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The Macular Assessment Program 1 Note to MAP Participant … • The Executive Summary, slide 4-18, can be used as a stand-alone core group of slides if you wish. • The remainder of the deck expands on the ‘Perception vs Reality’ comparative data of the MAP participants. Add any of these slides to the Executive Summary to support or enhance the presentation. • In addition, there are ‘Supplementary Slides’ at the end that illustrate the national aggregate results for each question asked in MAP. 2 Macular Assessment Program The Results Agenda 1. Objective / Background 2. Executive Summary 3. The Prevalence of AMD in Canada 4. Perception vs Reality: Comparing the optometrists’ perceptions to the assessments’ reality 5. Weighing the Risk Factors: Identifying level of importance 6. Intervention and follow-up 7. Conclusions 3 Executive Summary 4 Macular Assessment Program Objective • The overall objective of the Macular Assessment Program (MAP) was to raise the awareness of risk for Age-related Macular Degeneration (AMD) and the need for screening certain individuals – Identified patients at risk for AMD – Illustrated the prevalence of the condition within participating optometrists’ practice 5 Macular Assessment Program Background • The Assessment was conducted during the months of February, March, and April of 2013. • 290 optometrists from across Canada participated: – BC; AB; SK; MN; ON; Qc; NB; NS; PE; NL • The number of patients assessed: 4,955 6 Macular Assessment Program Background • The collection of the data was strictly anonymous • No patient identifiers were collected • 3rd party was responsible for data collection and management of all aggregate reports. • The sponsor or its Sales Representatives have NO access to individual practitioner results 7 Profile of the Participants Optometrist Profile • 59% of optometrists indicated that they have been in practice for more than 10 years • 79% of optometrists indicated that they practice as a group, with approximately 3 optometrists in a group practice • 57% of optometrists have 10,000 patients or more in their practice, of which 41% have >15,000 patients o 27% of patients are over 65 o 12% of patients are over 75 8 Awareness of the Risk for AMD According to optometrists’ opinions: • Based on the responses collected in the Practice Profile questionnaire, optometrists believed that 26% of their patients were at risk of AMD (Slide 22) • However, during the AMD risk assessment, optometrists diagnosed 34% of the patients with dry AMD (Slide 23) Frequency of AMD Being Diagnosed (Slide 33) • 64% of patients assessed at high risk were later diagnosed with dry AMD (Assessed n=1,025 / diagnosed n=781) • 36% of patients assessed at moderate risk were later diagnosed with dry AMD (Assessed n=1,948 / diagnosed n=734) • 15% of patients assessed at low risk were diagnosed with dry AMD (Assessed n=1,985 / diagnosed n=314) 9 Predictive Risk Factors Associated with AMD Risk Factors for AMD • From the table below, significant risk factors were identified at three stages of the MAP: 1. 2. 3. Practice Profile: which risk factors the optometrists’ feel are most important Risk Assessment: which risk factors were most frequently associated with the patients’ assessed level of risk AMD Diagnosis: which risk factors were most frequently associated with those patients diagnosed with AMD Non-modifiable risk factors Age Family History Gender Eye Colour Ethnicity Modifiable risk factors Smoker Sun Exposure Healthy Diet Obesity Exercise High Blood Pressure High Cholesterol Cardiovascular Disease 10 Predictive Risk Factors Associated with AMD Practice Profile: • The Practice Profile questionnaire revealed optometrists consider the five most important risk factors for AMD as: Age Smoking Family History Sun Exposure Diet Risk Assessment: • The most significant risk factors that optometrists indicated while establishing their patients’ assessment of risk were: Age Family History High BP Smoking Sun Exposure AMD Diagnosis: (Slides 26/29) • The most significant risk factors that were associated with patients diagnosed with AMD were: Age Family History Activity Level Sun Exposure Eye Colour 11 Predictive Risk Factors Associated with AMD • The MAP findings suggest that the risk factors associated the with the AMD Diagnosed patients could be considered as a predictive model (Slides 36-43) • Overall, there was broad agreement: − Age and Family History were two of the most important factors • However, there were a few important differences: − Optometrists believed that Smoking was very important, but the AMD Diagnosed predictive model found it was the 8th most statistically significant variable − Optometrists believed Activity Level was of moderate importance, but the AMD Diagnosed predictive model found it to be the 3rd most statistically significant variable 12 Predictive Risk Factors Associated with AMD Top 10 Risk Factor Statistical Significance Ranking AMD Optometrists’ Risk Factor Risk Factor Diagnosed Assessment Age Age 1 1 Family History Family History 2 2 High Blood Pressure Activity Level 3 3 Smoking Sun Exposure 4 4 Sun Exposure Eye Color 5 5 Cardiovascular Disease Cardiovascular Disease 6 6 Activity Level High Blood Pressure 7 7 Eye Color Smoking 8 8 Ethnicity Diet 9 9 Diet BP Treatment 10 10 13 When Diagnosis of AMD is Determined • Optometrists reported that they consult with patients on the modifiable risk factors more than 70% of the time. • Consultation does not vary between Patients at risk of AMD and those diagnosed with AMD 58% Percentage of time Consulting 60% 47% 32% 31% 28% 27% 20% 12% 11% 0% Exercise Regularly Maintain a Healthy Weight Keep blood pressure controlled Patients With AMD Smoking Cessation Lessen exposure to sunlight, wear sunglasses and hats Patients At Risk 14 When Diagnosis of AMD is Determined • Following diagnosis in the AMD Risk Assessment, the following medications/supplements were prescribed to patients