Takaisin

Glaukoomahoidon vaikuttavuus ja kustannusvaikuttavuus

Näytönastekatsaukset
Anja Tuulonen
11.8.2014

Näytön aste: D

Vaikka lääke-, laser- ja leikkaushoidot laskevat silmänpainetta ja vähentävät rakenteellisten ja toiminnallisten vaurioiden etenemisriskiä, hoitojen suora vaikutus näkövammaisuuden estämiseksi puuttuu, ja eri hoitomuotojen keskinäiset vaikuttavuuserot ja niiden potilaille tärkeiden hoitotulosten parantaminen ovat epäselviä.

Julkaistujen terveystaloustieteellisten simulaatiomallien mukaan glaukooman hoito olisi kustannusvaikuttavaa Yhdysvalloissa, Englannissa, Hollannissa ja Kiinassa verrattuna hoitamatta jättämiseen. Sen sijaan okulaarisen hypertension hoidon aloituskynnystä simuloivien mallien tulokset poikkeavat toisistaan riippuen maasta ja käytetyistä estimaateista glaukooman syntyä ajatellen.

Kommentti: Luotettavaa ja ”realistista” tietoa satunnaistetuista diagnostisista ja hoitotutkimuksista tavanomaisilla potilailla ei ole toistaiseksi julkaistu. Kaikissa simulaatiotutkimuksissa on siksi jouduttu käyttämään satunnaistetuissa tutkimuksissa julkaistuja kliinisiä tietoja, jotka eivät vastaa arkipäivän glaukooman hoitoa (esimerkiksi tiukat mukaanotto ja poissukukriteerit sekä tiheät kontrollit). Satunnaistetuissa tutkimuksissa sekä potilaiden hoitomyöntyvyys että ammattilaisten hoitoprotokollan noudattaminen ovat parempia kuin jokapäiväisessä hoitotyössä. Lisäksi tulokset on raportoitu vain toisesta silmästä eikä aina ole raportoitu, onko kyseessä potilaan parempi vai huonompi silmä. Koska tiedot sekä glaukooman aiheuttamasta näkövammaisuudesta että hoitojen vaikutuksesta sen estämiseksi ovat puutteellisia, julkaistuissa simulaatiomalleissa on käytetty toisistaan poikkeavia estimaatteja. Myös tietoa eri glaukooma-asteiden vaikutuksesta elämänlaatuun (utiliteetti) on hyvin niukasti.

Systemaattinen katsaus «Boland MV, Ervin AM, Friedman DS ym. Comparative e...»1

Systematic review searched for systematic reviews published by March 2011 as well primary studies without imposed language, sample size, or date restrictions up to 30 July 2012.

  • Treatments currently used for OAG, including medical, laser, and incisional surgery were examined in studies with participants aged ≥ 40 years who had primary or suspected OAG.
  • Evidence from additional primary studies that were published after the date of the last search conducted for systematic reviews.
  • The risk of bias, consistency, directness, and precision of the body of evidence was assessed.
  • The search found 11 258 publications, of which 379 were eligible. Also 169 systematic reviews were identified, of which 23 remained eligible for inclusion after screening. These systematic reviews also included all but 86 of the primary studies identified.
  • Because of appreciable variability in interventions, follow-up intervals, or assessments of outcomes, the focus was on qualitative rather than quantitative synthesis.
  • No systematic reviews of medical or surgical interventions for OAG were identified directly addressing visual impairment. Primary studies that met inclusion criteria were identified. However, none were of sufficient duration or size to identify outcomes that plausibly could be related to visual impairment due to glaucoma
  • Tutkimuksen laatu: tasokas
  • Sovellettavuus suomalaiseen väestöön: heikko

Katsaus «Tuulonen A. Economic considerations of the diagnos...»2

Non-systematic review of the literature

  • PubMed by October 2010 with key words Glaucoma and cost*
  • There is uncertainty whether to treat none, some or all patients with ocular hypertension. When treated, the conclusions for cost-effectiveness of different interventions are not congruent.
  • It is likely that the blindness rates in modeling studies have different estimates.
  • Tutkimuksen laatu: kelvollinen
  • Sovellettavuus suomalaiseen väestöön: kohtalainen

Simulaatiomalli «Li EY, Tham CC, Chi SC ym. Cost-effectiveness of t...»3

An economic simulation model determining the cost-effectiveness of treating NTG with IOP lowering therapy to prevent progressive visual field loss.

