bringing down the cost of glaucoma treatment with slt

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BRINGING DOWN THE COST OF
GLAUCOMA TREATMENT WITH SLT
E. Randy Craven, MD, Wilmer Eye Institute, Baltimore, USA
One of the biggest advantages of SLT is that, in addition to being
an effective approach for first-line glaucoma treatment, as adjunct
therapy with drugs, and as alternative therapy when drugs or surgery
fail, it has also been found to be a more economical approach when
compared to topical medications. Not only can SLT alleviate the
ongoing expense of medications for the patient, but it also
offers significant economic benefit for the wider
healthcare system.
| BRINGING DOWN THE COST OF GLAUCOMA TREATMENT WITH SLT |
With the increasing costs of healthcare in the United
States, there is currently a big push towards accountable
care costs. Health care providers and health plans
alike are trying to give the best care they can to their
patients at the most economical price. Patients too are
beginning to demand cheaper treatment alternatives.
This is equally true in the case of glaucoma, a long-term
chronic disease, in which treatment costs can escalate
for doctors, insurance plans, and patients.
Current estimates of the cost of glaucoma management
in the United States place this number at $2.5 billion
annually, of which $1.9 billion are in direct costs and
$600 million are in indirect costs.1 A major part of the
direct costs, between 38% to 52%, can be attributed
to glaucoma medication alone.2 Currently glaucoma
affects over 3 million individuals in the Unites States;3
however, this number is expected to rise considerably
in the coming years as the country’s population
ages.4 Worldwide, more than 79.6 million people are
expected to suffer from glaucoma by the year 2020.5
Consequently, the burden on the healthcare system from
glaucoma treatment is also expected to increase. To
that end, the time is ripe to identify more cost-effective
therapies in the treatment of glaucoma.
From Drugs to Lasers
Selective Laser Trabeculoplasty (SLT) has been proposed
as just such a therapy that can alleviate the costs of
glaucoma management while still providing effective
treatment. SLT, as the name suggests, selectively targets
pigmented trabecular meshwork (TM) cells without
causing thermal damage to non-pigmented structures.
The Glaucoma Laser Trial performed in 1995 and
published in the American Journal of Ophthalmology
showed that Laser Trabeculoplasty (LTP) is at least
as effective as medication as a primary therapy.6
Early studies with SLT have demonstrated that it can
safely and effectively reduce intraocular pressure
(IOP). For example, a prospective, non-randomized
study by Melamed, et al., published in the Archives of
Ophthalmology in 2003 showed that SLT decreased IOP
by 30% or 7.7 ± 3.5 mm Hg in 45 eyes of 31 patients
with open angle glaucoma or ocular hypertension.7
Furthermore, a recent prospective, randomized trial
by Katz, et al., published in the Journal of Glaucoma
comparing 360° SLT to prostaglandin analogs, the
mainstay medication for glaucoma treatment, showed
that the IOP lowering effects of the two treatments are
comparable.8,9
the long-term costs of SLT as compared to the use of
brand name and generic medications.10
the cost of additional topical medication that may be
Seider and colleagues calculated the cost of bilateral SLT
using the national average Medicare fee schedule and
found that SLT costs in the range of $600. This included
with SLT, such as transient uveitis and IOP spikes. Their
SLT: A New Standard in Glaucoma Treatment
necessary to manage minor side effects associated
findings suggest that SLT may prove more cost-effective
than medications in the long-run. In fact, by calculating
Table 1: Cost of Topical Glaucoma Medications and Break-Even Point of SLT
(Source: Seider MI, Keenan JD, Han Y. Cost of selective laser trabeculoplasty vs topical medications for
glaucoma. Arch Ophthalmol. 2012 Apr;130:529-30.)
Median Drug Cost
Lowest Drug Cost
Cost/mo, $a
Time Threshold, mob
Cost/mo, $c
Time Threshold, mob
Xalatan
107.06
6.3
107.06
6.3
Lumigan
102.58
6.6
102.58
6.6
Travatan Z
99.12
6.8
99.12
6.8
Alphagan P, 0.15%
88.85
7.6
88.85
7.6
Azopt
61.01
11.1
61.01
11.1
Trusopt
41.88
16.1
41.88
16.1
Combigan
90.16
7.5
90.16
7.5
Reducing Global Healthcare Costs with SLT
Cosopt
76.84
8.8
76.84
8.8
One of the biggest advantages of SLT is that in addition
to being effective, it has also been found to be a more
economical approach to treating glaucoma when
compared to topical medications. A recent study by
Seider, et al., published in the Archives of Ophthalmology
(2012) and sponsored by the Proctor foundation in San
Francisco, performed a cost-benefit analysis comparing
GENERIC
Latanoprost, 0.005%
51.65
13.1
12.00
56.3
Brimonidine tartrate, 0.2%
32.62
20.7
18.13
37.3
Dorzolamide hydrochloride, 2%
33.28
20.3
17.00
39.8
Timolol maleate, 0.5%
17.00
39.8
16.64
40.6
Timolol maleate/dorzolamide
61.25
11.0
61.25
11.1
Medication
BRAND NAMED
a
b
c
d
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SLT
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E. Randy Craven, MD
Median average wholesale price in the 2011 Red Book.3
Represents the threshold at which the topical medication becomes less cost effective than selective laser trabeculoplasty; this is also the minimum duration of time that selective laser trabeculoplasty
would need to be effective in order to be cost equivalent to the specified medication.
