BCLA CLEAR Presbyopia: Epidemiology and impact.

The global all-ages prevalence of epidemiologically-measured 'functional' presbyopia was estimated at 24.9% in 2015, affecting 1.8 billion people. This prevalence was projected to stabilise at 24.1% in 2030 due to increasing myopia, but to affect more people (2.1 billion) due to population dynamics. Factors affecting the prevalence of presbyopia include age, geographic location, urban versus rural location, sex, and, to a lesser extent, socioeconomic status, literacy and education, health literacy and inequality. Risk factors for early onset of presbyopia included environmental factors, nutrition, near demands, refractive error, accommodative dysfunction, medications, certain health conditions and sleep. Presbyopia was found to impact on quality-of-life, in particular quality of vision, labour force participation, work productivity and financial burden, mental health, social wellbeing and physical health. Current understanding makes it clear that presbyopia is a very common age-related condition that has significant impacts on both patient-reported outcome measures and economics. However, there are complexities in defining presbyopia for epidemiological and impact studies. Standardisation of definitions will assist future synthesis, pattern analysis and sense-making between studies.

Choosing Wisely: Applying Value-Based Economic Principles to Population Science Research Investment.

Scientific research requires a substantial investment of time, effort, and money by researchers and funders. The funding that would be needed for all meritorious proposals far exceeds available resources. Major funding organizations use a multistep process for allocating research dollars that follows and extends beyond scientific peer review with considerations including mission priority, budget, and potential duplication of past or ongoing research activities. At the level of programmatic review, the process tends to be less proscribed than scientific review, but considerations relate to and are akin to basic value-driven economic principles. We propose a framework that encompasses the elements of programmatic review and provide examples of how the economic principles of opportunity costs, diminishing marginal productivity, sunk costs, economic optimization, return on investment, and option value apply to both research planning and funding decisions. Examples use cancer control population science research, as the nature of observational and interventional research involves large population studies (large sample size, recruitment, and often long-duration follow-up costs) which demand a high level of resource utilization; the same principles can be applied throughout medical and population health research. Awareness of the aspects of programmatic review and context to focus discussion regarding funding decisions may help guide research planning, decision-making, and increase transparency of the overall review process.

Examining cancer screening disparities by race/ethnicity and insurance groups: A comparison of 2008 and 2018 National Health Interview Survey (NHIS) data in the United States.

BACKGROUND: Pervasive differences in cancer screening among race/ethnicity and insurance groups presents a challenge to achieving equitable healthcare access and health outcomes. However, the change in the magnitude of cancer screening disparities over time has not been thoroughly examined using recent public health survey data. METHODS: A retrospective cross-sectional analysis of the 2008 and 2018 National Health Interview Survey (NHIS) database focused on breast, cervical, and colorectal cancer screening rates among race/ethnicity and insurance groups. Multivariable logistic regression models were used to assess the relationship between cancer screening rates, race/ethnicity, and insurance coverage, and to quantify the changes in disparities in 2008 and 2018, adjusting for potential confounders. RESULTS: Colorectal cancer screening rates increased for all groups, but cervical and mammogram rates remained stagnant for specific groups. Non-Hispanic Asians continued to report consistently lower odds of receiving cervical tests (OR: 0.42, 95% CI: 0.32-0.55, p<0.001) and colorectal cancer screening (OR: 0.55, 95% CI: 0.42-0.72, p<0.001) compared to non-Hispanic Whites in 2018, despite significant improvements since 2008. Non-Hispanic Blacks continued to report higher odds of recent cervical cancer screening (OR: 1.98, 95% CI: 1.47-2.68, p<0.001) and mammograms (OR: 1.32, 95% CI: 1.02-1.71, p<0.05) than non-Hispanic Whites in 2018, consistent with higher odds observed in 2008. Hispanic individuals reported improved colorectal cancer screening over time, with no significant difference compared to non-Hispanics Whites in 2018, despite reporting lower odds in 2008. The uninsured status was associated with significantly lower odds of cancer screening than private insurance for all three cancers in 2008 and 2018. CONCLUSION: Despite an overall increase in breast and colorectal cancer screening rates between 2008 and 2018, persistent racial/ethnic and insurance disparities exist among race/ethnicity and insurance groups. These findings highlight the importance of addressing underlying factors contributing to disparities among underserved populations and developing corresponding interventions.

