Author: S. James Talks (United Kingdom)
Co-authors: Vincent Daien, Tariq Aslam, Jane Barratt, Anna Biberger, Tien Yin Wong, Ceri Hirst
Purpose
Real-world evidence demonstrates that adherence to the recommended treatment regimens of anti vascular endothelial growth factor agents (anti-VEGFs) in retinal diseases such as neovascular age-related macular degeneration (nAMD) is suboptimal, particularly beyond 12 months’ treatment. Suboptimal adherence can result in poor treatment outcomes. A prior systematic review (Okada et al, Ophthalmology 2021;128:234–247) demonstrated that behavioral, environmental, and logistical barriers may impact patient adherence to treatment regimens. This study sought to further evaluate behavioral and environmental influences that may impact adherence (according to definitions previously specified [Okada et al, 11th COPHy EU Congress, 2020]) to recommended anti-VEGF regimens, specifically in patients with nAMD. The outputs from this study will be used to generate hypotheses for interventions to support improved adherence for patients with nAMD.
Setting/Venue
The study was conducted in three centers (in France, Germany, and the UK) to provide insights from a range of different healthcare settings. A qualitative study design was employed to understand the holistic reasons for patient-driven non-adherence to treatment. The first patient interview was conducted in October 2020.
Methods
Patients (up to 10 per country) were identified and recruited via participating clinicians. The goal was to recruit patients representing diverse treatment durations and personal circumstances. Clinicians completed a brief online survey for each patient regarding disease characteristics and co-morbidities, and the clinician’s perception of the patient’s anti VEGF treatment knowledge and ability to manage their disease. Individual in-depth semi-structured interviews with patients were conducted by phone. The patient interview included questions on the patient’s nAMD history, knowledge, attitude towards nAMD, and the relationship with the clinician. Transcripts of patient interviews were used to develop a coding system, specifying key themes and sub-themes, which was refined throughout the analysis phase. Patients also completed the National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) and a health status scale (0‒100).
Results
Fifteen patients were included in the interim analysis (mean age 77 years; France: n=5, Germany: n=4, UK: n=6; seven ‘fully adherent’, four ‘adherent’, and four ‘non-adherent’). A challenge in recruiting non-adherent patients was noted and recruitment targets were relaxed due to a disruption of usual services caused by the coronavirus pandemic. Site-related factors that supported adherence included transparent communication between the patient and specialist/practice team, sufficient time to fully inform the patient, consistency in the treating physicians and practice team over the course of the treatment, and additional healthcare professional support (such as a psychologist within the ophthalmologist department). Regular scheduled appointments such as consistent injection days, having the next two appointments planned, and sharing information about the next appointment with the patient’s accompanying person or as a calendar entry were also found to support adherence. Patient-related factors that supported adherence included history of nAMD in the family, an awareness of the disease and importance of treatment, a younger age (approximately 70 years), limited/no requirement for caregiver support, recent diagnosis and treatment initiation, and a good early response to treatment. Easy transport to and from appointments and accessible/adequate site parking were also identified as supporting adherence.
Conlusions
Published evidence has shown that the effective treatment of nAMD is hindered by poor adherence and persistence to recommended anti-VEGF treatment regimens. In this study, we determined that provision of information explaining that nAMD is a chronic disease requiring long-term treatment is key to supporting adherence. We found that treatment itself is not a driver of non-adherence (besides fear of getting a first injection). Access to transportation was a common issue for both adherent and non-adherent patients. Challenges in study recruitment, aside from those associated with the COVID-19 pandemic, suggests that non-adherent patients may have been reticent to participate due to perceived criticism of their behavior, or a desire not to complain about the service or perceived lack of treatment benefit. Understanding the drivers of low adherence to anti-VEGF treatment is the first step towards developing relevant and meaningful interventions to support improved adherence and outcomes for patients with nAMD.
Financial Disclosure
S. James Talks: Travel support: Bayer; Board member: Bayer, Novartis; Grants: Bayer, Novartis, Roche; Travel expenses: Bayer, Novartis. Vincent Daien: Consultant: Bayer, Novartis, Théa, Horus Pharma Tariq Aslam: Consultant: Novartis, Bayer, Laboratoires, Théa Pharmaceuticals, Bausch & Lomb, Oraya. Jane Barratt: Nothing to disclose. Anna Biberger: Employee: Kantar Health. Tien Yin Wong: Clinical trial grants: Allergan, Bayer, Boehringer-Ingelheim, Genentech, Merck, Novartis, Oxurion (formerly ThromboGenics), Roche, Samsung Bioepis, NMRC Singapore, Novartis Singapore; Consulting fees/travel support/review fees/consultant fees: Allergan, Bayer, Boehringer-Ingelheim, Genentech, Merck, Novartis, Oxurion (formerly ThromboGenics), Roche, Samsung Bioepis; Stock: Plano, EyRIS. Ceri Hirst: Employee: Bayer Consumer Care AG, Basel, Switzerland. Michelle Sylvanowicz: Employee: Bayer Consumer Care AG, Basel, Switzerland. Robert P. Finger: Grant: Novartis, CentreVue, Heidelberg Engineering, Zeiss; Consultant: Novartis, Bayer, Roche/Genentech, Ellex, Alimera, Allergan, Santhera, Inositec, Opthea; Support for travel: Novartis. Medical writing support was provided by ApotheCom, and funded by Bayer Consumer Care AG, Pharmaceuticals, Switzerland.
Comments
Important add below co-authors: 7. - Michelle Sylvanowicz: Bayer Consumer Care AG, Basel, Switzerland 8. - Robert P Finger: Department of Ophthalmology, University of Bonn, Germany
