[Economic aspects of diabetic macular edema treatment at regional level in Russian Federation]. / Ékonomicheskie aspekty lecheniia diabeticheskogo makuliarnogo oteka na regional'nom urovne v Rossiiskoi Federatsii.

An assessment of economic burden of Diabetic Macular Edema (DME) in Russian Federation was conducted on the example of four pilot regions including Samara Region, Republic of Bashkortostan, Chuvash Republic and Yaroslavl Region. The assessment involved a newly developed interactive pharmacoeconomic model that uses data from questionnaire surveys of leading DME experts residing in the regions. In the course of the study, direct and indirect costs associated with DME were calculated. The highest direct costs of DME treatment were seen in the Republic of Bashkortostan - 302 482 RUB/year per patient. Direct cost of treating a single DME patient in the Samara Region was 34 271 RUB/year, in the Yaroslavl Region - 32 308 RUB/year and in the Chuvash Republic - 12 243 RUB/year. Indirect costs per DME patient in the Samara Region amounted to 67 530 RUB/year, in the Yaroslavl Region - 75 177 RUB/year, in the Republic of Bashkortostan - 102 884 RUB/year and in the Chuvash Republic - 81 082 RUB/year. Total annual costs per DME patient in the Samara Region was 101 801 RUB/year, in the Yaroslavl Region - 107 485 RUB/year, in the Republic of Bashkortostan - 405 366 RUB/year and in the Chuvash Republic - 93 325 RUB/year.

Use of Various Glaucoma Surgeries and Procedures in Medicare Beneficiaries from 1994 to 2012.

PURPOSE: Determine how procedural treatments for glaucoma have changed between 1994-2012. DESIGN: Retrospective, observational analysis. PARTICIPANTS: Medicare Part B beneficiaries. METHODS: We analyzed Medicare fee-for-service paid claims data between 1994-2012 to determine the number of surgical/laser procedures performed for glaucoma in the Medicare population each year. MAIN OUTCOME MEASURES: Number of glaucoma-related procedures performed. RESULTS: Trabeculectomies in eyes without previous scarring decreased 52% from 54 224 in 1994 to 25 758 in 2003, and a further 52% to 12 279 in 2012. Trabeculectomies in eyes with scarring ranged from 9054 to 13 604 between 1994-2003, but then decreased 48% from 11 018 to 5728 between 2003-2012. Mini-shunts done via an external approach (including ExPRESS [Alcon Inc, Fort Worth, TX]) increased 116% from 2718 in 2009 to 5870 in 2012. The number of aqueous shunts to the extraocular reservoir increased 231% from 2356 in 1994 to 7788 in 2003, and a further 54% to 12 021 in 2012. Total cyclophotocoagulation procedures increased 253% from 2582 in 1994 to 9106 in 2003, and a further 54% to 13 996 in 2012. Transscleral cyclophotocoagulations decreased 45% from 5978 to 3268 between 2005-2012; over the same period, the number of endoscopic cyclophotocoagulations (ECPs) increased 99% from 5383 to 10 728. From 2001 to 2005, the number of trabeculoplasties more than doubled from 75 647 in 2001 to 176 476 in 2005, but since 2005 the number of trabeculoplasties decreased 19% to 142 682 in 2012. The number of laser iridotomies was fairly consistent between 1994-2012, increasing 9% over this period and ranging from 63 773 to 85 426. Canaloplasties increased 1407% from 161 in 2007 to 2426 in 2012. Between 1994-2012, despite a 9% increase in beneficiaries, the total number of glaucoma procedures and the number of glaucoma procedures other than laser procedures decreased 16% and 31%, respectively. CONCLUSIONS: Despite the increase in beneficiaries, the number of glaucoma procedures performed decreased. Glaucoma procedures demonstrating a significant increase in use include canaloplasty, mini-shunts (external approach), aqueous shunt to extraocular reservoir, and ECP. Trabeculectomy use continued its long-term downward trend. The continued movement away from trabeculectomy and toward alternative intraocular pressure-lowering procedures highlights the need for well-designed clinical trials comparing these procedures.

The Relationship between Medicare Payment and Service Volume for Retina Procedures from 2005 through 2009.

