Patient-Reported Dry Eye Treatment and Burden of Care.

OBJECTIVES: Dry eye is a common condition that can decrease the quality of life. This survey-based study of persons with dry eye investigated self-reported treatments (initial, current), out-of-pocket expenses, time spent on self-management, sources of care, and sources of information about their condition. METHODS: Online dry eye newsletters and support groups were emailed a link to an electronic survey asking members to participate. Survey respondents were not required to answer every question. RESULTS: In total, 639 persons with self-reported dry eye responded (86% women, 14% men [n=623]; mean ± SD age, 55 ± 14 years [n=595]). Artificial tears were the most reported intervention (76% initially, 71% currently). The median (interquartile range) out-of-pocket treatment cost annually was $500 ($200-$1,320 [n=506]). In addition, 55% (n=544) estimated 5 to 20 min daily on self-management; 22% spent an hour or more. Ophthalmologists provided most dry eye care (67%, n=520). Only 48% (n=524) reported that their primary source of dry eye information came from their eye care clinician. CONCLUSIONS: Artificial tears are the primary treatment for dry eye. Ophthalmologists provide most dry eye care, but half of patients report that their eye care provider is not their primary source of information. Almost one fourth of patients spend an hour or more daily on treatments.

Economic impact of dry eye disease in Spain: A multicentre retrospective insurance claims database analysis.

PURPOSE: To analyse the occurrence and cost of dry eye disease in Spain in the recent years. METHODS: A cross-sectional analysis based on anonymised data from an insurance claims database that includes data from 1997 to 2015 from public and private hospitals and healthcare centres; 36,081 patients were eligible for the study after duplicate elimination. Five ICD9 codes associated with dry eye were used for patient selection, including vitamin A deficiency with xerophthalmic scars of cornea, xerophthalmia due to vitamin A deficiency, keratoconjunctivitis sicca not specified as Sjögren's, dry eye syndrome and keratoconjunctivitis sicca Sjögren's disease. RESULTS: Over 88% of the patients were female, and the mean age was 66 years. Patients with keratoconjunctivitis sicca Sjögren's disease represented more than 89% of all patients and had the highest percentage of women. Both the annual number of patients and the number of admissions have increased exponentially since 1997 raising from 1079 to 3097 and from 1344 to 5938, respectively. The in-hospital length of stay was 9.6 (standard deviation = 11.6) days where more than 65% of the admissions were due to emergencies. Total costs were found to increase from €4.9 to €30.3 million during the study period; in parallel, there was an increase in the mean annual cost per patient, which was on average €7379. CONCLUSION: Disease incidence is likely to increase due to the influence of modern-day workplace, and it is important to take into account the high economic burden and the large decrease in quality of life in regards to Spanish society and health policies.

What We Know About the Epidemiology of Dry Eye Disease in Japan.

The aim of this paper is to propose a systematic review on the prevalence of dry eye disease (DED) and its economic burden in Japan and other countries. A systematic review was performed of data gathered from a PubMed search between 2002 to 2017, using the following key words: "dry eye," "prevalence," "epidemiology," and "risk factors." There have been several cross-sectional studies evaluating the epidemiological aspect of DED in Japan: two population-based studies, two cross-sectional studies on visual display terminal (VDT) users, and one study focusing on high school students. One study calculated the direct cost of DED, and two calculated the indirect cost using a work productivity assessment to evaluate the economic burden. The prevalence of DED in the Japanese population was relatively high in all studies compared to reports from other countries. In Japan, the annual health plan cost per patient was estimated to be $323 (US). Work productivity loss per patient associated with definite DED was estimated to be between $741 and $6160. To conclude, it was found that DED is prevalent across generations in the Japanese population, and costs related to the disease lead to considerable economic burden.

Social-economic analysis of patients with Sjogren's syndrome dry eye in East China: a cross-sectional study.