Lowest price listed in the 2011 Red Book.3
The manufacturers of the brand-name drugs are as follows: Xalatan (latanoprost), Pfizer; Lumigan (bimatoprost), Allergan; Travatan Z (travoprost), Novartis; Alphagan P (brimonidine tartrate), Allergan;
Azopt (brinzolamide), Novartis; Trusopt (dorzolamide hydrochloride), Merck and Co; Combigan (brimonidine tartrate/timolol maleate), Allergan; and Cosopt (dorzolamide hydrochloride/timolol maleate),
Merck and Co.
SLT: A New Standard in Glaucoma Treatment
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| BRINGING DOWN THE COST OF GLAUCOMA TREATMENT WITH SLT |
E. Randy Craven, MD
SLT
e-BOOK
the cost of both brand name and generic medications using
the Red Book, one of the most reliable sources for pricing
Reducing Patient Healthcare Costs with SLT
information for drugs in the United States, and comparing
There is sufficient data to position SLT as an early treatment option in the algorithm of glaucoma treatment, and there is indeed a trend today towards the use of SLT as a primary
this to the costs of SLT, the study found that the break-even
therapy. Ophthalmologists need to discuss the use of SLT with their patients early on. Some patients may shy away from this option because of an inherent fear of lasers, but by
point for SLT as compared to brand name prostaglandin
explaining the safety and effectiveness of the therapy and the potential cost benefits, I have noticed that more patients are willing to opt for SLT. Clearly, the cost benefits for each
analogs was as little as 6 months, and as compared to
patient will be different depending upon their insurance plans; however, on average the out-of-pocket cost for patients with SLT is a few hundred dollars per year, whereas with
generics such as latanoprost and timolol, it was 13 and 40
medications this number is close to $1000 per year. Therefore, SLT provides a clear cost incentive to patients.
months, respectively.
In fact, another study by Cantor, et al., published in Current
Medical Research and Opinion found this to be true even
over the longer term.11 The authors of this study calculated
that the five-year cumulative cost of SLT was considerably
less than the cost of medications and filtering surgery $4838 for SLT versus $6571 and $6363 respectively for
medications and surgery. Furthermore, most glaucoma
patients using medications to control their IOP use two or
even three drugs simultaneously.
“The five-year cumulative cost of
SLT was considerably less at $4838,
compared to $6571 and $6363
respectively for medications and
surgery.”
Reducing Ophthalmologists’ Healthcare Costs with SLT
In addition to reducing global and patient glaucoma costs, SLT may also alleviate the cost of glaucoma treatment borne by ophthalmologists. Since SLT is more economical than
medications, ophthalmologists prescribing SLT may be more attractive to health care plans than an ophthalmologist prescribing two or three medications. However, understanding
whether acquiring a laser will provide a return on your investment will require a thorough financial analysis.
To do so, you will need to consider four factors:
1. Your volume of patients: A higher volume of patients will mean performing the procedure more often, which will directly economize the investment to acquire a laser.
2. You patient/payer mix: Whether your patients are covered by Medicare or a commercial insurance will also impact your return on investment. In my practice for instance, 75%
of patients are Medicare beneficiaries whereas the rest are covered by commercial insurance. The reimbursement provided by the different payers will also affect your revenue
and hence your return on investment.
3. Where the procedure is performed: Performing the procedure at your office versus at an ambulatory service centre (ASC) can also affect your revenue from SLT. Although ASC
procedures are generally reimbursed less than office procedures, performing the SLT procedure in an ASC may make more financial sense than performing SLT in the office
A study by Lee and Hutnik published in the Canadian
due to up-front costs for laser acquisition. However, if you own a stake in an ASC, performing SLT in an ASC would make more financial sense than performing the procedure
Journal of Ophthalmology found that SLT could provide
in the office due to additional revenue in terms of facility fees.
6-year cumulative savings of $206.54, $1666.64, and
$2992.67 over mono-, bi-, and tri-drug therapy,
4. When the procedure is performed: Whether you choose to perform SLT in the same visit as when you see the patient or schedule it on a separate day also affects your
revenue. Some health care plans may reimburse less for a same day procedure; however, scheduling a laser day can inconvenience the patient. Therefore, you will need to
weigh all options to see what works best for you and your patient.
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SLT: A New Standard in Glaucoma Treatment
SLT:
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| BRINGING DOWN THE COST OF GLAUCOMA TREATMENT WITH SLT |
respectively, even if SLT needs to be repeated in two
years’ time.12 The savings were greater if SLT did not
need to be repeated for three years following the initial
treatment. Furthermore, an economic study from the
Centre for Eye Research Australia (CERA) found that the
order of treatment options used could also affect overall
costs.13 Using SLT as the first-line therapy, followed
by medications and trabeculectomy, was found to be
cost-effective, returning $2.50 for every $1.00 spent.
