More frequent, more costly Health economic modelling aspects of monitoring glaucoma patients in EnglandReport as inadecuate

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BMC Health Services Research

, 16:611

Organization, structure and delivery of healthcare


BackgroundChronic open angle glaucoma COAG is an age-related eye disease causing irreversible loss of visual field VF. Health service delivery for COAG is challenging given the large number of diagnosed patients requiring lifelong periodic monitoring by hospital eye services. Yet frequent examination better determines disease worsening and speed of VF loss under treatment. We examine the cost-effectiveness of increasing frequency of VF examinations during follow-up using a health economic model.

MethodsTwo different VF monitoring schemes defined as current practice annual VF testing and proposed practice three VF tests per year in the first 2 years after diagnosis were examined. A purpose written health economic Markov model is used to test the hypothesis that cost effectiveness improves by implementing proposed practice on groups of patients stratified by age and severity of COAG. Further, a new component of the model, estimating costs of visual impairment, was added. Results were derived from a simulated cohort of 10000 patients with quality-adjusted life years QALYs and incremental cost-effectiveness ratios ICERs used as main outcome measures.

ResultsAn ICER of £21,392 per QALY was derived for proposed practice improving to a value of £11,382 once savings for prevented visual impairment was added to the model. Proposed practice was more cost-effective in younger patients. Proposed practice for patients with advanced disease at diagnosis generated ICERs > £60,000 per QALY; these cases would likely be on the most intensive treatment pathway making clinical information on speed of VF loss redundant. Sensitivity analysis indicated results to be robust in relation to hypothetical willingness to pay threshold identified by national guidelines, although greatest uncertainty was allied to estimates of implementation and visual impairment costs.

ConclusionIncreasing VF monitoring at the earliest stages of follow-up for COAG appears to be cost-effective depending on reasonable assumptions about implementation costs. Our health economic model highlights benefits of stratifying patients to more or less monitoring based on age and stage of disease at diagnosis; a prospective study is needed to prove these findings. Further, this works highlights gaps in knowledge about long term costs of visual impairment.

KeywordsGlaucoma Health economic model QALY Visual fields Health service delivery Visual impairment AbbreviationsCEACCost-effectiveness acceptability curves

COAGChronic open angle glaucoma

DSADeterministic sensitivity analysis

EGSEuropean Glaucoma Society

FVFMFrequency of visual field monitoring model

ICERIncremental cost-effectiveness ratio

IOPIntraocular pressure

MDMean deviation

NHSNational Health Service

NICENational Institute for Health and Care Excellence

PSAProbabilistic sensitivity analysis

QALYQuality-adjusted life year

UKUnited Kingdom

VFVisual field

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Author: Trishal Boodhna - David P. Crabb


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