Predicted patient demand for a new delivery system for glaucoma medicine

Eliciting preferences in glaucoma management-a systematic review of stated-preference studies

BACKGROUND

In most cases, glaucoma patients require long-term medical and/or surgical treatment. Preference studies investigate how different aspects of glaucoma management, such as health or process outcomes, are valued and herewith help stakeholders make care more responsive to patients' needs. As, to our knowledge, no overview of these studies is currently available, this study aims to systematically review and critically appraise these studies.

METHODS

A systematic literature review was conducted using keywords for stated-preference studies and glaucoma up to October 2021. Studies were included if they were original research and used a stated-preference methodology to investigate preferences in patients or healthcare professionals for different aspects of glaucoma management. Data were extracted and summarized. Furthermore, a quality appraisal of the included studies was performed using two validated checklists.

RESULTS

The search yielded 1214 articles after removal of duplicates. Of those, 11 studies fulfilled the inclusion criteria. Studies aimed to elicit preferences for glaucoma treatment (27%), glaucoma related health state valuation (36%), and services (36%) from the patient (91%) or ophthalmologists' perspective (9%). Altogether studies included 69 attributes. The majority of attributes were outcome related (62%), followed by process (32%) and cost attributes (6%). Outcome attributes (e.g., effectiveness) were most often of highest importance to the population.

CONCLUSIONS

This systematic review provides an up-to-date and critical review of stated-preference studies in the field of glaucoma, suggesting that patients have preferences and are willing to trade-off between characteristics, and revealed that outcome attributes are the most influential characteristics of glaucoma management.

Preferences for Enhanced Primary Care Services Among Older Individuals and Primary Care Physicians

OBJECTIVE

We aimed to identify the factors that are most important for community-dwelling older individuals (i.e., users) and primary care (PC) providers to enhance PC services.

METHODS

Discrete choice experiment surveys were administered to 747 individuals aged ≥ 60 years and 242 PC physicians in Singapore between December 2020 and August 2021. Participants were asked to choose between two hypothetical PC clinics and their current clinic. Latent class models were used to estimate the relative attribute importance (RAI) and to calculate the predicted uptake for enhanced PC services.

RESULTS

Based on the attributes and levels used in this study, the out-of-pocket cost (RAI: 47%) and types of services offered (RAI: 25%) were the most important attributes for users while working hours (RAI: 28%) and patient load (RAI: 25%) were the most important for providers. For out-of-pocket visit costs ranging from Singapore dollars (S)$100 to S$5, users' predicted uptake for enhanced PC services ranged from 46 to 84%. For daily patient loads ranging from 60 to 20 patients, providers' predicted uptake ranged from 64 to 91%, assuming their income remains unchanged.

CONCLUSIONS

Our study provides timely insights for the development of strategies to support the government's new health care initiative (HealthierSG), which places PC at the center of Singapore's healthcare system. The ability to choose their preferred clinic, low out-of-pocket costs and types of services offered (for users), and reasonable working conditions (for providers) were the key factors for users and providers to participate in enhanced PC services.

A Survey on Patients' Opinions of Alternative Drug Delivery Systems for the Treatment of Glaucoma in South-South Nigeria

PURPOSE

Despite the human ocular surface being easily accessible, ocular drug delivery can be challenging. When applied improperly, topical medications, the most popular first-line treatment used to treat glaucoma, can have a very brief contact time with the ocular surface and may not have the desired therapeutic impact. Drug delivery devices are gadgets that can address some of these problems. This study aims to determine patients' opinions on ocular drug delivery devices used in the treatment of primary open-angle glaucoma (POAG).

METHODS

A pretested interviewer-administered questionnaire was used in a cross-sectional study of 115 POAG patients recruited from outpatient clinics in two Nigerian tertiary health institutions. Participants were asked about their understanding and acceptance of five Ocular drug delivery systems (ODD), namely drug-emitting contact lenses (CL), punctual plugs, subconjunctival injections, intracameral implants, and trabecular meshwork micro-stents, for the treatment of POAG.

