Direct costs of blindness experienced by patients enrolled in managed care

Perioperative complications of legally blind patients undergoing total hip arthroplasty - A national in-patient sample database study

Background

Legally blind patients are more prone to injury-related falls, which may lead to hip fractures, often necessitating total hip arthroplasty (THA), as a corrective procedure. Many of these patients have unique medical needs and have increased rates of perioperative complications following surgical procedures. However, there is limited information on the hospitalization data and perioperative complications in this population following guidelines such as THA. The purpose of this study was to evaluate the patient characteristics, demographics, and prevalence of perioperative issues among THA patients who were legally blind.

Methods

Using 2016-2019 data from the Nationwide Inpatient Sample (NIS), the incidence of perioperative complications, length of stay (LOS), and the cost of care (COC) among patients undergoing THA who were categorized as legally blind patients, compared to those who were not were analyzed. Propensity matching was conducted to consider associated factors that may influence perioperative complications.

Results

From 2016 to 2019, 367,856 patients underwent THA, according to the NIS. Of those, 322 (0.1%) patients were categorized as legally blind, and the remaining 367,534 (99.9%) patients were not identified as legally blind (control). Legally blind patients were significantly younger than the control group (65.4 years vs. 66.7 years, p < 0.001). After propensity matching, legally blind patients had longer LOS (3.9 days vs. 2.8, p = 0.04), increased discharges to another facility (45.9% vs. 29.3%, p < 0.001), and fewer discharges to home (21.4% vs. 32.2%, p = 0.02) than control patients.

Conclusions

The legally blind group had significantly longer LOS, higher rates of discharge to another facility, and lower rates of discharge to home compared to the control group. This data will help providers make informed decisions about patient care and resource allocation for legally blind patients undergoing THA.

The economics of vision impairment and its leading causes: A systematic review

Vision impairment (VI) can have wide ranging economic impact on individuals, households, and health systems. The aim of this systematic review was to describe and summarise the costs associated with VI and its major causes. We searched MEDLINE (16 November 2019), National Health Service Economic Evaluation Database, the Database of Abstracts of Reviews of Effects and the Health Technology Assessment database (12 December 2019) for partial or full economic evaluation studies, published between 1 January 2000 and the search dates, reporting cost data for participants with VI due to an unspecified cause or one of the seven leading causes globally: cataract, uncorrected refractive error, diabetic retinopathy, glaucoma, age-related macular degeneration, corneal opacity, trachoma. The search was repeated on 20 January 2022 to identify studies published since our initial search. Included studies were quality appraised using the British Medical Journal Checklist for economic submissions adapted for cost of illness studies. Results were synthesized in a structured narrative. Of the 138 included studies, 38 reported cost estimates for VI due to an unspecified cause and 100 reported costs for one of the leading causes. These 138 studies provided 155 regional cost estimates. Fourteen studies reported global data; 103/155 (66%) regional estimates were from high-income countries. Costs were most commonly reported using a societal (n = 48) or healthcare system perspective (n = 25). Most studies included only a limited number of cost components. Large variations in methodology and reporting across studies meant cost estimates varied considerably. The average quality assessment score was 78% (range 35-100%); the most common weaknesses were the lack of sensitivity analysis and insufficient disaggregation of costs. There was substantial variation across studies in average treatment costs per patient for most conditions, including refractive error correction (range $12-$201 ppp), cataract surgery (range $54-$3654 ppp), glaucoma (range $351-$1354 ppp) and AMD (range $2209-$7524 ppp). Future cost estimates of the economic burden of VI and its major causes will be improved by the development and adoption of a reference case for eye health. This could then be used in regular studies, particularly in countries with data gaps, including low- and middle-income countries in Asia, Eastern Europe, Oceania, Latin America and sub-Saharan Africa.

Chronic disease interventions for people with visual impairment: A systematic review

AIM

To identify the characteristics of chronic disease interventions for people with visual impairment (PVI) and provide suggestions for future interventions.

