The Economic Burden of Vision Loss and Blindness in the United States.

PURPOSE: To estimate the economic burden of vision loss (VL) in the United States and by state. DESIGN: Analysis of secondary data sources (American Community Survey [ACS], American Time Use Survey, Bureau of Labor Statistics, Medical Expenditure Panel Survey [MEPS], National and State Health Expenditure Accounts, and National Health Interview Survey [NHIS]) using attributable fraction, regression, and other methods to estimate the incremental direct and indirect 2017 costs of VL. PARTICIPANTS: People with a yes response to a question asking if they are blind or have serious difficulty seeing even when wearing glasses in the ACS, MEPS, or NHIS. MAIN OUTCOME MEASURES: We estimated the direct costs of medical, nursing home (NH), and supportive services and the indirect costs of absenteeism, lost household production, reduced labor force participation, and informal care by age group, sex, and state in aggregate and per person with VL. RESULTS: We estimated an economic burden of VL of $134.2 billion: $98.7 billion in direct costs and $35.5 billion in indirect costs. The largest burden components were NH ($41.8 billion), other medical care services ($30.9 billion), and reduced labor force participation ($16.2 billion), all of which accounted for 66% of the total. Those with VL incurred $16 838 per year in incremental burden. Informal care was the largest burden component for people 0 to 18 years of age, reduced labor force participation was the largest burden component for people 19 to 64 years of age, and NH costs were the largest burden component for people 65 years of age or older. New York, Connecticut, Massachusetts, Rhode Island, and Vermont experienced the highest costs per person with VL. Sensitivity analyses indicate total burden may range between $76 and $218 billion depending on the assumptions used in the model. CONCLUSIONS: Self-reported VL imposes a substantial economic burden on the United States. Burden accrues in different ways at different ages, leading to state differences in the composition of per-person costs based on the age composition of the population with VL. Information on state variation can help local decision makers target resources better to address the burden of VL.

Vision Impairment and Blindness Prevalence in the United States: Variability of Vision Health Responses across Multiple National Surveys.

PURPOSE: To support survey validation efforts by comparing prevalence rates of self-reported and examination evaluated presenting visual impairment (VI) and blindness measured across national surveys. DESIGN: Cross-sectional comparison. PARTICIPANTS: Participants in the 2016 American Community Survey, the 2016 Behavioral Risk Factor Surveillance System, the 2016 National Health Interview Survey, the 2005-2008 National Health and Nutrition Examination Survey (NHANES), and the 2016 National Survey of Children's Health. METHODS: We estimated VI and blindness prevalence rates and confidence intervals for each survey measure and age group using the Clopper-Pearson method. We used inverse variance weighting to estimate the central tendency across measures by age-group, fitted trend lines to age-group estimates, and used the trend-line equations to estimate the number of United States persons with VI and blindness in 2016. We compared self-report estimates with those from NHANES physical evaluations of presenting VI and blindness. MAIN OUTCOME MEASURES: Variability of prevalence estimates of VI and blindness. RESULTS: Self-report estimates of blindness varied between 0.1% and 5.6% for those younger than 65 years and from 0.6% to 16.6% for those 65 or older. Estimates of VI varied between 1.6% and 24.8% for those younger than 65 years and between 2.2% and 26.6% for those 65 years or older. For summarized survey results and NHANES physical evaluation, prevalence rates for VI increased significantly with increasing age group. Blindness prevalence increased significantly with increasing age group for summarized survey responses but not for NHANES physical examination. Based on extrapolations of NHANES physical examination data to all ages, we estimated that in 2016, 23.4 million persons in the United States (7.2%) had VI or blindness, an evaluated presenting visual acuity of 20/40 or worse in the better-seeing eye before correction. Based on weighted self-reported surveys, we estimated that 24.8 million persons (7.7%) had presenting VI or blindness. CONCLUSIONS: Prevalence rates of VI and blindness obtained from national survey measures varied widely across surveys and age groups. Additional research is needed to validate the ability of survey self-report measures of VI and blindness to replicate results obtained through examination by an eye health professional.

The burden of hepatitis C to the United States Medicare system in 2009: Descriptive and economic characteristics.

