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Importance: Describing the characteristics and sources of health state utility values and reporting practice in the literature of cost-utility analyses facilitates an understanding of the level of the transparency, validity, and generalizability of cost-utility analyses. Improving the quality of reporting will support investigators in describing the incremental value of emerging glaucoma interventions., Objective: To describe the state of practice among published glaucoma cost-utility analysis studies, focusing on valuation of health and the quality of reporting., Evidence Review: We searched several databases including Medline, CINHAL, Embase, Web of Science, Scopus, Biosis previews, the Health Economic Evaluations Database, and the NHS Economic Evaluation Database (NHS EED). We included full-text, English, published cost-utility analyses of glaucoma interventions with quality-adjusted life years (QALYs) as the primary outcome measure to calculate incremental cost-utility ratios. Excluded studies were non-English language, reviews, editorials, protocols, or other types of economic studies (cost-benefit, cost-minimization, cost-effectiveness). Study characteristics, operational definitions of glaucoma health states and health state utilities were extracted. The original source of the health utility was reviewed to determine the scale of measurement and the source of preference weighting. Items from the Systematic Review of Utilities for Cost-Effectiveness (SpRUCE checklist) were used to assess the reporting and quality of health utilities in glaucoma CUA., Findings: 43 CUAs were included, with 11 unique sources of health utilities. A wide range of health utilities for the same Hodapp-Parrish-Anderson glaucoma health states were reported; ocular hypertension (0.84-0.95), mild (0.68-0.94), moderate (0.57-0.92), advanced (0.58-0.88), severe/blind (0.46-0.76), and bilateral blindness (0.26-0.5). Most studies reported the basis for using health utilities (34, 79%) and any assumptions or adjustments applied to the health utilities (22, 51%). Few studies reported a framework for assessing the relevance of health utilities to a decision context (8, 19%). Even fewer (3, 7%) applied a systematic search strategy to identify health utilities and used a structured assessment of quality for inclusion. Overall, reporting has not improved over time., Conclusions and Relevance: This review describes that few CUAs describe important rationale for using health state utility values. Including additional details on the search, appraisal, selection, and inclusion process of health utility values improves transparency, generalizability and supports the assessment of the validity of study conclusions. Future investigations should aim to use health utilities on the same scale of measurement across health states and consider the source and relevance to the decision context/purpose of conducting that cost-utility study., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Affordability and availability of medicines is a growing global challenge for health-care systems. Access to medicines is recognized as an important determinant of treatment adherence. The access to glaucoma medicines and how it affects glaucoma management are not known. The purpose of this study was to determine the availability, affordability, and accessibility of topical intraocular pressure (IOP) -lowering eye drops in Haryana state of northern India using the World Health Organization (WHO)/Health Action International (HAI) methods., Methods: A cross-sectional study was done to collect data on prices and availability of glaucoma topical medications in public and private sector pharmacies and retail outlets using the WHO/HAI methodology between October 2021 and January 2022. The availability and affordability of topical glaucoma medicines was determined. Comparison of the local price with international prices was done by calculating the median price ratio (MPR)., Results: A total of 191 facilities were randomly sampled across 11 ( n = 55) urban, 29 ( n = 92) semi-urban, and 44 ( n = 44) rural places during the study period. The availability of topical medication for glaucoma was low (35.7 ± 22.3) across all sampled sites and all classes of topical glaucoma medications. The median price of topical medication and availability were negatively correlated, Pearson's coefficient r (18) = -0.44, P 0.05, though the relationship was weak. A lowest paid, unskilled Indian government worker must spend between 15% and 203% of their daily wage to acquire a glaucoma medication., Conclusion: The availability and accessibility of topical glaucoma medications was low in this survey., (Copyright © 2024 Copyright: © 2024 Indian Journal of Ophthalmology.)

Objectives: This study sought to determine the economic cost of the management of glaucoma among patients seeking care in health facilities in Ghana., Design: A cross-sectional cost-of-illness (COI) study from the perspective of the patients was employed., Setting: The study was conducted in public and private eye care facilities in the Tema Metropolis of Ghana., Participants: About 180 randomly selected glaucoma patients seeking healthcare at two facilities participated in the study., Main Outcome Measure: Direct cost, including medical and non-medical costs, indirect cost, and intangible burden of management of glaucoma., Results: the cost per patient treated for glaucoma in both facilities was US$60.78 (95% CI: 18.66-107.80), with the cost in the public facilities being slightly higher (US$62.50) than the private facility (US$ 59.3). The largest cost burden in both facilities was from direct cost, which constituted about 94% of the overall cost. Medicines (42%) and laboratory and diagnostics (26%) were the major drivers of the direct cost. The overall cost within the study population was US$10,252.06. Patients paid out of pocket for the frequently used drug- Timolol, although expected to be covered under the National Health Insurance Scheme (NHIS). Patients, however, expressed moderate intangible burdens due to glaucoma., Conclusion: The cost of the management of glaucoma is high from the perspective of patients. The direct costs were high, with the main cost drivers being medicines, laboratory and diagnostics. It is recommended that the National Health Insurance Authority (NHIA) should consider payment for commonly used medications to minimize the burden on patients., Funding: None declared., Competing Interests: Conflict of interest: None declared, (Copyright © The Author(s).)

Purpose : To use a medical claim database to investigate medical costs and treatment patterns among patients newly starting glaucoma care. Subjects and methods : Subjects registered in the Japan Medical Database Center (JMDC) from January 2005 to March 2016 who were newly diagnosed with glaucoma, started glaucoma treatment, and had treatment records covering more than five years were included in the analysis. All direct medical costs were collected for a period of up to ten years. Factors affecting medical costs were analyzed. Changes in hypotensive eyedrops and choices related to glaucoma surgery were also analyzed. Results : Out of approximately 1.42 million subjects, 2,393 satisfied the inclusion and exclusion criteria. The average total medical cost incurred per patient over a period of ten years was US$9,030, including US$1,214 during the initial year. The proportion of the total cost represented by the cost of hypotensive eyedrops increased from 5.2% to 10.6% over the ten-year period. Medical costs were higher in patients younger than ten years old than in patients of all other age groups. The number of ocular hypotensive eyedrops increased from 0.9 to 1.5 over the ten-year period. Medical costs were higher for subjects with secondary glaucoma than for other subjects. Sixty-three patients underwent trabeculotomy or trabeculectomy, and trabeculectomy was the preferred choice in later years. Conclusions : The total direct medical cost associated with glaucoma was US$9,030 for the first ten years. Drug costs gradually increased with treatment duration and patient age and varied by glaucoma type.

Background/aims: Assess whether a new clinical pathway for glaucoma was acceptable to patients and healthcare professionals and whether it provided useful clinical information on non-responsiveness and non-adherence to the treatment of elevated intraocular pressure with latanoprost eye drops., Methods: A single arm non-randomised prospective observational study incorporating new glaucoma/ocular hypertension patients. To assess issues of acceptability, qualitative observation and interviews were conducted with patients and healthcare professionals. To determine clinical responsiveness, intraocular pressures were measured before and 4 hours after a clinician-instilled eye drop over two distinct appointments. Adherence data were collected using a Medicine Event Monitoring System. Economic analyses compared the costs between novel and standard care pathways., Results: Of 72 patients approached, 53 entered the study (74.3%) and 50 completed all procedures (94.3%). Intraocular pressure was reduced more than 15% in 83 out of 92 study eyes by final visit (90.2%). The non-response rate was 5.1% once the effect of low adherence was minimised. For the 1376 drop instillation days under observation, eye drops were instilled as prescribed on 1004 days (73.0%), over-instilled on 137 days (9.9%) and not instilled on 235 days (17.1%). The Cardiff Model of Glaucoma Care involved negligible cost, although acceptance for healthcare professionals showed variation., Conclusions: The Cardiff Model of Glaucoma Care offers novel clinical and adherence insights at marginal costs while acceptable to patients. Healthcare professionals felt that 4 hour and 4 week follow-up appointments could cause administrative problems. A streamlined version of the pathway has therefore been developed to facilitate clinical adoption., Trial Registration Number: ISRCTNID:ISRCTN75888393., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: To evaluate the cost-effectiveness (CE) and budget impact (BI) of introducing a patient visit support system (ACT Pack) along with standard of care (SoC), in glaucoma treatment in Japan., Methods: A Markov model was designed to estimate the CE and BI of introducing the support system from Japanese payer and governmental perspective, respectively. Inputted data for CE and BI analysis were referred from published literature and based on medical specialists' inputs. Base case scenario for CE considered the support system cost of 30,000 yen per patient per year and a time horizon of 45 years. BI analysis compared the financial impact due to introduction of support system with SoC compared to SoC alone scenario on Japanese healthcare system with a time horizon of 20 years., Results: The base case of CE analysis showed the incremental cost per quality-adjusted life years (QALYs) gained with the support system was 3,241,729 yen/QALY (29,470 USD/QALY). The sensitivity analysis showed that the probability of this support system being cost-effective at a threshold of 5 million yen/QALY (45,455 USD/QALY) was 53.26%. Blindness reduction after introduction of this support system was 8.68%. The BI analysis showed that the introduction of support system will lead to a cumulative cost savings of 1,132 billion yen (10 billion US dollars) for Japanese healthcare system over 20 years of time horizon., Limitation: Due to paucity of similar comparative studies, some assumptions were made based on medical specialists' inputs. Death status was not considered in the analysis., Conclusion: Introduction of this support system with SoC is cost-effective and will lead to blindness reduction in Japanese patients with glaucoma. Over a 20 year period, it will lead to an overall cost savings of 1,132 billion yen (10 billion US dollars) for the Japanese healthcare system.