This was true even if the cost of SLT treatment increased
4-fold. In such a case, they found that the return of
investment was $1.74 for each $1.00 spent.13
“Using SLT as the first-line therapy,
followed by medications and
trabeculectomy, was found to be
cost-effective, returning $2.50 for
every $1.00 spent. This was true
even if the cost of SLT treatment
increased 4-fold.”
Cost-benefits aside, SLT has other advantages for the
patient. Patients no longer need to worry about going
to the pharmacy to get their prescription filled, a fact
which has a large impact on patient compliance. In fact,
better compliance with SLT can also have an effect
on overall glaucoma costs. A study by Stein, et al.,
published in the Archives of Ophthalmology showed that
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SLT: A New Standard in Glaucoma Treatment
E. Randy Craven, MD
SLT
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laser trabeculoplasty (LTP) is more cost effective than
prostaglandin analogs over a 25-year period assuming
patient compliance to medication is 75%, which is a
rather optimistic estimate.14
SLT is also a rather benign procedure and patients have
a very short recovery time after surgery. It is also largely
free of complications, and minor complications such
as IOP increase and uveitis are quite quickly and easily
resolved.15 Additionally, SLT is a much safer and less
invasive technique than surgical interventions such as
trabeculectomy.
Economically Sound with SLT
In summary, SLT is changing ophthalmologists’ definition
of maximal medical therapy for glaucoma. Not only is
SLT as effective as medication, but it is also a more
economical option and promises to reduce the longterm costs of glaucoma treatment for the patient,
ophthalmologist, and the health care system.
E. Randy Craven, MD
“Not only is SLT as effective as
medication, but it is also a more
Dr. Craven is the Chief of Glaucoma at the King Khaled Eye
economical option and promises
Specialist Hospital in Saudi Arabia and is an Associate
to reduce the long-term costs of
Professor at the Wilmer Eye Institute in Baltimore, MD.
glaucoma treatment for the patient,
ophthalmologist, and the health care
system.”
CLICK HERE TO WATCH AN INTERVIEW WITH DR. CRAVEN
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| ACHIEVING VERSATILITY IN GLACUOMA MANAGEMENT |
SLT
e-BOOK
Resources:
1. Traverso CE, Walt JG, Kelly SP, et al. Direct costs of glaucoma and
10. Seider MI, Keenan JD, Han Y. Cost of selective laser
severity of the disease: a multinational longterm study of resource
trabeculoplasty vs topical medications for glaucoma. Arch
utilization in Europe. Br J Ophthalmol 2005;89:1245–49.
Ophthalmol. 2012 Apr;130:529-30.
2. Lee PP, Walt JG, Doyle JJ, et al. A multicenter, retrospective pilot
11. Cantor LB, Katz LJ, Cheng JW, Chen E, Tong KB, Peabody JW.
study of resource use and costs associated with severity of disease
Economic evaluation of medication, laser trabeculoplasty and
in glaucoma. Arch Ophthalmol 2006;124:12–19.
filtering surgeries in treating patients with glaucoma in the US.
3. Quigley HA. Number of people with glaucoma worldwide. Br J
Ophthalmol. 1996; 80:389-93.
4. Quigley HA, Broman AT. The number of people with glaucoma
worldwide in 2010 and 2020. Br J Ophthalmol 2006
Mar;90(3):262-7.
5. Quigley HA, Broman AT. The number of people with glaucoma
worldwide in 2010 and 2020. Br J Ophthalmol. 2006
Mar;90(3):262-7.
6. The Glaucoma Laser Trial (GLT) and glaucoma laser trial followup study: 7. Results. Glaucoma Laser Trial Research Group. Am J
Ophthalmol. Dec 1995;120:718-31.
7. Melamed S, Simon GJB, Levkovitch-Verbin H. Selective laser
Curr Med Res Opin. 2008;24:2905-18.
12. Lee R, Hutnik CM. Projected cost comparison of selective laser
trabeculoplasty versus glaucoma medication in the Ontario Health
Insurance Plan. Can J Ophthalmol 2006;41:449-56.
13. Taylor HR. Glaucoma: where to now? Ophthalmology
2009;116:821-2.
14. Stein JD, Kim DD, Peck WW, Giannetti SM, Hutton DW. Costeffectiveness of medications compared with laser trabeculoplasty
in patients with newly diagnosed open-angle glaucoma. Arch
Ophthalmol. 2012;130:497-505.
15. Barkana Y, Belkin M. Selective laser trabeculoplasty. Surv
Ophthalmol 2007;52:634-54.
trabeculoplasty as primary treatment for open-angle glaucoma. Arch
Ophthalmol. 2003;121:957-60.
8. Abramowicz M (2007). Drugs for some common eye disorders.
Treatment Guidelines From The Medical Letter, 5: 1-8.
9. Katz LJ, Steinmann WC, Kabir A, Molineaux J, Wizov SS, Marcellino
G. Selective Laser Trabeculoplasty Versus Medical Therapy as
Initial Treatment of Glaucoma: A Prospective, Randomized Trial. J
Glaucoma 2012;21:460-8.
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