Direct and indirect healthcare costs of ocular diseases in Italy: a literature review on glaucoma, diabetic retinopathy, and macular degeneration
Keywords:
Glaucoma; Diabetic retinopathy; Age-related macular degeneration; Economic Burden; Healthcare costs; Public healthAbstract
Background. Glaucoma, diabetic retinopathy, and age-related macular degeneration impose substantial economic burdens on healthcare systems due to their high prevalence and chronic nature. Nevertheless, comprehensive Italian data is limited. This study aims to collect Italian evidence on the economic impact of these conditions to support more effective healthcare planning.
Study Design. Systematic review.
Methods. A systematic literature search was conducted in accordance with PRISMA guidelines across PubMed, Scopus, Web of Science, and EMBASE databases. Studies reporting cost evaluations of managing glaucoma, diabetic retinopathy, and age-related macular degeneration in Italy were included. Direct, indirect and non-medical costs were considered.
Results. The review included 23 studies exhibiting considerable heterogeneity in timeframes, regions, and economic evaluation approaches. For glaucoma, annual direct costs ranged from €788.70 for early-stage cases to €8,368.51 for advanced cases requiring surgery. Annual costs associated with diabetic retinopathy ranged from €4,050 to €5,799 per patient, depending on disease severity and treatment approach. The financial burden of age-related macular degeneration varied considerably, with costs ranging from €1,399.20 for early-stage cases to €3,973.30 for advanced stages. Although non-medical and indirect costs, such as lost productivity and caregiving expenses were less frequently assessed, they represented a significant contributor to the overall financial burden.
Conclusions. This study highlights the substantial economic burden ocular diseases place on the Italian healthcare system. Early intervention and preventive strategies could reduce the long-term costs of managing diabetic retinopathy and age-related macular degeneration. Further research into indirect costs and cost-effective interventions is necessary to support more efficient healthcare resource allocation.
References
1. Atella V, Piano Mortari A, Kopinska J, Belotti F, Lapi F, Cricelli C, et al. Trends in age-related disease burden and healthcare utilization. Aging Cell. 2019 Feb;18(1):1-8. e12861. doi: 10.1111/acel.12861. Epub 2018 Nov 29.
2. Istituto Nazionale di Statistica (ISTAT). Previsioni della popolazione residente e delle famiglie. Popolazione in calo progressivo. 2022 Sep 22;1-31.
3. Bourne RRA, Steinmetz JD, Saylan M, Mersha AM, Weldemariam AH, Wondmeneh TG, et al. Causes of blindness and vision impairment in 2020 and trends over 30 years, and prevalence of avoidable blindness in relation to VISION 2020: the Right to Sight: an analysis for the Global Burden of Disease Study. Lancet Glob Health. 2021 Feb;9(2):e144-e160. doi: 10.1016/S2214-109X(20)30489-7. Epub 2020 Dec 1.
4. Sabanayagam C, Cheng CY. Global causes of vision loss in 2015: are we on track to achieve the Vision 2020 target? Lancet Glob Health. 2017 Dec;5(12):e1164-e1165. doi: 10.1016/S2214-109X(17)30412-6. Epub 2017 Oct 11.
5. Flaxman SR, Bourne RRA, Resnikoff S, Ackland P, Braithwaite T, Cicinelli MV, et al. Global causes of blindness and distance vision impairment 1990-2020: a systematic review and meta-analysis. Lancet Glob Health. 2017 Dec;5(12):e1221-e1234. doi: 10.1016/S2214-109-X(17)30393-5. Epub 2017 Oct 11.
6. Bonsaksen T, Brunes A, Heir T. Quality of life in people with visual impairment compared with the general population. J Public Health. 2023 Jul 8. doi:10.1007/s10389-023-01995-1.
7. Burton MJ, Ramke J, Marques AP, Bourne RRA, Congdon N, Jones I, et al. The Lancet Global Health Commission on Global Eye Health: vision beyond 2020. Lancet Glob Health. 2021;9(4):e489-551. doi: 10.1016/S2214-109-X(20)30488-5. Epub 2021 Feb 16.
8. Nuzzi A, Becco A, Boschiroli A, Coletto A, Nuzzi R. Blindness and visual impairment: quality of life and accessibility in the city of Turin. Front Med. (Lausanne). 2024 Mar 21;11:1361631. doi: 10.3389/fmed.2024.1361631.
