Improving Ophthalmic Care Access and Treatment Among Aging Adults

The Aging of Americans

The number of individuals 65 years or older is continuously growing in the United States. This population is projected to account for 20% of Americans by 2030, and 24% by 2060. Advanced age is associated with an increased prevalence of multiple chronic conditions (MCC). According to an analysis of data from the Centers for Disease Control and Prevention’s (CDC’s) 2017 Behavioral Risk Factor Surveillance System (BRFSS), the prevalence of MCC (defined as the presence at least two of 12 chronic conditions listed on the survey) in the United States among those aged 45 to 64 ranged from 51% to 74%, depending on the state or U.S. territory of residence, and ranged from 69% to 86% among those 65 years or older, again depending on the state or U.S. territory of residence.

Across all states and territories, the prevalence of MCC among adults aged 65 or older was significantly higher than for those aged 18-44 (P <.05). Chronic conditions included on the BRFSS include arthritis, asthma, cancer, chronic obstructive pulmonary disease (COPD), depression, diabetes, heart disease, high blood pressure, high cholesterol, kidney disease, obesity and stroke. The high prevalence of MCC among individuals in the United States aged 65 years or older suggests that resource allocation for this patient population will continue to present challenges to both health care systems and payers.

Eye diseases are also prevalent among older adults. According to a pooled analysis of data from six large population-based studies (the Beaver Dam Eye Study, Baltimore Eye Survey and Salisbury Eye Evaluation Study, Proyecto VER and Los Angeles Latino Eye Study [LALES], and the Chinese American Eye Study [CHES]), the prevalence of visual impairment (defined as visual acuity better than 20/200 but less than 20/40) among those aged 40-49, 50-59, 60-69, 70-79, and 80 years or older in the United States was projected to be 0.13 million, 0.17 million, 0.59 million, 0.99 million, and 1.77 million, respectively, for the year 2020, and was projected to be 0.16 million, 0.21 million, 0.70 million, 1.43 million, and 4.44 million, respectively, by the year 2050. For blindness (defined as visual acuity of 20/200 or less), the projected prevalence by age group was projected to be 0.11 million, 0.14 million, 0.19 million, 0.21 million, and 0.47 million, respectively, for the year 2020 and was projected to increase to 0.13 million, 0.15 million, 0.23 million, 0.32 million, and 1.18 million, respectively, by the year 2050. As visual impairment and blindness can have deleterious effects on both physical and mental health, the impact on health care spending both currently and in the future is likely to be substantial.

Eye examinations are a focal point of many quality measures and related programs, such as the Healthcare Effectiveness Data and Information Set (HEDIS), which includes a performance measure for DR screening in individuals with diabetes aged 18 to 75 years. Providers and payers who begin considering such preventative care measures now and plan in advance for the needs of the aging population will be better prepared for optimal management and effective resource allocation in the future.

The Impact for Older Adults With Eye Disease

Eye disease can have an effect on activities of daily living (ADLs), such as dressing, bathing, toileting, hobbies, housekeeping, cooking, shopping and transportation. Poor vision is associated with a lower rate of medication adherence resulting from an inability to accurately read important information contained on product labeling. Other consequences may include emotional distress from vision loss, decreased social engagement, situational depression, loss of independence, physical inactivity, falls, injuries and an increased likelihood to be admitted to long-term care facilities (LTCFs). In addition, persons with visual impairment have higher morbidity and mortality rates compared with those in the overall population.

At the level of the health system and of society, eye disease among older adults carries financial implications. In a retrospective claims-based analysis of patients 40 years or older with visual disorders including visual impairment, blindness, AMD, cataracts, DR, primary open-angle glaucoma, and refractive errors (myopia and hyperopia). The total societal cost of eye disease for the year 2004 was estimated to be $35.4 billion (2004 USD). Components of this societal cost estimate included costs to the patient (both direct and indirect [productivity losses]) and costs to third-party payers (Medicaid and Medicare in this case).

Data from the 2001 MarketScan Commercial Claims and Encounters Database, the 2002 National Ambulatory Medical Care Survey, the 2002 National Hospital Ambulatory Medical Care Survey (outpatient department file), Medicare claims data from the year 2000 (physician, outpatient and inpatient hospital files), and data from the Consumer Assessment of Health Plans Survey from a nationally representative sample of 167,993 Medicare fee-for-service beneficiaries were all utilized. 

