AI Can Improve the Economics of Blindness Prevention in Canada.

Diabetic retinopathy is a leading cause of vision loss in Canada and creates significant economic and social burden on patients. Diabetic retinopathy is largely a preventable complication of diabetes mellitus. Yet, hundreds of thousands of Canadians continue to be at risk and thousands go on to develop vision loss and disability. Blindness has a significant impact on the Canadian economy, on families and the quality of life of affected individuals. This paper provides an economic analysis on two potential interventions for preventing blindness and concludes that use of AI to identify high-risk individuals could significantly decrease the costs of identifying, recalling, and screening patients at risk of vision loss, while achieving similar results as a full-fledged screening and recall program. We propose that minimal data interoperability between optometrists and family physicians combined with artificial intelligence to identify and screen those at highest risk of vision loss can lower the costs and increase the feasibility of screening and treating large numbers of patients at risk of going blind in Canada.

A longitudinal study of the association between visual impairment and income change using a national health screening cohort.

We evaluated the influence of visual impairment (VI) on income change using the longitudinal database of a Korean National Health Insurance Service cohort. A total of 5292 participants ≥ 40 years old and registered as visually impaired persons were selected at a 1:4 ratio with 45,081 non-VI participants matched for age, sex, and income level. The income level of both the VI and non-VI groups increased over time. In the VI group, the income levels 3, 4 and 5 years were higher than the initial value, while the income levels from 1 through 5 years were increased each year in the non-VI group. The rate of change in income between time and VI were significant. In the subgroup analysis considering age, sex, and severity of VI, the rate of change in income were significant in < 65 years old subgroups. Regarding the severity of VI, a significant interaction was found for the mild-to-moderate VI subgroup. Although both the VI and non-VI groups showed increased income levels over 5 years, the degree of income increase in the VI group was relatively lower than that in the non-VI group. This finding was prominent in the middle-age subgroup. These results strongly suggested that VI induced an income inequality.

Role of socio-economic factors in visual impairment and progression of diabetic retinopathy.

BACKGROUND: To investigate the longitudinal associations between person-level and area-level socioeconomic status (PLSES and ALSES, respectively) with diabetic retinopathy (DR) and visual impairment (VI) in Asians with diabetes mellitus (DM). METHODS: In this population-based cohort study, we included 468 (39.4%) Malays and 721 (60.6%) Indians with DM, with a mean age (SD) of 58.9 (9.1) years; 50.6% were female and the mean follow-up duration was 6.2 (0.9) years. Individual PLSES parameters (education, monthly income and housing type) were quantified using questionnaires. ALSES was assessed using the Socioeconomic Disadvantage Index derived from Singapore's 2010 areal census (higher scores indicate greater disadvantage). Incident DR and VI were defined as absent at baseline but present at follow-up, while DR and VI progression were defined as a ≥1 step increase in severity category at follow-up. Modified Poisson regression analysis was used to determine the associations of PLSES and ALSES with incidence and progression of DR and VI, adjusting for relevant confounders. RESULTS: In multivariable models, per SD increase in ALSES score was associated with greater DR incidence (risk ratio (95% CI) 1.27 (1.13 to 1.44)), DR progression (1.10 (1.00 to 1.20)) and VI incidence (1.10 (1.04 to 1.16)), while lower PLSES variables were associated with increased DR (low income: 1.68 (1.21 to 2.34)) and VI (low income: 1.44 (1.13 to 1.83); ≤4 room housing: 2.00 (1.57 to 2.54)) incidence. CONCLUSIONS: We found that both PLSES and ALSES variables were independently associated with DR incidence, progression and associated vision loss in Asians. Novel intervention strategies targeted at low socioeconomic status communities to decrease rates of DR and VI are warranted.

Self-reported visual difficulties in Europe and related factors: a European population-based cross-sectional survey.

