VIMS Journal: December 2015

Special Article

Long Term Glaucoma Therapy: A Cost Intensive Socio Economic Burden

Dr. Bhaskar Mukherjee , Dr. Malini Majumdar

Glaucoma :
It is a multifactorial optic neuropathy in which there is a characteristic loss of retinal ganglion cells and atrophy of optic nerve leading to irreversible loss of visual field. [1] Glaucoma is a chronic disease for which lifelong control of intraocular pressure (IOP) is mandatory. The primary treatment for glaucoma is medical, as surgeries have a risk of failure and complications. Medicines are thought to be safer, however patients often needs >1 medications to reach the "target" IOP, which may increase the possibility of side effects, as well as long-term costs. In developed countries, the cost of glaucoma therapy is largely borne by government schemes or medical insurance companies while there are very few studies on the cost of glaucoma therapy in developing countries. [2]

Glaucoma -The Indian Scenario :
Glaucoma is the second leading cause of blindness in India and the country has been predicted to host nearly 20% of the world population by 2020. It was estimated that 12 million Indians will be affected by 2010 and 16 million by 2020. The reported prevalence of primary open angle glaucoma (POAG) is 0.41- 3.51%.

Management of Glaucoma in India :
Many of the newer diagnostic modalities for early diagnosis and monitoring progression of glaucoma are available in the country. The spectrum of antiglaucoma medications is available. Yet, more than 90% of the glaucoma remains undiagnosed contrary to 40-60% in developed countries. Less than one fifth of those with glaucoma in the Aravind Comprehensive Eye Survey (ACES) had been previously diagnosed as having the disease despite an eye examination in the past. In Chennai Glaucoma Study, a significant number (40%) diagnosed as POAG actually had primary angle closure glaucoma (PACG). Most ophthalmologist in India (70%) are located in urban areas and cater to only 23% of its population. A large percentage of blindness in our country stems from the population living in the rural areas where medical facilities are not easily available. Nearly 35% of the Indian population falls below the international poverty line and medications are still not affordable considering the life long need. In ACES, 42% of glaucoma patients reported one or more problems in using the medications. This makes glaucoma a cost- intensive disease, with a low socioeconomic status having a negative impact. [3] Apart from illiteracy and lack of awareness, two factors which may disrupt the ability to adhere to the treatment for glaucoma are cognitive impairment and depressive symptoms, common in older patients with glaucoma. [4] Studies done on prevalence of glaucoma have reported a high proportion of undiagnosed patients. Late diagnosis is related to increased risk of glaucoma associated with visual disability. Lack of awareness and non availability of appropriate screening procedures are among the major reasons for non-diagnosis or late diagnosis of glaucoma leading to increase in cost of glaucoma management. [5]

Glaucoma Therapy and Cost Analysis [6]:
Studies provide strong evidence that high IOP plays an important role in the neuropathy of POAG. It has been demonstrated that the reduction in the level of IOP lessens the risk of visual field progression in open angle glaucoma. Treatment strategies of glaucoma aims at lowering IOP, which helps to prevent optic nerve damage and glaucoma related blindness. Pharmacotherapy is usually the first line of treatment for elevated IOP and open-angle glaucoma. Major drug classes for medical treatment of POAG include alpha- agonists (brimonidine), beta-blockers (timolol, betaxolol, levobunalol), topical carbonic anhydrase inhibitors (dorzolamide, brinzolamide), oral carbonic anhydrase inhibitors (acetazola- mide), miotic agents (pilocarpine), prostaglandin (PG) analogs (travoprost, latanoprost), prostamides (bimatoprost), and sympathomimetic drugs (epinephrine, dipivefrine). The ophthalmologist have a wide range of choices for management of glaucoma, in terms of cost, efficacy and adverse effects. There is an increased demand from society and health care payers that clinical medicine in particular when aimed at treatment of chronic life-long disease should justify its cost. Taking into consideration, the broadening gap between therapeutic possibilities and resources available, the choices have to be made by prioritizing (rationing) all treatment strategies. Economic evaluation of glaucoma therapy needs to be targeted at assessment of efficiency, that is, health effects weighed against the sacrifices incurred for attaining them.

Cost analysis :
Cost of particular anti-glaucoma medications per day per eye =
[ (Cost per bottle / Number of drops per bottle )*(No. of drops required per day per eye)]
Cost of anti glaucoma medication for 4 weeks
per eye = Cost per day per eye x 28
Cost/year/eye= Cost/day/eye x 365.