Micro- or minimally invasive glaucoma surgeries (MIGS) have been the latest addition to the glaucoma surgical treatment paradigm. This term refers not to a single surgery, but rather to a group of distinct procedures and devices that aim to decrease intraocular pressure. Broadly, MIGS can be categorized into surgeries that increase the trabecular outflow [Trabectome, iStent (first and second generations), Hydrus microstent, Kahook Dual Blade and gonioscopy-assisted transluminal trabeculotomy], surgeries that increase suprachoroidal outflow (Cypass microstent and iStent Supra), and conjunctival bleb-forming procedures (Xen gel stent and InnFocus microshunt). Compared to traditional glaucoma surgeries, such as trabeculectomy and glaucoma drainage device implantation (Ahmed, Baerveldt, and Molteno valves), MIGS are touted to have less severe complications and shorter surgical time. MIGS represent an evolving field, and the efficacy and complications of each procedure should be considered independently, giving more importance to high-quality and longer-term studies.

Aims: To determine the cost and quality of life impact imposed by glaucoma in Tanzania, East Africa., Methods: An expert panel of eye health professionals was convened to agree current glaucoma practice in Tanzania. In addition a structured patient survey was developed and administered. Supplemental cost and quality of life information was collected using cost questionnaires and validated quality of life measures, including the EQ5D and VFQ-25., Results: Key findings include following. Non-adherence is a major issue, especially in rural settings where over 50% of the patients may fail to return for review. Whilst medical therapy is overwhelmingly the first line treatment, the cost of maintaining this represents up to 25% of a patient's income. There is an impact of glaucoma on patients general well-being as determined by the EQ-5D and more tellingly on visual function with particular impact on role limitations as determined by the VF25. Despite our sample being taken in a private clinic and thus containing a much larger proportion of professionals than the general population, one third of the population earned Tanzanian Shillings (TZS) 170,000 per month which is below the minimum wage., Conclusion: These findings are of great importance for health care planners seeking to determine cost-effective, acceptable methods of both identifying and treating this major cause of preventable blindness., Competing Interests: Author AFS is a consultant to Medmetrics Inc and was a paid health economics consultant on this project. This does not alter our adherence to PLOS ONE policies on sharing data and materials. No other authors have any competing interests to declare.

Background: Prostaglandin analogs are the most effective treatment for glaucoma, a common condition among older adults. Despite the availability of generic drugs, the costs associated with these prescription drugs are rising., Objective: To characterize Medicare prescription drug plan (PDP) formulary coverage and beneficiary out-of-pocket cost for prostaglandin analogs from 2009 to 2017 and Medicare spending on prostaglandin analogs from 2013 to 2017., Methods: This study was a retrospective analysis. We used 2009, 2013, and 2017 Medicare PDP formulary, beneficiary cost, and pricing files to determine beneficiary first-prescription out-of-pocket costs and plan coverage (unrestricted, restricted, or not covered) of branded latanoprost 0.005%, travoprost 0.004%, bimatoprost 0.03% and 0.01%, and tafluprost 0.0015% and of generic latanoprost 0.005% and generic bimatoprost 0.03%. We also used Medicare Part D spending data to determine aggregate spend in 2013 and 2017., Results: In 2009, 92% of plans covered branded latanoprost, 83% covered branded bimatoprost; and 49% covered branded travoprost, whereas in 2017, 6% of plans covered branded latanoprost; 95% covered branded bimatoprost; and 96% covered branded travoprost. Although generic latanoprost was universally covered, generic bimatoprost was only covered by 35% of plans in 2017. Median out-of-pocket cost of branded prostaglandins without generic equivalents was $35 (IQR = $29-$40) in 2009, $45 (IQR = $42-$101) in 2013, and $90 (IQR = $45-$159) in 2017. Median out-of-pocket cost of all available generic prostaglandins was $10 (IQR = $5-$33) in 2013 and $10 (IQR = $4-$15) in 2017. In 2013, Medicare spent $733 million on prostaglandin analogs; in 2017, this increased to $1.09 billion, with $943 million (86%) spent on branded prostaglandins and $148 million (14%) spent on generics., Conclusions: Medicare PDP coverage of branded prostaglandins remained stable from 2009 to 2017. While median beneficiary out-of-pocket costs associated with generic prostaglandins remained stable, those associated with branded prostaglandins increased nearly 3-fold., Disclosures: Research reported in this publication was supported by National Heart, Lung and Blood Institute of the National Institutes of Health under Award Number T35HL007649. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute or the National Institutes of Health. Shah has received research support through Mayo Clinic from the U.S. Food and Drug Administration (FDA) to establish Yale-Mayo Clinic Center for Excellence in Regulatory Science and Innovation (CERSI) program (U01FD005938); the Centers of Medicare and Medicaid Innovation under the Transforming Clinical Practice Initiative (TCPI); the Agency for Healthcare Research and Quality (U19HS024075, R01HS025164, R01HS025402, R03HS025517); and the National Heart, Lung and Blood Institute of the National Institutes of Health (NIH) (R56HL130496, R01HL131535), National Science Foundation, and the Patient Centered Outcomes Research Institute to develop a clinical data research network. Ross has received research support through Yale University from Johnson & Johnson to develop methods of clinical trial data sharing; Medtronic and the FDA to develop methods for postmarket surveillance of medical devices (U01FD004585); the FDA to establish Yale-Mayo Clinic Center for Excellence in Regulatory Science and Innovation program (U01FD005938); the Blue Cross Blue Shield Association to better understand medical technology evaluation; the Centers of Medicare & Medicaid Services to develop and maintain performance measures that are used for public reporting (HHSM-500-2013-13018I); the Agency for Healthcare Research and Quality (R01HS022882); the National Heart, Lung and Blood Institute of the NIH (R01HS025164); and the Laura and John Arnold Foundation to establish the Good Pharma Scorecard at Bioethics International and the Collaboration on Research Integrity and Transparency at Yale. The other authors have nothing to disclose.

The pressure on glaucoma services is ever-growing, and policymakers seek robust cost-effectiveness arguments in their decisions around resource allocation. The benefits of glaucoma are in preventing or delaying a future loss of vision and associated quality of life, and this expectation is quantified using a metric called utility which can be compared against other disease states. In recent clinical trials lasting up to 3 years, it has been difficult to show a difference in utility between glaucoma treatments in this limited period of time. When it comes to cost, the direct medical costs are only part of the broad range of costs that glaucoma brings to patients and communities, and the estimation of these costs can be difficult and imprecise. While the cost-effectiveness of glaucoma care, in general, is not in dispute, especially over longer time frames, the inability to measure changes in utility in shorter time frames impedes the uptake of innovations around the world. A number of approaches to improve the sensitivity and specificity of utility measurements are under investigation.

Background: Glaucoma is a collection of eye diseases that damage the eye's optic nerve resulting in vision loss and blindness. Treatment for glaucoma is primarily pharmacologic; however, studies have shown patients have difficulty adhering to topical regimens. The reasons for potentially poor adherence are numerous, including influence from a myriad of either physical or mental comorbid conditions faced by many glaucoma patients. Neither adherence nor associated outcomes have been estimated in these 2 groups of glaucoma patients., Objectives: To (a) characterize glaucoma patients with and without select physical or mental comorbidities and (b) estimate differences between the 2 groups for 3 types of outcomes: health care resource use (HCRU; office-based/outpatient-based provider visits, emergency room visits, inpatient stays, home health provider days, prescription fills); health care expenditures; and health-related quality of life (HRQoL) as measured by the physical and mental component scores of the Short Form-12., Methods: We used first-year data from each glaucoma patient's 2-year panel survey in the Medical Expenditure Panel Survey (MEPS) database, 2003-2014. Two groups were created using ICD-9-CM codes collected by MEPS to compare glaucoma patients with and without at least 1 selected physical or mental comorbid condition. Between-group comparisons in the outcomes of interest (HCRU, expenditure, HRQoL) were estimated using multivariable regression analyses while adjusting for socio-demographic and clinical characteristics at baseline., Results: We identified 2,928 unique glaucoma patients during the 11 years of collected data, including 1,539 (53%) who had at least 1 physical or mental comorbid condition of interest. Comparing those with at least 1 select physical or mental comorbidity to those without (n = 1,389), unadjusted HCRU and expenditures were greater in patients with a physical or mental comorbidity (all P < 0.05). After adjustment, significant associations with increased HCRU remained for office-based provider visits and home health provider days (each P < 0.01). Average total expenditures were $12,324 in those with comorbidities and $8,590 for those without. HRQoL (unadjusted and adjusted) was lower in those with a physical or mental comorbid condition (all P < 0.05)., Conclusions: Some differences in HCRU and expenditures were accounted for by differences in baseline characteristics between those with and those without 1 or more physical or mental comorbid conditions, but differences remained after adjustment. Results suggest that glaucoma patients with physical and mental comorbidities may experience greater HCRU and associated expenditures, and lower HRQoL, when compared with glaucoma patients without these comorbidities With this knowledge, future work may include estimating the effect of the number of these comorbid conditions on each of the 3 types of outcomes., Disclosures: This study received funding support from Allergan. During the time this work was conducted, Serbin was a postdoctoral fellow who was supported by a training grant from Allergan to the University of Washington. Campbell is an employee of Allergan. Serbin, Devine, and Basu each have nothing to disclose. This study was presented as a poster at the International Society for Pharmacoeconomics and Outcomes Research Meeting; May 20-24, 2017; Boston, MA.

