% among adult glaucoma patients. Adherence with the follow-up appointment with the glaucoma specialist was as high as 87%. Adherence with medical treatment found in the present study versus the literature review suggested that despite different sets of barriers, the adherence rate in Saudi adult glaucoma patients noted in our study was high. Knowledge, beliefs, and attitude are known to affect the adherence rate. In our study, education level and relatives having glaucoma were not associated with the adherence rate. This indirectly suggests that knowledge about the use of medication in the treatment of glaucoma that is gained by patients had a limited influence on adherence in our glaucoma patients. Modes of dispersing knowledge to elderly glaucoma patients and their impact on the adherence rates of medications for glaucoma management need to be further studied.

Factors associated with medication adherence in older patients: A systematic review

OBJECTIVE

Medication adherence is a major challenge in the treatment of older patients; however, they are under-represented in research. We undertook a systematic review focused on older patients to assess the reasons underlying non-adherence in this population.

METHODS

We searched multiple electronic databases for studies reporting reasons for non-adherence to medication regimens in patients aged 75 years and over. Our results were not limited to specific diseases, health-care settings, or geographical locations. The quality of eligible studies was assessed using the Newcastle-Ottawa Scale. A narrative synthesis of findings was performed.

RESULTS

A total of 25 publications were included, all of which were in community settings. Frequent medication review and knowledge regarding the purpose of the medication were positively associated with adherence. Factors associated with poor adherence were multimorbidity, cognitive impairment, complex regimens with multiple prescribing physicians, and problems with drug storage or formulation.

CONCLUSION

These findings suggest that interventions to improve adherence could focus on medication review aimed at simplifying regimens and educating patients about their treatment. Groups with poor adherence that may benefit most from such a model include patients with multiple comorbidities and cognitive impairment.

Psychometric Properties of the Reduced Version of the Glaucoma Treatment Compliance Assessment Tool (GTCAT)

PURPOSE

To measure the psychometric properties of a reduced, 27-statement version of the Glaucoma Treatment Compliance Assessment Tool (GTCAT).

METHODS

We administered the GTCAT to 183 participants who were using a single bottle of an ocular hypotensive agent, and objectively measured adherence with Medication Event Monitoring System devices over 60 days. Adherence was the number of days with correctly timed bottle openings divided by the total number of study days. Using the 47-statement GTCAT, we created a reduced GTCAT by removing statements that: (1) did not load using Principal Components Analysis (PCA); (2) did not have a univariable association with adherence; or (3) were highly correlated (.75 or higher) with another statement. We assessed the construct validity of the remaining statements using PCA and assessed the predictive validity using multiple logistic regression analysis.

RESULTS

We removed 20 statements because they did not appear in the PCA analysis; were not predictive of adherence; and/or had high correlation. PCA of the reduced GTCAT (27 statements) extracted 5 components of the Health Belief Model (knowledge, susceptibility, cues-to-action, self-efficacy, and barriers). Multiple regression showed that the 27 statements predicted adherence (Rsq = .11, p = .03).

CONCLUSIONS

The reduced version of the GTCAT is associated with adherence, which suggests that after external validation, future glaucoma medication adherence studies could use the reduced version to efficiently measure health behaviors and determine the benefit of the GTCAT to develop personalized interventions in glaucoma adherence.

Pharmacoepidemiological assessment of adherence and influencing co-factors among primary open-angle glaucoma patients-An observational cohort study

The goal of this study was to assess the adherence of primary open-angle glaucoma (POAG) patients to medication, and to determine co-factors influencing adherence, using a representative sample of members of the largest German public health insurer. The observational cohort study was based on a longitudinal data set from 2010-2013 and included 250,000 insured persons aged 50 and older with 10,120 diagnosed POAG patients. Uni- and multivariate analysis was performed to investigate several aspects of glaucoma, such as prevalence, adherence, and co-factors influencing adherence. The main outcome measured adherence with prescriptions filled within a year. Multivariate panel regression analysis was used to determine the co-factors influencing this adherence. Prevalence of POAG was 3.36% [CI: 3.28-3.43%], with 2.91% [CI: 2.81-3.01%] for males and 3.71% [CI: 3.61-3.81%] for females, increasing with age. The mean level of adherence in terms of prescriptions filled was 66.5% [CI: 65.50-67.60%]. The results of this analysis revealed a significant influence of age, duration of the disease, care need, distance to death, and multimorbidity as co-factors of non-adherence, whereas gender had no influence. The analysis provided detailed information about POAG health care aspects concerning prevalence and adherence. The most endangered risk groups for non-adherence were patients aged 50-59, patients older than 80 years, patients with a longer duration of POAG, patients with care needs, and patients with three or more severe diseases in addition to glaucoma. To know the predictors responsible for an increased risk to develop POAG is of importance for all persons involved in health care management. Therefore effective strategies to increase awareness of patients and medical care personnel about non-adherence and the importance of a regular and continuous medication to avoid further nerve fiber damage and possible blindness have to be developed.