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Editors Selection IGR 24-3

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Comment by Anja Tuulonen on:

20389 Cost-effectiveness of treating ocular hypertension, Stewart WC; Stewart JA; Nassar QJ et al., Ophthalmology, 2008; 115: 94-98

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It is always nice when common sense and common practice are aligned. And when both are aligned with sound economics, all makes sense. In this case, the authors of this economic analysis have demonstrated common sense and generally accepted medical practice are aligned.

In a very sound and robust economic analysis, using a universally accepted economic simulation process (Markov Modeling) of a realistic estimate of the actual range of patients, treatments, and progression the authors have validated common sense is economic sense. Their economic modeling results have validated it is sound to treat the ocular hypertension patients whom are at greatest risk of progressing to glaucoma. And it does not make good economic sense to categorically treat all ocular hypertensives.

It is worthwhile to repeat their conclusion: "treating selective OHT patients with risk factors […] does seem to be cost-effective for preventing the onset of glaucomatous damage."

Treatment of the OHT patient should still be a case-by-case personal decision between thephysician and the OHT patient. It should not be driven by population based economic analysis

In fair balance, however, this economic study does address in the limitations: "This model had several limitations […] future assumptions may improve a Markov analysis such as: quality-of-life weighted utilities specific to glaucoma", and that should be expanded to address the human patient factor of this patient 'seeing' disease.

Glaucoma progression is still currently medically and technologi-cally irreversible. And despite the best current medical treatments, in many patients continues to progress, and does appear difficult to alter the apparently linear progression 'curve'. Recent glaucoma studies have demonstrated the correlation of visual field loss and patient reported loss in multiple Quality of Life (QoL) domains, even early in the disease.

Does it make economic sense to treat the OHT patient, whose progression curve has yet to be determined due to being adequately detected early enough? That should still be a case-by-case personal decision between the physician and the OHT patient. It should not be driven by population based economic analysis.

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