Paula Anne Newman-Casey

The relationship between components of metabolic syndrome and open-angle glaucoma.

PURPOSE To determine whether an association exists between various components of metabolic syndrome (diabetes mellitus [DM], systemic arterial hypertension [HTN], hyperlipidemia, and obesity) and open-angle glaucoma (OAG) in a large, diverse group of individuals throughout the United States. DESIGN Longitudinal cohort study. PARTICIPANTS All beneficiaries aged ≥40 years continuously enrolled in a managed care network who had 1 or more visits to an eye care provider during 2001 to 2007 were identified. METHODS Billing codes were used to identify individuals with OAG and those with components of metabolic syndrome. Cox regression was used to determine the hazard of developing OAG in enrollees with individual components or combinations of components of metabolic syndrome, with adjustment for sociodemographic factors, systemic medical conditions, and other ocular diseases. MAIN OUTCOME MEASURES Hazard of developing OAG. RESULTS Of the 2 182 315 enrollees who met the inclusion criteria, 55090 (2.5%) had OAG. After adjustment for confounding factors, those with DM (hazard ratio [HR] = 1.35 [95% confidence interval [CI], 1.21-1.50]) or HTN (HR = 1.17 [95% CI, 1.13-1.22]) alone or in combination (HR = 1.48 [95% CI, 1.39-1.58]) had an increased hazard of developing OAG relative to persons with neither of these conditions. By contrast, persons with hyperlipidemia alone had a 5% decreased hazard of OAG (HR = 0.95 [95% CI, 0.91-0.98]). Comorbid hyperlipidemia attenuated the increased hazard between HTN (HR = 1.09 [95% CI, 1.05-1.12]) or DM (HR = 1.13 [95% CI, 1.05-1.21]) and OAG. CONCLUSIONS At a time when the prevalence of metabolic disorders in the United States, is increasing this study furthers our understanding of risk factors associated with OAG and helps identify persons who may be at increased risk for this condition.

Cost-Effectiveness of Bevacizumab and Ranibizumab for Newly Diagnosed Neovascular Macular Degeneration

PURPOSE We sought to determine the most cost-effective treatment for patients with newly diagnosed neovascular macular degeneration: monthly or as-needed bevacizumab injections, or monthly or as-needed ranibizumab injections. DESIGN Cost-effectiveness analysis. PARTICIPANTS Hypothetical cohort of 80-year-old patients with newly diagnosed neovascular macular degeneration. METHODS Using a mathematical model with a 20-year time horizon, we compared the incremental cost-effectiveness of treating a hypothetical cohort of 80-year-old patients with newly diagnosed neovascular macular degeneration using monthly bevacizumab, as-needed bevacizumab, monthly ranibizumab, or as-needed ranibizumab. Data came from the Comparison of Age-related macular degeneration Treatment Trial (CATT), the Medicare Fee Schedule, and the medical literature. MAIN OUTCOME MEASURES Costs, quality-adjusted life-years (QALYs), and incremental costs per QALY gained. RESULTS Compared with as-needed bevacizumab, the incremental cost-effectiveness ratio of monthly bevacizumab is

The Relationship Between Statin Use and Open-Angle Glaucoma

24,2 357/QALY. Monthly ranibizumab gains an additional 0.02 QALYs versus monthly bevacizumab at an incremental cost-effectiveness ratio of >

The Most Common Barriers to Glaucoma Medication Adherence: A Cross-Sectional Survey

10 million/QALY. As-needed ranibizumab was dominated by monthly bevacizumab, meaning it was more costly and less effective. In sensitivity analyses assuming a willingness to pay of

Switching To Less Expensive Blindness Drug Could Save Medicare Part B

100,000/QALY, the annual risk of serious vascular events would have to be ≥2.5 times higher with bevacizumab than that observed in the CATT trial for as-needed ranibizumab to have an incremental cost-effectiveness ratio of <

18 Billion Over A Ten-Year Period

100,000/QALY. In another sensitivity analysis, even if every patient receiving bevacizumab experienced declining vision by 1 category (e.g., from 20/25-20/40 to 20/50-20/80) after 2 years but every patient receiving ranibizumab retained their vision level, as-needed ranibizumab would have an incremental cost-effectiveness ratio of

Cost-Effectiveness of Various Interventions for Newly Diagnosed Diabetic Macular Edema

97,340/QALY. CONCLUSIONS Even after considering the potential for differences in risks of serious adverse events and therapeutic effectiveness, bevacizumab confers considerably greater value than ranibizumab for the treatment of neovascular macular degeneration.