BACKGROUND

Chronic diseases are more common in PVI than people without visual impairment, and PVI have difficulty managing chronic diseases due to physical, social, and psychological problems associated with visual impairment. However, evidence regarding chronic disease intervention for PVI is limited.

METHODS

This review was guided by the PRISMA methodology. Data were extracted and checked, and each study was evaluated to ensure their methodological quality using appropriate tools based on the study design. Findings were described through a qualitative synthesis, and the above process was carried out by all four researchers.

RESULTS

28 studies were selected. The intervention for mental disorders was the most common with about 39.3%, followed by stroke (25.0%), diabetes (17.8%), various chronic diseases (10.7%), chronic pain (3.6%), and scoliosis (3.6%). Most of the intervention was delivered individually, and the place of intervention often depends on the preference or convenience of PVI. A wide range of intervention materials was used, from large print, audio, or braille version reading materials to technology products. Based on the results, the main areas of the outcomes were daily living function, psychological conditions, and quality of life.

CONCLUSIONS

This review identified the components of interventions for PVI and provided intervention strategies. In particular, chronic disease interventions for PVI should be planned by considering how and where appropriate interventions are provided, various available materials, and the problems to be addressed.

Association of Vision Loss With Hospital Use and Costs Among Older Adults

Importance

Patients with vision loss who are hospitalized for common illnesses are often not identified as requiring special attention. This perception, however, may affect the outcomes, resource use, and costs for these individuals.

Objective

To assess whether the mean hospitalization lengths of stay, readmission rates, and costs of hospitalization differed between individuals with vision loss and those without when they are hospitalized for similar medical conditions.

Design, Setting, and Participants

This analysis of health care claims data used 2 sources: Medicare database and Clinformatics DataMart. Individuals with vision loss were matched 1:1 to those with no vision loss (NVL), on the basis of age, years from initial hospitalization, sex, race/ethnicity, urbanicity of residence, and overall health. Both groups had the same health insurance (Medicare or a commercial health plan), and all had been hospitalized for common illnesses. Vision loss was categorized as either partial vision loss (PVL) or severe vision loss (SVL). Data were analyzed from April 2015 through April 2018.

Main Outcomes and Measures

The outcomes were lengths of stay, readmission rates, and health care costs during hospitalization and 90 days after discharge. Multivariable logistic and linear regression models were built to identify factors associated with these outcomes among the NVL, PVL, and SVL groups.

Results

Among Medicare beneficiaries, 6165 individuals with NVL (with a mean [SD] age of 82.0 [8.3] years, and 3833 [62.2%] of whom were female) were matched to 6165 with vision loss. Of those with vision loss, 3401 (55.2%) had PVL and 2764 (44.8%) had SVL. In the Clinformatics DataMart database, 5929 individuals with NVL (with a mean [SD] age of 73.7 [15.1] years, and 3587 [60.5%] of whom were female) were matched to 5929 individuals with vision loss. Of the commercially insured enrollees with vision loss, 3515 (59.3%) had PVL and 2414 (40.7%) had SVL. Medicare enrollees with SVL, compared with those with NVL, had longer mean lengths of stay (6.48 vs 5.26 days), higher readmission rates (23.1% vs 18.7%), and higher hospitalization and 90-day postdischarge costs ($64 711 vs $61 060). Compared with those with NVL, Medicare beneficiaries with SVL had 4% longer length of stay (estimated ratio, 1.04; 95% CI, 1.01-1.07; P = .02), 22% higher odds of readmission (odds ratio, 1.22; 95% CI, 1.06-1.41; P = .007), and 12% higher costs (estimated cost ratio, 1.12; 95% CI, 1.06-1.18; P < .001). Similar findings were obtained for those with commercial health insurance. When these findings were extrapolated to hospitalizations of patients with vision loss nationwide, an estimated amount of more than $500 million in additional costs annually were spent caring for these patients.

Conclusions and Relevance

These findings suggest that opportunities for improving outcomes and reducing costs exist in addressing patients' vision loss and concomitant functional difficulties during hospitalization and thereafter.

