Focus on Glaucoma

Crunching the economic realities of glaucoma

Controversy surrounds the cost-effectiveness of therapy vs. surgery. Here’s a closer look at the numbers.

By Karen Blum

With the graying of America, the incidences of age-related eye diseases including glaucoma are predicted to rise. An estimated 3% of the global population over age 40 currently has glaucoma, the majority of whom are undiagnosed, according to a 2011 study,¹ and glaucoma prevalence worldwide is expected to reach nearly 80 million by the year 2020.

In the United States, open-angle glaucoma, one of the leading causes of blindness, affects an estimated 1.86% of the population (more than 2 million people) and is expected to affect 3.36 million people by the year 2020.

With pressures to control spiraling health-care costs, ophthalmologists and other physicians must work swiftly to determine the most cost-effective means of care — for monitoring patients, prescribing medications, performing surgery or a combination. But determining a course of action can depend on a variety of factors, including patient comfort, the severity of disease and patients’ ability to take medications.

ANALYZING MEDICARE’S COSTS

An eyedrop in the bucket

Glaucoma actually costs the US government less than one might think, according to a recent study of the Medicare fee-for-service population conducted by experts at Johns Hopkins’ Wilmer Eye Institute in Baltimore.³ In 2009, Medicare’s total glaucoma payments were $37.4 million for the study subset, for an overall estimated cost of $748 million, or 0.4% of $192 billion for all Medicare fee-for-service payments.

Elderly glaucoma patients often struggle with eyedrops, which can impact the efficacy and cost-effectiveness of treatment.

Office visits comprised about half of all glaucoma-related costs, diagnostic testing accounted for a third and surgical and laser procedures made up approximately 10% of costs. Less than 3% of patients with open-angle glaucoma underwent incisional surgery and about 5% had laser trabeculoplasty. Costs between 2002 and 2009 were stable, and cost per person per year decreased from $242 to $228.

“I bet the average person would be surprised to hear that it costs under $250 a year for Medicare to take care of glaucoma patients as eye doctors are now doing it, and that glaucoma care, even though it’s an extremely common problem, represents a smaller piece of the pie than you might have imagined,” says study director Harry Quigley, MD, professor of ophthalmology at Wilmer and director of its Glaucoma Center of Excellence.

FEW HIGH-COST PATIENTS

Only a small percentage of glaucoma patients ring up large amounts of health-care dollars, Dr. Quigley notes. A 2012 University of Michigan review⁴ of nearly 20,000 newly diagnosed open-angle glaucoma (OAG) patients in a large managed-care network found that the costliest 5% of enrollees were responsible for $10.2 million, or 24% of all glaucoma-related charges, whereas those whose costs fell within the lower two quartiles amassed only $7.9 million (19%) of charges.

Risk factors associated with the costliest recipients of glaucoma-related eye care were younger age, living in the northeastern United States, previous cataract surgery and a history of other eye conditions. “Understanding the characteristics of these individuals and finding ways to reduce disease burden and costs associated with their care can result in substantial cost savings,” the authors wrote.

Along with the direct medical costs such as IOP-lowering medications, physician and hospital visits, and glaucoma-related procedures, glaucoma can bring additional costs to patients for transportation, guide dogs or nursing home care, a 2011 study found.¹

Collateral costs of glaucoma

Some studies have shown that glaucoma and visual field loss are associated with other episodes of health-care utilization, like for the treatment of injuries, says David Rein, PhD, a research scientist at the National Opinion Research Center (NORC) at the University of Chicago, who specializes in health economics and outcomes.

“You would think people going blind would be bad drivers but actually those losing visual acuity tend to be safer drivers than the general population because they don’t drive as much, and when they do drive they go really, really slowly,” Dr. Rein says.

Yet that’s not true for people with glaucoma: “They don’t usually recognize their visual field loss so they’re more likely to get in accidents and more likely to have falls, especially among the elderly,” he says. “When they fall they can break a hip, so that can lead to a lot more health-care costs. It’s potentially worth spending a little more money on glaucoma prevention to help save systemic health care costs but we don’t know that for sure.”

COST-EFFECTIVE MEASURES

A case for screenings

Although the US Preventive Services Task Force has determined insufficient evidence exists to recommend for or against screening adults with no signs of vision problems for glaucoma, Dr. Rein and colleagues found in a 2009 study⁶ that routine glaucoma assessment and treatment can be highly cost effective.

Using a computer model, they simulated glaucoma incidence, natural progression, diagnosis and treatment among 20 million people from age 50 to death. The study found that evaluation and treatment reduced years of visual impairment and/or blindness for people with open-angle glaucoma, from 5.2 years to 2.6 when assuming a conservative effective treatment. At ages 75 to 70 — the peak age range for visual impairment and blindness among those in the study — treatment again halved the percentage of people with glaucoma and significant loss of vision, from 24.6% to 12.1%.

