Ophthalmic Surgery, Lasers and Imaging Retina

Clinical Science 

Social Cost of Blindness Due to AMD and Diabetic Retinopathy in the United States in 2020

Andrew A. Moshfeghi, MD, MBA; Tereza Lanitis, MSc; Georg Kropat, PhD; Andreas Kuznik, PhD; Andrea Gibson, PhD; Haidong Feng, MPH; Jonathan Prenner, MD

Abstract

BACKGROUND AND OBJECTIVE:

To estimate the social cost of blindness due to wet age-related macular degeneration (wAMD), diabetic macular edema (DME), and proliferative diabetic retinopathy (PDR) in the United States in 2020.

PATIENTS AND METHODS:

Excess costs that occur because of blindness were estimated as the difference in costs in blind versus non-blind individuals. Per-patient costs were aggregated using the number of cases of blindness due to wAMD, DME, and PDR projected in 2020.

RESULTS:

Associated annual excess direct costs, indirect costs, and quality-adjusted life year loss per blind individual were $4,944, $54,614, and 0.214, respectively. Combining estimates with 246,423 projected cases of blindness due to wAMD, DME, and PDR translated to total societal costs of $20 billion in 2020, estimated to triple by 2050.

CONCLUSION:

Excess social costs associated with blindness in individuals with wAMD, DME, and PDR are substantial, with more than half of the burden attributed to indirect costs.

[Ophthalmic Surg Lasers Imaging Retina. 2020;51:S6–S14.]

Abstract

BACKGROUND AND OBJECTIVE:

To estimate the social cost of blindness due to wet age-related macular degeneration (wAMD), diabetic macular edema (DME), and proliferative diabetic retinopathy (PDR) in the United States in 2020.

PATIENTS AND METHODS:

Excess costs that occur because of blindness were estimated as the difference in costs in blind versus non-blind individuals. Per-patient costs were aggregated using the number of cases of blindness due to wAMD, DME, and PDR projected in 2020.

RESULTS:

Associated annual excess direct costs, indirect costs, and quality-adjusted life year loss per blind individual were $4,944, $54,614, and 0.214, respectively. Combining estimates with 246,423 projected cases of blindness due to wAMD, DME, and PDR translated to total societal costs of $20 billion in 2020, estimated to triple by 2050.

CONCLUSION:

Excess social costs associated with blindness in individuals with wAMD, DME, and PDR are substantial, with more than half of the burden attributed to indirect costs.

[Ophthalmic Surg Lasers Imaging Retina. 2020;51:S6–S14.]

Introduction

Individuals with blindness have lower quality of life compared to individuals without visual impairment1 and require significant medical and social resources.2–4 Estimated annual costs for blind individuals range from $14,882 to $24,180, which is almost double the costs for non-blind individuals.5 Additionally, blindness is associated with high indirect and intangible costs, including caregiving costs, productivity losses, premature mortality, and excess financial burden. On a societal level, consequences can be substantial. The annual cost of adult vision problems in the United States (U.S.) in 2007 was approximately $51.4 billion.6

One in five cases of blindness in the U.S. are attributable to retinal diseases characterized by angiogenic processes in retinal blood vessels.7 Key among these are age-related macular degeneration (AMD) and diabetic retinopathy (DR), with complications such as diabetic macular edema (DME) and proliferative DR (PDR). Though these diseases represent some of the primary causes of blindness in the U.S., they are largely preventable. Laser photocoagulation and intravitreal anti-vascular endothelial growth factor (VEGF) therapies that inhibit this protein have been shown to improve or maintain vision in individuals with wet AMD (wAMD), DME, retinal vein occlusion (RVO), and PDR.8–10

Considering 80% of all cases of visual impairment are preventable or curable,11 a global joint initiative was established aiming to eliminate the main causes of preventable and treatable blindness by 2020.12,13 Since VISION 2020's initial launch, additional action plans were developed to target a reduction in the prevalence of visual impairment by 25% globally by 2019 (compared to 2010).12 Based on progress to date, that target will not be met, which indicates a need for more coordinated efforts globally and regionally in terms of political and financial commitment, improved access to eye care, enhanced preventative and primary care services, and raising community awareness among others.14

Understanding the excess social cost of blindness due to specific treatable retinal diseases in the U.S. may help better appreciate the economic benefits associated with investments in preventative services and interventions and consequently support policy making. The objective of this study was to estimate the excess social costs of blindness among individuals with wAMD, DME, and PDR in the U.S., as there are available therapeutic interventions that can prevent progression to blindness with these retinal diseases.

