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Editors Selection IGR 9-4

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Comment by Ivan Goldberg on:

49037 Cost-effectiveness of Medications Compared With Laser Trabeculoplasty in Patients With Newly Diagnosed Open-Angle Glaucoma, Stein JD; Kim DD; Peck WW et al., Archives of Ophthalmology, 2012; 130: 497-505

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As populations age and increase in number, numbers of glaucoma patients are rising exponentially and management economic burdens for individuals, families and communities are increasing pari passu. Comparisons of cost-effectiveness of different strategies to reduce intra-ocular pressure (IOP) are becoming more important. As health-care deliverers, ophthalmologists need to consider cost implications as part of their overall management plan developed in a therapeutic alliance with their patients. This does not imply cost domination of management plans, but incorporation as one factor in their development.

Ophthalmologists need to consider cost implications as part of their overall management plan developed in a therapeutic alliance with their patients

Stein and co-workers have tackled this task thoughtfully and with as much evidence as is available. Unavoidably significant assumptions are necessary, all of which are open to challenge: in their Markov model why assume a one-year cycle through each stage of the disease, adverse effects from laser trabeculoplasty (LTP) are likely over-estimated if assumed to be 5%, medication benefits are likely to be over-stated if prostaglandin analogues are assumed to be 30% more protective against visual-loss progression than beta blockers, and medication non-adherence, non-perseverance and dyscompliance are likely in a non-trial real-world population to be somewhat higher than the 25% figure used.

There are other potential issues: number of LTP treatments was not accounted for, nor was the cost of treating medication side effects, including presumably increased frequency of visits and medication changes.

To some extent, the authors were able to derive some comfort for several assumptions from the concordance of their projections and the evidence provided by the St Lucia and Chen and co-worker studies and the Glaucoma Laser Trial. Quite correctly, as variables may differ widely from the ones they used, they urge care when generalizing their findings to patients with other types of glaucoma, those outside the United States, those uninsured, and those without access to LTP.

Hopefully this excellent article will stimulate similar analyses around the world.¹

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