Of the $35.4 billion total paid by patients and third-party payers, $16.2 billion was attributable to direct medical costs (outpatient and pharmaceutical costs); $11.1 billion was attributable to direct nonmedical costs (nursing home care, guide dogs and federal programs for the visually impaired, including the Department of Education’s Independent Living Services for Older Blind Individuals, the American Printing House for the Blind, and the Library of Congress’ National Library Service for the Blind and Physically Handicapped); and the remaining $8.03 billion was attributable to work productivity losses. Of the $16.2 billion spent on outpatient and pharmaceutical costs, $6.8 billion was attributable to cataracts, $5.5 billion to refractive error, $2.9 billion to glaucoma, $575 million to AMD, and $493 million to DR. Of the $11 billion attributable to direct nonmedical costs, $10.96 billion was spent on nursing homes and long-term care, $62 million was spent on guide dogs, and $94 million was spent on federal programs for the visually impaired.

Table 1 provides a list of common eye diseases found in older adults and compares their anticipated prevalence increase from 2010 to 2050. The most common age-related eye diseases are cataracts, glaucoma, age-related macular degeneration (AMD), and diabetic retinopathy (DR).

Cataracts

Cataracts involve lens clouding and opacities that interfere with vision. Without surgery, the disease can progress to blindness. Globally, cataracts accounts for 47% of cases of blindness. However, low- and middle-income countries carry most of this burden and developed countries contribute far less. In less developed countries, cataracts accounts for 50% of blindness while it accounts for only 5% of blindness in higher income countries where surgery is much more accessible. Cataract rates increase substantially with age. According to an analysis of the 2002 Vision Health supplement of the National Health Interview Survey (NHIS) conducted by the CDC, the prevalence of cataracts among those aged 18-44, 45-54, 55-64, and 75 years or older was 0.5%, 2.7%, 9.3%, 31.0%, and 53.4%, respectively.

After adjusting for socioeconomic variables (age, sex, race/ethnicity, income level, and education status) and the presence of diabetes in multivariable logistic regression models, those in the 45-54, 55-64, 65-74, and 75 years or older age groups had 4.78, 17.04, 71.86, and 189.5 times greater odds of being diagnosed with cataracts compared with the age 18-44 age group, respectively, and these comparisons were all statistically significant (P <.05). According to the National Institutes of Health (NIH) National Eye Institute, 70% of white, 53% of black, and 61% Hispanic Americans will have developed cataracts by age 80. The number of Americans with cataracts is projected to double from 24.4 million in 2010 to approximately 50 million by 2050.

Glaucoma

Glaucoma is characterized by damage to or acquired atrophy of the optic nerve, causing vision impairment and ultimately, blindness. Primary open-angle glaucoma (POAG), which is chronic and slowly progressive, is the most common form of the disease. According to an analysis of the 2002 Vision Health supplement of the NHIS conducted by the CDC, the prevalence of glaucoma among those aged 18-44, 45-54, 55-64, and 75 or older years was 0.4%, 1.3%, 2.5%, 5.7%, and 10.3%, respectively. After adjusting for socioeconomic variables and the presence of diabetes in multivariable logistic regression models, those in the 45-54, 55-64, 65-74, and 75 years or older age groups had 3.5, 6.7, 14.6, and 29.28 times greater odds of being diagnosed with glaucoma compared with the age 18-44 age group, respectively, and these comparisons were all statistically significant (P <.05).

According to a retrospective chart review of nearly 1500 patients (mean age of 71 years) with glaucoma between July 2007 and July 2010 from Duke University’s Eye Center, 13% met criteria for legal blindness (best-corrected visual acuity of 20/200 or worse in both eyes or a constricted visual field of less than 20 degrees in both eyes), 24% met criteria for monocular vision (legal blindness in one eye), and 7% met criteria for being driving restricted (visual acuity worse than 20/50 in both eyes or a constricted field of vision less than 60 degrees in both eyes). According to the NIH National Eye Institute, glaucoma affected 2.7 million Americans in 2010, and that number is expected to more than double to 6.3 million by 2050 (Table 1).

Age-Related Macular Degeneration

AMD is a deterioration of the central portion of the retina, known as the macula, which is responsible for central visual acuity and color vision. The retina is located at the back of the eye and is responsible for sending images to the brain via the optic nerve. AMD can be categorized as either dry (ie, nonexudative or non-neovascular) or wet (ie, exudative or neovascular). Dry AMD is associated with drusen, which are yellowish lipid deposits in the retinal epithelium that contain pro-inflammatory factors and retinal atrophy (decreased retinal thickness). Wet AMD is characterized by formation of new blood vessels in the retinal tissue, which can cause fluid buildup and/or hemorrhage, leading to fibrosis (scarring).