Patients and Methods

Model Overview

Our analysis considered individuals in the U.S. with bilateral blindness (visual acuity [VA] ≤ 20/200 in the better-seeing eye [BSE]) due to wAMD, DME, or PDR (Figure A). RVO was not considered for this model since bilateral blindness rarely occurs among individuals with RVO. Outcomes of interest were the social cost of blindnes,s in 2020 considering direct costs, indirect costs, and intangible costs (Figure 1) as identified in published literature. All costs were inflated to values appropriate for 2020 by projecting consumer price indices based on historical data. The analysis sought to determine the excess costs that occur because of blindness, estimated as the difference between costs among blind individuals and costs among non-blind individuals that suffer from wAMD, DME, or PDR.

Model structure. In the model, the excess costs that occur as a result of blindness due to retinal diseases of interest were estimated as the difference of costs attributed to blindness due to the retinal diseases of interest and costs associated with non-blind individuals. DME = diabetic macular edema; PDR = proliferative diabetic retinopathy; US = United States; wAMD = wet age-related macular degeneration

Figure A.

Model structure. In the model, the excess costs that occur as a result of blindness due to retinal diseases of interest were estimated as the difference of costs attributed to blindness due to the retinal diseases of interest and costs associated with non-blind individuals. DME = diabetic macular edema; PDR = proliferative diabetic retinopathy; US = United States; wAMD = wet age-related macular degeneration

Structure of costs. Direct costs included costs associated with comorbidities (injuries, depression), retinal disease management, and assistance for daily living through services, devices, guide dogs, and government programs. Indirect costs included costs associated with productivity losses, caregiving, and tax deduction. Intangible costs included costs associated with monetized quality-adjusted life-years lost.

Figure 1.

Structure of costs. Direct costs included costs associated with comorbidities (injuries, depression), retinal disease management, and assistance for daily living through services, devices, guide dogs, and government programs. Indirect costs included costs associated with productivity losses, caregiving, and tax deduction. Intangible costs included costs associated with monetized quality-adjusted life-years lost.

Model Inputs

Epidemiological Inputs: The number of cases of blindness in the U.S. in 2020, regardless of underlying cause, were estimated by applying prevalence estimates of blindness to U.S. general population estimates (Table 1).15 Cases of blindness due to the retinal diseases of interest were estimated through the use of projected cause of blindness statistics in 2020.7

Epidemiology Inputs

Table 1:

Epidemiology Inputs

Direct Costs: Costs for ophthalmologic services, injury, and depression were obtained from a retrospective study of Medicare beneficiaries (Table A).3 Assistive devices and services costs by level of VA were based on questionnaires mailed to U.S. individuals with AMD and DR (Table B).

Excess Costs of Ophthalmic Services, Injury, and Depression as Compared to a Population With No or Mild Visual Impairment*1

Table A:

Excess Costs of Ophthalmic Services, Injury, and Depression as Compared to a Population With No or Mild Visual Impairment1

Costs of Assistive Devices and Services

Table B:

Costs of Assistive Devices and Services

Annual costs for guide dogs were estimated at $7,545 for 2020, considering costs for the dog's training, working life, and routine care.16 Guide dogs were considered applicable for only 0.83% of DR individuals, and mostly elderly individuals affected by wAMD were considered ineligible.15,17

Costs for government programs providing assistance with living, nutrition, income, and employment, among others, are detailed in Table C.

Government Programs Model Inputs

Table C:

Government Programs Model Inputs

Indirect Costs: Weekly self-reported caregiving time by level of VA was obtained from a mailed questionnaire for AMD and DR (Table D). As the proportion of caregivers who were employed versus not was not reported in the source study,18 each caregiver hour was valued at $26.27 based on the average hourly wage of all occupations.19 Therefore, lost leisure time and lost productivity were valued at the same cost; however, use of minimum wage among a proportion proxied to be unemployed was examined in scenario analysis.

Costs Due to Caregiving Time Model Inputs

Table D:

Costs Due to Caregiving Time Model Inputs

Productivity losses included incremental costs of lower labor force participation (Table E) and lower wages for blind individuals. The mean income for employed blind persons in 2020 was assumed to be $43,155, and the mean income in non-disabled persons was estimated to be $51,763.20

Employment Rates for Legally Blind Persons and Persons Without Disability

Table E:

Employment Rates for Legally Blind Persons and Persons Without Disability

The additional standard tax deduction for blind persons was estimated as the difference between tax deductions for blind versus non-disabled persons. The blindness additional tax deduction for 2020 was inflated from 2017 annual estimates ($1,673 for blind persons aged < 65 years and $3,347 for those aged ≥ 65 years).21 These deductions were assumed to be taxed at the 15% marginal rate.22

Intangible Costs: Years of life lost (YLL) were estimated based on age-adjusted background mortality,23 whereas accounting for excess mortality due to visual impairment and comorbidities associated with each disease of interest (Table F). Years of life were estimated for populations with and without blindness, assuming deaths would occur in mid-year on average, with YLL reflecting the difference between the two.