The case for investment in eye health: systematic review and economic modelling analysis.

Objective: To assess how the returns on investment from correcting refractive errors and cataracts in low- and middle-income countries compare with the returns from other global development interventions. Methods: We adopted two complementary approaches to estimate benefit-cost ratios from eye health investment. First, we systematically searched PubMed® and Web of Science™ on 14 August 2023 for studies conducted in low-and-middle-income countries, which have measured welfare impacts associated with correcting refractive errors and cataracts. Using benefit-cost analysis, we compared these impacts to costs. Second, we employed an economic modelling analysis to estimate benefit-cost ratios from eye health investments in India. We compared the returns from eye health to returns in other domains across global health and development. Findings: We identified 21 studies from 10 countries. Thirteen outcomes highlighted impacts from refractive error correction for school students. From the systematic review, we used 17 out of 33 outcomes for benefit-cost analyses, with the median benefit-cost ratio being 36. The economic modelling approach for India generated benefit-cost ratios ranging from 28 for vision centres to 42 for school eye screening, with an aggregate ratio of 31. Comparing our findings to the typical investment in global development shows that eye health investment returns six times more benefits (median benefit-cost ratio: 36 vs 6). Conclusion: Eye health investments provide economic benefits with varying degrees based on the intervention type and location. Our findings underline the importance of incorporating eye health initiatives into broader development strategies for substantial societal returns.

Cost-effectiveness analysis comparing in-office posterior nasal nerve ablation to surgical therapies.

BACKGROUND: Recently, in-office posterior nasal nerve ablation (PNA) devices have offered a new tool to treat refractory chronic rhinitis, but their cost-effectiveness relative to traditional interventions such as vidian neurectomy (VN) and posterior nasal neurectomy (PNN) remains unexplored. OBJECTIVE: To compare the cost-effectiveness of these interventions in patients with refractory chronic rhinitis. METHODS: A decision tree with embedded Markov models was created to compare the cost-effectiveness of PNN, VN, and PNA, measured in quality-adjusted life years (QALYs) over a 30-year time horizon with a $100,000/QALY willingness-to-pay threshold. One- and two-way sensitivity analyses were completed. RESULTS: Sensitivity analysis found that in-office PNA became cost-effective compared to VN when patients undergoing PNA were less than 20 % more likely than VN to have symptoms recur; this value was assumed to be twice as likely in the base case. In the base case, however, VN and in-office PNA were more effective and less expensive than PNN, while VN was cost-effective when compared to in-office PNA (incremental cost-effectiveness ratio $11,616.24/QALY). Other assumptions were not found to considerably impact incremental cost-effectiveness. CONCLUSION: Although highly limited by currently available data, PNA may be cost-effective compared to VN as long-term outcomes on the durability of its effects emerge. These data should not be used by payers considering coverage or utilization since long-term data is still nascent. However, that as new technologies emerge for rhinitis, it will be important to monitor longer-term outcomes to identify high value care, but based on limited data PNA devices may meet this standard.

Establishing a method to estimate the effect of antimyopia management options on lifetime cost of myopia.

BACKGROUND: Informed decisions on myopia management require an understanding of financial impact. We describe methodology for estimating lifetime myopia costs, with comparison across management options, using exemplars in Australia and China. METHODS: We demonstrate a process for modelling lifetime costs of traditional myopia management (TMM=full, single-vision correction) and active myopia management (AMM) options with clinically meaningful treatment efficacy. Evidence-based, location-specific and ethnicity-specific progression data determined the likelihood of all possible refractive outcomes. Myopia care costs were collected from published sources and key informants. Refractive and ocular health decisions were based on standard clinical protocols that responded to the speed of progression, level of myopia, and associated risks of pathology and vision impairment. We used the progressions, costs, protocols and risks to estimate and compare lifetime cost of myopia under each scenario and tested the effect of 0%, 3% and 5% annual discounting, where discounting adjusts future costs to 2020 value. RESULTS: Low-dose atropine, antimyopia spectacles, antimyopia multifocal soft contact lenses and orthokeratology met our AMM inclusion criteria. Lifetime cost for TMM with 3% discounting was US$7437 (CI US$4953 to US$10 740) in Australia and US$8006 (CI US$3026 to US$13 707) in China. The lowest lifetime cost options with 3% discounting were antimyopia spectacles (US$7280, CI US$5246 to US$9888) in Australia and low-dose atropine (US$4453, CI US$2136 to US$9115) in China. CONCLUSIONS: Financial investment in AMM during childhood may be balanced or exceeded across a lifetime by reduced refractive progression, simpler lenses, and reduced risk of pathology and vision loss. Our methodology can be applied to estimate cost in comparable scenarios.