According to an analysis of the 2002 Vision Health supplement of the NHIS conducted by the CDC, the prevalence of macular degeneration among those aged 18-44, 45-54, 55-64, and 75 years or older was 0.2%, 0.4%, 0.9%, 2.8%, and 8.7%, respectively. After adjusting for socioeconomic variables and the presence of diabetes in multivariable logistic regression models, those in the 45-54, 55-64, 65-74, and 75 years or older age groups had 2.14, 4.60, 15.97, and 51.30 times greater odds of being diagnosed with glaucoma compared to the age 18-44 age group, respectively, and these comparisons were all statistically significant (P <.05).

Wet AMD, which accounts for approximately 10%-15% of AMD cases, is responsible for 90% of AMD-associated severe vision loss. The prevalence of AMD is expected to grow from 2.07 million to 5.44 million cases between 2010 and 2050.

Diabetic Retinopathy

DR is characterized by damage to the microvasculature within the retina. It is broadly classified as nonproliferative (NPDR) or proliferative (PDR) based on the presence or absence of new blood vessel formation (neovascularization or angiogenesis).

NPDR is characterized by microaneurysms (vessel outpouching and leaks), lipid exudates, microhemorrhages, cotton-wool spots associated with nerve fiber damage, among other clinical findings. PDR is associated with angiogenesis (growth of new vessels into the retina), hemorrhages, and retinal detachment. PDR is considered a more severe stage of DR, as it is more likely to cause vision loss.

During advanced stages of DR, plasma can begin to leak out of retinal capillaries from a compromised blood-retinal barrier, leading to diabetic macular edema (DME), a severe complication of DR marked by swelling of the macula that can lead to severe vision loss. DME can develop without evident symptoms; therefore, early detection, timely treatment, and follow-up care are important to effectively treat DME and prevent blindness. The number of Americans with DR was estimated at 7.7 million in 2010 and is expected to reach more than 10 million by 2030 and 14.6 million by 2050.

A severity scale known as the Diabetic Retinopathy Severity Scale (DRSS) was developed in the 1990s by the Early Treatment Diabetic Retinopathy Study Research Group (ETDRS) sponsored by the National Eye Institute (NEI) and is still utilized today in research studies, but a more abbreviated version (the Diabetic Retinopathy Disease Severity Scale [DRDSS]) was recommended in 2002 for routine, practical management of patients. The DRSS requires the use of photography to grade DR and is based on a numeric scale with 13 cut-points for absence of DR (score of 10) to severe DR (score ≥81).36,37 Some of the cut-points on the DRSS are 35 for mild NPDR, 43 for moderate NPDR, 53 for severe NPDR, 61 for mild PDR, 65 for moderate PDR, and ≥81 for advanced PDR. On the DRDSS, there are five descriptive categories: no apparent retinopathy, mild NPDR, moderate NPDR, severe NPDR, and PDR.

In a retrospective administrative claims-based analysis of the 1997-2004 5% Medicare Beneficiary Encrypted Files (BEF), 33,735 patients with NPDR and 6,138 patients with PDR were identified (mean age 75 for both groups). Compared with patients with diabetes without DR (n = 178,383), average Medicare payments per patient for ophthalmic care (inpatient and outpatient) were significantly higher in both the NPDR and PDR groups (P <.001 for all comparisons). Specifically, ophthalmic care expenditures were $90 per patient in the non-DR group, $297 per patient in the NPDR group, and $1,223 per patient in the PDR group (all dollar values inflated to 2006 USD). As costs per patient were significantly higher in the PDR group compared to the NPDR, if progression from NPDR to PDR could be delayed or avoided altogether, perhaps Medicare expenditures could be decreased in this patient population.

Using data from the National Health and Nutrition Examination Survey (NHANES) 2005-2008, the prevalence of DR among those with diabetes aged 40 years or younger was estimated at approximately 29%. Using this same dataset, the prevalence of PDR and of DME among those with diabetes 40 years or older was 1.5% and 2.7%, respectively.

