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Editors Selection IGR 11-3

Health economics: Cost-effectiveness of tonometry

Comment by Steve Kymes on:

20827 Cost-effectiveness of early detection and treatment of ocular hypertension and primary open-angle glaucoma by the ophthalmologist, Peeters A; Schouten JS; Webers CA et al., Eye, 2008; 22: 354-362

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Peeters et al. (453) have conducted an impressive decision analysis concerning the cost-effectiveness of the use of tonometry in the screening of patients as part of a routine ophthalmic examination. Their findings that use of tonometry for all patients undergoing examination would seem to validate the practice employed in many other nations, in particular the U.S. where IOP is measured in most adult patients as part of routine care. However, the management option of risk stratification prior to tonometry may have been given short shrift. The investigators chose to conduct their risk stratification based upon family history. They undoubtedly chose this risk factor because it is one of the few for glaucoma that might be assessed without physical examination. However, the limitation of family history as a measure for assessing the risk of developing glaucoma or its progression can be seen in Table 4. Screening only the 'high risk' group resulted in over twice as many cases of blindness compared to the 'screen all' strategy, and nearly as many as the 'screen no one' strategy. This implies that a potent risk factor has been missed. Would the expense of a one-time pachymetry examination provide a better picture of who is at risk? Could the results of the examination of the optic nerve (which all patients undergo) provide information for risk stratification on this or a subsequent visit? While the authors have made a compelling case, one advantage of economic evaluation is that such 'hypotheticals' can be considered, and their investigation might have benefited from such considerations. A consideration of additional options might reduce the advantage seen in the 'screen all' strategy due to improved case finding, and could influence the decision of health policy makers. This is precisely why those conducting economic evaluation are encouraged by guidelines to consider all viable options when conducting their investigations.

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