Surgeon Volume and Laryngectomy Outcomes.

OBJECTIVE: To examine the relationship between surgeon volume and operative morbidity and mortality for laryngectomy. DATA SOURCES: The Nationwide Inpatient Sample was used to identify 45,156 patients who underwent laryngectomy procedures for laryngeal or hypopharyngeal cancer between 2001 and 2011. Hospital and surgeon laryngectomy volume were modeled as categorical variables. METHODS: Relationships between hospital and surgeon volume and mortality, surgical complications, and acute medical complications were examined using multivariable regression. RESULTS: Higher-volume surgeons were more likely to operate at large, teaching, nonprofit hospitals and were more likely to treat patients who were white, had private insurance, hypopharyngeal cancer, low comorbidity, admitted electively, and to perform partial laryngectomy, concurrent neck dissection, and flap reconstruction. Surgeons treating more than 5 cases per year were associated with lower odds of medical and surgical complications, with a greater reduction in the odds of complications with increasing surgical volume. Surgeons in the top volume quintile (>9 cases/year) were associated with a decreased odds of in-hospital mortality (OR = 0.09 [0.01-0.74]), postoperative surgical complications (OR = 0.58 [0.45-0.74]), and acute medical complications (OR = 0.49 [0.37-0.64]). Surgeon volume accounted for 95% of the effect of hospital volume on mortality and 16%-47% of the effect of hospital volume on postoperative morbidity. CONCLUSION: There is a strong volume-outcome relationship for laryngectomy, with reduced mortality and morbidity associated with higher surgeon and higher hospital volumes. Observed associations between hospital volume and operative morbidity and mortality are mediated by surgeon volume, suggesting that surgeon volume is an important component of the favorable outcomes of high-volume hospital care. Laryngoscope, 133:834-840, 2023.

Hospital Markup in Head and Neck Cancer Surgery in the US.

Importance: Marked variation in hospital costs and payments is a target for health care reform efforts. Limited data exist to explain variability in prices for head and neck surgical procedures. Objective: To characterize variations in hospital price markup for head and neck cancer surgery, and examine associations with market concentration and hospital for-profit status. Design, Setting, and Participants: In this cross-sectional study, the Nationwide Inpatient Sample was used to identify 150 275 patients who underwent head and neck cancer surgery for a malignant upper aerodigestive tract neoplasm from 2001 to 2011. The markup ratio (charges to costs) was modeled as a continuous and categorical variable. Hospital market concentration was evaluated using a variable-radius Herfindahl-Hirschman Index from the 2000, 2003, 2006, and 2009 Hospital Market Structure files. Data were analyzed from May 2019 to July 2019. Main Outcomes and Measures: Multivariable regression was used to evaluate associations between hospital and patient variables and hospital markup. Results: There were 150 275 patients (mean [SD] age, 61.8 [12.6] years; 104 974 [70.0%] male) from 2001 to 2011 for whom hospital market information was available. Hospital markup ratios ranged from 0.8 to 8.7, with a mean markup ratio of 2.8 (95% CI, 2.7-2.9). Hospitals in the lowest markup ratio quartile had a mean markup ratio of 1.8 (95% CI, 1.8-1.9), while hospitals in the top markup ratio quartile (extreme markup) had a mean markup ratio of 4.1 (95% CI, 4.0-4.2). Extreme markup hospitals were more often large (77.5% vs 66.6%), private for-profit hospitals (19.0% vs 1.3%), and were less likely to be high-volume hospitals (21.0% vs 9.4%) or in competitive markets (64.4% vs 82.0%). Postoperative complications occurred more often in extreme markup hospitals (22.7% vs 17.1%). On multivariate analysis, a significantly higher markup was associated with private, for-profit hospitals (47.9%; 95% CI, 33.3%-64.2%), hospitals in the West (25.5%; 95% CI, 12.6%-39.8%), Hispanic race (9.8%; 95% CI, 4.4%-15.5%), prior radiation therapy (5.3%; 95% CI, 1.3%-9.4%), comorbidity (3.5%; 95% CI, 1.7%-5.4%), and complications (2.8%; 95% CI, 0.3%-5.4%). Hospital market concentration modified the association between hospital for-profit status and markup, with higher markups in for-profit hospitals in moderately concentrated and concentrated (less competitive) markets. Conclusions and Relevance: In this cross-sectional study, there was wide variation in hospital markup for head and neck cancer surgery, with a 4-fold increase in charges relative to costs in 25% of hospitals. Variations in surgical price were primarily associated with hospital profit status. These data suggest that greater transparency is needed to address disparities in hospital pricing.

