The long term effectiveness and cost‐effectiveness of initiating treatment for ocular hypertension

Gestel, Aukje van; Schouten, Jan S. A. G.; Beckers, Henny J. M.; Severens, Johan L.; Hendrikse, Fred; Webers, Carroll A.B.

doi:10.1111/aos.12328

Cited by 15 publications

(8 citation statements)

References 34 publications

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“…Furthermore, whilst a range of ‘theoretical’ implementation costs were examined in the sensitivity analysis of our model results, it was beyond scope to examine in detail the costs associated with implementing proposed practice; this clearly ought to be the subject of further research along with consideration of the thoughts on increased testing of patients and clinicians [ 23 , 57 ]. Consideration of innovative and affordable health service delivery redesign is likely to be a wider debate that needs to be addressed too, as has been recently suggested for people with ocular hypertension [ 58 , 59 ].…”

Section: Discussionmentioning

confidence: 99%

More frequent, more costly? Health economic modelling aspects of monitoring glaucoma patients in England

Boodhna

Crabb

2016

BMC Health Serv Res

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BackgroundChronic open angle glaucoma (COAG) is an age-related eye disease causing irreversible loss of visual field (VF). Health service delivery for COAG is challenging given the large number of diagnosed patients requiring lifelong periodic monitoring by hospital eye services. Yet frequent examination better determines disease worsening and speed of VF loss under treatment. We examine the cost-effectiveness of increasing frequency of VF examinations during follow-up using a health economic model.MethodsTwo different VF monitoring schemes defined as current practice (annual VF testing) and proposed practice (three VF tests per year in the first 2 years after diagnosis) were examined. A purpose written health economic Markov model is used to test the hypothesis that cost effectiveness improves by implementing proposed practice on groups of patients stratified by age and severity of COAG. Further, a new component of the model, estimating costs of visual impairment, was added. Results were derived from a simulated cohort of 10000 patients with quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) used as main outcome measures.ResultsAn ICER of £21,392 per QALY was derived for proposed practice improving to a value of £11,382 once savings for prevented visual impairment was added to the model. Proposed practice was more cost-effective in younger patients. Proposed practice for patients with advanced disease at diagnosis generated ICERs > £60,000 per QALY; these cases would likely be on the most intensive treatment pathway making clinical information on speed of VF loss redundant. Sensitivity analysis indicated results to be robust in relation to hypothetical willingness to pay threshold identified by national guidelines, although greatest uncertainty was allied to estimates of implementation and visual impairment costs.ConclusionIncreasing VF monitoring at the earliest stages of follow-up for COAG appears to be cost-effective depending on reasonable assumptions about implementation costs. Our health economic model highlights benefits of stratifying patients to more or less monitoring based on age and stage of disease at diagnosis; a prospective study is needed to prove these findings. Further, this works highlights gaps in knowledge about long term costs of visual impairment.

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Section: Discussionmentioning

confidence: 99%

More frequent, more costly? Health economic modelling aspects of monitoring glaucoma patients in England

Boodhna

Crabb

2016

BMC Health Serv Res

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“…As there is limited capacity in hospital eye-care services, we developed alternative pathways to test whether less-intensive monitoring would be a cost-effective option for a national health service. These alternative monitoring scenarios were developed in consultation with ophthalmologists, nurses, patients and the public8 and a recent economic evaluation in the Netherlands that suggested that a treating OHT irrespective of glaucoma risk was a cost-effective approach in a Dutch context 20. As neither of the extreme scenarios based on NICE were cost-effective compared with minimal glaucoma monitoring, it is unlikely that any other strategy consistent with NICE guidance would be cost-effective.…”

Section: Discussionmentioning

confidence: 99%

“…A similar evaluation was conducted in the Netherlands, investigating direct treatment initiation in OHT evaluated from a societal perspective with a lifetime horizon 20. Direct pressure-lowering treatment was less costly and more effective than a strategy of delaying treatment until early signs of glaucoma are apparent.…”