BACKGROUND: Sjogren's syndrome is the leading cause for aqueous tear-deficiency dry eye. Little is known regarding the relationship between Sjogren's syndrome dry eye (SSDE) and patients' medical expenditure, clinical severity and psychological status changes. METHODS: Thirty-four SSDE patients and thirty non-Sjogren's syndrome dry eye (non-SSDE) subjects were enrolled. They were required to complete three self-report questionnaires: Ocular Surface Disease Index, Zung Self Rating Anxiety Scales, and a questionnaire designed by the researchers to study the patients' treatment, medical expenditure and income. The correlations between expenditures and these parameters were analyzed. RESULTS: The annual total expenditure on the treatment of SSDE was Chinese Yuan 7637.2 (approximately US$1173.8) on average, and the expense paid by SSDE patients themselves was Chinese Yuan 2627.8 (approximately US$403.9), which were 5.5 and 4.5 times higher than non-SSDE patients (both P < 0.001). The annual total expense on Chinese medicine and western medicine were 35.6 times and 78.4% higher in SSDE group than in non-SSDE group (both P < 0.001). Moreover, indirect costs associated with the treatment were 70.0% higher in SSDE group. In SSDE group, the score of Zung Self Rating Anxiety Scales had significantly positive correlation with total medical expenditure and the expense on Chinese medicine (ρ = 0.399 and ρ = 0.400,both P = 0.019). Nevertheless, total medical expenditure paid by the patients in non-SSDE group positively correlated with the score of Ocular Surface Disease Index (ρ = 0.386, P = 0.035). CONCLUSIONS: Medication expenditures and associated costs is an unignorable economic burden to the patients with SSDE. The medical expense had a significantly correlation with clinical severity of SSDE and the patients' psychological status.

Dry eye disease and work productivity loss in visual display users: the Osaka study.

PURPOSE: To estimate the impact of dry eye disease (DED) on work performance and productivity in office workers using visual display terminals (VDTs). DESIGN: Cross-sectional study. METHODS: Six hundred seventy-two Japanese young and middle-aged office workers using VDTs completed a questionnaire that was designed to measured at-work performance deficits and productivity losses using the Japanese version of the Work Limitations Questionnaire, completed by e-mail. Using the Japanese dry eye diagnostic criteria, respondents were classified into 3 groups: definite DED, probable DED, and non DED. RESULTS: Of the 672 office workers, 553 subjects (82.3%), including 366 men and 187 women, completed the questionnaire and underwent clinical evaluation. As for the total workplace productivity loss, the non DED group demonstrated a loss of 3.56%, those with probable DED demonstrated a loss of 4.06%, and those with definite DED demonstrated a loss of 4.82%, indicating significantly worse performance and productivity (P = .014, trend test). For the 4 subscales, DED was associated with significantly lower on-the-job time management (P = .009, trend test) and combined mental performance and interpersonal functioning (P = .011, trend test). After controlling for age, sex, VDT working hours, and diagnosis of DED, time management, physical demands, and mental and interpersonal functioning showed a significant relationship to DED (each P > .05). Annual DED productivity losses were estimated to be $6160 per employee when measured by total production and $1178 per employee calculated by wage. CONCLUSIONS: This study indicated that there is a significant impact of DED on the total productivity of Japanese VDT users.

Pharmacoeconomics of anterior ocular inflammatory disease.

PURPOSE OF REVIEW: Anterior ocular inflammatory disease (AOID) affects more that 40% of the U.S. population, which includes ocular allergies, various forms of infectious conjunctivitis, and dry eye diseases (tear film dysfunction). This review evaluates the recent economic costs of AOID treatment. RECENT FINDINGS: Rapid advances in pharmacotherapy of the anterior surface of the eye have been made as the expansion of the immunopathophysiology underlying these disorders ranging from the innate Toll-like receptors to the more specific IgE receptors are being unravelled. Even with these advances in AOID immunopathophysiology, progressive new treatments that address inflammatory mediators and their receptors with advancements in the development of ophthalmic remain limited. In 2011, AOID represents 40% of cost associated with ophthalmic drugs focusing on dry eye (31%), anti-infectives (30%), anti-allergics (25%), and anti-inflammatory agents (14%). With rising treatment costs, a need for cost-effective medicines remains to be pursued along with the development of treatment algorithms to maximize the therapeutic outcomes. SUMMARY: The economic burden of AOID has dramatically increased in recent years, with prescription drug expenditure approaching approximately $7 billion. There is an increasing need for major investment in this sector to improve outcomes as well as provide more effective alternative treatment modalities to the current options.

Managed care implications of age-related ocular conditions.