PURPOSE: To calculate the relationship between Medicare payment and service volume for the 3 highest-volume retina procedures: intravitreal injection (Current Procedural Terminology [CPT] code 67028), laser treatment for retinal edema (CPT code 67210), and laser treatment for proliferative retinopathy (CPT code 67228). DESIGN: Retrospective, longitudinal database study. PARTICIPANTS: One hundred percent dataset of all retina procedures performed on Medicare Part B beneficiaries within the United States from 2005 through 2009. METHODS: Fixed-effects regression model using Medicare Part B carrier data for all 50 states and the District of Columbia, controlling for time-invariant carrier-specific characteristics, national trends in service volume, Medicare beneficiary population, number of ophthalmologists, and income per capita. MAIN OUTCOME MEASURES: Medicare payment-service volume elasticities, defined as the percent change in service volume per 1% change in Medicare payment, for intravitreal injection, laser treatment for retinal edema, and laser treatment for proliferative retinopathy. RESULTS: For all 3 retina procedures, the regression coefficients representing the Medicare payment-service volume elasticity were nonsignificant: intravitreal injection elasticity, -0.75 (95% confidence interval [CI], -1.62 to 0.13; P = 0.09); laser treatment for retinal edema elasticity, 0.14 (95% CI, -0.38 to 0.65; P = 0.59); and laser treatment for proliferative retinopathy elasticity, 0.05 (95% CI, -0.26 to 0.35; P = 0.77). CONCLUSIONS: This study found no evidence suggesting that there is an association between Medicare payment and service volume for the 3 highest-volume retina procedures from 2005 through 2009.

A Quantitative Analysis of the Relationship between Medicare Payment and Service Volume for Glaucoma Procedures from 2005 through 2009.

PURPOSE: To calculate the association between Medicare payment and service volume for 6 commonly performed glaucoma procedures. DESIGN: Retrospective, longitudinal database study. SUBJECTS: A 100% dataset of all glaucoma procedures performed on Medicare Part B beneficiaries within the United States from 2005 to 2009. METHODS: Fixed-effects regression model using Medicare Part B carrier data for all 50 states and the District of Columbia, controlling for time-invariant carrier-specific characteristics, national trends in glaucoma service volume, Medicare beneficiary population, number of ophthalmologists, and income per capita. MAIN OUTCOME MEASURES: Payment-volume elasticities, defined as the percent change in service volume per 1% change in Medicare payment, for laser trabeculoplasty (Current Procedural Terminology [CPT] code 65855), trabeculectomy without previous surgery (CPT code 66170), trabeculectomy with previous surgery (CPT code 66172), aqueous shunt to reservoir (CPT code 66180), laser iridotomy (CPT code 66761), and scleral reinforcement with graft (CPT code 67255). RESULTS: The payment-volume elasticity was nonsignificant for 4 of 6 procedures studied: laser trabeculoplasty (elasticity, -0.27; 95% confidence interval [CI], -1.31 to 0.77; P = 0.61), trabeculectomy without previous surgery (elasticity, -0.42; 95% CI, -0.85 to 0.01; P = 0.053), trabeculectomy with previous surgery (elasticity, -0.28; 95% CI, -0.83 to 0.28; P = 0.32), and aqueous shunt to reservoir (elasticity, -0.47; 95% CI, -3.32 to 2.37; P = 0.74). Two procedures yielded significant associations between Medicare payment and service volume. For laser iridotomy, the payment-volume elasticity was -1.06 (95% CI, -1.39 to -0.72; P < 0.001): for every 1% decrease in CPT code 66761 payment, laser iridotomy service volume increased by 1.06%. For scleral reinforcement with graft, the payment-volume elasticity was -2.92 (95% CI, -5.72 to -0.12; P = 0.041): for every 1% decrease in CPT code 67255 payment, scleral reinforcement with graft service volume increased by 2.92%. CONCLUSIONS: This study calculated the association between Medicare payment and service volume for 6 commonly performed glaucoma procedures and found varying magnitudes of payment-volume elasticities, suggesting that the volume response to changes in Medicare payments, if present, is not uniform across all Medicare procedures.

Change in diabetic panretinal photocoagulation incidence.

BACKGROUND AND OBJECTIVE: Diabetic blindness occurs most often among working-age people. Panretinal photocoagulation (PRP) can prevent this outcome. Administrative data examined changes in PRP incidence rates. PATIENTS AND METHODS: Anonymous data from the "claims submitted" files of an insurer with nationwide representation was used. This health insurance was a job benefit, and the sample included 6,085,750 U.S. employees and their dependents. Those who received PRP for diabetic retinopathy were compared to all others with diabetes mellitus. Although some enrollees had more than one PRP procedure, each procedure was considered a unique event. The rate change was evaluated by chi-square tests with post hoc tests for pair-wise comparisons. RESULTS: A total of 14,856 PRP procedures were performed. An incidence rate reduction from 0.95% to 0.67% (chi-square = 243.6818, P < .0001) was found within the study interval. CONCLUSION: The incidence of PRP was reduced in this sample of U.S. workers and their dependents.

National trends in surgical therapy for benign prostatic hyperplasia in the United States (2000-2008).

