• Journal Highlights

    American Journal of Ophthalmology

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    Predictors and Short-term Costs of Laser Trabeculoplasty vs. Medication in OAG

    August 2016

    Laser trabeculoplasty (LT) has been posited as a way to reduce glaucoma treatment costs and medication nonad­herence. Schultz et al. examined costs for patients who received LT versus additional medications and found that while the glaucoma-specific (GS) phar­macy costs were lower for LT patients in the 24 months after the procedure, the overall GS treatment costs were comparable between the LT and medi­cation groups.

    This was a retrospective administra­tive claims analysis, based on medical and pharmacy claims data between 2007 and 2012. Records were ana­lyzed to identify open-angle glaucoma (OAG) patients already on prostaglan­din analogue monotherapy who had an index-date LT claim (LT cohort) or a second medication class claim (Rx co­hort); claims were reviewed for the 12 months before and 24 months after the index date. The study included 4,743 LT patients and 16,484 Rx patients.

    The researchers found that over the course of the study, the per-patient GS pharmacy costs were significantly lower in the LT cohort than the Rx cohort ($807 vs. $1,467, respectively; p < .0001). At 45 days after LT, 60% of patients did not have a pharmacy claim; this was down to 20% by 24 months. However, the LT cohort had significant­ly higher GS medical costs ($2,684 vs. $1,980; p < .0001), with 28% of those costs specifically related to the LT pro­cedure. The overall GS costs ($3,441 vs. $3,408, respectively, p = .325) were not significantly different between groups.

    The study also investigated the factors predicting whether a patient on OAG monotherapy would receive LT or an additional drug. Younger age, greater comorbidity (e.g., diabetes), and a his­tory of poor adherence were significant predictors for LT. Regional differences were also found, with highest rates of LT use in the Pacific, west north central, and east north central regions of the United States.

    The authors acknowledged some study limitations: The analysis was based only on claims data and did not account for the clinical findings of in­dividual patients; nor did it distinguish between laser treatments (e.g., argon vs. selective laser trabeculoplasty; or 180- vs. 360-degree application). Regardless, the authors concluded that these real-world claims data demonstrate that, overall, LT does not reduce the cost of glaucoma care.

    Economic Model of ROP Screening and Treatment: Mexico and the United States

    August 2016

    Using an economic model they de­veloped (EcROP), Rothschild et al. analyzed the impact of ROP screening in the United States and Mexico, which they selected as examples of high- and middle-income nations, respective­ly. They found that in both types of economies, well-designed screening programs were highly cost-effective.

    Although both the United States and Mexico have recommended ROP screening guidelines for premature infants, blindness from ROP remains a substantial burden, which the authors attribute to incomplete adherence to these guidelines. They estimated an 80% penetrance of screening in the United States and 52% in Mexico. For both countries, they then compared the direct and indirect costs of ROP-related blindness under actual conditions ver­sus an “ideal” model of 100% screening of the targeted population, followed by appropriate treatment.

    In addition to findings from pub­lished literature, the EcROP model incorporated country-specific econom­ic data based on local standard-of-care clinical protocols, as well as informa­tion from in-person interviews with caregivers of 52 children at schools for the blind or pediatric eye clinics in At­lanta, Georgia, and 43 in Mexico City.

    In determining the costs of blind­ness, EcROP included both direct costs (e.g., educational/training fees, special­ized equipment such as Braille writers, and government disability payments) and indirect costs (e.g., reduced pro­ductivity of the patient and the caregiv­er). For ROP screening and treatment, direct costs included all equipment, labor, and facilities expenses associated with evidence-based ROP screening, treatment, and follow-up; while indi­rect costs included caregiver produc­tivity lost to medical appointments. EcROP also included quality-adjusted life years (QALY) in the incremental cost-effectiveness analysis.

    The authors found that an ideal national ROP screening and treatment program would yield substantial sav­ings. They estimated that the incre­mental net benefit of an ideal program over current practice would be $5,556 per child ($206,574,333 annually) in the United States and $3,628 per child ($205,906,959 annually) in Mexico.

    They concluded that EcROP data support the cost savings and QALY improvement, as well as societal bene­fits, from implementation of effective ROP management. Although the time window for ROP identification and treatment is brief, the potential impact is lifelong for the patient and family.

    Minimum Standardized Patient-Centered Outcome Measures for Macular Degeneration

    August 2016

    Various types of outcome measures have been used in studies and in clin­ical management of macular degener­ation. On behalf of the International Consortium for Health Outcomes Measurement (ICHOM), Rodrigues et al. sought to define a minimum set of measures for tracking, comparing, and improving care of patients with conditions including neovascular and nonneovascular age-related macular degeneration (AMD), polypoidal cho­roidal vasculopathy, and neovascular myopic macular degeneration.

    The ICHOM working group con­sisted of 18 experts from 10 countries on 4 continents. They used a modi­fied Delphi technique, incorporating structured teleconferences and survey questionnaires, to arrive at consensus decisions. Potential outcomes were identified through review of outcomes collected in existing registries and re­ported in major clinical trials and were selected and refined by the group based on impact on patients, relationship to good clinical care, and feasibility of measurement in routine practice.

    Noting that increases in objectively measured distance visual acuity are not necessarily consistent with improved visual functioning, the authors recom­mended including measures of near visual acuity, reading speed, and con­trast sensitivity as well. Further, they emphasized the importance of real-life patient-reported outcome measures (PROMs) in disease management. The group established minimum standards in 3 major areas: (1) visual function­ing and vision-related quality of life, encompassing distance visual acuity as well as PROMs of mobility, emotion­al well-being, and ability to read and access information; (2) disutility of care, including treatment burden and complications; and (3) disease control, involving anatomic measures such as presence of fluid, edema, and hemor­rhage. In addition, the working group recommended a timeline for scheduling each of these measurements. ICHOM has made the full report freely available.

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    American Journal of Ophthalmology sum­maries are written by Peggy Denny and edited by Richard K. Parrish II, MD.

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