Cost-utility of primary open-angle glaucoma in Brazil

Guedes, Ricardo Augusto Paletta; Guedes, Vanessa Maria Paletta; Gomes, Carlos Eduardo de Mello; Chaoubah, Alfredo

doi:10.5935/0034-7280.20160002

Acessibilidade / Reportar erro

Brasil

Revista Brasileira de Oftalmologia

Español English

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

• Rev. bras. oftalmol. 75 (1) • Jan-Feb 2016 • https://doi.org/10.5935/0034-7280.20160002 copy

Cost-utility of primary open-angle glaucoma in Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To determine the most cost-effective strategy for the treatment of early-stage primary open-angle glaucoma, by comparing the following alternatives: observation, medical therapy or laser treatment.

Methods:

Using a Markov model, from the perspective of the Brazilian Public Health System (SUS) and a horizon of the average life expectancy of the Brazilian population, we compared the incremental cost-utility ratio (ICUR) among the three treatment alternatives, as well as their costs and the gain in quality of life as measured in QALYs (Quality-adjusted life years).

Results:

The ICUR of initial laser treatment and initial medical treatment over observation only, was R$ 2,811.39/QALY and R$ 3,450.47/QALY, respectively. Both strategies were cost-effective, with a slight advantage for the laser treatment. This difference decreases further when increasing age into the model. The two alternatives have provided significant gains in quality of life (around 2.5 QALYs for the laser treatment and 5.0 QALYs for treatment with eye drops).

Conclusion:

Both primary treatments, with laser trabeculoplasty as well as with medications, were cost-effective and provided real gains in quality of life when compared with no treatment of POAG.

Keywords:
Primary open-angle glaucoma/therapy; Primary open-angle glaucoma/economy; Laser therapy; Cost-effectiveness analysis; Quality of life; Brazil

Treatment Strategy	Resourse	Frequency (months)	Code (SUS)^* * Table code for procedures of the Brazilian Single Health System (SUS), SIGTAP table [cited 2013 Sep 8]	Unit Value (R$)
Clinical Treatment	Initial Costo^a a Initial Costo: includes complete eye examination with tonometry, fundoscopy and campimetry;	12	03.01.01.010-2	35.11
	Follow-up appointment^b b Follow-up appointment: includes complete eye examination with tonometry and fundoscopy;	3	03.03.05.001-2	17.74
	Use of 1 medication^c c Use of medication 1 of prostaglandin analogue type;	3	03.03.05.005-5	127.98
	Use of 2 medications^d d Use of 2 medications: prostaglandin analogue + timolol maleate 0.5%;	3	03.03.05.018.7	146.64
	Use of 3 medications^e e Use of 3 medications: prostaglandin analogue + timolol maleate 0.5%+ dorzolamide hydrochloride 2%;	3	03.03.05.022-5	226.02
Laser Treatment	Initial Costo^a a Initial Costo: includes complete eye examination with tonometry, fundoscopy and campimetry;	12	03.01.01.010-2	35.11
	Follow-up appointment^b b Follow-up appointment: includes complete eye examination with tonometry and fundoscopy;	3	03.03.05.001-2	17.74
	Monocular trabeculoplasty	NA	04.05.05.012-7	45.00
	New application of rabeculoplasty^f f The cost of a new trabeculoplasty was included as a 21% increase in the cost value of the first trabeculoplasty (as suggested in the literature9).	NA	04.05.05.012-7	9.45
	Use of 1 medication^c c Use of medication 1 of prostaglandin analogue type;	3	03.03.05.005-5	127.98
	Use of 2 medications^d d Use of 2 medications: prostaglandin analogue + timolol maleate 0.5%;	3	03.03.05.018.7	146.64

