Message from the Chair
Greg Hom, OD, MPH
I hope all of you had a wonderful spring!
I’d like to provide you with a quick update on the work being done by some hard-working members.
The Vision Care Section will be submitting two proposed policy statements to be considered by the Governing Council at the Annual Meeting in Washington, D.C., in November. One resolution seeks to increase awareness of the ocular health hazards of smoking tobacco. The other resolution advocates increasing involvement of eye care providers in emergency preparedness and response. Both statements are undergoing the review and revision process and we anticipate that they will survive hearings and be ratified at the Annual Meeting.
Since we’re on the subject of the Annual Meeting, be sure to register and book your hotel room at the APHA Web site: www.apha.org.
The Vision Care Section is constantly looking for ways to serve its members. Please feel free to contact me at firstname.lastname@example.org if you have any questions or comments. We are also in the early stages of other ways of engaging our members. Stay tuned for details!
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Message from the Newsletter Editor
Joan Stelmack OD, MPH
This newsletter includes a Message from the Chair highlighting Vision Section activities. The fall issue of the newsletter will provide further information on the Vision Care Section resolutions, activities and the Vision Care Program at the APHA Annual Meeting.
This issue of the newsletter includes two guest columns. The first column, written by Jeff Todd, describes a new report just released by Prevent Blindness America that estimated the costs associated with adult vision problems in the United States. This report follows a 2002 report by Prevent Blindness America estimating the prevalence of eye diseases on a state and national level.
The second column, written by Kevin Frick, PhD, provides an introduction to the use of economic analysis is health care. The article summarizes some of the terminology used in descriptions of these analyses and findings and examples of the different types of economic evaluations.
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New Report Highlights Increasing Burden of Adult Vision Problems in America
Prevent Blindness America recently released a new report estimating the costs associated with adult vision problems in the United States at $51.4 billion. The Economic Impact of Vision Problems: The Toll of Major Adult Eye Disorders, Visual Impairment, and Blindness on the U.S. Economy provides both the costs to the individual and their caregivers, and the impact on the U.S. economy of adult vision conditions including age-related macular degeneration, cataract, diabetic retinopathy, primary open-angle glaucoma, refractive error, visual impairment and blindness.
This report marks Phase III of a concerted effort by Prevent Blindness America to address the critical need for better eye health and to ensure that sufficient governmental resources are dedicated to the research, treatment and prevention of eye-related diseases. In 2002, in partnership with the National Eye Institute, Prevent Blindness America released the Vision Problems in the U.S. study detailing eye disease prevalence data on a national and state level. Following that report, the organization announced the Vision Problems Action Plan to effectively address the study results. This latter report was released in collaboration with the American Academy of Ophthalmology, the American Optometric Association, Lighthouse International, and the National Alliance for Eye and Vision Research.
The Economic Impact of Vision Problems brings to light the substantial effect vision problems have beyond physical and emotional implications by analyzing the considerable financial impact vision loss has on the individual, caregivers, the government and insurance premiums.
“These astounding numbers underscore the significant need to address the overall impact of vision problems on individuals, their families and our society," said Hugh R. Parry, President and CEO of Prevent Blindness America. “The goal of this report is to ensure our nation’s leaders understand the seriousness of America’s eye health and create a call to action to focus on treatment and prevention.”
Two teams of prominent health economists collaborated to produce the comprehensive report. They delved into public sources of data, teasing out the impact of vision problems on federal and state budgets, personal expenditures and health-related quality of life.
Kevin D. Frick, PhD, of The Johns Hopkins University Bloomberg School of Public Health and his team estimated the financial burden of visual impairment and blindness to the individual, caregivers, and other health care payers at $16 billion. Costs to the individual include medical care expenditures, informal care costs and health utility loss. Health utility loss refers to an evaluation of the quality of life in chronic medical conditions.
David B. Rein, PhD, of RTI International and his team, including researchers from the CDC, examined the burden of vision problems in American adults to the U.S. economy and determined the impact to be $35.4 billion; his figures reflect the cost of age-related macular degeneration, cataract, diabetic retinopathy, glaucoma, refractive error, visual impairment and blindness. Impact to the U.S. economy was determined through analysis of direct medical costs, other direct costs, such as nursing home care and government programs, and lost productivity.
Combining these costs, the total financial impact of major adult eye disorders, visual impairment, and blindness on the U.S. economy is $51.4 billion, which exceeds the total combined profits of the top two 2006 Fortune 500 companies, Exxon Mobil and Wal-Mart.
"As the baby boomer generation is aging, my research shows that the number of people in the United States with impaired vision -- including blindness -- could increase by at least 60 percent over the next three decades," Frick said. "It is a troubling reality that an increasing number of Americans are going to be faced with escalating costs due to vision loss unless we focus on prevention."
The report was officially released at a national vision symposium on April 18 in Washington, D.C., which brought together leading ophthalmic researchers and report authors, public health officials, advocacy organizations, caregivers and patients to discuss the important findings from the study.
In addition to presentations on the economic of vision loss, there were several panel discussions on the burden of vision loss on the patient, family and society; advances in treatment and care delivery; the impact of vision loss from the perspective of the professions; as well as perspectives from a patient and a family caregiver.
The APHA Vision Care Section was well-represented at the symposium. In addition to Dr. Frick, other VCS members included symposium organizers (Andrea Hays and Jeff Todd); and symposium speakers and moderators (Sandy Block, OD, MEd; R. Norman Bailey, OD, MPH; and Joan A. Stelmack, OD, MPH).