PURPOSE: There is a relative paucity of self-reported vision problems data in European countries. METHODS: In this context, we investigated self-reported vision problems through European Health Interview Survey 2, a cross-sectional European population survey based on a standardized questionnaire including 147 medical, demographic and socioeconomic variables applied to non-institutionalized individuals aged 15 years or more in 28 European countries, in addition to Iceland and Norway. RESULTS: The survey included 311 386 individuals (54.18% women), with overall crude prevalence of self-reported vision problems of 2.07% [95% CI; 2.01-2.14]. Among them, 1.70 % [1.61-1.78] of men, 2.41% [2.31-2.51] of women and 4.71% [4.53-4.89] of individuals aged 60 or more reported to have a lot of vision problems or to be not able to see. The frequency of self-reported vision problems was the highest in Eastern European countries with values of 2.43% [2.30-2.56]. In multivariate analyses, limiting long-standing illness, depression, daily smoking, lack of physical activity, lower educational level and social isolation were associated with self-reported vision problems with ORs of 2.66 [2.42-2.92], 2.16 [2.01-2.32], 1.11 [1.01-1.23], 1.31 [1.21-1.42], 1.29 [1.19-1.40] and 1.45 [1.26-1.67], respectively, while higher income was associated with less self-reported vision problems with OR of 0.80 [0.73-0.86]. CONCLUSIONS: This study demonstrated inequalities in terms of prevalence of self-reported vision problems in Europe, with higher prevalence in Eastern European countries and among women and older individuals.

Cost-effectiveness of Anti-VEGF treatments for age-related macular degeneration: a Brazilian perspective.

PURPOSE: To study the cost-effectiveness of ranibizumab and bevacizumab for the treatment of age-related macular degeneration. METHODS: We used a decision tree model to analyze the cost-effectiveness of ranibizumab and bevacizumab for the treatment of age-related macular degeneration, from the Brazilian Public Health System (SUS) perspective. Ranibizumab and bevacizumab were administered to patients with the same treatment procedure, and the difference in treatment costs was calculated based on the cost of the drugs. Direct costs were estimated using the information provided by the Brazilian SUS. Effectiveness in terms of quality-adjusted life years (QALYs) was calculated based on the utility values for visual impairment. Incremental cost-effectiveness ratio was calculated by comparing both treatments. The analytical horizon was one year. RESULTS: The decision tree analysis showed that the difference in treatment effectiveness was 0.01 QALY. Incremental cost-effectiveness ratio showed that ranibizumab treatment required an incremental annual cost of more than R$ 2 million to generate 1 additional QALY, as compared to bevacizumab. CONCLUSIONS: From the Brazilian SUS perspective, bevacizumab is more cost-effective than ranibizumab for the treatment of neovascular age-related macular degeneration. Its use could allow potential annual savings in health budget.

Cost-effectiveness of Anti-VEGF treatments for age-related macular degeneration: a Brazilian perspective / Estudo de custo-efetividade de tratamentos para a degeneração macular relacionada à idade: uma perspectiva brasileira

ABSTRACT Purpose: To study the cost-effectiveness of ranibizumab and bevacizumab for the treatment of age-related macular degeneration. Methods: We used a decision tree model to analyze the cost-effectiveness of ranibizumab and bevacizumab for the treatment of age-related macular degeneration, from the Brazilian Public Health System (SUS) perspective. Ranibizumab and bevacizumab were administered to patients with the same treatment procedure, and the difference in treatment costs was calculated based on the cost of the drugs. Direct costs were estimated using the information provided by the Brazilian SUS. Effectiveness in terms of quality-adjusted life years (QALYs) was calculated based on the utility values for visual impairment. Incremental cost-effectiveness ratio was calculated by comparing both treatments. The analytical horizon was one year. Results: The decision tree analysis showed that the difference in treatment effectiveness was 0.01 QALY. Incremental cost-effectiveness ratio showed that ranibizumab treatment required an incremental annual cost of more than R$ 2 million to generate 1 additional QALY, as compared to bevacizumab. Conclusions: From the Brazilian SUS perspective, bevacizumab is more cost-effective than ranibizumab for the treatment of neovascular age-related macular degeneration. Its use could allow potential annual savings in health budget.