Objective: To evaluate the prescribing trends of glaucoma drugs in six major cities of China from 2013 to 2017., Methods: A descriptive analysis using pharmacy prescription data was conducted. Outpatient prescription data was extracted from the Hospital Prescription Analysis Cooperative Project. Prescribing patterns, trends of visits, and corresponding expenditures for glaucoma medications were analyzed., Results: A total of 84297 ambulatory prescriptions were included in the current study. Visits by glaucoma patients increased from 13808 in 2013 to 20060 in 2017. Over the same period, the yearly expenditure for glaucoma drugs increased from 2.33 million to 3.95 million Chinese Yuan (CNY). Among all the six classes of glaucoma drugs (prostaglandin analogues, carbonic anhydrase inhibitors, α-receptor agonists, β-receptor antagonists, cholinergic agonists and fixed combinations), β-receptor antagonists were the most commonly prescribed in 2013, accounting for 34.3% of patients, but gradually decreased to 27.1% in 2017. Prostaglandin analogues became the most frequently prescribed drugs in 2017, accounting for 30.2% of the visits. Prostaglandin analogues are the most expensive and yielded a total expenditure of 2.34 million CNY in 2017, followed by carbonic anhydrase inhibitors, α-receptor agonists, β-receptor antagonists, fixed combinations, and cholinergic agonists. Combination therapy became increasingly prescribed in 2017., Conclusion: Glaucoma prescribing practices exhibited substantial changes over the study period. The number of glaucoma prescriptions continuously increased from 2013 to 2017, leading to increased prescription costs. These findings implied a similar trend observed in previous studies, as well as recommendations in the appropriate guidelines., Competing Interests: The authors have declared that no competing interests exist.

Background: Glaucoma is a condition that causes progressive damage to the optic nerve, which can lead to visual impairment and irreversible blindness. There is a spectrum of current treatments for glaucoma that aim to reduce intraocular pressure (IOP), including pharmacotherapy (eye drops), laser therapy, and the more invasive option of filtration surgery. A new class of treatments called minimally invasive glaucoma surgery (MIGS) may reduce IOP and offer a better safety profile than more invasive procedures. We conducted a budget impact analysis of MIGS for adults with glaucoma from the perspective of the Ontario Ministry of Health and Long-Term Care. We also conducted interviews with people with glaucoma and family members of people with glaucoma to determine patient preferences and values surrounding glaucoma and its treatment options, including MIGS. We completed this work to complement a health technology assessment conducted in collaboration with the Canadian Agency for Drugs and Technologies in Health (CADTH)., Methods: We analyzed the budget impact of publicly funding MIGS in adults with glaucoma in Ontario. We derived costs from the collaborative health technology assessment. 1 We assumed MIGS may be used in three subgroups: (1) MIGS in combination with cataract surgery as a replacement for cataract surgery alone in people with mild to moderate glaucoma; (2) MIGS alone as a replacement for other glaucoma treatments in people with mild to moderate glaucoma; and (3) MIGS (alone or in combination with cataract surgery) to replace filtration surgery (alone or in combination with cataract surgery) in people with advanced to severe glaucoma. We estimated the budget impact over 5 years for two possible uptake scenarios: a slow rate of uptake and a fast rate of uptake. To contextualize the lived experience of glaucoma and treatments for glaucoma, we also interviewed people with glaucoma and family members of people with glaucoma, some of whom had experience with surgical procedures such as MIGS and some of whom did not., Results: Assuming a slow uptake scenario, the annual budget impact of publicly funding MIGS in Ontario over the next 5 years ranges from $1 million in year 1 to $18 million in year 5. Assuming a fast uptake scenario, the annual budget impact of publicly funding MIGS in Ontario over the next 5 years ranges from $6 million in year 1 to $70 million in year 5. The budget impact varies depending on the proportion of people in each of the three subgroups described above. Introducing a new MIGS billing code may reduce the overall expenditures. Interview participants felt that less invasive surgical procedures, such as MIGS, could control glaucoma progression with minimal side effects and recovery time needed., Conclusions: We estimate that publicly funding MIGS in Ontario would result in additional costs over the next 5 years; however, this may depend on the populations using MIGS and if uptake is restricted or controlled. For the people with glaucoma we spoke with, avoiding blindness was their paramount concern, and MIGS was perceived as an effective treatment option with minimal side effects and recovery time required., (Copyright © Queen's Printer for Ontario, 2019.)

Importance: Patient perspectives are crucial in informing design of acceptable services., Background: This study determined patient preferences in glaucoma care., Design: A discrete choice experiment was used to evaluate the relative importance of out-of-pocket costs, waiting time, continuity of care, service location and expertise., Participants: Ninety-eight glaucoma suspects or glaucoma patients were recruited from one public and two private clinics in Sydney., Methods: Twelve choice-tasks were presented in random order and forced-choice preferences were elicited. Choice data were analysed using a multinominal logit model (NLOGIT 4.0)., Main Outcome Measures: The relative importance and the likelihood of choosing services with each attribute were determined. Willingness-to-pay and willingness-to-wait were calculated. Analyses were stratified by whether the patient attended a public or private glaucoma clinic and other demographic features., Results: Choice was influenced by four or five attributes: greater clinician expertise, the same clinician each visit, lower out-of-pocket costs and shorter wait times (all P < .05). Respondents were willing to pay an additional (Australian dollars) $325 (95% confidence interval [CI] 188-389) to see a senior eye doctor, and $87 (95% CI 60-116) to see the same clinician each visit. Respondents were willing to wait for these attributes; however, the estimates had wide confidence intervals and were beyond the range tested. Private patients had a stronger preference for expertise and continuity of care compared to public patients., Conclusions and Relevance: Expertise and continuity of care were important to glaucoma patients in this setting, and they were willing to pay out-of-pocket and concede longer waiting times to secure these preferences., (© 2019 Royal Australian and New Zealand College of Ophthalmologists.)

Importance: Under-detection and late diagnosis are major causes of glaucoma-related visual impairment. Cost-effective opportunistic glaucoma screening is of great interest in the early identification and prevention of glaucoma., Background: To describe the results of a health examination centre-based opportunistic glaucoma screening and referral model., Design: This single centre cross-sectional study was conducted in a health examination centre affiliated to a tertiary hospital in Shenyang, northeastern China., Participants: From 21 March to 30 September 2016, 14 367 individuals aged ≥ 30 years undergoing routine physical examinations were invited for this glaucoma screening., Methods: Presenting visual acuity, non-contact pneumotonometry and non-mydriatic fundus photography were evaluated. Fundus photographs were classified as non-glaucoma, possible, probable and definitive glaucoma. Participants with probable and definite glaucomatous discs or intraocular pressure ≥ 24 mmHg were referred for definitive examinations., Main Outcome Measures: Detection rate of glaucoma suspects and ocular hypertension (OHT). Cost to identify a single case with suspected and diagnosed glaucoma was also calculated., Results: Altogether, 277 glaucoma suspects and 327 ocular hypertension suspects were identified. Among 190 participants with probable/definite glaucomatous discs, 93 (48.9%) accepted further examination. Among these, 78 were diagnosed as glaucoma, seven as suspects and eight were excluded. Only 98 ocular hypertension suspects (30.0%) accepted further examinations: eight had primary angle closure and 23 had confirmed ocular hypertension. The cost to identify a single glaucoma suspect and definite glaucoma case were US$135 and US$857, respectively., Conclusions and Relevance: This novel screening model provides opportunities to improve glaucoma detection at low cost. Interventions to improve follow-up are needed., (© 2019 Royal Australian and New Zealand College of Ophthalmologists.)

Objective: To (1) examine the burden of multiple chronic conditions (MCC) in an urban health system, and (2) propose a methodology to identify subpopulations of interest based on diagnosis groups and costs., Design: Retrospective cross-sectional study., Setting: Mount Sinai Health System, set in all five boroughs of New York City, USA., Participants: 192 085 adult (18+) plan members of capitated Medicaid contracts between the Healthfirst managed care organisation and the Mount Sinai Health System in the years 2012 to 2014., Methods: We classified adults as having 0, 1, 2, 3, 4 or 5+ chronic conditions from a list of 69 chronic conditions. After summarising the demographics, geography and prevalence of MCC within this population, we then described groups of patients (segments) using a novel methodology: we combinatorially defined 18 768 potential segments of patients by a pair of chronic conditions, a sex and an age group, and then ranked segments by (1) frequency, (2) cost and (3) ratios of observed to expected frequencies of co-occurring chronic conditions. We then compiled pairs of conditions that occur more frequently together than otherwise expected., Results: 61.5% of the study population suffers from two or more chronic conditions. The most frequent dyad was hypertension and hyperlipidaemia (19%) and the most frequent triad was diabetes, hypertension and hyperlipidaemia (10%). Women aged 50 to 65 with hypertension and hyperlipidaemia were the leading cost segment in the study population. Costs and prevalence of MCC increase with number of conditions and age. The disease dyads associated with the largest observed/expected ratios were pulmonary disease and myocardial infarction. Inter-borough range MCC prevalence was 16%., Conclusions: In this low-income, urban population, MCC is more prevalent (61%) than nationally (42%), motivating further research and intervention in this population. By identifying potential target populations in an interpretable manner, this segmenting methodology has utility for health services analysts., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: The suprachoroidal space (SCS) has been a successful target to lower intraocular pressure (IOP) in glaucoma patients. We present the results of 4 patients who underwent a novel glaucoma surgical procedure to lower IOP: Intrascleral Ciliary Sulcus-Suprachoroidal Microtube., Methods: A sterile medical grade silicone microtube (Tube extender, New World Medical) was surgically placed to drain aqueous from the posterior chamber ciliary sulcus of the eye to the SCS. The internal diameter of the tube was 300 um and the length varied from 8-10mm. After informed consent was obtained and witnessed, this procedure was performed in glaucoma patients with pseudophakia. The tube was placed intrasclerally beneath an inferotemporal sclera flap (50% thickness approximately 4mm x 4mm). The anterior end of the tube was inserted into the ciliary sulcus approximately 2mm from the limbus and the posterior end was placed into the SCS approximately 4mm from the limbus. The microtube was sutured to the sclera with a 10-0 nylon suture. 8-0 vicryl sutures were used to close the sclera flap and the conjunctiva inferotemporally., Results: All 4 patients had lower IOP. The average reduction of IOP was 36% at 3 months. The amount of glaucoma medications per patient at 3 months dropped from an average of 3 to 0.25. The risks are similar to traditional glaucoma incisional surgery., Conclusion: This new technique of Intrascleral Ciliary Sulcus-Suprachoroidal Microtube in all four patients with mild, moderate, and advanced glaucoma demonstrated a significant lowering of IOP and a decrease in the number of medications. Further research is required to assess long term efficacy and safety., (Copyright © 2019 National Medical Association. Published by Elsevier Inc. All rights reserved.)

