Health care economic analyses.
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Cost of Illness↗
Biomedical subjects
Gary C Brown
Publications and source records attributed to Gary C Brown.
Dollars and sight: the economics of ophthalmology.
PURPOSE OF REVIEW: The purpose of this paper is to detail the economics of ophthalmology including trends in utilization, cost, and expenditure. RECENT FINDINGS: Eye care accounts for $23.1 billion, or approximately 1.93% of total health care expenditures annually. In 1991, eye care service costs in those 65 years or older were $5.5 billion, comprising 4.7% of Medicare spending. By 1999, the cost of eye care services in the 65 or older group had increased to $6 billion, but comprised only 2.8% of Medicare spending. SUMMARY: Although it is imperative that national health expenditure be controlled, ophthalmology has shouldered a disproportionate share of the cost cutting in recent years. When we consider the advances in ophthalmology and the contributions of ophthalmology to improved quality of life, the financial burden absorbed by ophthalmology is striking.
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Value-based medicine and vitreoretinal diseases.
PURPOSE OF REVIEW: The purpose of the review is to examine the role of value-based medicine and its impact, or potential impact, on vitreoretinal interventions. RECENT FINDINGS: Value-based medicine integrates evidence-based data from clinical trials with the patient-perceived improvement in quality of life conferred by an intervention. Cost-utility analysis, the healthcare economic instrument used to create a value-based medicine database, is being increasingly used to study the cost-effectiveness of vitreoretinal interventions. SUMMARY: Vitreoretinal interventions are generally cost-effective because of the great value they impart to patients. Laser surgical procedures, such as for diabetic retinopathy, threshold retinopathy of prematurity, and exudative macular degeneration appear to be especially cost-effective as a group.
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One eye versus two: a value-based approach.
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Cost of Illness↗
Update on the ocular manifestations of systemic arterial hypertension.
PURPOSE OF REVIEW: In a society with a steadily increasing population of patients with hypertension, a significant mortality risk factor, it is important that clinicians be cognizant of the changes seen in ophthalmic examination. This paper demonstrates both the acute and chronic stages of the disease. RECENT FINDINGS: This paper first presents the history of classifying different stages of hypertensive retinopathy, a condition associated with systemic arterial hypertension, as defined by Keith-Wagener-Barker. The most recent recommendations published in the Seventh Report of the Joint National Committee (JNC) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure are also described; this report defines the current status and classification of hypertension in the United States, as well as recommendations for its treatment and management. Finally, disease management strategies and currently accepted treatment options are presented. SUMMARY: Since systemic arterial hypertension is a key modifiable risk factor for various diseases such as myocardial infarction and stroke, it is crucial that we detect early signs of hypertension to promote better health for our patient population.
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Value-based medicine and ophthalmology: an appraisal of cost-utility analyses.
PURPOSE: To ascertain the extent to which ophthalmologic interventions have been evaluated in value-based medicine format. METHODS: Retrospective literature review. Papers in the healthcare literature utilizing cost-utility analysis were reviewed by researchers at the Center for Value-Based Medicine, Flourtown, Pennsylvania. A literature review of papers addressing the cost-utility analysis of ophthalmologic procedures in the United States over a 12-year period from 1992 to 2003 was undertaken using the National Library of Medicine and EMBASE databases. The cost-utility of ophthalmologic interventions in inflation-adjusted (real) year 2003 US dollars expended per quality-adjusted life-year (dollars/QALY) was ascertained in all instances. RESULTS: A total of 19 papers were found, including a total of 25 interventions. The median cost-utility of ophthalmologic interventions was 5,219 dollars/QALY, with a range from 746 dollars/QALY to 6.5 million dollars/QALY. CONCLUSIONS: The majority of ophthalmologic interventions are especially cost-effective by conventional standards. This is because of the substantial value that ophthalmologic interventions confer to patients with eye diseases for the resources expended.
Cost-Benefit Analysis↗
Quality of life associated with visual loss: a time tradeoff utility analysis comparison with medical health states.
PURPOSE: To assess the visual utility values of patients with ocular disease and to compare these values with those of patients with systemic health states DESIGN: Cross-sectional utility value assessment. METHODS: Consecutive patients with ophthalmic diseases were interviewed in a one-on-one fashion using a standardized time tradeoff utility value assessment form. These values were compared with utility values for systemic health states present in the literature. INTERVENTION: None. MAIN OUTCOME MEASURE: Time tradeoff utility value on a scale ranging from 1.0 (perfect visual health) to 0.0 (death). The ophthalmic patient groups were stratified into 4 visual groups dependent on the visual acuity in the better-seeing eye. The groups were as follows: group 1, 20/20 to 20/25; group 2, 20/30 to 20/50; group 3, 20/60 to 20/100; group 4, 20/200 to no light perception. RESULTS: A total of 500 subjects were enrolled in the study. The mean utility values for the visually stratified groups were: group 1, 0.88; group 2, 0.81; group 3, 0.72; group 4, 0.61. Comparable respective systemic health state utility values for each of the ophthalmic groups were: diabetes mellitus, status after kidney transplantation, moderate stroke, and moderately severe stroke. CONCLUSIONS: Visual loss is associated with a substantial and measurable diminution in quality of life. This diminution in quality of life can be directly compared with that induced by systemic health states.