Update of a Simple Model to Calculate the Annual Global Productivity Loss Due to Blindness and Moderate and Severe Vision Impairment.

PURPOSE: To develop a simple but more precise model to calculate potential annual productivity losses due to blindness and moderate and severe vision impairment (MSVI) at the national, regional, and global level. METHODS: Productivity loss was defined as the loss of minimum wage/Gross National Income per capita (GNI) incurred by people aged 50-64 years with blindness or MSVI, who were not able to work or worked with reduced earnings in 2020. We developed a global list of minimum wage data from on-line sources. All other model data were sourced from international, standardised, and open-access databases. For blindness, the total productivity loss (not working) incurred by 64%-90% of the affected population was summed up with partial productivity loss, defined as 10%-36% of the affected population earning one-third of that of the sighted population. For MSVI, the total productivity loss for 30%-55% of the affected population was summed with the partial productivity loss, defined as 45%-70% of the affected population having 35% reduced earnings. The costs of blindness and MSVI were summed to obtain the cost of combined vision loss. RESULTS: The global cost of vision loss based on minimum wage was US$160-US$216.32 billion for 2020. The global cost of vision loss using GNI was US$449.36-US$584.66 billion. CONCLUSIONS: A parsimonious model that considers minimum wage and GNI potentially lost due to blindness and MSVI can be used for eye care programming planning and advocacy at the national, regional, and global level.

Strategies for cataract and uncorrected refractive error case finding in India: Costs and cost-effectiveness at scale.

Background: India has the largest number of individuals suffering from visual impairment and blindness in the world. Recent surveys indicate that demand-based factors prevent more than 80% of people from seeking appropriate eye services, suggesting the need to scale up cost-effective case finding strategies. We assessed total costs and cost-effectiveness of multiple strategies to identify and encourage people to initiate corrective eye services. Methods: Using administrative and financial data from six Indian eye health providers, we conduct a retrospective micro-costing analysis of five case finding interventions that covered 1·4 million people served at primary eye care facilities (vision centers), 330,000 children screened at school, 310,000 people screened at eye camps and 290,000 people screened via door-to-door campaigns over one year. For four interventions, we estimate total provider costs, provider costs attributable to case finding and treatment initiation for uncorrected refractive error (URE) and cataracts, and the societal cost per DALY averted. We also estimate provider costs of deploying teleophthalmology capability within vision centers. Point estimates were calculated from provided data with confidence intervals determined by varying parameters probabilistically across 10,000 Monte Carlo simulations. Findings: Case finding and treatment initiation costs are lowest for eye camps (URE: $8·0 per case, 95% CI: 3·4-14·4; cataracts: $13·7 per case, 95% CI: 5·6-27·0) and vision centers (URE: $10·8 per case, 95% CI: 8·0-14·4; cataracts: $11·9 per case, 95% CI: 8·8-15·9). Door-to-door screening is as cost-effective for identifying and encouraging surgery for cataracts albeit with large uncertainty ($11·3 per case, 95% CI: 2·2 to 56·2), and more costly for initiating spectacles for URE ($25·8 per case, 95% CI: 24·1 to 30·7). School screening has the highest case finding and treatment initiation costs for URE ($29·3 per case, 95% CI: 15·5 to 49·6) due to the lower prevalence of eye problems in school aged children. The annualized cost of operating a vision center, excluding procurement of spectacles, is estimated at $11,707 (95% CI: 8,722-15,492). Adding teleophthalmology capability increases annualized costs by $1,271 per facility (95% CI: 181 to 3,340). Compared to baseline care, eye camps have an incremental cost-effectiveness ratio (ICER) of $143 per DALY (95% CI: 93-251). Vision centers have an ICER of $262 per DALY (95% CI: 175-431) and were able to reach substantially more patients than any other strategy. Interpretation: Policy makers are expected to consider cost-effective case finding strategies when budgeting for eye health in India. Screening camps and vision centers are the most cost-effective strategies for identifying and encouraging individuals to undertake corrective eye services, with vision centers likely to be most cost-effective at greater scale. Investment in eye health continues to be very cost-effective in India. Funding: The study was funded by the Seva Foundation.

