OBJECTIVES: The American Academy of Ophthalmology (AAO) recommends a baseline retinal examination within one year of hydroxychloroquine (HCQ) initiation due to irreversible HCQ-induced retinopathy. Little is known about adherence to the AAO guidelines in Medicare. We examined baseline retinal examination rate trends and associated factors among Medicare beneficiaries who newly initiated HCQ.

METHODS: A retrospective cohort study included data from a 5% national sample of Medicare beneficiaries who newly initiated HCQ from 2011-2015. The primary outcome was recipients of retinal exams (including dilated eye exam, Humphrey visual field test, or optional eye exams) within 3 months prior to or 13 months after initiating HCQ. We examined trend changes in annual retinal exam rates using Poisson regression. We used multivariable logistic regression to identify factors associated with recipients of baseline exams adjusting for sociodemographics, comorbidities (e.g., diabetes), and receiving any disease-specific laboratory tests within 6 months before initiating HCQ. Adjusted odds ratios (ORs) with 95% CI were reported.

RESULTS: Overall, 39.4% of the 3,771 new HCQ initiators received baseline retinal exams. Baseline exam rates increased from 32.9% in 2011 to 48.6% in 2014 (P_trend<0.0001). Beneficiaries receiving baseline exams were more likely to be older (mean age: 68.4±11.1 vs. 65.4±12.9) and have glaucoma (19.8% vs. 5.2%), compared to those not receiving exams (p<0.0001). African American beneficiaries (OR=0.77,95%CI=0.61-0.98) with low-income subsidy/dual Medicaid eligibility (OR=0.63,95%CI=0.45-0.89) were less likely to receive the exams. Beneficiaries with diabetes (OR=1.50,95%CI=1.28-1.76), glaucoma (OR=4.36,95%CI=3.45-5.52), and cataracts (OR=1.23,95%CI=1.01-1.49) were more likely to receive exams.

CONCLUSIONS: Although the trend of receiving baseline retinal exams significantly increased from 2011 to 2014, >50% of Medicare beneficiaries initiating HCQ did not receive any recommended retinal exam. There are needs to be more adherence to the AAO guideline for retinal screening for patients initiating HCQ, particularly among individuals with dual eligibility for Medicaid or low-income subsidy.