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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.

Importance: The Tube vs Trabeculectomy Trial (TVT) found that the 350-mm2 Baerveldt implant (tube) and trabeculectomy with mitomycin may be similarly effective in lowering intraocular pressure in primary open-angle glaucoma. However, to date, there are no published long-term clinical data on the cost-effectiveness of trabeculectomy with mitomycin vs tube insertion., Objective: To assess the cost-effectiveness of these procedures compared with maximal medical treatment., Design, Setting, and Participants: We used the Markov cohort model with a 5-year time horizon to study a hypothetical cohort of 100 000 patients who required glaucoma surgery., Main Outcomes and Measures: Quality-adjusted life-years (QALYs) gained, costs from the societal perspective, and the incremental cost-effectiveness ratio of medical treatment, trabeculectomy, and tube insertion. Costs were identified from Medicare Current Procedural Terminology and Ambulatory Payment Classification reimbursement codes and Red Book medication costs. The QALYs were based on visual field and visual acuity outcomes. The hypothetical societal limit to resources was included using a willingness-to-pay threshold of $50 000 per QALY. Costs and utilities were discounted at 3% per year. Uncertainty was assessed using deterministic sensitivity analyses., Results: The mean costs for medical treatment, trabeculectomy, and tube insertion were $6172, $7872 and $10 075, respectively; these amounts resulted in a cost difference of $1700 (95% CI, $1644-$1770) for medical treatment vs trabeculectomy, $3904 (95% CI, $3858-$3953) for medical treatment vs tube insertion, and $2203 (95% CI, $2121-$2261) for trabeculectomy vs tube insertion. The mean 5-year probability of blindness was 4% for both surgical procedures and 15% for medical treatment. The utility gained after medical treatment, trabeculectomy, and tube insertion was 3.10, 3.30, and 3.38 QALYs, respectively. The incremental cost-effectiveness ratio was $8289 per QALY for trabeculectomy vs medical treatment, $13 896 per QALY for tube insertion vs medical treatment, and $29 055 per QALY for tube insertion vs trabeculectomy. The cost-effectiveness of each surgical procedure was most sensitive to early and late surgical failure rates and was minimally affected by adverse events, rates of visual field progression, or medication costs., Conclusions and Relevance: Assuming a willingness to pay of $50 000 per QALY, trabeculectomy and tube insertion are cost-effective compared with medical treatment alone. Trabeculectomy, however, is cost-effective at a substantially lower cost per QALY compared with tube insertion. More research is necessary to reliably account for patient preferences between the 2 operations.

Importance: Laser trabeculoplasty (LTP) is routinely used to treat open-angle glaucoma; hence, understanding variations in its use over time and region is important., Objective: To determine trends over time and the regional variation in the performance of LTP., Design, Setting, and Participants: Database analysis of a 5% random sample of all Medicare beneficiaries 65 years or older with continuous Part B (medical insurance) coverage and no enrollment in a health maintenance organization for each year from 2002 through 2009., Interventions: We counted unique claims with a Current Procedural Terminology code of 65855 (LTP) submitted by ophthalmologists, optometrists, ambulatory surgery centers, or outpatient hospitals by region for each year. We examined trends over time and regional variation in LTP rates in 9 large geographic regions., Main Outcomes and Measures: Rate of LTP per 10,000 Medicare beneficiary person-years and per 10,000 diagnosed open-angle glaucoma (OAG) person-years., Results: The LTP rates per 10,000 Medicare beneficiary person-years were 36.3, 60.1, and 53.5 for 2002, 2006, and 2009, respectively. The 65.6% increase between 2002 and 2006 and the 11.0% decrease between 2006 and 2009 were statistically significant (tests for linear trend, P = .009 and P < .001, respectively). Similarly, the LTP rate among Medicare beneficiaries with OAG increased from 507.9 per 10,000 person-years in 2002 to 824.3 per 10,000 person-years in 2006 (62.3% increase; P = .009) and then decreased to 741 per 10,000 person-years by 2009 (10.1% decrease; P = .004). The rates per 10,000 OAG person-years differed significantly by region, ranging from 314 in the East South-Central region to 607 in the East North-Central region in 2002 (93.2% higher; P < .001). A similar range of variation was observed in subsequent years., Conclusions and Relevance: The rate of LTP for Medicare patients with OAG peaked in 2006 and then decreased through 2009. Nearly twice as many LTP procedures per Medicare beneficiary were performed in some regions compared with others throughout the period.

Objective: To determine the most cost-effective treatment option for patients with newly diagnosed mild open-angle glaucoma: observation only, treatment with generic topical prostaglandin analogs (PGAs), or treatment with laser trabeculoplasty (LTP)., Methods: Using a Markov model with a 25-year horizon, we compared the incremental cost-effectiveness of treating newly diagnosed mild open-angle glaucoma with PGAs, LTP, or observation only., Results: The incremental cost-effectiveness of LTP over no treatment is $16,824 per quality-adjusted life year. By comparison, the incremental cost-effectiveness of PGAs over no treatment is $14,179 per quality-adjusted life year, and they provide greater health-related quality of life relative to LTP. If PGAs are 25% less effective owing to poor patient adherence, LTP can confer greater value., Conclusions: Prostaglandin analogs and LTP are both cost-effective options for the management of newly diagnosed mild open-angle glaucoma. Assuming optimal medication adherence, PGAs confer greater value compared with LTP. However, when assuming more realistic levels of medication adherence (making them 25% less effective than the documented effectiveness reported in clinical trials), at current prices for PGAs, LTP may be a more cost-effective alternative.