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HomemifeaturePutting a Value on Patient Support

Putting a Value on Patient Support

In 2023, economics consultancy Evaluate reviewed the costs of developing glaucoma and the potential savings that might be delivered from better compliance with glaucoma treatment.

As part of this review, Evaluate looked at the impact Glaucoma Australia’s patient support program had on patients’ compliance with their treatment and found that a substantial increase in public expenditure in the patient support program would both increase compliance rates and be cost-effective.

Managing primary open-angle glaucoma (POAG) – the most prevalent type of glaucoma – cost Australia’s health system AU$355 million in 2005 and will increase to $784 million in 2025. Over the same period, total costs, including health system costs, indirect costs, and costs for loss of wellbeing, will increase from $1.9 billion to $4.3 billion, largely because of increasing prevalence due to Australia’s ageing population.1

People with early POAG progress more rapidly to advanced stages of the disease if they are not treated. Australia’s National Health and Medical Research Council (NHMRC) estimates that the average time for a person with POAG to progress to blindness without treatment is 23 years and, with treatment, 35 years.

No cure exists for glaucoma and the vision loss it causes is irreversible. Early diagnosis and adherence to a treatment regime – usually involving eye drops – are critical in ensuring that intraocular hypertension is managed, and disease progression slowed.

Early diagnosis and treatment would deliver significant reductions in annual healthcare costs.2

IMPACT OF GLAUCOMA ON PATIENTS

Glaucoma significantly impacts patients’ lives and often those of their families. People with lower vision are at four to eight times greater risk of breaking or fracturing a hip due to a higher risk of falling than the general population; twice as likely to suffer depression; and more likely to be hospitalised or die prematurely.3

People with lower vision often find their ability to perform daily activities impacted and may become dependent or require financial and/ or other support from the welfare system. Unsurprisingly, as their rate of vision loss increases, patients’ quality of life tends to decrease, especially when their ability to drive and maintain independence is affected. This is also closely associated with increased risks of social isolation, depression, and entry into long-term care.4 Employed people often worry about losing their jobs as their vision declines.

While getting support for their glaucoma and getting it early can help patients, few receive appropriate treatment and services sufficiently early, and sometimes lose capacity that might otherwise have been maintained.5

GLAUCOMA AUSTRALIA’S PATIENT SUPPORT PROGRAM

Glaucoma Australia is the single, unified voice for all things related to glaucoma. Its expertise has long been recognised by the NHMRC, whose most recent guidelines for the screening, prognosis, diagnosis, management and prevention of glaucoma recommended Glaucoma Australia’s educational resources to both healthcare professionals and people diagnosed with glaucoma as well as their families.6

One of the most impactful ways Glaucoma Australia influences Australians’ eye health is via its patient support program. This program is delivered by Glaucoma Australia at no cost to the patient or the health system. Glaucoma Australia receives no financial or other support from state or federal governments.

The program helps those diagnosed with glaucoma to better understand their disease and make informed decisions to maintain their quality of life; provides one on one support via orthoptist educators to help manage the anxiety associated with a glaucoma diagnosis; helps maximise appointment and treatment adherence; and supports eye health professionals to ‘extend their care’ thereby maximising long-term patient treatment outcomes.

The program includes automated email and SMS educational journeys, personalised inbound and outbound phone calls, a support line, webchat, website resources, social media, including YouTube films and Q&A live events, and two online support groups.

The patient support program significantly improves patients’ understanding of their disease. In a survey, 60% of participants rated their knowledge of glaucoma and its treatment as above average or excellent compared with 34% of patients at the time of joining the program, while only 20% stated that they always or frequently feel anxious about their glaucoma compared with 44% when they first joined.7

Treatment adherence is also greater with 85% reporting adherence with their eye drops compared to only 50% of patients six months after diagnosis who do not access this support and less than 37% of patients who are compliant three years after their diagnosis.7,8 Attendance at recommended appointments is also much higher at 91% compared with only 14% generally.

Despite this impact and its low cost of $150 per patient per year, the patient support program is accessed by only 1% of new glaucoma patients. The primary constraint on access is the program’s funding and consequent availability.

