A Review of Cost-Effectiveness Analyses for Open Angle Glaucoma Management.

PURPOSE: Cost-effectiveness analyses (CEAs) quantify and compare both costs and measures of efficacy for different interventions. As the costs of glaucoma management to patients, payers, and physicians are increasing, we seek to investigate the role of CEAs in the field of glaucoma and how such studies impact clinical management. METHODS: We adhered to the "Preferred Reporting Items for Systematic Reviews and Meta-analyses" guidelines for our systematic review structure. Eligible studies included any full-text articles that investigated cost-effectiveness or cost-utility as it relates to the field of open angle glaucoma management in the United States. Risk of bias assessment was conducted using the validated Joanna Briggs Institute Critical Appraisal Checklist for Economic Evaluations. RESULTS: Eighteen studies were included in the review. Dates of publication ranged from 1983 to 2021. Most of the studies were published in the 2000s and performed CEAs in the domains of treatment/therapy, screening, and adherence for patients with primary angle open glaucoma. Of the 18 articles included, 14 focused on treatment, 2 on screening, and 2 on adherence. Most of these studies focused on the cost-effectiveness of different topical medical therapies, whereas only a few studies explored laser procedures, surgical interventions, or minimally invasive procedures. Economic models using decision analysis incorporating state-transition Markov cycles or Montecarlo simulations were widely used, however, the methodology among studies was variable, with a wide spectrum of inputs, measures of outcomes, and time horizons used. CONCLUSION: Overall, we found that cost-effectiveness research in glaucoma in the United States remains relatively unstructured, resulting in unclear and conflicting implications for clinical management.

Cost-effectiveness of Prophylactic Laser Peripheral Iridotomy in Primary Angle-Closure Suspects.

PURPOSE: To investigate the cost-effectiveness (CE) of prophylactic laser peripheral iridotomy (LPI) in primary angle-closure (PAC) suspects (PACSs). DESIGN: Cost-effectiveness analysis utilizing Markov models. SUBJECTS: Patients with narrow angles (PACSs). METHODS: Progression from PACSs through 4 states (PAC, PAC glaucoma, blindness, and death) was simulated using Markov cycles. The cohort entered at 50 years and received either LPI or no treatment. Transition probabilities were calculated from published models, and risk reduction of LPI was calculated from the Zhongshan Angle Closure Prevention trial. We estimated costs of Medicare rates, and previously published utility values were used to calculate quality-adjusted life year (QALY). Incremental CE ratios (ICER) were evaluated at $50 000. Probabilistic sensitivity analyses (PSAs) addressed uncertainty. MAIN OUTCOME MEASURES: Total cost, QALY, and ICER. RESULTS: Over 2 years, the ICER for the LPI cohort was > $50 000. At 6 years, the LPI cohort was less expensive with more accrued QALY. In PSA, the LPI arm was cost-effective in 24.65% of iterations over 2 years and 92.69% over 6 years. The most sensitive parameters were probability of progressing to PAC and cost and number of annual office visits. CONCLUSIONS: By 6 years, prophylactic LPI was cost-effective. The rate of progressing to PAC and differing practice patterns most impacted CE. With uncertainty of management of narrow angles, cost may be a decision management tool for providers. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any materials discussed in this article.

Cost-Effectiveness Analysis of Minimally Invasive Trabecular Meshwork Stents with Phacoemulsification.

PURPOSE: To investigate the costs and effects of implanting trabecular meshwork bypass stents during cataract surgery from a societal perspective in the United States. DESIGN: Cost-utility analysis using Markov models and efficacy/safety data from published pivotal or randomized control trials (RCTs) of devices investigated. PARTICIPANTS: Patients aged 65 years and older with mild to moderate primary open-angle glaucoma with or without visually significant cataract. METHODS: With the use of Markov models, glaucoma progression through 4 glaucoma states (mild, moderate, advanced, severe/blind) and death were simulated over 35 years. The cohort with cataract entered the model and received cataract surgery with or without device implantation. We included a medication management only reference group to calculate total costs and outcomes for those without cataract. Intraocular pressure (IOP) reductions from RCTs were converted to glaucoma state transition probabilities using visual field (VF) mean deviation (MD) decline rates from the Early Manifest Glaucoma Trial. Progressive thinning of the retinal nerve fiber layer (RNFL) on OCT imaging related to IOP control warranted further intervention, including adding medication, selective laser trabeculoplasty (SLT), or incisional glaucoma surgery. We estimated whole costs at Medicare rates and obtained utility values for glaucoma states from previous studies. Incremental costs per quality-adjusted life-year (QALY) gained were evaluated at a QALY threshold of $50 000. One-way deterministic sensitivity analysis, scenario analyses, and probabilistic sensitivity analyses addressed parameter uncertainty and demonstrated model robustness. MAIN OUTCOME MEASURES: Total costs, QALY, and incremental cost-effectiveness ratio (ICER). RESULTS: Over 35 years in the base case, the Hydrus (Ivantis, Inc.) implanted with cataract surgery arm cost $48 026.13 and gained 12.26 QALYs. The iStent inject (Glaukos Corp.) implanted with cataract surgery arm cost $49 599.86 and gained 12.21 QALYs. Cataract surgery alone cost $54 409.25 and gained 12.04 QALYs. Initial nonsurgical management cost $57 931.22 and gained 11.74 QALY. The device arms dominated or were cost-effective compared with cataract surgery alone within 5 years and throughout sensitivity analyses. The iStent inject arm was cost-effective in 94.19% of iterations in probabilistic sensitivity analyses, whereas the Hydrus arm was cost-effective in 94.69% of iterations. CONCLUSIONS: Implanting the Hydrus Microstent or iStent inject during cataract surgery is cost-effective at a conservative QALY threshold.