Precis: As the only microinvasive glaucoma surgery (MIGS) with a reusable component, the cost per procedure of endoscopic cyclophotocoagulation (ECP) diminishes with each successive use. We present a cost comparison of ECP with other MIGS devices, based on our clinical practice., Purpose: ECP delivers diode laser via a reusable probe to the ciliary processes under direct visualization. The aim of our study is to evaluate the direct cost of ECP based on a retrospective review of cases and compare the cost per procedure with other MIGS devices., Methods: We conducted a retrospective review of ECP procedures performed at St Thomas' Hospital over 4.5 years. The cost of the ECP endoscope and diode laser consoles, reusable probes, and maintenance contracts were obtained from the hospital procurement log. The on-site Central Sterile Services Department was contacted for probe sterilization and repackaging costs. The cost per device for ECP and commonly performed MIGS procedures were obtained from the product specialists of each company., Results: A total of 332 procedures were performed using 37 ECP probes during the study period. Each reusable ECP laser probe was found to give an average of 8.97 laser treatments. The cost per procedure decreased over the course of 4.5 years from £819.43 for the first 42 cases to £341.50 after 332 cases. Compared with other MIGS devices, the cost per procedure of ECP after 100 procedures is second lowest to the Kahook Dual Blade and reduces with each successive procedure performed., Conclusion: The ability to reuse each ECP probe significantly lowers the cost per procedure compared with other MIGS devices in the United Kingdom. The cost per procedure continues to reduce with each successive procedure.

In clinical glaucoma research, the measurement of patient reported outcomes, functional assessment of disability, and health economic impact is critical. However, valid, time-efficient and comprehensive tools are not available and several current instruments lack in the appropriate precision for measuring the various dimensions of glaucoma-related quality of life (QoL), including functioning and mobility. Furthermore, statistical methods are inconsistently and sometimes incorrectly used in otherwise sound clinical studies. Standardizing and improving methods of patient-centered data collection and analysis in glaucoma studies are imperative. This paper outlines recommendations and provides a discussion of some of the pertinent issues relating to the optimization of patient-reported outcomes research in glaucoma.

Objective: Determine the prices and price variation of the prostaglandin analogs (PGAs) used in the United States and examine their trends from 2013 to 2016 using Medicare Part D data., Design: This is a retrospective cross-sectional study., Participants: All ophthalmologists and optometrists in all 50 states and DC who prescribed any PGA purchased through Part D from 2013 through 2016., Materials and Methods: Outcome measures were calculated using Excel 2016 based off of the 2013 to 2016 Medicare Part D Prescriber Data., Main Outcome Measures: The 2013 to 2016 nationwide prices of 7 PGAs, the states with the 2016 minimum and maximum average prices, the SDs in PGA prices among the cities in each state, and the nationwide average of these SDs for 2013 to 2016., Results: The 2016 nationwide prices of 30-day supplies of bimatoprost, latanoprost, lumigan, travatan Z, travoprost, xalatan, and zioptan in 2016 were: $107.90±25.19, $10.16±1.52, $167.30±17.66, $171.36±19.44, $92.53±15.14, $153.41±15.16, and $162.75±13.22, respectively. Each drug's SD in city prices within each state averaged nationwide for 30-day supplies in 2016 were $10.89, $1.44, $16.68, $17.23, $10.30, $10.07, and $9.48, respectively. Spending on these drugs totaled $861,180,924 in 2016. There was less price variation within each state as compared with the whole country. No substantial decreases in price variation exist for any drug from 2013 to 2016., Conclusions: There is substantial variation in PGA prices when purchased by Medicare Part D enrollees across the United States and within each state itself. Simultaneously, the prices and total expenditure on these medications are increasing yearly. Physicians should be cognizant of this price variation for these expensive and chronically used drugs and should educate patients to optimize their Part D supplemental plan.

Background: Glaucoma is a progressive, irreversible disease that can lead to vision loss and lower quality of life if treatment is not optimized. Effective glaucoma therapies are available to lower intraocular pressure (IOP) and minimize or delay disease progression. Nonetheless, adherence to treatment remains suboptimal for many patients., Objective: To identify potentially nonadherent patients and evaluate the effect of patient- and physician-centric educational interventions on adherence by using a validated predictive model of nonadherence to glaucoma medication., Methods: This prospective, randomized, controlled, and interventional study included Humana Medicare Advantage Prescription Drug plan patients with a glaucoma diagnosis between May and October 2014, ≥ 1 pharmacy claim for glaucoma medication, and ≥ 50% likelihood of nonadherence. Patients and physicians were randomized to cohorts A (no interventions), B (physician intervention), or C (patient and physician interventions). Physicians in cohorts B and C received information on the model, adherence, and patient profiles at baseline and months 3, 6, and 9. Patients in cohort C received educational materials on glaucoma and adherence (same schedule). The primary outcome was the proportion of days covered (PDC) with medication over 12 months. Adherence was defined as PDC ≥ 0.80., Results: Overall, 23,306 patients and 2,955 physicians were eligible. After excluding physicians with < 3 nonadherent patients, each cohort included 200 physicians and 600 patients. Mean PDC was 0.54-0.56 across cohorts. At 12 months, ≥ 90.5% of physicians and ≥ 75.5% of patients remained in the study; mean PDC was 0.53-0.54 across cohorts. No statistically significant between-cohort differences in PDC and adherence were observed., Conclusions: Intensive educational mailings to patients and their physicians did not improve PDC or adherence in this large population of potentially nonadherent patients with glaucoma. Findings highlight the difficulty of improving adherence in a disease that requires lifelong therapy despite being largely asymptomatic and can inform development of future interventions aimed at improving adherence to glaucoma therapy., Disclosures: This study was sponsored by Allergan plc (Dublin, Ireland). Fiscella and Chandwani are employees of Allergan plc. Caplan, Kamble, Bunniran, and Uribe are employees of Comprehensive Health Insights, a Humana company. The authors did not receive honoraria or other payments for authorship.

Background/aims: Teleophthalmology is well positioned to play a key role in screening of major chronic eye diseases. Economic evaluation of cost-effectiveness of teleophthalmology, however, is lacking. This study provides a systematic review of economic studies of teleophthalmology screening for diabetic retinopathy (DR), glaucoma and macular degeneration., Methods: Structured search of electronic databases and full article review yielded 20 cost-related articles. Sixteen articles fulfilled the inclusion criteria and were retained for a narrative review: 12 on DR, 2 on glaucoma and 2 on chronic eye disease., Results: Teleophthalmology for DR yielded the most cost savings when compared with traditional clinic examination. The study settings varied among urban, rural and remote settings, community, hospital and health mobile units. The most important determinant of cost-effectiveness of teleophthalmology was the prevalence of DR among patients screened, indicating an increase of cost savings with the increase of screening rates. The required patient pool size to be screened varied from 110 to 3500 patients. Other factors potentially influencing cost-effectiveness of teleophthalmology were older patient age, regular screening and full utilisation of the equipment. Teleophthalmology for glaucoma was more cost-effective compared with in-person examination. Similarly, increasing number of glaucoma patients targeted for screening yielded more cost savings., Conclusions: This economic review provides supportive evidence of cost-effectiveness of teleophthalmology for DR and glaucoma screening potentially increasing screening accessibility especially for rural and remote populations. Special selection of the targeted screening population will optimise the cost-effectiveness of teleophthalmology., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Importance: Medical and surgical interventions for glaucoma are effective only if they are affordable to patients. Little is known about how affordable glaucoma interventions are in developing and developed countries., Objective: To compare the prices of topical glaucoma medications, laser trabeculoplasty, and trabeculectomy relative with median annual household income (MA-HHI) for countries worldwide., Design, Setting and Participants: Cross-sectional observational study. For each country, we obtained prices for glaucoma medications, laser trabeculoplasty, and trabeculectomy using government pricing data, drug databases, physician fee schedules, academic publications, and communications with local ophthalmologists. Prices were adjusted for purchasing power parity and inflation to 2016 US dollars, and annual therapy prices were examined relative to the MA-HHI. Interventions costing less than 2.5% of the MA-HHI were considered affordable., Main Outcomes and Measures: Daily cost for topical glaucoma medications, cost of annual therapy with glaucoma medications, laser trabeculoplasty, and trabeculectomy relative to MA-HHI in each country., Results: Data were obtained from 38 countries, including 17 developed countries and 21 developing countries, as classified by the World Economic Outlook. We observed considerable variability in intervention prices compared with MA-HHI across the countries and across interventions, ranging from 0.1% to 5% of MA-HHI for timolol, 0.1% to 27% for latanoprost, 0.2% to 17% for laser trabeculoplasty, and 0.3% to 42% for trabeculectomy. Timolol was the most affordable medication in all countries studied and was 2.5% or more of MA-HHI in only 2 countries (5%). The annual cost of latanoprost was 2.5% or more of MA-HHI in 15 countries (41%) (15 developing countries [75%] and no developed countries). The cost of laser trabeculoplasty was 2.5% or more of the MA-HHI in 15 countries (44%) (11 developing countries [65%] and 4 developed countries [24%]). The cost of trabeculectomy was 2.5% or more of the MA-HHI in 28 countries (78%) (18 developing countries [95%] and 10 developed countries [59%]). In 18 countries (53%), laser trabeculoplasty cost less than a 3-year latanoprost supply., Conclusions and Relevance: For many patients worldwide, the costs of medical, laser, and incisional surgical interventions were 2.5% or more of the MA-HHI. Successfully reducing global blindness from glaucoma requires addressing multiple contributing factors, including making glaucoma interventions more affordable.