Adult↗
Cost-utility analysis of cataract surgery in the second eye.
OBJECTIVE: To perform a reference case cost-utility analysis of second-eye cataract surgery by using the current literature on cataract outcomes and complications. DESIGN: Computer-based econometric modeling. METHODS: Visual acuity data of patients treated and observed over a 4-month postoperative period were obtained from the U.S. National Cataract Patient Outcomes Research Team report. The results from this prospective study were combined with those of other studies that investigated the complication rates of cataract surgery to complete the cohort of patients and outcomes. These synthesized data were incorporated with time trade-off utility values, which accounted for prior successful cataract surgery in the fellow eye. Cost-utility determinations were made with decision analysis, and present value modeling was used to account for the time value of money and health state consequences. MAIN OUTCOME MEASURES: The number of quality-adjusted life-years (QALYs) gained was calculated for the study group undergoing second-eye cataract surgery, assuming that the postoperative vision in the second eye was equivalent to the vision in the first eye after surgery (20/27). This was divided into the cost of the procedure to find the number of year 2001 nominal U.S. dollars spent per QALY gained. RESULTS: Second-eye cataract surgery, as compared with unilateral pseudophakia, resulted in a mean gain of 1.31 undiscounted QALYs per patient treated. A 3% annual discount rate, dependent on the duration of benefit, was used, yielding 0.92 discounted QALYs gained over a 12-year life expectancy. The mean discounted cost of treatment for each patient totaled 2509 US dollars. The cost divided by the QALYs gained (benefit) resulted in 2727 US dollars per QALY gained for this procedure. Sensitivity analysis varying costs and utility values revealed a range from 2045 US dollars to 3649 US dollars per QALY gained. CONCLUSIONS: Second-eye cataract surgery is an extremely cost-effective procedure when compared with other interventions across medical specialties. The cost-effectiveness of second-eye surgery diminishes only slightly from the 2023 US dollars per QALY gained from first-eye cataract surgery. This suggests that patients with good vision in one eye and visual loss from cataract in the fellow eye derive substantial benefit from cataract extraction.
Cataract↗
Value-based medicine: evidence-based medicine and beyond.
Value-based medicine is the practice of medicine emphasizing the value received from an intervention. Value is measured by objectively quantifying: 1) the improvement in quality of life and/or 2) the improvement in length of life conferred by an intervention. Evidence-based medicine often measures the improvement gained in length of life, but generally ignores the importance of quality of life improvement or loss. Value-based medicine incorporates the best features of evidence-based medicine and takes evidence-based data to a higher level by incorporating the quality of life perceptions of patients with a disease in concerning the value of an intervention. Inherent in value-based medicine are the costs associated with an intervention. The resources expended for the value gained in value-based medicine is measured with cost-utility analysis in terms of the US dollars/QALY (money spent per quality-adjusted life-year gained). A review of the current status and the likely future of value-based medicine is addressed herein.
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CME review: A cost-utility analysis of laser photocoagulation for extrafoveal choroidal neovascularization.
PURPOSE: The purpose of this study was to perform a reference case (average case), cost-utility analysis of laser photocoagulation for extrafoveal choroidal neovascularization associated with age-related macular degeneration using a model incorporating patient preferences. METHODS: Visual acuity data for patients treated and observed over a 5-year period were obtained from previously reported studies by the Macular Photocoagulation Study Group. The results from this prospective, randomized trial were incorporated in a cost-utility model using time-trade-off utility analysis and decision analysis with Markov modeling according to the recommendations of the Panel on Cost-Effectiveness in Health and Medicine. Expenditures and health care benefits were each discounted at a 3% yearly rate. RESULTS: Laser photocoagulation therapy for extrafoveal choroidal neovascularization in age-related macular degeneration, compared with observation, resulted in a mean gain of 0.0740 quality-adjusted life-year per patient treated. The mean cost of treatment for the average patient totaled 1,715 US dollars. The cost divided by the health care benefit resulted in 23,176 year 2001 US dollars per quality-adjusted life-year gained for this procedure for a reference case. Sensitivity analyses, varying the cost, utility values, and discount parameters, resulted in dollars per quality-adjusted life-year gained ranging from 16,117 to 49,766 US dollars. CONCLUSION: Laser photocoagulation for extrafoveal choroidal neovascularization associated with age-related macular degeneration appears to be cost-effective when compared with interventions across multiple medical specialties.
