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among the U.S. population younger than 40

among the U.S. population younger than 40. John Wittenborn Wittenborn-John@norc.org JohnSWittenborn@gmail.com. The Economic Burden of Vision Loss and Eye Disorders. Presenter Disclosures. John Wittenborn

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among the U.S. population younger than 40

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  1. among the U.S. population younger than 40 John Wittenborn Wittenborn-John@norc.org JohnSWittenborn@gmail.com The Economic Burden of Vision Loss and Eye Disorders

  2. Presenter Disclosures Footer Information Here • John Wittenborn • The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: • No relationships to disclose

  3. Overview review previous estimates ARVO guidelines prevalence medical costs other direct costs indirect costs total costs sensitivity analysis comparing costs to older adults

  4. Previous estimates – landmark studies Frick K, Gower EW, et al. Economic impact of visual impairment and blindness in the United States. Arch Ophthalmol 2007;125:544-550. Rein DB, Zhang P, et al. The economic burden of major adult visual disorders in the United States. Arch Ophthalmol 2006;124(12):1754-1760. • Landmark studies by Frick (2007) and Rein (2006) reported costs for the population aged 40 and older in 2004 • Rein et al • Calculated direct medical costs from Medicare and Marketscan claims for 4 diseases • macular degeneration, cataracts, glaucoma, and diabetic retinopathy • Estimated other direct and indirect costs • Government programs, long-term care placement, productivity losses • Frick et al • Econometric analysis of MEPS data • Medical costs of low vision • Loss of well-being

  5. Rein and Frick papers were combined by Prevent Blindness America (PBA) to form an overall estimate of the economic burden of vision loss and eye disorders in the US $51.4bn in 2004 $35.4bn from Rein et al $16bn from Frick et al Previous estimates – PBA report Prevent Blindness America. The economic impact of vision problems: The toll of major eye disorders, visual impairment, and blindness on the US economy. Chicago: Prevent Blindness America; 2007.

  6. Previous estimates - limitations Did not include the population younger than age 40 Direct medical costs limited to private medical insurance and Medicare claims for 4 major age-related eye diseases Rein et al costs have not yet been updated

  7. ARVO guidelines • Association for Research in Vision and Ophthalmology released consensus guidelines (Frick et al 2010) • Defined analysis perspectives and cost categories Frick K, Kymes SM, Lee P, et al. The cost of visual impairment: purposes, perspectives and guidance. Invest Ophthalmol Vis Sci 2010;51(4):1801-1805.

  8. Prevalence – low vision, 2005-2008 NHANES National Center for Health Statistics. National Health and Nutrition Examination Survey Data. Hyattsville, MD: US Department of Health and Human Services; September 1, 2011. 2005–2008. Population in thousands • Auto-refractor corrected visual acuity in the better-seeing eye • Analysis excludes uncorrected refractive error • Thresholds are >20/40, >20/80, and >20/200 for mild, moderate impairment and blindness, respectively • Self-reported blind persons included in blindness • NHANES does not measure contrast sensitivity or visual field before age 40 • NHANES does not measure acuity among children <12 • Instead, prevalence imputed based on UK blindness registry incidence rates Population in thousands

  9. Prevalence – diagnosed disorders, 2003-2008 MEPS National Center for Health Statistics. National Health and Nutrition Examination Survey Data. Hyattsville, MD: US Department of Health and Human Services; September 1, 2011. 2005–2008. ICD-9-CM: International classification of diseases. ICD-9-CM Index Addenda. In: National Center for Health Statistics, ed. Hyattsville, MD: National Center for Health Statistics; 2011 Population in thousands, a Not distinguishable from zero • Identified ICD-9 diagnosis codes related to eyes • Eye diseases and disorders, visual function disorders, conjunctivitis, eye injuries and burns, disorders of ocular adnexa • Estimated prevalence of any of these ICD-9s as a primary diagnosis in MEPS conditions file

  10. Medical costs, 2003-2008 MEPS • Estimated medical costs attributable to diagnosed disorders and undiagnosed vision loss • 2-part GLM model, gamma distribution with log link • Primary dependent variable is total medical expenditures excluding “optometry” costs • Independent variables • comprehensive diagnosed eye disorder variable (diagnosed disorder) • self-reported low vision without any eye diagnosis (undiagnosed low vision) • socio-demographics, hypertension and diabetes Trogdon JG, Finkelstein EA, Hoerger TJ. Use of econometric models to estimate expenditure shares. Health Serv Res Jan 29 2008.