Purpose: A review of the effectiveness, costs, and cost-effectiveness of detection and treatment strategies for glaucoma control in Sub-Saharan Africa (SSA) was conducted., Methods: Detailed searches were performed using the Ovid Medline, Ovid Embase, The Cochrane Library, Web of Science, Scopus, and LILACS databases up to September 2016. The key Medical Subject Heading search terms used included glaucoma, diagnosis, treatment, effectiveness, costs, cost-effectiveness, and Sub-Saharan Africa. Effectiveness was measured as the proportion of study participants with an intra-ocular pressure less than or equal to 22 mmHg., Results: A total of 5658 records were examined with 48 papers identified. The sensitivity and specificity of portable instruments or smartphone technologies to detect glaucomatous changes ranged from 58.3% to 93.8% and from 82.4% to 96.8%, respectively. The overall effect size for various glaucoma interventions was: 0.39 (95% confidence interval (CI) 0.27-0.54, I 2  = 64.85, p = 0.036) for laser trabeculoplasty; 0.56 (95% CI 0.23-0.84, I 2  = 85.74, p = 0.001) for drainage implant devices; 0.66 (95% CI 0.61-0.71, I 2  = 0.00, p = 0.402) for medical management; and 0.73 (95% CI 0.65-0.80, I 2  = 93.25, p = 0.000) for all other non-drainage tube surgical interventions, including trabeculectomy surgery and the use of anti-metabolites. The mean annual cost of anti-glaucoma drugs across SSA was USD 394, with a mean direct non-medication cost per year of USD 54, and a mean surgical cost per year of USD 283., Conclusions: While effective glaucoma control interventions exist, their widespread use and diffusion across SSA remain challenging principally due to low per capita income levels and high glaucoma treatment costs.

Purpose: To evaluate the association of socioeconomic status (SES) with severity of glaucoma and assess the impacts of both SES and disease-severity factors on the costs of glaucoma medications among different glaucoma subtypes in West Bengal, India., Methods: This cross-sectional study (2014-16) followed the treatment of 304 primary glaucoma patients for at least 18 months. The visual field based glaucoma staging was followed for stages 0-3; patients with field of vision <10° were categorized as stage 4 (end stage). We checked only the mean cost of glaucoma medications per patient and not "direct costs." The individuals' monthly incomes were classified into: low, moderate, and higher SES., Results: Urban residence (odds ratio [OR] 0.6, P < 0.009), higher SES (OR 0.3, P < 0.001), and higher awareness (nearly 50%, P < 0.007) significantly lowered the odds of having end-stage glaucoma. Sixty-nine percent primary angle-closure glaucoma (PACG) and 79% juvenile open-angle glaucoma (JOAG) belonged to low SES, forming the bulk of end-stage glaucoma. Overall medical cost from stage 0 to advanced stage in all subtypes rises except in primary open-angle glaucoma (POAG). Only 28% eyes from low SES were treated with branded drugs in early disease and that too declined to 16% in stage 4, while 57% higher SES used branded medications in early disease stage. Expenditure as a percent of income was the highest in JOAG (16%) followed by PACG (15%) and POAG (14%) among low SES., Conclusions: Results indicate SES influences on disease outcome, the clinical management, and the glaucoma medication expenses in West Bengal. Medical costs of glaucoma increase with worsening disease severity; greater use of generic drugs does not always ensure direct cost savings.

Purpose: The purpose of this study was to report the early outcomes in terms of efficacy and safety of a new, indigenously manufactured, low-cost nonvalved drainage device [AADI (Aurolab Aqueous Drainage Implant)] in the management of refractory glaucoma in the Indian population., Methods: Retrospective review of consecutive patients older than 12 years, who underwent glaucoma drainage device surgery (GDD) using AADI, by a single fellowship-trained surgeon, between January 2014 and December 2016, who had at least 3 months of documented post-op follow-up., Outcome Measures: Primary-intraocular pressure (IOP).Secondary-number of antiglaucoma medication (AGM), LogMAR best corrected visual acuity (BCVA), and complications.Complete success was defined as IOP ≥5 mm Hg and ≤21 mm Hg or reduction of IOP by ≥20% from baseline without AGM; qualified success with use of AGM. Failure was defined as inability to meet IOP criteria, loss of perception of light, explantation or any additional glaucoma surgery., Results: A total of 54 eyes of 51 patients were included. Mean follow up was 12.1±6.3 months. The IOP and number of AGM required was significantly lower at every visit postoperatively (P<0.001). Median LogMAR BCVA remained unchanged (P=0.5). Complications occurred in 22 patients (40.7%). Complete success was seen in 66.6%; overall success was 92.6%., Conclusions: New nonvalved GDD (AADI) surgery is effective in reducing IOP and need for AGM with a safety profile similar to published reports of prevailing GDDs. It thus has the ability to breach the cost barrier in low-to-middle income countries; further follow-up is required to determine sustainability over time.

Medication cost for the same indication can vary considerably and can affect patient compliance. In this comparative cost analysis of commonly prescribed ophthalmology medications, the differences in cost between generic and brand name medications as well as different medications within an individual drug class were evaluated. Eye preparations from the Ontario Drug Benefit Formulary were identified, and further agents commonly prescribed by ophthalmologists were included. The standardized prescription drug cost, which includes the cost of the medication, mark-up, and dispensing cost, was provided by Ontario Shoppers Drug Mart stores in July 2016 for 103 common medications using typical dosages and durations. Based on medication class, the highest and lowest cost medications were antiallergy agents (Zaditor [ketotifen], Vasocon [naphazoline]), antibiotic ophthalmic solutions (Vigamox [moxifloxacin], generic ciprofloxacin), oral antibiotics (Cipro [ciprofloxacin], generic cephalexin), antibiotic ophthalmic ointments (generic erythromycin, Tobrex [tobramycin]), antiviral treatment (Valtrex [oral valacyclovir], Viroptic [topical trifluridine]), blepharitis treatment (Zithromax [oral azithromycin], generic oral tetracycline), beta-adrenergic inhibitors (Timoptic [topical timolol], generic topical timolol), topical prostaglandin analogues (Xalatan [latanoprost], generic travoprost), oral carbonic anhydrase inhibitors (methazolamide, acetazolamide), topical carbonic anhydrase solutions (Trusopt preservative-free [dorzolamide], Azopt [brinzolamide]), topical alpha-adrenergic agonists (Alphagan [brimonidine], generic brimonidine), topical muscarinic agonists (Isopto carpine [pilocarpine], Diocarpine [pilocarpine]), topical combination glaucoma agents (Cosopt [dorzolamide-timolol], generic dorzolamide-timolol), topical lubricants (Lacri-lube, Isopto tears), topical nonsteroidal anti-inflammatory drugs (Acuvail [ketorolac], Ilevro [nepafenac]), and steroids (Durezol [difluprednate], Pred mild [prednisolone]). Substantial cost differences exist between ophthalmology medications of the same class. We encourage ophthalmologists to be aware of the associated costs of the medications they prescribe and to use this information in their decision making., (Copyright © 2018 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Background: Glaucoma is the foremost cause of irreversible blindness, and more than 50% of cases remain undiagnosed. Our objective was to report the costs of a glaucoma detection programme operationalised through Philadelphia community centres., Methods: The analysis was performed using a healthcare system perspective in 2013 US dollars. Costs of examination and educational workshops were captured. Measures were total programme costs, cost/case of glaucoma detected and cost/case of any ocular disease detected (including glaucoma). Diagnoses are reported at the individual level (therefore representing a diagnosis made in one or both eyes). Staff time was captured during site visits to 15 of 43 sites and included time to deliver examinations and workshops, supervision, training and travel. Staff time was converted to costs by applying wage and fringe benefit costs from the US Bureau of Labor Statistics. Non-staff costs (equipment and mileage) were collected using study logs. Participants with previously diagnosed glaucoma were excluded., Results: 1649 participants were examined. Mean total per-participant examination time was 56 min (SD 4). Mean total examination cost/participant was $139. The cost/case of glaucoma newly identified (open-angle glaucoma, angle-closure glaucoma, glaucoma suspect, or primary angle closure) was $420 and cost/case for any ocular disease identified was $273., Conclusion: Glaucoma examinations delivered through this programme provided significant health benefit to hard-to-reach communities. On a per-person basis, examinations were fairly low cost, though opportunities exist to improve efficiency. Findings serve as an important benchmark for planning future community-based glaucoma examination programmes., Competing Interests: Competing interests: MW reports grants from US Centers for Disease Control and Prevention (CDC) during the conduct of the study; and reports grants from Iridex, Diopsys, Heidelberg Engineering, Allergan, OrCam, Merck, Partridge Foundation and Pennsylvania Department of Health, outside the submitted work. PL reports other funding from CDC outside of the submitted work. LJK reports grants from the CDC during the conduct of the study; and reports grants and personal fees from Allergan, from Aerie Pharmaceutical, Bausch & Lomb, InnFocus, Mati Therapeutics, and Diopsys, and personal fees from Alcon, Glaukos, Sucampo, Inotek, Sensimed AG, Alimera Sciences, ForSight Vision, Ocular Therapeutix, and Aerpio Therapeutics, outside the submitted work., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: To evaluate the safety and efficacy of a low-cost glaucoma drainage device (GDD), Aurolab aqueous drainage implant (AADI), similar in design to the Baerveldt glaucoma implant (BGI), in refractory childhood glaucoma., Methods: This prospective interventional study was conducted in a tertiary care postgraduate teaching institute. Children aged <16 years with uncontrolled intraocular pressure (IOP) refractory to medical treatment and considered at high risk of failure following trabeculectomy were recruited. Eligible children were implanted with the AADI. Those completing minimum 6-month follow-up were included. Main outcome measures were IOP reduction from preoperative values and postoperative complications., Results: 34 eyes of 31 patients were analysed. Average follow-up was 18.3±6.9 months. Mean IOP reduced from 27.4±7.5 mm Hg on maximum medication to 14.6±10.74 mm Hg, 13.8±7.5 mm Hg, 12.8±5.6 mm Hg and 14.7±5.8 mm Hg at 1 week, 6 months, 1 year (32 eyes of 29 children) and 2 years (25 eyes of 22 children) postoperatively, respectively (p<0.001). The cumulative probability of success was 91.18% at 6 months and 81.7% at 18-24 months. Mean number of topical medications decreased from 3.1±0.6 to 1.8±1.3 at 6 months and 1.6±1.1 at 24 months (p<0.001). Preoperatively, 25 patients required systemic acetazolamide, decreasing to three patients at 2 years. There was no tube erosion or infection. One eye developed retinal detachment., Conclusion: The AADI appears to be a viable low-cost GDD with effectiveness and safety profile comparable with published reports of the BGI and Ahmed glaucoma valve implant in children., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Significance: This article is the first to investigate the nature of medication cost discussions between ophthalmologists and glaucoma patients. Only 87 of the 275 office visits analyzed had a discussion of medication cost. Providers should consider discussing medication cost with patients to identify potential cost-related barriers to medication use., Purpose: Glaucoma is an incurable chronic eye disease affecting a growing portion of the aging population. Some of the most commonly utilized treatments require lifelong use, requiring high patient adherence to ensure effectiveness. There are numerous barriers to glaucoma treatment adherence in the literature, including cost. The aim of this secondary analysis was to describe the frequency and nature of patient-physician communication regarding medication cost during glaucoma office visits., Methods: This was a mixed-methods secondary analysis of video-recorded participant office visits (n = 275) from a larger observational study of glaucoma communication. We analyzed medical information, demographic characteristics, and interviewer-administrated questionnaires, as well as verbatim transcripts of interviews., Results: Only 87 participants discussed medication cost during their glaucoma office visit. The majority of the subjects who discussed cost had mild disease severity (51%), took one glaucoma medication (63%), and had Medicare (49%) as well as a form of prescription insurance (78%). The majority of glaucoma office visits did not discuss medication cost, and providers often did not ask about cost problems. Of the few conversations related to cost, most focused on providers offering potential solutions (n = 50), medical and prescription service coverage (n = 41), and brand or generic medication choices (n = 41)., Conclusions: Our findings are similar to previous studies showing few patients have conversations with providers about the cost of glaucoma medications. Providers should consider bringing up medication cost during glaucoma office visits to prompt a discussion of potential cost-related barriers to medication use.