Demonstration of technical feasibility and viability of whole eye transplantation in a rodent model

INTRODUCTION

Whole eye transplantation (WET) holds promise for vision restoration in devastating/disabling visual loss (congenital or traumatic) not amenable to surgical or neuroprosthetic treatment options. The eye includes multiple tissues with distinct embryonic lineage and differential antigenicity. Anatomically and immunologically, the eye is unique due to its avascular (cornea) and highly vascular (retina) components. Our goal was to establish technical feasibility, demonstrate graft viability, and evaluate histologic changes in ocular tissues/adnexae in a novel experimental model of WET that included globe, adnexal, optic nerve (ON), and periorbital soft tissues.

METHODS

Outbred Sprague-Dawley rats (n = 5) received heterotopic vascularized WET from donors. Each WET included the entire globe, adnexa, ON, and periorbital soft tissues supplied by the common carotid artery and external jugular vein. Viability and perfusion were confirmed by clinical examination, angiography and magnetic resonance imaging (MRI). Globe, adnexal, and periorbital tissues were analyzed for histopathologic changes, and the ON was examined for neuro-regeneration at study endpoint (30 days) or Banff Grade 3 rejection in the periorbital skin (whichever was earlier).

RESULTS

Gross examination confirmed transplant viability and corneal transparency. Average operative duration was 64.0 ± 5.8 min. Average ischemia time was 26.0 ± 4.2 min. MRI revealed loss of globe volume by 36.0 ± 2.8% after transplantation. Histopathology of globe and adnexal tissues showed unique and differential patterns of inflammatory cell infiltration. The ON revealed a neurodegeneration pattern.

CONCLUSION

The present study is the first in the literature to establish an experimental model of WET. This model holds significant potential in investigating mechanistic pathways, monitoring strategies or developing management approaches involving ocular viability, immune rejection, and ON regeneration after WET.

Healthcare use among persons with visual impairment: Difference-in-difference estimations

BACKGROUND

Studies on healthcare service use among persons with visual impairments in countries with different healthcare systems are needed for drawing global inferences.

OBJECTIVE

The goal was to assess the impact of visual impairment on healthcare service use.

METHODS

A retrospective cohort study on health insurance claims data from the National Health Insurance System (NHIS) was conducted. All data from 2002 to 2013 for 2206 and 8824 persons with and without visual impairments, respectively, were extracted and aggregated monthly, generating a total of 162,876 and 568,459 person-month observations, respectively. The dependent variable was total expenditures. Difference-in-difference estimations based on a multivariate log-normal random-effect regression were employed.

RESULTS

Persons with visual impairments spent 5.7% and 6.8% more on total healthcare expenditures per month and outpatient healthcare expenditures, respectively, than those without visual impairments, after adjusting for pre-impairment differences. Further results revealed an upward trend in expenditures, particularly among those with visual impairments; this increase was the highest during the year prior impairment (approximately 32% and 21% more for total and outpatient services, respectively, compared with baseline). Inpatient healthcare expenditures showed a similar increase (by approximately 26%) during the year prior impairment compared with baseline; however, the magnitude dropped to approximately 14% and 6% during the 1st and 2nd years of impairment, respectively. Conversely, the annual pattern of expenditure increase was parallel over time for persons without visual impairments, regardless of service.

CONCLUSION

Our findings suggest a need for health management and effective care use, particularly the year prior to visual impairment onset.

[Health-related quality of life after implantation of a keratoprosthesis with biological haptic]

BACKGROUND

Many studies report comparatively good long-term results among patients with keratoprostheses with biological haptic. However, overall costs are correspondingly high. A clear cost-benefit relationship is therefore desirable.

OBJECTIVE

This study investigates health-related quality of life after implantation of a keratoprosthesis with biological haptic.

MATERIALS AND METHODS

We present a retrospective analysis of medical data of 25 patients treated between 1996 and 2006 at the Department of Ophthalmology, University Hospital Homburg/Saar and the Klinikum Offenburg. Health-related quality of life was assessed by means of a questionnaire based on validated instruments, with particular emphasis on physical symptoms, mental health, functional limitations, and social interactions.

