Despite the proven benefits of anti-VEGF injections for patients with retinal vein occlusion, a retrospective review of billing codes showed one in four patients lost to follow-up after receiving an intravitreal injection.
Until recently, the follow-up rates of patients receiving anti-VEGF injections for retinal vein occlusion (RVO) were not considered, Jason Hsu, MD, study co-author, told Ocular Surgery News.
“These injections have proven benefits but often require ongoing monitoring and treatment. Our finding that about a quarter of patients with retinal vein occlusions who receive an injection do not return in a timely manner, if ever, is significant as poor compliance leads to a higher risk of long-term vision loss,” he said.
Loss to follow-up evaluated
The retrospective review analyzed billing codes from Jan. 1, 2012, to Jan. 1, 2017. Information from patient records, including ethnicity, gender, race, age, date of each office visit and date of each injection, was entered into an electronic database. The study authors defined loss to follow-up (LTFU) as a subsequent visit occurring more than 12 months after an intravitreal injection or no further visits occurring at least 12 months after an injection.
A total of 3,400 patients with RVO who underwent intravitreal anti-VEGF injections were included in the study. After an injection, 863 patients (25.4%) were LTFU. Of those, 789 patients had no further visits for more than 12 months after their last injection. Only 74 patients returned for further treatment after more than 1 year since their last injection.
“Patients who do not return for treatments risk further vision loss, which may be irrecoverable. It will be important to validate our findings in a larger data set, as such a large-scale loss to follow-up, if true, could portend increased societal costs due to the ramifications of lost productivity and potential increased costs of later care,” Hsu said.
Higher risks for certain subgroups
Hsu said potential risk factors for not following up include central RVO rather than branch RVO and poorer baseline visual acuity. African American and Hispanic patients were also at higher risk. Patients younger than 65 years of age had the highest LTFU rate of 31.4% while those between 65 and 80 years of age had the lowest LTFU rate of 22.1%.
“There really are a whole host of potential reasons for loss to follow-up, some of which we have to hypothesize, though some are based on feedback from my own patients. For example, many patients don’t feel comfortable driving after receiving an injection and therefore need family or friends to bring them for visits. Such issues with transportation may explain in part why those who live farther from the medical office were less likely to return,” he said.
Improving LTFU rates is a difficult issue. One hope is that targeted interventions, such as better education and reminder systems, can be implemented to improve follow-up rates, Hsu said.
“Implementing a tracking system for all patients receiving injections is critical,” Hsu said. “If a patient misses an appointment, our staff calls the patient directly. If we are unable to reach the patient, a letter is sent detailing the importance of follow-up and asking the patient to call for a return appointment. Text reminders would be another idea.”
Future drugs and drug delivery systems that require less frequent dosing could improve follow-up rates as well. – by Robert Linnehan
- Gao X, et al. Ophthalmic Surg Lasers Imaging Retina. 2019;doi:10.3928/23258160-20190301-05.
- For more information:
- Jason Hsu, MD, can be reached at Retina Service, Wills Eye Hospital, Mid-Atlantic Retina, Suite 1020, 840 Walnut St., Philadelphia, PA 19107; email: firstname.lastname@example.org.
Disclosure: Hsu reports he receives grants from Roche/Genentech and Santen, as well as grants and personal fees from Ophthotech.