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Tunnel Vision the Economic Impact of Primary Open Angle Glaucoma - a Dynamic Economic Model 105 Main Heading Tocontents Go Here Tunnel Vision Tu n n e l Vi s i o n The Economic Impact of Primary Open Angle Glaucoma - The Economic Impact of Primary OpenAngle Glaucoma - A Dynamic Economic Model A Dynamic Economic Model Centre for Eye Research Australia Centre for Eye Research Australia Acknowledgments and Disclaimer 11. References This report was prepared jointly by the Centre Weih L, Van Newkirk M, McCarty C, Taylor H (1998) “Patterns of glaucoma medication use in for Eye Research Australia and Access Economics urban and rural Victoria” Australian and New Zealand Journal of Ophthalmology, 26[Suppl]: Pty Limited. S12 S15. We acknowledge particularly the expert input Weinand F, Althen F (2006) “Long term clinical results of SLT in the treatment of POAG” Eur J and prior research of Ophthalmology, 16: 100-4. Professor Hugh Taylor AC Weinreb RN, Khaw PT (2004) “Primary open-angle glaucoma” The Lancet, 363: 1711-20. Centre for Eye Research Australia and University of Melbourne Weinreb RN, Friedman DS, Fechtner RD, Cioffi GA, Coleman AL, Girkin CA, Liebmann JM, Singh K, Wilson MR, Wilson R, Kannel WB (2004) “Perspective: Risk Assessment in the Management of Professor Jonathan Crowston Patients with Ocular Hypertension” American Journal of Ophthalmology, 138[3]: 458-67. Centre for Eye Research Australia and University of Melbourne Wensor M, McCarty C, Stanislavsky Y, Livingston P, Taylor H (1998) “The prevalence of glaucoma in the Melbourne Visual Impairment Project” Ophthalmology, 105: 733-9. Associate Professor Jill Keeffe OAM Centre for Eye Research Australia and Wilson MR, Coleman AL, Fei Yu, Sasaki IF, Kim MH (2002) “Depression in patients with glaucoma University of Melbourne as measured by self-reported surveys” Ophthalmology, 105[5]: 1018-22. Ms Lynne Pezzullo Wolfs RC, Klauver CC, Ramrattan RS, van Duijin CM, Hofman A, de Jong PT (1998) “Genetic risk Access Economics Pty Ltd of primary open-angle glaucoma. Population based familial aggregation study” Arch Ophthal, Ms Penny Taylor 116: 1640-45. Access Economics Pty Ltd Zahari M, Mukesh B, Rait J, Taylor H, McCarty C (2006) “Progression of visual field loss in open Mr Peter Moore angle glaucoma in the Melbourne Visual Impairment Project” Clinical and Experimental Access Economics Pty Ltd Ophthalmology, 34: 20–6. Zeiter JH, Shin DH (1994) “Diabetes in primary open-angle glaucoma patients with inferior visual field defects” Graefes Archive for Clinical & Experimental Ophthalmology, 232[4]: 205-10. Zghal I, Jeddi A, Hadj Alouane WB, Malouche N, Ayed S, Gaigi S (2000) “Primary open-angle glaucoma and diabetes [French]” Tunisie Medicale, 78[8-9]: 518-21. Zwerling C, Sprince NL, Davis CS, Whitten PS, Wallace RR, Herringa SG (1998) “Occupational injuries among older workers with disabilities: a prospective cohort study of the Health and Retirement Survey, 1992 to 1994” American Journal of Public Health, 88: 1691-16. While every effort has been made to ensure the accuracy of this document, the uncertain nature of economic data, forecasting and analysis means that Access Economics Pty Limited is unable to make any warranties in relation to the information contained herein. Access Economics Pty Limited, its employees and agents disclaim liability for any loss or damage which may arise as a consequence of any person relying on the information contained in this document. Publication of this work has been made possible by an unrestricted grant from Allergan who had no part in the direction or findings contained in this report. Centre for Eye Research Australia, University of Melbourne, Australia, February 2008. Centre for Eye Research Australia Tunnel Vision The Economic Impact of Primary Open Angle Glaucoma - A Dynamic Economic Model 105 Main heading toContents go here EXECUTIVE SUMMARY 7 1. Background 10 2. Primary Open Angle Glaucoma 11 3. Risk Factors 13 3.1 Intraocular pressure 13 3.2 Age 15 3.3 Cup-to-disc ratio 16 3.4 Central corneal thickness 16 3.5 Family history and genetics 17 3.6 Ethnicity 17 3.7 Diabetes mellitus 18 3.8 Other potential risk factors 19 4. Epidemiology 20 4.1 Definition of disease stage 20 4.2 Remission 20 4.3 Mortality 20 4.4 Population 21 4.5 Progression 21 4.6 Prevalence and incidence 29 4.7 Disease stages defined 33 5. Treatment 34 5.1 Medication 34 5.2 Laser treatment 39 5.3 Conventional surgery (trabeculectomy) 41 5.4 Prevalence estimates for each treatment group 43 5.5 Treatment efficacy 44 5.6 Side effects 50 6. Disease Costs 55 6.1 Discount rates 55 6.2 The cost to quality of life and wellbeing 56 6.3 Health system costs 60 6.4 Indirect costs 68 6.5 Deadweight losses 69 7. Summary of Model Parameters 70 8. The Model 73 9. Intervention Scenarios 76 9.1 The base case 76 9.2 Improved diagnosis rate 80 9.3 Change