with AMD • PRN ™ Eye Omega Advantage • PRN ™ Macular Vitamin Benefit • Macula 2 ™ Essentials • Macula 2 ™ Omega-3 • Private Label/Generic Store brands • Referral for injectable medication 15 When Diagnosis of AMD is Determined Referring patients with AMD ‒ The percentage of ODs that refer a patient to an ophthalmologist or retina specialist increases by the stage of AMD 100% 59% 50% 32% 15% 0% Stage 1 Stage 2 Stage 3 ‒ The number of referred patients with stage 2 or stage 3 AMD is statistically higher than for stage 1 AMD 16 Patient Follow-up Follow-up period for patients with AMD • The percentage of Optometrists that schedule a follow up visit within 3-6 months increases by the stage of AMD • For stage 3 AMD patients, 44% of follow ups are within the next 6 months Follow-up period for patients at High Risk of AMD • The percentage of Optometrists that schedule a follow up visit within 6 months increases by level of risk for AMD • For patients with high risk of AMD, 61% of follow ups are between 6 to 12 months and just 11% are more than 12 months 17 MAP Summary • Optometrists perception of risk and prevalence of AMD in their practice is much lower than reality: • • • Optometrists were able, for the most part, to predict AMD. However, comparing the risk factors associated with their assessment of risk to the risk factors associated with the patients diagnosis with AMD, the weight of importance of the latter should be considered: • • ODs believe that 26% of their patients were at risk of AMD and 10% had AMD However, optometrists diagnosed 34% of the MAP patients with dry AMD The 5 most significant risk factors that were associated with patients diagnosed with AMD were: Age; Family History; Activity Level; Sun Exposure; Eye Colour It is not until a diagnosis of Stage 2 or 3 AMD is confirmed that the majority of optometrists refer patients to an ophthalmologist or retina specialist . Only 15% of MAP patients diagnosed with Stage 1 AMD were referred. • Vitalux® plus Omega-3 is the supplement most recommended for patients with dry AMD 18 The Prevalence of AMD in Canada 19 Aging Canadian Population • Proportion of older adults is increasing more rapidly than all other age groups1: – 2009: 1 in 7 was >65 (4.7 million) – 2036: 1 in 4 will be >65 (10.4 million) • Due to: – Lower birth rate2 – Longer life expectancy2 • With aging population expect increased incidence of AMD References: 1. Statistics Canada. An aging population. 2010. Available at: http://www.statcan.gc.ca/pub/11-402-x/2010000/chap/pop/pop02-eng.htm. Accessed February 29th, 2012. 2. Turcotte M, Schellenberg G. Portrait of Seniors in Canada 2006. Ottawa; Statistics Canada. Catalogue no. 89-519-XIE. February 2007. 20 AMD in Canada Estimated number of Canadians affected by AMD:3 Percentage (%) of Canadians with AMD Number of Canadians with AMD¶ 43-53 8.5 467,500 55-64 14.4 529,126 65-74 19.4 440,768 ≥75 36.8 748,512 Age (Years) Estimated Total 2,185,906 It is estimated that 78,000 new AMD patients and 10,000 new wet AMD will be diagnosed each year. ¶Extrapolated from Beaver Dam Eye Study 1988-19904 Population statistics for age groups <65: Statistics Canada 2006 Census; For age groups >65, Statistics Canada projections (medium growth), 2005. References: 8. Klein R, Klein BE, Linton KL. Prevalence of age-related maculopathy: The Beaver Dam Eye Study. Ophthalmology. 1992; 99: 933-943. 12. Somani S, Hoskin-Mott A, Mishra A, et al. Managing patients at risk for age-related macular degeneration: a Canadian strategy. Canadian Journal of Optometry. 2009: 71(2) 14-20. 21 Perception vs Reality: Optometrists’ perceptions vs the Assessments’ reality 22 AMD in Practice Practice Profile: Optometrists perceive that: • 26% of their patients are at risk of AMD and 10% already have AMD 30% Means of Responses 26% 25% 20% 15% 10% 10% 5% 0% At Risk of AMD Have AMD Response Options OD8 (Profile). Approximately what percentage of all of your patients do you think are at risk of AMD? What percentage currently have AMD? (n=290) 23 AMD in Practice Percentage of Patients with this condition Perception vs Reality • AMD Risk Assessment: approximately 20% of patients are at high risk of AMD and 34% have AMD 34% 35% 30% 26% 25% 20% 20% 15% 10% 10% 5% 0% At Risk of AMD AMD Risk Assessment OD8 (Profile). Approximately what percentage of all of your patients do you think are at risk of AMD? (n=290) Q15 (Assessment). Based on your assessment what do you feel is this patient’s level of risk for AMD? (n=4955) Q17 (Assessment). According to the AREDS Study, how would you classify this patient’s stage of AMD? (n=1662) Have AMD Practice Profile 24 Non-Modifiable Risk Factors Practice Profile: Optometrists perceive that: • Age (9.2) and family history of AMD (9.0) are the most important risk factors for AMD Ethnicity (7.2) and eye colour (7.1) are moderately important • Means of Responses 10 9.2 8 9.0 6.8 7.1 7.2 5 3 0 Age Family history of Gender Light Eye Colour AMD Response Options Ethnicity OD10 (Profile). On a scale of 1 (Not at all important) to 10 (Very important), how important are the following risk factors for AMD? (n=290) 25 Non-Modifiable Risk Factors Practice Profile: Optometrists perceive that: • Age (9.2) and family history of AMD (9.0) are the most important risk factors for AMD Ethnicity (7.2) and eye colour (7.1) are moderately important • Means of Responses • 10Although indicated as moderately important by the 9.2 9.0 optometrists, 56% and 88% of the MAP patients 7.2 8 diagnosed with AMD have6.8light eye7.1colour and are Caucasian 5 3 0 Age Family history of Gender Light Eye Colour AMD Response Options Ethnicity OD10 (Profile). On a scale of 1 (Not at all important) to 10 (Very important), how important are the following risk factors for AMD? (n=290) 26 Non-Modifiable Risk Factors In Patients Diagnosed With AMD Perception vs Reality • AMD Risk Assessment: Although indicated as moderately important by the optometrists, 56% and 88% of patients diagnosed with AMD have light eye