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Surveillance for Ocular Hypertension: An Evidence Synthesis and Economic Evaluation

Health Technology Assessment, No. 16.29

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Author Information

,1,* ,1 ,2 ,1,3 ,4 ,1 ,5,6 ,1 ,7 ,1 ,8 ,7 ,9 ,8 ,10 ,5,6 ,4 ,5 ,6 ,1,3 ,1 ,4 ,3 ,2 and 1.

1 Health Services Research Unit, University of Aberdeen, Aberdeen, UK
2 Public Health, Epidemiology and Biostatistics Unit, University of Birmingham, Birmingham, UK
3 Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
4 Department of Primary Health Care, University of Oxford, Oxford, UK
5 Glaucoma Research Unit, Moorfields Eye Hospital NHS Foundation Trust, London, UK
6 Department of Optometry and Visual Science, City University, London, UK
7 Glaucoma Services, Rotterdam Eye Hospital, Rotterdam, the Netherlands
8 Queen's Medical Centre, University Hospital, Nottingham, UK
9 Queen Margaret Hospital, Dunfermline, UK
10 Eye Centre, Tampere University Hospital, Tampere, Finland
* Corresponding author

Abstract

Objectives:

To determine effective and efficient monitoring criteria for ocular hypertension [raised intraocular pressure (IOP)] through (i) identification and validation of glaucoma risk prediction models; and (ii) development of models to determine optimal surveillance pathways.

Design:

A discrete event simulation economic modelling evaluation. Data from systematic reviews of risk prediction models and agreement between tonometers, secondary analyses of existing datasets (to validate identified risk models and determine optimal monitoring criteria) and public preferences were used to structure and populate the economic model.

Setting:

Primary and secondary care.

Participants:

Adults with ocular hypertension (IOP > 21mmHg) and the public (surveillance preferences).

Interventions:

We compared five pathways: two based on National Institute for Health and Clinical Excellence (NICE) guidelines with monitoring interval and treatment depending on initial risk stratification, ‘NICE intensive’ (4-monthly to annual monitoring) and ‘NICE conservative’ (6-monthly to biennial monitoring); two pathways, differing in location (hospital and community), with monitoring biennially and treatment initiated for a ≥ 6% 5-year glaucoma risk; and a ‘treat all’ pathway involving treatment with a prostaglandin analogue if IOP > 21 mmHg and IOP measured annually in the community.

Main outcome measures:

Glaucoma cases detected; tonometer agreement; public preferences; costs; willingness to pay and quality-adjusted life-years (QALYs).

Results:

The best available glaucoma risk prediction model estimated the 5-year risk based on age and ocular predictors (IOP, central corneal thickness, optic nerve damage and index of visual field status). Taking the average of two IOP readings, by tonometry, true change was detected at two years. Sizeable measurement variability was noted between tonometers. There was a general public preference for monitoring; good communication and understanding of the process predicted service value. ‘Treat all’ was the least costly and ‘NICE intensive’ the most costly pathway. Biennial monitoring reduced the number of cases of glaucoma conversion compared with a ‘treat all’ pathway and provided more QALYs, but the incremental cost-effectiveness ratio (ICER) was considerably more than £30,000. The ‘NICE intensive’ pathway also avoided glaucoma conversion, but NICE-based pathways were either dominated (more costly and less effective) by biennial hospital monitoring or had a ICERs > £30,000. Results were not sensitive to the risk threshold for initiating surveillance but were sensitive to the risk threshold for initiating treatment, NHS costs and treatment adherence.

Limitations:

Optimal monitoring intervals were based on IOP data. There were insufficient data to determine the optimal frequency of measurement of the visual field or optic nerve head for identification of glaucoma. The economic modelling took a 20-year time horizon which may be insufficient to capture long-term benefits. Sensitivity analyses may not fully capture the uncertainty surrounding parameter estimates.

Conclusions:

For confirmed ocular hypertension, findings suggest that there is no clear benefit from intensive monitoring. Consideration of the patient experience is important. A cohort study is recommended to provide data to refine the glaucoma risk prediction model, determine the optimum type and frequency of serial glaucoma tests and estimate costs and patient preferences for monitoring and treatment.

Funding:

The National Institute for Health Research Health Technology Assessment Programme.

Contents

Suggested citation:

Burr JM, Botello-Pinzon P, Takwoingi Y, Hernández R, Vazquez-Montes M, Elders A, et al. Surveillance for ocular hypertension: an evidence synthesis and economic evaluation. Health Technol Assess 2012;16(29).

Suggested citation:

Rodgers M, Asaria M, Walker S, McMillan D, Lucock M, Harden M, et al. The clinical effectiveness and cost-effectiveness of low-intensity psychological interventions for the secondary prevention of relapse after depression: a systematic review. Health Technology Assessment, 2012;16(28).

Declaration of competing interests: none

The research reported in this issue of the journal was commissioned by the HTA programme as project number 07/46/02. The contractual start date was in February 2009. The draft report began editorial review in June 2011 and was accepted for publication in November 2011. As the funder, by devising a commissioning brief, the HTA programme specified the research question and study design.The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HTA editors and publisher have tried to ensure the accuracy of the authors' report and would like to thank the referees for their constructive comments on the draft document. However, they do not accept liability for damages or losses arising from material published in this report.

The views expressed in this publication are those of the authors and not necessarily those of the HTA programme or the Department of Health.

© 2012, Crown Copyright.

Included under terms of UK Non-commercial Government License.

Bookshelf ID: NBK100061
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