Treatment Strategy		Anual cost(R$)	Variation fo sensitivity (± 20%)	Reference
Without treatment		0.00	*****	*****
Clinical Treatment	Initial	881.59	705.27 - 1057.91	^a a ) Clinical Treatment: Average annual cost based on: Annual initial appointment + 4 follow-up appointments + eyedrops needed for 1 year of treatment in the reference center of SUS Proportion of the amount of eyedrops used in each evolutionary stage of glaucoma (Source: the authors themselves); Amount of eyedrops per year (Reference: Reference Centers for glaucoma treatment of SUS);17,18 Eyedrops prices paid by SUS to the reference centers (Source: SUS);17,18 Cost of adverse effects: Only the cost of Asthma Crisis secondary to inadvertent use of beta-blockers in these patients were included. RR = 2.29. An increase of 23.8% was made to the final average cost per patient (Source: Tunnel Vision).9
	Moderate	941.07	752.85 - 1129.28
	Severe	1.015.96	812.77 - 1219.15
	Blindness	1.063.79	851.03 - 1276.54
Laser Treatment	Initial	524.49	419.59 - 629.39	^b b ) Laser treatment: First year accounts for: 1 initial appointment + 4 follow-up appointments + trabeculoplasty in both eyes + eyedrops necessary to complement the treatment + new trabeculoplasty (Source: SUS).17,18 Following years: 1 initial appointment + 4 follow-up appointments + eyedrops necessary to complement the treatment (Source SUS).17,18 Efficacy estimated at 50% at the end of the first year, i.e. 50% of the patients without eyedrops. The other 50% were divided as follows: 25% requiring prostaglandin analogues, and 25% requiring prostaglandin analogue + timolol maleate 0.5% (Source: Tunnel Vision).9 The cost of repeating the trabeculoplasty has been added in the initial cost (21% more), according to the study of Cantor et al. 2008.19 Adverse events of using timolol maleate 0.5% (asthma attack): 23.8% added to the average value of using PG + Ti 0.5% (Source: Tunnel Vision).9 The cost was considered the same for all evolutionary stages of glaucoma.
(First year)	Moderate	524.49	419.59 - 629.39
	Severe	524.49	419.59 - 629.39
	Blindness	524.49	419.59 - 629.39
Laser Treatment	Initial	415.59	332.47 - 498.71
(Following years)	Moderate	415.59	332.47 - 498.71
	Severe	415.59	332.47 - 498.71
	Blindness	415.59	332.47 - 498.71

Health States	Utility Value	Variation for sensitivity analysis	Reference
Early glaucoma	0.92	0.80 - 0.99	^a a . Utility values based on the studies of Lee BS et al. (2008) and Brown MM et al. (2001).15,16; ^, ^b b . The average utility values are the same for the different strategies of treatment of POAG.23
Moderate glaucoma	0.89	0.70 - 0.95	^a a . Utility values based on the studies of Lee BS et al. (2008) and Brown MM et al. (2001).15,16; ^, ^b b . The average utility values are the same for the different strategies of treatment of POAG.23
Severe glaucoma	0.86	0.60 - 0.90	^a a . Utility values based on the studies of Lee BS et al. (2008) and Brown MM et al. (2001).15,16; ^, ^b b . The average utility values are the same for the different strategies of treatment of POAG.23
Blindness	0.26	0.20 - 0.60	^a a . Utility values based on the studies of Lee BS et al. (2008) and Brown MM et al. (2001).15,16; ^, ^b b . The average utility values are the same for the different strategies of treatment of POAG.23
Death	0.0000	*****

Treatment Strategy	P (Inicial to Moderate)	P (Moderate to Severe)	P (Severe to Blindness)	P (Death)	Reference
Without treatment	0.14893	0.28595	0.30000	IBGE	^a a ) Strategy without treatment: Initial to moderate glaucoma Rein et al and EMGT (Early Manifest Glaucoma Trial).20,21 Moderate to severe glaucoma: A multiplier (1.92) was used multiplied by the fact of having glaucoma in both eyes (Leske et al. 2003). Rein et al and EMGT 20,21 Severe glaucoma to blindness: Tunnel Vision.9
Clinical Treatment	0.02242	0.02242	0.02242	IBGE	^b b ) Transition probability: Clinical treatment strategy: Initial to moderate glaucoma Rein et al and CIGTS (Collaborative Early glaucoma Treatment Study).20,24 Moderate to severe glaucoma: Rein et al and CIGTS. 20,24 Severe glaucoma to blindness: Rein et al and CIGTS. 20,24
Laser treatment	0.07447	0.14297	0.15000	IBGE	^c c ) Transition probability: Laser treatment strategy: Initial to moderate glaucoma 50% reduction in the rate of progression of untreated (Tunnel Vision).9 Moderate to severe glaucoma: 50% reduction in the rate of progression of untreated (Tunnel Vision).9 Severe glaucoma to blindness: 50% reduction in the rate of progression of untreated (Tunnel Vision).9

P: Probability
IBGE: Brazilian Institute of Geography and Statistics. It refers to the probability of dying each year in the model, according to the Life Table for the Brazilian population.¹⁴14 Instituto Brasileiro de Geografia e Estatística (IBGE). Tábuas de vida. 2013. [citado 2015 Fev 10]. Disponível em http://www.ibge.gov.br/home/estatistica/populacao/tabuadevida/2013/default.shtm.
http://www.ibge.gov.br/home/estatistica/...
^a
) Strategy without treatment:

Initial to moderate glaucoma Rein et al and EMGT (Early Manifest Glaucoma Trial).²⁰20 Rein DB, Wittenborn JS, Lee PP, Wirth KE, Sorensen SW, Hoerger TJ, et al. The cost-effectiveness of routine office-based identification and subsequent medical treatment of primary open-angle glaucoma in the United Stated. Ophthalmology. 2009; 116(5): 823-32.^,²¹21 Leske MC, Hejil A, Hussein M, Bengtsson B, Hyman L, Komaroff E. Factors for glaucoma progression and the effect of treatment: the Early Manifest Glaucoma Trial. Arch Ophthalmol. 2003; 121(1): 48-56.

