A cost-effectiveness analysis of a health education programme for elderly persons with age-related macular degeneration: A longitudinal study

Cost-effectiveness of basic vision rehabilitation (The basic VRS-effect study): study protocol for a randomised controlled trial

PURPOSE

To investigate the cost-effectiveness of a basic vision rehabilitation service (basic-VRS) in Portugal. We designed a parallel group, randomised controlled trial whose aim is to compare the effects and costs of 'usual low vision care' with a 'basic-VRS intervention' on self-reported visual ability and other psychosocial and health-related quality-of-life outcomes.

METHODS

The trial will recruit participants that meet the following inclusion criteria: (1) visual acuity between 0.4-1.0 logMAR in the better-seeing eye, (2) cause of vision loss is diabetic retinopathy or age-related macular degeneration, (3) 18 years or older and iv) live in the community (not in nursing homes or other type of institution). Participants will be randomised to one of the study arms consisting of immediate intervention and delayed intervention. The delayed intervention group will receive 'usual care' or no intervention in the first 12 weeks. Visual acuity, contrast sensitivity and retinal structure will be assessed during the study.

RESULTS

The primary outcome measure is visual ability, which will be evaluated with the Massof Activity Inventory, we expect that the intervention will raise the overall person measure or visual ability. Reading, health-related quality-of-life, anxiety and depression and social support will be also assessed. The analysis will be undertaken on an intention-to-treat basis. A cost-effectiveness analysis will be performed to provide information about the cost per unit of utility. To evaluate the cost-effectiveness of the intervention we will adopt the perspective of the healthcare system.

CONCLUSION

This study will provide additional evidence about the effects of basic-VRS on self-reported visual ability. Findings from this study should also contribute to better planning of low vision provision and, consequently, may contribute to reduce barriers to basic-VRS.

Low vision rehabilitation for better quality of life in visually impaired adults

BACKGROUND

Low vision rehabilitation aims to optimise the use of residual vision after severe vision loss, but also aims to teach skills in order to improve visual functioning in daily life. Other aims include helping people to adapt to permanent vision loss and improving psychosocial functioning. These skills promote independence and active participation in society. Low vision rehabilitation should ultimately improve quality of life (QOL) for people who have visual impairment.

OBJECTIVES

To assess the effectiveness of low vision rehabilitation interventions on health-related QOL (HRQOL), vision-related QOL (VRQOL) or visual functioning and other closely related patient-reported outcomes in visually impaired adults.

SEARCH METHODS

We searched relevant electronic databases and trials registers up to 18 September 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) investigating HRQOL, VRQOL and related outcomes of adults, with an irreversible visual impairment (World Health Organization criteria). We included studies that compared rehabilitation interventions with active or inactive control.

