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Supplements Managed Care Issues in Glaucoma: Emerging Trends and Treatment
The Prevalence of Glaucomatous Risk Factors in Patients From a Managed Care Setting: A Pilot Evaluation
Ervin N. Fang, MD; Simon K. Law, MD, PharmD; John G.Walt, MBA; Tina H. Chiang, PharmD, MBA; and Erin N. Williams, RN
Disease Progression and the Need for Neuroprotection in Glaucoma Management
Rohit Varma, MD; Patti Peeples, RPh, PhD; John G.Walt, MBA; and Thomas J. Bramley, PhD
Current Management of Glaucoma and the Need for Complete Therapy
Stuart J. McKinnon, MD, PhD; Lawrence D. Goldberg, MD; Patti Peeples, RPh, PhD; John G.Walt, MBA; and Thomas J. Bramley, PhD
History of Neuroprotection and Rationale as a Therapy for Glaucoma
Leonard A. Levin, MD, PhD; and Patti Peeples, RPh, PhD
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Managed Care and the Impact of Glaucoma
Claiborne E. Reeder, RPh, PhD; Meg Franklin, PharmD, PhD; and Thomas J. Bramley, PhD

Managed Care and the Impact of Glaucoma

Claiborne E. Reeder, RPh, PhD; Meg Franklin, PharmD, PhD; and Thomas J. Bramley, PhD
To better understand the efficient and appropriate use of glaucoma medications, cost-effectiveness data can be enlightening. The following section summarizes several studies that evaluate the relative cost and effectiveness of glaucoma therapies. For a more comprehensive analysis of the economic impact of glaucoma, the relative cost-effectiveness of glaucoma treatments, and limitations of the published literature, a recent review article by Schmier et al is recommended.19

Noecker and Walt used clinical trial data for bimatoprost and latanoprost to calculate the monthly cost to achieve a 1% reduction in IOP in glaucoma and ocular hypertensive patients. The authors determined that the incremental cost for each 1% lowering of IOP by bimatoprost over latanoprost was $0.29.20 Some concerns with the design of this study have been raised in the literature. Kymes, in a letter to the editor, questions some of the model assumptions and the sensitivity analyses performed as part of the analysis.21

Using a US healthcare payer perspective, Goldberg and Walt compared the cost-effectiveness of glaucoma treatment with bimatoprost with other IOP-lowering medications in adult patients with chronic glaucoma or ocular hypertension. Total annual costs and cost per treatment success for 0.03% bimatoprost once daily were compared with the following: 0.5% timolol twice daily (generic), 0.005% latanoprost once daily, and the fixed combination of 0.5% timolol and 2.0% dorzolamide twice daily. (Treatment success was defined as moving a patient from an initial IOP range of 22 mm Hg to 34 mm Hg to a lower target IOP range of 13 mm Hg to 17 mm Hg.) Estimates were based on 2003 medical resource costs for physician visits. Drug acquisition costs and treatment success rates were obtained from published clinical trials. The outcome of interest was the percentage of patients achieving target IOPs. The authors found that a higher percentage of patients achieved target IOPs with bimatoprost than with each of the other medications. At most target pressures, the cost per treatment success for patients starting treatment on bimatoprost was less than that for patients started on other medications. The incremental cost of achieving additional clinical success (measured in 1 mm Hg interval decrements from 17 mm Hg to 13 mm Hg) for bimatoprost ranged from $800 to $1700, compared with timolol generics, and from $300 to $3100 for the combination of timolol and dorzolamide. Results of the analysis show that bimatoprost was more effective and less costly than latanoprost.22

Day et al evaluated differences in persistency and treatment costs for latanoprost, bimatoprost, or beta-blockers in open-angle glaucoma or ocular hypertensive patients. This study design was a retrospective, multicenter, parallel comparison of patients who were prescribed ocular hypotensive monotherapy between September 1996 and August 2002. Among the regimens for the first year of therapy, persistence was the greatest for latanoprost. There was a statistically significant difference between groups in final IOP for latanoprost (17.3 mm Hg), bimatoprost (18.0 mm Hg), and the betablockers (17.9 mm Hg). The average number of glaucoma-related visits was statistically greater for beta-blockers (3.3) compared with latanoprost (2.9) and bimatoprost (3.1). Moreover, the average number of therapy changes was statistically greater for bimatoprost (0.45) and beta-blockers (0.47) than for latanoprost (0.27). The cost of glaucoma-related visits and medications was lowest for beta-blockers ($119.30) and highest for bimatoprost ($163.80). The authors concluded that patients treated with latanoprost were more persistent, had lower average IOP, fewer glaucoma-related visits, and fewer medicine changes compared with bimatoprost or betablocker therapy. In contrast to these findings, the beta-blocker treatment group had lower overall cost.23 However, study design limitations that could affect the findings regarding latanoprost efficacy and bimatoprost persistency have been debated.24