Moderate to severe glaucoma: A multiplier (1.92) was used multiplied by the fact of having glaucoma in both eyes (Leske et al. 2003). Rein et al and EMGT ²⁰20 Rein DB, Wittenborn JS, Lee PP, Wirth KE, Sorensen SW, Hoerger TJ, et al. The cost-effectiveness of routine office-based identification and subsequent medical treatment of primary open-angle glaucoma in the United Stated. Ophthalmology. 2009; 116(5): 823-32.^,²¹21 Leske MC, Hejil A, Hussein M, Bengtsson B, Hyman L, Komaroff E. Factors for glaucoma progression and the effect of treatment: the Early Manifest Glaucoma Trial. Arch Ophthalmol. 2003; 121(1): 48-56.

Severe glaucoma to blindness: Tunnel Vision.⁹9 Centre for Eye Research Australia. Tunnel Vision: the economic impact of primary open angle glaucoma - a dynamic economic model. Australia: University of Melbourne; 2008.
^b
) Transition probability: Clinical treatment strategy:

Initial to moderate glaucoma Rein et al and CIGTS (Collaborative Early glaucoma Treatment Study).²⁰20 Rein DB, Wittenborn JS, Lee PP, Wirth KE, Sorensen SW, Hoerger TJ, et al. The cost-effectiveness of routine office-based identification and subsequent medical treatment of primary open-angle glaucoma in the United Stated. Ophthalmology. 2009; 116(5): 823-32.^,²⁴24 Lichter PR, Musch DC, Gillespie BW, Guire KE, Janz NK, Wren PA, et al. Interim clinical outcomes in the Collaborative Initial Glaucoma Treatment Study comparing initial treatment randomized to medications or surgery. Ophthalmology. 2001;108(11): 1943-53.

Moderate to severe glaucoma: Rein et al and CIGTS. ²⁰20 Rein DB, Wittenborn JS, Lee PP, Wirth KE, Sorensen SW, Hoerger TJ, et al. The cost-effectiveness of routine office-based identification and subsequent medical treatment of primary open-angle glaucoma in the United Stated. Ophthalmology. 2009; 116(5): 823-32.^,²⁴24 Lichter PR, Musch DC, Gillespie BW, Guire KE, Janz NK, Wren PA, et al. Interim clinical outcomes in the Collaborative Initial Glaucoma Treatment Study comparing initial treatment randomized to medications or surgery. Ophthalmology. 2001;108(11): 1943-53.

Severe glaucoma to blindness: Rein et al and CIGTS. ²⁰20 Rein DB, Wittenborn JS, Lee PP, Wirth KE, Sorensen SW, Hoerger TJ, et al. The cost-effectiveness of routine office-based identification and subsequent medical treatment of primary open-angle glaucoma in the United Stated. Ophthalmology. 2009; 116(5): 823-32.^,²⁴24 Lichter PR, Musch DC, Gillespie BW, Guire KE, Janz NK, Wren PA, et al. Interim clinical outcomes in the Collaborative Initial Glaucoma Treatment Study comparing initial treatment randomized to medications or surgery. Ophthalmology. 2001;108(11): 1943-53.
^c
) Transition probability: Laser treatment strategy:

Initial to moderate glaucoma 50% reduction in the rate of progression of untreated (Tunnel Vision).⁹9 Centre for Eye Research Australia. Tunnel Vision: the economic impact of primary open angle glaucoma - a dynamic economic model. Australia: University of Melbourne; 2008.

Moderate to severe glaucoma: 50% reduction in the rate of progression of untreated (Tunnel Vision).⁹9 Centre for Eye Research Australia. Tunnel Vision: the economic impact of primary open angle glaucoma - a dynamic economic model. Australia: University of Melbourne; 2008.

Severe glaucoma to blindness: 50% reduction in the rate of progression of untreated (Tunnel Vision).⁹9 Centre for Eye Research Australia. Tunnel Vision: the economic impact of primary open angle glaucoma - a dynamic economic model. Australia: University of Melbourne; 2008.

Sociedade Brasileira de Oftalmologia Rua São Salvador, 107 , 22231-170 Rio de Janeiro - RJ - Brasil, Tel.: (55 21) 3235-9220, Fax: (55 21) 2205-2240 - Rio de Janeiro - RJ - Brazil
E-mail: rbo@sboportal.org.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] Corresponding author: Ricardo Augusto Paletta Guedes Av Barão do Rio Branco, 2337 Grupo 801/807/808/810, Centro. Juiz de Fora – MG. ZIP Code: 36010-905 Phone No.: 32 3215 1927 E-mail: palettaguedes@yahoo.com