UNLABELLED: The aim of this work was to estimate and describe the Medicare beneficiaries diagnosed with hepatitis C virus (HCV) in 2009, incremental annual costs by disease stage, incremental total Medicare HCV payments in 2009 using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data covering the years 2002 to 2009. We weighted the 2009 SEER-Medicare data to create estimates of the number of patients with an HCV diagnosis, used an inverse probability-weighted two-part, probit, and generalized linear model to estimate incremental per patient per month costs, and used simulation to estimate annual 2009 Medicare burden, presented in 2014 dollars. We summarized patient characteristics, diagnoses, and costs from SEER-Medicare files into a person-year panel data set. We estimated there were 407,786 patients with diagnosed HCV in 2009, of whom 61.4% had one or more comorbidities defined by the study. In 2009, 68% of patients were diagnosed with chronic HCV only, 9% with cirrhosis, 12% with decompensated cirrhosis (DCC), 2% with liver cancer, 2% with a history of transplant, and 8% who died. Annual costs for patients with chronic infection only and DCC were higher than the values used in many previous cost-effectiveness studies, and treatment of DCC accounted for 63.9% of total Medicare's HCV expenditures. Medicare paid $2.7 billion (credible interval: $0.7-$4.6 billion) in incremental costs for HCV in 2009. CONCLUSIONS: The costs of HCV to Medicare in 2009 were substantial and expected to increase over the next decade. Annual costs for patients with chronic infection only and DCC were higher than values used in many cost-effectiveness analyses.

The cost-effectiveness, health benefits, and financial costs of new antiviral treatments for hepatitis C virus.

BACKGROUND: New hepatitis C virus (HCV) treatments deliver higher cure rates with fewer contraindications, increasing demand for treatment and healthcare costs. The cost-effectiveness of new treatments is unknown. METHODS: We conducted a microsimulation of guideline testing followed by alternative treatment regimens for HCV among the US population aged 20 and older to estimate cases identified, treated, sustained viral response, deaths, medical costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER) of different treatment options expressed as discounted lifetime costs and benefits from the healthcare perspective. RESULTS: Compared to treatment with pegylated interferon and ribavirin (PR), and a protease inhibitor for HCV genotype (G) 1 and PR alone for G2/3, treatment with PR and Sofosbuvir (PRS) for G1/4 and treatment with Sofosbuvir and ribavirin (SR) for G2/3 increased QALYs by 555 226, reduced deaths by 80 682, and increased costs by $26.2 billion at an ICER of $47 304 per QALY gained. As compared to PRS/SR, treating with an all oral regimen of Sofosbuvir and Simeprevir (SS) for G1/4 and SR for G2/3, increased QALYs by 1 110 451 and reduced deaths by an additional 164 540 at an incremental cost of $80.1 billion and an ICER of $72 169. In sensitivity analysis, where treatment with SS effectiveness was set to the list price of Viekira Pak and then Harvoni, treatment cost $24 921 and $25 405 per QALY gained as compared to PRS/SR. CONCLUSIONS: New treatments are cost-effectiveness per person treated, but pent-up demand for treatment may create challenges for financing.

Behavioral Risk Factor Surveillance System and American Community Survey Estimates of Vision Difficulty Prevalence.

Importance: Inconsistent estimates of self-reported vision impairment across survey sources may cause confusion about the true size of the population with vision problems. Objective: To explain why the American Community Survey (ACS) and Behavioral Risk Factor Surveillance System (BRFSS) produce different prevalence estimates for self-reported vision problems in the US, despite using the same question wording. Design, Setting, and Participants: This was a cross-sectional analysis of the 2021 ACS and BRFSS using subgroup analysis and decomposition. Respondents were from 49 states and the District of Columbia. Included in the analysis were a civilian noninstitutionalized population 18 years and older. Data were analyzed from August 2022 to October 2023. Intervention: Aspects of sample design and composition. Main Outcomes and Measures: Self-reported vision problems. Results: This study included a weighted sample of 2.8 million individuals (median [IQR] age, 47.7 [32.8-63.1] years; 51% male). The estimate of self-reported vision problems prevalence from the BRFSS (4.89%; 95% CI, 4.73%-5.04%) was 1.7 times as high as the estimate from the ACS (2.95%; 95% CI, 2.92%-2.97%) for similarly defined populations. If the BRFSS sample were weighted to align with the composition of other disability types in the ACS, the prevalence of vision problems would be 3.67% (95% CI, 3.53%-3.80%), closing about 63% of the gap between survey estimates. Conclusion and Relevance: Results of this survey study suggest that the focus on health may be associated with the higher prevalence in the BRFSS through differential nonresponse or question priming. Differences in other survey operations including frame construction, proxy reporting, and imputation had little impact.

The prevalence of bilateral hearing loss in the United States in 2019: a small area estimation modelling approach for obtaining national, state, and county level estimates by demographic subgroup.