Range of cost of various anti glaucoma drugs in India. [7]

Sr.No Drug Range of price(₹)
1. Timolol 0.5% 13.50-89
2. Betoxalol 0.5% 29-33.95
3. Levobunalol 62-67
4. Pilocarpine 2% 12-42
5. Brimonidine 0.15% 100.25-300
6. Latoprost 0.005% 229-1142
7. Bimatoprost 0.3mg/ml 250-1348
8. Dorzolmide 195-202
9. Dorzolamide + Timolol 204-208
10. Bimatoprost+Timolol 167-280
11. Brimonidine+Timolol 150-178
12. Travoprost 553-756

Timolol may be started as an initial treatment in poorer patients, when not contraindicated, as it is extremely cost-effective and prostaglandin analogues may be reserved as an alternative or as add-on therapy for patients not achieving "target" IOP with timolol. Pilocarpine, which is a cheap, effective and comfortable alternative, should be utilized especially in cases of angle closure glaucoma. It should be available in developing countries. The availability of quality controlled generic drugs may make a significant impact to the cost of medical therapy. As most patients were on more than one drug, drug combinations may be considered, both from an economic and quality of life aspect, after evaluating the efficacy of each component. Besides, all glaucoma investigations, such as the perimetry, imaging and diurnal phasing costs around ₹ 900/- in private hospitals and that of tonometry which is included in consultation charges is in average ₹ 400/- in any metropolitan city. Hence, the total cost would rise significantly if the cost of these essential investigations at least twice a year is included. Glaucoma surgery (Trabeculectomy) costs around 5000/- to 7000/- in any private hospital. Thus, there is need for proper follow up guidelines, which should be drafted for these patients to avoid unnecessary OPD visits at short intervals, thereby increasing the cost of treatment.

Conclusion 3:
As awareness about glaucoma can lead to early detection, a very important step in preventing glaucoma-related blindness, similarly educating masses with proper implementation of health communication principles, will offer a promise of improving awareness. Studies have shown that there exists a relationship between education level & awareness of disease. This has a direct influence on disease process and thereby long term cost burden of glaucoma treatment. Furthermore, there is a need to identify interventions that reinforce people's attitude above the perceived level of awareness about glaucoma and to devise strategies that can influence behavior to the risk of blindness from glaucoma.

Economic evaluation of glaucoma therapy needs to be targeted at assessment of efficiency, that is health effects weighed against the cost incurred for attaining them. The deciding criterion should be cost effectiveness of treatment strategy rather than efficiency or cost alone.

Implementation of glaucoma screening programs for all patients over 40 years presenting to the hospital would help detect glaucoma early, which would decrease cost in the long term. Primary surgery could be considered for the low socio- economic group and also for drug non compliant patients. A successful trabeculectomy operation remains viable atleast for 20 years, thereby reducing the long term cost for glaucoma management. The socioeconomic impact of medical therapy in glaucoma is considerable, and treatment should be individualized to suit the educational and socio economic aspect of each patient. Economic burden of travelling and loss of livelihood due to the frequent follow ups at the hospital has to be taken into consideration. This can be minimized by introduction of teleophthalmology facilities in peripheral areas. Introduction of quality controlled generic drugs, and use of cheaper alternatives such as timolol and pilocarpine in suitable candidates may address the cost issue for some patients. Periodic training of ophthalmologists at district hospitals in the management and follow up of glaucoma patients will be helpful.

References
  1. Basak SK, Essentials of Ophthalmology, Current Books International, Kolkata, 2008;263

  2. Nayak B, Gupta S, Kumar G, Dada T, Gupta V, Sihota R.Socioeconomics of long-term glaucoma therapy in India. Indian J Ophthalmol. 2015; 63:20-24.

  3. Ramakrishnan R, Khurana M. Surgical management of glaucoma: An Indian perspective. Indian J Ophthalmol. 2011; 59:118-122.

  4. Yochim BP, Mueller AE, Kane KD, Kahook MY. Prevalence of Cognitive Impairment, Depression and Anxiety Symptoms Among Older Adults With Glaucoma. J Glaucoma. 2012; 21:250-254.

  5. Rewri P, Kakkar M. Awareness, knowledge, and practice: A survey of glaucoma in north Indian rural residents. Indian J Ophthalmol. 2014; 62:482-485.

  6. Natt NK, Gupta A, Singh G, Singh T. A pharcoeconomic analysis to determine the relative cost-effectiveness of bimatoprost 0.03% eye drops and brimonidine 0.2% eyedrops in patients of primary open-angle glaucoma/ocular hypertension. Indian J Ophthalmol; 62:1136-1140.

  7. < https://www.medlineindia.com /eye> accessed on 20.10.2015.

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