Variation in Ophthalmologist Use of Antivascular Endothelial Growth Factor Therapy Among Medicare Beneficiaries

Antivascular endothelial growth factor (anti-VEGF) drugs used for ophthalmic conditions account for more than $6 billion in Part B Medicare costs.¹ Recent research^2,3 has shown that bevacizumab may be equally as effective as the more-expensive agents (aflibercept and ranibizumab) for some but not all retinal vascular diseases. Using provider-level billing data for Medicare beneficiaries, we analyzed geographic trends in anti-VEGF therapy to identify whether the use of lower-cost drugs increased among ophthalmologists from calendar years 2012 to 2013.

After obtaining study exemption from the Rhode Island Hospital Institutional Review Board, we downloaded a publically available Medicare file.⁴ We deleted all names from the datasheet and then identified the number of ophthalmologists who billed for ranibizumab, bevacizumab, or aflibercept in calendar years 2012 and 2013 using Healthcare Common Procedure Coding System codes J2778, J9035, and J0178/Q2046. Ophthalmologists were categorized according to Dartmouth Atlas of Healthcare hospital referral regions,⁵ US Census regions,⁶ and 2006 rural-urban commuting area codes⁷ using physicians’ zip codes.

The most widely used anti-VEGF drug within each hospital referral region was mapped using ArcGIS (Esri) and χ² analyses were conducted to compare (1) the use of anti-VEGF drugs based on census region, urban/rural status, and year; and (2) the use of anti-VEGF drugs in 2013 vs 2012 based on census regions and urban/rural location. Pairwise regional comparisons were made (Northeast, Midwest, South, and West). All unique ophthalmologists billing for anti-VEGF drugs in either 2012 or 2013 were combined in the census region and urban/rural analyses.

The Figure shows the anti-VEGF drugs used by the greatest percentage of ophthalmologists within each hospital referral region. Overall, there was a difference in the use of anti-VEGF drugs by census region. In the Midwest, most ophthalmologists used aflibercept (423 [81.2%]) and ranibizumab (401 [77.0%]), while only 101 (19.4%) prescribed bevacizumab. In the West, 606 ophthalmologists (91.5%) used bevacizumab, 379 (57.3%) used aflibercept, and 347 (52.4%) prescribed ranibizumab. A similar proportion of ophthalmologists used the 3 drugs in the Northeast and South. There was also variation in drug use by urban/rural status. More urban ophthalmologists prescribed aflibercept (1772 [71.1%]) than ranibizumab (1680 [67.4%]) and bevacizumab (1590 [63.8%]). From 2012 to 2013, there was variation in anti-VEGF drug use overall. In 2012, a total of 1359 (57.0%) ophthalmologists prescribed aflibercept, which increased to 1835 (69.6%) in 2013. Ranibizumab use decreased slightly from 66.2% (n = 1580) to 61.8% (n = 1629) and bevacizumab use increased slightly from 60.8% (n = 1450) to 62.8% (n = 1656) of ophthalmologists (Table).

From 2012 to 2013, there was a change in bevacizumab use across census regions. In 2013, bevacizumab was used by 95 of 500 Midwestern ophthalmologists (19.0%) compared with only 43 of 434 of the prescribers (9.9%) in 2012. In the West, 573 of 635 ophthalmologists (90.2%) used bevacizumab in 2013 compared with 493 of 585 (84.3%) in 2012. Bevacizumab use decreased slightly in the Northeast (336 of 500 [67.2%] in 2012; 366 of 549 [66.7%] in 2013) and the South (572 of 856 [66.8%] in 2012; 613 of 935 [65.6%] in 2013). There were no significant changes in the use of ranibizumab or aflibercept based on census regions or for any of the drugs by urban/rural status across the 2-year period.

Using Medicare-released provider payment data, we found wide variation in the use of anti-VEGF drugs, with the proportion of ophthalmologists prescribing aflibercept increasing overall from 2012 to 2013. Several factors may explain this variation, including differences in state laws regulating compounding pharmacies, differences in the distribution of retinal vascular disease across the country, payor policies requiring the use of bevacizumab before switching to a costlier drug, differences in effectiveness of the drugs based on visual acuity, and the recent approval of aflibercept for ophthalmic conditions. Identifying factors that we can target to encourage the adoption of lower-cost, safe, and appropriate drugs may lead to billions of dollars in savings in health care costs.

Corresponding Author: Paul B. Greenberg, MD, Division of Ophthalmology, Alpert Medical School, Brown University, One Hoppin Street, Coro Center W, Ste 200, Providence, RI 02903 (paul_greenberg@brown.edu).

Published Online: June 30, 2016. doi:10.1001/jamaophthalmol.2016.2051.

Author Contributions: Dr Greenberg had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Thakore, French.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Thakore, Behrens, French.

Obtained funding: French.

Administrative, technical, or material support: Thakore, Behrens, French.

Study supervision: Greenberg, French.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: Dr French is supported by an unrestricted grant from Research to Prevent Blindness and the Department of Health and Human Services National Institutes of Health, National Eye Institute grant 1R21EY024050-01A1.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.