  • Transitional probabilities were derived from the Collaborative Normal Tension Glaucoma Study and cost data obtained from the literature and the Medicare fee schedule.
  • The extra cost of treating all patients with NTG over a 10-year period in the US was $34,225 per QALY, patients with disc hemorrhage US $24,350, migraine US $25,533, and females US $27,000 per QALY.
  • The cost-effectiveness of treating all NTG patients was sensitive to cost fluctuation of medications, choice of utility score associated with disease progression, and insensitive to cost of consultations and laser/surgery
  • Tutkimuksen laatu: kelvollinen
  • Sovellettavuus suomalaiseen väestöön: heikko

Systemaattinen katsaus ja simulaatiomalli «Burr JM, Botello-Pinzon P, Takwoingi Y ym. Surveil...»4

The UK Health Technology Assessment compared five alternative surveillance and treatment pathways in OHT.

  • The two most intensive pathways were based on the NICE guidelines (check-ups from every 4-12 -month to 6-24 -month intervals depending on initial risk), two further pathways followed biennial follow-up schemes differing in location (surveillance either in hospital or in primary care), and in the fifth ‘Treat all’ pathway, all IOPs > 21 mmHg were treated with prostaglandins. In ‘Treat all’ pathway, IOP was measured annually in community optometry with referral to a hospital only if IOP reduction was <15 %.
  • The results of the model indicated no clear benefit from intensive monitoring in OHT. ‘Treat all’ was the least and ‘NICE intensive’ was the most costly pathway.
  • Compared to 'Treat all' –strategy, however, the pathway with 2-year check ups in an eye hospital (and treatment with > 5 % glaucoma risk in 5 years) reduced the incidence of conversion to glaucoma and provided more QALYs. However, simultaneously this pathway cost considerably more - above the limit of the society’s willingness to pay in the UK.
  • For the cost-benefit analysis the biennial hospital pathway was the only pathway relative to ‘no surveillance’ that had a positive net benefit.
  • The results of the UK model were sensitive treatment adherence. Due to sparse evidence, the UK model (based on expert opinion) assumed adherence of 50 % in 'Treat all' pathway and 75 % in the other four monitoring pathways.
  • Tutkimuksen laatu: kelvollinen
  • Sovellettavuus suomalaiseen väestöön: kohtalainen

Systemaattisia katsauksia ja simulaatiomalleja (Hollanti) «van Gestel A. Glaucoma management. Economic evalua...»5

An economic simulation model in Holland (built on systematic evaluation of literature)

  • The results suggested that treating all OHT patients with IOP > 21 mmHg would be cost saving compared to watchful waiting – even if 43 % of the simulated untreated OHT patients never converted to glaucoma in their entire lifetime.
  • Non-adherence to the medication was not considered in the model. It was assumed that including adherence would have a small impact of the outcomes but would have unnecessarily increased the complexity of the model.
  • In eyes with manifest glaucoma, in lieu of 'guessing' the initial target pressure and redefining it according to rate of progression, the model suggested to aim at a standard IOP < 15 mmHg in all glaucoma patients - even if it the model indicated that 72 % would need direct combination therapy and 46 % would require glaucoma surgery.
  • According to the model, these simplified strategies would decrease demand for intensive monitoring.
  • Tutkimuksen laatu: kelvollinen
  • Sovellettavuus suomalaiseen väestöön: kohtalainen

Kirjallisuutta

  1. Boland MV, Ervin AM, Friedman DS ym. Comparative effectiveness of treatments for open-angle glaucoma: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 2013;158:271-9 «PMID: 23420235»PubMed
  2. Tuulonen A. Economic considerations of the diagnosis and management for glaucoma in the developed world. Curr Opin Ophthalmol 2011;22:102-9 «PMID: 21192264»PubMed
  3. Li EY, Tham CC, Chi SC ym. Cost-effectiveness of treating normal tension glaucoma. Invest Ophthalmol Vis Sci 2013;54:3394-9 «PMID: 23599342»PubMed
  4. Burr JM, Botello-Pinzon P, Takwoingi Y ym. Surveillance for ocular hypertension: an evidence synthesis and economic evaluation. Health Technol Assess 2012;16:1-271, iii-iv «PMID: 22687263»PubMed
  5. van Gestel A. Glaucoma management. Economic evaluations based on a patient level simulation model. Ipskamp Drukkers, Enschede, Holland, 2012. ISBN 978-94-6191-403-3