OBJECTIVE: To report an update of the change in usage trends for different surgical treatments of benign prostatic hyperplasia (BPH) among the United States Medicare population data from 2000-2008. The rate of usage of thermotherapy and laser therapy in the surgical treatment of BPH has been changing over the past decade in conjunction with a steady decrease of transurethral resection of the prostate (TURP). METHODS: Using the 100% Medicare carrier file for the years 2000-2008, we calculated counts and population-adjusted rates of BPH surgery. Rates of TURP, thermotherapy, and laser-using modalities were calculated and compared in relation to age, race, clinical setting, and reimbursement. RESULTS: After years of a steady rise, the total rate of all BPH procedures peaked in 2005 at 1078/100,000 and then declined by 15.4% to 912/100,000 in 2008. TURP rates continued to decline from 670 in 2000 to 351/100,000 in 2008. Rates of microwave thermoablation peaked in 2006 at 266/100,000 and then declined 26% in 2008. Laser vaporization almost completely replaced laser coagulation and in 2008 was the most commonly performed procedure second to TURP, with the majority performed as outpatient procedures (70%) and an increasing percentage in the office (12%). Men between ages 70 and 75 had the highest rate of procedures. Reimbursement rates correlate using some but not all procedures. Racial disparities reported previously appear to have resolved. CONCLUSION: Surgical treatment of BPH continues to change rapidly. TURP continues to decline and laser vaporization is the fastest growing modality. There is a big shift toward outpatient/office procedures. Reimbursement rates do not appear to have a consistent effect on usage.

Treatment patterns for neovascular age-related macular degeneration: analysis of 284 380 medicare beneficiaries.

PURPOSE: To examine trends in the treatment of newly diagnosed neovascular age-related macular degeneration (AMD). DESIGN: Retrospective cohort study. METHODS: Among 284 380 Medicare beneficiaries with a new diagnosis between 2006 and 2008, we used the cumulative incidence function to estimate procedure rates and the mean frequency function to estimate the cumulative mean number of intravitreous injections. We used Cox log-binomial regression to estimate predictors of the use of vascular endothelial growth factor (VEGF) antagonists within 1 year after diagnosis. Discontinuation of anti-VEGF therapy was defined by absence of treatment for 12 months. Discontinuation rates were calculated using the Kaplan-Meier method. RESULTS: The proportion of patients receiving anti-VEGF therapy increased from 60.3% to 72.7%, photodynamic therapy decreased from 12.8% to 5.3%, and thermal laser treatment decreased from 5.5% to 3.2%. Black patients (hazard ratio, 0.77; 95% confidence interval, 0.75-0.79) and patients of other/unknown race (0.83; 0.81-0.84) were less likely than white patients to receive anti-VEGF therapy. Patients with dementia were less likely to receive anti-VEGF therapy (0.88; 0.88-0.89). Among patients who received anti-VEGF therapy, the mean number of injections within 1 year of the first injection was 4.3 per treated eye. Anti-VEGF therapy was discontinued in 53.6% of eyes within 1 year, and in 61.7% of eyes within 18 months. CONCLUSIONS: Treatment of new neovascular AMD changed significantly between 2006 and 2008, most notably in the increasing use of anti-VEGF therapies. However, few patients treated with anti-VEGF medications received monthly injections, and discontinuation rates were high.

Resource use and costs associated with diabetic macular edema in elderly persons.

OBJECTIVE: To examine trends in resource use and the effect of incident diabetic macular edema (DME) on 1- and 3-year total direct medical costs in elderly patients. METHODS: We used a nationally representative 5% sample of Medicare beneficiaries from 2000 through 2004 to identify patients with incident DME and a control cohort of patients with diabetes mellitus but no history of retinal disease. We summed Medicare reimbursement amounts for all claims and applied generalized linear models to estimate the effect of DME on 1- and 3-year costs. We also examined the use of select imaging techniques and treatments. RESULTS: After adjusting for demographic characteristics and baseline comorbid conditions, DME was associated with 31% higher 1-year costs and 29% higher 3-year costs. There were significant shifts in the use of testing and treatment modalities. From 2000 to 2004, use of intravitreal injection increased from 1% to 13% of patients; use of optical coherence tomography increased from 2.5% to more than 40%. Use of laser photocoagulation decreased over time. CONCLUSIONS: After adjusting for demographic variables and baseline comorbid conditions, new-onset DME was a significant independent predictor of total medical costs after 1 and 3 years. Diagnostic and treatment modalities used for DME have changed significantly.

Problem-solving capacity for vitreoretinal diseases in a university health center.

