Glaucoma Management: Changing Treatment Algorithms I have the - - PowerPoint PPT Presentation

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Andrew G. Iwach, M.D.

Associate Clinical Professor University of California, San Francisco San Francisco, California

Glaucoma Management: Changing Treatment Algorithms

• I have the following financial interests or relationships to disclose:
• Consultant

– AcuMEMS – Alcon – Bausch & Lomb

Financial Disclosure

Flora Lum, M.D. AAO Policy Director, Quality of Care and Knowledge Base Development William L. Rich III, MD, FACS AAO Medical Director of Health Policy Sue Vicchrilli, COT, OCS AAO Coding Executive Cherie L. McNett AAO Director of Health Policy Cathy Cohen AAO Vice President, Governmental Affairs Shan Lin, M.D. AAO Health Policy Committee Patient Care Committee, American Glaucoma Society Cynthia Mattox, M.D. AAO Health Policy Committee Emmett Cunningham. Jr., M.D., PhD., MPH Stanford University Faculty. Clarus Ventures Industry Members

Acknowledgments

0.00 0.05 0.10 0.15 6 12 18 24 30 36 42 48 54 60 66 72 78 84

Primary POAG Endpoints*

Log Rank P-value <0.001, Hazard Ratio 0.40, 95% CI (0.27, 0.59)

*through 8 Nov 2001

Proportion POAG Medication Observation

Months

2

Treatment vs. Observation

POAG = primary open-angle glaucoma; OHT = ocular hypertension.

• 1. Kass MA et al. Arch Ophthalmol. 2002;120:701-713.

10 20 30 40 50 60 70

OHT Over 5 Years1

Untreated Treated

Most Patients are Asymptomatic

Diagnostic Studies in Ophthalmology

Medicare data, courtesy of Dr. William L. Rich III

Managing the Odds

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Glaucoma: Managing the Odds

Medical Trends

IOP Lowering Medications: Retail Market

Thank you to Rick Halprin at Alcon recent data from IMS

IOP Lowering Medications: Retail Market

Thank you to Rick Halprin at Alcon recent data from IMS

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The Concept of Persistency

Impacting Factors

With economic issues With added side effects With complicated dosing Ideal After human complacency/denial

10 20 30 40 50 60 70 80 90 100

Persistent Patients (%) 3 mo 6 mo 9 mo 12 mo

Glaucoma & Ectropion

• 74 year old, Exfoliation Syndrome
• Meds: Simbrinza bid

– Brinzolamide 1.0% – Brimonidine Tartrate 0.2%

• Tearing, Lid Crusting, Discharge
• Lid Redness + Ectropion
• Diagnosis:

– ? Tear Duct Issue – ? Drug Reaction

• Need for Surgery??

Glaucoma & Ectropion

Vijay Hegde, et al: Drug-Induced Ectropion: What Is Best Practice? Ophthalmology 2007;114:362–366

Sustained Release Travoprost (OTX-TP)

• Intended use:

– Reduction of intraocular pressure in patients with

• pen-angle glaucoma or ocular hypertension
• Product design:

– Non-invasive punctum plug formulation – Tailored drug release (2-3 months) – Visible for retention monitoring – Comfortable and absorbable

• Components:

– Polyethylene glycol hydrogel – PLA microparticles – Travoprost ophthalmic solution – Fluorescein

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Punctum plug size Fluorescent plug

• bserved under blue light

Ocular Therapeutix, Inc.

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Sustained Release Travoprost (OTX-TP)

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1 2 3 4 5 10 15 20 25 30

Hyperemia Score (0 to 4)

Days Hyperemia

n=24

Baseline Error Bars = Standard deviation

0 = None 1 = Trace 2 = Mild 3 = Moderate 4 = Severe *Data on file at Ocular Therapeutix

Surgical Trends

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Success: Perspectives

Surgeon vs. Patient

Surgeon Patient

Surgical Trends: 1994-2014

Medicare data, courtesy of Dr. William L. Rich III iStents: 2007: 200/month 2014: 4000/month Total: 40,000+ in US so far

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Surgical Trends: Aqueous Shunts and Cyclophotocoagulation

Medicare data, courtesy of Dr. William L. Rich III

MicroPulse CP Laser

Anterior Uveitis

• 72 y.o Vietnamese Male
• Pre-Op:

– 20/40 – IOP 27 mmHg, Max Meds

• Post-Op Day 1:

– IOP = 10, No Meds – Light Perception – Hyphema, Corneal Haze

• Meds: Durezol q 1 Hour
• Axial Length: 20.8 mm

Week 6: Hand Motion Vision

Non-Medical Trends Affecting Glaucoma Managment

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Newer Health Plans: Impact on Continuity of Care

• Older PPO Provider Networks are Only Available with Older Insurance Plans
• Older Insurance Plans have been …

a) Discontinued b) Significant Increase Premium Increase

• Remaining Older Insurance PPO Plans Closed to New Patients
• Newer “PPO” Panels are cheaper but have very restricted Provider Panels
• e.g. Blue Cross Pathway PPO and Pathway X PPO
• Insurance Companies Use Cost and Quality Metrics to Invite Provider to New Plans
• Annual Reassessment, Poor/Inconsistent Communication
• Disruption of Continuity of Care

Impact on Glaucoma Management

Big Data: Impact on Medical Care ACA: Impact on Glaucoma Care

Prescribing Patterns

http://projects.propublica.org/checkup/providers/search

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Prescribing Patterns

http://projects.propublica.org/checkup/providers/search

Propublica Partners with Yelp

Corporations: Customer Satisfaction

Do you have an opinion?

ICD-9 / ICD-10 Comparisons

ICD-9 ICD-10 Diagnosis Usage Inpatient and Outpatient Inpatient and Outpatient Number of Characters 3-5 Numeric/ alphanumeric 3-7 Alphanumeric Number of Codes ~17,000 ~141,000 Chapters 17 21

ICD-10 Fundamentals

Of the 21 chapters in ICD-10, 10 involve diagnosis pertaining to eyes

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ICD-10 Fundamentals ICD-10 Fundamentals ICD-10 Fundamentals

Glaucoma Center of San Francisco

www.GlaucomaSF.com

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January 28

Annual Gala

January 29

New Horizons Forum

January 30

Glaucoma Symposium January 28 – 30, 2016 San Francisco, CA

Celebrate Innovate Educate

Glaucoma Center of San Francisco

www.GlaucomaSF.com