Older, Minority Patients More Likely to Miss Anti-VEGF Treatment for nAMD

Anthony Obeid, MD, MPH

Though intravitreal antivascular endothelial growth factor (anti-VEGF) therapies have proven to be very efficacious for patients with neovascular age-related macular degeneration (nAMD), their burden of administration may be too extreme for patients to adhere treatment.

A new study from the Wills Eye Hospital in Philadelphia reported that 22.2% of more than 9000 patients with nAMD were lost to follow-up (LTFU) in between 12-month intervals of anti-VEGF care. Though patients were not allotted any subsequent follow-up visit, investigators believe their lack of adherence can be attributed to patient age, race, income, living situation, or disease progression.

Led by Anthony Obeid, MD, MPH, of the Retina Service at Wills Eye Hospital, investigators conducted a cohort analysis of 9007 patients with nAMD who received anti-VEGF injection therapy at an urban, private retina practice with multiple locations. Patients were observed from April 1, 2012 to January 12, 2016, with LTFU defined as a receipt of 1 or more injections with no subsequent follow-up visit within 12 months.

Mean patient age was 81.2 years, with 5917 (65.7%) reported as female. The majority of patients (n = 7905 [87.8%]) were white. In total, investigators reported 2003 patients (22.2%) were LTFU. Odds to LTFU were greater among patients aged 81-85 years (OR 1.58; 95% CI, 1.38-1.82; P < .001), 86-90 years (OR 2.29; P < .001), and 90 years and older (OR 3.31; P < .001) versus patients aged 80 years or younger.

Patients belonging to a minority group (African American OR 1.47; P = .05; Asian OR 2.63; P < .001; other race OR 3.07; P = .006) were also more likely to be LTFU than white patients. Similarly, patients who reported an adjusted gross income of $50,000 or less or $51,000 to $75,000 (OR 1.52, 1.35, respectively; P < .0001) were more likely to be LTFU than patients making more than $100,000 annually.

Distance from their clinic was also a factor in treatment adherence. The odds of LTFU for patients living 21-30 miles (OR 1.33; P = .02) and more than 30 miles (OR 1.55; P < .001) from their clinic were greater than that for patients living 10 miles or less from the clinic.

Lastly, patients to receive unilateral injections (OR 1.44; P < .001) had greater LTFU odds than patients receiving bilateral injections.

Among patients who were LTFU, just 149 (7.4%) attended a follow-up visit after the observed 12 months. In the total LTFU patient population, they reported a mean 7.8 injection treatments and 8.5 clinic visits. In patients not LTFU, they reported a mean 14.3 injections and 17.1 visits.

Investigators emphasized that the disparity of LTFU among races has been a previously analyzed topic—with mixed results. Noncompliance among African American patients has been linked to visit costs, insurance, and burden of personal time, while noncompliance in other races such as Chinese Americans has been associated with language barriers. That said, more analysis is needed.

“However, because of the complexity of the subject and the number of factors that might influence LTFU, a definitive explanation regarding why these rates actually differ remains unclear,” investigators wrote.

In an essay accompanying the study, David C. Musch, PhD, MPD, of the University of Michigan, noted that regardless of how generalizable the rate of 22% LTFU-patients is, it is an unacceptable adherence rate.

“Without receiving a thorough evaluation of their macular status and regular injections of an anti-VEGF agent as needed, the often substantial visual disability from nAMD will at best remain constant and more likely increase in its severity and negative effect on quality of life,” Musch wrote.

He noted that previous analysis evidenced that patients better understanding the severity of their condition, as well as the benefit of frequent therapy, has led to improved rates of treatment adherence. That said, shortcomings from initial therapies—even for a disease that could cause blindness&mdash;could bolster the LTFU rate, as well as nAMD comorbidities including depression.

Musch advocated for the implementation of team-based, motivational care for patients with nAMD that emphasizes patient confidence in autonomous care. He added that automated services such as emails or text messages reminding patients of appoints or their treatment regimen may help their adherence.

“This type of comprehensive self-management program should help patients with nAMD better realize their potential for improved vision through adhering to recommended follow-up and anti-VEGF treatment as required,” Musch wrote. “Convincing patients that poor adherence will greatly counter the beneficial effects of treatment is a very important first step; helping them to act on this knowledge by using practical and feasible interventions must follow.”

The study, "Loss to Follow-up Among Patients With Neovascular Age-Related Macular Degeneration Who Received Intravitreal Anti—Vascular Endothelial Growth Factor Injections," was published online in JAMA.