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    JAMA Ophthalmology

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    Cost-Related Medication Nonadherence and Cost Savings in Patients With Glaucoma

    September JAMA Ophthalmology

    Understanding factors that lead to nonadherence to glaucoma treatment is important in reducing glaucoma-related disability. Blumberg et al. evaluated how implementation of the Medicare Part D prescription drug benefit in 2006 affected cost-related nonadherence and cost-reduction strategies among Medicare beneficiaries with and without glaucoma. They also examined risk factors associated with such nonadherence.

    This serial cross-sectional study used 2004-2009 Medicare Current Beneficiary Survey data linked with Medicare claims. Data extraction began in January 2014, and analyses were performed between September and November of 2014. Participants were all Medicare beneficiaries; they included patients with a glaucoma-related diagnosis in the year prior to the collection of the survey data, those with a nonglaucomatous ophthalmic diagnosis in the year prior to the collection of the survey data, and those without a recent eye care professional claim.

    Between 2004 and 2009, the number of Medicare beneficiaries with glaucoma who reported taking smaller doses and skipping doses because of cost dropped from 9.4% and 8.2% to 2.7% (p < .001) and 2.8% (p = .001), respectively. However, failure to obtain prescriptions owing to cost did not improve significantly in the same period (3.4% in 2004 and 2.1% in 2009; p = .12). After implementation of Part D, there was a decrease in the percentage of glaucoma patients using cost-reduction strategies, for example, price shopping (from 26.2% to 15.2%), purchasing outside the United States (from 6.9% to 1.3%), and spending less money on basic needs to save for medications (from 8.0% to 3.5%; p < .001 for all comparisons).

    In a multivariate analysis, the main independent risk factors common to all cost-related nonadherence measures were female sex, younger age, lower income (<$30,000), self-reported visual disability, and a smaller Lawton index (a measure of independence in activities of daily living).

    The authors concluded that after the implementation of Part D, there was a decrease in the rate at which beneficiaries with glaucoma reported engaging in cost-saving measures. Although there was a decline in the rate of several cost-related nonadherence behaviors, patients reporting failure to fill prescriptions because of cost remained stable. The results suggest that efforts to improve cost-related nonadherence should focus on both financial hardship and medical therapy prioritization, particularly in certain high-risk sociodemographic groups.

    Behavioral Intervention and Rates of Dilated Fundus Examination

    September JAMA Ophthalmology

    Data show that African-American individuals are at high risk of diabetes mellitus and diabetic retinopathy (DR) but have suboptimal rates of dilated fundus examinations (DFEs). Thus, Weiss et al. tested the efficacy of a program of behavioral activation for DR prevention on rates of DFEs in older African-American patients in a masked randomized clinical trial at 2 urban medical centers from Oct. 1, 2010, to May 31, 2014.

    Participants included 206 African-American individuals aged 65 years and older with diabetes mellitus who had not obtained a DFE in the preceding 12 months. Participants were randomized either to behavioral activation for DR prevention or to supportive therapy (the control group). In this study, behavioral activation was designed to provide education to patients, to help them identify and address health care barriers, and to promote goal setting to improve rates of DFEs. The primary outcome was medical documentation of a DFE at 6-month follow-up. Secondary outcomes included the Risk Perceptions and Risk Knowledge Survey of Diabetes Mellitus, Diabetes Self-Care Inventory, Patient Health Questionnaire 9, and National Eye Institute Visual Function Questionnaire 25 scores, as well as hemoglobin A1c levels.

    The results showed that more participants in the behavioral activation group (87.9%) had obtained a DFE compared with those in the supportive therapy group (34.1%) by the 6-month follow-up assessment (p < .001). Overall, participants in the behavioral activation group were 2.5 times more likely to obtain a DFE compared with those in the supportive therapy group (risk ratio, 2.58; p < .001). No short-term effect on secondary outcomes of hemoglobin A1c levels, depression, or the Risk Perceptions and Risk Knowledge Survey of Diabetes Mellitus, or National Eye Institute Vision Function Questionnaire 25 composite scores was identified; however, both groups had improved adherence to diabetes mellitus self-care behaviors from baseline to 6-month follow-up.

    The authors concluded that behavioral activation for DR prevention significantly increased rates of DFEs in older African-American individuals with diabetes mellitus, suggesting that behavioral interventions may have the potential to positively affect screening for DR in at-risk populations.

    Elevated IOP After Intravitreal Triamcinolone Acetonide

    September JAMA Ophthalmology

    The Standard Care vs. Corticosteroid for Retinal Vein Occlusion (SCORE) Study showed that intravitreal triamcinolone acetonide (IVTA) is effective at reducing macular edema and improving visual acuity in participants with retinal vein occlusion (RVO). In this secondary analysis, Aref et al. assessed the incidence, risk factors, and timing of IOP elevation after IVTA.

    SCORE was a randomized clinical trial conducted between 2005 and 2009 at 75 sites, involving patients with macular edema secondary to RVO. In that trial, participants were randomized to standard care, 1 mg of IVTA, or 4 mg of IVTA and followed for a mean of 24.7 months.

    In the current study, data from 616 of the 682 original SCORE patients were analyzed. Kaplan-Meier incidences of IOP elevation greater than 10 mm Hg from baseline at 36 months were 0.02, 0.09, and 0.45 in the standard care, 1-mg IVTA, and 4-mg IVTA groups, respectively. The rates of IOP-related events were higher for the 4-mg IVTA group compared with the other groups (p ≤ .001 for main outcome measure). Younger age, 4-mg IVTA vs. 1-mg IVTA treatment, and higher baseline IOP were found to confer greater risk for IOP-related events (p < .05 for all). The median number of days elapsed from time of first injection to IOP elevation greater than 10 mm Hg from baseline was 34.0 and 52.5 days in participants treated with 1-mg and 4-mg IVTA, respectively.

    These data indicate that IVTA therapy, particularly the 4-mg dose, is associated with an increased risk for IOP elevation and that IOP-related events may take several months from the time of first IVTA injection to occur. The authors urged clinicians to be mindful of the risk factors associated with IOP increase when they weigh the risks and benefits of IVTA therapy and also of the need for long-term follow-up of patients at risk for this complication.

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    JAMA Ophthalmology summaries are based on authors’ abstracts as edited by senior editor(s).

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