Improving Ophthalmic Care Access and Treatment Among Aging Adults

As the American population ages, chronic conditions are becoming an increasing challenge for payers. In addition to conditions such as cardiovascular disease and diabetes, eye disease is also prevalent among aging adults.

August 20, 2020

Improving Ophthalmic Care Access and Treatment Among Aging Adults

The Aging of Americans

The number of individuals 65 years or older is continuously growing in the United States. This population is projected to account for 20% of Americans by 2030, and 24% by 2060. Advanced age is associated with an increased prevalence of multiple chronic conditions (MCC). According to an analysis of data from the Centers for Disease Control and Prevention’s (CDC’s) 2017 Behavioral Risk Factor Surveillance System (BRFSS), the prevalence of MCC (defined as the presence at least two of 12 chronic conditions listed on the survey) in the United States among those aged 45 to 64 ranged from 51% to 74%, depending on the state or U.S. territory of residence, and ranged from 69% to 86% among those 65 years or older, again depending on the state or U.S. territory of residence.

Across all states and territories, the prevalence of MCC among adults aged 65 or older was significantly higher than for those aged 18-44 (P <.05). Chronic conditions included on the BRFSS include arthritis, asthma, cancer, chronic obstructive pulmonary disease (COPD), depression, diabetes, heart disease, high blood pressure, high cholesterol, kidney disease, obesity and stroke. The high prevalence of MCC among individuals in the United States aged 65 years or older suggests that resource allocation for this patient population will continue to present challenges to both health care systems and payers.

Eye diseases are also prevalent among older adults. According to a pooled analysis of data from six large population-based studies (the Beaver Dam Eye Study, Baltimore Eye Survey and Salisbury Eye Evaluation Study, Proyecto VER and Los Angeles Latino Eye Study [LALES], and the Chinese American Eye Study [CHES]), the prevalence of visual impairment (defined as visual acuity better than 20/200 but less than 20/40) among those aged 40-49, 50-59, 60-69, 70-79, and 80 years or older in the United States was projected to be 0.13 million, 0.17 million, 0.59 million, 0.99 million, and 1.77 million, respectively, for the year 2020, and was projected to be 0.16 million, 0.21 million, 0.70 million, 1.43 million, and 4.44 million, respectively, by the year 2050. For blindness (defined as visual acuity of 20/200 or less), the projected prevalence by age group was projected to be 0.11 million, 0.14 million, 0.19 million, 0.21 million, and 0.47 million, respectively, for the year 2020 and was projected to increase to 0.13 million, 0.15 million, 0.23 million, 0.32 million, and 1.18 million, respectively, by the year 2050. As visual impairment and blindness can have deleterious effects on both physical and mental health, the impact on health care spending both currently and in the future is likely to be substantial.

Eye examinations are a focal point of many quality measures and related programs, such as the Healthcare Effectiveness Data and Information Set (HEDIS), which includes a performance measure for DR screening in individuals with diabetes aged 18 to 75 years. Providers and payers who begin considering such preventative care measures now and plan in advance for the needs of the aging population will be better prepared for optimal management and effective resource allocation in the future.

The Impact for Older Adults With Eye Disease

Eye disease can have an effect on activities of daily living (ADLs), such as dressing, bathing, toileting, hobbies, housekeeping, cooking, shopping and transportation. Poor vision is associated with a lower rate of medication adherence resulting from an inability to accurately read important information contained on product labeling. Other consequences may include emotional distress from vision loss, decreased social engagement, situational depression, loss of independence, physical inactivity, falls, injuries and an increased likelihood to be admitted to long-term care facilities (LTCFs). In addition, persons with visual impairment have higher morbidity and mortality rates compared with those in the overall population.

August 20, 2020

Economic Burden of Eye Disease on Health Care

At the level of the health system and of society, eye disease among older adults carries financial implications. In a retrospective claims-based analysis of patients 40 years or older with visual disorders including visual impairment, blindness, AMD, cataracts, DR, primary open-angle glaucoma, and refractive errors (myopia and hyperopia). The total societal cost of eye disease for the year 2004 was estimated to be $35.4 billion (2004 USD). Components of this societal cost estimate included costs to the patient (both direct and indirect [productivity losses]) and costs to third-party payers (Medicaid and Medicare in this case).

Data from the 2001 MarketScan Commercial Claims and Encounters Database, the 2002 National Ambulatory Medical Care Survey, the 2002 National Hospital Ambulatory Medical Care Survey (outpatient department file), Medicare claims data from the year 2000 (physician, outpatient and inpatient hospital files), and data from the Consumer Assessment of Health Plans Survey from a nationally representative sample of 167,993 Medicare fee-for-service beneficiaries were all utilized. 

