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Editors Selection IGR 9-3

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John Walt

Comment by John Walt on:

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

See also comment(s) by Augusto Azuara Blanco • Paul Healey • Steve Kymes • Anja Tuulonen • William Steward •


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The study by Stewart et al. used a Markov model to evaluate the cost-effectiveness of treating patients with OHT. The time horizon of the model was five years. The authors found that "treating selective OHT patients with high risk factors identified in the OHTS […] does seem to be cost-effective for preventing the onset of glaucomatous damage." The estimation of the impact of glaucoma in quality of life has a major influence in the model. Stewart et al. ignored the previous work in this area by, e.g., Jampel,1 Saw et al.,2 and Kobeltet al.3 The most important flaw in the article is the use of a clearly wrong utility value of 0.57 for patients with 'moderate glaucoma'.

Firstly, patients defined as 'moderate' glaucoma by Stewart et al. would still have an MD loss of less than 6 dB in the worse eye. The visual function of patients with such visual field loss is overall very good. Secondly, to have an idea how misguided their use of utility value has been, I will give a few examples of patients with 'better quality of life' (according to Stewart et al.) than those in model (i.e., early glaucoma in the worse eye): patients with visual acuity in the better-seeing eye of 20/200 (utility = 0.66),4,5 breast cancer patients who underwent chemotherapy (utility = 0.74),6 impotence and incontinence after transurethral resection of prostate (utility = 0.60),7 or pre-operative ulcerative colitis (utility = 0.58).8

References

  1. Jampel HD. Glaucoma patients' assessment of their visual function and quality of life. Trans Am Ophthalmol Soc 2000; 99: 301-317.
  2. Saw SM, Gazzard G, Eong KG, Oen F, Seah S. Utility Values in Singapore Chinese Adults with Primary Open Angle and Primary Angle Closure Glaucoma. J Glaucoma 2005; 14: 455-462.
  3. Kobelt G, Jonsson B, Bergstrom A, Chen E, Linden C, Alm A. Cost-effectiveness analysis in glaucoma: what drives utility? Results from a pilot study in Sweden. Acta Ophthalmol Scand 2006; 84: 363-371.
  4. Brown GC. Vision and quality of life. Trans Am Ophthalmol Soc 1999; 97; 473-511.
  5. Brown MM, Brown GC, Sharma S, Garrett S. Evidence-based medicine, utilities and quality of life. Curr Opin Ophthalmol 1999; 10: 221-226.
  6. Hayman JA, Hillner BE, Harris JR, Weeks JC. Cost-effectiveness of routine radiation therapy following conservative surgery for early-stage breast cancer. J Clin Oncol 1998; 16: 1022-1029.
  7. Krumins PE, Fihn SD, Kent DL. Symptom severity and patients' values in the decision to perform a transurethral resection of the prostate. Med Decis Making 1988; 8: 1-8.
  8. McLeod RS, Churchill DN, Lock AM, Vanderburgh S, Cohen Z. Quality of life of patients with ulcerative colitis preoperatively and postoperatively. Gastroenterology 1991; 101: 1307-1313.

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