RESULTS

At a patient age of 49.8 ± 15.7 years (minimum-maximum: 19-78 years; 6 female, 19 male), the mean duration of corneal blindness was 13.8 ± 13.1 years (minimum-maximum: 1-47 years). Changes in visual acuity and subjective satisfaction were statistically significant (p <0.001). Quality of life (on a scale of 1 to 6: median 2) at the time "before the onset of eye disease" and ≥15 months after surgery were identical. Patients with a postoperative visual acuity ≤0.1 (n =11) also showed a statistically significant (p =0.016) benefit in this context.

CONCLUSION

The expenditures and costs of keratoprosthetics can be justified by an improvement in the health-related quality of life of the persons concerned. Even a postoperative visual acuity of ≤0.1 correlates with a statistically significant improvement in the subjective quality of life of these patients.

Controlled release of photoswitch drugs by degradable polymer microspheres

BACKGROUND

QAQ (quaternary ammonium-azobenzene-quaternary ammonium) and DENAQ (diethylamine-azobenzene-quaternary ammonium) are synthetic photoswitch compounds that change conformation in response to light, altering current flow through voltage-gated ion channels in neurons. These compounds are drug candidates for restoring light sensitivity in degenerative blinding diseases, such as age-related macular degeneration (AMD).

PURPOSE

However, these photoswitch compounds are cleared from the eye within several days, they must be administered through repeated intravitreal injections. Therefore, we are investigating local, sustained delivery formulations to constantly replenish these molecules and have the potential to restore sight.

METHODS

Here, we encapsulate QAQ and DENAQ into several molecular weights of poly(lactic-co-glycolic) acid (PLGA) through an emulsion technique to assess the viability of delivering the compounds in their therapeutic window over many weeks. We characterize the loading efficiency, release profile and bioactivity of the compounds after encapsulation.

RESULTS

A very small burst release was observed for all of the formulations with the majority being delivered over the following two months. The lowest molecular weight PLGA led to the highest loading and most linear delivery for both QAQ and DENAQ. Bioactivity was retained for both compounds across the polymers.

CONCLUSION

These results present encapsulation into polymers by emulsion as a viable option for controlled release of QAQ and DENAQ.

Vaccinating Italian infants with a new multicomponent vaccine (Bexsero®) against meningococcal B disease: A cost-effectiveness analysis

The European Medicines Agency has approved a multicomponent serogroup B meningococcal vaccine (Bexsero®) for use in individuals of 2 months of age and older. A cost-effectiveness analysis (CEA) from the societal and Italian National Health Service perspectives was performed in order to evaluate the impact of vaccinating Italian infants less than 1 y of age with Bexsero®, as opposed to non-vaccination. The analysis was carried out by means of Excel Version 2011 and the TreeAge Pro® software Version 2012. Two basal scenarios that differed in terms of disease incidence (official and estimated data to correct for underreporting) were considered. In the basal scenarios, we considered a primary vaccination cycle with 4 doses (at 2, 4, 6 and 12 months of age) and 1 booster dose at the age of 11 y, the societal perspective and no cost for death. Sensitivity analyses were carried out in which crucial variables were changed over probable ranges. In Italy, on the basis of official data on disease incidence, vaccination with Bexsero® could prevent 82.97 cases and 5.61 deaths in each birth cohort, while these figures proved to be three times higher on considering the estimated incidence. The results of the CEA showed that the Incremental Cost Effectiveness Ratio (ICER) per QALY was €109,762 in the basal scenario if official data on disease incidence are considered and €26,599 if estimated data are considered. The tornado diagram indicated that the most influential factor on ICER was the incidence of disease. The probability of sequelae, the cost of the vaccine and vaccine effectiveness also had an impact. Our results suggest that vaccinating infants in Italy with Bexsero® has the ability to significantly reduce meningococcal disease and, if the probable underestimation of disease incidence is considered, routine vaccination is advisable.

