Health Economic Analysis in Glaucoma

Assessment of Missing Data on Glaucoma Severity Among Participants in the NIH All of Us Research Program of the United States

PRCIS

There were statistically significant differences across multiple socioeconomic characteristics and self-reported barriers to care among primary glaucoma patients with severity staging data versus those missing this data in the NIH All of Us database.

PURPOSE

To characterize missing data among glaucoma patients within All of Us .

MATERIALS AND METHODS

We used diagnosis codes to define cohorts of primary glaucoma patients with and without severity staging specified. Descriptive analyses were conducted by presence of disease severity stage. Analysis of missing data was conducted using a set intersection plot and the Little Test of Missing Completely at Random. T tests were performed to evaluate differences.

RESULTS

Of 2982 participants, 1714 (57%) did not have glaucoma severity stage specified, and 11 of 23 analyzed variables had missing data. The Little Test indicated data was not missing completely at random ( P <0.001). Significant differences existed between the 2 cohorts with respect to age, age of first glaucoma diagnosis, gender, ethnicity, education, income, insurance, history of glaucoma surgery and medication use, and answers regarding the ability to afford eyeglasses and having seen an eye care provider in the last 12 months (all P- values ≤0.01).

CONCLUSION

There were significant differences between glaucoma participants with glaucoma severity stage specified versus those with unstaged disease across multiple socioeconomic characteristics and self-reported barriers to care. Glaucoma severity staging data was not missing completely at random. The unstaged cohort included higher rates of multiple underrepresented communities, which may potentially contribute to bias in ophthalmology research as participants from vulnerable populations may be disproportionately excluded from electronic health records or claims data studies where diagnosis codes with severity/staging levels are used to examine risk factors for disease, progression, and treatment efficacy.

Safety reporting in trials on glaucoma interventions registered in ClinicalTrials.gov and corresponding publications

Accurate, comprehensive, and consistent reporting of adverse events is of great importance for treatment decisions in clinical practice and patient safety. Aiming to evaluate the completeness and transparency of reported adverse events we conducted a retrospective analysis of completed clinical trials on glaucoma interventions registered in ClinicalTrials.gov from September 27, 2009, and updated and with results on or before November 1, 2023, as well as in corresponding journal publications. Any difference in completeness, number, or terminology/description of adverse events and all-cause mortality between ClinicalTrials.gov and the publication was categorized as inconsistent reporting of adverse events. All 79 trials with results both in the registry and a journal publication exhibited at least one inconsistency in reporting adverse events. In 19 publications (24%), the number of serious adverse events was smaller than in the registry. 69 (87%) trials reported more other adverse events in the registry than in the publication. Trials completed after the FDAA mandate for summary reporting of all-cause mortality more often reported this item in the registry but not in the publication. Trials on glaucoma interventions do not consistently report adverse events and thus introduce concerns about study credibility and potential harms of the interventions. Journals and other stakeholders in trial reporting must address this problem to ensure the safety of patients and trust in health interventions.

Clinical risk stratification in glaucoma

Glaucoma is the leading cause of preventable sight loss in the United Kingdom and the provision of timely glaucoma care has been highlighted as a significant challenge in recent years. Following a recent high-profile investigation, The Healthcare Safety Investigation Branch recommended the validation of risk stratification models to safeguard the vision-related quality of life of glaucoma patients. There continues to be no nationally agreed evidence-based risk stratification model for glaucoma care across the United Kingdom. Some models have used simple measures of disease staging such as visual field mean deviation as surrogates for risk, but more refined, individualised risk stratification models should include factors related to both visual impairment and visual disability. Candidate tools should also incorporate both ocular and systemic co-morbidities, rate of disease progression, visual needs and driving status and undergo clinical refinement and validation to justify implementation. The disruption to routine glaucoma care caused by the COVID-19 pandemic has only highlighted the importance of such risk stratification models and has accelerated their development, application and evaluation. This review aims to critically appraise the available evidence underpinning current approaches for glaucoma risk stratification and to discuss how these may be applied to contemporary glaucoma care within the United Kingdom. Further research will be essential to justify and validate the utility of glaucoma risk stratification models in everyday clinical practice.