Background: The goal of this study was to re-estimate rates of bilateral hearing loss Nationally, and create new estimates of hearing loss prevalence at the U.S. State and County levels. Methods: We developed small area estimation models of mild, and moderate or worse bilateral hearing loss in the U.S. using data from the National Health and Nutrition Examination Survey (2001-2012, 2015-2018), the American Community Survey (2019), Census County Business Patterns (2019); Social Security Administration Data (2019); Medicare Fee-for-Service and Advantage claims data (2019); the Area Health Resources File (2019), and other sources. We defined hearing loss as mild (>25 dB through 40 dB), moderate or worse (>40 dB), or any (>25 dB) in the better hearing ear based on a 4-frequency pure-tone-average threshold, and created estimates by age group (0-4, 5-17, 18-34, 35-64, 65-74, 75+), gender, race and ethnicity, state, and county. Findings: We estimated that 37.9 million (95% Uncertainty Interval [U.I.] 36.6-39.1) Americans experienced any bilateral hearing loss; 24.9 million (95% U.I. 23.6-26.0) with mild and 13.0 million (95% U.I. 12.1-13.9) with moderate or worse. The prevalence rate of any hearing loss was 11.6% (95% U.I. 11.2%-12.0%). Hearing loss increased with age. Men were more likely to have hearing loss than women after age 35, and non-Hispanic Whites had higher rates of hearing loss than other races and ethnicities. Higher hearing loss prevalence was associated with smaller population size. West Virginia, Alaska, Wyoming, Oklahoma, and Arkansas had the highest standardised rate of bilateral hearing loss, and Washington D.C., New Jersey, New York, Maryland, and Connecticut had the lowest. Interpretation: Bilateral Hearing loss varies by State and County, with variation associated with population age, race and ethnicity, and population size. Geographic estimates can be used to raise local awareness of hearing loss as a problem, to prioritize areas for hearing loss prevention, identification, and treatment, and to guide future research on the hearing loss risk factors that contribute to these differences. Funding: CDC's National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health.

The global burden of hepatitis E virus genotypes 1 and 2 in 2005.

UNLABELLED: We estimated the global burden of hepatitis E virus (HEV) genotypes 1 and 2 in 2005. HEV is an emergent waterborne infection that causes source-originated epidemics of acute disease with a case fatality rate thought to vary by age and pregnancy status. To create our estimates, we modeled the annual disease burden of HEV genotypes 1 and 2 for 9 of 21 regions defined for the Global Burden of Diseases, Injuries, and Risk Factors Study (the GBD 2010 Study), which represent 71% of the world's population. We estimated the seroprevalence of anti-HEV antibody and annual incidence of infection for each region using data from 37 published national studies and the DISMOD 3, a generic disease model designed for the GBD Study. We converted incident infections into three mutually exclusive results of infection: (1) asymptomatic episodes, (2) symptomatic disease, and (3) death from HEV. We also estimated incremental cases of stillbirths among infected pregnant women. For 2005, we estimated 20.1 (95% credible interval [Cr.I.]: 2.8-37.0) million incident HEV infections across the nine GBD Regions, resulting in 3.4 (95% Cr.I.: 0.5-6.5) million symptomatic cases, 70,000 (95% Cr.I.: 12,400-132,732) deaths, and 3,000 (95% Cr.I.: 1,892-4,424) stillbirths. We estimated a probability of symptomatic illness given infection of 0.198 (95% Cr.I.: 0.167-0.229) and a probability of death given symptomatic illness of 0.019 (95% Cr.I.: 0.017-0.021) for nonpregnant cases and 0.198 (95% Cr.I.: 0.169-0.227) for pregnant cases. CONCLUSION: The model was most sensitive to estimates of age-specific incidence of HEV disease.

The economic burden of vision loss and eye disorders among the United States population younger than 40 years.

OBJECTIVE: To estimate the economic burden of vision loss and eye disorders in the United States population younger than 40 years in 2012. DESIGN: Econometric and statistical analysis of survey, commercial claims, and census data. PARTICIPANTS: The United States population younger than 40 years in 2012. METHODS: We categorized costs based on consensus guidelines. We estimated medical costs attributable to diagnosed eye-related disorders, undiagnosed vision loss, and medical vision aids using Medical Expenditure Panel Survey and MarketScan data. The prevalence of vision impairment and blindness were estimated using National Health and Nutrition Examination Survey data. We estimated costs from lost productivity using Survey of Income and Program Participation. We estimated costs of informal care, low vision aids, special education, school screening, government spending, and transfer payments based on published estimates and federal budgets. We estimated quality-adjusted life years (QALYs) lost based on published utility values. MAIN OUTCOME MEASURES: Costs and QALYs lost in 2012. RESULTS: The economic burden of vision loss and eye disorders among the United States population younger than 40 years was $27.5 billion in 2012 (95% confidence interval, $21.5-$37.2 billion), including $5.9 billion for children and $21.6 billion for adults 18 to 39 years of age. Direct costs were $14.5 billion, including $7.3 billion in medical costs for diagnosed disorders, $4.9 billion in refraction correction, $0.5 billion in medical costs for undiagnosed vision loss, and $1.8 billion in other direct costs. Indirect costs were $13 billion, primarily because of $12.2 billion in productivity losses. In addition, vision loss cost society 215 000 QALYs. CONCLUSIONS: We found a substantial burden resulting from vision loss and eye disorders in the United States population younger than 40 years, a population excluded from previous studies. Monetizing quality-of-life losses at $50 000 per QALY would add $10.8 billion in additional costs, indicating a total economic burden of $38.2 billion. Relative to previously reported estimates for the population 40 years of age and older, more than one third of the total cost of vision loss and eye disorders may be incurred by persons younger than 40 years. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

The cost-effectiveness of birth-cohort screening for hepatitis C antibody in U.S. primary care settings.