colour and are Caucasian 9.2 10 9.0 88% 6.8 61% 50% 7.1 7.2 56% 47% 5 25% 0% 0 Age (>75) Famly History (Yes) Gender (Female) Patients Diagnosed With Dry AMD (Assessment) Eye Colour (Light) Ethnicity (Caucasian) Reported importance of factors Percentage of Patients with this condition 100% Perception of importance (Profile) OD10 (Profile). On a scale of 1 (Not at all important) to 10 (Very important), how important are the following risk factors for AMD? (n=290) Q2-Q6 (Assessment). Age, Family History, Gender, Eye Colour, Ethnicity (n=1662) 27 Modifiable Risk Factors Practice Profile: Optometrists perceive that: • Smoker (9.1), high sun exposure (8.4) and unhealthy diet (8.0) are the most important risk factors for AMD • Obesity (7.3) and cardiovascular disease (7.2) are moderately important 10.0 9.1 Means of Responses 8.4 8.0 7.3 7.5 7.0 7.0 7.0 7.2 Lack Of Exercise High blood pressure High Cholestrol Cardiovascular Diesease 5.0 2.5 0.0 Smoker High Sun Exposure Unhealthy diet Obesity Response Options OD10 (Profile). On a scale of 1 (Not at all important) to 10 (Very important), how important are the following risk factors for AMD? (n=290) 28 Modifiable Risk Factors Practice Profile: Optometrists perceive that: • Smoker (9.1), high sun exposure (8.4) and unhealthy diet (8.0) are the most important risk factors for AMD • Obesity (7.3) and cardiovascular disease (7.2) are moderately important Means of Responses •10.0Although smoking, high sun exposure, and an 9.1 8.0 unhealthy 8.4 diet were indicated as very important by 7.3 7.2 7.0 7.0 7.0 7.5 the optometrists, a large portion of MAP patients diagnosed with AMD are inactive, and have high 5.0 blood pressure and high cholesterol 2.5 0.0 Smoker High Sun Exposure Unhealthy diet Obesity Lack Of Exercise High blood pressure High Cholestrol Cardiovascular Diesease Response Options OD10 (Profile). On a scale of 1 (Not at all important) to 10 (Very important), how important are the following risk factors for AMD? (n=290) 29 Modifiable Risk Factors In Diagnosed Patients 100% 10 9.1 8.0 8.0 7.0 7.0 7.0 7.2 7.2 56% 50% 5 38% 39% 24% 11% 14% 8% Reported importance of factors Percentage of Patients with this condition Perception vs Reality • AMD Risk Assessment: Although viewed as moderately important, a large portion of MAP patients diagnosed with AMD are inactive, and have high blood pressure and high cholesterol. 3% 0% 0 Smoker (Current) Sun Exposure Unhealthy Diet (High) (Poor) Obesity (Obese) Lack of High Blood High Exercise (In- Pressure (yes) Cholesterol active) (Yes) Patients Diagnosed With Dry AMD (Assessment) History Of CVD (Yes) Perception of importance (Profile) OD10 (Profile). On a scale of 1 (Not at all important) to 10 (Very important), how important are the following risk factors for AMD? (n=290) Q7-Q14 (Assessment). Smoker, Sun Exposure, Healthy Diet, Obesity, Exercise, High Blood Pressure,, High Cholesterol, CVD (n=1662) 30 Smoking In Diagnosed Patients • Percentage of Patients with this condition • Practice Profile: smoking is perceived to be one of the most important factors AMD Risk Assessment: approximately 40% of patients are past and current smokers 100% 50% 30% 11% 0% Current Smoker Past Smoker Patients Diagnosed With Dry AMD (Assessment) OD10 (Profile). On a scale of 1 (Not at all important) to 10 (Very important), how important are the following risk factors for AMD? (n=290) Q7 (Assessment). Smoker (n=1662) 31 Tests To Diagnose AMD • Practice Profile: majority of optometrists indicated they diagnose patients for AMD by using dilated eye exam, retinal digital photography, visual acuity and Amsler grid • • AMD Risk Assessment: patients were diagnosed using similar tests. Perceived usage of these tests are significantly higher Percentage of Use 100% 99% 90% 90% 90% 90% 84% 76% 62% 50% 35% 21% 0% Dilated Eye Exam Retinal Digital Photography Optical coherence tomography Visual acuity AMD Risk Assessment Amsler grid 2% 1% -- -- Angiography Annidis 3% 8% Other Practice Profile OD11 (Profile). How do you diagnose patients for AMD? Select all that apply (n=290) Q16 (Assessment). Which test(s) will you utilize to establish an AMD diagnosis? Please select all that apply. (n=4955) 32 Weighing the Risk Factors: Identifying level of importance 33 Risk vs Diagnosis • • • 64% of patients assessed as High Risk were later diagnosed with AMD 36% of patients assessed as Moderate Risk were later diagnosed with AMD 15% of patients assessed as Low Risk were later diagnosed with AMD AMD Risk assessed vs Diagnosed 64% diagnosed with AMD 15% diagnosed with AMD 21% 40% Low Moderate 36% diagnosed with AMD 39% Q15 (Assessment). Based on your assessment what do you feel is this patient’s level of risk for AMD? (n=4955) Q17 (Assessment). According to the AREDS Study, how would you classify this patient’s stage of AMD (n=4955) High 34 Risk vs Diagnosis • • • High Risk: 1025 patients - 781 were later diagnosed with AMD Moderate Risk: 1948 patients - 734 were later diagnosed with AMD Low Risk: 1982 patients - 314 were later diagnosed with AMD Percentage Of Patients 50.0% Moderate Risk= 1948 patients (Diagnosed with AMD=734, Negative=1097, n/a=117) High Risk= 1025 patients (Diagnosed with AMD=781, Negative=228, n/a=15) 25.0% Low Risk= 1982 patients (Diagnosed with AMD=314, Negative=1428, n/a=240) 39.3% 40.0% Moderate Low 20.7% 0.0% High Response Options Q15 (Assessment). Based on your assessment what do you feel is this patient’s level of risk for AMD (n=4955) 35 Diagnosis Patients: AREDS Stage • • 1662 patients diagnosed with dry AMD, 167 patients with wet AMD ‒ 83% of patients with stage 3 are more than 75 years old ‒ 22% of patients with stage 3 AMD have family history ‒ 60% of patients with stage 2 AMD have light eye colour 2753 patients did not have AMD Percentage Of Patients 80.0% High Risk= 228 patients Negative= 2753 patients 55.6% 40.0% Moderate Risk= 1097 patients Low Risk= 1428 patients Stage1= 1128 patients 22.8% Stage2= 372 patients 7.5% 7.5% Stage3= 162 patients 