Perspective

RVO patients at risk for loss to follow-up after anti-VEGF treatment

Twenty-five percent of patients with retinal vein occlusion did not return on schedule after receiving intravitreal injections.

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.

Jason Hsu, MD
Jason Hsu

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

Disclosure: Hsu reports he receives grants from Roche/Genentech and Santen, as well as grants and personal fees from Ophthotech.

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.

Jason Hsu, MD
Jason Hsu

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.

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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

Disclosure: Hsu reports he receives grants from Roche/Genentech and Santen, as well as grants and personal fees from Ophthotech.

    Perspective

    We congratulate Gao and colleagues on their study, which reports a 25.4% rate of loss to follow-up among patients treated between Jan. 1, 2012, and Jan. 1, 2017, with at least one intravitreal anti-VEGF injection at Wills Eye Hospital or the offices of Mid-Atlantic Retina for macular edema secondary to retinal vein occlusion (RVO). The true rate of loss to follow-up within their study population may be lower due to such limitations of the study design as the inability to account for patients who were followed elsewhere and to accurately account for patient deaths.

    Despite such limitations, the study points out an important potential barrier to optimizing visual outcomes associated with anti-VEGF treatment for macular edema associated with RVO. In the Study of COmparative Treatments for REtinal Vein Occlusion 2 (SCORE2), for example, among the 155 of 236 participants (66%) who completed a month 24 study visit and who, between months 12 and 24 of the study, were treated only with anti-VEGF therapy for macular edema due to central retinal vein occlusion (CRVO) or hemiretinal vein occlusion (HRVO), the mean number of anti-VEGF injections administered during the second year was greater than five. Overall, among the SCORE2 participants who completed a month 24 visit, the mean number of treatments (including any treatment, not just anti-VEGF therapy) administered during the second year was about four, but the number of treatments varied widely, from 0 to 13, over this 12-month span.

    The group of SCORE2 participants who received no treatment during the second year of follow-up demonstrated a marked decrease in visual acuity between months 12 and 24 compared with participants who received treatment during the second year. These SCORE2 results point out the importance of continued monitoring and individualized treatment to optimize visual acuity outcomes among patients with macular edema due to CRVO or HRVO. Thus, the high rate of loss to follow-up among patients with RVO treated with intravitreal anti-VEGF therapy reported by Gao and colleagues is concerning and highlights an important potential obstacle to optimizing visual acuity outcomes among patients with macular edema due to RVO.

    Ingrid U. Scott, MD, MPH

    Jack and Nancy Turner Professor of Ophthalmology
    Professor of Public Health Sciences at Penn State College of Medicine
    Hershey, Pennsylvania

    • Michael S. Ip, MD
    • OSN Retina/Vitreous Board Member

    Disclosures: Scott and Ip report no relevant financial disclosures.