BACKGROUND: In the United States, hepatitis C virus (HCV) infection is most prevalent among adults born from 1945 through 1965, and approximately 50% to 75% of infected adults are unaware of their infection. OBJECTIVE: To estimate the cost-effectiveness of birth-cohort screening. DESIGN: Cost-effectiveness simulation. DATA SOURCES: National Health and Nutrition Examination Survey, U.S. Census, Medicare reimbursement schedule, and published sources. TARGET POPULATION: Adults born from 1945 through 1965 with 1 or more visits to a primary care provider annually. TIME HORIZON: Lifetime. PERSPECTIVE: Societal, health care. INTERVENTION: One-time antibody test of 1945-1965 birth cohort. OUTCOME MEASURES: Numbers of cases that were identified and treated and that achieved a sustained viral response; liver disease and death from HCV; medical and productivity costs; quality-adjusted life-years (QALYs); incremental cost-effectiveness ratio (ICER). RESULTS OF BASE-CASE ANALYSIS: Compared with the status quo, birth-cohort screening identified 808,580 additional cases of chronic HCV infection at a screening cost of $2874 per case identified. Assuming that birth-cohort screening was followed by pegylated interferon and ribavirin (PEG-IFN+R) for treated patients, screening increased QALYs by 348,800 and costs by $5.5 billion, for an ICER of $15,700 per QALY gained. Assuming that birth-cohort screening was followed by direct-acting antiviral plus PEG-IFN+R treatment for treated patients, screening increased QALYs by 532,200 and costs by $19.0 billion, for an ICER of $35,700 per QALY saved. RESULTS OF SENSITIVITY ANALYSIS: The ICER of birth-cohort screening was most sensitive to sustained viral response of antiviral therapy, the cost of therapy, the discount rate, and the QALY losses assigned to disease states. LIMITATION: Empirical data on screening and direct-acting antiviral treatment in real-world clinical settings are scarce. CONCLUSION: Birth-cohort screening for HCV in primary care settings was cost-effective. PRIMARY FUNDING SOURCE: Division of Viral Hepatitis, Centers for Disease Control and Prevention.

Cost-effectiveness of screening for microalbuminuria among African Americans.

Compared with other racial groups, African Americans have a similar prevalence of CKD but are much more likely to progress to ESRD, suggesting that the cost-effectiveness of screening strategies requires dedicated study in this population. Here, we calibrated the CKD Health Policy Model so that it accurately forecasts the higher rates for ESRD observed for African Americans. We then used the calibrated model to estimate the cost-effectiveness of screening for microalbuminuria followed by treatment with angiotensin-converting enzyme inhibitors or angiotensin II-receptor blockers. Incorporating racial differences in risk factors did not fully explain the much higher lifetime incidence of ESRD among African Americans. Thus, to calibrate the model, we applied a 20% increase in the rate of GFR decline at stage 3 and a 60% increase in the rate of GFR decline at stage 4, which resulted in a model that closely reflects lifetime ESRD incidence among African Americans. Compared with usual care, screening African Americans for microalbuminuria at 10-, 5-, 2-, and 1-year intervals had incremental cost-effectiveness ratios of $9000, $11,000, $19,000, and $35,000 per quality-adjusted life year, respectively. Incremental cost-effectiveness ratios for the same screening intervals were higher for non-African Americans: $17,000, $23,000, $44,000, and $81,000 per quality-adjusted life year, respectively. In summary, these models suggest that screening African Americans for microalbuminuria at either 5- or 10-year intervals is highly cost-effective.

Trends in the Prevalence and Treatment of Diabetic Macular Edema and Vision-Threatening Diabetic Retinopathy Among Commercially Insured Adults Aged <65 Years.