Section: Discussionmentioning

confidence: 99%

Monitoring ocular hypertension, how much and how often? A cost-effectiveness perspective

et al. 2015

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Objective: To assess the efficiency of alternative monitoring services for people with ocular hypertension (OHT), a glaucoma risk factor.Design: Discrete event simulation model comparing five alternative care pathways: treatment at OHT diagnosis with minimal monitoring; biennial monitoring (primary and secondary care) with treatment if baseline predicted 5-year glaucoma risk is ≥6%; monitoring and treatment aligned to National Institute for Health and Care Excellence (NICE) glaucoma guidance (conservative and intensive). Setting: UK health services perspectiveParticipants: Simulated cohort of 10,000 adults with ocular hypertension (Mean Intraocular Pressure (IOP) 24.9mmHg (SD 2.4). Main outcome measures:Costs, glaucoma detected, quality adjusted life years (QALYs).Results: Treating at diagnosis was the least costly and least effective in avoiding glaucoma and progression. Intensive monitoring following NICE guidance was most costly and effective. However, considering a wider cost-utility perspective, biennial monitoring was less costly and provided more QALYS than NICE pathways, but was unlikely to be cost-effective compared with treating at diagnosis (£86,717 per additional QALY gained). The findings were robust to risk thresholds for initiating monitoring but were sensitive to treatment threshold, NHS service costs and treatment adherence. Conclusions:For confirmed ocular hypertension, glaucoma monitoring more frequently than every two years is unlikely to be efficient. Primary treatment and minimal monitoring (assessing treatment responsiveness [IOP]) could be considered, however further data to refine glaucoma risk prediction models and value patient preferences for treatment are needed. Consideration to innovative and affordable service redesign focused on treatment responsiveness rather than more glaucoma testing is recommended. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 INTRODUCTIONAvoiding sight loss is a public health priority [1] but decisions have to be made in terms of how best to manage eye care across competing demands. In the UK, about 24,000 people are newly registered with sight loss each year (blind and partial sight) with glaucoma being second to macular degeneration as the leading cause. [2,3] Although ocular hypertension is the main and only modifiable risk factor for glaucoma [4,5] organising a monitoring programme to monitor intraocular pressure (IOP) and detect early glaucoma has the potential to overburden health care and patients. Choices have to be made.The UK National Institute for Health and Care Excellence (NICE) clinical guideline for glaucoma [6] recommends long-term monitoring of ocular hypertension in specialist (health care professional accredited in glaucoma) led service either in secondary care (consultant led hospital eye service) or primary care (community optometry) depending on loc...

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“…On the contrary, it was argued that analyses based on the cohorts of OHTS represent a relatively low-risk population. With a patient-level simulation model, van Gestel et al 39 suggested that an early treatment strategy is an advantage in a heterogeneous population of OHT patients. In addition, they also suggested that a 'watchful waiting' approach could be appropriate for the subgroup with a low conversion risk (10 % in 5 years), which agreed with the treatment strategy suggested by an expert panels (to treat a patient with >15 % conversion risk in 5 years).…”

Section: Screening and Treatment Of 'Pre-glaucomatous Status' Screenimentioning

confidence: 99%

Cost-effectiveness in the Treatment of Glaucoma

Chan¹,

Li²,

Tham³

2014

US Ophthalmic Review

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The cost-effectiveness of treating different types of glaucoma and ‘pre-glaucoma status’—namely ocular hypertension, primary angle closure suspect, and primary angle closure—were investigated by numerous studies. Overtreatment could lead to undesirable opportunity cost and unnecessary exposure to adverse effects for the patients; under-treating moderate to advance glaucoma could lead to preventable blindness. Despite being a leading cause of blindness, the need for a comprehensive glaucoma screening program and early intervention of pre-glaucoma status is questionable. Numerous reports have investigated the cost-effectiveness of treating ocular hypertension, primary open angle glaucoma, and normal tension glaucoma. The cost-effectiveness of different treatment modalities and their application at different stages of glaucoma were also discussed. To date, there is no cost-effectiveness analysis for the treatment of primary angle closure glaucoma. Some early reports also suggested that prophylactic treatment for primary angle closure and primary angle closure suspect might not be the most effective modalities.

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The long term effectiveness and cost‐effectiveness of initiating treatment for ocular hypertension

Cited by 15 publications

References 34 publications

More frequent, more costly? Health economic modelling aspects of monitoring glaucoma patients in England

More frequent, more costly? Health economic modelling aspects of monitoring glaucoma patients in England

Monitoring ocular hypertension, how much and how often? A cost-effectiveness perspective

Cost-effectiveness in the Treatment of Glaucoma

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