Fiscella and Walt compared the cost-effectiveness of bimatoprost with latanoprost in the treatment of glaucoma or ocular hypertension. In this study, the estimated yearly costs and cost per treatment success for bimatoprost ophthalmic solution were compared with latanoprost ophthalmic solution. The treatment model was based on common clinical practice for newly diagnosed patients with glaucoma or ocular hypertension. Clinical success was defined as achieving a 20% reduction in IOP. After 6 months of treatment, the clinical success rates were significantly higher with bimatoprost than with latanoprost, while the average yearly cost per patient was similar for bimatoprost ($1151) and latanoprost ($1193). However, the cost per treatment success averaged $568 less with bimatoprost than with latanoprost. The authors attributed the lower cost per treatment success to the greater efficacy of bimatoprost. This finding held even when responder rates were adjusted to account for patients who withdrew from treatment because of adverse events.25

If glaucoma is not treated adequately in the early stages, progression of the disease can result in appreciable resource utilization and costs for end-stage therapy. Visual rehabilitation care is often required for patients who advance to this stage, inflicting a significant economic burden on the healthcare system.26 Other consequences associated with vision loss can also contribute significantly to the healthcare system burden. Javitt et al examined a Medicare population to determine the effects of vision loss on medical and pharmacy costs for eyerelated and non–eye-related costs. Results from the study demonstrated that any degree of vision loss was associated with an increased risk for other costly outcomes, such as depression, injury, and hospital/ ancillary unit admissions. Costs attributable to vision loss accounted for 27% to 41% of these excess costs. When findings were extrapolated to the entire Medicare population, it was estimated that blindness and vision loss were responsible for $2.14 billion in non–eye-related costs for 2003.9

In their recent review article, Schmier et al emphasize the need for more research on the costs of glaucoma and the cost-effectiveness of glaucoma treatments.19 The need for this type of information will become even more important as the prevalence and economic burden of glaucoma increases and new glaucoma treatments emerge. Although the newer glaucoma therapies will certainly be more efficacious, they will likely be more expensive. Evidence of the value of these therapies, in the context of the total cost of glaucoma and its treatment, will be needed by those in managed care who make formulary and coverage decisions.

New Developments in Glaucoma
Until recently, treatment of glaucoma focused on lowering IOP as a treatable risk factor in the disease. However, the definition of glaucoma has evolved from one of elevated IOP to one characterized by an IOP-sensitive, progressive optic neuropathy. This change in definition has generated a refocus of treatment to include the role of neuroprotectants in glaucoma management. Neuroprotection is a potentially new treatment strategy for glaucoma patients that could have a profound clinical impact on patient care. In the context of glaucoma, neuroprotection refers to administering medications that interact with neuronal or glial elements within the retina or optic nerve to facilitate the survival of retinal ganglion cells.27 In the future, medications that serve as neuroprotectants may be considered in conjunction with IOP-reducing therapy to provide what is being termed complete therapy for glaucoma patients. Such a combination could provide dually targeted treatment for patients with IOP-dependent glaucoma. It would also potentially reduce the rate of disease progression when IOP is not controlled or when progression occurs even with IOP at acceptable levels. Minimizing the consequences of glaucoma progression can ultimately reduce the economic and clinical burden of the disease to the patient and the payer.9,26 When making managed care decisions, the costs of complete therapy will have to be weighed against the consequences of inadequate or incomplete therapy.

Given changes in the healthcare system, population demographics, and treatment alternatives, glaucoma is now a major consideration for MCOs. With the elderly population increasing, these issues will only escalate and present further problems for the healthcare system. Early detection and treatment of glaucoma is essential in preventing the devastating personal and economic consequences of end-stage glaucoma. Although early treatment has been shown to be beneficial, the literature suggests there is still a great need for improvement in lowering IOP, managing appropriate follow-up intervals, and adhering to glaucoma medication regimens. Research suggests that the addition of neuroprotective agents to traditional antiglaucoma agents (complete therapy) may improve glaucoma outcomes. As more treatments for glaucoma enter the market, MCOs will be faced with a myriad of therapeutic options. Weighing the cost of these options and the benefits of early treatment, combined with the need to address treatment and outcome deficits, will prove to be a challenge. Additional research is needed to help organizations better understand the cost and consequences of glaucoma treatment. Measures of therapeutic value, such as cost-effectiveness comparisons, can assist MCOs in making formulary decisions as well as other decisions that impact patient care. The remainder of this supplement focuses on the current management of glaucoma and the role of neuroprotection as it pertains to complete therapy in this patient  population.

Acknowledgment: Laurie Kozbelt assisted in the preparation of this manuscript.

Author Affiliations: From University of South Carolina, Columbia, SC; Xcenda, Palm Harbor, FL; Allergan, Inc, Irvine, CA.

Funding Source: The research and manuscript were funded by Allergan, Inc.

Author Disclosures: Author (CER) received an honorarium from Allergan, Inc; authors (MF, TJB) are employed by Xcenda.

Authorship Information: Concept and design (CER, MF, TJB); acquisition of data (MF, TJB); analysis and interpretation of data (CER, MF, TJB); drafting of the manuscript (CER, MF, TJB); critical revision of the manuscript for important intellectual content (CER, TJB); and supervision (TJB).

Address Correspondence to: Claiborne E. Reeder, RPh, PhD, Director, Xcenda, 3270 Girardeau Ave, Columbia, SC 29204. E-mail:

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