THE COSTS OF GLAUCOMA

The principal costs involved with glaucoma include direct medical costs, costs associated with aids and compensation for low vision, rehabilitation services, paid caregiving, and lost income.9 As patients’ glaucoma worsens, these costs increase and this is impacted by factors such as underdiagnosis, underestimates of the severity of damage, insufficient reduction of intraocular pressure (IOP), inadequate assessment of peaks and means of IOP, and difficulty in evaluating the rate of progression.10 Greater compliance with medication that lowers patients’ IOP and regular appointments should reduce the impact of these factors.

Before considering the savings available from investment in compliance, the increased cost of testing must also be reviewed as this represents a potential cost to the federal Government via Medicare. Clear benefits exist from being diagnosed as early as possible and the potential for arresting disease progression early would deliver both system savings and better quality of life for patients. However, increased testing is recommended only for those with assessed risk factors.

POTENTIAL SAVINGS FROM BETTER COMPLIANCE

Evaluate’s paper considered four sets of potential savings that might be achieved as a result of better compliance with glaucoma treatment. These were the reduction in avoidable acute hospital services, for which the four to eight times greater risk of hip fracture was used; reduction in the rate of demand for increased treatment services and medicines for the disease; reduction in demand for residential aged care or other aged care services; and the costs of visionrelated disability services under the National Disability Insurance Scheme (NDIS). These costs are compared with Glaucoma Australia’s patient support program, which costs $150 per person per year.

Hip Fracture

In Australia, 93.2% of hip fractures are caused by falls11 and the average cost of a hip fracture to the health system is approximately $16,666.67.12 Across the general population, this means the mean individual cost or incidence by price in a given year is $33.16. However, at a four times higher rate for people with glaucoma-related vision impairment, this would be a mean of $132.67 and, at an eight times rate, it would be a mean of $265.33. Clearly, if expenditure on the Glaucoma Australia patient support program could be targeted only to people at risk of glaucoma, these data alone would make the program fiscally attractive.

Ongoing Treatment Costs

The inflated mean treatment costs of only glaucoma-related medicines and interventions is $8,115.97 per person per annum. Of this total, $1,990.47 is for medicine costs with the remaining $5,290.04 being for other glaucoma-related interventions. Studies indicate that the worsening of glaucoma is associated with at least a doubling of annual eye-related outpatient costs,13 which indicates a mean cost in Australia for severe glaucoma of $16,231.94 per annum. If the incremental difference is applied only to the 9.5% of glaucoma patients who experience avoidable residual vision loss, then the average increase in cost over the entire glaucoma population would be some $771 per annum. This clearly outstrips the cost of the patient support program.

Aged Care

The expected increased cost of aged care for a person with substantial vision loss due to glaucoma is $117,026.11 Accounting for the 9.04% of patients who could avoid progression to serious vision loss, this would be distributed across all persons with glaucoma as $10,579.15 across their post-65 years’ life. Evaluate’s paper notes that these are blunt calculations but, again, the potential costs associated with glaucoma in aged care dwarf the cost of Glaucoma Australia’s patient support program.

Comparison with Disability Funding

The mean cost of an NDIS package, where vision loss is the primary source of disability, is $46,800. While this is lower than the average across all packages of $72,000,14 this is an annual cost for what is likely to be many years and certainly for substantially longer than the average stay in residential aged care.

Glaucoma is predominantly experienced by people aged over 65 who cannot enter the NDIS. However, when a person experiences early vision loss, the amount of what would be funded is substantially greater than any combination of aged care or carer benefits available later in life.

This means that there is a comparative standard for funding the management of vision loss that makes the cost of minimising it – at $150 per person – trivial.

CONCLUSION AND RECOMMENDATIONS

On each of the four comparators – hip fracture, ongoing treatment costs, aged care, and disability funding – Evaluate found that expenditure on the patient support program would be significantly outstripped by expected savings. Public expenditure on Glaucoma Australia’s patient support program would be cost-effective and was recommended as it would have a positive return to government, patients, and the economy.

Evaluate also recommended a more detailed study of compliance investment in glaucoma in Australia. This would generate data needed to perform a detailed cost-benefit analysis and to identify ways to capture more reliable data about the prevalence of glaucoma.