3.3% 3.4% Stage 2 Stage 3 Wet AMD 0.0% n/a for this patient Negative Stage 1 Q17 (Assessment). According to the AREDS Study, how would you classify this patient’s stage of AMD (n=4955) 36 AMD Outcome Prediction Models • Using ‘multivariate logistic regression’ MAP bio-statisticians are analyzing the MAP findings to develop an AMD Outcome Prediction ‘Tool’ • All Risk Factors included in the AMD assessment questionnaire were considered as inputs for two Prediction models: 1. Model for Optometrist Assessment of AMD risk • Interprets how the optometrists’ used risk factors to assess AMD risk 2. Model for Dry and Wet AMD Diagnosis • Estimate the probability of AMD and the relative probability of the AREDS stages of AMD • In following slides AMD Diagnosis means Dry and Wet AMD 37 Outcome prediction models: Results • Both models identified a number of risk factors as significant in predicting patient outcomes with respect to AMD – 11 of 16 possible risk factors were included in the Optometrists Risk assessment model – 10 of 16 possible risk factors were included in the AMD diagnosis model (both outline on the next 2 slides) – The significant risk factors for each model were ranked according to statistical significance of impact (p-value) • The description for each significant attribute indicates the direction of impact on expected AMD outcome 38 Key Impact Risk Factors: Optometrists’ Assessment of Risk Prior to Diagnosis Optometrist Risk Assessment Model Rank Variable Description of Impact on AMD Risk P-Value 1 Age As age increases, risk of AMD increases <.001 2 Family History Patient's with family history of AMD have an increased risk for AMD <.001 3 Blood Pressure <.001 4 Smoking 5 Sun Exposure 6 Cardiovascular Disease 7 Activity Level High blood pressure is associated with an increased AMD risk Non-smokers (at least 10 years) are associated with a decreased risk for AMD Low sun exposure is associated with a decreased risk for AMD Diagnosis of cardiovascular disease is associated with an increased risk for AMD Active patients have a decreased risk for AMD 8 Eye Color Light eye color is associated with an increased risk of AMD <.001 9 Ethnicity Asian:Pacific ethncity is associated with a decrease risk of AMD <.01 10 Diet A healthy diet is associated with a decreased risk of AMD <.01 11 Weight Obese or overweight patients have an increased risk for AMD <.05 Cholesterol Gender <.001 <.001 <.001 <.001 Risk Factors that are not significant Cholesterol Treatment BP Treatment Cardiovascular disease treatment n = 3,012 (269 distinct physicians) Note: patients with “Moderate” risk scores were excluded from this model Note: This ranks the statistical importance of the risk factor and not the clinical importance. 39 Key Impact Risk Factors: AMD Diagnosis AMD Diagnosis Model Rank Variable Description of Impact on AMD Risk P-Value 1 Age As age increases, risk of AMD increases <.001 2 Family History Patient's with family history of AMD have an increased risk for AMD <.001 3 Activity Level Active patients have a decreased risk for AMD <.001 4 Sun Exposure Low sun exposure is associated with a decreased risk of AMD <.001 5 Eye Color Light eye color is associated with an increased risk of AMD <.001 6 Cardiovascular Disease Cardiovascular disease is associated with an increased risk for AMD <.01 7 Blood Pressure High blood pressure is associated with an increased AMD risk <.01 8 Smoking Non-Smokers are associated with a decreased risk for AMD <.05 9 Diet A healthy diet is associated with a decreased risk of AMD <.05 10 BP Treatment Patients on blood pressure treatment are at a decreased risk of AMD <.05 Cholesterol Gender Ethnicity Variables that are not significant Cholesterol treatment Weight Cardiovascular treatment n = 4,967 (276 distinct physicians) Note: This ranks the statistical importance of the risk factor and not the clinical importance 40 Model Result Comparison • The two models showed statistical agreement for the majority of risk factors (Model comparison table on next slide) • 3 risk factors showed notable differences between the models with respect to the significance ranking – The Optometrist Assessment model placed higher importance on the following risk factors than the AMD Diagnosis model: Smoking, high blood pressure – The Optometrist Assessment model placed lower importance on the following risk factors than the AMD Diagnosis model: Activity level 41 Model Comparison Risk Factor Age Family History Activity Level Sun Exposure Eye Color Cardiovascular Disease Blood Pressure Smoking Diet BP Treatment Ethnicity Weight Cholesterol Gender Cholesterol Treatment Cardiovascular treatment AMD Diagnosis 1 2 3 4 5 6 7 8 9 10 Not Significant Not Significant Not Significant Not Significant Not Significant Not Significant Model Optometrist Risk Assessment 1 2 7 5 8 6 3 4 10 Not significant 9 11 Not significant Not significant Not significant Not significant Yellow highlighting indicates notable variation between model outcomes. 42 Physician Risk Level vs. AMD Stage • To illustrate the proportion of diagnosed patients within the AREDS stages of AMD, patients are grouped according to optometrists’ assessed level of risk (Outlined on next slide) – Patients classified as high risk by physicians are fairly evenly spread out across the five diagnosis groups – A significant majority of patients classified as moderate risk by optometrists are in the negative or Stage 1 AMD diagnosis groups – Most of the patients classified as low risk by optometrists fall into the negative AMD diagnosis group 43 Optometrists Risk Level vs. AMD Diagnosis Optometrist Risk Assessment Negative AMD Diagnosis Stage 1: Early Dry AMD Stage 2: Stage 3: Intermediate Dry Advanced Dry AMD AMD Wet AMD High 24% 29% 21% 13% 13% Moderate 62% 28% 7% 1% 2% Low 84% 14% 1% 0.30% 0.45% Patients classified by Optometrists as: • High risk - are fairly evenly spread out across the five diagnosis groups • Moderate risk - majority are in the negative or Stage 1 AMD