“This study concluded that evaluations to detect frank glaucoma followed by treatment for those in whom glaucoma is detected is definitely cost effective,” Dr. Rein says.

Early intervention eases burden

Adds Rohit Varma, MD, MPH, chair of ophthalmology and visual sciences at the University of Illinois Chicago College of Medicine, “Early identification and treatment of patients with glaucoma and those with ocular hypertension at high risk of developing vision loss may reduce the individual burden of disease on health-related quality of life and also may minimize personal and societal economic burdens.”

SURGERY VS. DROPS

The case for surgery early on

Once physicians make a diagnosis, should they manage patients with surgery or medications? Some studies have found surgery reduces medication-related costs, Dr. Varma says, and the earlier surgery is used, the less the overall cost of medication. “It’s important to work through treatment algorithms in a quicker manner than we do now, where some patients are left on drops for many years,” he says.

“The single most important thing is to very early on get a trajectory of the disease,” he adds. At the time of diagnosis, some glaucoma patients already have lost vision and will lose considerably more, while others may have more stable disease and not need immediate treatment. Regular visual fields can help evaluate peripheral and central vision and suggest patients’ prognoses.

Why medications get the nod

But medications tend to win out over surgery. “Not that many glaucoma patients merit having surgery because of the rapidity or progression of severity of disease, and physicians and patients jointly choose medical treatment over laser or surgery because they’re more comfortable with it or because they feel it’s more effective,” Dr. Quigley says.

Paul Lee, MD, JD, professor and chair of ophthalmology and visual sciences, and director of the University of Michigan’s Kellogg Eye Center in Ann Arbor, concurs. “If you talk to patients and give them options, many would still prefer to use medications because laser surgery is still surgery and so they view it that way,” he says.

A close call

Two studies from 2012 that compared glaucoma medications to laser trabeculoplasty head-to-head found both options to be cost effective. The first, from the University of Michigan,⁷ established a Markov model to compare the cost-effectiveness of treating newly diagnosed mild open-angle glaucoma with prostaglandin analogs (PGAs), laser trabeculoplasty (LTP) or observation only over a 25-year period. All patients started with mild glaucoma and averaged age 60.

During the study term, the long-term cost of LTP was $13,788 and the cost of PGAs was $18,101. “Assuming optimal medication adherence, generic PGAs confer greater value compared with LTP,” the authors said. “However, when assuming more realistic levels of medication adherence, at current prices for PGAs, LTP may be a more cost-effective alternative.”

Drug vs. SLT costs

A cost analysis from University of California San Francisco researchers⁸ compared the costs of bilateral selective laser trabeculoplasty (SLT), estimated at $675.76, to several topical and generic medications ranging in price from $17 to $107 a month, finding that SLT would become less costly than generic latanaprost after about 13 months.

SLT could be repeated as frequently as every 13 months and cost the same as treatment with generic latanaprost, but the authors noted that since a single SLT treatment can be effective for three to five years when used in addition to topical medication, SLT could be less expensive on the whole.

Spending on glaucoma medications in the United States increased significantly in the early 2000s, from a mean of $445 per person in 2001 to a mean of $557 in 2006, a 2011 study found.⁹ But costs should be shrinking, experts say. “It’s extremely likely that due to the onset of generic drugs in every major glaucoma eye drop category that drug costs probably have fallen” to half or a third of what it used to be, Dr. Quigley says, noting that brand-name prostaglandins, alpha-agonists and carbonic anhydrase inhibitors all have come off patent within the past five years.

EMERGING COST CONTROLLERS

IRIS registry analytics

On the horizon, new technology may help showcase the best practices when it comes to glaucoma and other eye conditions. The American Academy of Ophthalmology has launched its Intelligent Research in Sight (IRIS) registry, a collection and reporting software tool that amasses patient data directly from a practice’s EHR system. The goal is to enable ophthalmologists to statistically analyze their own care, compare it to care provided by their colleagues and highlight areas for improvement. The registry is due to go live in April.

“It’s a way of leveraging the expertise of ophthalmologists all over the country, or internationally, to figure out what works well, and what’s associated with complications so we can more rapidly figure out what’s going on and improve the care we deliver to patients,” Dr. Lee says.

Telemedicine may have a role

In addition, several groups around the world are looking at how to apply telemedicine to the glaucoma population, and it “will begin to pop up on people’s radar screens for actual use very shortly,” either for screening or for methods to take photographs or conduct visual field testing of glaucoma patients, Dr. Lee says.

As more practices join the IRIS registry and embrace telemedicine, the diagnosis and management of glaucoma should become even more cost effective, enabling ophthalmologists to initiate treatment or perform surgery earlier in the disease course. OM

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