Alastair Furnival has a background in public policy, economics, and political strategy. Prior to co-founding Evaluate, Mr Furnival was Chairman of a leading public affairs firm, a Vice-President at Boston-based Charles River Associates, and regional chief economist for a multinational food company. He has been an advisor to federal and state governments, including as a Chief of Staff to Health and Ageing Ministers in the Howard and Abbott governments.

Catherine McGovern is a partner of Evaluate. For nearly 30 years, she has worked in and with government as a consultant, adviser, and government relations specialist in health, industry, research and development, and social services.

Ms McGovern was an adviser in the Howard government in the industry, science, and resources portfolio. She has been Head of Government Affairs and Policy for GlaxoSmithKline Australia and has extensive policy and regional experience with GSK in the UK and Europe in relation to health policy and networks, research and development, investment decisions, education, and other corporate matters.

Disclosure: Evaluate’s research was commissioned and funded by Glaucoma Australia.

References

  1. Dirani, M., Crowston, J.G., Taylor, P.S., et al., Economic impact of primary open-angle glaucoma in Australia, Clin Exp Ophthalmolo. 2011 Sept–Oct;39(7):623–32 DOI: 10.1111/j.1442-9071.2011.02530.x.
  2. Quoted in National Health and Medical Research Council (2010), A Guide to Glaucoma for Primary Health Care Providers: A Companion Document to NHMRC Guidelines for the Screening, Prognosis, Management and Prevention of Glaucoma 2010, NHMRC.
  3. Attebo, K., Mitchell, P., Smith, W., Visual acuity and the causes of visual loss in Australia, The Blue Mountains Eye Study, Ophthalmology, 1996 Mar;103(3):357-64. DOI: 10.1016/s0161-6420(96)30684-2.
  4. Medeiros, F.A., Evaluating quality of life in glaucoma, Glaucoma Today, May/June 2016. Available at: glaucomatoday.com/articles/2016-may-june/evaluatingquality-of-life-in-glaucoma [accessed December 2022].
  5. Bui, B.B., The impact of glaucoma on mental health and wellbeing, presentation for Glaucoma Australia, 2022. available at: youtube.com/watch?v=NGWCo_ZHpHw, [accessed December 2022].
  6. National Health and Medicare Research Council, NHMRC Guidelines for the screening, prognosis, diagnosis, management. and prevention of glaucoma 2010, 2010. Available at: nhmrc.gov.au/about-us/resources/rescindedguidelines [accessed December 2022].
  7. Glaucoma Australia Patient Impact Measurement Survey 2023.
  8. Bansal, R., Tsai, J. (2007) Medical treatment: compliance/ adherence to glaucoma medication – a challenge, Journal of Current Glaucoma Practice, 22–25. DOI: 10.5005/jpjournals-10008-1052.
  9. Schmier J.K. Halpern, M.T., Jones, M.L., et al., The economic implications of glaucoma: A literature review, Pharmacoeconomics, 2007; 25(4): 287–308. DOI: 10.2165/00019053-200725040-00003.
  10. Remo Jr., S., et al., Why do people (still) go blind from glaucoma?, Translational Vision Science and Technology March 2015, Vol.4, 1. DOI: 10.1167/tvst.4.2.1.
  11. Australian Institute of Health and Welfare, Hip fracture incidence and hospitalisations in Australia 2015–16, 2018, p13. Available at: aihw.gov.au/reports/injury/hip-fractureincidence-in-australia-2015-16/summary [accessed January 2023].
  12. Australian Commission on Quality and Safety in Healthcare & IHPA, Best practice pricing and clinical quality information on hip fracture care. Available at: safetyandquality.gov.au/sites/default/files/migrated/Bestpractice-pricing-and-clinical-quality-information-on-hipfracture-care-report_April-2016.pdf [accessed February 2023].
  13. Shih, V., Parekh, M., Multani, J.K., et al., Clinical and economic burden of glaucoma by disease severity: a United States claims-based analysis. Ophthalmol Glaucoma. 2021 Sep–Oct;4(5):490-503. DOI: 10.1016/j. ogla.2020.12.007.
  14. National Disability Insurance Scheme-sourced data.