Jason Hsu, MD: Tackling Treatment Adherence in Patients with Diabetic Retinopathy

A fundamental goal of medicine is to improve outcomes for patients. That’s a monumental challenge in its own right, but becomes virtually insurmountable when patients work against the physicians who seek to help them.

Jason Hsu, MD, knows this problem well. The co-director of retina research at the Retina Service of Wills Eye Hospital in Philadelphia, PA, conducts research on patients with proliferative diabetic retinopathy (PDR), a condition that could be avoided with certain lifestyle changes and treatment interventions. It’s easy to understand why these patients, who are often non-adherent to their diabetes medications, are often lost to follow-up after they initially receive intravitreal injections of anti-VEGF or pan-retinal photocoagulation (PRP) therapies.

The problem is, neither anti-VEGF nor PRP are “one-and-done” treatments. Both require follow-up and monitoring to sustain outcomes. Losing patients to follow-up means that positive outcomes will decline, and could even lead to increased blindness. “It’s a much bigger issue than I think has been given press in our field,” Hsu told MD Magazine at the 2018 annual meeting of the Association for Research in Vision and Ophthalmology (ARVO) in Honolulu, HI. “Unless someone in the practice is carefully monitoring these patients—especially these high-risk patients that are getting injections—then those patients are just gone.”

Hsu and colleagues conducted a retrospective cohort study to determine just how serious of the lost to follow-up issue really was. In a 4-year study of 2302 patients with PDR receiving intravitreal injections with anti-VEGF or PRP, they found that a total of 1718 patients (74.6%) followed-up post-procedure and 584 patients (25.4%) were lost to follow-up. Of the patients receiving PRP, 28% were lost to follow-up, compared with 22.1% of patients receiving anti-VEGF.

Shortly after that data was revealed, Hsu and colleagues began work on a follow up study to determine whether anti-VEGF or PRP could sustain improved outcomes for a longer period in patients with PDR who were lost to follow-up. The findings will be presented at 4PM Hawaii time on April 29 at ARVO 2018, and covered summarily by MD Magazine.

Jason Hsu, MD:

It's a much bigger issue than I think has been given press in our field. We actually just recently published a paper that's in Ophthalmology looking at lost to follow-up rates in patients with proliferative diabetic retinopathy.

In that study, we looked at patients that got an anti-VEGF injection or PRP, and then were lost to follow-up for a year or more after that treatment.

We found that a quarter of patients -- and we looked at 2,300 patients over a 4 year period -- so a quarter of them got an injection or got PRP and never came back for a year, if ever.

It's a huge concern. When we look at even shorter durations of lost to follow-up -- 3 months, 6 months -- those rates are even higher. So there's definitely a big issue with potentially going towards anti-VEGF monotherapy because of this risk that patients have, if they are lost to follow-up.

Medicine is sort of like an open system. You see a patient, you treat them, but unless you know them personally or have a certain relationship with the patient you're not thinking about each patient. "Oh, where are they? I didn't see them last month!"

So unless someone in the practice is carefully monitoring those patients--especially these high-risk patients that are getting injections--then those patients are just gone.

We did make some changes. Number 1, we make phone calls now when a patient misses an appointment. We normally do this anyhow, but we make multiple phone calls to the injection patients. We send them certified letters if we aren't able to reach them, explaining how important it is that they come back for follow-up.

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