RESUMO Objetivo: Estudar o custo-efetividade do ranibizumabe e bevacizumabe no tratamento da degeneração macular relacionada à idade neovascular. Métodos: Utilizamos um modelo de árvore de decisão para analisar a relação custo-efetividade do ranibizumabe e bevacizumabe no tratamento da degeneração macular relacionada à idade, sob a perspectiva do Sistema Único de Saúde. O ranibizumabe e bevacizumabe foram administrados a pacientes com o mesmo procedimento de tratamento, e a diferença nos custos do tratamernto foi calculada com base no custo dos medicamentos. Os custos diretos foram estimados utilizando as informações fornecidas pelo SUS. A efetividade foi determinada em anos de vida ajustados pela qualidade (QALY) baseados em valores de utilidade em deficiênciavisual. A razãoincremental custo-efetividadefoicalculada comparando os dois tratamentos. O horizonte analítico foi de um ano. Resultados: A análise da árvore de decisão mostrou que a diferença na efetividade do tratamento foi de 0,01 QALY. A razão incremental de custo-efetividade mostrou que o tratamento com ranibizumabe exigiu um custo anual incremental de R$ 2 milhões para gerar um QALY adicional, em comparação ao bevacizumabe. Conclusões: Do ponto de vista do SUS, o bevacizumabe é mais custo-efetivo que o ranibizumabe no tratamento da degeneração macular relacionada à idade neovascular. O seu uso poderia gerar uma grande economia anual para o orçamento em saúde.

The L V Prasad Eye Institute: A comprehensive case study of excellent and equitable eye care.

Global healthcare delivery systems are facing ever-increasing challenges on multiple fronts. The need to study and define successful models of care delivery systems has become increasingly important. The L V Prasad Eye Institute (LVPEI) has a distinctive eye care delivery system offering rich lessons at many operational levels. The system has been developed on the basis of LVPEI's foundational public eye health study, and follows a complexity-driven (dependent on disease complexity) clinical care system forming a five-tier pyramidal model - at the apex is the quaternary care centre at Hyderabad, followed by increasing numbers of tertiary, secondary or community, primary, and rural eye care centres, where the revenue from paying patients covers free-care via an economic cross-subsidy. This has achieved a level of scale, efficiency, social impact, and clinical and scientific innovation rarely seen in a single health system. Building on the foundational principles of this pyramidal care with a robust economic cross-subsidy model, LVPEI has seamlessly established successful professional, academic, and educational systems that combine innovation, scientific discovery, and the development of in-house technologies focused on improving service quality and clinical decision making. In this case study, we show that all elements of the LVPEI model are practical and may be applicable to academic medical centres in diverse healthcare settings; currently, this is being tested in Liberia, West Africa.

Thirty Year Projected Magnitude (to 2050) of Near and Distance Vision Impairment and the Economic Impact if Existing Solutions are Implemented Globally.

Purpose: Recent global, regional and country-level prevalence estimates for blindness and vision impairment will be important when designing future public health policies. The aim of this paper is to contribute to this discussion by estimating the productivity impact of known effective interventions to treat all preventable cases of vision impairment at the global, regional and country-level up to 2050. We also provide estimates of potential reduction in the number of people with vision impairment, as well as averted vision-impaired years up to 2050.Methods: We combined recent estimates of the prevalence of blindness, distance and near vision impairment with the World Bank's World Development Indicators (WDI) and estimated the global, regional and country-level productivity gains up to 2030, 2040 and 2050 from known effective interventions, primarily cataract surgery and treated uncorrected refractive errors. The magnitude of productivity gains relative to baseline depended on population size, estimated current and future prevalence of vision impairment, level of economic development, long-term wage growth, and long-term real interest rates.Results: Globally, we estimate that the number of people affected by blindness could be reduced from the estimated 114.6 million by 2050 to 58.3 million. This would be associated with over one billion blind life-years averted and US$ 984 billion in global productivity gains. These numbers are dwarfed by the impact of interventions to reduce the prevalence of Moderate and Severe Vision Impairment (MSVI) [Presenting Acuity <20/60 to 20/400 in the better-seeing eye]. We estimate that the number of people affected by MSVI could be reduced by 435.8 million people to 147.9 million by 2050. This reduction would translate to over 9 billion MSVI -life-years avoided and US$ 17 trillion in productivity gains by 2050. While other causes of VI would not be possible to eliminate completely based on current known effective treatments, low-cost interventions to eliminate VI from uncorrected presbyopia would avert 1.2 billion presbyopia life-years and achieve US$ 1.05 trillion in productivity gains by 2050. In total, the global productivity gains for all three categories are estimated to be US$ 19 trillion by 2050. East Asia makes up the greatest share of productivity gains due to the high number of people affected by VI and the region's continuing economic growth.Conclusion: Implementation of currently known and effective treatments of avoidable blindness, MSVI and presbyopia would be expected to contribute significant productivity gains to the global economy at a fraction of the estimated costs to deliver them.