diagnosis groups • Low risk - most fall into the negative AMD diagnosis group n = 4,967 patients (276 distinct physicians) 44 Intervention and Follow-up 45 Supplements For Patients With AMD • AMD Risk Assessment: Vitalux® plus Omega-3 is recommended 44% of the time for patients diagnosed with dry AMD • PRN ™ Eye Omega Advantage • PRN ™ Macular Vitamin Benefit • Macula 2 ™ Essentials • Macula 2 ™ Omega-3 • Private Label/Generic Store brands • Referral for injectable medication Q18b (Assessment). Medications/Supplements (n=290) Q17 (Assessment). According to the AREDS Study, how would you classify this patient’s stage of AMD? (n=1662) 46 Additional Examinations/Test • More than half of the time doctors use/will use Dilated Eye Exam, Visual Acuity and Retinal Digital Photography tests Q18a (Assessment). Additional Examinations/Tests(n=290) Q17 (Assessment). According to the AREDS Study, how would you classify this patient’s stage of AMD? (n=1662) 47 Additional Examinations/Test • More than half of the time doctors use/will use Dilated Eye Exam, Visual Acuity and Retinal Digital Photography tests Dilated Eye Exam (Today) Dilated Eye Exam (In Future) Retinal Digital Photography (Today) Retinal Digital Photography (Future) OCT (Today) OCT (Future) Visual acuity (Today) Visual acuity (Future) Amsler grid (Today) Amsler grid (Future) Angiography (Today) Angiography (Future) Annidis (Today) Annidis (Future) Other 60% 70% Although Optical Coherence Tomography (OCT) 50% was used only 11% of the time in the diagnosis of AMD the 62% percentage of confirmed11%diagnosis was39%significant: 65% • Stage1 - 18% 70% • Stage2 - 28% 47% • Stage 3 - 27% 60% 1% • Wet AMD - 31% 6% 0% 0% 3% 0% 10% 20% 30% 40% 50% Q18a (Assessment). Additional Examinations/Tests(n=290) Q17 (Assessment). According to the AREDS Study, how would you classify this patient’s stage of AMD? (n=1662) 60% 70% 80% 48 Optometrists’ Consultation Percentage of time Consulting • Practice Profile: Optometrists reported that they consult with patients on the modifiable risk factors more than 70% of the time 98% 1 96% 90% 71% 74% 70% 0.5 0 Exercise Regularly Maintain a Healthy Weight Keep blood pressure controlled Practice Profile Smoking Cessation Lessen Perform Amsler exposure to grid tests at sunlight, wear home sunglasses and hats OD14 (Profile). How do you consult on the following modifiable risk factors issues (Exercise regularly, Maintain a healthy weight)? Select all that apply. (n=290) 49 Optometrists’ Consultation • • Optometrists approach to consulting on the Modifiable Risk factors does not vary between Patients at risk of AMD and those diagnosed with AMD Only the use of the Amsler grid at home is recommended significantly more often with Patients diagnosed with AMD 58% Percentage of time Consulting 60% 47% 37% 32% 31% 28% 25% 27% 20% 12%11% 2% 0% Exercise Regularly Maintain a Healthy Weight Keep blood pressure controlled Patients With AMD Smoking Cessation Lessen exposure Perform Amsler to sunlight, wear grid tests at sunglasses and home hats Patients Without AMD OD14 (Profile). How do you consult on the following modifiable risk factors issues (Exercise regularly, Maintain a healthy weight)? Select all that apply. (n=290) Q18C (Assessment). Lifestyle Modification (Exercise regularly, Maintain a healthy weight) (n=1662) 50 Consultation: I do not Discuss Modifiable Risk Factors that optometrists indicated they do not discuss: Maintaining a Healthy Weight; Keeping blood pressure controlled; and Exercising regularly Percent of Optometrists • 28% 26% 15% Maintaining a healthy weight Keeping blood pressure controlled Exercising regularly OD14 (Profile). How do you consult on the following modifiable risk factors issues? (n=290) 51 Other Ocular Diseases Discovered • Almost half of the patients with AMD have cataracts which is significantly higher than those patients without AMD ‒ Number of AMD patients who have retinopathy, dry eye disease and systemic disease is significantly higher than those without AMD 100% 50% 47% 29% 24% 6% 8% Retinopathy Glaucoma 12% 6% 0% n/a for this patient Cataract Patients With AMD 100% 50% Dry eye disease Systemic disease (diabetes, thyroid, cardio vascular disease) Other 46% 32% 13% 4% 5% Retinopathy Glaucoma 6% 7% 0% n/a for this patient Cataract Patients Without Dry eye disease Systemic disease (diabetes, thyroid, cardio vascular AMD disease) Q17 (Assessment). According to the AREDS Study, how would you classify this patient’s stage of AMD? (n=1662) Q19 (Assessment). Based on your Assessment, what other ocular diseases did you discover? Please select all that apply. (n=1662) Other 52 Referral To An Ophthalmologist • Optometrists indicated that 20% of the time they refer their patients to an Ophthalmologist for treatment of wet AMD or for AMD monitoring Percentage Of Patients 40% 20% 20% 18% 0% For treatment of Wet AMD For AMD monitoring Response Options OD15 (Profile). What percentage of your AMD patients has required a referral to an Opthomologist (n=290) 53 Referring Patients With AMD • • • • The percentage of referred patients goes up by the stage of AMD The number of referred patients with stage 2 or stage 3 AMD to an ophthalmologist or retina specialist is significantly higher than those for stage 1 AMD and patients without AMD 62% of the time optometrists refer patients with stage 3 AMD to an ophthalmologist or retina specialist Optometrists seldom refer any patients with AMD to a nutritionist 100% 59% 50% 32% 15% 0% Stage 1 Stage 2 Q17 (Assessment). According to the AREDS Study, how would you classify this patient’s stage of AMD? (n=1662) Q20 (Assessment). Will you be referring this patient? (n=1662) Stage 3 54 Follow Up: Patients With High Risk Of AMD • • The percentage of Optometrists that schedule a follow up visit within 6 months increases by level of risk for AMD For patients with high risk of AMD, 61% of follow ups are between 6 to 12 months and just 11% are more than 12 months 100% 61% 56% 45% 46% 50% 28% 22% 13% 