Of the $35.4 billion total paid by patients and third-party payers, $16.2 billion was attributable to direct medical costs (outpatient and pharmaceutical costs); $11.1 billion was attributable to direct nonmedical costs (nursing home care, guide dogs and federal programs for the visually impaired, including the Department of Education’s Independent Living Services for Older Blind Individuals, the American Printing House for the Blind, and the Library of Congress’ National Library Service for the Blind and Physically Handicapped); and the remaining $8.03 billion was attributable to work productivity losses. Of the $16.2 billion spent on outpatient and pharmaceutical costs, $6.8 billion was attributable to cataracts, $5.5 billion to refractive error, $2.9 billion to glaucoma, $575 million to AMD, and $493 million to DR. Of the $11 billion attributable to direct nonmedical costs, $10.96 billion was spent on nursing homes and long-term care, $62 million was spent on guide dogs, and $94 million was spent on federal programs for the visually impaired.

August 20, 2020

Importance of Prophylactic Screening and Early Detection

Eye Screenings and Treatment

Importance of Prophylactic Screening and Early Detection

Early detection and treatment can prevent vision loss and complications. In most cases, if the disease is identified and treated early, vision loss can be prevented. Because symptoms may not always be present at early stages, compliance with eye examination screenings may help avoid preventable vision loss. The AAO recommends that adults 65 years or older without eye disease risk factors should receive an examination by an ophthalmologist everyone to two years given the increased incidence of eye disease as individuals age. Adults with Type 1 diabetes should be examined by an ophthalmologist within five years of onset of the disease and then at least annually; those with Type 2 diabetes should be examined at diagnosis and then at least annually. Adults with acute or chronic disease may require eye examinations with frequencies ranging between hours and months, depending on the nature of the condition.

Eye Examination Adherence

Lack of ophthalmic monitoring and treatment can result in poor clinical outcomes, such as blindness; therefore, it is important to learn why patients do not always adhere to recommended eye examination schedules. Adherence to recommended examination schedules is low: approximately 50% of Americans with diabetes receive annual eye examinations, and the percentage among underserved and minority populations averages just 10% to 12%.44 Results from a 2015 cross-sectional study showed that 52.1% of patients with glaucoma (n = 121), 33.7% of those with AMD (n = 86), and 30.3% of those with DR (n = 33) failed to reschedule a missed appointment within a month of the recommended follow-up date. Most patients in the study were white (61.6%), privately insured (72.1%) and college educated (76.7%). The mean age of those with poor adherence was 70.5 years (SD = 14.3). Primary reasons for poor adherence to follow-up care involved a low level of understanding of the disease, legal blindness and difficulty taking time off from work. This issue of adherence to recommended eye examinations can be addressed in several ways, such as by increasing patient education and networking opportunities with fellow patients, offering affordable transportation services, improving clinical efficiencies, and increasing access to services remotely through telemedicine and similar means.

August 20, 2020

Current Treatment Recommendations

Treatment Recommendations

The American Academy of Ophthalmology recommends surgical procedures for cataracts, glaucoma, and DR, using the following specified procedures. For cataracts, small incision phacoemulsification with foldable intraocular lens implantation with either a biaxial or coaxial approach is recommended. For primary open-angle glaucoma, effective medical, laser, and incisional surgical approaches for lowering intraocular pressure are recommended. For DR, recommendations call for laser photocoagulation surgery for noncenter-involved DME and pan-retinal photocoagulation surgery for PDR.

Pharmaceutical options as first-line treatment for wet AMD and center-involved DME with vision loss include anti-VEGF agents. Anti-VEGFs have reduced the incidence of AMD-induced blindness by nearly 50% in some countries. Early detection and treatment are critical for optimizing outcomes with anti-VEGFs. The anti-VEGFs aflibercept, brolucizumab, and ranibizumab are approved by the FDA for use as intravitreal treatment of retinal problems to improve or maintain vision.

August 20, 2020

Novel Opthalmic Therapies in the Pipeline

Further innovations in treatment for eye disease are expected in the future. Understanding genetic components to therapy response will help individualize treatments for better results. Single nucleotide polymorphisms in genes may influence treatment response in wet AMD. Meanwhile, clinical trials are ongoing for current anti-VEGFs. CAN-TREAT is reviewing ranibizumab dosage and extended frequency for wet AMD. LUMINOUS is a 5-year outcomes-related trial of ranibizumab for wet AMD and other eye diseases. RIVAL compares aflibercept and ranibizumab with a treat-and-extend regimen for AMD. Several other new therapies for eye diseases are also in the pipeline.

There is growing concern regarding eye disease among older Americans. Early detection and treatment are critical. The use of effective therapies is important, beginning with helping patients to adhere to recommendations for screenings, eye examinations, and treatment. Such initiatives can improve outcomes for patients and reduce costs for the health care system. They also can improve quality measure outcomes and ratings for providers and practices. Just as population health executives are preparing for increases in the prevalence of health conditions such as cardiovascular disease, diabetes, and cancer among aging adults, executives must also consider the growing impact of eye disease and plan for the onset of an increasing clinical and economic burden from visual conditions as the population ages. Being prepared with strategies to manage these conditions will allow for optimization of resources and outcomes.