Pharmacoeconomics 2006; 24 (2): 207-209COMMENTARY 1170-7690/06/0002-0207/$39.95/0

© 2006 Adis Data Information BV. All rights reserved.

How Much is the Cost ofVisual ImpairmentCaveat Emptor

Catherine Meads and Chris Hyde

Department of Public Health and Epidemiology, University of Birmingham, Edgbaston,Birmingham, England

Lafuma et al.’s[1] paper in this issue of amounted to £6455 (range £1375–17 100) in thePharmacoEconomics on the cost of visual impair- first year and £6295 (range £1325–16 800) in subse-ment is the latest in a series of cost estimates carried quent years.out recently. The paper is clearly of great potential To our knowledge, there have been two pub-value in attempting to derive and compare non-med- lished cohort studies of the costs of blindness inical costs of visual impairment across four major elderly persons with age-related macular degenera-European countries: France, Italy, Germany and the tion: one Australian[3] and one French,[4] both veryUK. This, however, assumes that the costs are gen- different care systems than that in the UK. Theerally accurate, and we explore this in the context of Australian paper[3] was published in 2000 (year ofthe UK in particular. costing 1998–9) and produced a very similar point

estimate but narrower sensitivity analysis intervalsIn this respect, our National Institute for Healthto the NICE estimates for elderly persons withand Clinical Excellence (NICE) technology apprais-age-related macular degeneration: £6183 with aal report on photodynamic therapy for age-relatedrange of £4104–9476. They also estimated the directmacular degeneration[2] provides a starting point. Incost of blindness for a school student with congeni-order to assess verteporfin (Visudyne®,1 Novartistal vision impairment to be £6714 (rangeOphthalmics AG, Switzerland), the then only cur-£2150–10 019), and a working-aged person withrently licensed photodynamic therapy agent for thisdiabetic retinopathy to be £7452 (rangeindication, it was considered necessary to assess the£4071–11 249) [converted using 1999–2000 ex-costs averted should blindness be prevented. Sincechange rates, inflated to 2002 using the Retail Pricesthere were no primary studies in the UK that fol-Index]. The French paper[4] was published in 2003lowed a cohort of elderly people with failing eye-(year of costing 2000) and gave results for an oldersight and recorded the costs incurred, the best strate-person with age-related macular degeneration ofgy was felt to be to estimate the costs and probabili-£5312 with a 95% confidence interval of 4183, 6442ties of various outcomes (blindness registration,(€ conversion rate 0.689 February 2005). This in-low-vision aids, low-vision rehabilitation, housingcluded all socioeconomic (medical and non-medi-and council tax benefits, social security, blind per-cal) costs of the condition.son’s tax allowance, care of depression, hip replace-

ment, community care and residential care) and In addition, in 2003, there was also an extensivecarry out extensive sensitivity analysis. The result- review of cost estimates and cost-of-illness calcula-ing annual cost estimate (to December 2000) tions[5] (cost estimates for 2002–3) that put the annu-

1 The use of trade names is for product identification purposes only and does not imply endorsement.

208 Meads & Hyde

al cost of an elderly person with visual impairment the National Coordinating Centre for Health Tech-nology Assessment). The Australian paper[3] does(blind and partially sighted) at £4980 (low estimatenot mention sponsorship and the French paper[4]£2602, high estimate £7067). The annual cost of aacknowledged Novartis Pharma S.A. In addition,child with visual impairment was estimated to bethe extensive review of cost estimates[5] was written£1123 (£627–1750) and for a working-age personby Ethical Solutions Ltd, a British medical commu-was £19 841 (£13 356–21 900). These were non-nications company. This is worthy of note becausetreatment-related cost estimates and included disa-increasing use is being made of medical communi-bility living allowance, attendance allowance, car-cation and public relation services by the drug com-ers’ allowance, vision rehabilitation, income sup-panies in a strategy known as ‘third-party tech-port, productivity losses, community care, homenique’,[8] whereby a drug company uses a third partycare and residential care. So there is reasonableto put forward its message, without the apparentconsistency between cost estimates prior to the cur-‘spin’ of the drug company itself. Medical commu-rent publication that estimates the annual non-medi-nication is increasingly ‘wooing’ patient groups.cal cost of visual impairment in visually impaired

persons of all ages to be £9421 (€ conversion rate Although qualitatively similar to some of the0.689 February 2005). By way of comparison, if we external influences on the other estimates, quantita-use the most similar cost estimate listed above,[5]

tively, the level of sponsorship in the study byand assume a population distribution of registered Lafuma et al.[1] is apparently different. The paperblind and partially sighted persons of 3% aged 0–17 acknowledges that it was supported by an un-years, 19% aged 18–64 years and 78% aged >65 restricted grant from Alcon France and that oneyears,[6] then we can calculate an annual cost of author is an Alcon employee.visual impairment in all ages to be £6456 (range

Alcon Research Ltd is currently conducting a£4586–9725).

clinical trial of a product called anecortave acetate,[9]