The economic burden of visual impairment and blindness: a systematic review

OBJECTIVES

Visual impairment and blindness (VI&B) cause a considerable and increasing economic burden in all high-income countries due to population ageing. Thus, we conducted a review of the literature to better understand all relevant costs associated with VI&B and to develop a multiperspective overview.

DESIGN

Systematic review: Two independent reviewers searched the relevant literature and assessed the studies for inclusion and exclusion criteria as well as quality.

ELIGIBILITY CRITERIA FOR INCLUDED STUDIES

Interventional, non-interventional and cost of illness studies, conducted prior to May 2012, investigating direct and indirect costs as well as intangible effects related to visual impairment and blindness were included.

METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement approach to identify the relevant studies. A meta-analysis was not performed due to the variability of the reported cost categories and varying definition of visual impairment.

RESULTS

A total of 22 studies were included. Hospitalisation and use of medical services around diagnosis and treatment at the onset of VI&B were the largest contributor to direct medical costs. The mean annual expenses per patient were found to be US$ purchasing power parities (PPP) 12 175-14 029 for moderate visual impairment, US$ PPP 13 154-16 321 for severe visual impairment and US$ PPP 14 882-24 180 for blindness, almost twofold the costs for non-blind patients. Informal care was the major contributor to other direct costs, with the time spent by caregivers increasing from 5.8 h/week (or US$ PPP 263) for persons with vision >20/32 up to 94.1 h/week (or US$ PPP 55 062) for persons with vision ≤20/250. VI&B caused considerable indirect costs due to productivity losses, premature mortality and dead-weight losses.

CONCLUSIONS

VI&B cause a considerable economic burden for affected persons, their caregivers and society at large, which increases with the degree of visual impairment. This review provides insight into the distribution of costs and the economic impact of VI&B.

Analysis of Excess Direct Medical Costs of Vision Impairment in Taiwan

OBJECTIVES

To quantify the annual excess direct medical costs of vision impairment from the perspective of the Bureau of National Health Insurance in Taiwan and to examine whether the costs vary by severity and duration of vision impairment.

METHODS

A retrospective matched cohort analysis was conducted by using data from the Longitudinal Health Insurance Databases between January 1, 2000, and December 31, 2008. All patients newly diagnosed with vision impairment were categorized as having moderate vision loss, severe vision loss, or blindness. Each patient with vision impairment was matched to one randomly selected patient with normal vision by age (±1 year) and sex. At each level of vision impairment, generalized linear models were used to quantify the total annual excess costs and component costs incurred in the first and second years.

RESULTS

Vision impairment was associated with significantly higher crude excess medical costs. At each level of vision impairment, the total crude medical costs were attributable to different resource utilization and dominated by non-eye-related medical care. After adjusting for covariates, the first-year annual excess costs increased with escalating severity of vision impairment: New Taiwan (NT) $9894 for moderate vision loss, NT $22,760 for severe vision loss, and NT $52,687 for blindness. Similarly, the second-year adjusted costs were estimated as NT $3477, NT $19,532, and NT $28,272 for moderate vision loss, severe vision loss, and blindness, respectively.

CONCLUSIONS

Consistent with Western countries, vision impairment is associated with significantly increased health care costs in Taiwan. The excess costs seem to increase with severity of vision impairment and decrease in the second year.

Healthcare charges in patients with glaucoma who undergo laser trabeculoplasty

INTRODUCTION

The objective of this study was to assess the impact of laser trabeculoplasty (LTP) on healthcare charges in patients with primary open-angle glaucoma (POAG).

METHODS

Using a managed care database (PharMetrics; Watertown, MA, USA), we formed a case-control group nested within a POAG cohort (n=72,412) formed using International Classification of Disease, Ninth Edition (ICD-9) coding data. Cases (n=1145) had LTP (Current Procedural Terminology code: 65855) with ≥1 year of continuous enrollment both prior to, and following LTP index date in PharMetrics from 1998-2005. Using the date of LTP as the index date, controls (n=2290) without LTP were matched to cases on gender, age, and index year in a 2:1 ratio. Cases and controls had ≥6 months of continuous enrollment in PharMetrics prior to receiving a diagnosis of POAG (ICD-9 code: 365.11). One-year total and ophthalmology healthcare charges were calculated in the year pre- and post-index date (excluding charges for LTP at the index date). Conditional logistic regression models and multiple linear regression models determined the impact of LTP on healthcare charges, while controlling for glaucoma duration and other key covariates.

