Managed Care and the Impact of Glaucoma

Changes in the healthcare system, population demographics, and treatment alternatives have contributed to an emerging awareness of glaucoma among managed care organizations. Early diagnosis and treatment are essential to thwarting the personal and economic consequences of end-stage glaucoma. Despite recognition of the need for early intervention and therapy, the literature suggests a great need still exists for improvements in lowering intraocular pressure, managing appropriate follow-up, and improving adherence to current glaucoma medication regimens. As the elderly population continues to increase, these issues will intensify and present further problems for the healthcare system. The purpose of this introductory manuscript is to highlight the literature on the clinical and economic impact of glaucoma and its importance to the managed care community. The remainder of the supplement will focus on the current management of glaucoma and the potential role of neuroprotection in this patient population.

(Am J Manag Care. 2008;14:S5-S10)

Managed care organizations (MCOs) continually encounter new challenges as novel therapies are developed, diseases become more treatable, and the structure of the healthcare system continues to evolve in terms of reimbursement and population demographics. One such case is in the area of ophthalmology, particularly in the treatment of glaucoma, where the addition of the prostaglandin analogues and alpha₂ agonists to the armamentarium introduced more treatment options for glaucoma. In addition, the Health Plan Employer Data and Information Set (HEDIS^®) requirements set forth by the National Committee for Quality Assurance (NCQA) were updated in 2005 to include glaucoma screenings. Moreover, the advent of Medicare Part D introduced managed care to a new population with more age-related conditions such as glaucoma. Appropriate management of this new population requires health plans to understand the consequences of disease and the benefits of available treatments for glaucoma.

Impact of GlaucomaGlaucoma affects approximately 2.5 million persons in the United States older than age 55. Many of these cases are thought to be undiagnosed, with as many as half of these patients unaware that they have the disease.^1,2 Moreover, the prevalence of glaucoma is increasing. It is estimated that by 2010, there will be 60.5 million people worldwide with open-angle glaucoma or angle closure glaucoma, with 79.6 million cases projected worldwide by 2020. Of these cases, approximately 74% will be open-angle glaucoma.³ In the United States, the number of individuals with potentially treatable openangle glaucoma is expected to reach 3 million by 2020.⁴ Left untreated, glaucoma leads to blindness. It is the second most common cause of legal blindness in the United States and the leading cause of legal blindness in African Americans.⁵ Moreover, glaucoma-related blindness is largely preventable with early detection and appropriate treatment regimens.⁶

Although there are several different types of glaucoma, the most common form is primary open-angle glaucoma (POAG), which accounts for more than 90% of cases in the United States.⁷ Risk factors associated with open-angle glaucoma include elevated intraocular eye pressure (IOP), older age, race (African American), diabetes, and a positive family history of glaucoma.⁵ Glaucoma usually affects both eyes, although each eye may be affected to a varying degree. In the early stages, glaucoma is rather insidious; patients with open-angle glaucoma rarely exhibit symptoms. Consequently, glaucoma is often an incidental finding during a routine eye examination or during an examination performed for other reasons. In patients who are symptomatic, glaucoma usually manifests itself as a gradual loss of peripheral vision. Unfortunately, this vision loss often occurs after 40% or more of the optic nerve fibers are damaged. Optic disc changes may be detected before patients experience symptoms of visual loss, further supporting the need for regular ophthalmic examinations that include glaucoma screenings.⁵ According to the American Academy of Ophthalmology (AAO), the most effective way to diagnose glaucoma early is to screen for elevated IOP or disc changes as part of a regular comprehensive eye examination.⁸

As a treatable risk factor, lowering IOP has been the primary target for glaucoma therapy. Patients are usually prescribed ophthalmic drops as the initial treatment of choice for glaucoma. The mechanism of action of these topical eyedrops is to reduce IOP by either decreasing aqueous production or increasing aqueous outflow. Several therapeutic classes of glaucoma agents are available; if one drop is found to be ineffective, the patient can be switched to a medication from a different class or have a second medication added to the regimen to adequately control the glaucoma. Without adequate control, irreversible vision loss can occur. Moreover, the consequences of poorly treated glaucoma are not limited to just the eye. Research has demonstrated that any degree of vision loss is associated with increased medical costs as well as an increased risk of depression, injury, skilled nursing facility utilization, and long-term care placement.⁹ In most cases, however, glaucoma can be controlled and vision loss prevented with early detection and effective treatment.⁶