PURPOSE: To evaluate the effectiveness of the tertiary care delivered to patients with vitreoretinal diseases in a defined urban population; to substantiate the planning and allocation of resources in order to improve the tertiary eye care delivery system in a specific area. METHODS: Data were collected from consecutive first-time patients between June 1, 2003 and July 31, 2004 in the Department of Ophthalmology, State University of Campinas, São Paulo, Brazil. Problem-solving capacity values were calculated for vitreoretinal surgery and photocoagulation. Data were entered into the Statistical Package for the Social Sciences (version 10.0). RESULTS: Of the 7500 patients referred to the Department, 641 were deemed suitable for analysis. The diagnoses analyzed were retinal detachment (26.0%), diabetic retinopathy (21.0%), and vitreous hemorrhage (7.7%). The median ages were 52, 59 and 57.5, respectively. Of all patients referred for retinal detachment, 26.5% were inoperable. The values obtained for the problem-solving capacity (PSC) showed that 38.1%, 33.0% and 93.5% of those eligible for an ophthalmic intervention (for retinal detachment, vitreous hemorrhage and diabetic retinopathy) had obtained treatment. The main reason for not giving treatment was the unavailability of operating room time and photocoagulation time (87.1%). CONCLUSIONS: This was the first study of tertiary eye care service performance in Latin America. Sight-threatening conditions such as retinal detachment and diabetic retinopathy are not thoroughly covered by the health system in this area. Various ways to reduce the problem are considered. The study has provided valuable information on planning high-complexity eye services in the population in question.

Incidence of exudative age-related macular degeneration among elderly Americans.

PURPOSE: To estimate the 3-year incidence of exudative age-related macular degeneration (AMD) and its treatment by laser photocoagulation in elderly Americans. DESIGN: Population-based cohort study using insurance claims data. PARTICIPANTS: A random 5% sample of Medicare beneficiaries, age 65 and older. METHODS: Incidence of exudative AMD and of laser photocoagulation for this condition was assessed based on four categories of ascertainment criteria that included procedure and diagnosis codes associated with exudative AMD, choroidal neovascularization, and its treatment. MAIN OUTCOME MEASURES: Incidence of AMD and of associated laser photocoagulation. RESULTS: Overall, the 3-year incidence of exudative AMD is estimated to be between 9.4 per 1000 and 11.4 per 1000 Americans age 65 and older (depending on ascertainment criteria), based on those diagnosed and treated by ophthalmologists for the condition. These estimates bracket the measured incidence of exudative AMD in the Beaver Dam Eye Study and lie within its 95% confidence interval. The 3-year incidence of exudative AMD with attendant laser photocoagulation was 2.3 per 1000. Women were found to have a slightly higher incidence of AMD than men using all ascertainment criteria (P < 0.001), and white Americans were found to have a fivefold-to-sixfold higher ascertainment criteria than black Americans (P < 0.001). CONCLUSIONS: The reported incidence of exudative AMD identified in the population of Medicare beneficiaries suggests that measurements on incidence for this condition derived from the Beaver Dam Eye Study can be generalized to the U.S. population.

Optical properties of native and coagulated human liver tissue and liver metastases in the near infrared range.

BACKGROUND AND OBJECTIVE: Knowledge about optical parameters and the resultant light distribution in laser-treated tissue is important for predicting the effects of laser-induced thermotherapy of liver metastases (LITT). MATERIALS AND METHODS: The absorption and scattering coefficients as well as the anisotropy factors and the optical penetration depths of human liver tissue and colorectal liver metastases were determined at 850, 980, and 1,064 nm under native and thermocoagulated conditions. RESULTS: Liver metastases had a lower anisotropy factor, absorption, and scattering coefficient than healthy liver (P < 0.01), resulting in a significantly higher optical penetration depth in metastatic tissue. Coagulation significantly changes the optical parameters by reducing the optical penetration depth in both tissue types (P < 0.01). CONCLUSIONS: A greater optical penetration depth in metastatic tissue is advantageous for LITT, since larger tumor volumes can be coagulated. At the same time, an adjustment of the application parameters during LITT is necessary to achieve optimal therapeutic success.

Evaluation of argon laser treatment of diabetic retinopathy and its diffusion in The Netherlands.

Argon laser treatment of diabetic retinopathy (DR) is the best evaluated case in the field of minimally invasive therapy. A well-organized randomized controlled trial was followed by formal cost-analyses and cost-effectiveness analyses. Laser treatment of DR proved to be cost-effective in a situation where there was no satisfactory treatment previously. Subsequently, screening strategies for retinopathy were developed. Systematic screening for DR in diabetic populations would be cost-saving from a societal perspective. The availability of effective and cost-effective therapy and cost-saving screening strategies for DR warrants active policy making to stimulate the implementation of strategies to control retinopathy in diabetic populations. Such strategies would ideally include both guided diffusion of argon lasers and the organization of screening programs. Data from the Netherlands are used to illustrate the diffusion of argon lasers in health care. After a slow start, argon lasers have diffused widely in the Dutch health care system. This development is complemented by recommendations for screening of the European diabetic population, which were issued in 1991. More active cooperation of all parties involved would benefit in preventing blindness from DR.