RESULTS

Sixty (52.2%) participants, whose average age was 50 ± 9.8 years, were men. Self-pay was used for eye health treatments by 65% of participants. Of the participants, 68.7% admitted to using eye drops on their own. 57% of people were said to take their glaucoma medications consistently. CL and subconjunctival implants were seen to be most acceptable according to 39% and 30% of participants, respectively. Major factors determining the acceptability of ODD for POAG treatment were observed to be cost and effectiveness.

CONCLUSION

Patients in our cohort who are being treated for POAG have a fairly positive attitude towards ODD. The prospective use of these devices for POAG treatment in Nigeria will depend on their efficacy and cost, as well as how ophthalmologists will weigh ODD options.

A Systematic Review of Discrete Choice Experiments and Conjoint Analysis on Genetic Testing

BACKGROUND

Although genetic testing has the potential to offer promising medical benefits, concerns regarding its potential negative impacts may influence its acceptance. Users and providers need to weigh the benefits, costs and potential harms before deciding whether to take up or recommend genetic testing. Attribute-based stated-preference methods, such as discrete choice experiment (DCE) or conjoint analysis, can help to quantify how individuals value different features of genetic testing.

OBJECTIVES

The aim of this paper was to conduct a systematic review of DCE and conjoint analysis studies on genetic testing, including genomic tests.

METHODS

A systematic search was conducted in seven databases: Web of Science, CINAHL Plus with Full Text (EBSCO), PsycINFO, PubMed, Embase, The Cochrane Library and SCOPUS. The search was conducted in February 2021 and was limited to English peer-reviewed articles published until the search date. The search keywords included relevant keywords such as 'genetic testing', 'genomic testing', 'pharmacogenetic testing', 'discrete choice experiment' and 'conjoint analysis'. Narrative synthesis of the studies was conducted on survey population, testing type, recruitment and data collection, survey development, questionnaire content, survey validity, analysis, outcomes and other design features.

RESULTS

Of the 292 articles retrieved, 38 full-text articles were included in this review. Nearly two-thirds of the studies were published since 2015 and all were conducted in high-income countries. Survey samples included patients, parents, general population and healthcare providers. The articles assessed preferences for pharmacogenetic testing (28.9%), predictive testing and diagnostic testing (18.4%), while only one (2.6%) study investigated preferences for carrier testing. The most common sampling method was convenience sampling (57.9%) and the majority recruited participants via web-enabled surveys (60.5%). Review of literature (84.6%), discussions with healthcare professionals (71.8%) and cognitive interviews (53.8%) were commonly used for attribute identification. A survey validity test was included in only one-quarter of the studies (28.2%). Cost attributes were the most studied attribute type (76.9%), followed by risk attributes (61.5%). Among those that reported relative attribute importance, attributes related to benefits were the most commonly reported attributes with the highest relative attribute importance. Preference heterogeneity was investigated in most studies by modelling, such as via mixed logit analysis (82.1%) and/or by using interaction effects with respondent characteristics (74.4%). Willingness to pay was the most commonly estimated outcome and was presented in about two-thirds (n = 25; 64.1%) of the studies.

CONCLUSION

With the continuous advancement in genetic technology resulting in expanding options for genetic testing and improvements in delivery methods, the application of genetic testing in clinical care is expected to rise. DCEs and conjoint analysis remain robust and useful methods to elicit preferences of potential stakeholders. This review serves as a summary for future researchers when designing similar studies.

