Value-Based Medicine

Dry Eye Treatment: Is it Cost Effective?

By Melissa M. Brown, MD, MN, MBA

This month I would like to apply some of the key Value-Based Medicine principles and knowledge to an ocular problem that is evident to some degree in so many of our patients: dry eye syndrome. As you know, the problems and sequelae of dry eyes can be severe despite great attention and care. And many additional people experience symptoms that are mild yet interfere in daily activities. However, especially in light of issues such as healthcare reform and a much-publicized federal budget crisis, we must ask this question: Is treatment of dry eye cost effective?

The Return on Treatment

Patients with dry eye syndrome symptoms often have difficulty with tasks at all distances—such as reading and computer use, television viewing and driving. Sitting in closed areas of high air flow, such as cars or airplanes, or cold or windy weather conditions, can often cause discomfort, tearing and blurring of vision. These patients can fall between the cracks, often because more defined issues such as cataracts or glaucoma are the focus of our attention as care providers. However, the data surrounding dry eye syndrome are clear and illuminating.

Work done by Schiffman et al. reveals that the mean utility (as measured by time tradeoff methodology, or TTO) for mild dry eye is 0.81, for moderate dry eye is 0.78, and severe dry eye diminishes one's quality-of-life to a mean 0.72 utility.¹ To put that in perspective, further TTO utility work shows those measures to be similar to living with severe migraine headaches (0.82), ankylosing spondylitis (0.78), moderate-to-severe dyspnea (0.75), and hemodialysis (0.72).²

Put in this perspective, severe dry eye syndrome is a disabling disease that decreases quality of life to a high degree, much greater than that appreciated by physicians and the general community. Dry eye syndrome, however, is yet another ophthalmic problem for which treatment confers considerable improvement in quality of life. Various available treatments include topical tear replacements, punctal plugs, canalicular ligation, permanent punctal occlusion and topical cyclosporine, the latter administered to prevent the body's immune system from attacking the cells within the lids that produce the normal tear film.

When refractory disease is treated with cyclosporine, currently the only available prescription drug for dry eye syndrome, the mean utility rises to 0.97. Adverse events, such as burning, stinging, blurriness or redness, when experienced with treatment, generally reduce the overall mean utility improvement by up to 0.1 to 0.2.

Getting Down to the QALY

As many of you know now, total value gain is measured in quality-adjusted life-years (QALYs) and is determined by multiplying the years of utility gain by years of benefit duration. When we look at the total value gained from treatment referent to no treatment, the benefit incurred annually is approximately 0.05 QALY and thus estimated to improve quality of life by roughly 7%; the vehicle used in formulation of cyclosporine can improve quality of life by 4%.

This compares favorably with the value gained from beta-adrenergic blocker agents used for hypertension (6% to 9%) or commonly prescribed “statins” for the treatment of hyperlipidemias (4%). Once we calculate the comparative effectiveness of treatment, we integrate the associated costs of therapy, to obtain a cost-utility (cost-effectiveness) ratio of approximately $35,000/QALY using the third-party insurer cost perspective (direct medical costs only). Utilizing societal costs (caregiver costs, loss of employment, decreased salary, etc.), the cost-utility ratio is typically lower than with the third-party insurer cost perspective. For some interventions, the financial return to society can be much greater than the direct medical costs expended.

The third-party insurer cost-utility ratio for the utility of topical cyclosporine compares well with the commonly accepted standards of being “very cost-effective” when <$50,000/QALY. As the comparative and cost effectiveness of our medical treatments continue to be of increasing interest, let's remember that commonly used ocular treatments demonstrate great human and financial value to our patients and to society at large. Use of the various therapies for dry eye syndrome, including topical cyclosporine, can be critical tools to improve quality of life in patients with dry eye syndrome. OM

References

1. Schiffman, RM, et al. Utility Assessment among Patients with Dry Eye Disease. Ophthalmology 2003;110:1412-1419.
2. Brown, MM et al. Value-Based Medicine, Comparative Effectiveness, and Cost Effectiveness Analysis of Topical Cyclosporine for the Treatment of Dry Eye Syndrome, Arch Ophthalmol. 2009;127:146-152.

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Melissa M. Brown, MD, MN, MBA, is president and CEO of the Center for Value-Based Medicine in Philadelphia. She can be reached via e-mail at mbrown@valuebasedmedicine.com.