  11. Medical and other health costs, 2003-2008 MEPS • Optometry visits and medical vision aids (glasses, contacts) are not included in the MEPS medical provider component • Diagnosed disorders and low vision predict only a small fraction of these costs • Costs are self-reported and not verified by MEPS • We calculated total patient-reported optometry visit and medical vision aid costs in MEPS • Accounting approach • Costs are calculated based on weighted average per person costs

  12. Medical costs by diagnosis, 2008 MarketScan data • MarketScan commercial claims database can show the breakdown of costs by individual diagnosis • MarketScan only includes private health insurance claims, it does not capture: • Government payers (Medicaid, CHIP etc.) • Vision insurance plans • Most out of pocket costs • Other costs attributable to conditions (i.e., depression, injuries) • Costs can be considered a subset of the total costs from MEPS • Due to this, we do not report any $ values from MarketScan • MarketScan is used to show the relative insurance costs of individual diagnoses

  13. Low vision aids, devices and guide dogs Brézin A, Lafuma A, Fagnani F, Mesbah M, Berdeaux G. Prevalence and burden of self-reported blindness, low vision, and visual impairment in the French community. Arch Ophthalmol 2005;123:1117-1124. Lafuma A, Brézin A, Lopatriello S, et al. Evaluation of non-medical costs associated with visual impairment in four European countries: France, Italy, Germany and the UK. Pharmacoeconomics2006;24(2):193-205. Wirth KE, Rein DB. The economic costs and benefits of dog guides for the blind. Ophthalmic EpidemiolMar-Apr 2008;15(2):92-98. • Low vision aids are non medical personal, home, and workplace devices for low vision • Utilization rates identified by a special French census • French utilization applied to US specific blindness prevalence and unit costs • The national cost of guide dogs for the blind was updated and allocated to the <40 population based on the proportion of blindness

  14. Caregivers • We assume no long-term care placement due to low vision • We assume no informal care use by adults Brézin A, Lafuma A, Fagnani F, Mesbah M, Berdeaux G. Prevalence and burden of self-reported blindness, low vision, and visual impairment in the French community. Arch Ophthalmol 2005;123:1117-1124. U.S. Bureau of Labor Statistics. American Time Use Survey—2010 Results. In: US Department of Labor, ed.Vol USDL-11-0919. Washington, DC: US Department of Labor; 2011 Relative rates of informal care utilization by the blind identified in French census French relative rates of informal care for the blind applied to the average levels of informal care for US children by age based on the American Time Use Survey Cost of this time calculated based on US average wage

  15. Special education Apling RN. Individuals with Disabilities Education Act: Full Funding of State Formula. Washington DC: Congressional Research Service, The Library of Congress; December 27 2001. 97-433 EPW. Distribution of eligible students based on the Federal quota census of January 05, 2009. 2010. http://www.aph.org/fedquotpgm/dist10.html. Updated Last Updated Date. Accessed September 15, 2011 • Individuals with Disabilities Education Act and the Act to Promote Education of the Blind • requires states to provide free intervention and educational programming for children with blindness through age 21 • Number of children receiving special education due to blindness based on the American Printing House for the Blind registry • Cost of special education for the blind based on updated value cited by the Act

  16. School and Pre-school Vision Screening Naser N, Hartmann EE. Comparison of state guidelines and policies for vision screening and eye exams: Preschool through early childhood. Paper presented at: Association for Research in Vision and Ophthalmology annual meeting., 2008 Rein DB, Wittenborn JS, Zhang X, Song M, Saaddine JB, For the Vision Cost-effectiveness Study Group. The potential cost-effectiveness of amblyopia screening programs. J Pediatr Ophthalmol Strabismus . 2012 49(3):146-55. • School screening is generally based on individual state law and implemented at the school district level • Screening ages and frequency based on a nationwide survey of school screening • Costs and penetration rates of school and preschool screening based on our earlier evaluation of 3 PBA sponsored vision screening programs in NC, VA and GA • We assume screening is acuity chart with stereopsis