Burden of visual impairment associated with eye diseases: exploratory survey of 298 Chinese patients.

OBJECTIVES: To explore the economic burden, prevalence of catastrophic healthcare expenditure (CHE) and the quality of life (QoL) of Chinese patients with visual impairment (VI) associated with eye diseases. DESIGN: A questionnaire survey from March to May 2016 by structured face-to-face interviews of patients with VI. PARTICIPANTS: 302 patients who were diagnosed with moderate VI or worse in both eyes (visual acuity <6/18) were included, and 298 patients (98.7%) who completed the survey questionnaires were eligible for the study. OUTCOME MEASURES: The economic burden was estimated by calculating participants' direct costs covered in 2015 and the definition of CHE was out-of-pocket (OOP) costs exceeding 30% of annual household income. QoL was weighed by health utility value using time-trade-off valuation techniques. RESULTS: Annual average direct costs per patient caused by VI were US$6988.6±US$10 834.3, and 70.3% were direct medical costs of which only 26.9% were reimbursable by medical insurance. 32.2% of households that suffered from CHE, in particular, were less wealthy patients with VI living in rural areas and without medical insurance. The health utility value was rated at 0.65 on average, and patients with VI aged 51-57, living alone and insured by commercial medical insurance had relatively less QoL. CONCLUSION: Our study explored the economic burden and QoL of VI associated with patients with eye diseases in China, indicating a substantial economic burden and poor QoL. Preferential medical insurance policies should be designed in relation to people with VI to further reduce the health inequalities, avoid CHE and promote QoL.

Managed care opportunities and approaches to supporting appropriate selection of treatment for sight preservation.

When evaluating the impact of vision-destroying diseases, pharmacologic therapies represent a significant cost to patients, insurance providers, and society. Currently, up to 11 million people in the United States have some form of age-related macular degeneration (AMD), which is one of the leading causes of vision loss in older Americans. Ophthalmologists have administered more than 6 million intravitreal injections of aflibercept, bevacizumab, pegaptanib, and ranibizumab last year. Comprehensive assessment requires managed care administrators and clinicians to understand the direct and indirect costs of vision loss as well as the comparative safety and efficacy profiles for each agent. In AMD, it is critical to understand the established and emerging treatment patterns.

Pediatric Case Finding in Madagascar: A Controlled, Prospective Population-based Assessment of Key Informant Productivity and Cost.

Purpose: The Key Informant (KI) case finding method, which trains community members to screen children for eye problems and refer them to eye services, is a common strategy to identify and refer children with blindness and visual impairment. However, studies to date have not determined the benefit and cost of adding KIs to routine outreach activities.Methods: Four eye programs in Madagascar with established outreach camps added KIs to a portion of their camps distributed equally throughout their service region over a one year period. KIs recorded children screened and their attendance at an outreach camp. Outreach personnel used standardized registration forms to gather age, sex, visual acuity, diagnosis and treatment data. Costs were gathered for the KI program and outreach camps.Results: In one year, the 4 eye programs held 138 outreach camps, 43 with KIs. The KI camps were more productive than regular camps seeing an average of 61 and 24 children and 50 and 19 children with an eye problem, for KI and regular camps, respectively. The KI camps also saw more children with moderate or severe visual impairment or blindness with 21 and 8 children (per 10 camps) for KI and regular camps, respectively. A KI camp cost $463 ($642 vs. $179) more than a regular camp and $3 ($8 vs. $11) more per child seen.Conclusion: The KI method significantly increased the number of children attending outreach camps, at all levels of visual impairment and blindness, at a modest increase in costs.

Association of Visual Impairment With Economic Development Among Chinese Schoolchildren.