DATA COLLECTION AND ANALYSIS

We used standard methods expected by Cochrane. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 44 studies (73 reports) conducted in North America, Australia, Europe and Asia. Considering the clinical diversity of low vision rehabilitation interventions, the studies were categorised into four groups of related intervention types (and by comparator): (1) psychological therapies and/or group programmes, (2) methods of enhancing vision, (3) multidisciplinary rehabilitation programmes, (4) other programmes. Comparators were no care or waiting list as an inactive control group, usual care or other active control group. Participants included in the reported studies were mainly older adults with visual impairment or blindness, often as a result of age-related macular degeneration (AMD). Study settings were often hospitals or low vision rehabilitation services. Effects were measured at the short-term (six months or less) in most studies. Not all studies reported on funding, but those who did were supported by public or non-profit funders (N = 31), except for two studies. Compared to inactive comparators, we found very low-certainty evidence of no beneficial effects on HRQOL that was imprecisely estimated for psychological therapies and/or group programmes (SMD 0.26, 95% CI -0.28 to 0.80; participants = 183; studies = 1) and an imprecise estimate suggesting little or no effect of multidisciplinary rehabilitation programmes (SMD -0.08, 95% CI -0.37 to 0.21; participants = 183; studies = 2; I2 = 0%); no data were available for methods of enhancing vision or other programmes. Regarding VRQOL, we found low- or very low-certainty evidence of imprecisely estimated benefit with psychological therapies and/or group programmes (SMD -0.23, 95% CI -0.53 to 0.08; studies = 2; I2 = 24%) and methods of enhancing vision (SMD -0.19, 95% CI -0.54 to 0.15; participants = 262; studies = 5; I2 = 34%). Two studies using multidisciplinary rehabilitation programmes showed beneficial but inconsistent results, of which one study, which was at low risk of bias and used intensive rehabilitation, recorded a very large and significant effect (SMD: -1.64, 95% CI -2.05 to -1.24), and the other a small and uncertain effect (SMD -0.42, 95%: -0.90 to 0.07). Compared to active comparators, we found very low-certainty evidence of small or no beneficial effects on HRQOL that were imprecisely estimated with psychological therapies and/or group programmes including no difference (SMD -0.09, 95% CI -0.39 to 0.20; participants = 600; studies = 4; I2 = 67%). We also found very low-certainty evidence of small or no beneficial effects with methods of enhancing vision, that were imprecisely estimated (SMD -0.09, 95% CI -0.28 to 0.09; participants = 443; studies = 2; I2 = 0%) and multidisciplinary rehabilitation programmes (SMD -0.10, 95% CI -0.31 to 0.12; participants = 375; studies = 2; I2 = 0%). Concerning VRQOL, low-certainty evidence of small or no beneficial effects that were imprecisely estimated, was found with psychological therapies and/or group programmes (SMD -0.11, 95% CI -0.24 to 0.01; participants = 1245; studies = 7; I2 = 19%) and moderate-certainty evidence of small effects with methods of enhancing vision (SMD -0.24, 95% CI -0.40 to -0.08; participants = 660; studies = 7; I2 = 16%). No additional benefit was found with multidisciplinary rehabilitation programmes (SMD 0.01, 95% CI -0.18 to 0.20; participants = 464; studies = 3; I2 = 0%; low-certainty evidence). Among secondary outcomes, very low-certainty evidence of a significant and large, but imprecisely estimated benefit on self-efficacy or self-esteem was found for psychological therapies and/or group programmes versus waiting list or no care (SMD -0.85, 95% CI -1.48 to -0.22; participants = 456; studies = 5; I2 = 91%). In addition, very low-certainty evidence of a significant and large estimated benefit on depression was found for psychological therapies and/or group programmes versus waiting list or no care (SMD -1.23, 95% CI -2.18 to -0.28; participants = 456; studies = 5; I2 = 94%), and moderate-certainty evidence of a small benefit versus usual care (SMD -0.14, 95% CI -0.25 to -0.04; participants = 1334; studies = 9; I2 = 0%). ln the few studies in which (serious) adverse events were reported, these seemed unrelated to low vision rehabilitation.

AUTHORS' CONCLUSIONS

In this Cochrane Review, no evidence of benefit was found of diverse types of low vision rehabilitation interventions on HRQOL. We found low- and moderate-certainty evidence, respectively, of a small benefit on VRQOL in studies comparing psychological therapies or methods for enhancing vision with active comparators. The type of rehabilitation varied among studies, even within intervention groups, but benefits were detected even if compared to active control groups. Studies were conducted on adults with visual impairment mainly of older age, living in high-income countries and often having AMD. Most of the included studies on low vision rehabilitation had a short follow-up, Despite these limitations, the consistent direction of the effects in this review towards benefit justifies further research activities of better methodological quality including longer maintenance effects and costs of several types of low vision rehabilitation. Research on the working mechanisms of components of rehabilitation interventions in different settings, including low-income countries, is also needed.

A cost-effectiveness study of ICT training among the visually impaired in the Netherlands

BACKGROUND

Due to the ageing population, the number of visually impaired people in the Netherlands will increase. To ensure the future availability of services in rehabilitative eye care, we aim to assess the cost-effectiveness of information and communication technology (ICT) training among visually impaired adults from a societal perspective, using primary data from two large rehabilitative eye care providers in the Netherlands.