RESULTS

While the mean age of cases (60.1±13.1 years) and controls (60.3±13.6 years) was similar (P=0.5589), cases had more comorbid systemic conditions (P<0.05) and underwent more cataract surgery in the year after index date (4.4% vs. 2.1%; P=0.002). In the year after index date, ophthalmology-related charges increased by $1364 for cases vs. $30 for controls (P=0.0003). Total healthcare charges increased by $5084 for cases and $1594 for controls in the year after index date (P=0.0085). Cases and controls experienced similar increases in ophthalmology-related pharmacy charges from the year pre- to the year post-index date ($26 vs. $43, P=0.385). In both logistic regression and linear regression models, which adjusted for several covariates, performing LTP was associated with increased total healthcare and ophthalmology-related charges.

CONCLUSION

Among patients with POAG in this study, performing LTP was associated with increased total and ophthalmology-related healthcare charges, while ophthalmology pharmacy charges did not decline.

Healthcare charges in patients who transition from ocular hypertension to primary open-angle glaucoma based on ophthalmic coding data

INTRODUCTION

The purpose of this research was to assess the impact of transition from ocular hypertension (OHT) to primary open-angle glaucoma (POAG) on healthcare charges.

METHODS

A case-control group was identified using PharMetrics claims database (1998-2005). Cases (n=1055) had a transition from OHT to POAG based on International Classification of Disease, Ninth Edition coding (ICD-9=365.11). Controls (n=2110) retained an ICD-9 code for OHT (ICD-9=365.04) and were matched to cases (2:1) on gender, age, diagnosis year, and follow-up time post-diagnosis. The index date marked the transition for cases and a date of similar duration after OHT diagnosis for controls. Conditional logistic regression and multiple linear regression models determined the impact of transitioning on healthcare charges.

RESULTS

Cases had significantly higher increases in ophthalmology-related charges ($797 vs. -$385, P<0.0001) but similar total healthcare charges ($1689 vs. $1386, P=0.8277) from the year pre- to year post-index date when compared with controls. After adjusting for key covariates, cases were 1.56 times (95% CI: 1.33-1.82) more likely to have increased total charges and 5.26 times (95% CI: 4.27-6.47) more likely to have increased ophthalmology-related charges compared with controls. In multiple linear regression analyses, cases experienced $48 (55%) higher increases in ophthalmology-related charges from the year pre- to year post-index date compared with controls ($85 vs. $37, respectively; P<0.0001).

CONCLUSION

Patients with a transition from OHT to POAG based on ICD-9 coding had higher ophthalmology-related charges the year after transition compared with patients who retained a code for OHT. Prevention of this transition could result in healthcare resource savings.

Strategy for developing an evidence-based transdisciplinary vision rehabilitation team approach to treating vision impairment

BACKGROUND

Many individuals with vision impairment experience significant loss of the ability to perform daily living activities, which often results in a further decline and loss of quality of life. Appropriate rehabilitation of the population with vision impairment has the potential to both improve individual abilities for health and personal management as well as maximize utilization of available health care resources.

METHODS

The case for an evidence-based model for the vision rehabilitation health care team as a medical rehabilitation program is presented. The recommended strategy has 3 main components: development of a consensus team clinical practice guideline leading to a future evidence-based team guideline for vision rehabilitation; evaluation and measurement of the knowledge, attitudes, and practices of the involved vision rehabilitation professionals before and after implementation of the new paradigm; and measurement of outcomes that estimate the effects of the proposed paradigm on patient care by measuring both the improvement in visual ability of the patient and the economic impact of the model on optometric practice.

CONCLUSIONS

Development of a state-of-the-art evidence-based transdisciplinary team model guideline will facilitate improvement in the quality of life of individuals with diseases that result in chronic vision impairment.