TY - JOUR
T1 - Geographic and Demographic Variation in Use of Ranibizumab Versus Bevacizumab for Neovascular Age-related Macular Degeneration in the United States
AU - Gower, Emily W.
AU - Stein, Joshua D.
AU - Shekhawat, Nakul S.
AU - Mikkilineni, Shravani
AU - Blachley, Taylor S.
AU - Pajewski, Nicholas M.
N1 - Funding Information:
Limitations of this study include those associated with analysis of administrative claims data. Misclassification owing to coding errors is possible but unlikely, given that diagnosis codes for common ophthalmic conditions, including AMD, correspond to actual clinical diagnoses listed in medical records with 97% accuracy. 52 Although we attempted to identify patients with newly diagnosed AMD, some beneficiaries may have had preexisting disease that was not captured. Given the visually disabling symptoms associated with neovascular AMD, we doubt that many affected patients would go for lengthy periods of time without visiting an eye care provider. 53 Finally, the range of our data only covers through 2009, and so our analyses do not address how treatment patterns have changed with the approval of aflibercept for the treatment of AMD. However, a US Government Accountability Office report noted that in 2013, among 75 new Medicare Part B drugs, ranibizumab and aflibercept (along with the osteoporosis drug denosumab) accounted for >50% of the $5.9 billion Medicare spent on new Part B drugs. 54 In addition, the average expenditure per beneficiary on ranibizumab was $9423, vs $9936 for aflibercept. Finally, recent data suggest that use of ranibizumab has declined while use of both bevacizumab and aflibercept has increased. 55 Therefore, the cost implications of the treatment of AMD likely have not changed drastically for Medicare, providers, and patients, suggesting that significant geographic and demographic variation is still likely to be present for these agents. Financial factors may also consciously or subconsciously influence a provider's decision to prescribe one medication over another; however, such data cannot be obtained and accounted for in our models. For example, CMS reimburses physicians 6% more than the average sales price for medication, which results in a nearly 3-fold higher profit margin for ranibizumab compared with bevacizumab ($95 vs $29). 15 Some physicians have been given incentives for high-volume purchase of ranibizumab, 56 which would further increase the profit difference between the 2 biologics. Our models also cannot account for increased costs associated with maintaining a stock of high-cost ranibizumab. For example, some practices purchase monitored refrigerators to ensure that someone is alerted in the event of a power failure. When these are used, a person must be on call at all times so as to address any potential power failures, and this can represent a significant cost to the physician's practice. Two large clinical trials have reported similar efficacy of bevacizumab and ranibizumab for treating AMD. 4,7 However, it remains unclear whether the safety of the 2 treatments is equivalent, since existing clinical trials have not had an adequate sample size for studying rare adverse events. Reports of serious ocular infection related to repackaging bevacizumab remain a concern. 57 Some meta-analyses have concluded that there is no clear indication of a differential risk of adverse events, while others have indicated increased risks associated with bevacizumab. 5,21,58 These meta-analyses also remain limited by relatively small sample sizes that prevent complete evaluation of the potential risks. If indeed there is a difference in the safety profile of these 2 drugs, it will be even more important to ensure that Medicare recipients have adequate access to both agents regardless of the community they reside in. A third anti-VEGF agent, aflibercept, became commercially available in 2011. In the future, analyses should be conducted to investigate how access to this latest biologic changes the use of the other 2 agents and how that varies across different communities. Unfortunately, it was infeasible for us to explore this in the present study. In this study, we identified significant geographic and demographic variation in use of ranibizumab vs bevacizumab for newly diagnosed neovascular AMD. Further investigation is needed to understand the factors underlying these differences and the extent to which they affect patient outcomes. Funding/Support: The Medicare claims data used in this manuscript were originally purchased through a research grant from Genentech (E.W.G.). Work was also supported in part by the National Eye Institute, National Institutes of Health, Bethesda, Maryland (1K23-EY019511 to J.D.S.) and a Physician Scientist Award from Research to Prevent Blindness, Inc, New York, New York (to J.D.S.). The sponsors or funding organizations had no role in the design or conduct of this research. Financial Disclosures: The following authors have no financial disclosures: Emily W. Gower, Joshua D. Stein, Nakul S. Shekhawat, Shravani Mikkilineni, Taylor S. Blachley, and Nicholas M. Pajewski. All authors attest that they meet the current ICMJE criteria for authorship.