9. Società Oftalmologica Italiana (SOI). Glaucoma. L’importanza di una diagnosi precoce. Available from: https://www.sedesoi.com/vademecum-glaucoma/ [Last accessed: 2024 Nov 7].
10. Avogaro A, Fadini GP. Microvascular complications in diabetes: A growing concern for cardiologists. Int J Cardiol. 2019 Sep 15;291:29-35. doi: 10.1016/j.ijcard.2019.02.030. Epub 2019 Feb 25.
11. Bourne RRA, Jonas JB, Bron AM, Cicinelli MV, Das A, Flaxman SR, et al; Vision Loss Expert Group of the Global Burden of Disease Study. Prevalence and causes of vision loss in high-income countries and in Eastern and Central Europe in 2015: magnitude, temporal trends and projections. Br J Ophthalmol. 2018 May;102(5):575-585. doi: 10.1136/bjophthalmol-2017-311258. Epub 2018 Mar 15.
12. Vision Loss Expert Group of the Global Burden of Disease Study; GBD 2019 Blindness and Vision Impairment Collaborators. Global estimates on the number of people blind or visually impaired by glaucoma: A meta-analysis from 2000 to 2020. Eye (Lond). 2024 Aug;38(11):2036-2046. doi: 10.1038/s41433-024-02995-5. Epub 2024 Apr 2.
13. Associazione Medici Diabetologi (AMD) - Società Italiana di Diabetologia (SID). Standard italiani per la cura del diabete mellito. 2018; 6-12.
14. Li JQ, Welchowski T, Schmid M, Mauschitz MM, Holz FG, Finger RP. Prevalence and incidence of age-related macular degeneration in Europe: a systematic review and meta-analysis. Br J Ophthalmol. 2020 Aug;104(8):1077-1084. doi: 10.1136/bjophthalmol-2019-314422. Epub 2019 Nov 11.
15. Wittenborn JS, Zhang X, Feagan CW, Crouse WL, Shrestha S, Kemper AR, et al. The economic burden of vision loss and eye disorders among the United States population younger than 40 years. Ophthalmology. 2013 Sep;120(9):1728-35. doi: 10.1016/j.ophtha.2013.01.068. Epub 2013 Apr 28.
16. Albrecht M, Nica M, Colombo D, Ferri C, Tadini P, Introini U, et al. Il trattamento con farmaci intravitreali anti-VEGF in pazienti naïve in Italia. Global & Regional Health Technology Assessment. 2018;5:1-10. doi:10.1177/2284240318793905.
17. Bandello F, Augustin A, Sahel JA, Benhaddi H, Negrini C, Hieke K, et al. Association between visual acuity and medical and non-medical costs in patients with wet age-related macular degeneration in France, Germany and Italy. Drugs Aging. 2008;25(3):255-68. doi: 10.2165/00002512-200825030-00007.
18. Christensen TL, Poulsen PB, Holmstrom S, Walt JG, Vetrugno M. A Markov modelled pharmacoeconomic analysis of bimatoprost 0.03% in the treatment of glaucoma as an alternative to filtration surgery in Italy. Curr Med Res Opin. 2005 Nov;21(11):1837-44. doi: 10.1185/030079905X65592.
19. De Natale R, Le Pen C, Berdeaux G. Efficiency of glaucoma drug regulation in 5 European countries: a 1995-2006 longitudinal prescription analysis. J Glaucoma. 2011 Apr-May;20(4):234-9. doi: 10.1097/ijg.0b013e3181e0791c.
20. Denti C, Garattini L, Lanzetta P, Parazzini F, Ricci E, Gruppo di Studio Progetto CARMA. Costi della Degenerazione Maculare legata all’età in Italia. [Cost of Age-Related MAcular degeneration in Italy]. Pharmacoeconomics-Ital-Res-Articles. 2002 Sep;4(2):57-63. doi: 10.1007/BF03320595. Epub 2013 Feb 27.
21. Fea AM, Cattel F, Gandolfi S, Buseghin G, Furneri G, Costagliola C. Cost-utility analysis of trabecular microbypass stents (TBS) in patients with mild-to-moderate open-angle Glaucoma in Italy. BMC Health Serv Res. 2021 Aug 17;21(1):824. doi: 10.1186/s12913-021-06862-x.
22. Ferrario L, Foglia E, Garagiola E. Innovazione nel trattamento del glaucoma: sostenibilità dell’adozione del device XEN gel stent all ’interno del contesto italiano. 2020;7:1-40. doi: 10.25428/ucresearchreport/7_2020.
