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The Macular Assessment Program

The Macular Assessment Program. The Executive Summary, slide 4-18, can be used as a stand-alone core group of slides if you wish.

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The Macular Assessment Program

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  1. The Macular Assessment Program

  2. 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. Note to MAP Participant …

  3. Macular Assessment Program The Results Agenda Objective / Background Executive Summary The Prevalence of AMD in Canada Perception vs Reality: Comparing the optometrists’ perceptions to the assessments’ reality Weighing the Risk Factors: Identifying level of importance Intervention and follow-up Conclusions

  4. Executive Summary

  5. 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

  6. 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

  7. 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

  8. 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 • 27% of patients are over 65 • 12% of patients are over 75

  9. 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 diagnosed34% 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)

  10. Predictive Risk FactorsAssociated with AMD Risk Factors for AMD • From the table below, significant risk factors were identified at three stages of the MAP: • 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

  11. Predictive Risk FactorsAssociated with AMD Practice Profile: • The Practice Profile questionnaire revealed optometrists consider the five most important risk factors for AMD as: Risk Assessment: • The most significant risk factors that optometrists indicated while establishing their patients’ assessment of risk were: AMD Diagnosis: (Slides 26/29) • The most significant risk factors that were associated with patients diagnosed with AMD were:

  12. Predictive Risk FactorsAssociated 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

  13. Predictive Risk FactorsAssociated with AMD

  14. 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

  15. When Diagnosis of AMD is Determined • PRN ™ Eye Omega Advantage • PRN ™ Macular Vitamin Benefit • Macula 2 ™ Essentials • Macula 2 ™ Omega-3 • Private Label/Generic Store brands • Referral for injectable medication Following diagnosis in the AMD Risk Assessment, the following medications/supplements were prescribed to patients with AMD

  16. 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 • The number of referred patients with stage 2 or stage 3 AMD is statistically higher than for stage 1 AMD

  17. 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

  18. MAP Summary • Optometrists perception of risk and prevalence of AMD in their practice is much lower than reality: • ODs believe that 26% of their patients were at riskof AMD and 10% had AMD • However, optometrists diagnosed 34%of the MAP patients with dry AMD • 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: • 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

  19. The Prevalenceof AMD in Canada

  20. 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.

  21. AMD in Canada Estimated number of Canadians affected by AMD:3 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: Klein R, Klein BE, Linton KL. Prevalence of age-related maculopathy: The Beaver Dam Eye Study. Ophthalmology. 1992; 99: 933-943. 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.

  22. Perception vs Reality:Optometrists’ perceptions vs the Assessments’ reality

  23. AMD in Practice • Practice Profile: Optometrists perceive that: • 26% of their patients are at risk of AMD and 10% already have AMD 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)

  24. AMD in Practice • Perception vs Reality • AMD Risk Assessment: approximately 20% ofpatientsare at high risk of AMD and 34%have AMD 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)

  25. Non-Modifiable Risk Factors • Practice Profile: Optometrists perceive that: • Age (9.2) and familyhistory of AMD (9.0) are the most important risk factors for AMD • Ethnicity (7.2) and eyecolour (7.1) are moderately important 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 • Practice Profile: Optometrists perceive that: • Age (9.2) and familyhistory of AMD (9.0) are the most important risk factors for AMD • Ethnicity (7.2) and eyecolour (7.1) are moderately important • Although indicated as moderately important by the optometrists, 56% and 88% of the MAP patients diagnosed with AMD have light eye colour and are Caucasian 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)

  27. 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 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)

  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 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 • 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 • Although smoking, high sun exposure, and an unhealthy diet were indicated as very important by the optometrists, a large portion of MAP patients diagnosed with AMD are inactive, andhave high blood pressure and high cholesterol 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)

  30. Modifiable Risk Factors In Diagnosed Patients • Perception vs Reality • AMD Risk Assessment: Although viewed as moderately important, a large portion of MAP patients diagnosed with AMD are inactive, andhave high blood pressure and high cholesterol. 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)

  31. Smoking In Diagnosed Patients • Practice Profile: smokingis perceived to be one of the most important factors • AMD Risk Assessment: approximately 40% of patients are past and current smokers 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)

  32. 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 andAmsler grid • AMD Risk Assessment: patients were diagnosed using similar tests. • Perceived usage of these tests are significantly higher 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)

  33. Weighing the Risk Factors:Identifying level of importance

  34. 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 64% diagnosed with AMD 15% diagnosed with AMD 36% diagnosed with AMD 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)

  35. 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 Q15 (Assessment). Based on your assessment what do you feel is this patient’s level of risk for AMD (n=4955)

  36. 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 High Risk= 228 patients Q17 (Assessment). According to the AREDS Study, how would you classify this patient’s stage of AMD (n=4955)

  37. 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: • Model for Optometrist Assessment of AMD risk • Interprets how the optometrists’ used risk factors to assess AMD risk • 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

  38. 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

  39. Key Impact Risk Factors: Optometrists’ Assessment of Risk Prior to Diagnosis 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.

  40. Key Impact Risk Factors: AMD Diagnosis n = 4,967 (276 distinct physicians) Note: This ranks the statistical importance of the risk factor and not the clinical importance

  41. 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

  42. Model Comparison Yellow highlighting indicates notable variation between model outcomes.

  43. 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

  44. Optometrists Risk Level vs. AMD Diagnosis • 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)

  45. Intervention and Follow-up

  46. 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)

  47. Additional Examinations/Test • More than half of the time doctorsuse/will useDilated 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)

  48. Additional Examinations/Test • More than half of the time doctorsuse/will useDilated Eye Exam, Visual Acuity and Retinal Digital Photography tests • Although Optical Coherence Tomography (OCT) was used only 11% of the time in the diagnosis of AMD the percentage of confirmed diagnosis was significant: • Stage1 - 18% • Stage2 - 28% • Stage 3 - 27% • Wet AMD - 31% 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)

  49. Optometrists’ Consultation • Practice Profile: Optometrists reported that they consult with patients on the modifiable risk factors more than 70% of the time 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)

  50. 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 25% 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)

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