Importance: Few studies have reported the association of economic growth with trends of visual impairment in schoolchildren in China or elsewhere. Objectives: To describe 30-year trends and patterns in visual impairment in China and to explore the association between visual impairment and economic development. Design, Setting, and Participants: In this time series analysis of 7 successive cross-sectional surveys from 1985 to 2014, a total of 1 951 084 schoolchildren aged 7 to 18 years from all provinces and autonomous regions of mainland China, excluding Tibet, were studied. In 1985, the survey was conducted between March to June; In 1991-2014, the surveys were conducted between September and November. Data analysis was performed from April 1, 2018, to January 31, 2019. Exposures: The province-level gross domestic product (GDP) per capita was extracted from the China Statistical Yearbook. Main Outcomes and Measures: Visual impairment, defined as unaided distance visual acuity of worse than 6/7.5 (20/25 Snellen equivalent), and moderate to severe visual impairment, defined as unaided distance visual acuity of worse than 6/18 (20/63 Snellen equivalent), in the worse eye. Results: A total of 1 951 084 participants (mean [SD] age, 12.6 [3.4] years; 50.5% male) were included in the analysis. Among students aged 7 to 18 years, the prevalence of visual impairment increased from 23.7% (95% CI, 23.6%-23.8%) in 1985 to 35.1% (95% CI, 34.9%-35.3%) in 1995 to 55.0% (95% CI, 54.8%-55.3%) in 2014. In 2014, the prevalence was higher among girls (58.3%; 95% CI, 54.8%-55.3%) vs boys (51.8%; 95% CI, 51.5%-52.1%) (prevalence ratio [PR] girls vs boys, 1.12; 95% CI, 1.11-1.13) and among students living in urban (59.9%; 95% CI, 59.6%-60.2%) vs rural (50.2%; 95% CI, 49.9%-50.5%) areas (PR urban vs rural, 1.17; 95% CI, 1.16-1.18), although a more rapid relative increase in prevalence occurred in rural areas (15.3% in 1985 to 50.2% in 2014) than in urban areas (31.5% in 1985 to 59.9% in 2014). From 1995 to 2014, the GDP in China increased from $1263 to $7594 (in 2014 US$ constant price). After demographic characteristics (cluster effect of school, age, sex, urban vs rural location, and relative socioeconomic status within province) were adjusted for, the regression model revealed that every 100% increase in GDP was associated with a 20% (PR, 1.20; 95% CI, 1.20-1.21) increase in the relative risk of visual impairment and a 27% (PR, 1.27; 95% CI, 1.26-1.27) increase in the relative risk of moderate to severe visual impairment. The association was stronger in male (PR, 1.22; 95% CI, 1.21-1.23 for male [as reference] vs 1.19; 95% CI, 1.18-1.19 for female; P < .001), rural (PR, 1.32; 95% CI, 1.31-1.33 for rural [as reference] vs 1.12; 95% CI, 1.12,-1.33 for urban; P < .001), and younger age groups (PR, 1.27; 95% CI, 1.24-1.29 for 7-9 years of age [as reference] vs 1.34; 95% CI, 1.32-1.36 for 10-12 years of age; P < .001; 1.21; 95% CI, 1.20-1.22 for 13-15 years of age; P < .001; and 1.12; 95% CI, 1.11,-1.13 for 16-18 years of age; P < .001). Conclusions and Relevance: The rapid increase of visual impairment prevalence and the association between GDP and visual impairment over time suggest that further exacerbation of childhood visual impairment may occur as economic development continues in China.

Association of Sensory and Cognitive Impairment With Healthcare Utilization and Cost in Older Adults.