Excess Mortality Assumed for Each Indication and Level of VA

Table F:

Excess Mortality Assumed for Each Indication and Level of VA

To estimate quality-adjusted life years (QALYs), utility values based on VA in the BSE were applied to accumulated life years (Tables GI).1 Utility values derived from alternative sources were examined in scenario analysis (Table H and Table I). The monetary value of a QALY was based on the lower limit of the range of $100,000 to $150,000 per QALY, the value-based price benchmark recommended by the Institute for Clinical and Economic Review (ICER).24

Utility Values Based on Brown et al. 200218

Table G:

Utility Values Based on Brown et al. 200218

Regression Models Used to Derive Utility Values* (Scenario Analysis)

Table H:

Regression Models Used to Derive Utility Values (Scenario Analysis)

Utility Values for Blind and Non-Blind Individuals Based on Alternative Sources and Assumed Distribution of Visual Acuity

Table I:

Utility Values for Blind and Non-Blind Individuals Based on Alternative Sources and Assumed Distribution of Visual Acuity

Distribution of VA in Blind and Non-Blind Individuals

To determine excess costs associated with blindness where costs were reported by level of VA (eg, service, injury, devices, and caregiver costs), the distribution of VA among blind and non-blind individuals was obtained from retrospective studies and trial data (Table J). In absence of granular VA data in both eyes, VA was assumed to be normally distributed, and VA in the fellow eye was assumed to be independent of VA in the affected eye. However, this assumption was extensively tested in scenario analysis.

Distribution of Visual Acuity (ETDRS Letters)

Table J:

Distribution of Visual Acuity (ETDRS Letters)

Analysis

The social cost of blindness was estimated based on 2020 projections, considering direct, indirect, and intangible costs. One-way sensitivity analysis (OWSA) was conducted where each input considered in the model was varied by its 95% confidence intervals while keeping all else equal. Results were plotted in the form of tornado diagrams, with parameters shown in the order of their influence on the total costs. In addition, probabilistic sensitivity analysis (PSA) was conducted, assigning a probability distribution to each parameter. Results associated with the simultaneous selection of random values from the distribution of each of these parameters were generated based on 1,000 iterations.

Scenario analysis consisted of altering the distribution of VA across indications: sources used to inform utility values; interpolation of costs related to services, devices, and caregiver use; estimates of the economic value associated with lost leisure time; and the thresholds assumed to assign monetary value to QALYs lost. Projections of costs for 2030, 2040, and 2050 were also examined, assuming prevalence and cause of blindness remain constant.

Results

Base Case

Of the 246,423 cases of blindness due to the retinal diseases of interest estimated by the model for 2020, the majority were attributed to wAMD and primarily included elderly individuals aged 80 years or older (Table 2).

Projected Cases of Blindness Due to wAMD, DME, and PDR in 2020

Table 2:

Projected Cases of Blindness Due to wAMD, DME, and PDR in 2020

More than half of the excess direct costs per patient were attributed to government program costs (Table 3). Blindness was associated with an approximate increase of $54,000 per person per year in indirect costs, primarily driven by caregiver-associated costs. Total aggregated direct and indirect costs were estimated at $1.2 and $13.5 billion, respectively, for 2020. Total aggregated intangible costs were estimated to be $6.2 billion based on an estimated 9,741 YLL due to blindness and an estimated 52,856 QALYs lost. Overall, the analysis suggests that blindness due to wAMD, DME, and PDR will incur a total cost of $20 billion in 2020, with $16 billion arising from blindness due to wAMD (Table K). By 2050, the number of individuals with blindness is projected to increase more than two-fold and the overall burden is projected to triple to $62 billion (Table 4).

Excess Cost Per Blind Patient and Aggregated for Overall Population

Table 3:

Excess Cost Per Blind Patient and Aggregated for Overall Population

Excess Social Costs of Blindness by Underlying Cause (in Millions)

Table K:

Excess Social Costs of Blindness by Underlying Cause (in Millions)

Projected Costs Associated With Blindness Over Time

Table 4:

Projected Costs Associated With Blindness Over Time

Sensitivity Analysis

In OWSA, the total costs varied from $9 billion to $37 billion. Epidemiology- and caregiver use-related parameters were the most influential parameters (Figure 2). Mean estimates of total costs in the PSA were similar to deterministic estimates, varying between $7 billion and $40 billion (Table L).

Deterministic one-way sensitivity analysis. AMD = age-related macular degeneration; DME = diabetic macular edema; DR = diabetic retinopathy; PDR = proliferative diabetic retinopathy; RVO = retinal vein occlusion; US = United States; wAMD = wet age-related macular degeneration

Figure 2.