The economic costs of age-related ocular diseases and vision loss are increasing rapidly as our society ages. In addition to the direct costs of treating age-related eye diseases, elderly persons with vision loss are at significantly increased risk for falls and fractures, experiencing social isolation, and suffering from an array of comorbid medical conditions compared with individuals with normal vision. Recent studies estimate the total economic burden (direct and indirect costs) of adult vision impairment in the United States at $51.4 billion. This figure is expected to increase as the baby boomer generation continues to age. While a number of highly effective new therapies have caused a paradigm shift in the management of several major age-related ocular diseases in recent years, these treatments come at a substantial cost. This article reviews the economic burdens and treatment-related costs of 4 major ocular diseases of aging-glaucoma, age-related macular degeneration, diabetic retinopathy, and dry eye disease-and the implications for managed care.

Dry eye medication use and expenditures: data from the medical expenditure panel survey 2001 to 2006.

PURPOSE: To study dry eye medication use and expenditures from 2001 to 2006 using a nationally representative sample of US adults. METHODS: This study retrospectively analyzed dry eye medication use and expenditures of participants of the 2001 to 2006 Medical Expenditure Panel Survey, a nationally representative subsample of the National Health Interview Survey. After adjusting for survey design and for inflation using the 2009 inflation index, data from 147 unique participants aged 18 years or older using the prescription medications Restasis and Blephamide were analyzed. The main outcome measures were dry eye medication use and expenditures from 2001 to 2006. RESULTS: Dry eye medication use and expenditures increased between the years 2001 and 2006, with the mean expenditure per patient per year being $55 in 2001 to 2002 (n=29), $137 in 2003 to 2004 (n=32), and $299 in 2005 to 2006 (n=86). This finding was strongly driven by the introduction of topical cyclosporine emulsion 0.05% (Restasis; Allergan, Irvine, CA). In analysis pooled over all survey years, demographic factors associated with dry eye medication expenditures included gender (female: $244 vs. male: $122, P<0.0001), ethnicity (non-Hispanic: $228 vs. Hispanic: $106, P<0.0001), and education (greater than high school: $250 vs. less than high school: $100, P<0.0001). CONCLUSIONS: We found a pattern of increasing dry eye medication use and expenditures from 2001 to 2006. Predictors of higher dry eye medication expenditures included female gender, non-Hispanic ethnicity, and greater than a high school education.

Longitudinal evidence on punctal plug use in an elderly population.

PURPOSE: The purpose of this study was to determine whether changes in Medicare reimbursement for punctal plug insertion were associated with a decrease in the incidence of insertion and dry eye diagnosis. METHODS: Incident cases of dry eye syndrome (DES) diagnoses and punctal plug insertions among Medicare beneficiaries were identified from Medicare 5% Part B from 1994 to 2008, using a 3-year look-back. Dry eye syndrome diagnoses and punctal plug insertion codes were ascertained from the international classification of diseases and current procedural terminology codes. Medicare payment data were obtained from the Centers for Medicare and Medicaid Services from 1994 to 2008 for punctal plug insertion. Rates were calculated for both the incidence of DES and the use of punctal plugs. RESULTS: From 2001 to 2008, inflation-adjusted Medicare reimbursement for punctal plug insertion decreased 55.1%, whereas the Medicare population-adjusted incidence of dry eye diagnosis increased 23.3%. Nine percent of individuals diagnosed with DES between 1991 and 2008 underwent punctal plug placement with a mean of 2.0 plugs placed per patient. Total punctal plug placement increased 322.2% between 1994 and 2003, and then reached a plateau. First-time punctal plug insertion rates within 365 days of DES diagnosis increased 111.8% from 1994 to 2002, and then declined 47.0% from 2002 to 2008. CONCLUSIONS: Although the frequency of DES diagnosis in the Medicare population has increased over time, first-time punctal plug insertion rates, especially within the first year following DES diagnosis, have declined coincidently with the increasing presence of a medical alternative and declining Medicare payment. Choice of therapies may have cost and care implications.

Cost of dry eye treatment in an Asian clinic setting.

