VanderBeek Brian L, Scavelli Kurt, Yu Yinxi
Scheie Eye Institute, Department of Ophthalmology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Leonard Davis Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
Scheie Eye Institute, Department of Ophthalmology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
Ophthalmol Retina. 2020 Jan;4(1):41-48. doi: 10.1016/j.oret.2019.05.016. Epub 2019 May 25.
To assess how patient choices (out-of-pocket costs, insurance plan, geographic region) impact initiation of therapy for diabetic macular edema (DME).
Retrospective cohort study using administrative medical claims data from a large, national insurer.
All patients newly diagnosed with DME from 2013 through 2016 were observed for 90 days after diagnosis or until first treatment was received.
Multivariate logistic regression was used to create odds ratios comparing different baseline demographic and patient-related factors.
The primary outcome was the odds of receiving the different possible initial treatments for DME (anti-vascular endothelial growth factor [VEGF], focal laser treatment, steroids, or observation), no treatment, and not following up.
Of the 6220 newly diagnosed DME patients, 3010 (48.4%) underwent a follow-up examination within 90 days of diagnosis, and of those, 1453 patients (48.3%) received treatment in the observation window, including 614 (20.4%) with bevacizumab, 191 (6.3%) with ranibizumab or aflibercept, 560 (18.6%) with focal laser, 38 (1.3%) with steroid injection, and 50 (1.7%) with an injection of an unspecified drug. Having a copay (vs. $0) lowered the odds of receiving any treatment (odds ratio [OR] = 0.60; 95% confidence interval [CI], 0.51-0.71; P < 0.001) and of receiving each treatment individually (anti-VEGF treatment: OR = 0.72; 95% CI, 0.59-0.88; bevacizumab: OR = 0.73; 95% CI, 0.59-0.91; ranibizumab or aflibercept: OR, 0.70; 95% CI, 0.49-0.99; focal laser: OR = 0.44; 95% CI, 0.35-0.55; P < 0.001). Contrary to having a copay, having a high deductible and type of insurance plan were not associated with initiating treatment (P > 0.41 for all comparisons). Patients in the Northeast showed lower odds of initiating anti-VEGF treatment (OR = 0.60; 95%CI, 0.44-0.82; P < 0.001) and specifically bevacizumab (OR = 0.47; 95% CI, 0.33-0.67; P < 0.001). Furthermore, Northeast patients who were treated with anti-VEGF showed a higher odds of receiving ranibizumab or aflibercept compared with bevacizumab (OR = 2.39; 95% CI, 1.31-4.37; P < 0.001). Southern Midwest patients showed a higher odds of treatment (anti-VEGF: OR = 1.35; 95%CI, 1.02-1.77; P < 0.001; bevacizumab: OR = 1.40; 95% CI, 1.04-1.87; focal laser: OR = 1.39; 95% CI, 1.01-1.89; P < 0.001).
Patient choices such as copays and where they live are important factors in determining the initial choice of treatment for DME.
评估患者的选择（自付费用、保险计划、地理区域）如何影响糖尿病性黄斑水肿（DME）治疗的起始。
使用来自一家大型全国性保险公司的行政医疗理赔数据进行回顾性队列研究。
2013年至2016年新诊断为DME的所有患者在诊断后观察90天或直至接受首次治疗。
使用多变量逻辑回归来创建比值比，以比较不同的基线人口统计学和患者相关因素。
主要结局是接受DME不同可能初始治疗（抗血管内皮生长因子[VEGF]、局部激光治疗、类固醇或观察）、未治疗和未随访的几率。
在6220例新诊断的DME患者中，3010例（48.4%）在诊断后90天内接受了随访检查，其中1453例患者（48.3%）在观察期内接受了治疗，包括614例（20.4%）接受贝伐单抗治疗、191例（6.3%）接受雷珠单抗或阿柏西普治疗、560例（18.6%）接受局部激光治疗、38例（1.3%）接受类固醇注射以及50例（1.7%）接受未指明药物注射。有自付费用（相对于0美元）降低了接受任何治疗的几率（比值比[OR]=0.60；95%置信区间[CI]，0.51 - 0.71；P<0.001）以及单独接受每种治疗的几率（抗VEGF治疗：OR = 0.72；95%CI，0.59 - 0.88；贝伐单抗：OR = 0.73；95%CI，0.59 - 0.91；雷珠单抗或阿柏西普：OR，0.70；95%CI，0.49 - 0.99；局部激光：OR = 0.44；95%CI，0.35 - 0.55；P<0.001）。与有自付费用相反，高免赔额和保险计划类型与开始治疗无关（所有比较的P>0.41）。东北部的患者开始抗VEGF治疗的几率较低（OR = 0.60；95%CI，0.44 - 0.82；P<0.001），特别是贝伐单抗（OR = 0.47；95%CI，0.33 - 0.67；P<0.001）。此外，接受抗VEGF治疗的东北部患者接受雷珠单抗或阿柏西普的几率高于贝伐单抗（OR = 2.39；95%CI，1.31 - 4.37；P<0.001）。中西部南部的患者治疗几率较高（抗VEGF：OR = 1.35；95%CI，1.02 - 1.77；P<0.001；贝伐单抗：OR = 1.40；95%CI，1.04 - 1.87；局部激光：OR = 1.39；95%CI，1.01 - 1.89；P<0.001）。
患者的选择，如自付费用和居住地点，是决定DME初始治疗选择的重要因素。