Global economic productivity losses from vision impairment and blindness.

BACKGROUND: In the absence of accessible, good quality eye health services and inclusive environments, vision loss can impact individuals, households and communities in many ways, including through increased poverty, reduced quality of life and reduced employment. We aimed to estimate the annual potential productivity losses associated with reduced employment due to blindness and moderate and severe vision impairment (MSVI) at a regional and global level. METHODS: We constructed a model using the most recent economic, demographic (2018) and prevalence (2020) data. Calculations were limited to the working age population (15-64 years) and presented in 2018 US Dollars purchasing power parity (ppp). Two separate models, using Gross Domestic Product (GDP) and Gross National Income (GNI), were calculated to maximise comparability with previous estimates. FINDINGS: We found that 160.7 million people with MSVI or blindness were within the working age and estimated that the overall relative reduction in employment by people with vision loss was 30.2%. Globally, using GDP we estimated that the annual cost of potential productivity losses of MSVI and blindness was $410.7 billion ppp (range $322.1 - $518.7 billion), or 0.3% of GDP. Using GNI, overall productivity losses were estimated at $408.5 billion ppp (range $320.4 - $515.9 billion), 0.5% lower than estimates using GDP. INTERPRETATION: These findings support the view that blindness and MSVI are associated with a large economic impact worldwide. Reducing and preventing vision loss and developing and implementing strategies to help visually impaired people to find and keep employment may result in significant productivity gains. FUNDING: MJB is supported by the Wellcome Trust (207472/Z/17/Z). JR's appointment at the University of Auckland is funded by the Buchanan Charitable Foundation, New Zealand. The Lancet Global Health Commission on Global Eye Health was supported by grants from The Queen Elizabeth Diamond Jubilee Trust, Moorfields Eye Charity (GR001061), NIHR Moorfields Biomedical Research Centre, The Wellcome Trust, Sightsavers, The Fred Hollows Foundation, The SEVA Foundation, The British Council for the Prevention of Blindness and Christian Blind Mission. The funders had no role in the design, conduct, data analysis of the study, or writing of the manuscript.

IMI Impact of Myopia.

The global burden of myopia is growing. Myopia affected nearly 30% of the world population in 2020 and this number is expected to rise to 50% by 2050. This review aims to analyze the impact of myopia on individuals and society; summarizing the evidence for recent research on the prevalence of myopia and high myopia, lifetime pathological manifestations of myopia, direct health expenditure, and indirect costs such as lost productivity and reduced quality of life (QOL). The principal trends are a rising prevalence of myopia and high myopia, with a disproportionately greater increase in the prevalence of high myopia. This forecasts a future increase in vision loss due to uncorrected myopia as well as high myopia-related complications such as myopic macular degeneration. QOL is affected for those with uncorrected myopia, high myopia, or complications of high myopia. Overall the current global cost estimates related to direct health expenditure and lost productivity are in the billions. Health expenditure is greater in adults, reflecting the added costs due to myopia-related complications. Unless the current trajectory for the rising prevalence of myopia and high myopia change, the costs will continue to grow. The past few decades have seen the emergence of several novel approaches to prevent and slow myopia. Further work is needed to understand the life-long impact of myopia on an individual and the cost-effectiveness of the various novel approaches in reducing the burden.

Potential Unintended Consequences of National Infectious Disease Screening Strategies in Deceased Donor Kidney Transplantation: A Cost-Effectiveness Analysis.