A Case for the Use of Artificial Intelligence in Glaucoma Assessment.

We hypothesize that artificial intelligence (AI) applied to relevant clinical testing in glaucoma has the potential to enhance the ability to detect glaucoma. This premise was discussed at the recent Collaborative Community on Ophthalmic Imaging meeting, "The Future of Artificial Intelligence-Enabled Ophthalmic Image Interpretation: Accelerating Innovation and Implementation Pathways," held virtually September 3-4, 2020. The Collaborative Community on Ophthalmic Imaging (CCOI) is an independent self-governing consortium of stakeholders with broad international representation from academic institutions, government agencies, and the private sector whose mission is to act as a forum for the purpose of helping speed innovation in healthcare technology. It was 1 of the first 2 such organizations officially designated by the Food and Drug Administration in September 2019 in response to their announcement of the collaborative community program as a strategic priority for 2018-2020. Further information on the CCOI can be found online at their website (https://www.cc-oi.org/about). Artificial intelligence for glaucoma diagnosis would have high utility globally, because access to care is limited in many parts of the world and half of all people with glaucoma are unaware of their illness. The application of AI technology to glaucoma diagnosis has the potential to broadly increase access to care worldwide, in essence flattening the Earth by providing expert-level evaluation to individuals even in the most remote regions of the planet.

Gender Compensation Gap for Ophthalmologists in the First Year of Clinical Practice.

PURPOSE: To identify the role of gender and other factors in influencing ophthalmologists' compensation. DESIGN: Cross-sectional study. PARTICIPANTS: U.S. practicing ophthalmologists. METHODS: Between January and March 2020, an anonymous survey was sent to U.S. residency program directors and practicing ophthalmologists who recently completed residency training. Respondents who completed residency ≤ 10 years ago and responded to questions about gender, fellowship training, state of practice, and salary were included. Propensity score match (PSM) analysis was performed with age, academic residency, top residency, fellowship, state median wage, practice type, ethnicity, and number of workdays. Multivariate linear regression (MLR) analysis controlled for additional factors along with the aforementioned variables. MAIN OUTCOME MEASURES: Base starting salary with bonus (SWB) received in the first year of clinical position was the main outcome measure. A multiplier of 1.2 (20%) was added to the base salary to account for bonus. RESULTS: Of 684 respondents, 384 (56% were female, 44% were male) from 68 programs were included. Female ophthalmologists received a mean initial SWB that was $33 139.80 less than that of their male colleagues (12.5%, P = 0.00). The PSM analysis showed an SWB difference of -$27 273.89 (10.3% gap, P = 0.0015). Additionally, SWB differences were calculated with the number of workdays substituted by operating room (OR) days (-$27 793.67 [10.5% gap, P = 0.0013]) and clinic days (-$23 597.57 [8.90% gap, P = 0.0064]) in separate PSM analyses. The SWB differences between genders were significant using MLR analyses, which also controlled for work, clinic, and OR days separately (-$22 261.49, $-18 604.65, and $-16 191.26, respectively; P = 0.017, P = 0.015, P = 0.002, respectively). Gender independently predicted income in all 3 analyses (P < 0.05). Although an association between gender and the attempt to negotiate was not detected, a greater portion of men subjectively reported success in negotiation (P = 0.03). CONCLUSIONS: Female ophthalmologists earn significantly less than their male colleagues in the first year of clinical practice. Salary differences persist after controlling for demographic, educational, and practice type variables with MLR and PSM analyses. These income differences may lead to a substantial loss of accumulated earnings over an individual's career.

Detecting Common Eye Diseases Using the First Teleophthalmology GlobeChek Kiosk in the United States: A Pilot Study.