Purpose: Nonmedical out-of-pocket cost to both patients and their companions of office visits for routine glaucoma care has not been extensively studied in the United States. We evaluate potential key predictors of patient expenditures that are critical to assessing the cost-effectiveness of glaucoma health care delivery., Materials and Methods: In total, 300 patients responded to the survey in 3 clinics in 2 clinical practice settings. Main outcome measures included both average visit and yearly expenditures., Results: Of the 300 patients, the majority were female (n=187, 62.3%) and African American (n=171, 57.0%). The median age was 66 years. The median [range; mean (SD)] expenditure per patient visit was $22.10 ($11.1, $42.9; $44.1 (72.8)). Patients with companions paid $38.77 more in average visit expenditure (β: 0.87, P<0.001). The average visit expenditure for retired patients was $17.37 less when compared with nonretired patients (β: -0.4, P=0.004). Patients living in a rural or suburban area paid $43.91 and $14.13 more per visit, respectively (β: 0.73, P=0.0004; β: 0.31, P=0.03), compared with patients living in an urban area. Patients with noncommercial insurance paid $24.01 less in average visit expenditure (β: -0.66, P=0.0008). The median yearly patient expenditure was $96.70 [$44.6, $222.7; $210.4 (333.9)]. Patients with companions paid $192.37 more in yearly expenditure (β: 0.9, P<0.001) than those without companions, whereas retired patients paid $80.83 less in yearly expenditure (β: -0.39, P=0.03) than nonretirees. Patients with noncommercial insurance paid $109.34 less in yearly expenditure (β: -0.63, P=0.01)., Conclusions: Although a small part of the total cost of glaucoma care, nonmedical out-of-pocket costs constitute a substantial noncovered medical expense to most patients in the United States. Patients who are employed, come with companions, live in nonurban areas, or are on Medicare have greater expenditures.

Purpose of Review: Despite a decrease in real average growth rates per capita since 2009, healthcare costs continue to rise worldwide. Numerous patient-related and doctor-related factors have contributed to this rise. Glaucoma is the leading cause of irreversible blindness and requires chronic, usually lifelong treatment. As with other chronic diseases, the adherence to prescribed treatment is often low and maybe influenced by the cost of the therapy. The purpose of this review is to seek potential solutions to best control the escalating costs of glaucoma care., Recent Findings: The studies we selected for this review can be divided into four different categories: costs of diagnostic tests; costs of direct comparisons between drugs or laser and conventional surgery; patient-related factors (such as adherence); and general aspects regarding costs: theoretical models and calculations., Summary: It is challenging to find reliable studies concerning this subject matter. As patients are under the umbrellas of variously organized healthcare systems which span different cultures, the costs between countries are difficult to compare. However, one common aspect to lower costs in glaucoma care is to improve patient adherence. Theoretical models with actual patient studies could enable cost reductions by comparing multiple diagnostic and therapeutic scenarios. VIDEO ABSTRACT: http://links.lww.com/COOP/A22.

Glaucoma is the most common cause of incurable blindness. If untreated, glaucoma leads to permanent vision loss starting with unnoticeable blind spots in the peripheral visual field. Due to the age-related nature of glaucoma, the disease is becoming an increasing socio-economical challenge. Extrapolations have predicted more than 110 million people with glaucoma in 2040. Twice as many patients were diagnosed with glaucoma in Denmark in 2011 as in 1996. Light is shedded on the need for improved awareness of the significant present and future burden of glaucoma.

Purpose: To date, there are limited data on the economic burden of childhood glaucoma, a relatively rare but visually debilitating disease. The purpose of this study is to evaluate the immediate costs of illness associated with childhood glaucoma during the first 4 years after presentation., Methods: Data on age, sex, surgical interventions, visits, examinations under anesthesia, and medications were collected yearly following presentation in patients with childhood glaucoma. Inclusion criteria included diagnosis of primary or secondary childhood glaucoma, age less than 21 years, and follow-up of 4 years. A total of 23 patients (39 eyes) were included. Cost analysis used 2013 hospital-specific charges and US average hourly wage to calculate outcomes of total, direct, and indirect costs (significance level P<0.05)., Results: The annual cost of care of childhood glaucoma averaged $21,441.61 per patient, representing 1100% of annual costs in adult glaucoma and an increase of 800% in annual costs of health care per pediatric patient. The average total 4-year cost of care was $85,074.96 per patient. Surgical interventions and examinations under anesthesia were the greatest contributors to costs, representing 69.0% and 23.2% of total 4-year costs, respectively. The annual costs of care for childhood glaucoma were highest in the first year compared with subsequent years, averaging $46,293.62 per patient (P<0.05)., Conclusions: Childhood glaucoma carries a substantial economic burden with the highest costs occurring in the first year after presentation. The greatest contributors to cost of illness are surgical interventions and examinations and anesthesia.

Purpose: To develop an expert system for glaucoma screening in a working population based on a human expert procedure using images of optic nerve head (ONH), visual field (frequency doubling technology, FDT) and intraocular pressure (IOP)., Methods: 4167 of 13037 (32%) employees between 40 and 65 years of Evonik Industries were screened. An experienced glaucoma expert (JW) assessed papilla parameters and evaluated all individual screening results. His classification into "no glaucoma", "possible glaucoma" and "probable glaucoma" was defined as "gold standard". A screening model was developed which was tested versus the gold-standard. This model took into account the assessment of the ONH. Values and relationships of CDR and IOP and the FDT were considered additionally and a glaucoma score was generated. The structure of the screening model was specified a priori whereas values of the parameters were chosen post-hoc to optimize sensitivity and specificity of the algorithm. Simple screening models based on IOP and / or FDT were investigated for comparison., Results: 111 persons (2.66%) were classified as glaucoma suspects, thereof 13 (0.31%) as probable and 98 (2.35%) as possible glaucoma suspects by the expert. Re-evaluation by the screening model revealed a sensitivity of 83.8% and a specificity of 99.6% for all glaucoma suspects. The positive predictive value of the model was 80.2%, the negative predictive value 99.6%. Simple screening models showed insufficient diagnostic accuracy., Conclusion: Adjustment of ONH and symmetry parameters with respect to excavation and IOP in an expert system produced sufficiently satisfying diagnostic accuracy. This screening model seems to be applicable in such a working population with relatively low age and low glaucoma prevalence. Different experts should validate the model in different populations.