Choroidal Neovascularization↗
Cost-effectiveness of ocular interventions.
The cost-effectiveness of ophthalmic interventions has become increasingly important as the US health care budget continues to grow. During the past two decades, a methodology rooted in utility analysis has provided a way to objectively assess the value of an intervention for a specific disease. Specifically within the field of ophthalmology, there is a growing body of literature on utility analysis using patient preference-based outcomes for ophthalmic disease. This has led the way to combining costs with utility values to derive a cost-utility analysis, or cost-effectiveness, for a given ophthalmic procedure. This article outlines this methodology, provides a reference-case example for initial cataract surgery, and describes a comparative study of the value associated with interventions within the field of ophthalmology and across other medical specialties.
Cost-Benefit Analysis↗
Update on treatment of retinal arterial occlusions.
Retinal arterial occlusion remains a difficult clinical entity to manage. Treatment can best be categorized as conservative (ocular massage, pharmacologic, anterior chamber paracentesis) and invasive (catheterization of the proximal ophthalmic artery through the femoral artery with the infusion of thrombolytic agents). Most reports remain anecdotal due to its low incidence (0.85/100,000/y).
Humans↗
Update on photodynamic therapy.
To date, photodynamic therapy with verteporfin has been shown to benefit those patients with age-related molecular degeneration and choroidal neovascularization that is subfoveal and predominately classic (> 50%). As of this writing, the Food and Drug Administration is requiring additional data before verteporfin is approved for treatment of occult subfoveal choroidal neovascularization. Photodynamic therapy has also proved beneficial for subfoveal lesions secondary to high myopia. Although there is potential for patients with angioid streaks, ocular histoplasmosis syndrome, and idiopathic causes of choroidal neovascularization to benefit from photodynamic therapy, randomized clinical trials have not been performed. Photodynamic therapy has not been shown to benefit patients with minimally classic (< 50%) lesions.
Humans↗
Quality of life with visual acuity loss from diabetic retinopathy and age-related macular degeneration.
OBJECTIVE: To compare the quality of life in patients with visual acuity loss occurring secondary to diabetic retinopathy with visual acuity loss occurring secondary to age-related macular degeneration (ARMD). METHODS: Consecutive patients with diabetic retinopathy and ARMD were evaluated using the time trade-off method of utility value analysis. Both groups were stratified according to the degree of visual acuity loss in the better-seeing eye (group 1: 20/20-20/25, group 2: 20/30-20/40, group 3: 20/50-20/100, group 4: < or =20/200). Utility values obtained from the patients, once stratified for visual acuity group, were compared with use of the t test and the Mann-Whitney U test. In addition, a 2-way analysis of variance was performed to control for potential confounding variables. RESULTS: No difference was found between the utility value means of the diabetic retinopathy (n = 333) and ARMD (n = 246) subgroups stratified according to visual acuity levels: group 1, P =.54; group 2, P =.96; group 3, P =.09; and group 4, P =.32. A 2-way analysis of variance demonstrated that, among the variables of ocular disease, sex, age, and visual acuity in the better-seeing eye, only visual acuity was significantly associated with utility values (P =.003). CONCLUSIONS: At similar levels of visual acuity loss, that associated with diabetic retinopathy causes a similar reduction in quality of life to that associated with ARMD. This information has important implications for use in cost-utility analyses of ophthalmic interventions.
Aged↗
A cost-utility analysis of interventions for severe proliferative vitreoretinopathy.
PURPOSE: The purpose of this study was to report a reference case, patient preference-based, incremental, cost-utility analysis for treatments of retinal detachment associated with severe proliferative vitreoretinopathy (PVR). DESIGN: Computer-based economic model utilizing data from the Medicare health insurance system in the United States. METHODS: A cost-utility analysis compared vitreoretinal surgery using expanding gases and silicone oil therapy to the natural course of retinal detachment associated with severe PVR. The model applies long-term published visual data from the Silicone Study Group, time tradeoff utility analysis, decision analysis with Markov modeling, and discounting of costs and health benefits as per the Panel on Cost-Effectiveness in Health and Medicine. The major outcome measure was in year 2000 United States dollars per quality-adjusted life-year (dollars/QALY) gained. RESULTS: Vitreoretinal surgery for retinal detachment complicated by severe PVR, as compared with no treatment, resulted in a mean gain of 0.128-0.200 discounted (3% annual rate) quality-adjusted life-years per treated patient. Silicone oil (dollars/QALY gained of 40,252 dollars) was slightly more cost-effective than perfluoropropane (C(3)F(8)) gas (dollars/QALY gained of 46,926 dollars) in eyes with PVR without previous vitrectomy, whereas C(3)F(8) gas (dollars/QALY gained of 46,162 dollars) was more cost-effective than silicone oil (dollars/QALY gained of 62,383 dollars) with previous vitrectomy and PVR. Sensitivity analysis resulted in a dollars/QALY gained of 13,347 dollars when 10% of opposite eyes had a severe visual loss to 202,128 dollars when a discount rate of 10% was utilized and opposite eyes initially had good vision. CONCLUSIONS: The incremental expense of interventions for retinal detachment associated with PVR is cost-effective when compared with other widely accepted interventional therapies across diverse medical specialties.
