Wednesday, October 13, 2010

AMD Update 13: Retinal Procedures on the Rise

A new study, just published in the October issue of Archives of Ophthalmology and reported by Ophthalmology Web, MedPage Today, and Medscape Medical News,  shows that among those in the Medicare population (age 65 plus), treatments for retinal conditions nearly doubled between 1997 and 2007 – and this trend is expected to continue with the aging of the population and seniors living longer.

Since more than 50% of all permanent blindness in older Americans is the result of two different retinal diseases: age-related macular degeneration and diabetic retinopathy. Advancing age raises the risk for both conditions. As the number of US residents older than 65 years continues to grow -- the figure is predicted to double by 2040 -- the incidence of both diseases will likely escalate. To prepare for that prospect, the researchers analyzed Medicare fee-for-service claims filed during the 10-year period 1997 - 2007.

The new report, "Use of retinal procedures in Medicare beneficiaries from 1997 to 2007", by Pradeep Y. Ramulu, M.D., M.H.S., Ph.D., of the Wilmer Eye Institute, Johns Hopkins University, Baltimore, and colleagues, states:  "Retinal disease is highly prevalent among older individuals, and both age-related macular degeneration (AMD) and diabetic retinopathy account for more than half the irreversible blindness in older Americans. The prevalence of both macular degeneration and diabetic retinopathy increases with age, and the number of Americans affected by these conditions is expected to increase substantially as the number of Americans older than 65 years doubles from 2010 to 2040." The authors continued, as background information to the article, "The last decade has seen substantial changes in the treatment options available for many retinal diseases, particularly in the treatment of neovascular AMD," a form of the disease involving abnormal blood vessel growth in the eye.

Procedure volumes changed most markedly for treatments directed toward neovascular AMD. New treatments for this condition include intravitreal therapy-injections of drugs administered directly into the eye-of antibodies that block the formation of new blood vessels. (Both Avastin and Lucentis.) Between 1997 and 2001, fewer than 5,000 such injections were performed each year. However, rates more than doubled each year through 2006, increasing between 2001 (when 4,215 of these procedures were performed) and 2007 (when injections totaled 812,413). “These treatments now represent a major component of the treatment of retinal disease”, the researchers observed.

Aside from the VEGF inhibitors, other pharmacologic agents used for intraocular injections have included steroids for macular edema and pegaptanib (Macugen) for macular degeneration.

Prior to the introduction of pharmacologic agents, including Avastin in 2005  and Lucentis in 2006, the sole treatment option to have demonstrated benefit for choroidal neovascularization was thermal laser treatment. Thermal laser treatments also fell by 83% between 1997 and 2007, from a high of 56,966 to 13,821. Then in 2000, photodynamic therapy became available.

Photodynamic therapy peaked in 2004 with 133,565 procedures and then decreased 83 percent to 22,675 procedures in 2007. Laser treatment of choroidal lesions (potentially cancerous eye tumors) and neovascular AMD also decreased 83 percent, from a peak of 82,089 in 1999 to 13,821 in 2007.

Vitrectomy-surgical removal of the gel inside the eye, used to treat retinal detachments – increased 72 percent, from 11,212 in 1997 to 19,923 in 2007. Scleral buckling, a treatment for the same condition involving placing a silicon buckle around the eye, can be performed with or without vitrectomy. Scleral buckling alone became less common during the study period (a 69 percent decrease, from 8,691 to 2,660).

The increasing use of retinal procedures means that greater attention should be paid to the financial implications, the authors observed. The annual price tag for ranibizumab (Lucentis) is about $24,000 for a single patient, and investigations are needed to determine if lower-cost options (Avastin) could provide equivalent improvements in vision and quality of life. For instance, a study currently underway – the CATT Study,  is comparing the less costly Avastin with Lucentis in a double-blinded four-arm study. (Initial results of this study are expected to be released early next year.)

"Observing use patterns adds value, because it demonstrates how disease is treated and can be used to identify possible discrepancies between the best evidence-based treatments for a condition (as defined by clinical trials and meta-analyses from the literature) and current practice patterns," the authors concluded. "In this report, we observed that intravitreal injections of pharmacologic agents have gained widespread acceptance for the treatment of neovascular AMD and that vitrectomy is being increasingly applied to a wide range of retinal conditions."

The researchers stated several limitations to their study: the focus on only Medicare claims prohibited the discovery of trends in those younger than 65 years and prevents generalization of findings to those with private insurance, and in addition, possible systematic errors in coding may have biased results.

The National Institutes of Health supported the study.


Arch Ophthalmol. 2010;128:1335-1340


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