OBJECTIVES: To estimate the cost and patterns of expenditure of dry eye treatment. METHODOLOGY: We retrieved data on the type and cost of dry eye treatment in Singapore National Eye Centre from pharmacy and clinic inventory databases over a 2 year period (2008-2009) retrospectively. According to the type of treatment, data were sorted into 7 groups; meibomien gland disease (MGD) treatment, preservative free lubricant eye drops, preserved lubricant eye drops, lubricant ointments and gels, cyclosporine eye drops, oral supplements and non-pharmacological treatments/procedures. Each recorded entry was considered as one patient episode (PE). Comparisons in each group between two years were carried out using Pearson Chi-Square test. Significance level was set at alpha  =  0.05. RESULTS: Cost data from 54,052 patients were available for analysis. Total number of recorded PEs was 132,758. Total annual expenditure on dry eye treatment for year 2008 and 2009 were US$1,509,372.20 and US$1,520,797.80 respectively. Total expenditure per PE in year 2008 and 2009 were US$22.11 and US$23.59 respectively. From 2008 to 2009, there was a 0.8% increase in total annual expenditure and 6.69% increase in expenditure per PE. Pharmacological treatment attributes to 99.2% of the total expenditure with lubricants accounting for 79.3% of the total pharmacological treatment expenditure. Total number of units purchased in preservative free lubricants, cyclosporine eye drops and MGD therapy have increased significantly (p<0.001) whereas number of units purchased in preserved lubricants and ointments/gels have reduced significantly (p<0.001) from 2008 to 2009. CONCLUSION: Dry eye imposes a significant direct burden to health care expenditure even without considering indirect costs. Health care planners should be aware that these direct costs appear to increase over the time and more so for particular types of medications. Given the limitations of socio-economic data, true societal costs of Dry eye syndrome are likely to be much higher than estimated.

The economic burden of dry eye disease in the United States: a decision tree analysis.

PURPOSE: The aim of this study was to estimate both the direct and indirect annual cost of managing dry eye disease (DED) in the United States from a societal and a payer's perspective. METHODS: A decision analytic model was developed to estimate the annual cost for managing a cohort of patients with dry eye with differing severity of symptoms and treatment. The direct costs included ocular lubricants, cyclosporine, punctal plugs, physician visits, and nutritional supplements. The indirect costs were measured as the productivity loss because of absenteeism and presenteeism. The model was populated with data that were obtained from surveys that were completed by dry eye sufferers who were recruited from online databases. Sensitivity analyses were employed to evaluate the impact of changes in parameters on the estimation of costs. All costs were converted to 2008 US dollars. RESULTS: Survey data were collected from 2171 respondents with DED. Our analysis indicated that the average annual cost of managing a patient with dry eye at $783 (variation, $757-$809) from the payers' perspective. When adjusted to the prevalence of DED nationwide, the overall burden of DED for the US healthcare system would be $3.84 billion. From a societal perspective, the average cost of managing DED was estimated to be $11,302 per patient and $55.4 billion to the US society overall. CONCLUSIONS: DED poses a substantial economic burden on the payer and on the society. These findings may provide valuable information for health plans or employers regarding budget estimation.

Value-based medicine, comparative effectiveness, and cost-effectiveness analysis of topical cyclosporine for the treatment of dry eye syndrome.

OBJECTIVE: To assess the comparative effectiveness and cost-effectiveness (cost-utility) of a 0.05% emulsion of topical cyclosporine (Restasis; Allergan Inc, Irvine, California) for the treatment of moderate to severe dry eye syndrome that is unresponsive to conventional therapy. METHODS: Data from 2 multicenter, randomized, clinical trials and Food and Drug Administration files for topical cyclosporine, 0.05%, emulsion were used in Center for Value-Based Medicine analyses. Analyses included value-based medicine as a comparative effectiveness analysis and average cost-utility analysis using societal and third-party insurer cost perspectives. MAIN OUTCOME MEASURES: Outcome measures of comparative effectiveness were quality-adjusted life-year (QALY) gain and percentage of improvement in quality of life, and for cost-effectiveness were cost-utility ratio (CUR) using dollars per QALY. RESULTS: Topical cyclosporine, 0.05%, confers a value gain (comparative effectiveness) of 0.0319 QALY per year compared with topical lubricant therapy, a 4.3% improvement in quality of life for the average patient with moderate to severe dry eye syndrome that is unresponsive to conventional lubricant therapy. The societal perspective incremental CUR for cyclosporine over vehicle therapy is $34,953 per QALY and the societal perspective average CUR is $11,199 per QALY. The third-party-insurer incremental CUR is $37,179 per QALY, while the third-party-insurer perspective average CUR is $34,343 per QALY. CONCLUSIONS: Topical cyclosporine emulsion, 0.05%, confers considerable patient value and is a cost-effective therapy for moderate to severe dry eye syndrome that is unresponsive to conventional therapy.