METHODS

Participants were asked to fill in a questionnaire, which used six different instruments at three different time points: pre training, post training and three months post training. We investigated whether the participants' quality of life and well-being improved after the training and whether this improvement persisted three months post training. Economic evaluation was conducted by comparing costs and outcomes before and after training. Quality of life and well-being were derived from the EQ-5D and ICECAP-O, respectively. Costs for productivity losses and medical consumption were obtained from the questionnaires. Information regarding the costs of training sessions was provided by the providers.

RESULTS

Thirty-eight participants filled in all three questionnaires. The mean age at baseline was 63 years (SD = 16). The effect of ICT training on ICT skills and participants' well-being was positive and persisted three months after the last training session. Assuming these effects remain constant for 10 years, this would result in an incremental cost-effectiveness ratio (ICER) of € 11,000 per quality-adjusted life-year (QALY) and € 8000 per year of well-being gained, when only the costs of ICT training are considered. When the total costs of medical consumption are included, the ICER increases to € 17,000 per QALY gained and € 12,000 per year of well-being gained. Furthermore, when the willingness-to-pay threshold is € 20,000 per year of well-being, the probability that ICT training will be cost-effective is 75% (91% when including only the costs of ICT training).

CONCLUSION

Our study suggests that ICT training among the visually impaired is cost-effective when the effects of ICT training on well-being persist for several years. However, further research involving a larger sample and incorporating long-term effects should be conducted.

Economic evaluation of stepped-care versus usual care for depression and anxiety in older adults with vision impairment: randomized controlled trial

BACKGROUND

A stepped-care program was found effective in preventing depressive and anxiety disorders in older adults with vision impairment. However, before a decision can be made about implementation, the cost-effectiveness of this program should be investigated. Therefore, we aimed to compare the cost-effectiveness of stepped-care versus usual care within low vision rehabilitation.

METHODS

An economic evaluation from a societal perspective was performed alongside a multicenter randomized controlled trial. Data were collected by masked assessors during 24 months. Included were 265 older adults with vision impairment and subthreshold depression and/or anxiety. They were randomly assigned to stepped-care plus usual care (n = 131) or usual care alone (n = 134). Stepped-care comprised 1) watchful waiting, 2) guided self-help based on cognitive behavioral therapy, 3) problem solving treatment, and 4) referral to a general practitioner. Costs were based on direct healthcare costs and indirect non-healthcare costs. Main outcome measures were quality-adjusted life years (QALYs) and the cumulative incidence of major depressive, dysthymic and/or anxiety disorders. Secondary outcomes were symptoms of depression and anxiety.

RESULTS

Based on intention-to-treat, significant differences were found in the incidence of depressive/anxiety disorders (mean difference 0.17; 95% CI 0.06 to 0.29) and symptoms of anxiety (mean difference 1.43, 95% CI 0.10 to 2.77) in favor of stepped-care versus usual care; no significant difference was found for QALYs and symptoms of depression. Societal costs were non-significantly lower in the stepped-care group compared with the usual care group (mean difference: -€877; 95% confidence interval (CI): -8039 to 5489). Cost-effectiveness acceptability curves showed that the probability of cost-effectiveness was 95% or more at a willingness-to-pay of €33,000 per disorder prevented. The probability that stepped-care was cost-effective compared to usual care was 59% or more for a ceiling ratio of 0 €/QALY and increased to 65% at 20000 €/QALY.

CONCLUSIONS

This economic evaluation shows that stepped-care is dominant to usual care, with a probability of around 60%, due to its clinical superiority and its modest cost savings. However, it depends on the willingness-to-pay of decision makers whether or not stepped-care is considered cost-effective compared with usual care.

TRIAL REGISTRATION

identifier: NTR3296 , date: 13-02-2012.

A randomised controlled trial of a self-management programme for low vision implemented in low vision rehabilitation services

OBJECTIVE

To investigate the effectiveness of a low vision self-management programme (LVSMP) in older adults.