Deterministic one-way sensitivity analysis. AMD = age-related macular degeneration; DME = diabetic macular edema; DR = diabetic retinopathy; PDR = proliferative diabetic retinopathy; RVO = retinal vein occlusion; US = United States; wAMD = wet age-related macular degeneration

Probabilistic Sensitivity Analysis Results

Table L:

Probabilistic Sensitivity Analysis Results

Scenario Analysis

Across the examined scenarios, the cost varied between $13 billion and $34 billion (Table M). The biggest impact on total cost was the use of approximately $370,000 as the value of a statistical life year (VSLY) for the QALY monetization, compared to the $100,000 used for the base-case analysis. Assuming caregivers follow the same age distribution as individuals with blindness, and valuing lost leisure time due to caregiving at the minimum wage instead of the average wage, resulted in a cost of $13 billion.

Scenario Analyses Results Scenario Analyses Results

Table M:

Scenario Analyses Results

References Cited in Supplemental Tables References Cited in Supplemental Tables

Table N:

References Cited in Supplemental Tables

Discussion

To our knowledge, this is the first study that estimates the excess social cost of blindness specifically due to wAMD, DME, and PDR. Social costs were projected to total approximately $20 billion in the U.S. for 2020, primarily driven by caregiving costs, followed by intangible costs, which made up almost a third of the costs. Several studies have estimated the social cost of blindness on a population or per patient level.2,3,22 In contrast to findings from previous studies,22 we found that caregiving costs dominated productivity losses. This is likely attributable to different underlying patient populations, as previous studies considered patient populations with vision impairment (ie, younger populations with larger proportions who were employed).

However, results need to be interpreted alongside the financial value assigned to caregivers who may not have been formally employed, as well as the financial value assigned to a QALY lost, for which no market exists. In the absence of information on the employment status of caregivers and lack of consensus on how to value lost leisure time, the national average wage was assigned to each caregiver hour, similar to the approach used in the source study.18 However, it is possible that some caregivers were not employed, thus the opportunity cost of caregiving may have been lower. Scenario analysis indicated that valuing lost leisure time due to caregiving at the minimum wage, while utilizing assumptions on the age distribution and employment rate of caregivers, resulted in a total cost of $13 billion. In a similar context, to obtain a conservative estimate of intangible costs for the base case, we used $100,000, the lower end of the ICER-recommended range for a value-based price benchmark, to represent the financial value of a QALY lost. Quantification of QALYs lost using the estimated $370,000 VSLY from the scenario analysis would increase the total costs of blindness to $34 billion. With 52,856 QALYs lost, regardless of the approach used to quantify QALYs lost, the societal impact must be considered substantial.

The social cost of blindness varied between $9 billion and $37 billion in OWSA. The most influential parameter was the proportion of blindness cases caused by AMD, which reduced the base-case proportion from 14.86% to 3.72% resulting in the lowest cost estimate of $9 billion. Earlier estimates of the proportion of blindness cases attributed to AMD varied between 4.4% in black persons and 54.4% in white persons15 (40% on average). In the base-case analysis, it was assumed that 14.86% of blindness cases were attributed to AMD, with 90% of those attributed to wAMD.7,25 Although projections suggest a decline in the proportion of cases of blindness due to AMD over time, lower-end estimates of 4.51% used in scenario analyses appear overly conservative. Regardless, scenario analyses indicated that the burden is substantial even when lower estimates are examined.

The considerable burden projected is particularly important considering evidence that use of intravitreal anti-VEGF treatment to reduce the incidence of blindness due to wAMD and DR may not be optimized in clinical practice. Despite the effectiveness of intravitreal anti-VEGF agents,8–10 fewer injections appear to be given in a real-world setting compared to the number of injections advised by the product's labels.26 Under-treatment with anti-VEGF in wAMD, DME, and PDR can result in poorer visual outcomes.27 Previous economic evaluations of intravitreal anti-VEGF agents indicated that, from a payer perspective, the benefits of anti-VEGF treatment may not outweigh the additional costs associated with treatment.28 However, our study indicates the majority of the cost burden associated with blindness due to these chronic diseases occurs at a societal level (94%). Therefore, it is possible that considering the broader societal cost perspective in economic evaluations assessing preventive treatments may alter earlier conclusions.

Limitations

Our analysis was limited by data gaps, necessitating the use of assumptions. As the objective of this model was to estimate the attributable costs of blindness in individuals with wAMD, DME, and PDR, and costs were most commonly reported by level of VA, the VA levels for the blind and non-blind populations were required. These VA distributions were derived from published clinical trials and retrospective analyses, using assumptions to determine the joint distribution of VA in both eyes. This may have resulted in an unrepresentative distribution of VA among blind and non-blind individuals as inclusion and exclusion criteria in the clinical trials restricted individuals by VA level, whereas retrospective real-world analyses generally evaluated treatment-naïve individuals. Therefore, the prevalent patient population examined in our analyses may have had milder or more severe levels of VA loss as compared to the cohorts examined in clinical trials or retrospective studies. Despite uncertainties associated with the underlying data, the use of alternative sources, assumptions on normality/skewness of the distribution, and assumptions on correlation of VA in both eyes did not result in considerable variation of the cost outcomes, with these scenarios varying total costs between $19 billion and $21 billion.