Recommendations for Glaucoma Care and Patterns of Care

For glaucoma therapy to be effective in lowering and controlling IOP, the proper regimen must be prescribed and used appropriately. Appropriate use involves compliance (adherence and persistence) with the regimen on the part of the patient, which can be problematic in those with glaucoma. As newly diagnosed patients are often asymptomatic, the use of medication does not provide the patient with immediately obvious benefits, such as pain relief or improved vision. This perceived benefit absence can lead to decreased patient compliance. Medication compliance in an elderly population is also affected by other factors, such as difficulty with self-administration of eyedrops, increased frequency of administration side effects (eg, irritation, burning, or blurred vision), unaffordable out-of-pocket expenses for medicines, or simply forgetting to administer the medication.¹⁵

Measuring adherence with ophthalmic medications is difficult in the elderly population. Assessments of medication adherence are often based on administrative paid claims databases rather than on more direct patient evaluation. Use of paid claims databases can be a potential problem for dosage forms such as eyedrops, where the quantitydispensed field may contain inaccuracies related to claims-filing procedures (eg, claims for a 2.5-mL bottle may be reported as 2 mL or 3 mL if a whole number must be entered into the field, or the number of bottles dispensed may be entered instead of the number of milliliters). Inconsistencies between the claim and actual medication use can also be related to variation in factors such as the number of drops per milliliter dispensed, vial overfill, and estimates of reported days’ supply. After adjusting for the influence of these factors on compliance, Wilensky et al found that patients considered to be new therapy starts and taking IOP-lowering prostaglandin/prostamide medications had an average adherence rate of 76%. Such a rate indicates that opportunities exist to improve adherence and decrease the long-term consequences of glaucoma.¹⁶

Costs Associated With Glaucoma

Until recently, treatment of glaucoma focused on lowering IOP as a treatable risk factor in the disease. However, the definition of glaucoma has evolved from one of elevated IOP to one characterized by an IOP-sensitive, progressive optic neuropathy. This change in definition has generated a refocus of treatment to include the role of neuroprotectants in glaucoma management. Neuroprotection is a potentially new treatment strategy for glaucoma patients that could have a profound clinical impact on patient care. In the context of glaucoma, neuroprotection refers to administering medications that interact with neuronal or glial elements within the retina or optic nerve to facilitate the survival of retinal ganglion cells.²⁷ In the future, medications that serve as neuroprotectants may be considered in conjunction with IOP-reducing therapy to provide what is being termed complete therapy for glaucoma patients. Such a combination could provide dually targeted treatment for patients with IOP-dependent glaucoma. It would also potentially reduce the rate of disease progression when IOP is not controlled or when progression occurs even with IOP at acceptable levels. Minimizing the consequences of glaucoma progression can ultimately reduce the economic and clinical burden of the disease to the patient and the payer.^9,26 When making managed care decisions, the costs of complete therapy will have to be weighed against the consequences of inadequate or incomplete therapy.

ConclusionsGiven changes in the healthcare system, population demographics, and treatment alternatives, glaucoma is now a major consideration for MCOs. With the elderly population increasing, these issues will only escalate and present further problems for the healthcare system. Early detection and treatment of glaucoma is essential in preventing the devastating personal and economic consequences of end-stage glaucoma. Although early treatment has been shown to be beneficial, the literature suggests there is still a great need for improvement in lowering IOP, managing appropriate follow-up intervals, and adhering to glaucoma medication regimens. Research suggests that the addition of neuroprotective agents to traditional antiglaucoma agents (complete therapy) may improve glaucoma outcomes. As more treatments for glaucoma enter the market, MCOs will be faced with a myriad of therapeutic options. Weighing the cost of these options and the benefits of early treatment, combined with the need to address treatment and outcome deficits, will prove to be a challenge. Additional research is needed to help organizations better understand the cost and consequences of glaucoma treatment. Measures of therapeutic value, such as cost-effectiveness comparisons, can assist MCOs in making formulary decisions as well as other decisions that impact patient care. The remainder of this supplement focuses on the current management of glaucoma and the role of neuroprotection as it pertains to complete therapy in this patient population.

Acknowledgment: Laurie Kozbelt assisted in the preparation of this manuscript.

Author Affiliations: From University of South Carolina, Columbia, SC; Xcenda, Palm Harbor, FL; Allergan, Inc, Irvine, CA.

Funding Source: The research and manuscript were funded by Allergan, Inc.

Author Disclosures: Author (CER) received an honorarium from Allergan, Inc; authors (MF, TJB) are employed by Xcenda.

Authorship Information: Concept and design (CER, MF, TJB); acquisition of data (MF, TJB); analysis and interpretation of data (CER, MF, TJB); drafting of the manuscript (CER, MF, TJB); critical revision of the manuscript for important intellectual content (CER, TJB); and supervision (TJB).

Address Correspondence to: Claiborne E. Reeder, RPh, PhD, Director, Xcenda, 3270 Girardeau Ave, Columbia, SC 29204. E-mail: gene.reeder@xcenda.com.

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