Teleglaucoma Using a New Smartphone-Based Tool for Visual Field Assessment

PRCIS

COVID-19 underlines the importance of telemedical diagnostics. The smartphone-based campimetry (Sb-C) is a newly developed digital application allowing visual field testing using a head-mounted device and a smartphone. It enables visual field screening remotely from a clinic.

BACKGROUND

Sb-C is a newly developed tool for functional ophthalmic diagnosis. This study aimed to examine the comparability of the Sb-C and Octopus 900 to ensure ophthalmological care in times of social distancing.

METHODS

Total 93 eyes were included in the study. After an ophthalmological examination, the visual field was tested by the Octopus program G1 and by the smartphone-based campimeter. The Sb-C was performed using VR glasses and an iPhone 6. The software Sb-C was downloaded and installed as SmartCampiTracker app and is examining the 30-degree visual field with 59 test positions corresponding to the G pattern of Octopus G1. Sensitivities were recorded and saved on the app. In addition, test-retest reliability was tested on 6 ophthalmologically healthy participants.

RESULTS

The group comprised 48 women and 45 men (mean age: 62.52±12.2 y) including 19 controls, 17 patients with ocular hypertension, 11 preperimetric glaucomas, and 46 perimetric glaucomas. The mean sensitivity (MS) of all points of G1 perimetry was 23.13 dB (95% CI, 22.08-24.18). The MS of the Sb-C was 21.23 dB (95% CI, 20.37-22.08). The correlation between the mean MS measured by G1 perimetry and the Sb-C was strong ( r =0.815, P <0.05). The test-retest reliability showed a correlation of r =0.591 ( P <0.05) .

CONCLUSIONS

With some technical adjustments, the Sb-C shows promise for screening glaucoma and monitoring disease progression remotely from an ophthalmologic clinic.

Cost effectiveness analysis associated to the treatment of primary open-angle glaucoma according to disease severity

Introduction/Objective. POAG treatment should be individually tailored to the disease severity and type, effectiveness and secondary side effects of the medications used. This research aimed to assess the direct medical costs and the cost effectiveness associated with pharmacotherapy in visually impaired people with primary open-angle glaucoma according to disease severity. Methods. This scientific study is designed as an observational cross-sectional study with a quantitative analytical approach and was conducted in the period from July 2020 to June 2021 on the territory of North Macedonia. The study included 157 patients with binocular POAG in the early, moderate and advanced clinical stage, up to the age of 67, with changes in visual acuity and work ability. During the assessment of the effects of pharmacotherapy were analyzed the types, mutual correlations and effectiveness of the most commonly prescribed antiglaucomatous medications and the cost benefit from their administration. Direct medical costs are calculated according to disease severity in the last 12 months using real-time data of public interest. Results. The beta blockers due to their affordable price and availability are the dominant option with high-cost benefit for primary treatment of POAG. Antiglaucoma medications and diagnostic procedures are major components of direct medical treatment costs. Conclusion. Pharmacotherapy is the dominant alternative compared to other types of treatment because it is safer and is associated with greater effictiveness and lower direct medical costs.

Clinical Practice Management of Primary Open-Angle Glaucoma in the United States: An Analysis of Real-World Evidence

PURPOSE

To investigate clinical management of primary open-angle glaucoma (POAG) in the United States using real-world evidence and to examine healthcare resource utilization (HCRU), medication adherence/persistence, and procedure use.

DESIGN

A cross-sectional, retrospective analysis of Optum's de-identified Market Clarity Dataset (July 1, 2013-December 31, 2019).

PATIENTS AND METHODS

Patients ≥18 years with POAG diagnosis and continuous enrollment for 1-year pre- and post-index were eligible and categorized into four mutually exclusive cohorts: CH1, treated with antiglaucoma medication(s) only; CH2, underwent glaucoma procedure(s) only; CH3, treated with antiglaucoma medication(s) and underwent procedure(s); and CH4, received no treatment for POAG. Adherence and persistence with antiglaucoma medications, and disease-specific HCRU were analyzed. Pairwise two-sample comparisons and multivariate regressions were conducted.