OBJECTIVE: Examine the 10-year trend in the prevalence and treatment of diabetic macular edema (DME) and vision-threatening diabetic retinopathy (VTDR) among commercially insured adults with diabetes. RESEARCH DESIGN AND METHODS: We analyzed the 10-year trend (2009-2018) in health care claims for adults aged 18-64 years using the IBM MarketScan Database, a national convenience sample of employer-sponsored health insurance. We included patients continuously enrolled in commercial fee-for-service health insurance for 24 months who had a diabetes ICD-9/10-CM code on one or more inpatient or two or more different-day outpatient claims in the index year or previous calendar year. We used diagnosis and procedure codes to calculate the annual prevalence of patients with one or more claims for 1) any DME, 2) either DME or VTDR, and 3) antivascular endothelial growth factor (anti-VEGF) injections and laser photocoagulation treatment, stratified by any DME, VTDR with DME, and VTDR without DME. We calculated the average annual percent change (AAPC). RESULTS: From 2009 to 2018, there was an increase in the annual prevalence of patients with DME or VTDR (2.1% to 3.4%; AAPC 7.5%; P < 0.001) and any DME (0.7% to 2.6%; AAPC 19.8%; P < 0.001). There were sex differences in the annual prevalence of DME or VTDR and any DME, with men having a higher prevalence than women. Annual claims for anti-VEGF injections increased among patients with any DME (327%) and VTDR with DME (206%); laser photocoagulation decreased among patients with any DME (-68%), VTDR with DME (-54%), and VTDR without DME (-62%). CONCLUSIONS: Annual claims for DME or VTDR and anti-VEGF injections increased whereas those for laser photocoagulation decreased among commercially insured adults with diabetes.

Prevalence of Diabetic Retinopathy in the US in 2021.

Importance: Diabetic retinopathy (DR) is a common microvascular complication of diabetes and a leading cause of blindness among working-age adults in the US. Objective: To update estimates of DR and vision-threatening diabetic retinopathy (VTDR) prevalence by demographic factors and US county and state. Data Sources: The study team included data from the National Health and Nutrition Examination Survey (2005 to 2008 and 2017 to March 2020), Medicare fee-for-service claims (2018), IBM MarketScan commercial insurance claims (2016), population-based studies of adult eye disease (2001 to 2016), 2 studies of diabetes in youth (2021 and 2023), and a previously published analysis of diabetes by county (2012). The study team used population estimates from the US Census Bureau. Study Selection: The study team included relevant data from the US Centers for Disease Control and Prevention's Vision and Eye Health Surveillance System. Data Extraction and Synthesis: Using bayesian meta-regression methods, the study team estimated the prevalence of DR and VTDR stratified by age, a nondifferentiated sex and gender measure, race, ethnicity, and US county and state. Main Outcomes and Measures: The study team defined individuals with diabetes as those who had a hemoglobin A1c level at 6.5% or more, took insulin, or reported ever having been told by a physician or health care professional that they have diabetes. The study team defined DR as any retinopathy in the presence of diabetes, including nonproliferative retinopathy (mild, moderate, or severe), proliferative retinopathy, or macular edema. The study team defined VTDR as having, in the presence of diabetes, severe nonproliferative retinopathy, proliferative retinopathy, panretinal photocoagulation scars, or macular edema. Results: This study used data from nationally representative and local population-based studies that represent the populations in which they were conducted. For 2021, the study team estimated 9.60 million people (95% uncertainty interval [UI], 7.90-11.55) living with DR, corresponding to a prevalence rate of 26.43% (95% UI, 21.95-31.60) among people with diabetes. The study team estimated 1.84 million people (95% UI, 1.41-2.40) living with VTDR, corresponding to a prevalence rate of 5.06% (95% UI, 3.90-6.57) among people with diabetes. Prevalence of DR and VTDR varied by demographic characteristics and geography. Conclusions and Relevance: US prevalence of diabetes-related eye disease remains high. These updated estimates on the burden and geographic distribution of diabetes-related eye disease can be used to inform the allocation of public health resources and interventions to communities and populations at highest risk.

Association Between Social Determinants of Health and Examination-Based Vision Loss vs Self-reported Vision Measures.