According to an analysis of the 2002 Vision Health supplement of the NHIS conducted by the CDC, the prevalence of DR among those with diabetes who were 18-44, 45-54, 55-64, and 75 or years older was 8.0%, 9.8%, 9.5%, 12.4%, and 9.2%, respectively. After adjusting for socioeconomic variables in multivariable logistic regression models, those in the 45-54, 55-64, 65-74, and 75 or older age groups had 19%, 22%, 49%, and 18% greater odds of being diagnosed with DR compared with the age 18-44 age group, respectively.

Eye Screenings and Treatment

Importance of Prophylactic Screening and Early Detection

Early detection and treatment can prevent vision loss and complications. In most cases, if the disease is identified and treated early, vision loss can be prevented. Because symptoms may not always be present at early stages, compliance with eye examination screenings may help avoid preventable vision loss. The AAO recommends that adults 65 years or older without eye disease risk factors should receive an examination by an ophthalmologist everyone to two years given the increased incidence of eye disease as individuals age. Adults with Type 1 diabetes should be examined by an ophthalmologist within five years of onset of the disease and then at least annually; those with Type 2 diabetes should be examined at diagnosis and then at least annually. Adults with acute or chronic disease may require eye examinations with frequencies ranging between hours and months, depending on the nature of the condition.

Eye Examination Adherence

Lack of ophthalmic monitoring and treatment can result in poor clinical outcomes, such as blindness; therefore, it is important to learn why patients do not always adhere to recommended eye examination schedules. Adherence to recommended examination schedules is low: approximately 50% of Americans with diabetes receive annual eye examinations, and the percentage among underserved and minority populations averages just 10% to 12%.44 Results from a 2015 cross-sectional study showed that 52.1% of patients with glaucoma (n = 121), 33.7% of those with AMD (n = 86), and 30.3% of those with DR (n = 33) failed to reschedule a missed appointment within a month of the recommended follow-up date. Most patients in the study were white (61.6%), privately insured (72.1%) and college educated (76.7%). The mean age of those with poor adherence was 70.5 years (SD = 14.3). Primary reasons for poor adherence to follow-up care involved a low level of understanding of the disease, legal blindness and difficulty taking time off from work. This issue of adherence to recommended eye examinations can be addressed in several ways, such as by increasing patient education and networking opportunities with fellow patients, offering affordable transportation services, improving clinical efficiencies, and increasing access to services remotely through telemedicine and similar means.

Treatment Recommendations

The American Academy of Ophthalmology recommends surgical procedures for cataracts, glaucoma, and DR, using the following specified procedures. For cataracts, small incision phacoemulsification with foldable intraocular lens implantation with either a biaxial or coaxial approach is recommended. For primary open-angle glaucoma, effective medical, laser, and incisional surgical approaches for lowering intraocular pressure are recommended. For DR, recommendations call for laser photocoagulation surgery for noncenter-involved DME and pan-retinal photocoagulation surgery for PDR.

Pharmaceutical options as first-line treatment for wet AMD and center-involved DME with vision loss include anti-VEGF agents. Anti-VEGFs have reduced the incidence of AMD-induced blindness by nearly 50% in some countries. Early detection and treatment are critical for optimizing outcomes with anti-VEGFs. The anti-VEGFs aflibercept, brolucizumab, and ranibizumab are approved by the FDA for use as intravitreal treatment of retinal problems to improve or maintain vision.

Further innovations in treatment for eye disease are expected in the future. Understanding genetic components to therapy response will help individualize treatments for better results. Single nucleotide polymorphisms in genes may influence treatment response in wet AMD. Meanwhile, clinical trials are ongoing for current anti-VEGFs. CAN-TREAT is reviewing ranibizumab dosage and extended frequency for wet AMD. LUMINOUS is a 5-year outcomes-related trial of ranibizumab for wet AMD and other eye diseases. RIVAL compares aflibercept and ranibizumab with a treat-and-extend regimen for AMD. Several other new therapies for eye diseases are also in the pipeline.

There is growing concern regarding eye disease among older Americans. Early detection and treatment are critical. The use of effective therapies is important, beginning with helping patients to adhere to recommendations for screenings, eye examinations, and treatment. Such initiatives can improve outcomes for patients and reduce costs for the health care system. They also can improve quality measure outcomes and ratings for providers and practices. Just as population health executives are preparing for increases in the prevalence of health conditions such as cardiovascular disease, diabetes, and cancer among aging adults, executives must also consider the growing impact of eye disease and plan for the onset of an increasing clinical and economic burden from visual conditions as the population ages. Being prepared with strategies to manage these conditions will allow for optimization of resources and outcomes.