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One in four anti-VEGF therapy patients with DME lost to follow-up
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A quarter of patients with diabetic macular edema who received an anti-VEGF injection to treat nonproliferative diabetic retinopathy did not return for a follow-up visit within the ensuing 12 months, according to a study.
The retrospective cohort study analyzed billing data for 1,632 patients who underwent treatment at Wills Eye Hospital or Mid Atlantic Retina from Jan. 1, 2012, to Jan. 1, 2017. A total of 413 subjects (25.3%) were deemed lost to follow-up (LTFU), meaning they did not appear for an office visit within a year of receiving an injection.
The study not only looked at the rate of LTFU but also potential risk factors contributing to noncompliance, including age, gender, race/ethnicity, average adjusted gross income, eye involvement, diabetic retinopathy stage, insurance coverage and distance from the patient’s home to the clinic. Most predictive of LTFU were lower income, certain race/ethnicities and worse baseline visual acuity.
There was a statistically significant difference in the number of patients LTFU with average adjusted gross income of less than $50,000 per year compared with incomes of $50,000 to $75,000 or income greater than $75,000 per year (P < .001). Regarding race/ethnicity, Hispanic patients and patients reported as “other” and “unknown” were more likely than whites to be LTFU. In a subgroup analysis, the highest rate of LTFU was seen in patients with baseline visual acuity of 20/80 or worse, at a rate of 3.57 times the rate of LTFU in patients with baseline visual acuity of 20/50 or better (P < .001).
One explanation for the poor follow-up “may be due to a cultural and communication barrier because there are no Hispanic physicians in our practice. ... Given the increased prevalence of diabetes coupled with higher rates of noncompliance with eye care, greater attention should be paid to this population to lower the risk of vision impairment,” the study authors wrote. – by Scott Buzby
Disclosures: The authors report no relevant financial disclosures for this study.
Perspective
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Andrew P. Schachat, MD
Gao and co-authors studied loss to follow-up for patients with diabetic macular edema receiving anti-VEGF injections. While the standard treatment used to be “ETDRS laser,” now the standard approach involves anti-VEGF injections combined over time, in some patients, with laser treatment. This newer approach achieves superior outcomes in clinical studies. ETDRS laser treatment is durable; we have 5-, 10- and even 20-year outcome data. The newer anti-VEGF approach of course only has a few years of follow-up data. The authors found in a real-world setting that “approximately one in four patients with NPDR who had DME had no follow-up visit for at least 1 year after an anti-VEGF injection.” This is important for at least two reasons. First, about 25% of patients did not likely achieve all the possible benefit, and more importantly, second, those lost to follow-up might still have active retinopathy at risk of progressing. While newer is often better, and newer, more effective treatments represent a welcome advance, if adherence is poor, bad outcomes may be lurking.
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