Retina Docs Prescribe for Themselves, Patients Differently

Laird Harrison

August 11, 2014

SAN DIEGO — Retina specialists would treat exudative age-related macular degeneration differently in themselves than in their patients, a new survey shows.

"We're more likely to recommend bevacizumab for our patients than for ourselves, and we're more likely to choose a conservative treatment paradigm for ourselves than for our patients," said Jonathan Prenner, MD, an associate clinical professor of ophthalmology at Rutgers Robert Wood Johnson Medical School in New Brunswick, New Jersey.

Dr. Prenner presented the survey results here at the 32nd Annual Meeting of the American Society of Retina Specialists. They were published online May 22 in Retina.

To explore potential inconsistencies in prescribing, Dr. Prenner and his team identified 2 random samples of retina specialists from the American Society of Retina Specialist database. The groups were matched by age, sex, and geographic location.

Of the specialists surveyed, 226 responded, for a rate of 28.3%.

 
We're more likely to choose a conservative treatment paradigm for ourselves than for our patients.
 

All specialists were presented the case of a 70-year-old with 20/100 visual acuity in the left eye secondary to exudative age-related macular degeneration, minimally classic choroidal neovascularization on angiography, and subretinal fluid and cystoid macular edema on optical coherence tomography. The right eye demonstrated high-risk drusen.

One group of specialists was asked to recommend treatment for a hypothetical patient, and the other group was asked to recommend treatment if they themselves were the patient.

It was important to ask a different question to each group, Dr. Prenner explained. If the specialists had been asked both questions, the answer to one might have influenced the answer to the other.

The respondents were significantly more likely to prescribe bevacizumab to the patient than to themselves (= .011).

They were also significantly more likely to recommend a treat-and-extend approach for the patient than for themselves, and much less likely to inject on a monthly schedule (= .004).

Table. Treatment Recommendations

Recommendation For Patient, % For Specialist, %
Drug    
   Bevacizumab 52.2 32.7
   Ranibizumab 27.4 32.7
   Aflibercept 20.4 34.6
Dosing    
   Monthly 2.0 13.0
   As needed 25.0 24.0
   Treat and extend 73.0 63.0

 

The results differed significantly by geography as well. In the West, bevacizumab was more likely to be used and aflibercept was less likely to be used.

During his presentation, Dr. Prenner did not offer any reasons for the differences. "It will be interesting to talk about this at cocktail parties," he said.

However, in the published results, he and his colleagues speculate that economics could be a factor. They report that the annual cost is estimated to be up to $23,400 for ranibizumab, up to $14,800 for aflibercept (8 doses), and about $595 for bevacizumab.

Physicians are more likely to have extensive health insurance and the financial means to afford more expensive drugs, the researchers explain.

"In contrast, physicians may prefer treatment with ranibizumab or aflibercept because of the safety profile, US Food and Drug Administration approval status, and the ability to obtain the drug from sources other than a compounding pharmacy," they write.

The results are "intriguing," said session moderator Robert Avery MD, an ophthalmologist in Santa Barbara, California, who was not involved in the survey.

He noted that the number of respondents was relatively small, and wondered if the results could be explained by selection bias. "I wish there was a way of getting bigger numbers or asking the same doctors at different times," he told Medscape Medical News.

However, he acknowledged the role of economics. "In practice, it may not be viable to use the most expensive drug in every patient," he said.

Dr. Prenner reports financial relationships with Alcon, Genentech, Neurotech, Ophthotech, Panoptica, and Regeron. Dr. Avery reports financial relationships with Alcon, Alexion, Allergan, Bausch + Lomb, Genentech, I-Tech JV Development, Notal Vision, Novartis, Ophthotech, QLT, Regeneron, and Replenish.

32nd Annual Meeting of the American Society of Retina Specialists (ASRS). Presented August 9, 2014.

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