United States cost-effectiveness study of two dry eye ophthalmic lubricants.

PURPOSE: Dry eye is thought to be the most common ocular problem in the United States. However, it is only recently that it has been recognized as a disease with significant economic burden and impact on quality of life. This article presents an economic model of cost-effectiveness of two ophthalmic lubricants commonly used in the treatment of dry eye-Systane and Refresh Tears. METHOD: We conducted a meta-analysis, pooling the results of two clinical trials of patients with dry eye treated with Systane and Refresh Tears which presented response rates for improvements in ocular dryness, the key symptom of dry eye. An economic model was used to estimate the incremental cost-effectiveness ratio (ICER) for Systane versus Refresh Tears over a 12 month treatment period. RESULTS: Systane is significantly more effective than Refresh Tears at improving symptoms of "dryness" (75% vs 41%). Systane costs on average $57.79 per year more than Refresh Tears. Assigning a quality-adjusted life year (QALY) gain of 0.03 to responders results in an incremental cost per QALY gain of $5,837. CONCLUSION: Both Refresh Tears and Systane are effective and cost-effective interventions. Systane costs more than Refresh Tears, however clinical trial evidence shows it to be more effective. The ICER for Systane versus Refresh Tears is well below the generally accepted $50,000 per QALY threshold.

Prevalence, burden, and pharmacoeconomics of dry eye disease.

Data from a large US managed care database suggest that the prevalence of clinically diagnosed dry eye disease (DED) is 0.4% to 0.5% overall, and is highest among women and the elderly. The burden of DED to the patient can be substantial, impacting visual function, daily activities, social and physical functioning, workplace productivity, and quality of life (QOL). Preliminary analysis suggests that DED also has a considerable economic impact in terms of both direct and indirect costs. A number of therapies have been shown to improve DED signs and symptoms, but few clinical trials have addressed QOL and economic issues. Limited data suggest that topical cyclosporine has the potential to reduce physician visits and use of other medications, including artificial tears; however, further research is needed to clarify its impact on both the direct and indirect costs of DED.

Utilization characteristics of topical cycolsporine and punctal plugs in a managed care database.

A retrospective administrative claims analysis of treatment options for dry eye disease (DED) evaluated treatment patterns and utilization characteristics of patients receiving cyclosporine, punctal plugs, or a combination of cyclosporine and punctal plugs, and examined differences in health plan costs with the 2 treatments. A total of 23,821 commercial health plan enrollees that initiated treatment with cyclosporine or punctal plugs between January 1, 2004, and December 31, 2005, were reviewed. There were 9065 subjects in the cyclosporine group, with a mean of 3.93 (median of 3) prescription fills reported in the 365-day follow-up period per subject. The mean health plan cost per patient was $336 (median $228), with total health plan costs of $3.05 million. In the punctal plugs cohort of 8758 subjects, there was a mean of 2.85 punctal plugs procedures per patient in the follow-up period. Total health plan costs for punctal plugs procedures were $3.28 million (mean cost per patient $375). During the follow-up period, 21.1% of punctal plugs patients subsequently received cyclosporine, whereas only 11.4% of topical cyclosporine patients subsequently received punctal plugs. Our results suggest that use of topical cyclosporine before punctal plugs insertion may be of benefit to patients with DED and could result in a savings in overall treatment costs.

The annual cost of dry eye syndrome in France, Germany, Italy, Spain, Sweden and the United Kingdom among patients managed by ophthalmologists.

