Surveillance for ocular hypertension: an evidence synthesis and economic evaluation.
Open accessAbstract
OBJECTIVES: To determine effective and efficient monitoring criteria for ocular hypertension [raised intraocular pressure (IOP)] through (i) identification and validation of glaucoma risk prediction models; and (ii) development of models to determine optimal surveillance pathways. DESIGN: A discrete event simulation economic modelling evaluation. Data from systematic reviews of risk prediction models and agreement between tonometers, secondary analyses of existing datasets (to validate identified risk models and determine optimal monitoring criteria) and public preferences were used to structure and populate the economic model. SETTING: Primary and secondary care. PARTICIPANTS: Adults with ocular hypertension (IOP > 21 mmHg) and the public (surveillance preferences). INTERVENTIONS: We compared five pathways: two based on National Institute for Health and Clinical Excellence (NICE) guidelines with monitoring interval and treatment depending on initial risk stratification, 'NICE intensive' (4-monthly to annual monitoring) and 'NICE conservative' (6-monthly to biennial monitoring); two pathways, differing in location (hospital and community), with monitoring biennially and treatment initiated for a ≥ 6% 5-year glaucoma risk; and a 'treat all' pathway involving treatment with a prostaglandin analogue if IOP > 21 mmHg and IOP measured annually in the community. MAIN OUTCOME MEASURES: Glaucoma cases detected; tonometer agreement; public preferences; costs; willingness to pay and quality-adjusted life-years (QALYs). RESULTS: The best available glaucoma risk prediction model estimated the 5-year risk based on age and ocular predictors (IOP, central corneal thickness, optic nerve damage and index of visual field status). Taking the average of two IOP readings, by tonometry, true change was detected at two years. Sizeable measurement variability was noted between tonometers. There was a general public preference for monitoring; good communication and understanding of the process predicted service value. 'Treat all' was the least costly and 'NICE intensive' the most costly pathway. Biennial monitoring reduced the number of cases of glaucoma conversion compared with a 'treat all' pathway and provided more QALYs, but the incremental cost-effectiveness ratio (ICER) was considerably more than £30,000. The 'NICE intensive' pathway also avoided glaucoma conversion, but NICE-based pathways were either dominated (more costly and less effective) by biennial hospital monitoring or had a ICERs > £30,000. Results were not sensitive to the risk threshold for initiating surveillance but were sensitive to the risk threshold for initiating treatment, NHS costs and treatment adherence. LIMITATIONS: Optimal monitoring intervals were based on IOP data. There were insufficient data to determine the optimal frequency of measurement of the visual field or optic nerve head for identification of glaucoma. The economic modelling took a 20-year time horizon which may be insufficient to capture long-term benefits. Sensitivity analyses may not fully capture the uncertainty surrounding parameter estimates. CONCLUSIONS: For confirmed ocular hypertension, findings suggest that there is no clear benefit from intensive monitoring. Consideration of the patient experience is important. A cohort study is recommended to provide data to refine the glaucoma risk prediction model, determine the optimum type and frequency of serial glaucoma tests and estimate costs and patient preferences for monitoring and treatment. FUNDING: The National Institute for Health Research Health Technology Assessment Programme.
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There were four further cost-utility analyses that used economic modelling rather than empirical methods, and two cost-consequence analyses.
“There were also four further CUAs that used economic modelling rather than empirical methods [8–10, 34], and two cost-consequence analyses [16, 35].”
From Use of health economic evaluation in the implementation and improvement science fields—a systematic literature review (2019) · cites this paper as [9]
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- Authors
- Burr, J., Botello-Pinzon, P., Takwoingi, Y., Hernández, R., Vazquez-Montes, M., Elders, A., Asaoka, R., Banister, K., van der Schoot, J., Fraser, C., King, A., Lemij, H., Sanders, R., Vernon, S., Tuulonen, A., Kotecha, A., Glasziou, P., Garway-Heath, D., Crabb, D., Vale, L., Azuara-Blanco, A., Perera, R., Ryan, M., Deeks, J., & Cook, J.
- Affiliations
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
- University of Aberdeen (GB)
- University of Birmingham (GB)
- University of Oxford (GB)
- Moorfields Eye Hospital NHS Foundation Trust (GB)
- Hospital Universitario Son Dureta (ES)
- Rotterdam Eye Hospital (NL)
- Queen Margaret Hospital (GB)
- Tampere University Hospital (FI)
- City, University of London (GB)
- ORCID
- Venue
- Health Technology Assessment
- Published
- 2012-06
- Volume
- 16
- Issue
- 29
- Pages
- 1-271, iii
- ISSN
- 1366-5278 (ISSN-L)
- 2046-4924
- PMC
- PMC4781499
- OpenAlex
- W1992417415
- Cited by
- 180
- References
- 397
- Citations by year
- 2026: 2 · 2025: 2 · 2024: 6 · 2023: 3 · 2022: 4 · 2021: 8 · 2020: 10 · 2019: 14 · 2018: 12 · 2017: 28 · 2016: 15 · 2015: 19 · 2014: 31 · 2013: 20 · 2012: 6
- FWCI
- 3.74
- Type
- journal article
- Language
- en
- Open access
- diamond
- doi.org
- Locations
- Health Technology Assessment (publishedVersion, cc-by)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Research Portal (Queen's University Belfast) (publishedVersion, other-oa)
- Aberdeen University Research Archive (Aberdeen University) (submittedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- UCL Discovery (University College London) (submittedVersion)
- University of Birmingham Research Portal (University of Birmingham) (submittedVersion)
- St Andrews Research Repository (St Andrews Research Repository) (submittedVersion)
- Funders
- Health Technology Assessment programme (07/46/02)
- Topics
- Health Sciences › Medicine › Ophthalmology › Glaucoma and retinal disorders
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Health Systems, Economic Evaluations, Quality of Life
- Health Sciences › Medicine › Epidemiology › Ophthalmology and Visual Impairment Studies
- Keywords
- ocular hypertension, intraocular pressure, tonometer agreement, surveillance interval, cost-effectiveness, NICE guidelines, public preferences, quality-adjusted life years, central corneal thickness, optic nerve injury, discrete event simulation
- MeSH terms
- Age Factors, Antihypertensive Agents, Cost-Benefit Analysis, Glaucoma, Open-Angle, Humans, Intraocular Pressure, Mass Screening, Models, Theoretical, Ocular Hypertension, Cohort Studies, Randomized Controlled Trials as Topic, Risk Assessment, Quality-Adjusted Life Years, Administration, Ophthalmic
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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