Additional uncertainty was introduced into the model from source data that did not provide the level of granularity to infer the excess costs associated with blindness. To derive these missing costs for blind and non-blind individuals (where costs were reported for a group of blind and non-blind individuals), linear interpolation was conducted. Scenarios with and without interpolations (ie, use of the same costs for blind and non-blind individuals where this granularity was not provided) were tested, but no appreciable differences between the interpolated and non-interpolated scenarios were observed.

Our results may not capture recent healthcare and policy changes. Estimates on caregiver, service and assistive device use, and comorbidities were based on estimates published in 2006 and 2009.4,18,29 Similarly, age-specific prevalence of blindness was based on population-based studies of blindness and low vision from 1990 to 2001.15 Advancements over the last decade would undoubtedly influence the level of care provided to individuals with these retinal diseases, including estimated prevalence of blindness. Improvements in the management of individuals and potential improved VA in non-blind individuals may have increased excess cost estimates; however, this limitation may be more pertinent to epidemiology estimates. The introduction of intravitreal anti-VEGF treatment for wAMD, DME, and PDR, coupled with improvements in patient care, may have resulted in lower incidence and corresponding prevalence of blindness. In the current study, the number of cases of blindness in the U.S. in 2020 were estimated at 1.36 million, with 246,423 attributable to wAMD and DR. These estimates appear to align with projections by Chan et al. published in 2018,30 who projected 1.08 million and 1.59 million cases of blindness in the U.S. in 2017 and 2030, respectively. Nonetheless, projections in the international study conducted by Flaxman et al. suggest that 1.03 million individuals above the age of 50 will be blind in 2020 in high-income North America, with 202,000 cases attributed to AMD and DR.7 Although our estimates are slightly higher, projections by Flaxman are for individuals aged 50 and above, as opposed to 40 and above considered in our study. Moreover, estimates are based on high-income North American regions, most likely explaining the higher number of cases estimated in this study. Reducing the number of blindness cases to 202,000 decreased the estimated burden to $16 billion.

In conclusion, excess social costs associated with blindness in wAMD and DR individuals are substantial, with the minority of the burden attributed to direct healthcare costs. Due to the aging population, the burden is projected to triple by 2050 if management of these conditions does not improve. Investments in research, preventive services, and optimized use of currently available efficacious treatments have the potential to lead to substantial savings in the future. Policies are required to address the growing burden associated with preventable blindness due to wAMD, DME, and PDR.

References

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  5. Köberlein J, Beifus K, Schaffert C, Finger RP. The economic burden of visual impairment and blindness: a systematic review. BMJ Open. 2013;3(11):e003471. doi:10.1136/bmjopen-2013-003471 [CrossRef] PMID:24202057
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  10. Stewart MW. Anti-VEGF therapy for diabetic macular edema. Curr Diab Rep. 2014;14(8):510. doi:10.1007/s11892-014-0510-4 [CrossRef] PMID:24919750
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Epidemiology Inputs

Input Mean SE Source
Epidemiology: U.S. Population by Age in 2020 (Millions)
40–49 40.77 NA United States Census Bureau*25
50–54 20.64
55–59 21.88
60–64 21.14
65–69 18.19
70–74 14.88
75–79 10.11
80+ 13.25
Total 160.87
Cause of Blindness In 2020 (Retinal Diseases of Interest)
AMD 14.86% 6.95% Flaxman et al., 20179
DR 4.74% 2.69%
Proportion of wAMD and DR Cases That Cause Blindness
wAMD 90.00% 9.00% BrightFocus Foundation45
DME (as a proportion of DR) 47.58% 4.76% Jeppesen and Bek, 200455

Projected Cases of Blindness Due to wAMD, DME, and PDR in 2020

Blindness Due to Retinal Diseases of Interest
Age Blind wAMD DME PDR Total
40–49 48,927 6,543 1,103 1,216 8,863
50–54 26,829 3,588 605 667 4,860
55–59 35,006 4,682 789 870 6,341
60–64 50,738 6,786 1,144 1,261 9,191
65–69 65,497 8,760 1,477 1,628 11,864
70–74 87,802 11,743 1,980 2,182 15,904
75–79 111,237 14,877 2,508 2,764 20,150
80+ 934,362 124,962 21,071 23,218 169,250
Total 1,360,397 181,940 30,678 33,805 246,422