Importance: Recent evidence suggests that social determinants of health (SDOH) affect vision loss, but it is unclear whether estimated associations differ between clinically evaluated and self-reported vision loss. Objective: To identify associations between SDOH and evaluated vision impairment and to assess whether these associations hold when examining self-reported vision loss. Design, Setting, and Participants: This population-based cross-sectional comparison included participants 12 years and older in the 2005 to 2008 National Health and Nutrition Examination Survey (NHANES), participants of all ages (infants and older) in the 2019 American Community Survey (ACS), and adults 18 years and older in the 2019 Behavioral Risk Factor Surveillance System (BRFSS). Exposures: Five domains of SDOH that are based on Healthy People 2030: economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context. Main Outcomes and Measures: Presenting vision impairment of 20/40 or worse in the better-seeing eye (NHANES) and self-reported blindness or serious difficulty seeing, even with glasses (ACS and BRFSS). Results: Of 3 649 085 included participants, 1 873 893 were female (51.1%) and 2 504 206 were White (64.4%). SDOH across domains of economic stability, educational attainment, health care access and quality, neighborhood and built environment, and social context were significant predictors of poor vision. For example, higher income (poverty to income ratio [NHANES]: OR, 0.91; 95% CI, 0.85-0.98; [ACS]: OR, 0.93; 95% CI, 0.93-0.94; categorical income [BRFSS:<$15 000 reference]: $15 000-$24 999; OR, 0.91; 95% CI, 0.91-0.91; $25 000-$34 999: OR, 0.80; 95% CI, 0.80-0.80; $35 000-$49 999: OR, 0.71; 95% CI, 0.71-0.72; ≥$50 000: OR, 0.49; 95% CI, 0.49-0.49), employment (BRFSS: OR, 0.66; 95% CI, 0.66-0.66; ACS: OR, 0.55; 95% CI, 0.54-0.55), and owning a home (NHANES: OR, 0.85; 95% CI, 0.73-1.00; BRFSS: OR, 0.82; 95% CI, 0.82-0.82; ACS: OR, 0.79; 95% CI, 0.79-0.79) were associated with lower odds of vision loss. The study team identified no differences in the general direction of the associations when using either clinically evaluated or self-reported vision measures. Conclusions and Relevance: The study team found evidence that associations between SDOH and vision impairment track together when using either clinically evaluated or self-reported vision loss. These findings support the use of self-reported vision data in a surveillance system to track trends in SDOH and vision health outcomes within subnational geographies.

Validity of Administrative Claims and Electronic Health Registry Data From a Single Practice for Eye Health Surveillance.

Importance: Diagnostic information from administrative claims and electronic health record (EHR) data may serve as an important resource for surveillance of vision and eye health, but the accuracy and validity of these sources are unknown. Objective: To estimate the accuracy of diagnosis codes in administrative claims and EHRs compared to retrospective medical record review. Design, Setting, and Participants: This cross-sectional study compared the presence and prevalence of eye disorders based on diagnostic codes in EHR and claims records vs clinical medical record review at University of Washington-affiliated ophthalmology or optometry clinics from May 2018 to April 2020. Patients 16 years and older with an eye examination in the previous 2 years were included, oversampled for diagnosed major eye diseases and visual acuity loss. Exposures: Patients were assigned to vision and eye health condition categories based on diagnosis codes present in their billing claims history and EHR using the diagnostic case definitions of the US Centers for Disease Control and Prevention Vision and Eye Health Surveillance System (VEHSS) as well as clinical assessment based on retrospective medical record review. Main Outcome and Measures: Accuracy was measured as area under the receiver operating characteristic curve (AUC) of claims and EHR-based diagnostic coding vs retrospective review of clinical assessments and treatment plans. Results: Among 669 participants (mean [range] age, 66.1 [16-99] years; 357 [53.4%] female), identification of diseases in billing claims and EHR data using VEHSS case definitions was accurate for diabetic retinopathy (claims AUC, 0.94; 95% CI, 0.91-0.98; EHR AUC, 0.97; 95% CI, 0.95-0.99), glaucoma (claims AUC, 0.90; 95% CI, 0.88-0.93; EHR AUC, 0.93; 95% CI, 0.90-0.95), age-related macular degeneration (claims AUC, 0.87; 95% CI, 0.83-0.92; EHR AUC, 0.96; 95% CI, 0.94-0.98), and cataracts (claims AUC, 0.82; 95% CI, 0.79-0.86; EHR AUC, 0.91; 95% CI, 0.89-0.93). However, several condition categories showed low validity with AUCs below 0.7, including diagnosed disorders of refraction and accommodation (claims AUC, 0.54; 95% CI, 0.49-0.60; EHR AUC, 0.61; 95% CI, 0.56-0.67), diagnosed blindness and low vision (claims AUC, 0.56; 95% CI, 0.53-0.58; EHR AUC, 0.57; 95% CI, 0.54-0.59), and orbital and external diseases (claims AUC, 0.63; 95% CI, 0.57-0.69; EHR AUC, 0.65; 95% CI, 0.59-0.70). Conclusion and Relevance: In this cross-sectional study of current and recent ophthalmology patients with high rates of eye disorders and vision loss, identification of major vision-threatening eye disorders based on diagnosis codes in claims and EHR records was accurate. However, vision loss, refractive error, and other broadly defined or lower-risk disorder categories were less accurately identified by diagnosis codes in claims and EHR data.

Trends in Prevalence and Treatment of Diabetic Macular Edema and Vision-Threatening Diabetic Retinopathy Among Medicare Part B Fee-for-Service Beneficiaries.