OBJECTIVES: To examine the association between self-reported vision impairment (VI), hearing impairment (HI), and dual-sensory impairment (DSI), stratified by dementia status, on hospital admissions, hospice use, and healthcare costs. DESIGN: Retrospective analysis. SETTING: Medicare Current Beneficiary Survey from 1999 to 2006. PARTICIPANTS: Rotating panel of community-dwelling Medicare beneficiaries, aged 65 years and older (N = 24 009). MEASUREMENTS: VI and HI were ascertained by self-report. Dementia status was determined by self-report or diagnosis codes in claims data. Primary outcomes included any inpatient admission over a 2-year period, hospice use over a 2-year period, annual Medicare fee-for-service costs, and total healthcare costs (which included information from Medicare claims data and other self-reported payments). RESULTS: Self-reported DSI was present in 30.2% (n = 263/871) of participants with dementia and 17.8% (n = 4112/23 138) of participants without dementia. In multivariable logistic regression models, HI, VI, or DSI was generally associated with increased odds of hospitalization and hospice use regardless of dementia status. In a generalized linear model adjusted for demographics, annual total healthcare costs were greater for those with DSI and dementia compared to those with DSI without dementia ($28 875 vs $3340, respectively). Presence of any sensory impairment was generally associated with higher healthcare costs. In a model adjusted for demographics, Medicaid status, and chronic medical conditions, DSI compared with no sensory impairment was associated with a small, but statistically significant, difference in total healthcare spending in those without dementia ($1151 vs $1056; P < .001) but not in those with dementia ($11 303 vs $10 466; P = .395). CONCLUSION: Older adults with sensory and cognitive impairments constitute a particularly prevalent and vulnerable population who are at increased risk of hospitalization and contribute to higher healthcare spending. J Am Geriatr Soc 67:1617-1624, 2019.

Cost Utility of Voretigene Neparvovec for Biallelic RPE65-Mediated Inherited Retinal Disease.

OBJECTIVE: The gene therapy voretigene neparvovec (VN) is the first Food and Drug Administration-approved treatment for vision loss owing to the ultra-rare RPE65-mediated inherited retinal disorders. We modeled the cost-utility of VN compared with standard of care (SoC). STUDY DESIGN: A 2-state Markov model, alive and dead, with a lifetime horizon. METHODS: Visual acuity (VA) and visual field (VF) were tracked to model quality-adjusted life-years (QALYs). VN led to an improvement in VA and VF that we assumed was maintained for 10 years followed by a 10-year waning period. The cost of VN was $850 000, and other direct medical costs for depression and trauma were included for a US healthcare system perspective. A modified societal perspective also included direct nonmedical costs and indirect costs. RESULTS: VN provided an additional 1.3 QALYs over the remaining lifetime of an individual. The average total lifetime direct medical cost for individuals treated with VN was $1 039 000 compared with $213 400 for SoC, leading to an incremental cost-effectiveness ratio (ICER) of $643 800/QALY from the US healthcare system perspective. Direct nonmedical costs totalled $1 070 900 for VN and $1 203 300 for SoC, and indirect costs totalled $405 400 for VN and $482 900 for SoC, leading to an ICER of $480 100/QALY from the modified societal perspective. CONCLUSIONS: At the current price, VN was unlikely to reach traditional cost-effectiveness standards compared with SoC. VN has important implications for both development and pricing of future gene therapies; therefore clinical and economic analyses must be carefully considered.

Luxturna: FDA documents reveal the value of a costly gene therapy.

In 2017, the US Food and Drug Administration (FDA) approved voretigene neparvovec-rzyl (Luxturna), a gene therapy used to treat a rare form of inherited blindness. Widely described by the media as a curative treatment that 'restores vision', it was priced at US$850000. Although voretigene neparvovec-rzyl represents a substantial therapeutic advance, most reports have failed to adequately describe study outcomes as documented by FDA reviewers. These documents reveal that the drug is not expected to restore normal vision, that only about half of treated patients met the FDA's threshold for minimally meaningful improvement, that improvements might not persist long-term, that the most common measure of visual function was rejected as a primary endpoint after yielding mixed results, and that two patients experienced permanent vision loss. Over US$100 million of additional publicly-funded costs are not evident from the US$850000 figure.

Potential Lost Productivity Resulting from the Global Burden of Myopia: Systematic Review, Meta-analysis, and Modeling.