Excess Cost Per Blind Patient and Aggregated for Overall Population

Cost/Outcome Per Patient Aggregated Cost (in Millions)
Bilateral Blindness No Bilateral Blindness Excess Cost
Direct Annual Costs
Government program costs $2,441 $0 $2,441 $602
Assistive devices and services costs $1,827 $450 $1,377 $339
Depression $1,202 $577 $625 $154
Fracture $609 $353 $257 $63
Ophthalmologic services $665 $437 $228 $56
Guide dog $16 $0 $16 $4
Total $6,761 $1,817 $4,944 $1,218
Indirect Annual Costs
Caregiving $54,681 $4,152 $50,530 $12,452
Productivity losses* $49,829 $45,758 $4,071 $1,003
Tax loss $13 $0 $13 $3
Total $104,523 $49,909 $54,614 $13,458
Intangible Annual Costs
Years of life 0.879 0.919 $3,953 $974
QALY 0.521 0.735 $21,449 $5,286

Projected Costs Associated With Blindness Over Time

Year 2020 2030 2040 2050
Total Cost (Billions; $) 19.96 32.46 49.18 62.00
Direct Cost (Billions; $) 1.22 1.84 2.71 3.48
Indirect Cost (Billions; $) 13.46 23.18 36.54 47.41
Intangible Cost (Billions; $) 5.29 7.44 9.94 11.11
QALYs Lost 52,856 74,402 99,396 111,082
Years of Life Lost 9,741 14,468 20,434 23,170
Number of Cases 246,423 346,273 461,722 515,745

Excess Costs of Ophthalmic Services, Injury, and Depression as Compared to a Population With No or Mild Visual Impairment*1

Visual Impairment Injury ($) Depression ($) Ophthalmologic Services ($)
Blind 552 1,054 409
Severe 618 1,224 703
Moderate 463 685 596

Costs of Assistive Devices and Services

Level of Impairment VA in Better- seeing Eye Devices Cost of AMD 2 ($) Devices Cost of DR 3 ($) Services Cost of AMD 2 ($) Services Cost of DR 3 ($)
Mild to no impairment ≥20/20 109 63 6 7
≥20/25–<20/20 109 86 6 6
≥20/32–<20/40 109 86 6 6
≥20/40–<20/50 363 149 13 9
≥20/50–<20/63 1,434 149 25 9
≥20/63–<20/70 1,434 332 25 25
Moderate visual impairment ≥20/70–<20/80 1,434 332* 25 25*
≥20/80–<20/125 1,961 372* 62 27*
≥20/125–<20/150 1,961 445* 62 29*
≥20/150–<20/160 2,151 524* 76 31*
≥20/160–<20/200 2,090* 552* 77* 32*
Severe visual impairment (U.S. Blindness) ≥20/200–<20/250 2,112* 588* 83* 33*
≥20/250–<20/500 2,199 731* 46 37*
Profound visual impairment (WHO Blindness) ≤20/500 2,199 1,071* 46 42*

Government Programs Model Inputs

Government Program with Total Budget Information Target Population Annual Budget or Payment (in 2017; $) Number of Beneficiaries Estimated Annual Payment Per Individual ($)*
Employment Status Age (Years) Monthly Wage ($)
Independent Living Services for the Blind4 Unemployed > 55 to < 65 0 34,963,723 4,281,079 8.17
National Library Service for the Blind and Physically Handicapped5 Employed/Unemployed All ages All wages 56,870,934 430,000 132.26
Purchase from People who are Blind or Severely Disabled6 Employed All ages All wages 8,637,250 60,960 141.69
American Foundation for the Blind7 Employed/Unemployed All ages All wages 14,383,181 1,360,397 10.57
Government Program with Expense Information per Individual Target Population Annual Payment per Individual
Employment Status Age (years) Monthly Wage ($)
Supplemental Security Income Program8 Employed/Unemployed < 65 < 2,000 7,686
Social Security Disability Insurance9 Unemployed < 65 0.00 15,404
Supplemental Nutrition Assistance Program10 Employed/Unemployed < 65 < 2,000 3,498