in the treatment protocol (Primary laser) 83 9.4 Research and development 87 9.5 Combinations 89 The Economic Impact of Primary Open Angle Glaucoma - A Dynamic Economic Model 1 Contents 10. Appendix 1: Meta-Analysis - Falls and Hip Fractures 92 10.1 Fixed-effects versus random-effects 92 10.2 Heterogeneity 92 10.3 Forest plots 93 10.4 Publication bias 96 10.5 Additional supportive literature 97 11. References 98 Figures Figure 1.1: Peripheral visual field loss in POAG 10 Figure 2.1: The glaucoma continuum 11 Figure 2.2: Healthy optic nerve 12 Figure 2.3 Glaucomorous optic nerve 12 Figure 3.1: Goldmen tonometery 14 Figure 3.2: Demographic distribution of glaucoma, Australians over 40 15 Figure 3.3: Cup-To-Disk ratio 16 Figure 3.4: Corneal thickness 17 Figure 3.5: Pseudoexfoliation pupil margin 19 Figure 4.1: Schematic of the level of impairment for definite glaucoma 29 Figure 4.2: Original prevalence rates 30 Figure 4.3: Smoothed prevalence rates (moving average across three age groups) 31 Figure 5.1: Glaucoma medication dispensed by year and type of script (% of total scripts) 35 Figure 5.2: MBS Trabeculoplasty Procedures, 1994-2005 40 Figure 5.3: Trabeculectomy 41 Figure 5.4: MBS Total of Trabeculectomy Procedures, 1994-2005 42 Figure 8.1: Main Menu 73 Figure 8.2: Options Sheet 74 Figure 8.3: Model Design 75 Figure 9.1: Prevalence OHT and POAG, base case 77 Figure 9.2: Value burden of disease due to POAG ($m), base case 78 Figure 9.3: Impact of increased diagnosis rates on DALYs(a) 82 Figure 9.4: Impacts of increased diagnosis rates on treatment costs 82 Figure 9.5: Cost Effectiveness Plane - Increase Diagnosis Rate(a) 83 Figure 9.6: Cost-savings resulting from a protocol change(a) 85 Figure 9.7: Burden of Disease 85 Figure 9.8: Decline in DALYs from new efficacious treatment 88 2 Centre for Eye Research Australia Tunnel Vision Main heading toContents go here Figure 9.9: Treatment costs with new treatment costing $1000 per person per year 88 Figure 9.10: Reduction in DALYs, combined interventions 90 Figure 9.11: Treatment costs, combined interventions 91 Figure 9.12: Total costs, combined scenarios 91 Figure 9.13: Cost effectiveness plane, Combined Scenarios(a) 91 Figure 10.1: Annotated Forest Plot (Random Effects Model) for Visual 94 Impairment and Falls Figure 10.2: Annotated Forest Plot (Random Effects Model) Glaucome/VFL and Falls 95 Figure 10.3: Annotated Forest Plot (Random Effects Model) for Visual Impairment and Hip Fractures 95 Tables Table 1.1: Disease stage 7 Table 3.1: Significant risk factors for OHT progression to glaucoma, identified by the OHTS 14 Table 3.2: Hazard ratios for development of POAG from OHT 14 Table 3.3: Risk factors for glaucoma progression, identified by the early manifest glaucoma trial 15 Table 3.4: Association Between Diabetes Mellitus and Glaucoma 19 Table 4.1: Relative risk of mortality by stage of Visual Impairment 21 Table 4.2: Natural progression rates (cumulative probability) 15 year period 25 Table 4.3: Estimates of disease progression in untreated patients 27 Table 4.4: Definitions of level of impairment for definite glaucoma 29 Table 4.5: OHT and Glaucoma prevalence rates 30 Table 4.6: Incidence and prevalence of ocular hypertension (% of age group) 32 Table 4.7: Proportion of people with glaucoma by age and severity (%), smoothed (moving average across three age groups) 32 Table 4.8: Disease Stage 33 Table 5.1: IOP lowering medications 35 Table 5.2: Proportion of each drug class by state, 2005 36 Table 5.3: Number of medications taken in combination 37 Table 5.4: Trabeculectomy - MBS services processed by jurisdiction by year 42 Table 5.5: Incidence and treatment failure rate for each stage of treatment from dismod II 44 Table 5.6: Progression rates (cumulative probability) in treated patients (15 year period) 46 Table 5.7: Studies of the efficacy of laser treatment 47 Table 5.8: Success rates for trabeculectomy 49 Table 5.9: Medication side effects 50 Table 5.10: Risk of COPD (% of Population), 2001 51 Table 5.11: Health System Cost of COPD ($ per Person), 2005 52 The Economic Impact of Primary Open Angle Glaucoma - A Dynamic Economic Model 3 Contents Table 5.12: Trabeculectomy Side-Effects 53 Table 5.13: Prevalence of Cataract (% of Population) 54 Table 5.14: Health System Cost of Cataract ($ per Person), 2005 54 Table 6.1: AIHW Disability Weightings 59 Table 6.2: Health Costs by Who Bears the Cost, 2004-05 60 Table 6.3: Cost of Medication per Person per Annum 61 Table 6.4: Total Cost of Trabeculoplasty Per Treatment 61 Table 6.5: Total Cost of Trabeculectomy Per Treatment 62 Table 6.6: Probability of Residing in an Aged Care facility, 2004-05 63 Table 6.7: Increased Risk of Falls From Visual impairment 64 Table 6.8: Meta-Analysis, Falls (Random Effects Model) 64 Table 6.9: Relative Risk of an accidental fall by Severity 65 Table
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