Background: Many glaucoma patients do not adhere to their medication regimens because they fail to internalize the (health) costs of non-adherence, which may not occur until years or decades later. Behavioural economic theory suggests that adherence rates can be improved by offering patients a near-term benefit. Our proposed strategy is to offer adherence-contingent rebates on medication and check-up costs. This form of value pricing (VP) ensures that rebates are granted only to those most likely to benefit. Moreover, by leveraging loss aversion, rebates are expected to generate a stronger behavioural response than equivalent financial rewards., Methods/design: The main objective of the Study on Incentives for Glaucoma Medication Adherence (SIGMA) is to test the VP approach relative to usual care (UC) in improving medication adherence. SIGMA is a randomized, controlled, open-label, single-centre superiority trial with two parallel arms. A total of 100 non-adherent (Morisky Medication Adherence Scale ≤6) glaucoma patients from the Singapore National Eye Centre are block-randomized (blocking factor: single versus multiple medications users) into the VP and UC arms in a 1:1 ratio. The treatment received by VP patients will be strictly identical to that received by UC patients, with the only exception being that VP patients can earn either a 50 % or 25 % rebate on their glaucoma-related healthcare costs conditional on being adherent on at least 90 % or 75 % of days as measured by a medication event monitoring system. Masking the arm allocation will be precluded by the behavioural nature of the intervention but blocking size will not be disclosed to protect concealment. The primary outcome is the mean change from baseline in percentage of adherent days at month 6. A day will be counted as adherent when the patients take all their medication(s) within the appropriate dosing windows., Discussion: This trial will provide evidence on whether adherence-contingent rebates can improve medication adherence among non-adherent glaucoma patients, and more generally whether this approach represents a promising strategy to cost-effectively improve chronic disease management., Trial Registration: NCT02271269 . Registered on 19 October 2014.

Purpose: To assess the cost-effectiveness of cataract surgery in advanced glaucoma (AG) patients., Materials and Methods: A total of 93 patients with AG who underwent cataract surgeries were collected prospectively from June 2010 through June 2013 in Shanghai First People's Hospital, Shanghai Jiao Tong University, Shanghai, and were followed up for at least 3 months. A standard phacoemulsification technique was used to remove cataract(s). No complications occurred intraoperatively or postoperatively. Costs associated with surgery were recorded. Utility values of cataract surgery were obtained by using time trade-off method. Quality-adjusted life-years (QALYs) were calculated using the patients' life expectancy at a 3% discounted rate. Incremental cost-utility analysis was performed (compared with no treatment) by calculating the incremental cost-effectiveness ratio (ICER), that is, the mean incremental cost for each QALY. The bootstrap method was used for statistical analysis, and sensitivity analyses were performed to test robustness of the results., Results: The mean incremental cost of cataract surgery was 9876 Chinese yuan (CNY) [1593 US dollar (USD)] [95% confidence interval (CI), 9144-10,570 CNY (1475-1705 USD)].The mean additional QALYs gained were 2.20 (95% CI, 1.85-2.54), and the incremental cost for each additional QALY was 4508 CNY (727 USD) [95% CI, 3890-5234 CNY (627-844 USD)], far lower than the per capita annual disposable income in Shanghai, 40,188 CNY (6482 USD)., Conclusion: For AG patients, cataract surgery does help obtain more QALYs and was highly cost effective.

Background: Glaucoma is the leadi ng cause of irreversible blindness in the USA. Glaucomatous vision loss is preventable with proper eye care, including appointment adherence. Therefore, interventions that improve appointment adherence can reduce the number of patients with more severe glaucoma., Objectives: The primary study aim was to determine the efficacy and cost-effectiveness of a multifaceted personal reminder intervention, which included a customized letter and personal telephone outreach, in improving appointment adherence of patients with glaucoma. A secondary study aim was to identify patient characteristics that were associated with non-adherence., Methods: This prospective, randomized, controlled study included a cost-effectiveness analysis completed using a decision analytic model. The subjects included 256 patients with glaucoma. Study measures included appointment adherence and incremental cost effectiveness ratios., Results: Patients in the intervention group were more likely to adhere to appointments (82.31 vs. 69.05 %; RR 1.23; 95 % CI 1.04-1.37, p < 0.012) than patients in the usual care group. Patients in the intervention group were 23 % more likely to adhere to appointments (RR 1.23; 95 % CI 1.08-1.41, p < 0.0021) than patients in the usual care group, when adjusting for age, secondary insurance, primary open angle glaucoma diagnosis, number of previous visits at Wills Eye Hospital, and follow-up recommendation using Poisson regression. Per-patient cost of the program was US$11.32, and cost per follow-up attended within the adherence window was US$73.56., Conclusions: A low cost reminder intervention consisting of a personalized letter and telephone outreach significantly improved appointment adherence of patients with glaucoma.

Importance: The effect of glaucoma on nonglaucomatous medical conditions and resultant secondary health care costs is not well understood., Objective: To assess self-reported medical conditions, the use of medical services, and total health care costs among Medicare beneficiaries with glaucoma., Design, Setting, and Participants: Longitudinal observational study of 72,587 Medicare beneficiaries in the general community using the Medicare Current Beneficiary Survey (2004-2009). Coding to extract data started in January 2015, and analyses were performed between May and July 2015., Main Outcomes and Measures: Self-reported health, the use of health care services, adjusted mean annual total health care costs per person, and adjusted mean annual nonoutpatient costs per person., Results: Participants were 72,587 Medicare beneficiaries 65 years or older with (n = 4441) and without (n = 68,146) a glaucoma diagnosis in the year before collection of survey data. Their mean age was 76.9 years, and 43.2% were male. Patients with glaucoma who responded to survey questions on visual disability were stratified into those with (n = 1748) and without (n = 2639) self-reported visual disability. Medicare beneficiaries with glaucoma had higher adjusted odds of inpatient hospitalizations (odds ratio [OR], 1.27; 95% CI, 1.17-1.39; P < .001) and home health aide visits (OR, 1.27; 95% CI, 1.13-1.43; P < .001) compared with Medicare beneficiaries without glaucoma. Furthermore, patients with glaucoma with self-reported visual disability were more likely to report depression (OR, 1.47; 95% CI, 1.26-1.71; P < .001), falls (OR, 1.34; 95% CI, 1.09-1.66; P = .006), and difficulty walking (OR, 1.22; 95% CI, 1.02-1.45; P = .03) compared with those without self-reported visual disability. In the risk-adjusted model, Medicare beneficiaries with glaucoma incurred an additional $2903 (95% CI, $2247-$3558; P < .001) annual total health care costs and $2599 (95% CI, $1985-$3212; P < .001) higher costs for nonoutpatient services compared with Medicare beneficiaries without glaucoma., Conclusions and Relevance: Glaucoma is associated with greater use of inpatient and home health aide services and with higher annual total and nonoutpatient medical costs. Perception of vision loss among patients with glaucoma may be associated with depression, falls, and difficulty walking. Reducing the prevalence and severity of glaucoma may result in improvements in associated nonglaucomatous medical conditions and resultant reduction in health care costs.

Purpose: To evaluate discrepancies in doses per bottle, bottle fill volume, and cost among branded and generic formulations of latanoprost., Design: Comparative economic analysis., Methods: This study was conducted at the Ruiz Department of Ophthalmology and Visual Science at The University of Texas Health Science Center at Houston (UTHealth). Four regionally available latanoprost formulations were measured. Number of drops per bottle and actual bottle fill volume were measured for a calculated sample size (10 bottles). Annual cost (using average wholesale price), days use per bottle, drops per milliliter, and number of bottles used per year were calculated. Data were summarized using mean and standard deviation; 1-way analysis of variance and post hoc Tukey's studentized range test were used for comparing means among manufacturers., Results: Pfizer's branded lantanoprost, Xalatan (New York, New York, USA), had the largest fill volume (P < .001). Pfizer had the highest yearly cost at $1198 (P < .001), whereas Akorn (Lake Forest, Illinois, USA) and Bausch & Lomb (Rochester, New York, USA) had the lowest ($184 and $201, respectively). Pfizer and Bausch & Lomb had the most drops per bottle (87.3 and 88.7, respectively), which was statistically more (P < .001) than either Akorn or Sandoz (Princeton, New Jersey, USA) (77.6 and 76.6, respectively), but there was no statistical difference among the standard deviation of drops per bottle (Levene 0.14)., Conclusions: Annual cost and number of doses per bottle, factors important to patients, vary significantly depending on the manufacturer of latanoprost. Practitioners can better advise patients by being aware of these differences., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Although prevention of progression is the most important issue in the treatment of glaucoma patients, information on visual aids and social law entitlements is also helpful. In this article, the main aspects of compensation for visual impairment are outlined so that you can competently support your patients, without much effort, with helpful tips and appropriate instructions., (Georg Thieme Verlag KG Stuttgart · New York.)

Loss of earnings, disability and inability to work may be used to assess the same health damage, but these legal terms are defined differently, as they have different objectives. Important practical distinctions between these terms are explained and their inter-relationships are discussed., (Georg Thieme Verlag KG Stuttgart · New York.)