The Potential Association Between Postmenopausal Hormone Use and Primary Open-Angle Glaucoma

PURPOSE To determine whether 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (statins) affect the risk of developing open-angle glaucoma (OAG) in persons with hyperlipidemia. DESIGN Retrospective, longitudinal cohort analysis. PARTICIPANTS Individuals aged ≥60 years with hyperlipidemia enrolled in a national United States managed care network between 2001 and 2009. METHODS Multivariable Cox regression analyses were performed to assess the relationship between statin use and the development of OAG (from no prior OAG diagnosis), progression from a prior diagnosis of glaucoma suspect to a diagnosis of OAG, and need for medical or operative interventions for OAG. Regression models were adjusted for sociodemographic factors and medical and ocular comorbidities. MAIN OUTCOME MEASURES Hazard ratios (HRs) with 95% confidence intervals (CIs). RESULTS Of the 524 109 individuals with hyperlipidemia, 316 182 (60%) had ≥1 outpatient prescription for statins. The hazard of developing OAG decreased 0.3% (adjusted HR, 0.997; 95% CI 0.994-0.999) for every additional month of statin consumption. Individuals with hyperlipidemia who took statins continuously for 2 years had an 8% (adjusted HR, 0.922; 95% CI, 0.870-0.976) decreased OAG risk relative to those who received no statin therapy. The hazard of progressing from a diagnosis of glaucoma suspect to OAG decreased 0.4% (adjusted HR, 0.996; 95% CI, 0.993-0.999) for every additional month of statin exposure. Individuals who took statins continuously for 2 years had a 9% (adjusted HR, 0.907; 95% CI, 0.846-0.973) decreased risk of progressing from glaucoma suspect to OAG relative to those who received no statin therapy. The hazard of requiring medical treatment for OAG decreased 0.4% (adjusted HR, 0.996; 95% CI, 0.993-0.998) for every additional month of statin exposure. No differences in need for glaucoma surgery were noted among those with OAG who were and were not taking statins (adjusted HR, 1.002; 95% CI, 0.994-1.010). CONCLUSIONS Statin use was associated with a significant reduction in the risk of OAG among persons with hyperlipidemia. Given the mounting evidence of statin protection against OAG including both basic science and observational clinical studies, an interventional prospective study might provide additional insights into the role of statins in the prevention of early OAG.

Risk Factors Associated with Developing Branch Retinal Vein Occlusion Among Enrollees in a United States Managed Care Plan

PURPOSE To evaluate the frequency of 11 commonly cited barriers to optimal glaucoma medication adherence among glaucoma patients and to identify barriers contributing to poor adherence. DESIGN Prospective, cross-sectional survey. PARTICIPANTS One hundred ninety adults with glaucoma taking 1 or more glaucoma medication who received care in glaucoma clinics in Ann Arbor, Michigan, and Baltimore, Maryland. METHODS Participants completed a survey on demographic and disease characteristics, barriers to optimal glaucoma medication adherence, interest in an eye drop aid, and self-reported adherence (measured by the Morisky Adherence Scale). Descriptive statistics and logistic regression analyses were performed. MAIN OUTCOME MEASURES Frequency and number of barriers to adherence among both adherent and nonadherent patients. Odds ratios (ORs) with 95% confidence intervals (CIs) identifying barriers associated with poor adherence. RESULTS Twenty-seven percent of the sample reported poor adherence. Sixty-one percent of all participants cited multiple barriers and 10% cited a single barrier as impediments to optimal adherence. Twenty-nine percent of subjects cited no barriers, although only 13% of patients who cited no barriers were nonadherent. Among nonadherent patients, 31% or more cited each of the 11 barriers as important. Logistic regression analysis, adjusted for age, revealed that the following barriers were associated with higher odds of nonadherence: decreased self-efficacy (OR, 4.7; 95% CI, 2.2-9.7; P ≤ 0.0001), difficulty instilling drops (OR, 2.3; 95% CI, 1.1-4.9; P = 0.03), forgetfulness (OR, 5.6; 95% CI, 2.6-12.1; P ≤ 0.0001), and difficulties with the medication schedule (OR, 2.9; 95% CI, 1.4-6.0; P = 0.006). For each additional barrier cited as important, there was a 10% increased odds of being nonadherent (OR, 1.1; 95% CI, 1.0-1.2; P = 0.01). CONCLUSIONS Each of the 11 barriers was important to at least 30% of surveyed patients with poor adherence, with most identifying multiple barriers to adherence. Low self-efficacy, forgetfulness, and difficulty with drop administration and the medication schedule were barriers associated with poor adherence. Interventions to improve medication adherence must address each patients unique set of barriers.

Association of Geroprotective Effects of Metformin and Risk of Open-Angle Glaucoma in Persons With Diabetes Mellitus

The biologic drugs bevacizumab and ranibizumab have revolutionized treatment of diabetic macular edema and neovascular age-related macular degeneration, leading causes of blindness. Ophthalmologic use of these drugs has increased and now accounts for roughly one-sixth of the Medicare Part B drug budget. The two drugs have similar efficacy and potentially minor differences in adverse-event rates; however, at