METHODS

Participants (n=153) were existing clients of a national low vision rehabilitation organisation randomly allocated to usual services (n=60) or usual services plus LVSMP (n=93). The LVSMP was an 8-week group programme facilitated by low vision counsellors. The primary outcome was vision-specific quality of life (QoL) measured using the Impact of Vision Impairment (IVI) questionnaire. Secondary outcomes emotional well-being, self-efficacy and adaptation to vision loss were measured using the depression, anxiety, stress scale (DASS), general self-efficacy scale (GSES), and short form adaptation to age-related vision loss scale (AVL12).

RESULTS

At one and six month follow-up assessments, no significant between-group differences were found for vision-specific QoL, emotional well-being, adaptation to vision loss or self-efficacy (p>0.05). Univariate and multivariate analyses revealed no impact of the intervention on outcome measures.

CONCLUSIONS

In contrast to previous work, our study found limited benefit of a LVSM programme on QoL for older adults accessing low vision services.

PRACTICE IMPLICATIONS

When implementing self-management programmes in low vision rehabilitation settings, issues of client interest, divergence of need, programme accessibility and fidelity of intervention delivery need to be addressed.

One-year outcome of frailty indicators and activities of daily living following the randomised controlled trial: "Continuum of care for frail older people"

Background

The intervention; “Continuum of Care for Frail Older People”, was designed to create an integrated continuum of care from the hospital emergency department through the hospital and back to the older person’s own home. The aim of this study is to evaluate the effects of the intervention on functional ability in terms of activities of daily living (ADL).

Methods

The study is a non-blinded controlled trial with participants randomised to either the intervention group or a control group with follow-ups at three-, six- and 12 months. The intervention involved collaboration between a nurse with geriatric competence at the emergency department, the hospital wards and a multi-professional team for care and rehabilitation of the older people in the municipality with a case manager as the hub. Older people who sought care at the emergency department at Sahlgrenska University Hospital/Mölndal and who were discharged to their own homes in the municipality of Mölndal, Sweden were asked to participate. Inclusion criteria were age 80 and older or 65 to 79 with at least one chronic disease and dependent in at least one ADL. Analyses were made on the basis of the intention-to-treat principle. Outcome measures were ADL independence and eight frailty indicators. These were analysed, using Chi-square and odds ratio (OR).

Results

A total of 161 participated in the study, 76 persons allocated to the control group and 85 to the intervention group were analysed throughout the study. There were no significant differences between the groups with regards to change in frailty compared to baseline at any follow-up. At both the three- and twelve-month follow-ups the intervention group had doubled their odds for improved ADL independence compared to the control (OR 2.37, 95% CI; 1.20 – 4.68) and (2.04, 95% CI; 1.03 – 4.06) respectively. At six months the intervention group had halved their odds for decreased ADL independence (OR 0.52, 95% CI; 0.27 – 0.98) compared to the control group.

Conclusions

The intervention has the potential to reduce dependency in ADLs, a valuable benefit both for the individual and for society.

Trial registration

ClinicalTrials.gov: NCT01260493

The psychological challenge of late-life vision impairment: concepts, findings, and practical implications

The intention is to summarize the body of evidence speaking to the psychological challenges faced by visually impaired older adults, as well as their coping efforts. This evidence is substantiated by a rich set of concepts, theories, and empirical findings that have accumulated under the umbrella of age-related psychoophthalmology (APO). I introduce the field of APO and continue with a discussion of important concepts and theories for a better understanding of adaptational processes in visually impaired older adults. I then summarize the most relevant and most recent data from four areas: (1) everyday competence, (2) cognitive functioning, (3) social functioning, and (4) subjective well-being-related outcomes, depression, and adaptational processes. Thereafter, major insights related to the current state-of-the art psychosocial interventions with visuallyimpaired older adults are reviewed. I close with the need that the public health community should become more aware of and address the psychosocial needs of visually impaired older adults.