Importance: It is important to understand in more detail how patients with glaucoma were affected by the implementation of Medicare Part D, which was designed to provide beneficiaries with near-universal prescription drug coverage., Objectives: To determine changes in prescription drug coverage and out-of-pocket spending after the implementation of Medicare Part D across income strata and to identify characteristics of beneficiaries associated with prescription status., Design, Setting, and Participants: Longitudinal observational study in the general community using the Medicare Current Beneficiary Survey (pooled 2004, 2005, 2007, and 2008 data). Participants were noninstitutionalized Medicare beneficiaries who filled at least 1 glaucoma prescription during the survey years. The dates of this analysis were January 2004 to December 2009., Main Outcomes and Measures: Effect of the implementation of the Medicare Part D drug benefit, including prescription drug coverage and risk-adjusted out-of-pocket spending related to glaucoma medications., Results: Respondents included 12,079 participants in the 2004 survey, 11,089 participants in the 2005 survey, 11,995 participants in the 2007 survey, and 11,723 participants in the 2008 survey. The sample included 19,045 glaucoma prescriptions, and 2519 Medicare beneficiaries filled at least 1 glaucoma prescription during the study years. Overall 574 (22.8%) beneficiaries reported living below the poverty level, and 795 (31.6%) had incomes consistent with near-poor status. The implementation of Medicare Part D resulted in increased rates of prescription drug coverage across all economic strata, with reductions in beneficiaries without coverage from 22.8% to 4.0%, 29.1% to 7.3%, and 19.9% to 3.7% among poor, near-poor, and higher-income beneficiaries, respectively. Despite these gains, near-poor status remained a risk factor for lack of prescription drug coverage after the implementation of Medicare Part D (odds ratio, 2.46; 95% CI, 1.26-4.55; P = .04). No differences were identified in adjusted out-of-pocket prescriptions drug costs between the near poor and those with higher income, although out-of-pocket costs were 37% (95% CI, 26%-49%; P < .001) lower among the poor relative to those with higher income., Conclusions and Relevance: Medicare Part D enrolled most beneficiaries with glaucoma who previously lacked prescription drug coverage. The results of this study suggest that coverage gains lagged among the near poor. While these data evaluated changes in coverage among cohorts of beneficiaries and not from longitudinal follow-up of patients, targeted efforts to improve prescription drug coverage among vulnerable beneficiaries would likely improve access to prescribed ocular hypotensive medications.

Glaucoma is the leading cause of irreversible vision loss and costs the American economy $2.9 billion. Teleglaucoma remotely detects glaucoma improving access to ophthalmic care in rural areas. It helps manage glaucoma more efficiently to preserve vision and reduce healthcare costs. A cost-effectiveness analysis was conducted using healthcare provider or third-party payer perspective within rural Canada. The study population were patients at-risk of glaucoma which includes those with diabetes and/or hypertension, family history of glaucoma, adults older than 50 years, and concurrent ocular conditions in rural Alberta. Markov modelling was used to model glaucoma health states. Effectiveness was measured in Quality-Adjusted Life Years (QALYs) and costs were used in Canadian dollars. Using TreeAge Pro 2009, incremental cost-effectiveness ratios (ICER) were developed in dollars per QALYs. Deterministic and probabilistic sensitivity analyses were performed to assess the factors affecting cost-effectiveness. Teleglaucoma had a 20% increase in ophthalmologist-referral rate; it reduced patient travel times by 61 hours and physician wait times by 30% in comparison to in-person examination (standard of care). Teleglaucoma costs $872 per patient screened which was 80% less than in-person examination. Teleglaucoma had a greater incremental effectiveness providing an additional 0.12 QALY per patient examination. It was more sensitive (86.5%) and less specific (78.6%) than in-person examination. Teleglaucoma was more cost-effective than in-person examination with an ICER of-$27,460/QALY. This indicated that teleglaucoma will save $27, 460 for each additional QALY gained. Long term benefits showed teleglaucoma prevents 24% cases of glaucoma blindness after 30 years. Teleglaucoma demonstrated improved health outcomes, as well as, cost benefits. It increases access to ophthalmic care and improves healthcare service efficiency, specifically in rural areas. Teleglaucoma is more cost-effective than current in-person examination and can improve the quality of life in glaucoma patients.

Background: Glaucoma is the leading cause of irreversible blindness in the world. Estimated to affect 60 million people worldwide, this figure is expected to rise to 80 million by 2020. Untreated, glaucoma leads to visual decay and eventually to blindness, and can significantly reduce quality of life. First-line treatment in patients with primary open-angle glaucoma and exfoliative glaucoma is topical medical therapy with ocular hypotensives as eye drops. However, eye drops have several disadvantages including cost, possible local and systemic side effects, and adherence and perseverance issues. Randomised controlled trials have demonstrated that selective laser trabeculoplasty is equally as effective in lowering intraocular pressure as eye drops. However, the impact of these two treatment modalities from the patient and economic perspectives has not been adequately determined. Thus, it remains unclear whether topical medical therapy or selective laser trabeculoplasty should be recommended as first-line treatment for glaucoma., Methods/design: This protocol describes an international, multi-centre, randomised controlled trial to determine the optimum first-line therapy for people with primary open-angle glaucoma and exfoliative glaucoma. This study will compare the effect of selective laser trabeculoplasty and topical medication with respect to patients' generic and glaucoma-specific quality of life. The trial will also provide a detailed cost-effectiveness analysis and compare the clinical effectiveness with respect to the degree of intraocular pressure lowering and rates of treatment failure. Research coordinators in each centre will identify and recruit previously untreated patients with primary open-angle glaucoma and exfoliative glaucoma. Those who meet the eligibility criteria will be invited to enter a randomised controlled trial with either selective laser trabeculoplasty or topical ocular hypotensive therapy, according to a stepped regimen. Outcome assessment will be measured at 6 weeks and at 6, 12, and 24 months post-treatment. Regular clinic follow-ups will continue as clinically indicated between study outcome visits., Discussion: The Glaucoma Initial Treatment Study is the first multi-centred RCT to determine the optimum first-line therapy for people with glaucoma. Our trial will have an unprecedented capacity to meaningfully transform the treatment and management of glaucoma in Australia and overseas., Trial Registration: ACTRN12611000720910; Date registered: 11 July 2011.

Importance: Understanding factors that lead to nonadherence to glaucoma treatment is important to diminish glaucoma-related disability., Objectives: To determine whether the implementation of the Medicare Part D prescription drug benefit affected rates of cost-related nonadherence and cost-reduction strategies in Medicare beneficiaries with and without glaucoma and to evaluate associated risk factors for such nonadherence., Design, Setting, and Participants: Serial cross-sectional study using 2004 to 2009 Medicare Current Beneficiary Survey data linked with Medicare claims. Coding to extract data started in January 2014 and analyses were performed between September and November of 2014. Participants were all Medicare beneficiaries, including those with a glaucoma-related diagnosis in the year prior to the collection of the survey data, those with a nonglaucomatous ophthalmic diagnosis in the year prior to the collection of the survey data, and those without a recent eye care professional claim., Intervention: Effect of the implementation of the Medicare Part D drug benefit., Main Outcomes and Measures: The change in cost-related nonadherence and the change in cost-reduction strategies., Results: Between 2004 and 2009, the number of Medicare beneficiaries with glaucoma who reported taking smaller doses and skipping doses owing to cost dropped from 9.4% and 8.2% to 2.7% (P < .001) and 2.8%, respectively (P = .001). However, reports of failure to obtain prescriptions owing to cost did not improve in the same period (3.4% in 2004 and 2.1% in 2009; P = .12). After Part D, patients with glaucoma had a decrease in several cost-reduction strategies, namely price shopping (26.2%-15.2%; P < .001), purchasing outside the United States (6.9%-1.3%; P < .001), and spending less money to save for medications (8.0% to 3.5%; P < .001). Using a multivariate analysis, the main independent risk factors common to all cost-related nonadherence measures were female sex, younger age, lower income (<$30 000), self-reported visual disability, and a smaller Lawton index., Conclusions and Relevance: After the implementation of Part D, there was a decrease in the rate that beneficiaries with glaucoma reported engaging in cost-saving measures. Although there was a decline in the rate of several cost-related nonadherence behaviors, patients reporting failure to fill prescriptions owing to cost remained stable. This suggests that efforts to improve cost-related nonadherence should focus both on financial hardship and medical therapy prioritization, particularly in certain high-risk sociodemographic groups.

Purpose: To determine the socioeconomic impact of long-term glaucoma therapy., Materials and Methods: One hundred and fifty consecutive glaucoma patients on medical therapy, following up at our glaucoma service for at least 6 months were recruited. A questionnaire regarding monthly income, cost of glaucoma medications prescribed, availability of medications, travel time, time spent in review clinics, compliance, education status, medical insurance and systemic or local side-effects was administered., Results: The patients seen at the tertiary government hospital had an average monthly income of Rs. 10,912/- (range: Rs. 500/- to Rs. 50,000/-) with approximately 56% of the patients having an income of less than Rs. 5000/month. The expenditure on anti-glaucoma medications ranged from 0.3% in high income group to 123% of their monthly gross income in low income group (P < 0.0001). The total expenditure including travel, stay, and loss of wages of patients and accompanying persons ranged from 1.6% in high income group to 137% of the monthly income in low income group (P < 0.0001). Mean time required for a glaucoma clinic visit was 15.66 h, (range: 6-96 h/month). About 2.7% experienced systemic side-effects and 21.3% had complaints of ocular adverse effects. About 90% of the patients were compliant. 92% were not covered by any insurance plan/government reimbursement for their treatment., Conclusions: Medical therapy for glaucoma is an economic burden to many patients and should be individualized, according to the socioeconomic status, availability of drugs and the required distance to travel to reach the specialist clinics.