Sustained-release drug delivery systems for the treatment of glaucoma

Glaucoma, a leading cause of irreversible blindness, affects more than 64 million people worldwide and is expected to grow in number due to the aging global population and enhanced methods of detection. Although topical therapies are often effective when used as prescribed, the drawbacks of current medical management methods include poor patient adherence, local and systemic side effects, and in some cases, limited therapeutic efficacy. Novel ocular drug delivery platforms promise to deliver differentiated drug formulations with targeted delivery leveraging patient-independent administration. Several platforms are in various stages of development with promising pre-clinical and clinical data. The Bimatoprost Sustained Release (SR) intracameral implant was approved in the United States in March of 2020, making it the first long-term injectable therapy available for the treatment of glaucoma. This review aims to provide an update on novel sustained release drug delivery systems that are available today as well as those that might be commercialized in coming years.

Effects of rosiglitazone/PHBV drug delivery system on postoperative fibrosis in rabbit glaucoma filtration surgery model

The aim of this study is to investigate the effects and toxicities of poly(3-hydroxybutyric acid-co-3-hydroxyvaleric acid) (PHBV)-loading rosiglitazone on preventing scar formation after glaucoma filtration surgery (GFS) in the rabbit model. Rosiglitazone/PHBV drug delivery system was prepared via electrospinning. Release behavior of RSG/PHBV membrane was evaluated by high-performance liquid chromatography. The different concentration membranes were implanted under the conjunctiva of the rabbit’s eyes (RSG/PHBV groups). Also, MMC-soaked sponges were placed under the conjunctiva of the eyes (positive group) for 3 min. Intraocular pressures and bleb features were then assessed for 4 weeks postoperative. Bleb sections were stained with HE, Masson’s trichrome and α smooth muscle action (αSMA) immunohistochemistry. The protein expression of collagen I, αSMA, and connective tissue growth factor in the bleb area were then quantified. The following results were observed: (1) the concentration of rosiglitazone would not affect the morphology of RSG/PHBV membrane. (2) RSG/PHBV membrane would effective and safety prevent the formation of fibrosis after GFS in the rabbit model. Implantation of RSG/PHBV membrane prevents scar formation after GFS. What’s more, it ameliorated toxicity to conjunctiva and cornea compared with the placement of MMC. The RSG/PHBV membrane would be a more effectivity and safer strategy than MMC.

Beyond cost-effectiveness: A five-step framework for appraising the value of health technologies in Asia-Pacific

Given resource constraints and the potential for increasingly high-cost, cost-effective medicines to become available, policymakers require strategies that go beyond cost-effectiveness when making resource allocation decisions. This manuscript presents a five-step framework that complements traditional health technology assessment (HTA) guidance documents that policymakers in Asia-Pacific and elsewhere may consider when setting up HTA guidelines and/or evaluating whether or not to subsidize a medicine or other health innovations. The framework recommends that subsidy decisions be based on five criteria: the relative burden of the condition as compared with other conditions (step 1), comparative and cost-effectiveness of the medicine (steps 2 and 3), the short-term impact on the budget (step 4), and other considerations including patient and societal preferences (step 5). Our approach, which is a complement to traditional HTA guidance documents, is not prescriptive but provides an evidence-based framework that HTA agencies in Asia-Pacific can follow as they aim to deliver value-based medicines to their constituents.

Miniaturization in Glaucoma Monitoring and Treatment: A Review of New Technologies That Require a Minimal Surgical Approach

In the management of glaucoma, recent and upcoming innovations have the potential to contribute to both the efficacy of intraocular pressure (IOP) monitoring and the number of available treatment options. These new devices and procedures have two things in common: they are part of the trend in medicine towards miniaturization, and they require a limited surgical procedure to become effective. This review focuses on the Eyemate (Argos) intraocular sensor, which offers a new way to reliably measure 24 h IOP, and on intraocular sustained release systems for pharmacological glaucoma therapy. It also briefly reflects on the miniature implants currently used in minimally invasive glaucoma surgery (MIGS).

