Gazzard G et al (2019) Lancet 2019; 393: 1505–16 Published Online March 9, 2019 http://dx.doi.org/10.1016/S0140-6736(18)32213-X
This weeks blog is brought to you by: Professor Sir Muir Gray, Founding Director.
Key text from the paper chosen by 3VH
Background; Primary open angle glaucoma and ocular hypertension are habitually treated with eye drops that lower intraocular pressure. Selective laser trabeculoplasty is a safe alternative but is rarely used as first-line treatment. We compared the two [treatments]….
Selective trabeculoplasty should be offered as a first-line treatment for open angle glaucoma and ocular hypertension, supporting a change in clinical practice.
Use of selective laser trabeculoplasty as the first-line treatment resulted in a significant reduction in the cost of surgery and medication for ocular hypertension and OAG, with an overall cost saving to the NHS of £451 per patient in specialist ophthalmology costs; for every patient given selective laser trabeculoplasty first instead of eye drops the cost savings are greater than the cost of selective laser trabeculoplasty for two additional patients, or equal to the cost of five additional ophthalmology specialist appointments.
3VH – Implications for value
So often new procedures are introduced as a replacement for older lower value care, but generally they end up being an additional burden on scarce resources. This was certainly true of the introduction of novel oral anticoagulants where despite spending £0.5billion on these new treatments, we are unaware of any warfarin clinic closing. Our suggestion would be that clinicians working with finance colleagues and patient groups should be given the responsibility for the total budget for the population they serve so they can shift resources from, in the example from this week’s paper, from drop treatment to laser trabeculoplasty, and if resources were freed from the glaucoma system budget, from that budget to the macular degeneration system budget.
This powerful randomised controlled trial, accorded the honour of a Lancet editorial makes a very clear case for switching resources from drug therapy to operative therapy for a very common condition – glaucoma. It focuses on one of the three dimensions of triple value technical value defined as Benefit derived in return for a given resource investment for all the people in need in a population, ensuring equity as well as good outcomes. For example is the balance of investment for people with glaucoma between screening , drug treatment and trabeculectomy and is there evidence of underuse by people in deprived sectors of the community.
The other two dimensions are of course population and personal value are summarised in the appendix to this note. (Also in the Appendix is a link to the CASP checklist for appraising a report of randomised controlled trial).
This is a very important paper but what will happen to its conclusion? Probably there will be a drift of trabeculectomy into practice, with slow or negligible decline in drug treatment and the overspend of the hospital providing the surgical treatment will just creep up and up.
Surely however Gus Gazzard and his clinical colleagues should be put together with finance colleagues to form a glaucoma value improvement community and given the power to implement the necessary changes. While they are at it they might as well tackle the two other dimensions of value, asking questions such as
- did everyone who had a cataract operation have the opportunity of using a decision aid to help them decide whether or not to request the intervention?
- what is the amount invested for people with eye disease comparison with the allocation in other similar populations and how is that distributed to people with glaucoma or to people with cataract or to people with AMD or to people with retinopathy?
The clinicians, with support from statisticians have found the answer, now the clinicians with support from finance colleagues need to implement the answer
Improving the outcomes that matter to an individual for a given amount of resources (money, leadership, time, assets and carbon) used not only by the health system but also by the individual and their family, recognising that the experience of care is a critical element. For example did everyone who had a cataract operation have the opportunity of using a decision aid to help them decide whether or not to request the intervention.
Allocating and Investing resources (money, leadership, time, assets and carbon) more wisely within a health and social care system to optimise the outcomes for the population for which the health and social care system is responsible. For example what is the amount invested for people with eye disease comparison with the allocation in other similar populations and how is that distributed to people with glaucoma or to people with cataract or to people with AMD or to people with retinopathy.
Link to CASP Website here