IMPORTANCE: While diabetes prevalence among US adults has increased in recent decades, few studies document trends in diabetes-related eye disease. OBJECTIVE: To examine 10-year trends (2009-2018) in annual prevalence of Medicare beneficiaries with diabetes with a diagnosis of diabetic macular edema (DME) or vision-threatening diabetic retinopathy (VTDR) and trends in treatment. DESIGN, SETTING, AND PARTICIPANTS: In this cross-sectional study using Centers for Medicare & Medicaid Services research identifiable files, data for patients 65 years and older were analyzed from claims. Beneficiaries were continuously enrolled in Medicare Part B fee-for-service (FFS) insurance for the calendar year and had a diagnosis of diabetes on 1 or more inpatient claims or 2 or more outpatient claims during the calendar year or a 1-year look-back period. MAIN OUTCOMES AND MEASURES: Using diagnosis and procedure codes, annual prevalence was determined for beneficiaries with 1 or more claims for (1) any DME, (2) either DME or VTDR, and (3) anti-vascular endothelial growth factor (VEGF) injections, laser photocoagulation, or vitrectomy, stratified by any DME, VTDR with DME, and VTDR without DME. Racial and ethnic disparities in diagnosis and treatment are presented for 2018. RESULTS: In 2018, 6 960 823 beneficiaries (27.4%) had diabetes; half were aged 65 to 74 years (49.7%), half (52.7%) were women, and 75.7% were non-Hispanic White. From 2009 to 2018, there was an increase in the annual prevalence of beneficiaries with diabetes who had 1 or more claims for any DME (1.0% to 3.3%) and DME/VTDR (2.8% to 4.3%). Annual prevalence of anti-VEGF increased, particularly among patients with any DME (15.7% to 35.2%) or VTDR with DME (20.2% to 47.6%). Annual prevalence of laser photocoagulation decreased among those with any DME (45.5% to 12.5%), VTDR with DME (54.0% to 20.3%), and VTDR without DME (22.5% to 5.8%). Among all 3 groups, prevalence of vitrectomy in 2018 was less than half that in 2009. Prevalence of any DME and DME/VTDR was highest among Hispanic beneficiaries (5.0% and 7.0%, respectively) and Black beneficiaries (4.5% and 6.2%, respectively) and lowest among non-Hispanic White beneficiaries (3.0% and 3.8%, respectively). Among those with DME/VTDR, anti-VEGF was most prevalent among non-Hispanic White beneficiaries (30.3%). CONCLUSIONS AND RELEVANCE: From 2009 to 2018, prevalence of DME or VTDR increased among Medicare Part B FFS beneficiaries alongside an increase in anti-VEGF treatment and a decline in laser photocoagulation and vitrectomy.

Prevalence of Age-Related Macular Degeneration in the US in 2019.

Importance: Age-related macular degeneration (AMD) is a leading cause of vision loss and blindness. AMD prevalence has not been estimated for the US in over a decade and early-stage AMD prevalence estimates are scarce and inconsistently measured. Objective: To produce estimates of early- and late-stage AMD prevalence overall and by age, gender, race and ethnicity, county, and state. Design, Setting, and Participants: The study team conducted a bayesian meta-regression analysis of relevant data sources containing information on the prevalence of AMD among different population groups in the US. Data Sources: We included data from the American Community Survey (2019), the National Health and Nutrition Examination Survey (2005-2008), US Centers for Medicare & Medicaid Services claims for fee-for-service beneficiaries (2018), and population-based studies (2004-2016). Study Selection: We included all relevant data from the US Centers for Disease Control and Prevention's Vision and Eye Health Surveillance System. Data Extraction and Synthesis: The prevalence of early- and late-stage AMD was estimated and stratified when possible by factors including county, age group, gender, and race and ethnicity. Data analysis occurred from June 2021 to April 2022. Main Outcomes or Measures: The prevalence of early- (defined as retinal pigment epithelium abnormalities or the presence of drusen 125 or more microns in diameter in either eye) and late-stage (defined as choroidal neovascularization and/or geographic atrophy in either eye) manifestations of AMD. Results: This study used data from nationally representative and local population-based studies that represent the populations in which they were conducted. For 2019, we estimated that there were 18.34 million people 40 years and older (95% uncertainty interval [UI], 15.30-22.03) living with early-stage AMD, corresponding to a crude prevalence rate of 11.64% (95% UI, 9.71-13.98). We estimated there were 1.49 million people 40 years and older (95% UI, 0.97-2.15) living with late-stage AMD, corresponding to a crude prevalence rate of 0.94% (95% UI, 0.62-1.36). Prevalence rates of early- and late-stage AMD varied by demographic characteristics and geography. Conclusions and Relevance: We estimated a higher prevalence of early-stage AMD and a similar prevalence of late-stage AMD as compared with earlier studies. State-level and county-level AMD estimates may help guide public health practice.

Cost-effectiveness of glaucoma interventions in Barbados and Ghana.

