1
Andrew G. Iwach, M.D.Associate Clinical Professor
University of California, San FranciscoSan Francisco, California
Glaucoma Management:Changing Treatment Algorithms
• I have the following financial interests or relationships to disclose:
• Consultant– AcuMEMS– Alcon– Bausch & Lomb
Financial Disclosure
Flora Lum, M.D.AAO Policy Director, Quality of Care and Knowledge Base Development
William L. Rich III, MD, FACS
AAO Medical Director of Health Policy
Sue Vicchrilli, COT, OCSAAO Coding Executive
Cherie L. McNettAAO Director of Health Policy
Cathy CohenAAO Vice President, Governmental Affairs
Shan Lin, M.D.AAO Health Policy Committee
Patient Care Committee, American Glaucoma Society
Cynthia Mattox, M.D.AAO Health Policy Committee
Emmett Cunningham. Jr., M.D., PhD., MPHStanford University Faculty. Clarus Ventures
Industry Members
Acknowledgments
0.00
0.05
0.10
0.15
6 12 18 24 30 36 42 48 54 60 66 72 78 84
Primary POAG Endpoints*Log Rank P-value <0.001, Hazard Ratio 0.40, 95% CI (0.27, 0.59)
*through 8 Nov 2001
Pro
port
ion
PO
AG
Medication Observation
Months
2
Treatment vs. Observation
POAG = primary open-angle glaucoma; OHT = ocular hypertension.
1. Kass MA et al. Arch Ophthalmol. 2002;120:701-713.
0
10
20
30
40
50
60
70
OHT Over 5 Years1
Untreated Treated
Most Patients are Asymptomatic
Diagnostic Studies in Ophthalmology
Medicare data, courtesy of Dr. William L. Rich III
Managing the Odds
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Glaucoma: Managing the Odds
Medical Trends
IOP Lowering Medications: Retail Market
Thank you to Rick Halprin at Alcon recent data from IMS
IOP Lowering Medications: Retail Market
Thank you to Rick Halprin at Alcon recent data from IMS
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The Concept of PersistencyImpacting Factors
With economic issuesWith added side effects
With complicated dosing
IdealAfter human complacency/denial
0
10
2030
40
50
60
7080
90100
Per
sist
ent
Pat
ien
ts (
%)
3 mo 6 mo 9 mo 12 mo
Glaucoma & Ectropion
• 74 year old, Exfoliation Syndrome
• Meds: Simbrinza bid– Brinzolamide 1.0%
– Brimonidine Tartrate 0.2%
• Tearing, Lid Crusting, Discharge
• Lid Redness + Ectropion
• Diagnosis:
– ? Tear Duct Issue
– ? Drug Reaction
• Need for Surgery??
Glaucoma & Ectropion
Vijay Hegde, et al: Drug-Induced Ectropion: What Is Best Practice? Ophthalmology 2007;114:362–366
Sustained Release Travoprost (OTX-TP)
• Intended use:– Reduction of intraocular pressure in patients with
open-angle glaucoma or ocular hypertension
• Product design:– Non-invasive punctum plug formulation– Tailored drug release (2-3 months)– Visible for retention monitoring– Comfortable and absorbable
• Components:– Polyethylene glycol hydrogel– PLA microparticles– Travoprost ophthalmic solution– Fluorescein
16
Punctum plug size
Fluorescent plug observed under blue light
Ocular Therapeutix, Inc.
5
Sustained Release Travoprost (OTX-TP)
18
0
1
2
3
4
0 5 10 15 20 25 30
Hype
remi
a Sco
re (0
to 4)
Days
Hyperemian=24
Baseline
Error Bars = Standard deviation
0 = None 1 = Trace 2 = Mild 3 = Moderate 4 = Severe
*Data on file at Ocular Therapeutix
Surgical Trends
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Success: PerspectivesSurgeon vs. Patient
SurgeonPatient
Surgical Trends: 1994-2014
Medicare data, courtesy of Dr. William L. Rich III
iStents: 2007: 200/month 2014: 4000/month Total: 40,000+ in US so far
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Surgical Trends: Aqueous Shunts and Cyclophotocoagulation
Medicare data, courtesy of Dr. William L. Rich III
MicroPulse CP LaserAnterior Uveitis
• 72 y.o Vietnamese Male
• Pre-Op:
– 20/40
– IOP 27 mmHg, Max Meds
• Post-Op Day 1:
– IOP = 10, No Meds
– Light Perception
– Hyphema, Corneal Haze
• Meds: Durezol q 1 Hour
• Axial Length: 20.8 mm
Week 6: Hand Motion Vision
Non-Medical Trends Affecting Glaucoma Managment
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Newer Health Plans: Impact on Continuity of Care
• Older PPO Provider Networks are Only Available with Older Insurance Plans
• Older Insurance Plans have been …a) Discontinuedb) Significant Increase Premium Increase
• Remaining Older Insurance PPO Plans Closed to New Patients
• Newer “PPO” Panels are cheaper but have very restricted Provider Panels
• e.g. Blue Cross Pathway PPO and Pathway X PPO
• Insurance Companies Use Cost and Quality Metrics to Invite Provider to New Plans
• Annual Reassessment, Poor/Inconsistent Communication• Disruption of Continuity of Care
Impact on Glaucoma ManagementBig Data: Impact on Medical Care
ACA: Impact on Glaucoma Care Prescribing Patterns
http://projects.propublica.org/checkup/providers/search
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Prescribing Patterns
http://projects.propublica.org/checkup/providers/search
Propublica Partners with Yelp
Corporations: Customer SatisfactionDo you have an opinion?
ICD-9 / ICD-10 ComparisonsICD-9 ICD-10
Diagnosis Usage Inpatient and Outpatient
Inpatient and Outpatient
Number of Characters
3-5 Numeric/alphanumeric
3-7 Alphanumeric
Number of Codes~17,000 ~141,000
Chapters 17 21
ICD-10 Fundamentals
Of the 21 chapters in ICD-10, 10 involve diagnosis pertaining to eyes
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ICD-10 Fundamentals ICD-10 Fundamentals
ICD-10 Fundamentals Glaucoma Center of San Francisco
www.GlaucomaSF.com
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January 28Annual Gala
January 29New Horizons Forum
January 30Glaucoma Symposium
January 28 – 30, 2016San Francisco, CA
Celebrate Innovate Educate
Glaucoma Center of San Francisco
www.GlaucomaSF.com