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Could the use of microstents be cost-effective and save money for patients and health care systems compared with medications alone?
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There is not an answer, yet, to this question
Minimally invasive glaucoma surgery includes an ever-increasing number of procedures and devices (Trabectome, iStent, CyPass, Xen, Hydrus, to mention a few) targeted for mild to moderate glaucoma with the potential advantages of decreasing glaucoma medication requirements and avoiding the sight-threatening complications of trabeculectomy. A frequently asked question is, are MIGS cost-effective? It is very difficult to answer this question. Cost-effective compared with what? Medication or trabeculectomy? Cost-effective for whom? Governments, insurance companies, the patient or all of the aforementioned together?
With the landscape of MIGS continually evolving in terms of both devices and the next generation of earlier MIGS, an overarching statement is simply not possible. This, coupled with limited long-term studies on efficacy and complications, especially when considering the disease glaucoma, which is a disease of years and not months, makes it next to impossible to provide an evidence-based response to this important question. Nonetheless, with the current health care focus on value-based outcomes, this question is increasingly important, and it behooves physicians to include a cost analysis as an outcome in studies of new technology.
Yvonne Buys, MD, FRCSC, is a professor, Department of Ophthalmology and Vision Science, University of Toronto. Disclosure: Buys reports no relevant financial disclosures.
Adherence will play a key role in the evaluation of cost-effectiveness
Over the past decade, MIGS procedures have been used by many glaucoma and cataract surgeons in patients with early to moderate glaucoma. However, studies looking at the cost-effectiveness of these procedures are very few, mainly because there are insufficient long-term data available. To my knowledge, none of these studies draws a direct comparison between MIGS and glaucoma medications.
Adherence is a critical aspect for the success of glaucoma therapy and will play an important role in deciding whether MIGS procedures are cost-effective. Glaucoma is a chronic disease that is well known to have a low adherence rate, and many patients react with adverse events to locally applied medications. Reducing the number and frequency of eye drops after an intervention could probably help to improve adherence rate. On the other hand, MIGS requires regular, frequent and careful monitoring of the patient in the follow-up to detect signs of progression, which may occur despite a reduction in IOP. It is crucial for the patient to be aware that glaucoma is not cured by surgery and progression may occur despite a successful operation.
We need carefully planned long-term studies to assess whether MIGS are cost-effective and can reduce the overall costs of lifelong treatment for patients, health care systems and the community at large. Short-term cost-effectiveness is obviously limited by the cost of surgery and implants, but the long-term balance is yet unknown.
Frances Meier-Gibbons, MD, an OSN Europe Edition Board Member, is medical director of Eye Center Rapperswil, Switzerland. Disclosure: Meier-Gibbons reports no relevant financial disclosures.