Costs Due to Caregiving Time Model Inputs

AMD: Schmier et al. 2006 11 DME, PDR: Schmier et al. 2009 3
VA Use of Any Caregiver Services (%) Average Hours Received Per Week Annual Costs for Caregiving ($) Use of Any Caregiver Services (%) Average Hours Received Per Week Annual Costs for Caregiving ($)
≥20/20 4.8 5.8 382 6.50 5.9 529
≥20/25–<20/20 4.8 5.8 382 13.20 14.6 2,646
≥20/32–<20/40 4.8 5.8 382 13.20 14.6 2,646
≥20/40–<20/50 25.4 6.6 2,299 24.40 33.4 11,171
≥20/50–<20/63 50.0 8.8 6,033 24.40 33.4 11,171
≥20/63–<20/70 50.0 8.8 6,033 35.30 31.9 15,416
≥20/70–<20/80 50.0 8.8 6,033 35.30 31.9 15,416
≥20/80–<20/125 77.3 18.4 19,503 39.03 35.5 18,987
≥20/125–<20/150 77.3 18.4 19,503 45.34 37.7 23,458
≥20/150–<20/160 77.9 24.1 25,735 52.22 40.2 28,779
≥20/160–<20/200 82.6 25.6 29,002 54.71 41.1 30,823
≥20/200–<20/250 89.5 27.7 34,003 57.81 42.2 33,446
≥20/250–<20/500 61.5 94.1 79,353 70.28 46.7 44,960
≤20/500 61.5 94.1 79,353 97.00 52.7 70,121

Employment Rates for Legally Blind Persons and Persons Without Disability

Age (Years) Employment Rate of Legally Blind 12 (%) Employment Rate of Persons Without Disability 13 (%)
40–49 33.0 80.1
50–54 33.0 76.2
55–59 33.0 69.7
60–64 33.0 54.7
65–69 5.0 31.2
70–74 5.0 18.9
75–79 0* 8.1
80+ 0* 0

Excess Mortality Assumed for Each Indication and Level of VA

Indication HR of Mortality vs. General Population Source
AMD 1.76 Fisher et al. 201514
DME 1.41 Hirai et al. 200815
PDR 4.16 van Hecke et al. 200516
Visual Acuity HR of Mortality vs. Population with VA >20/60 Source
≤ 20/60 in the BSE 1.23 Christ et al. 200817
VA ≤ 20/200 in the BSE (blind) 1.54 Christ et al. 200817

Utility Values Based on Brown et al. 200218

VA AMD DR
Mean SE Mean SE
≥ 20/20 0.84 0.027 0.86 0.020
≤ 20/30 to > 20/50 0.80 0.024 0.80 0.017
≤ 20/50 to >20/200 0.71 0.029 0.77 0.018
≤ 20/200 0.59 0.027 0.60 0.032

Regression Models Used to Derive Utility Values* (Scenario Analysis)

Variable Model 1: BSE Model Model 3: BSE & WSE Model Model 4: WSE & BSE-WSE Interaction Model Model 5: WSE & BSE-WSE Interaction Model Plus Blind Dummy
Beta SE Beta SE Beta SE Beta SE
BSE −0.324 0.029 −0.182 0.087 −0.039 0.153 −0.042 0.158
WSE −0.151 0.038 −0.079 0.109 −0.085 0.109
Interaction −0.113 −0.090 −0.105 0.116
Blindness −0.007 0.079
Constant 0.817 0.029 0.848 0.038 0.769 0.073 0.771 0.073

Utility Values for Blind and Non-Blind Individuals Based on Alternative Sources and Assumed Distribution of Visual Acuity

Brown 2002 Model 1 Model 3 Model 4 Model 5
Indication Bilateral Blindness No Bilateral Blindness Bilateral Blindness No Bilateral Blindness Bilateral Blindness No Bilateral Blindness Bilateral Blindness No Bilateral Blindness Bilateral Blindness No Bilateral Blindness
AMD 0.59 0.79 0.45 0.79 0.43 0.71 0.44 0.69 0.43 0.69
DME 0.60 0.83 0.43 0.81 0.41 0.72 0.41 0.69 0.40 0.69
PDR 0.60 0.82 0.51 0.80 0.52 0.78 0.54 0.73 0.53 0.73

Distribution of Visual Acuity (ETDRS Letters)

Study Indication BSE WSE
Mean SD Mean SD
Kataja et al. 201720 wAMD 58.68 41.07 65.92 37.67
Ehlken et al. 201821 DME 65.34 45.84 67.85 71.56
Gross et al. 201522 PDR 75.10 12.65 71.28 13.32

Excess Social Costs of Blindness by Underlying Cause (in Millions)

wAMD DME PDR Total

Direct Annual Costs±
  Government program costs $444 $75 $83 $602
  Assistive devices and services costs $302 $20 $17 $339
  Depression $106 $19 $30 $154
  Fracture $42 $8 $13 $63
  Ophthalmologic services $36 $6 $14 $56
  Guide dog $0 $2 $2 $4
  Total $930 $129 $159 $1,218

Indirect Annual Costs±
  Caregiving $10,162 $1,300 $990 $12,452
  Productivity losses* $741 $125 $138 $1,003
  Tax loss $2 $0 $0 $3
  Total $10,905 $1,425 $1,128 $13,458

Intangible Annual Costs±
  QALY $3,778 $725 $782 $5,286

  Total social costs
  Year: 2020 $15,614 $2,279 $2,069 $19,962
  Year: 2050 $49,129 $6,863 $5,992 $62,004