(A full copy of the report can be found at www.preventblindness.org/research/Impact_of_Vision_Problems.pdf)
The articles on which The Economic Impact of Vision Problems is based include:
Rein DB, Zhang P, Wirth KE, Lee PP, Hoerger TJ, McCall N, Klein R, Tielsch JM, Vijan S, Saaddine J. The economic burden of major adult visual disorders in the United States. Arch Ophthalmol 2006; 124(12):1754-1760.
Frick KD, Gower EW, Kempen JH, Wolff JL. Economic impact of visual impairment and blindness in the United States. Arch Ophthalmol 2007; 125(4):544-550.
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Economics and Vision Care
Economics has two branches that have become more distinct over the years. While the reader may immediately think of macroeconomics and microeconomics (which do need to be considered and which are quite distinct), I am referring instead to economic analysis and economic evaluation.
Economic analysis, particularly as it relates to health, is the use of economic theory to attempt to explain health-related behavior. It could be patient behavior, e.g. does insurance coverage lead to more appropriate use of optometric services? If insurance coverage does lead to better use of optometric services, is that the only barrier to the use of such services? The latter question is at the edge of health economics and health services research. It could be provider behavior, e.g. are there incentives that could be used to encourage optometrists to make better use of a referral network of low vision care providers? It could be organizational behavior — why does a hospital choose to offer a particular type of eye surgery? These are all interesting questions. These questions are not often studied using economic theory to explain behaviors. However, the economic study of the incentives that the market provides and the study whether these incentives lead to efficient use of resources is useful. Realistically, this is not necessarily what most people think of when they think about health economics. For an excellent primer on health economics, you might read A Health Economics Primer by Shirley Johnson-Lans.
Many people, when they hear the term economics, think, instead, of economic evaluation. Whereas economic analysis tries to explain observed behavior using economic theory, economic evaluation instead focuses on describing the relative costs and benefits of a particular health behavior, treatment or policy change. The terms used for economic evaluation can include cost analysis, cost-consequence analysis, cost-effectiveness analysis, cost-utility analysis, and cost-benefit analysis. Not only are the relative cost and benefits being compared, but usually the “incremental” relative costs and benefits are being compared. A cost analysis is just that, evaluating the costs. The key is to specify whose costs and what types of costs. The types of costs can include both “direct,” where money actually changes hands, and “indirect,” which is most often the value of time for individuals who spend their time obtaining an intervention.
The rest of this column will be used to explain incremental costs and benefits and to give a brief example of each type of economic evaluation. The term incremental costs and benefits implies that we are asking about extra costs and benefits. For example, if a local government has decided that it is definitely going to screen preschoolers for vision problems, it then must decide how to do that. It could ask “what is the cheapest way to make sure that all children are screened?” Alternatively, it could ask “what is the cheapest way to make sure that all cases of visual impairment are identified?” Either of these would actually be a cost-minimization analysis. This implies having a specific goal with more than one way of achieving that goal (or two approaches to implementing a policy that yield the same results) and comparing costs. Each of the questions above is somewhat shortsighted as the first pays no attention to what happens to the children after they have been screened. Further, the second question does not allow for the misidentification of any cases and will probably result in all children going for a gold standard exam that may not be feasible in terms of personnel available.
That leads to the other types of cost comparison analyses. A cost-consequence analysis simply describes the difference in costs and the difference in a set of consequences. This might be the appropriate approach for pediatric vision screening in which cases of amblyopia, strabismus, and refractive error may all be found and there is no obvious way to assign a relative weight to them. In this case, the costs and number of cases identified and referred for follow up would simply be described.
A cost-effectiveness analysis might be applied to glaucoma treatment. How many people are prevented from experiencing disabling visual field impairments by each of several different types of treatments? One might ask, in comparison to the least expensive alternative, how many extra cases are prevented at what extra cost as more expensive alternatives are chosen.
A cost-utility analysis translates the visual outcomes into effects on quality of life and mortality. The effects on quality of life and mortality when combined into a single measure are referred to as a quality adjusted life year. The question that is then raised is how much extra it costs to buy additional quality adjusted life years. Both the cost-effectiveness analysis and cost-utility analysis are comparable to assessing unit prices at a grocery store — how much does the orange juice cost per ounce? If you could buy the least expensive store brand that comes in a 48 ounce bottle but would prefer the name brand that comes in a 64 ounce bottle, how much extra do you pay per ounce for the larger bottle?
A cost-benefit analysis translates visual outcomes into a dollar amount. There are many different approaches to doing this translation. The key is that everything is expressed in dollars, and the dollar value of the benefit can then be compared directly with the dollar value of the costs. The analyst can describe whether the benefits are larger than the costs and the policy maker can include that consideration in the decision making process.
While economic evaluation is not the only tool that should be used as it is impossible to place an economic value on everything, e.g. fairness, this set of tools provides a potentially powerful set of results that can be used to guide policy discussion. There is a lot of economic evaluation being done in vision care today. When we have tools that can be very powerful, we must all take responsibility for their appropriate use. It is important for those of us with expertise in the area to be willing to share that expertise in the research and peer review process. It is important for those of us who have the expertise but who were not originally trained in eye care topics to learn about eye care as the best economic evaluations tend to be the result of productive collaboration among people with expertise in the many different areas of public health related to vision care (i.e. clinical, economic, epidemiological, etc.). It is important for those who weren’t originally trained in economics but who have the opportunity to collaborate on economic evaluations or use the results for policy making or writing guidelines to invest some time in understanding economics. For a readable introduction to economic evaluation, one might begin with Methods for the Economic Evaluation of Health Care Programmes by Michael Drummond and colleagues.
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