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Editors Selection IGR 14-1

Response

Comment by Josh Stein 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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My colleagues and I thank the experts for their thoughtful comments on our study. In undertaking the analysis, my colleagues and I aimed to build a Markov model that captured and compared the costs, outcomes, and health-related quality-of-life effects of two glaucoma treatment strategies: laser trabeculoplasty and long-term medication use. To do so, we sought the highest-quality data sources available in the literature; however, we soon encountered a challenge in this regard: The study offering arguably the highest level of evidence comparing medications with laser trabeculoplasty for open-angle glaucoma (OAG) was the Glaucoma Laser Trial (GLT) ‐ a randomized clinical trial conducted approximately 25 years ago ‐ yet the glaucoma medications that were routinely prescribed at that time were beta blockers and para-sympathomimetic agents, not topical prostaglandin analogs, which are often the first-line medical therapy used today in patients with newly diagnosed OAG.

The only way to devise a Markov model that made use of the highest- quality evidence from the GLT, yet generated results applicable to management decisions today, was to make several assumptions about some of the model parameters for which little published data currently exist. Knowing that some of these assumptions could be called into question (including several of the cogent points raised here by the expert commentators), we tried, whenever possible, to perform sensitivity analyses to test whether the findings of our model would change if some of the parameter estimates varied from those we had included in the actual model. By performing the sensitivity analyses we established, for example, that the strategy ultimately determined to be the most cost-effective treatment for newly-diagnosed OAG would be unchanged if we were to reduce the assumed incidence of laser-related adverse events from 5% (the estimate used in our base model) to 0%, or if we assumed prostaglandin analogues are actually less effective than the estimates used in the base model. In the future, as evidence from newer trials comparing medical therapy to laser trabeculoplasty, such as the SLT/ Med Trial, become available, the newer data can be entered into the Markov model we developed to reassess the cost-effectiveness of glaucoma therapies.

As health-care resources continue to be constrained, analyses such as this one will, we believe, become increasingly important in helping to determine which interventions confer the greatest value. Future cost-effectiveness and comparative effectiveness analyses can be conducted to re-evaluate existing treatments for glaucoma on the basis of newer data, and to compare the values of established interventions with those of relatively new treatments to the marketplace.

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