  17. Federal assistance programs • Budgetary costs of federal supportive services • National Library Services for the Blind • American Printing House for the Blind • Committee for Purchase from People who are Blind or Severely Disabled

  18. Transfers, tax losses and deadweight loss p q Gallaway L, Vedder R. The impact of transfer payments on economic growth: John Stuart Mill versus Ludwig von Mises. The Quarterly Journal of Australian Economics 2002;5(1):57-65. • Transfer payments are not included in costs • Social Security Disability Insurance (SSDI) • Supplemental Security Income (SSI) • Supplemental Nutrition Assistance Program (food stamps) • Reduced tax revenue is based on the • prevalence of blindness, the • marginal income tax rate for blind persons 18-39 • blindness income tax deduction • Deadweight loss (cost of economic inefficiency) is estimated at 38% of transfer payments • Costs allocated to the population younger than age 40 based on the proportion of legally blind adults that are younger than 40

  19. Productivity losses • Median income level by self-reported vision status for ages 18-39 based on Survey of Income and Program Participation data • assumes self-reported difficulty seeing = moderate impairment • assumes self-reported inability to see printed words = blindness • Productivity losses equal to the reduction in income associated with vision loss, multiplied by the prevalence of moderate impairment and blindness from NHANES • Restricted to ages 18-39

  20. Loss of well-being • Loss of well-being from low vision and blindness based on weighted average reduction in utility reported in 12 published articles • Utilities converted to quality adjusted life years (QALYs) lost by multiplying utility losses by: • age-specific background utility rates • the prevalence of mild and moderate impairment and blindness • Limitation: • All included studies were predominately older adults • We excluded the only child-based study identified • Very small sample and reported far larger utility impacts than the adult studies • We do not consider increased mortality from low vision

  21. Results – total costs, $millions a Transfer payments not included in costs

  22. Results – proportion of insurance costs by diagnosed condition, 2008 MarketScan commercial claims database A Excludes disorders of refraction and accommodation as few of these costs are filed to private insurance

  23. Loss of well-being, QALYS lost and cost in $millions • We do not include monetized loss of well-being in the baseline results • Including these would increase by $10.8bn to total $38.3bn • Assuming the same $50,000 willingness to pay per QALY gained value used by Frick et al 2006 A Monetary costs are in millions.

  24. Sensitivity analysis - univariate • Univariate sensitivity analysis shows impact on total results from changing a single cost or parameter value across a specified range

  25. Sensitivity – probabilistic sensitivity analysis (PSA) 97.5%, $37.4bn Median, $27.8bn 2.5%, $21.5bn • PSA varies all major parameters in the analysis • All parameters are simultaneously sampled from their respective prior distributions • Sampling is repeated for 10,000 replications • 95% credible intervals are derived as the 2.5 and 97.5 percentile cost values from the results of the 10,000 replications

  26. Results – PSA results with 95% credible intervals

  27. How does this compare to the 40+ costs? • Major methodological differences limits comparability • This analysis would predict higher costs for the 40+ population, especially for utility costs a. Updated from 2004 to 2012 US$ using CPI components R. Value from Rein et al 2006 F. Value from Frick et al 200+

  28. Next steps… • Paper currently under review • Wittenborn JS, Zhang X, Feagan C, Crouse W, Shrestha S, Kemper A, Hoerger TJ, Saaddine J, for the Vision Cost-effectiveness Study Group. The Economic Burden of Vision Loss and Eye Disorders Among the U.S. Population Younger than Age 40. in process. • Most of the way towards estimating total US population costs

  29. For more information: John Wittenborn 1-312-519-5718 Wittenborn-John@norc.org JohnSWittenborn@gmail.com Funding provided by the US Centers for Disease Control and Prevention The findings and conclusions in this paper are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention or NORC at the University of Chicago

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