3% 6% 11% 6% 4% 0% Low Less than 3 months Moderate 3 to 6 months 6 to12 months Q15 (Assessment). Based on your assessment what do you feel is this patient’s level of risk for AMD? (n=4955) Q21 (Assessment). When are you scheduling a follow-up visit with this patient? (n=1662) High More than 12 months 55 Follow Up: Patients Diagnosed with AMD • • The percentage of Optometrists that schedule a follow up visit within 3-6 months increases by the stage of AMD For stage 3 AMD patients, 44% of follow ups are within the next 6 months 100% 68% 59% 44% 47% 50% 33% 17% 12% 5% 4% 6% 3% 3% 0% Stage 1 Less than 3 months Stage 2 3 to 6 months 6 to12 months Stage 3 More than 12 months Q17 (Assessment). According to the AREDS Study, how would you classify this patient’s stage of AMD? (n=1662) Q21 (Assessment). When are you scheduling a follow-up visit with this patient? (n=1662) 56 Summary 57 MAP Conclusions Prevalence of AMD in Practice • Optometrists perceive that – 26% of their patients are at risk of AMD – 10% already have AMD • In reality – ~20% of patients are at high risk of AMD – 34% have AMD • Total Patients Assessed: 4,955 • Total Diagnosed with AMD: 1662 – Stage 1: 1,128 – Stage 2: 372 – Stage 3: 162 58 MAP Conclusions • Optometrists perceive that: – Age and Family History of AMD are the most important Non-Modifiable risk factors for AMD – Ethnicity and Eye Colour are moderately important • MAP patients diagnosed with AMD – 88% are Caucasian – 56% have light eye colour 59 MAP Conclusions • Optometrists perceive that the most important Modifiable risk factors for AMD are: – Smoking, – High Sun Exposure – Unhealthy Diet • However, a large portion of MAP patients diagnosed with AMD are – inactive, and – have high blood pressure and high cholesterol. 60 MAP Conclusions Top 10 Risk Factor Prevalence Ranking Risk Factor AMD Diagnosis Optometrists’ Assessment Risk Factor Age 1 1 Age Family History 2 2 Family History Activity Level 3 3 Blood Pressure Sun Exposure 4 4 Smoking Eye Color 5 5 Sun Exposure Cardiovascular Disease 6 6 Cardiovascular Disease Blood Pressure 7 7 Activity Level Smoking 8 8 Eye Color Diet 9 9 Ethnicity BP Treatment 10 10 Diet Scientific evidence points to chronic vascular disease, including cardiovascular disease, as a potential cause. Scientists believe that slow degradation of the blood vessels in the choroid, which provides blood to the retina, may lead to macular degeneration.5, 5. Vascular endothelial growth factor in eye diseasehttp://www.lef.org/magazine/mag2009/dec2009_Halt-The-Leading-Cause-of-Age-Related-Blindness_01.htm. 61 MAP Conclusions • Optometrists reported that they consult with patients on the modifiable risk factors more than 70% of the time. • However… a portion of optometrist also indicated that they ‘Do Not Discuss’ the following: – Maintaining a healthy weight - 28% – Keeping blood pressure controlled - 15% – Exercising regularly - 26% 62 MAP Conclusions • Top 5 Supplements recommended by Optometrists Supplement Vitalux plus Omega-3 Vitalux- S plus OMEGA-3 Vitalux AREDs Omega 3 Fish Oil – any brand Vitalux Healthy Eyes % of time recommended 44% 13% 10% 10% 9% 63 References References: Slide #19 1. Statistics Canada. An aging population. 2010. Available at: http://www.statcan.gc.ca/pub/11-402-x/2010000/chap/pop/pop02-eng.htm. Accessed February 29th, 2012. 2. Turcotte M, Schellenberg G. Portrait of Seniors in Canada 2006. Ottawa; Statistics Canada. Catalogue no. 89-519-XIE. February 2007. References: Slide #20 3. Somani S, Hoskin-Mott A, Mishra A, et al. Managing patients at risk for age-related macular degeneration: a Canadian strategy. Canadian Journal of Optometry. 2009: 71(2) 14-20. 4. Klein R, Klein BE, Linton KL. Prevalence of age-related maculopathy: The Beaver Dam Eye Study. Ophthalmology. 1992; 99: 933-943. References: Slide #60 5. Vascular endothelial growth factor in eye disease. http://www.lef.org/magazine/mag2009/dec2009_Halt-The-Leading-Cause-of-Age-RelatedBlindness_01.htm References: Slide #71 6. American Health Assistance Foundation (http://www.ahaf.org/macular/about/risk.html#risk) Speaker Notes/References: Slide # 24 • One third of adults over the age of 75 are affected by age-related macular degeneration* *American Health Assistance Foundation http://www.ahaf.org/macular/about/risk.html#risk • An individual is more likely to be affected by age-related macular degeneration if someone in his or her immediate family has been affected* *American Health Assistance Foundation http://www.ahaf.org/macular/about/risk.html#risk • Females are twice as likely as males to be affected by age-related macular degeneration Women’s Eye Health.org http://www.womenseyehealth.org/causes/amd.php • Individuals with light-colored eyes are more likely to be affected by dry age-related macular degeneration. This may be due to the fact that lightpigmented eyes offer less protection from damaging UV light. * *American Health Assistance Foundation http://www.ahaf.org/macular/about/risk.html#risk • Caucasians are more likely to be affected by age-related macular degeneration than other races. This may be due to differences in genetic background or pigmentation* *American Health Assistance Foundation http://www.ahaf.org/macular/about/risk.html#risk 64 References Speaker Notes/References: Slide # 27 • Smoking increases an individual’s chances of developing age-related macular degeneration by two to five-fold. Smoking causes oxidative damage, which is thought to contribute to the development and progression of this disease * * American Health Assistance Foundation http://www.ahaf.org/macular/about/risk.html#risk • Prolonged sun exposure enables ultra-violet (UV) light to damage retinal tissue directly, and can also lead to the accumulation of products that are harmful to the retina * * American Health Assistance Foundation http://www.ahaf.org/macular/about/risk.html#risk • A high fat diet, and/or one that is low in nutrients and antioxidants - Individuals with diets high in fat, cholesterol