BACKGROUND: In order to counter the lack of sufficient kidney donors, there has been interest in expanding the utilization of organs from increased infectious-risk donors. Negative nucleic acid testing of increased infectious-risk organs has been shown to increase their use as compared to only enzyme-linked immunosorbent assay negativity. However, it is not known how the expanded use of nucleic acid testing on a national scale might affect total donor utilization. OBJECTIVE: The objective of this paper was to determine if a national screening policy requiring the use of nucleic acid testing in both increased infectious-risk and non-increased infectious-risk renal transplant donors would increase the donor organ pool. METHODS: This study used decision-tree analysis to determine the cost-effectiveness of four US national screening policies based on an increasingly expansive use of nucleic acid testing for increased infectious-risk and non-increased infectious-risk kidneys. Parameters were taken from the literature. All costs were reported in 2020 US dollars using a Medicare payer perspective and a life-time horizon. RESULTS: The use of nucleic acid screening solely for increased infectious-risk organs was the dominant strategy. Our results were robust to deterministic and probabilistic sensitivity analyses. One of the main driving factors of cost-effectiveness was the false-positive rate of nucleic acid testing. CONCLUSION: Before implementing nucleic acid screening outside of increased infectious-risk organs, its false-positivity rate should be directly studied to ensure that its use does not detrimentally affect transplantation numbers, quality-adjusted life-years, and costs.

Cost-minimisation Analysis from a Non-inferiority Trial of Ready-Made versus Custom-Made Spectacles for School Children in India.

Purpose: Uncorrected refractive error is the leading cause of visual impairment in children. Many countries, including India, implement school eye health programmes involving vision screening and provision of free spectacles. This is costly for governments/organisations involved. This analysis estimates potential cost-savings if ready-made spectacles, in addition to traditional custom-made spectacles, are available for dispensing in school eye health programmes.Methods: An economic evaluation was conducted alongside a randomised controlled trial comparing spectacle wear of ready-made spectacles versus custom-made spectacles for children aged 11-15 years in schools in India. A cost-minimisation approach was used to calculate cost-savings of a 'ready-made spectacles available' programme compared with a 'custom-made spectacles only' school programme. The analysis was from a service provider perspective. Main outcomes: cost-saving per child needing spectacles and cost-saving per 1000 children screened.Results: The prevalence of uncorrected refractive error was 2.23%, and 86% of children were eligible for ready-made spectacles. The cost per child needing spectacles in a custom-made spectacles only programme was USD$26.91, and in a ready-made spectacles available programme was $11.15, producing a 58.6% cost-saving per child needing spectacles of $15.76. Considering the total cost of the eye health programme, this equated to a 15.1% cost-saving per 1000 children screened of $361. Results were robust to multivariate sensitivity analyses.Conclusion: Our study is the first to demonstrate the significant cost-saving potential of ready-made spectacles in school eye health programmes for uncorrected refractive error compared with custom-made spectacles alone. This has substantial economic benefits for national/international programmes.

Cost effectiveness of SEEK: A primary care-based child maltreatment prevention model.

BACKGROUND: Funding for prevention interventions is often quite limited. Cost-related assessments are important to best allocate prevention funds. OBJECTIVES: To determine the (1) overall cost for implementing the Safe Environment for Every Kid (SEEK) model, (2) cost of implementation per child, and (3) cost per case of maltreatment averted. DESIGN: Cost-effective analysis of a randomized controlled trial. PARTICIPANTS AND SETTING: 102 pediatric providers at 18 pediatric primary care practices. 924 families with children < 6 years receiving care by those providers. METHODS: Practices and their providers were randomized to either SEEK training and implementation or usual care. Families in SEEK and control practices were recruited for evaluation. Rates of psychological and physical abuse were calculated by parent self-report 12 months following recruitment. Model costs were calculated including salaries for team members, provider time for training and booster sessions, and development and distribution of materials. RESULTS: Implementing SEEK in all 18 practices would have cost approximately $265,892 over 2.5 years; $3.59 per child per year; or $305.58 ($229.18-$381.97) to prevent one incident. Based on a very conservative cost estimate of $2779 per maltreatment incident, SEEK would save an estimated $2,151,878 in health care costs for 29,610 children. CONCLUSIONS: The SEEK model is cost saving. Cost per case of psychological and physical abuse averted were significantly lower than the short-term costs of medical and mental health care for maltreated children. SEEK model expansion has the potential to significantly decrease medical, mental health, and other related costs associated with maltreatment.