This poses the question of why the estimate by which is intended to stop the progression of dry age-Lafuma et al.[1] is different. Differences in who is related macular degeneration to wet age-relatedbeing costed, setting, country, time and costing ap- macular degeneration, a much more aggressive formproach (top-down vs bottom-up) may all be impor- of the condition. NICE reviews guidance on tech-tant factors generally, but do not seem particularly nology appraisals every 3 years if change is antici-potent explanatory variables in this example. Pos- pated,[10] and the guidance on photodynamic therapysibilities that could account for some of the variation for age-related macular degeneration is due to beseen here include differences in cost drivers consid- updated in September 2006.[11] It seems likely, ifered when taking a societal perspective. There were other reviews are a model,[12] that the scope of thisdifferences across all four studies but little to sug- review will be widened to other treatments for age-gest why one had such a higher cost estimate than related macular degeneration, such as anecortavethe other three. In terms of method, dealing with acetate.uncertainty is critical, but this is not acknowledged Another question is why might high estimates ofor explored at all by Lafuma et al.[1]

cost of blindness be helpful to manufacturers of newIn our view, a further possible difference that products to treat age-related macular degeneration?

requires careful exploration is sponsorship. This is The Novartis industry submission to NICE for thebecause independently produced estimates of cost technology appraisal of photodynamic therapy foreffectiveness ratios apparently tend to be higher than age-related macular degeneration included a re-those sponsored by the manufacturer, when assess- markably low estimate of the cost of blindness.[13]

ing the same product.[7] Of the existing four cost This was surprising in that, if the cost of the condi-estimates in this example, the first was for NICE tion is high, the lower the cost utility of treatment(UK government-supported research mediated by becomes if all other parameters are kept steady. As

© 2006 Adis Data Information BV. All rights reserved. Pharmacoeconomics 2006; 24 (2)

How Much is the Cost of Visual Impairment? Caveat Emptor 209

5. Ethical Strategies Ltd. The costs of blindness: an analysis of thedrug companies have an interest in reducing the costcosts of visual impairment and blindness in the United King-utility of their products to approximately £30 000dom. Reading: Guide Dogs for the Blind Association, 2003per QALY,[14] it would be expected that a high cost

6. Department of Health. Registered blind and partially sightedof blindness would be of benefit to any drug compa-people year ending 31 March 2003. London: Office for Nation-

ny marketing a treatment to prevent blindness. Thisal Statistics, 2003

was pointed out after the NICE technology appraisal7. Miners AH, Garau M, Fidan D, et al. Comparing estimates of

of photodynamic therapy for age-related macularcost effectiveness submitted to the National Institute for

degeneration.[12]Clinical Excellence (NICE) by different organisations: retro-

spective study. BMJ 2005; 330 (7482): 65-8There are numerous ways in which evidence can8. Burton B, Rowell A. Unhealthy spin. BMJ 2003; 326: 1205-7be promoted in support of products ahead of tech-9. Alcon Incorporated. Protocol C-02-60 information for potentialnology appraisals by NICE.[15] Until there is an

participants about a phase III clinical trial to evaluate anindependent British prospective costing study, theinvestigational treatment for stopping the progression of drycost of blindness to use within a technology apprais-AMD to wet AMD [online]. Available from URL: http://al for NICE will be the subject of continued debate.www.alconlabs.com/us/eo/clinicalstudies/ [Accessed 2005

Feb 21]

10. National Institute for Clinical Excellence. Guide to the technol-Acknowledgementsogy appraisal process. London: NICE, 2004

11. National Institute for Clinical Excellence. Guidance on the useNo sources of funding were used to assist in the prepara- of photodynamic therapy for age-related macular degenera-

tion of this commentary. The authors have no conflicts oftion. London: NICE, 2004

interest that are directly relevant to the content of this com-12. Hill R, Bagust A, Bakhai A, et al. Coronary artery stents: a rapidmentary.

systematic review and economic evaluation. Health Technol

Assess 2004; 8 (35): 1-242

13. Meads C, Hyde C. What is the cost of blindness? Br JReferences Ophthalmol 2003; 87: 1201-4

1. Lafuma A, Brezin A, Lopatriello S, et al. Evaluation of non- 14. Raftery J. NICE: faster access to modern treatments? Analysismedical costs associated with visual impairment in four Euro- of guidance on health technologies. BMJ 2001; 323: 1300-3pean countries: France, Italy, Germany and the UK.

15. Burls A, Sandercock J. How to make a compelling submissionPharmacoeconomics 2006; 24 (2): 193-205to NICE: tips for sponsoring organisations. BMJ 2003; 327:2. Meads C, Salas C, Roberts T, et al. Clinical effectiveness and

cost utility of photodynamic therapy for wet age-related macu- 1446-8lar degeneration: a systematic review and economic evalua-tion. Health Technol Assess 2003; 7 (9): 1-98

3. Wright SE, Keeffe JE, Thies LS. Direct costs of blindness in Correspondence and offprints: Dr Catherine Meads, Depart-Australia. Clin Experiment Ophthalmol 2000; 28: 140-2 ment of Public Health and Epidemiology, University of

4. Bonastre J, Le Pen C, Soubrane G, et al. The burden of age- Birmingham, Edgbaston, Birmingham, B15 2TT, England.related macular degeneration. Pharmacoeconomics 2003; 21(3): 181-90 E-mail: C.A.Meads@bham.ac.uk

© 2006 Adis Data Information BV. All rights reserved. Pharmacoeconomics 2006; 24 (2)