PURPOSE: More than 90% of blindness worldwide exists in the developing world, but information on the social and economic burden and the cost-effectiveness of treatment in these settings is often limited or nonexistent. We demonstrate the use of computer modeling to simulate the current and future epidemiology, outcomes, and treatment of primary open-angle glaucoma in high-incidence populations of the developing world. METHODS: A previously validated vision model was modified to simulate the incidence progression and social and economic outcomes of glaucoma in Barbados, which was the source of epidemiology data, and Ghana, which has similar propensity for glaucoma but lower socioeconomic development. We then assessed the cost-effectiveness of hypothetical case-finding and treatment scenarios, including U.S. guideline-level care and one-time laser surgery. RESULTS: Barbados incurs relatively greater social and economic burden from glaucoma than Ghana. In Barbados, population screening followed by U.S. guideline levels of care appears to be highly cost-effective. Because of a younger population with higher mortality at younger ages, glaucoma appears to cause less visual impairment and blindness in Ghana than in Barbados, resulting in lower per capita disability and productivity losses. Population screening or guideline-level treatment scenarios were generally not cost-effective in Ghana, but treating self-referring patients with a hypothetical one-time laser surgery was highly cost-effective relative to World Health Organization willingness to pay thresholds. CONCLUSIONS: The social and economic burden of glaucoma is higher in developed nations because of increased life expectancy, an older population age profile, and higher per capita gross domestic product. Similarly, lower mortality rates and higher per capita gross domestic product increase the relative cost-effectiveness of screening and treatment interventions intended to mitigate glaucoma burden.

A cost-benefit analysis of lipid standardization in the United States.

INTRODUCTION: By improving lipid standardization, the Centers for Disease Control and Prevention's (CDC's) Lipid Standardization Program and Cholesterol Reference Method Laboratory Network have contributed to the marked reduction in heart disease deaths since 1980. The objective of this study was to estimate the benefits (ie, the value of reductions in heart disease deaths) and costs attributable to these lipid standardization programs. METHODS: We developed a logic model that shows how the inputs and activities of the lipid standardization programs produce short- and medium-term outcomes that in turn lead to improvements in rates of cardiovascular disease and death. To calculate improvements in long-term outcomes, we applied previous estimates of the change in heart disease deaths between 1980 and 2000 that was attributable to statin treatment and to the reduction in total cholesterol during the period. Experts estimated the share of cholesterol reduction that could be attributed to lipid standardization. We applied alternative assumptions about the value of a life-year saved to estimate the value of life-years saved attributable to the programs. RESULTS: Assuming that 5% of the cholesterol-related benefits were attributable to the programs and a $113,000 value per life-year, the annual benefit attributable to the programs was $7.6 billion. With more conservative assumptions (0.5% of cholesterol-related benefits attributable to the programs and a $50,000 value per life-year), the benefit attributable to the programs was $338 million. In 2007, the CDC lipid standardization programs cost $1.7 million. CONCLUSION: Our estimates suggest that the benefits of CDC's lipid standardization programs greatly exceed their costs.

The Prevalence of Diagnosis of Major Eye Diseases and their Associated Payments in the Medicare Fee-for-Service Program.

PURPOSE: To estimate the prevalence of diagnosis of major eye disorders and their associated payments, in total and per-person diagnosed, among Medicare fee-for-service (FFS) beneficiaries in 2018. METHODS: We analyzed 100% Medicare Part B FFS claims and Part D Events among beneficiaries continuously enrolled for 12 months in 2018 to calculate the proportion of beneficiaries with ≥1 claim indicating age-related macular degeneration (AMD), cataract, diabetic retinopathy (DR), or glaucoma, and their associated payments, including Medicare and patient out-of-pocket. Eye disease and eye care services were identified using case definitions from the Centers for Disease Control and Prevention's (CDC) Vision & Eye Health Surveillance System (VEHSS). Outcomes are reported by disease overall and by age group (0-39, 40-64, 65-84, 85+ years), sex, race/ethnicity, and U.S. state. RESULTS: Among nearly 30 million Medicare Part B FFS beneficiaries in 2018, over 41% (12.4 million) had a claim containing a diagnosis of at least one of the four eye disorders; 33.7% with cataract, 13.3% with glaucoma, 9.2% with AMD and 3.2% with DR. Payments for eye care services and drugs associated with these four conditions were $10.1billion; $3.6 billion for cataract, $3.5 billion for AMD, $2.2 billion for glaucoma and $0.8 billion for DR. The average cost per beneficiary diagnosed was $816: $1,290 for AMD, $781 for DR, $543 for glaucoma, and $360 for cataract. CONCLUSIONS: Major eye disorders are common among Medicare FFS beneficiaries and account for approximately 4.3% of Medicare Part B and 1% of Medicare Part D spending.