Is MIGS more cost-effective than medical treatment?
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MIGS results in significant net savings
The answer to this question hinges on whether one believes that MIGS procedures decrease medication burden. The preponderance of evidence demonstrates that nearly all MIGS procedures result in decreased ocular hypotensive medications compared with controls and that this benefit persists for years. By reducing the amount of medications over time, MIGS results in net savings and is therefore more cost-effective than medical treatment. Glaucoma medications are a huge part of prescription drug costs in the U.S. and other countries. In 2013, branded glaucoma medications cost Medicare Part D $1.2 billion and the U.K. 104 million pounds, and these numbers have continued to rise. Although some may argue that there are cheaper generic medications available, ophthalmologists still prescribe branded drugs 71% of the time. Several studies have compared costs between medications and MIGS procedures and have found cost savings with MIGS. A study by Berdahl and colleagues found 5-year cost savings of $1,797 when using two iStents (Glaukos) vs. medication alone. This savings may increase over time and may become more significant as cataract surgery is performed in increasingly younger patients.
The final point is that adherence with a MIGS procedure is 100%, while patient adherence to medication regimens can be abysmal. There is certainly added cost to the system when patients have glaucoma progression due to nonadherence. Further studies will continue to show that MIGS procedures are more cost-effective than medical treatment, and hopefully insurers will realize this benefit when setting procedure reimbursement.
- Agrawal P, et al. Ophthalmol Ther. 2018;doi:10.1007/s40123-018-0131-0.
- Berdahl JP, et al. J Med Econ. 2017;doi:10.1080/13696998.2017.1327439.
- Kerr NM, et al. Clin Exp Ophthalmol. 2017;doi:10.1111/ceo.12888.
- Newman-Casey PA, et al. Ophthalmology. 2018;doi:10.1016/j.ophtha.2017.05.024.
- Poitras V, et al. Optimal use of minimally invasive glaucoma surgery: a health technology assessment. www.ncbi.nlm.nih.gov/books/NBK543897. Published January 2019.
- Samuelson TW, et al. Ophthalmology. 2019;doi:10.1016/j.ophtha.2019.03.006.
Daniel Terveen, MD, is from Vance Thompson Vision, Sioux Falls, South Dakota. Disclosure: Terveen reports no relevant financial disclosures.
Not sufficient data to draw conclusions
By doing a literature search, we come across 224 publications on MIGS, of which only eight address the issue of cost and cost-effectiveness. Out of these eight, only three are based on valuable clinical data, and they all agree that the currently available evidence is not sufficient to draw conclusions. Most of the reviews look at older MIGS procedures, such as iStent (Glaukos) and Hydrus (Ivantis), or the CyPass (Alcon), which has since been withdrawn, while newer procedures such as canaloplasty or PreserFlo (Santen, previously InnFocus microshunt) are not represented. In addition, none of these studies directly compares MIGS and glaucoma medications.
MIGS covers such a wide variety of different interventions with different technologies and different mechanisms to reduce IOP that no general statement is possible, as we would be comparing apples and pears. This is probably one of the reasons why cost-effectiveness studies are lacking. What we would need is a long-term prospective trial comparing the costs of a patient on medical treatment with two or three medications, who is of course compliant to the therapy, vs. the costs of a patient who has undergone an operation. To my knowledge, such a study does not exist, and it would be for just one MIGS technique out of many. We should also take into account the different cost of performing MIGS in combination with cataract surgery or as a stand-alone procedure, the frequency of follow-up visits and the many variables related to the management of complications when they occur. The Xen (Allergan) needling rate, for instance, is much higher than it was discussed in the beginning, and that means the cost of the primary intervention plus one or maybe more than one needling revision. Some of my colleagues stopped using Xen because they would not consider it as microinvasive anymore, given the high rate of secondary procedures.
In conclusion, I would answer this question by saying that there are not enough data available yet. What we would need is a long-term prospective trial comparing the costs of a patient on medical therapy with two or three medications, who is of course compliant to the therapy, vs. the costs of a patient who has undergone an operation plus the related follow-up visits.
Frances Meier-Gibbons, MD, is from Eye Center Rapperswil, Switzerland. Disclosure: Meier-Gibbons reports she is a consultant for Aerie Pharmaceuticals, Alcon, Allergan, Glaukos, Heidelberg Engineering, Novartis, Santen and Théa.