OBJECTIVES: To estimate the annual cost associated with the management of dry eye patients by ophthalmologists in France, Germany, Italy, Spain, Sweden, and the United Kingdom (UK) from the perspective of the healthcare systems in the respective countries. METHODS: Published epidemiological and healthcare resource use data attributable to dry eye syndrome was supplemented with information obtained from interviewing ophthalmologists in the six countries. RESULTS: The estimated prevalence of dry eye syndrome among patients reporting to ophthalmologists was less than 0.1% in all six countries. The total annual healthcare cost of 1,000 dry eye syndrome sufferers managed by ophthalmologists ranged from 0.27 million US dollars (95% CI: 0.20 US dollars; 0.38 million US dollars) in France to 1.10 million US dollars (95% CI: 0.70 US dollars; 1.50 million US dollars) in the UK. A large proportion of dry eye patients either self-treat or are managed by their general practitioner. Hence, our analysis reflects the prevalence and costs of those patients severe enough to warrant treatment by an ophthalmologist. CONCLUSIONS: Given the limitations of the available economic evidence and our data sources, dry eye syndrome does not appear to impose a direct burden to the health care expenditure in the countries investigated. However, given that many dry eye sufferers self-treat with over-the-counter artificial tears and other medications, data which our study did not capture, the true societal costs of dry eye syndrome, borne by both patient and government, are likely to be higher.

The economic burden of dry eye: a conceptual framework and preliminary assessment.

PURPOSE: To develop a conceptual framework for analyzing the economic burden of dry eye and a preliminary assessment of key factors that contribute to that burden. METHODS: The MEDLINE database was searched from 1966 to May 2003 combining the term "dry eye" with various economic terms. In addition, individual interviews with a panel of clinicians were conducted to provide additional insight on resource use. RESULTS: Direct resource utilization among dry eye sufferers includes healthcare professional visits, nonpharmacological therapies, pharmacological treatments, and surgical procedures, with the latter 2 categories being the major cost drivers. Complementary and alternative medicine (CAM) therapies are a newly recognized component of the dry eye economic burden. There is wide variation in patterns of diagnosis and treatment, but current therapies are not universally effective. Given the prevalence of the condition, indirect costs may be large. Utilization of pharmacological therapies, especially those other than tear replacements, the extent of CAM use, cost of complications of surgical procedures, and indirect costs are unknown. The natural history and probability that patients will transition between therapies, based on underlying disease severity, need to be elucidated. CONCLUSIONS: Dry eye is a prevalent condition with the potential for a high economic burden; additional studies are needed to further characterize the economic impact.

Relative costs of various preserved artificial tear solutions for the treatment of dry eye conditions.

PURPOSE: Tear substitutes are one of the primary treatment modalities for dry eye conditions. The goal of this research was to determine the least costly preserved artificial tear product for treating patients with mild dry eye conditions. METHODS: Eight manufacturers' samples of artificial tears were examined to determine the effect of bottle angle on the dispensing drop size, the average drop volume, the number of drops per bottle, the measured volume of a bottle compared with its advertised volume, and the approximate cost per year for dry eye treatment. Drop sizes (mass) were determined by weighing to the nearest milligram. The retail cost was assessed to determine the most economical tear substitute. RESULTS: For all samples tested, a smaller drop was produced when the bottle was held at a 45-degree angle as compared with a 90-degree angle from horizontal. At a 45-degree angle, Natural Tears Formula by Murine and Artificial Tears by Heath Pride produced the smallest drops, less than 0.030 g, closest to the volume of the lacrimal lake. Smaller drop size produced accordingly more drops per bottle. The measured total bottle volume averaged 3.5% more than the volumes stated on the labels. The most inexpensive sample based on cost per year of treatment was Natural Tears Formula by Murine at $11.29 annually. CONCLUSIONS: Cost comparison of commercial over-the-counter artificial tears is an important factor to patients being treated for a dry eye condition. Several factors are important when considering the economics of article tear substitutes: drop size, number of drops per bottle, the volume of the bottle, and the cost of treatment per year. Because this information may not be readily available to patients, it is of great importance that physicians educate their patients to make treatment of dry eye as affordable as possible. The least expensive artificial tear treatments could require prolonged use of the same bottle, which may be associated with contamination of the contents of that bottle over time. The potential contamination with the long-term use of artificial tears in a bottle is significant. Patients using the least expensive artificial tear treatments should be advised against prolonged use of the same bottle.

Considerations in the pharmacoeconomics of dry eye.

Dry eye disease diminishes the quality of patients' lives and drives utilization of health care resources. Until recently, all treatments for dry eye have been palliative. A new treatment, cyclosporine A ophthalmic emulsion, addresses the disease's underlying causes. It warrants pharmacoeconomic analysis to determine its place in managed care.