RESULTS

Examined 232,572 eligible patients (CH1=60,895; CH2=4330; CH3=6027; CH4=161,320). Prostaglandin analogs were most prescribed antiglaucoma medications (CH1: 69.7%; CH3: 62.7%), of which latanoprost was most common (CH1: 51.3%; CH3: 46.1%). Disease-specific office visits occurred in 26.3%, 78.2%, 75.0%, 23.8%, and surgical services visits occurred in 3.8%, 36.3%, 42.5%, 3.3%, in CH1-CH4, respectively. Adherence was higher (medication possession ratio: 47.1% vs 39.4%; P<0.0001), and more patients remained persistent across 1-year post-index period in CH1 vs CH3 (25.4% vs 16.1%; P<0.0001). Positive predictors of medication persistence included being female, ≥55 years, and history of dyslipidemia or thyroid disease (all P≤0.0003).

CONCLUSION

Overall, 70% POAG patients might not have received antiglaucoma treatment. Since POAG is a slowly progressive blinding disease, the lack of antiglaucoma treatment and suboptimal adherence/persistence with medications are of major concerns. Targeted screening and educational approaches are needed to improve POAG management.

Development and Validation of a Preference-Based Glaucoma Utility Instrument Using Discrete Choice Experiment

Importance

A glaucoma-specific instrument for estimating utilities across the spectrum of glaucoma severity is currently lacking, hindering the assessment of the cost-effectiveness of glaucoma treatments.

Objective

To develop and validate the preference-based Glaucoma Utility Instrument (Glau-U) and to ascertain the association between Glau-U utilities and severity of glaucoma and vision impairment.

Design, Setting, and Participants

This cross-sectional study was conducted in 2 stages at the Singapore National Eye Centre glaucoma clinics. Stage 1 focused on the identification and pretesting of the Glau-U attributes and was carried out between June 2009 and May 2016. Stage 2 involved the development and administration of the discrete choice experiment (DCE) survey and tasks and was conducted between May 7, 2018, and December 11, 2019. Stage 2 participants were English- or Mandarin-speaking Singaporean citizens or permanent residents of Chinese, Malay, or Indian ethnicity who were 40 years or older and had a clinical diagnosis of glaucoma in at least 1 eye.

Exposures

Glau-U comprised 6 quality-of-life attributes: activities of daily living, lighting and glare, movement, eye discomfort, other effects of glaucoma, and social and emotional effects. The descriptions or response options for these attributes were no difficulty or never, some difficulty or sometimes, or severe difficulty or often.

Main Outcomes and Measures

Utility weights for Glau-U were developed using a DCE questionnaire, which was interviewer administered to participants. Mixed logit regression determined utility weights for each health state. Glau-U utility weights across better- or worse-eye glaucoma and vision impairment severity were calculated using 1-way analysis of variance. Correlations between Glau-U utilities and better- or worse-eye visual fields and EuroQol 5-Dimension utilities were ascertained to assess convergent and divergent validity.

Results

Of the 304 participants (mean [SD] age, 68.3 [8.7] years; 182 men [59.9%]), 281 (92.4%) had no vision impairment in the better eye, 13 (4.3%) had mild impairment, and 10 (3.3%) had moderate to severe vision impairment. Mean (SD) Glau-U utilities decreased as better-eye glaucoma severity increased (none: 0.73 [0.21]; mild: 0.66 [0.21]; moderate: 0.66 [0.20]; severe: 0.60 [0.28]; and advanced or end-stage: 0.22 [0.38]; P < .001), representing reductions of 20.7% to 76.1% in quality-adjusted life-years compared with a health state that included preperimetric glaucoma. Mean (SD) Glau-U utilities also decreased as better-eye vision impairment worsened from 0.67 (0.23) for none to 0.58 (0.32) for mild to 0.46 (0.29) for moderate to severe vision impairment. Glau-U utilities demonstrated moderate correlations with better-eye (r = 0.34; P < .001) and worse-eye (r = 0.33; P < .001) mean deviation scores and low correlations with EuroQol 5-Dimension utilities (r = 0.22; P < .001), supporting convergent and divergent validity.

Conclusions and Relevance

Use of Glau-U revealed large decrements in utility that were associated with late-stage glaucoma, suggesting that this new instrument may be useful for cost-effectiveness analyses of interventions and informing resource allocation policies for glaucoma and vision loss.

Current Glaucoma Practice: The Covid-19 Impact

How to cite this article: Bhartiya S. Current Glaucoma Practice: The Covid-19 Impact. J Curr Glaucoma Pract 2020;14(1):1–2.