Purpose
Diverse challenges exist in providing continuous anti-VEGF therapy in a Veteran Affairs (VA) hospital setting. This study was designed to study the utilization of anti-VEGF therapy and management trends for the treatment of neovascular age-related macular degeneration (AMD) at a regional VA Medical Center (VAMC) in an effort to improve the quality of AMD care in a selected veteran’s population.
Methods
This study was a prospective longitudinal cohort analysis of VA patients with neovascular AMD receiving anti-VEGF (ranibuzimab and aflibercept) injections at the West Los Angeles VAMC and followed for up to 1 year. Demographic and clinical data were gathered from the electronic health record. Healthcare utilization outcomes including number of injections per eye per year, number of OCT’s performed per patient per year, and rate of patients lost to follow-up were studied. Social limitations including concurrent mental health disease and commuting distance were also analyzed.
Results
There were 1551 anti-VEGF injections per year performed in the ophthalmology service for all diagnoses, and 53% of injections were given to treat AMD. A cohort of 116 consecutive AMD patients was evaluated with an average patient age of 81.1 years. 93% of patients were male. Mean number of injections per eye per year was 4.7. Mean number of OCTs performed per year was 3.3. Over 50% of patients were lost to follow-up. 4% of patients were lost to follow up due to death; causes included cardiopulmonary arrest and cerebrovascular accident. Average commuting distance from home to clinic was 92 miles (range 0-1200 miles) and was directly correlated with lack of follow-up. 68% of patients had a concurrent diagnosis of mental illness. Mental illness was not correlated to mean number of injections. Missed injection opportunities were not related to lack of access to specialist care.
Conclusions
In this regional Veteran population with neovascular AMD, healthcare utilization of anti-VEGF related resources was comparable to existing Medicare data. Unique barriers to optimal healthcare administration were the high rate of social and mental health limitations. Our data suggests that this regional VAMC provided sufficient clinical resources and patient access to treatment. However, social and mental health issues should be addressed to further optimize healthcare delivery in the Veteran population.