Probabilistic Sensitivity Analysis Results

Type of Cost Deterministic Mean Probabilistic Mean 2.5th Percentile 97.5th Percentile
Total Cost (billions; $) 19.96 20.17 7.21 39.66
Direct Cost (billions; $) 1.22 1.23 0.47 2.30
Indirect Cost (billions; $) 13.46 13.57 4.79 27.02
Intangible Cost (billions; $) 5.29 5.37 1.95 10.33
QALYs lost 52,856 53,687 19,507 103,315
Years of life lost 9,741 9,730 3,343 19,622
Number of cases 246,423 248,525 95,663 473,238

Scenario Analyses Results

Variable Name Source Total Cost ($) Direct Cost ($) Indirect Cost ($) Intangible Cost ($) QALYs Lost
Base case 19,962 1,218 13,458 5,286 52,856
Distribution of VA for AMD individuals Cummins et al. 201323 20,371 1,159 14,382 4,830 48,302
Distribution of VA for DME individuals, Scenario 1 Ip et al. 201824 19,395 1,219 12,994 5,182 51,825
Distribution of VA for DME individuals, Scenario 2 Korobelnik et al. 201425 19,380 1,211 13,015 5,155 51,550
Distribution of VA for DME individuals, Scenario 3 Hanhart et al. 201426 19,975 1,215 13,482 5,278 52,776
Distribution of VA for PDR individuals, Scenario 1 Rice et al. 201527 19,962 1,218 13,458 5,286 52,856
Distribution of VA for PDR individuals, Scenario 2 Sivaprasad et al. 201728 20,109 1,242 13,533 5,286 52,856
Distribution of VA assumed to follow a gamma distribution 19,257 1,191 12,895 5,172 51,722
VA in both eyes assumed to be perfectly correlated 20,965 1,290 14,783 4,892 48,917
Utilities estimated based on Claxton Model 1, BSE model Claxton et al. 201719 22,744 1,218 13,458 8,068 80,679
Utilities estimated based on Claxton Model 3, BSE & WSE model Claxton et al. 201719 21,547 1,218 13,458 6,871 68,705
Utilities estimated based on Claxton Model 4, BSE, WSE & BSE-WSE interaction model Claxton et al. 201719 20,799 1,218 13,458 6,123 61,228
Utilities estimated based on Claxton Model 5, BSE, WSE, blindness & BSE-WSE interaction model Claxton et al. 201719 20,852 1,218 13,458 6,176 61,757
No interpolation of caregiver costs 19,693 1,218 13,190 5,286 52,856
No interpolation of caregiver, services, or device costs 19,700 1,225 13,190 5,286 52,856
Costs for caregivers not in employment* valued at the lower 10th percentile of wages ($10.36) Bureau of Labor Statistics13 13,296 1,218 6,792 5,286 52,856
Intangible costs monetized at $150,000 ICER 201829 22,605 1,218 13,458 5,336 52,856
Intangible costs monetized at VSLY Mason et al. 200930 Moran and Monje 201631 34,166 1,218 13,458 19,489 52,856

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Authors

From Roski Eye Institute, Department of Ophthalmology, Keck School of Medicine, University of Southern California, Los Angeles, California (AAM); Evidera, London, United Kingdom (TL, GK); Regeneron Pharmaceuticals, Tarrytown, New York (AK, AG); Evidera, Waltham, Massachussetts (HF); and the Department of Ophthalmology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (JP).

Supported by by Regeneron Pharmaceuticals and, in part, by an unrestricted grant to the Department of Ophthalmology at the University of Southern California Keck School of Medicine from Research to Prevent Blindness (New York, NY).

Dr. Moshfeghi has served as a consultant to Regeneron, Genentech, Allergan, Visunex, Valeant, Spark, EyePoint, Allegro, and Novartis and has equity interest in Pr3vent, OptiSTENT, and Visunex. Drs. Lanitis, Kropat, and Feng are employees of Evidera, who were paid consultants to Regeneron in relation to this study. Drs. Kuznik and Gibson are employees of, and own stock and stock options in, Regeneron, the manufacturer of Eylea. Dr. Prenner was a consultant to Regeneron in relation to this study and has served as a consultant to Alcon.

Medical writing and editorial support were provided by Brenda MacIntyre, RPh, and Melanie Jardim, PhD, (Evidera, Morrisville, NC) and funded by Regeneron Pharmaceuticals.

Address correspondence to Jonathan Prenner, MD, Department of Ophthalmology, Rutgers Robert Wood Johnson Medical School, 10 Plum Street, New Brunswick, NJ 08901; email: jonathanprenner@gmail.com.

Received: August 01, 2019
Accepted: August 27, 2019

10.3928/23258160-20200401-01

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