23. Foglia E, Ferrario L, Bandello F, Ferri C, Figini I, Franzin M, et al. Diabetic macular edema, innovative technologies and economic impact: New opportunities for the Lombardy Region healthcare system? Acta Ophthalmol. 2018 Jun;96(4):e468-e474. doi: 10.1111/aos.13620. Epub 2017 Dec 14.
24. Gandjour A, Kleinschmit F, Lauterbach KW; INTERCARE International Investigators. European comparison of costs and quality in the prevention of secondary complications in Type 2 diabetes mellitus (2000-2001). Diabet Med. 2002 Jul;19(7):594-601. doi: 10.1046/j.1464-5491.2002.00763.x.
25. Garattini L, Castelnuovo E, Lanzetta P, Viscarra C, Ricci E, Parazzini F, et al. Direct medical costs of age-related macular degeneration in Italian hospital ophthalmology departments. A multicenter, prospective 1-year study. Eur J Health Econ. 2004 Feb;5(1):22-7. doi: 10.1007/s10198-003-0198-x.
26. Holmstrom S, Buchholz P, Walt J, Wickstrøm J, Aagren M. The cost-effectiveness of bimatoprost, latanoprost and timolol in treatment of primary open angle glaucoma in five European countries. Curr Med Res Opin. 2006 May;22(5):897-905. doi: 10.1185/030079906X104687.
27. Hommer A, Wickstrøm J, Friis MM, Steeds C, Thygesen J, Ferreras A, et al. A cost-effectiveness analysis of fixed-combination therapies in patients with open-angle glaucoma: a European perspective. Curr Med Res Opin. 2008 Apr;24(4):1057-63. doi: 10.1185/030079908x280626. Epub 2008 Feb 29.
28. Invernizzi A, Bevilacqua MT, Cozzi M, Bianchi C, Pagani A, Cigada M, et al. Diabetic retinopathy screening: The first telemedical approach in an Italian hospital. Eur J Ophthalmol. 2016 Jun 10;26(4):369-74. doi: 10.5301/ejo.5000719. Epub 2015 Dec 14.
29. Koleva D, Motterlini N, Schiavone M, Garattini L; Study Group GLAUCO. Medical costs of glaucoma and ocular hypertension in Italian referral centres: a prospective study. Ophthalmologica. 2007;221(5):340-7. doi: 10.1159/000104765.
30. Lazzaro C, van Steen C, Ghirelli G, Sacchi M, Sisto D, Uva M, et al. A latanoprost cationic emulsion (STN1013001) vs. other latanoprost formulations (Latanoprost) in open angle glaucoma/ocular hypertension and ocular surface disease: an Italian cost-utility analysis. Expert Rev Pharmacoecon Outcomes Res. 2023 Feb;23(2):251-265. doi: 10.1080/14737167.2023.2161515. Epub 2023 Jan 9.
31. Lee PP, Kelly SP, Mills RP, Traverso CE, Walt JG, Doyle JJ, et al. Glaucoma in the United States and europe: predicting costs and surgical rates based upon stage of disease. J Glaucoma. 2007 Aug;16(5):471-8. doi: 10.1097/IJG.0b013e3180575202.
32. Muscio A, Ciriaci D, Cruciani F. A simulation of cost-benefit analysis of blindness prevention in Italy. Clin Ter. 2011;162(6):e187-94.
33. Perrone V, Dovizio M, Veronesi C, Citraro R, De Francesco A, Dell’Orco S, et al. Retrospective Analysis of the Pharmaco-Utilization of VEGF Inhibitors and Health Care Costs among Patients with Wet Age-Related Macular Degeneration and Other Ocular Diseases in Italy. Int J Environ Res Public Health. 2022 Feb 23;19(5):2548. doi: 10.3390/ijerph19052548.
34. Perrone V, Formica D, Piergentili B, Rossetti L, Degli Esposti L. Real-World Analysis on the Characteristics, Therapeutic Paths and Economic Burden for Patients Treated for Glaucoma in Italy. Healthcare (Basel). 2023 Feb 21;11(5):635. doi: 10.3390/healthcare11050635.
35. Porta M, Rizzitiello A, Tomalino M, Trento M, Passera P, Minonne A, et al. Comparison of the cost-effectiveness of three approaches to screening for and treating sight-threatening diabetic retinopathy. Diabetes Metab. 1999 Mar;25(1):44-53.