Publisher Copyright:
© 2017 Elsevier Inc.
PY - 2017/12
Y1 - 2017/12
N2 - Purpose To examine demographic and geographic variation in the use of ranibizumab and bevacizumab for the treatment of neovascular age-related macular degeneration (AMD) among Medicare beneficiaries. Design Retrospective cohort study. Methods Using a 100% sample of Medicare claims data, we evaluated Medicare beneficiaries (N = 195 812) with an index claim for neovascular AMD between July 1, 2006, and June 30, 2009, to determine whether beneficiaries first received ranibizumab or bevacizumab following initial diagnosis. Results The overall proportion of beneficiaries that first received ranibizumab for neovascular AMD was 35%, and varied significantly (0.9%–84.6%) across the 306 US hospital referral regions (median = 33%, interquartile range = 17%–49%). Based on hierarchical logistic regression models, the likelihood of receiving ranibizumab declined over time (adjusted odds ratio (aOR) comparing treatment in 2009 vs 2006 = 0.39, P < .001). After we controlled for year of treatment, black beneficiaries were 45% less likely to receive ranibizumab compared to non-blacks (P < .0001). Beneficiaries residing in urban areas (aOR vs isolated rural towns = 1.12, P < .001), in zip codes with higher median incomes, and in the New England and East South Central census regions (aOR vs Pacific census region = 5.57, P < .001; aOR = 3.58, P < .001, respectively) had increased odds of receiving ranibizumab. Conclusions The odds of receiving bevacizumab vs ranibizumab as initial therapy for neovascular AMD among US Medicare beneficiaries varied substantially across geographic and demographic groups. Relatively fewer patients received ranibizumab for initial neovascular AMD treatment in 2009 vs 2006. Future research should study the drivers of variation in utilization of these interventions, the extent this variation indicates differential access to these agents, and whether treatment choice impacts patient outcomes.
AB - Purpose To examine demographic and geographic variation in the use of ranibizumab and bevacizumab for the treatment of neovascular age-related macular degeneration (AMD) among Medicare beneficiaries. Design Retrospective cohort study. Methods Using a 100% sample of Medicare claims data, we evaluated Medicare beneficiaries (N = 195 812) with an index claim for neovascular AMD between July 1, 2006, and June 30, 2009, to determine whether beneficiaries first received ranibizumab or bevacizumab following initial diagnosis. Results The overall proportion of beneficiaries that first received ranibizumab for neovascular AMD was 35%, and varied significantly (0.9%–84.6%) across the 306 US hospital referral regions (median = 33%, interquartile range = 17%–49%). Based on hierarchical logistic regression models, the likelihood of receiving ranibizumab declined over time (adjusted odds ratio (aOR) comparing treatment in 2009 vs 2006 = 0.39, P < .001). After we controlled for year of treatment, black beneficiaries were 45% less likely to receive ranibizumab compared to non-blacks (P < .0001). Beneficiaries residing in urban areas (aOR vs isolated rural towns = 1.12, P < .001), in zip codes with higher median incomes, and in the New England and East South Central census regions (aOR vs Pacific census region = 5.57, P < .001; aOR = 3.58, P < .001, respectively) had increased odds of receiving ranibizumab. Conclusions The odds of receiving bevacizumab vs ranibizumab as initial therapy for neovascular AMD among US Medicare beneficiaries varied substantially across geographic and demographic groups. Relatively fewer patients received ranibizumab for initial neovascular AMD treatment in 2009 vs 2006. Future research should study the drivers of variation in utilization of these interventions, the extent this variation indicates differential access to these agents, and whether treatment choice impacts patient outcomes.
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U2 - 10.1016/j.ajo.2017.10.010
DO - 10.1016/j.ajo.2017.10.010
M3 - Article
C2 - 29106914
AN - SCOPUS:85032949576
SN - 0002-9394
VL - 184
SP - 157
EP - 166
JO - American journal of ophthalmology
JF - American journal of ophthalmology
ER -