Computer Simulation↗
Incremental cost-effectiveness of initial cataract surgery.
PURPOSE: The purpose of this study was to perform a reference case, cost-utility analysis of initial cataract surgery using the current literature on cataract outcomes and complications. DESIGN: Computer-based econometric modeling. METHODS: Visual acuity data of patients treated and observed over a 4-month postoperative period was obtained from the US National Cataract Patient Outcomes Research Team (PORT). The results from this prospective study were combined with other studies that investigated the complication rates of cataract surgery to complete the cohort of patients and outcomes. These synthesized data were incorporated with time-tradeoff utility values, decision analysis, and econometric modeling to account for the time value of money. MAIN OUTCOME MEASURES: The number of quality-adjusted life-years (QALYs) gained was calculated for the study group undergoing cataract extraction in the first eye when the vision was the same in both eyes. This was divided into the cost of the procedure to find the year 2000 nominal US dollars spent per quality-adjusted life-year ($/QALY) gained. RESULTS: Initial cataract surgery, compared with observation, resulted in a mean gain of 1.776 QALYs per patient treated. A 3% annual discount rate was used to account for the benefit over time, yielding 1.25 QALYs gained. The mean cost of treatment (also discounted at a 3% annual rate) of each patient totaled 2525 US dollars. The cost divided by the discounted benefit resulted in $2020/QALY gained for this procedure. CONCLUSIONS: Initial cataract surgery seems to be highly cost-effective compared with procedures across multiple medical specialties. This information, incorporating patient preferences into evidenced-based medicine, will play an increasingly important role in the evaluation of health care in the future.
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A cost-utility analysis of therapy for amblyopia.
OBJECTIVE: Evaluation of the incremental cost-effectiveness of therapy for amblyopia. DESIGN: Cost-utility reference-case analysis. METHODS: A cost-utility analysis was performed from a third-party insurer perspective by using decision analysis, evidence-based data from the literature, and patient preference-based time trade-off utility values. DATABASE: Patient-derived time trade-off ocular utility values and the American Academy of Ophthalmology Preferred Practice Pattern guidelines for the treatment of amblyopia. INTERVENTION: Treatment of childhood amblyopia using medical and surgical therapies per the American Academy of Ophthalmology Preferred Practice Pattern. MAIN OUTCOME MEASURE: Dollars (year 2001 nominal U.S. dollars) expended per quality-adjusted life-year ($/QALY) gained. RESULTS: Treatment for amblyopia resulted in a $/QALY gained of $2281 with a discount rate of 3% for costs and outcomes. Sensitivity analysis, varying costs and utility values by 10%, resulted in a $/QALY gained range from $2053 to $2509. CONCLUSIONS: When compared with other interventions in health care, therapy for amblyopia seems to be highly cost-effective. This information is increasingly important for health care policy makers.
Amblyopia↗
Incremental cost-effectiveness of laser therapy for visual loss secondary to branch retinal vein occlusion.
PURPOSE: To ascertain the incremental cost-effectiveness of therapeutic interventions for improving visual loss associated with branch retinal vein occlusion. METHODS: A cost-utility analysis incorporating data from the Branch Vein Occlusion Study Group was performed using patient-based preferences obtained from time tradeoff utility analysis, decision analysis with Markov modeling, and economic modeling with future value analysis. The cost-effectiveness results are expressed in dollars/QALY (dollars expended per quality-adjusted life-year) gained. This unique model takes into account the visual acuity in the better seeing eye and the recurrent risk for visual loss in the contralateral eye. RESULTS: Laser therapy for macular edema secondary to branch retinal vein occlusion was associated with an incremental dollars/QALY gained of 6118 dollars (in year 2000 U.S. dollars). Two-way sensitivity analysis, varying the discount rate and the proportion of patients developing a vascular occlusion in the contralateral eye, revealed a range of dollars/QALY gained from 3370 dollars to 19,299 dollars. CONCLUSIONS: Laser therapy appears to be a cost-effective intervention for improving visual loss associated with macular edema secondary to branch retinal vein occlusion. Variants of the methodology employed to calculate the incremental cost-effectiveness of this intervention can be widely applied across all specialties in medicine.
Aged↗