Patient non-adherence continues to hinder effective disease management for optometrists, reveals the latest Optometric Management “Readers’ Survey.” It’s no secret that a major cause of this is patient cost.

So, in this column, I count the cost of glaucoma intervention to glaucoma patients, and I provide steps for financial navigation.

Counting the cost

At age 65, females and males are expected to live, on average, another 19.7 years and 17.0 years, respectively.¹ As this age is similar to the average age of glaucoma diagnosis at 66 years of age,² a newly diagnosed glaucoma patient could, in theory, use drops for nearly two decades.

Cost-of-illness studies³ have examined these direct costs (expenses for medical and surgical therapy, office visits, and testing, etc.⁴) and indirect costs (loss of work, loss of productivity, increased family dependence, etc.⁴) and show that, proportional to disease severity and patient adherence to treatment,⁵patients may spend, on average, between $623 to $2,511 per year⁶ on glaucoma management. This could translate to low-income and middle-income homes spending 26.08% and 5.17%, respectively, of their monthly income on treatment.⁷

On a larger scale, the economic annual burden of glaucoma in the United States is $2.9 billion⁸ and, due to a growing prevalence, will exponentially increase to $17.3 billion by 2050.⁹ One of the main reasons for this increase is the cost of drops, even generic ones.¹⁰

Steps for financial navigation

As we consider the potential “…nonaffordability of existing glaucoma therapies…”¹¹ and because a “…lack of affordability is known to be associated with medication nonadherence, contributing to disease progression,”¹¹ ODs need to find ways to cut costs for their patients. These ways include:

• Provide financial support resources. For advanced glaucoma patients and/or for whom generic glaucoma drops may not be appropriate, I recommend predictable branded drops, while utilizing patient resources, such as in-office coupons, patient rebates, and direct online patient assistance programs from our industry partners (See Financial Support Resources,” above.)
• Prescribe generic alternatives when appropriate. Effective first-line drops are available in generic alternatives and cost less.A caveat: Due to the significant variability among generic medications in efficacy, formulation, ease of use, and tolerability,¹² this step may not be appropriate for every patient. Also, switching to a generic drop due to side effects (with associated less patient adherence) and formulation differences¹² may result in a loss of IOP control. In short, the “…shift to generic prescribing has great potential for reducing health care-related costs; however, it is important that the limitations of generic medications are understood and addressed.”¹²
• Consider selective laser trabeculoplasty (SLT). When topical therapy is unsustainable,¹³ consider SLT as a cost-effective option.¹³ (See “SLT Hesitancy” at https://bit.ly/OM1021SLT .)

A “Penny” saved...

A “retinal nerve fiber layer” saved is a “visual field decibel” earned. Therefore, perhaps the best thing we could do is to diagnose glaucoma earlier and detect progression sooner. In short, “…managing glaucoma efficiently and delaying disease progression would help significantly reduce the economic burden of this disease.”⁷ OM

For more solutions to patient non-adherence, see bit.ly/OM2104GlaucomaAdherence .

References

1. Centers for Disease Control and Prevention. National Center for Health Statistics. Mortality in the United States, 2021. https://www.cdc.gov/nchs/products/databriefs/db456.htm. Accessed Oct. 10, 2023.

2. Öhnell H, Bengtsson B, Heijl A. Making a Correct Diagnosis of Glaucoma: Data From the EMGT. J Glaucoma. 2019;28(10):859-864. doi: 10.1097/IJG.0000000000001342.

3. Prager AJ, Liebmann JM, Cioffi GA, Blumberg DM. Self-reported Function, Health Resource Use, and Total Health Care Costs Among Medicare Beneficiaries With Glaucoma. JAMA Ophthalmol. 2016;134(4):357-65. doi: 10.1001/jamaophthalmol.2015.5479.

4. Usgaonkar UPS, Naik R, Shetty A. The economic burden of glaucoma on patients. Indian J Ophthalmol. 2023;71(2):560-566. doi: 10.4103/ijo.IJO_1676_22.

5. Fiscella RG, Lee J, Davis EJ, Walt J. Cost of illness of glaucoma: a critical and systematic review. Pharmacoeconomics. 2009;27(3):189-98. doi: 10.2165/00019053-200927030-00002.

6. Schlenker MB, Trope GE, Buys YM. Comparison of United States and canadian glaucoma medication costs and price change from 2006 to 2013. J Ophthalmol. 2015;2015:547960. doi: 10.1155/2015/547960.

7. Kapetanakis VV, Chan MPY, Foster PJ, et al. Global variations and time trends in the prevalence of primary open angle glaucoma (POAG): a systematic review and meta-analysis. Br J Ophthalmol. 2016;100(1):86-93 (see figure 2). doi: 10.1136/bjophthalmol-2015-307223.

8. Thomas S, Hodge W, Malvankar-Mehta M. The Cost-Effectiveness Analysis of Teleglaucoma Screening Device. PLoS One. 2015;10(9):e0137913. doi: 10.1371/journal.pone.0137913.

9. Feldman RM, Cioffi GA, Liebmann JM, Weinreb RN. Current Knowledge and Attitudes Concerning Cost-Effectiveness in Glaucoma Pharmacotherapy: A Glaucoma Specialists Focus Group Study. Clin Ophthalmol. 2020;14:729-739. doi: 10.2147/OPTH.S236030.

10. Allison K, Patel D, Alabi O. Epidemiology of Glaucoma: The Past, Present, and Predictions for the Future. Cureus. 2020;12(11):e11686. doi: 10.7759/cureus.11686.

11. Zhao PY, Rahmathullah R, Stagg BC, et al. A Worldwide Price Comparison of Glaucoma Medications, Laser Trabeculoplasty, and Trabeculectomy Surgery. JAMA Ophthalmol. 2018;136(11):1271-1279. doi: 10.1001/jamaophthalmol.2018.3672.

12. Tatham AJ. The Use of Generic Medications for Glaucoma. J Ophthalmol. 2020;2020. doi: 10.1155/2020/1651265.

13. Stein JD, Kim DD, Peck WW, Giannetti SM, Hutton DW. Cost-effectiveness of medications compared with laser trabeculoplasty in patients with newly diagnosed open-angle glaucoma. Arch Ophthalmol. 2012;130(4):497-505. doi: 10.1001/archophthalmol.2011.2727.

DR. LIFFERTH is clinical editor of Optometric Management. He practices at Center for Sight, is a member of the Optometric Glaucoma Society, and a Glaucoma Diplomate of the American Academy of Optometry. For additional glaucoma cases, you can also follow Dr. Lifferth on his Instagram account: glaucomaqd. Email him at glaucomaqd@yahoo.com.