Challenges of glaucoma care – high volume, high quality, low cost

R eduction of intraocular pressure (IOP) has been shown beneficial in preventing glaucomatous progression in ocular hypertension (OHT) and manifest glaucoma. As treatment, however, does not ‘cure’ glaucoma nor lead to complete stop of deterioration, patients still keep becoming blind from glaucoma. As the rate of progression in treated patients is very variable, an attempt to segment the patients into ‘fast progressors’ and ‘usual ‘ patients seems logical – considering both burden of treatment to the patient and limited resources available in eye care. Therefore, in addition to measuring IOP, such segmentation with a function test has been considered a ‘must’, that is, a minimum level of care in several guidelines (e.g. Heijl 1997; Tuulonen et al. 2003; European Glaucoma Society 2008). Two articles in this issue of Acta Ophthalmologica deal with test frequency in glaucoma care (Heijl 2013; Linden et al. 2013). Based on a questionnaire to all providers of glaucoma care in 2005, the survey estimated that a quarter of visits (17–35%) during 1 week were related to glaucoma in Sweden (Linden et al. 2013). The lowest proportion of glaucoma visits (17%) was estimated in the southern part of the country in spite of the highest frequency of perimetry, possibly due to research activity in perimetry (Linden et al. 2013) as well productive process in which one person takes visual fields (VF) in 2–4 patients simultaneously (Tuulonen 2012). If comparable with one-year 2011 statistics in the South, the proportion of glaucoma visits seemed to have further decreased in Scania in 2007–2011 (Tuulonen 2012). Compared to the previous Swedish ‘once or twice per year’ recommendation of VF testing (Heijl 1997), the 2005 survey seemed to reveal underperformance in every-day clinics with fields taken every 2–3 years on an average – not to talk about the more recent recommendation of six fields during the first 2 years (Chauhan et al. 2008; Heijl et al. 2010). The true number of yearly VFs were, however, not reported. If the incidence of new treated patients per year in Sweden were similar to Denmark in 2002– 2007 (Olsen et al. 2013) and Finland in 2003 (Tuulonen et al. 2009), that is, 0.9 per 1000 inhabitants per year, as well as 60% of those on treatment had manifest glaucoma and 40% OHT (Hagman 2012), the number of patients requiring VFs in 2005 could have been around 110 000 in Sweden (e.g. two fields per year in new patients, once yearly in manifest glaucoma patients, and one field every 2 years in OHT). In 2011, with increase in population and glaucoma patients together with the new recommendations, would have meant about a 35% increase in yearly VFs in Sweden. These certainly very rough guesses obviously mean that at least simulations would be required to estimate resource use. Based on the Swedish 2005 survey, fundus images were estimated to be taken on an average every 8th year (Linden et al. 2013). The frequencies of field testing and imaging were the same as reported in 83 patients in Turku, Finland, during 11 years of follow-up (Hagman 2012). When compared with a higher spending city in Finland during the same time period in 1994–2006 (i.e. yearly VFs, images every 2 years, 28% higher medication costs, 46% higher testing and followup costs, 3 times more laser therapy and twice more surgery in Oulu than in Turku), the quality of life of patients between the two cities was not different. There was actually a statistically significant counter-intuitive difference in the early glaucoma group, that is, patients using more resources reported worse quality of life. Higher resource allocation as such may not always lead to measurable benefits to the patients or society in terms of less glaucoma-induced visual disability and ⁄or better quality of life. Registry data in 2002–2007 of Olsen et al. (2013) in this issue of Acta reported that drug costs in Denmark accounted for 57% of total costs, which is smaller compared with that of up to 73% in Finland in 2001–2006 (Hagman 2012). Although the populations in Denmark and Finland are the same (5.4 million inhabitants) as well as the incidence of new treated patients (Tuulonen et al. 2009; Olsen et al. 2013), Finland had 18 000 more treated patients in 2007 (32%) compared with the estimate of 56 000 presented for Denmark (Finnish Statistics on medicines 2007, Olsen et al. 2013). The fact that if and when more OHT patients are treated, both treatment and tests will have an effect on total and per-patient costs. It is a long-known reality that very different conclusions may result from the same evidence (Tuulonen 2005). Instead of treating different patients differently (as recommended by Heijl 2013), based also on systematic evaluation of literature, recent Dutch simulation model suggested that treating Acta Ophthalmologica 2013