PURPOSE: We estimated the potential global economic productivity loss resulting from vision impairment (VI) and blindness as a result of uncorrected myopia and myopic macular degeneration (MMD) in 2015. CLINICAL RELEVANCE: Understanding the economic burden of VI associated with myopia is critical to addressing myopia as an increasingly prevalent public health problem. METHODS: We estimated the number of people with myopia and MMD corresponding to critical visual acuity thresholds. Spectacle correction coverage was analyzed against country-level variables from the year of data collection; variation in spectacle correction was described best by a model based on a human development index, with adjustments for urbanization and age. Spectacle correction and myopia data were combined to estimate the number of people with each level of VI resulting from uncorrected myopia. We then applied disability weights, labor force participation rates, employment rates, and gross domestic product per capita to estimate the potential productivity lost among individuals with each level and type of VI resulting from myopia in 2015 in United States dollars (US$). An estimate of care-associated productivity loss also was included. RESULTS: People with myopia are less likely to have adequate optical correction if they are older and live in a rural area of a less developed country. The global potential productivity loss associated with the burden of VI in 2015 was estimated at US$244 billion (95% confidence interval [CI], US$49 billion-US$697 billion) from uncorrected myopia and US$6 billion (95% CI, US$2 billion-US$17 billion) from MMD. Our estimates suggest that the Southeast Asia, South Asia, and East Asia Global Burden of Disease regions bear the greatest potential burden as a proportion of their economic activity, whereas East Asia bears the greatest potential burden in absolute terms. CONCLUSIONS: Even under conservative assumptions, the potential productivity loss associated with VI and blindness resulting from uncorrected myopia is substantially greater than the cost of correcting myopia.

Improving eye care in residential aged care facilities using the Residential Ocular Care (ROC) model: study protocol for a multicentered, prospective, customized, and cluster randomized controlled trial in Australia.

BACKGROUND: Older adults in residential aged care facilities have unnecessarily high levels of vision impairment (VI) which are largely treatable or correctable. However, no current comprehensive eye health service model exists in this setting in Australia. We aimed to determine the clinical, person-centered, and economic effectiveness of a novel eye care model, the Residential Ocular Care (ROC). METHODS/DESIGN: This protocol describes a multicentered, prospective, randomized controlled trial. A total of 395 participants with distance vision < 6/12 (0.30 LogMAR) and/or near vision N8 (1.00 M) or worse will be recruited from 38 urban and rural aged care facilities across Victoria, Australia. Aged care facilities will be randomized (1:1) to one of two parallel groups. Participants in the ROC group will receive a comprehensive and tailored eye care pathway that includes, as necessary, refraction and spectacle provision, cataract surgery, low vision rehabilitation, and/or a referral to an ophthalmologist for funded treatment. Usual care participants will be referred for an evaluation to the eye care service associated with the facility or an eye care provider of their choice. The primary outcome will be presenting near and distance vision assessed at the two- and six-month follow-up visits, post baseline. Secondary outcomes will include vision-specific quality of life, mobility, falls, depression, and eye care utilization at two and six months. An incremental cost-effectiveness analysis will also be undertaken. DISCUSSION: The ROC study is the first multicentered, prospective, customized, and cluster randomized controlled trial in Australia to determine the effectiveness of a comprehensive and tailored eye care model for people residing in aged care facilities. Results from this trial will assist health and social care planners in implementing similar innovative models of care for this growing segment of the population in Australia and elsewhere. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry, ACTRN12615000587505 . Registered on 4 June 2015 - retrospectively registered.

Eye care utilisation in Newfoundland and Labrador: access barriers and vision health outcomes.

OBJECTIVE: Our prior study revealed significantly lower use of eye care providers in Newfoundland and Labrador (NFLD). This study reports factors associated with this low use and related vision health outcomes. DESIGN: Cross-sectional survey. PARTICIPANTS: A total of 14 925 Caucasian respondents to the Canadian Community Health Survey - Healthy Aging 2008/2009 aged ≥65 years. METHODS: Univariate and multivariate analyses were performed using self-reported survey data. RESULTS: NFLD, along with 3 other provinces, does not insure seniors for routine eye examinations. Among seniors without self-reported glaucoma, cataracts, and diabetes, the use of eye care providers in NFLD (36.3%) is the lowest compared with provinces with (50.7%, p < 0.05) and without (42.2%, p > 0.05) government-insured eye examinations. Among seniors with known eye disease insured for eye care in all provinces, eye care utilisation in NFLD (63.1%) is still the lowest across all provinces (69.4%-71.3%, p > 0.05). Compared with the national average, NFLD seniors have significantly higher proportions of low income (61.7% vs 47.4%), no postsecondary education (53.6% vs 42.2%), and rural residency (40.6% vs 18.9%). These factors are all associated with low levels of eye care utilisation. Compared with insured provinces, NFLD has a significantly lower prevalence of self-reported cataracts (16.7% vs 23.1) and glaucoma (3.8% vs 7.0%), and a slightly higher prevalence of presenting visual impairment (4.0% vs 3.5%). CONCLUSIONS: Lack of government insurance, low socioeconomic status, and living in nonurbanised areas all contribute to the underutilisation of eye care providers in NFLD. This underutilisation appears to be associated with reduced detection of eye diseases.