PURPOSE: The aim of this study was to assess the benefit and feasibility of the teleophthalmology GlobeChek kiosk in a community-based program. DESIGN: Single-site, nonrandomized, cross-sectional, teleophthalmologic study. METHODS: Participants underwent comprehensive evaluation that consists of a questionnaire form, brief systemic evaluation, screening visual field (VF), and GlobeChek kiosk screening, which included but not limited to intraocular pressure, pachymetry, anterior segment optical coherence tomography, posterior segment optical coherence tomography, and nonmydriatic fundus photography. The results were evaluated by a store-and-forward mechanism and follow-up questionnaires were obtained through phone calls. RESULTS: A total of 326 participatents were screened over 4 months. One hundred thirty-three (40.79%) participants had 1 condition in either eye, and 47 (14.41%) had >1 disease. Seventy (21.47%) had glaucoma, 37 (11.34%) narrow-angles, 6 (1.84%) diabetic retinopathy, 4 (1.22%) macular degeneration, and 43 (13.10%) had other eye disease findings. Age >65, history of high blood pressure, diabetes mellitus, not having a dental examination >5 years, hemoglobn A1c measurement of ≥5.6, predibates risk score of ≥9, stage 2 hypertension, and low blood pressure were found to be significant risk factors. As for the ocular parameters, all but central corneal thickness, including an intraocular pressure >21 mm Hg, vertical cup to disc ratio >0.7, visual field abnormalities, and retinal nerve fiber layer thinning were found to be significant. CONCLUSIONS: GlobeChek kiosk is both workable and effective in increasing access to care and identifying the most common causes of blindness and their risk factors.

Comparative Cost-effectiveness of the Baerveldt Implant, Trabeculectomy With Mitomycin, and Medical Treatment.

IMPORTANCE: The Tube vs Trabeculectomy Trial (TVT) found that the 350-mm2 Baerveldt implant (tube) and trabeculectomy with mitomycin may be similarly effective in lowering intraocular pressure in primary open-angle glaucoma. However, to date, there are no published long-term clinical data on the cost-effectiveness of trabeculectomy with mitomycin vs tube insertion. OBJECTIVE: To assess the cost-effectiveness of these procedures compared with maximal medical treatment. DESIGN, SETTING, AND PARTICIPANTS: We used the Markov cohort model with a 5-year time horizon to study a hypothetical cohort of 100 000 patients who required glaucoma surgery. MAIN OUTCOMES AND MEASURES: Quality-adjusted life-years (QALYs) gained, costs from the societal perspective, and the incremental cost-effectiveness ratio of medical treatment, trabeculectomy, and tube insertion. Costs were identified from Medicare Current Procedural Terminology and Ambulatory Payment Classification reimbursement codes and Red Book medication costs. The QALYs were based on visual field and visual acuity outcomes. The hypothetical societal limit to resources was included using a willingness-to-pay threshold of $50 000 per QALY. Costs and utilities were discounted at 3% per year. Uncertainty was assessed using deterministic sensitivity analyses. RESULTS: The mean costs for medical treatment, trabeculectomy, and tube insertion were $6172, $7872 and $10 075, respectively; these amounts resulted in a cost difference of $1700 (95% CI, $1644-$1770) for medical treatment vs trabeculectomy, $3904 (95% CI, $3858-$3953) for medical treatment vs tube insertion, and $2203 (95% CI, $2121-$2261) for trabeculectomy vs tube insertion. The mean 5-year probability of blindness was 4% for both surgical procedures and 15% for medical treatment. The utility gained after medical treatment, trabeculectomy, and tube insertion was 3.10, 3.30, and 3.38 QALYs, respectively. The incremental cost-effectiveness ratio was $8289 per QALY for trabeculectomy vs medical treatment, $13 896 per QALY for tube insertion vs medical treatment, and $29 055 per QALY for tube insertion vs trabeculectomy. The cost-effectiveness of each surgical procedure was most sensitive to early and late surgical failure rates and was minimally affected by adverse events, rates of visual field progression, or medication costs. CONCLUSIONS AND RELEVANCE: Assuming a willingness to pay of $50 000 per QALY, trabeculectomy and tube insertion are cost-effective compared with medical treatment alone. Trabeculectomy, however, is cost-effective at a substantially lower cost per QALY compared with tube insertion. More research is necessary to reliably account for patient preferences between the 2 operations.

Novel electrophysiological instrument for rapid and objective assessment of magnocellular deficits associated with glaucoma.

PURPOSE: To introduce a rapid and objective electrophysiological technique that can assess visual function in the magnocellular pathway, which is thought to be affected in early-stage glaucoma. METHODS: Low-contrast bright or dark isolated-checks were luminance-modulated against a static background at 10 Hz in order to drive preferentially the magnocellular ON or OFF pathway. Visual evoked potentials were recorded during 1-s epochs of stimulation and responses at the stimulus frequency were measured. Artifact rejection features ensured that eight valid runs were obtained per eye. Signal-to-noise ratios (SNR) were derived based on a multivariate statistic. In order to demonstrate its functionality, a small group of patients with glaucoma (N = 18, Snellen acuity of 20/30 or better) and control observers (N = 16) were tested. A participant failed the test if either eye yielded an SNR < or = 1. Receiver-operating-characteristic curve analysis was used to estimate the accuracy of group classification. RESULTS: The instrument was found to elicit reliable responses from control observers. For the 15% bright condition, all control observers yielded significant isolated-check VEPs (icVEPs), whereas the majority of patients failed to do so, indicating significant losses in central visual function. This condition produced the highest classification accuracy (94%), followed by the 10% dark condition (91%). CONCLUSIONS: Both ON and OFF divisions of the magnocellular pathway can be assessed rapidly through the application of the icVEP technique. This measure of central visual function may be of value in the detection of glaucomatous deficits and may complement tests of peripheral function.