The Cost-effectiveness of Routine Office-based Identification and Subsequent Medical Treatment of Primary Open-Angle Glaucoma in the United States

Objective: To estimate the incremental cost-effectiveness of routine glaucoma assessment and treatment under current eye care visit and treatment patterns and different levels of treatment effectiveness (from randomized trials). Design: We compared the costs and benefits of routine glaucoma assessment and treatment compared with no treatment using conservative and optimistic assumptions regarding treatment efficacy and including and excluding prediagnostic assessment costs. Participants and Controls: Computer simulation of 20 million people followed from age 50 years to death or age 100 years. Methods: With the use of a computer model, we simulated glaucoma incidence, natural progression, diagnosis, and treatment. We defined glaucoma incidence conservatively as a mean deviation of -4 decibels (dB) on visual field testing in either eye for all diagnoses to be both clinically meaningful and unambiguous. We simulated the annual probability of subsequent progression and the quantity of visual field lost when progression occurred. Main Outcome Measures: Visual field loss, ophthalmologic and nursing home costs, quality-adjusted life years (QALYs), cost per QALY gained, and cost per year of sight gained. Costs and QALYs were discounted to 2005 values using a 3% rate. Results: Compared with no treatment and when including diagnostic assessment costs, the incremental cost-effectiveness of routine assessment and treatment was $46,000 per QALY gained, assuming conservative treatment efficacy, and $28,000 per QALY gained, assuming optimistic treatment efficacy. Compared with no treatment and when excluding diagnostic assessment costs, the incremental cost-effectiveness of routine assessment and treatment was $20,000 per QALY gained, assuming conservative treatment efficacy, and $11,000 per QALY gained, assuming optimistic treatment efficacy. The cost-effectiveness was most sensitive to the treatment costs and the value of QALY losses assigned to visual field losses. Conclusions: Glaucoma treatment was highly cost-effective when the costs of diagnostic assessments were excluded or when we assumed optimistic treatment efficacy. The cost was reasonable and in line with other health interventions even when diagnostic assessment costs were included and assuming conservative efficacy. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. Ophthalmology 2009;116:823-832 (C) 2009 by the American Academy of Ophthalmology.