36. Scarpa G, Urban F, Vujosevic S, Tessarin M, Gallo G, Visentin A, et al. The Nonmydriatic Fundus Camera in Diabetic Retinopathy Screening: A Cost-Effective Study with Evaluation for Future Large-Scale Application. J Ophthalmol. 2016;2016:4625096. doi: 10.1155/2016/4625096. Epub 2016 Nov 3.
37. Scuteri D, Vero A, Zito M, Naturale MD, Bagetta G, Nucci C, et al. Diabetic retinopathy and age-related macular degeneration: a survey of pharmacoutilization and cost in Calabria, Italy. Neural Regen Res. 2019 Aug;14(8):1445-1448. doi: 10.4103/1673-5374.253528.
38. Traverso CE, Walt JG, Kelly SP, Hommer AH, Bron AM, Denis P, et al. Direct costs of glaucoma and severity of the disease: a multinational long term study of resource utilisation in Europe. Br J Ophthalmol. 2005 Oct;89(10):1245-9. doi: 10.1136/bjo.2005.067355.
39. Meier-Gibbons F, Töteberg-Harms M. Influence of Cost of Care and Adherence in Glaucoma Management: An Update. J Ophthalmol. 2020 Apr 8;2020:5901537. doi: 10.1155/2020/5901537.
40. Lazcano-Gomez G, Ramos-Cadena MLA, Torres-Tamayo M, Hernandez de Oteyza A, Turati-Acosta M, Jimenez-Román J. Cost of glaucoma treatment in a developing country over a 5-year period. Medicine (Baltimore). 2016 Nov;95(47):e5341. doi: 10.1097/MD.0000000000005341.
41. Wong WL, Su X, Li X, Cheung CM, Klein R, Cheng CY, et al. Global prevalence of age-related macular degeneration and disease burden projection for 2020 and 2040: a systematic review and meta-analysis. Lancet Glob Health. 2014 Feb;2(2):e106-16. doi: 10.1016/S2214-109X(13)70145-1. Epub 2014 Jan 3.
42. Burton MJ, Ramke J, Marques AP, Bourne RRA, Congdon N, Jones I, et al. The Lancet Global Health Commission on Global Eye Health: vision beyond 2020. Lancet Glob Health. 2021 Apr;9(4):e489-e551. doi: 10.1016/S2214-109-X(20)30488-5. Epub 2021 Feb 16.
43. Ministry of Health, Italy. Prevenzione ipovisione e cecità. Available from: https://www.salute.gov.it/portale/prevenzioneIpovisioneCecita/homePrevenzioneIpovisioneCecita.jsp [Last accessed: 2024 Nov 7].
44. Law 10 February 1962, n. 66. Nuove disposizioni relative all’Opera nazionale per i ciechi civili. GU Serie Generale n. 61 del 07-03-1962. Available from: https://www.gazzettaufficiale.it/eli/id/1962/03/07/062U0066/sg [Last accessed: 2024 Nov 7].
45. Nuove norme in materia di indennità di accompagnamento ai ciechi civili ed ai pluriminorati. GU Serie Generale n.7 del 10-01-1992). Available from: https://www.gazzettaufficiale.it/atto/serie_generale/caricaDettaglio-Atto/originario?atto.dataPubblicazioneGazzetta=1992-01-10&atto.codiceRedazionale=092G0014 [Last accessed: 2024 Nov 7].
46. Law 21 November 1988, n. 508. Norme integrative in materia di assistenza economica agli invalidi civili ai ciechi civili e ai sordomuti. GU Serie Generale n. 277 del 25-11-1988. Available from: https://www.gazzettaufficiale.it/eli/id/1988/11/25/088G0583/sg [Last accessed: 2024 Nov 7].
47. Ministry of Health, Italy. Relazione del ministro della Salute sullo stato di attuazione delle politiche inerenti la prevenzione della cecità, l’educazione e la riabilitazione visiva (legge 284/97) - Dati 2020. Available from: https://www.salute.gov.it/portale/documentazione/p6_2_2_1.jsp?id=3402 [Last accessed: 2024 Nov 7].
48. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care. 2004 May;27(5):1047-53. doi: 10.2337/diacare.27.5.1047.
49. Associazione Medici Diabetologi (AMD), Associazione Medici Dirigenti (ANAAO-ASSOMED), Consorzio Mario Negri Sud, et al. Linee-guida per lo screening, la diagnostica e il trattamento della retinopatia diabetica in Italia. 2015.
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