Discrete Choice Experiments in Health Economics: Past, Present and Future

OBJECTIVES

Discrete choice experiments (DCEs) are increasingly advocated as a way to quantify preferences for health. However, increasing support does not necessarily result in increasing quality. Although specific reviews have been conducted in certain contexts, there exists no recent description of the general state of the science of health-related DCEs. The aim of this paper was to update prior reviews (1990-2012), to identify all health-related DCEs and to provide a description of trends, current practice and future challenges.

METHODS

A systematic literature review was conducted to identify health-related empirical DCEs published between 2013 and 2017. The search strategy and data extraction replicated prior reviews to allow the reporting of trends, although additional extraction fields were incorporated.

RESULTS

Of the 7877 abstracts generated, 301 studies met the inclusion criteria and underwent data extraction. In general, the total number of DCEs per year continued to increase, with broader areas of application and increased geographic scope. Studies reported using more sophisticated designs (e.g. D-efficient) with associated software (e.g. Ngene). The trend towards using more sophisticated econometric models also continued. However, many studies presented sophisticated methods with insufficient detail. Qualitative research methods continued to be a popular approach for identifying attributes and levels.

CONCLUSIONS

The use of empirical DCEs in health economics continues to grow. However, inadequate reporting of methodological details inhibits quality assessment. This may reduce decision-makers' confidence in results and their ability to act on the findings. How and when to integrate health-related DCE outcomes into decision-making remains an important area for future research.

Glaucoma - Next Generation Therapeutics: Impossible to Possible

The future of next generation therapeutics for glaucoma is strong. The recent approval of two novel intraocular pressure (IOP)-lowering drugs with distinct mechanisms of action is the first in over 20 years. However, these are still being administered as topical drops. Efforts are underway to increase patient compliance and greater therapeutic benefits with the development of sustained delivery technologies. Furthermore, innovations from biologics- and gene therapy-based therapeutics are being developed in the context of disease modification, which are expected to lead to more permanent therapies for patients. Neuroprotection, including the preservation of retinal ganglion cells (RGCs) and optic nerve is another area that is actively being explored for therapeutic options. With improvements in imaging technologies and determination of new surrogate clinical endpoints, the therapeutic potential for translation of neuroprotectants is coming close to clinical realization. This review summarizes the aforementioned topics and other related aspects.

The Role of Minimally Invasive Glaucoma Surgery Devices in the Management of Glaucoma

SIGNIFICANCE

Noncompliance is a problem affecting glaucoma patients. Approaches to improve adherence include the use of drug-delivery systems and safer forms of surgery. Minimally invasive glaucoma surgery (MIGS) has reduced complications, particularly in combination with cataract surgery, and with its good intraocular pressure (IOP) reduction may reduce or eliminate glaucoma medications.Glaucoma is a progressive disease and a leading cause of irreversible blindness. Elevated IOP is the most important risk factor, but effective medical management is dependent on patient adherence. This review summarizes the adherence problem in glaucoma and the efforts, including MIGS, to provide effective IOP control that is not dependent on patient compliance.The current understanding of patient adherence to pharmacological treatment of glaucoma is discussed including the challenges facing glaucoma patients. Historical approaches to providing IOP control in a sustained and reliable way are presented culminating in a review of the burgeoning use of MIGS devices.It is estimated that, in the United States, 27% of prescriptions written, across all medications, are not filled or are filled but not taken. For ocular hypotensive medications, even when filled, a large percentage (which varies widely by study) are not instilled as prescribed. To address this problem, methods for sustained drug delivery have been and continue to be developed, as well as surgical and laser approaches. Most recently, MIGS devices have gained popularity because of the ease of implantation during cataract surgery, favorable safety profile, and the possibility for effective and long-lasting IOP lowering, as well as the reduction or elimination of need for IOP-lowering medication.Poor adherence to treatment is relatively common among glaucoma patients and is associated with progression of disease. Recommending MIGS implantation during cataract surgery may offer optometrists a valuable treatment option in managing glaucoma patients, particularly where good adherence is in doubt.