Barriers to uptake of referral services from secondary care to tertiary care and its associated factors in L V Prasad Eye Institute network in Southern India: a cross-sectional study.

OBJECTIVE: To examine barriers to the uptake of referral services from secondary care centres to higher level tertiary care centres. DESIGN: Cross-sectional study. SETTING: Secondary care hospital in Khammam District in the Telangana state of India. PARTICIPANTS: Nine hundred and three patients who were referred from a secondary care centre to tertiary care centres between June 2011 and December 2012, were over the age of 18 and lived within 50 km of the secondary care centre were identified. Six hundred and sixteen (68.2%) of these patients were successfully contacted, and 611 (99%) of those contacted consented to participation in the study. INTERVENTIONS: Those who attended at higher centres after referral (compliant) and those who failed to attend (non-compliant) were interviewed with a standard questionnaire designed for the study. PRIMARY AND SECONDARY OUTCOME MEASURES: Outcome measures were barriers to the uptake of eye care services for the non-compliant participants and the associated risk factors for non-compliance. RESULTS: Of the contacted patients, 418 (68.4%) were compliant and 193 (31.6%) were non-compliant. The mean age of interviewed patients was 48.4 years (SD: 17.9 years) and 365 (59.7%) were male. Of those who did not comply with their referral, the major identified barriers were 'cannot afford treatment cost' (30%) and 'able to see adequately' (20.7%). Multivariable analysis showed that participants in the non-compliant group were more likely to have had only one prior visit to the centre (OR: 2.5, 95% CI 1.6 to 3.9), be referred for oculoplastic services (OR: 3.0, 95% CI 1.0 to 8.8) and to be the main earning member of the family (OR: 1.9, 95% CI 1.2 to 2.8). CONCLUSIONS: Non-compliance with referrals in this population is largely attributable to economic and attitudinal reasons. Focusing on these specific barriers and targeting groups at higher risk of non-compliance could potentially improve uptake of referral services.

The Economic Burden of Visual Impairment and Comorbid Fatigue: A Cost-of-Illness Study (From a Societal Perspective).

Purpose: To investigate the burden of visual impairment and comorbid fatigue in terms of impact on daily life, by estimating societal costs (direct medical costs and indirect non-health care costs) accrued by these conditions. Methods: This cost-of-illness study was performed from a societal perspective. Cross-sectional data of visually impaired adults and normally sighted adults were collected through structured telephone interviews and online surveys, respectively. Primary outcomes were fatigue severity (FAS), impact of fatigue on daily life (MFIS), and total societal costs. Cost differences between participants with and without vision loss, and between participants with and without fatigue, were examined by (adjusted) multivariate regression analyses, including bootstrapped confidence intervals. Results: Severe fatigue (FAS ≥ 22) and high fatigue impact (MFIS ≥ 38) was present in 57% and 40% of participants with vision loss (n = 247), respectively, compared to 22% (adjusted odds ratio [OR] 4.6; 95% confidence interval [CI] [2.7, 7.6]) and 11% (adjusted OR 4.8; 95% CI [2.7, 8.7]) in those with normal sight (n = 233). A significant interaction was found between visual impairment and high fatigue impact for total societal costs (€449; 95% CI [33, 1017]). High fatigue impact was associated with significantly increased societal costs for participants with visual impairment (mean difference €461; 95% CI [126, 797]), but this effect was not observed for participants with normal sight (€12; 95% CI [-527, 550]). Conclusions: Visual impairment is associated with an increased prevalence of high fatigue impact that largely determines the economic burden of visual impairment. The substantial costs of visual impairment and comorbid fatigue emphasize the need for patient-centered interventions aimed at decreasing its impact.