THE ECONOMIC BURDEN OF GLAUCOMA

INTRODUCTION

Around 3% of the general population above the age of 40 years suffers from glaucoma.

Glaucoma accounts for more than 10 million visits to physicians each year.

The personal and societal burden of disease in terms of health issues, quality of life and economic variables exponentially increases with the degree of glaucomatous visual field and visual acuity losses. 

In 2010 approximately 60.5 million people (2.65% of the global population >40) suffered from glaucoma (44.7 million Primary Open Angle Glaucoma [POAG] vs. 15.7 million Primary angle closure Glaucoma [PACG]).

In 2020 the prevalence of glaucoma is expected to be nearly 79.6 million (POAG:PACG::58.6M:15.7M).

The number of bilaterally blind POAG patients is currently 4.5 million, which is forecast to increase to 5.9 million by 2020.

POAG is 3 times more prevalent in black vs. white patients.

POAG increases with age.

The Baltimore Eye Survey found black women to have the following demographics:

Age group (years)	Glaucoma prevalence
50-54	2.24%
70-74	5.89%
>80	9.82%

It has been reported that glaucoma treatment in USA is often delayed apparently due to the complex insurance policies of the country. An analysis of US Medicare claims data (1992-2002) found an average of 27.4% beneficiaries diagnosed with POAG did not receive the required medical/surgical therapy within a year of diagnosis.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3206636/ 

THE ECONOMICS OF GLAUCOMA

Glaucoma causes significant economic hardships on patients.

Direct medical costs include: medications, physician fees, hospital charges and procedures. 

Direct non-medical costs are related to: transportation, government purchase programs, guide dogs and nursing home care.

Indirect costs: loss of productivity such as days missed from work, productivity costs borne by caregivers such as family members and friends.

Direct costs in different countries are:

USA= $ 2.9 billion

Australia= Aus$ 144.2 million

Since half of all glaucoma patients are currently undiagnosed, the actual costs of treatment are expected to be higher.

US Medicare figures suggest glaucoma patients have to fork out $ 1688 greater than non-glaucoma individuals during their lifetime. This is not statistically significant.

The annual incremental cost is approximately $ 137 per patient per year.

The financial burden of glaucoma increases with progression of disease severity.

The following findings were reported in a study from the USA:

STAGE OF DISEASE	Avg. direct costs per patient per year
Asymptomatic ocular hypertension (OHT) /early glaucoma (Stage 0)	$623
Advanced glaucoma (Stage 3)	$1915
End stage glaucoma/blindness (Stage 5)	$2511

In a European study the direct costs of treatment increased by approximately € 86 for each incremental increase in glaucoma stage; ranging from €455 per person year (Stage 0) to €969 per person year (Stage 4).

A retrospective study conducted in USA and Europe found that increased annual costs were associated with higher initial IOP level; higher baseline glaucoma stage; use of ocular hypotensive medication and glaucoma-related surgery.

The total annual direct treatment costs per patient (with majority of patients being in early stage) in France and Sweden is estimated to be €390 and €531, respectively.

Individuals in LATE stage disease incur significant additional indirect costs due to family/home help and rehabilitation needs.

In Europe, the average annual direct health care cost of glaucoma-related blindness is estimated to be €429-523 per patient.

If rehabilitation costs and economic burden on families is included the annual TOTAL costs go up to €11,758-19,111.

Studies conducted in France, Denmark Germany and United Kingdom show that the annual health care costs in patients with late-stage glaucoma average €830 per patient.

A model developed to manage OHT found that treating all patients was not cost effective; while, risk factors identified in OHTS did point to cost-effective treatment strategy.

In another study, Kymes et al have found that treating individuals with IOP >24 mmHg and a >2% annual risk of developing glaucoma met cost-effectiveness standards.

INDIVIDUAL BURDEN OF GLAUCOMA

Glaucoma has a significant impact on health related quality of life (HRQoL) in multiple ways such as effects on driving, walking and reading.

There is also worsening of psychological burden as disease advances. Patients experience growing fear of blindness, social withdrawal from impaired vision and depression.

The concept of HRQoL reflects an individual’s well-being and focuses on dimensions of physical functioning, social functioning, mental health and general health perceptions.

VF loss linearly and negatively affects HRQoL. Greater the VF loss the worse is the HRQoL.

Patients with glaucoma in both eyes had significantly lower scores on the “Activities of Daily Vision Scale” than those without glaucoma.

The poorest visual functioning was reported in patients with bilateral or severe visual impairment.

Patients with bilateral glaucoma are shown to have substantially reduced mobility.

With the progression of glaucoma individuals are less able to perform activities of daily living.

When compared with a control group with similar systemic medical conditions, those with glaucoma were >3 times more likely to have history of falls in last 12 months; >6 times more likely to have been involved in atleast 1 motor vehicle accident within the previous 5 years and more likely to have been at fault when involved in a motor vehicle accident.

Even individuals with NEWLY DIAGNOSED POAG have been reported to have higher risk of depression, nursing home admission and home health service than those in a matched control cohort.

TAKE HOME MESSAGE

Glaucoma related visual disabilities are PREVENTABLE.

The BURDENS of functional visual loss are not fully recognized.

The economic and individual costs increase with disease severity.

Proactive glaucoma management and public health education may help to reduce the overall burden of the disease.

Recent economic studies have shown a dramatic increase in the number of patients with glaucoma receiving treatment but a reduction in use of surgical procedures to treat the condition, especially as first-line therapy. The greater part of medical expenditure is now on medication, with new, more potent, better tolerated, but more costly drugs replacing older and less expensive medications. Treatment costs are directly related to the severity of disease and the number of different treatments used; they are also negatively correlated with treatment efficacy in reducing intraocular pressure. However, long-term economic benefits that may be associated with use of more potent new drugs (by delaying institutionalization) have never been documented. Glaucoma screening has also been found not to be cost effective, although these results should be reconsidered in the light of new data.

Rouland JF, Berdeaux G, Lafuma A. The economic burden of glaucoma and ocular hypertension: implications for patient management: a review. Drugs Aging. 2005;22(4):315-21.

A statistically significant increasing linear trend (p = 0.018) in direct cost as disease severity worsened was demonstrated. The direct cost of treatment increased by an estimated €86 for each incremental step ranging from €455 per person year for stage 0 to €969 per person year for stage 4 disease. Medication costs ranged from 42% to 56% of total direct cost for all stages of disease.

Conclusions: These results demonstrate for the first time in Europe that resource utilization and direct medical costs of glaucoma management increase with worsening disease severity. Based on these findings, managing glaucoma and effectively delaying disease progression would be expected to significantly reduce the economic burden of this disease. These data are relevant to general practitioners and healthcare administrators who have a direct influence on the distribution of resources.

Traverso CE, Walt JG, Kelly SP, et al. Direct costs of glaucoma and severity of the disease: a multinational long term study of resource utilization in Europe. British Journal of Ophthalmology 2005;89:1245-1249.