Low vision, ADL and hearing assistive device use among older persons with visual impairments

Assistive devices (AD) have long played an important role in occupational therapy practice as a way of enabling activities of daily living (ADL), but no studies to date have investigated the use of low vision AD among older persons with age-related macular degeneration (AMD) as well as devices for ADL performance and hearing. The purpose of this study was to describe AD users and to investigate the association of AD and ADL. A health promotion program versus an individual program was investigated within a randomised design. The study was based on data from 131 participants, 28-months after intervention. Data on prescribed ADs were examined through medical records and registers. The participants in the health promotion program used low vision AD in combination with ADL devices to a higher degree, whereas participants in the individual program used just optical AD. Greater use of non-optical AD within the individual program and greater use of ADL devices within the health promotion program was weakly associated with higher level of ADL dependence. There was no significant association between the number of low vision AD and having a decreased, a maintained or improved level of dependence at 28 months.

Occupational therapy in diabetic care-areas of need perceived by older adults with diabetes

This study explored the perception of older adults with diabetes regarding the areas of service considered helpful to their daily activities and routines. A survey questionnaire was designed and given to 52 community-dwelling older adults with diabetes. Results showed that cholesterol control, managing blood sugar, foot care, fatigue management and pacing, and pain management/reduction were the areas of most concern that deserve services. The findings suggest that, in providing holistic client-centered interventions to individuals with diabetes, occupational therapists need to be able to prioritize clients' concerns and help them incorporate diabetes management into their routines and lifestyle.

A randomized controlled trial of a health-promotion programme and its effect on ADL dependence and self-reported health problems for the elderly visually impaired

BACKGROUND

Ageing with visual impairment is associated with a high degree of disability whereby age-related macular degeneration in particular causes dependence in activities of daily living (ADL) even at an early stage.

AIMS

To compare an activity-based, health-promotion programme with an individual programme, targeting the elderly with age-related macular degeneration concerning the effect on the development of dependence in ADL, general health, and self-reported health problems.

METHODS

A randomized controlled study with a 28-month follow-up. A total of 229 persons were randomized to the study and 131 (57%) were followed up (individual intervention n=69, health-promotion programme n=62) at 28-month.

RESULTS

The health-promotion group maintained their ADL level despite a significant decrease in visual acuity, while the individual intervention group increased its dependence in ADL. General health systematically dropped to a lower level in both groups, but participants from the health-promotion group reported fewer health problems. There were significantly fewer reports of tiredness and dizziness among the health-promotion participants.

CONCLUSION

The health-promotion programme seems to have slowed down the disablement process among elderly with decreased vision by enabling them to maintain their ADL level and by reducing self-reported health problems for at least 28 months following intervention.

[Quality of life by limited vision in old age: the example of age-related macula degeneration]

Age-related macula degeneration (AMD) is accompanied by considerable consequences regarding the psychosocial quality of life. A considerable body of research literature now indicates, for instance, an increased rate of depression and substantial loss of everyday capabilities in AMD patients. However, inter-individual differences are large and part of the explanation lies in differences in the ability to cope with and detach oneself from aims in life. The negative impact of AMD on the qualify of life is associated with a need for psychosocial support, but this need is barely met at present. A series of studies nevertheless supports the view that successful intervention is possible even with very old patients. In this respect the problems at present have less to do with recognition than with application and implementation.

Age-related macular degeneration: the costs to society and the patient

PURPOSE OF REVIEW

The current literature was reviewed to assess the patient and societal costs associated with age-related macular degeneration (ARMD).

RECENT FINDINGS

An increasing number of studies discuss the growing direct ophthalmologic, direct nonophthalmologic, and indirect costs associated with ARMD. Most reports, however, focus on only one of these aspects. The prevalence of this debilitating disease will increase as life expectancy increases.

SUMMARY

ARMD continues to be a major public health problem in developed countries. The treatment and management of exudative ARMD are changing dramatically. These therapies will likely become a more significant portion of the overall healthcare burden of ARMD. To date, no comprehensive study exists that attempts to calculate the total cost of ARMD.