and sugar, and low in antioxidants are more likely to be affected by age-related macular degeneration. * * American Health Assistance Foundation http://www.ahaf.org/macular/about/risk.html#risk • Overweight individuals are more likely to be affected by age-related macular degeneration. An individual with a body mass index (BMI is a measure of body fat) of greater than 30 is 2.5 times more likely to be affected by age-related macular degeneration * * American Health Assistance Foundation http://www.ahaf.org/macular/about/risk.html#risk • In dry age-related macular degeneration, the retina does not receive adequate oxygen, leading to the death of cells in the macula. It is known that exercise improves cardiovascular health, and might prevent an individual from developing this disease. * * American Health Assistance Foundation http://www.ahaf.org/macular/about/risk.html#risk • Individuals with high blood pressure are more likely to be affected by age-related macular degeneration. High blood pressure, like smoking, leads to a constriction, or narrowing, of the blood vessels that nourish the retina, negatively affecting its health. * * American Health Assistance Foundation http://www.ahaf.org/macular/about/risk.html#risk • Cholesterol exists within the drusen. Researchers suggest that the formation of AMD lesions and their aftermath may be a pathological response to the retention of a subendothelial apolipoprotein B, similar to a widely accepted model of atherosclerotic coronary artery disease. As such, researchers have now found that bio-markers predictive of cardiovascular risk are risk factors for AMD. Live Extension http://www.lef.org/protocols/eye_ear/macular_degeneration_02.htm C-Reactive Protein and Homocysteine are Associated With Dietary and Behavioral Risk Factors for Age-Related Macular Degeneration (Seddon 2006) http://www.ncbi.nlm.nih.gov/pubmed/16530626 Vascular endothelial growth factor in eye disease. http://www.lef.org/magazine/mag2009/dec2009_Halt-The-Leading-Cause-of-Age-Related Blindness_01.htm • Scientific evidence points to chronic vascular disease, including cardiovascular disease, as a potential cause. Scientists believe that slow degradation of the blood vessels in the choroid, which provides blood to the retina, may lead to macular degeneration Vascular endothelial growth factor in eye disease. http://www.lef.org/magazine/mag2009/dec2009_Halt-The-Leading-Cause-of-Age-Related-Blindness_01.htm 65 Supplementary Slides 66 Appendix: Practice Profile 67 Years In Practice • Almost 6 out of 10 doctors indicated that they have been in practice for more than 10 years Percentage Of Responses 60% 42% 30% 26% 15% 17% 0% 1 to 5 5 to 10 10 to 15 Response Options More than 15 OD1 (Profile). How many years have you been in practice? (n=290) 68 Hours Of Practice Per Year • 93% of doctors indicated that they practice more than 1000 hrs per year Percentage Of Responses 70% 63% 35% 30% 6% 1% 0% <500 500 - 1,000 hrs 1,000 - 1,500 hrs Response Options > 1,500 hrs OD2 (Profile). How many hours do you practice per year? (n=290) 69 Group Or Solo Practice • Almost 80% of doctors indicated that they practice as a group • Optical chain • Corporate chain • Associate Percentage Of Responses 100% 79% 50% 19% 2% 0% Group Solo Response Options Other OD3 (Profile). Is your practice a group or solo practice? (n=290) 70 Number Of Doctors In Group Practice • On average, 3 optometrists are in a group practice Mean of Responses 5.0 3.4 2.5 0.0 Optometrists -- 0.1 0.1 General practitioner/family medicine doctors Ophthalmologists Other Response Options OD4 (Profile). If group, how many of the following doctors are in your practice? (n=290) 71 Number Of Support Staff • On average, there are 9 support staff who interact with patients in a doctor’s practice 10 Mean of Responses 8.5 5 0 Support Staff Mean Response Options OD5 (Profile). How many support staff, who interact with patients, are in your practice? (n=290) 72 Patient Volume • Doctors see a large number of active patients ─ 97% of doctors mention they see around 1000 patients or more in their practice Percentage Of Responses 50% 41% 25% 25% 15% 16% 3% 0% -<500 500 to 1,000 1,000 to 5,000 to 5,000 10,000 Response Options 10,000 to 15,000 >15,000 OD6 (Profile). Approximately how many active patients do you have in your practice? (n=290) 73 Patient Age • • Doctors state that 12% of their patients are over 75; One third of adults over the age of 75 are affected by age-related macular degeneration6 40% Means of Responses 33% 20% 19% 19% 17% 12% 0% Under 45 years 45 to 45 years 55 to 64 years 65 to 74 years 75 years old or old old old old older Response Options OD7 (Profile). What percentage of your patients fall in the following age ranges? (n=290) 6. (http://www.ahaf.org/macular/about/risk.html#risk) 74 Number Of Patients, Who Have AMD • In the practice profile, doctors believe that 26% of their patients are at risk of AMD and 10% already have AMD 30% Means of Responses 26% 15% 10% 0% At Risk of AMD Have AMD Response Options OD8 (Profile). Approximately what percentage of all of your patients do you think are at risk of AMD? What percentage currently have AMD? (n=290) 75 Equipment In Office • Most doctors have Amsler grid (99%) and Retinal Digital Photography (89%) equipment in their office • Foresee Percentage Of Responses 100% 99% 89% PHP • Frequency Doubling Technology (FDT) • Heidelberg Retinal Tomography (HRT) • Humphrey Visual Field Analyzer • Automated Visual Field Analyzer •Optos / Optomap • Visual fields / Full threshold Visual Fields 50% 32% 17% 1% 0% Retinal Digital Photography Optical coherence tomography (OCT) Amsler grid Angiography Other Response Options OD9 (Profile). Which of the following equipment do you have in your office? Please select all that apply. (n=290) 76 Non-Modifiable Risk Factors • • In the practice profile, doctors believe that Age (9.2) and family history of AMD (9.0) are the most important risk factors for AMD Ethnicity (7.2) and eye colour (7.2) are moderately important Means of Responses 10 9.2 9.0 6.8 7.2 7.2 5 0 Age Family history of Gender Light Eye Colour AMD Response Options Ethnicity OD10 (Profile). On a scale of 1 (Not at all important) to 10 (Very important), how important are the following risk factors for AMD? (n=290) 77 Modifiable Risk Factors • • In the practice profile, doctors believe that Smoker (9.1), high sun exposure (8.4) and unhealthy diet (8.0) are the most important modifiable risk factors for AMD Obesity (7.3) and cardiovascular disease (7.2) are moderately important Means of Responses 10.0 9.1 8.4 8.0 7.3 7.0 7.0 7.0 7.2 Obesity Lack Of Exercise High blood pressure High Cholestrol Cardiovascular Diesease 5.0 0.0 Smoker High Sun Exposure Unhealthy diet Response Options OD10 (Profile). On a scale of 1 (Not at all important) to 10 (Very important), how important are the following risk factors for AMD? (n=290) 78 Injectable Medications For Patients With AMD • • 65% of the time patients are treated with lucentis 35% of the time patients are treated with avastin 65% 35% Lucentis® Lucentis Avastin® Avastin -- -- Macugen® Macugen Other Other OD13 (Profile). When your patient is treated with injectable medication, what medication(s)is most often used? (n=290) 79 How Do You Consult On Maintaining A Healthy Weight? • Almost 70% of the time doctors discuss maintaining a healthy weight with their patients 67% 28% 11% 8% 3% 2% OD14 (Profile). How do you consult on the following modifiable risk factors issues? (n=290) 80 How Do You Consult On Keeping Blood Pressure Controlled? • 70% of the time doctors discuss keeping blood pressure controlled with their patients 70% 36% 15% 9% 2% -- OD14 (Profile). How do you consult on the following modifiable risk factors issues? (n=290) 81 How Do You Consult On Maintaining A Healthy Diet? • 96% of the time doctors discuss maintaining a healthy diet with their patients 96% 22% 4% 1% 3% 4% 2% OD14 (Profile). How do you consult on the following modifiable risk factors issues? (n=290) 82 How Do You Consult On Exercising Regularly? • 71% of the time doctors discuss exercising regularly with their patients 71% 26% 10% 2% -- OD14 (Profile). How do you consult on the following modifiable risk factors issues? (n=290) 83 How Do You Consult On Lessening exposure to sunlight, wear sunglasses and hats? • 96% of the time doctors discuss lessening exposure to sunlight, wear sunglasses and hats with their patients 96% 20% 3% -- 2% OD14 (Profile). How do you consult on the following modifiable risk factors issues? (n=290) 84 How Do You Consult On Performing Amsler grid tests at home? • • 90% of the time doctors discuss performing amsler grid tests at home Almost half of the time pamphlet are used to consult on modifiable risk factors 90% 48% 2% 2% OD14 (Profile). How do you consult on the following modifiable risk factors issues? (n=290) 85 Referral To An Ophthalmologist • Doctors indicates that 20% of the time they refer their patients for treatment of wet AMD or for AMD monitoring Percentage Of Patients 40% 20% 20% 18% 0% For treatment of Wet AMD For AMD monitoring OD15 (Profile). What percentage of your AMD patients has required a referral to an Opthomologist (n=290) 86 Appendix: AMD Risk Assessment 87 Last Visit 60% Percentage Of Patients 51% 30% 20% 13% 6% 10% 0% < 3 months ago 3 to 6 months 6 to 12 months 12 to 18 ago ago months ago Response Options >18 months Q1 (Assessment). When did you last see this patient? (n=4955) 88 Age 20% 16% Percentage Of Patients 15% 13% 12% 12% 11% 10% 10% 10% 0% 45 to 49 50 to 54 55 to 59 60 to 64 65 to 69 70 to 74 75 to 79 Response Options >=80 Q2 (Assessment). Age (n=4955) 89 Family History 100% Percentage Of Patients 77% 50% 23% 0% Yes No Response Options Q3 (Assessment). Family History (n=4955) 90 Gender Percentage Of Patients 80% 59% 41% 40% 0% Male Female Response Options Q4 (Assessment). Gender (n=4955) 91 Eye Colour 60% Percentage Of Patients 49% 29% 30% 22% 0% Light Medium Response Options Dark Q5 (Assessment). Eye Colour (n=4955) 92 Ethnicity 100% Percentage Of Patients 85% 50% 1% 1% 5% 3% 1% 2% 1% 0% Response Options Q6 (Assessment). Ethnicity (n=4955) 93 Smoker Percentage Of Patients 100% 62% 50% 20% 7% 4% 1% Current (1 Pack/day) Current (>1 Pack/day) 1% 2% 3% 0% Current (<1 Pack/day) Past: not Past: not Past: not Past: bit smoked for < smoked for 1 smoked for 5 smoked for > 1 year to 5 years to 10 years 10 years Never Response Options Q7 (Assessment). Smoker (n=4955) 94 Sun Exposure 60% Percentage Of Patients 53% 32% 30% 15% 0% High Moderate Response Options Low Q8 (Assessment). Sun Exposure (n=4955) 95 Healthy Diet 60% Percentage Of Patients 53% 39% 30% 8% 0% Yes Somewhat Response Options Poor Q9 (Assessment). Healthy Diet (n=4955) 96 Obesity 80% Percentage Of Patients 66% 40% 27% 4% 4% 0% Obese Overweight Normal Response Options Underweight Q10 (Assessment). Obesity (n=4955) 97 Exercise Percentage Of Patients 80% 52% 40% 30% 18% 0% Active Moderately Active Response Options In-Active Q11 (Assessment). Exercise (n=4955) 98 High Blood Pressure Percentage Of Patients 80% 55% 44% 40% 2% 0% Yes No Response Options Not available Q12 (Assessment). High Blood Pressure (n=4955) 99 High Cholesterol 80% Percentage Of Patients 66% 40% 32% 2% 0% Yes No Response Options Not available Q13 (Assessment). High Cholesterol (n=4955) 100 History Of Cardiovascular Disease 100% Percentage Of Patients 81% 50% 16% 3% 0% Yes No Response Options Not available Q14 (Assessment). History of Cardiovascular Disease (n=4955) 101 Recommendation For Healthy Diet • More than half of time doctors recommend eating a varied and nutritious diet that includes leafy green vegetables, and fruit, Percentage Of Patients 60% 54% 41% 30% 30% 17% 14% 0% None required at this time Required but not discussed Eat a varied and nutritious diet that includes leafy green vegetables, and fruit Eat fish (omega-3 fatty acids) Avoid saturated fats Response Options Q18d (Assessment). Healthy Diet (n=4955) 102