Methodological quality of the review: Medium confidence
Author: Monali S Malvankar-Mehta; Ryan Wilson; Erik Leci; Kelly Hatch; Sapna Sharan
Region: UK, USA, India, Germany, China, Singapore, Sweden, Tanzania
Sector: Refractive errors and amblyopia
Subsector: Cost and quality of life of overlooked eye care needs
Equity focus: No
Study population: Children
Type of programme: Community based
Review type: Other review
Quantitative synthesis method: Systematic review
Qualitative synthesis method: Not applicable
Background: Although much of the developed world has some level of universal health coverage, many vital health services still burden patients with significant out-of-pocket costs. In ophthalmology, this is perhaps truest in the field of pediatric ophthalmology where, specifically, the cost of contact lenses and glasses for refractive errors is rarely covered by single payer universal health care programmes, yet is frequently prescribed. This issue is compounded by several problems that are unique to pediatric eye care and eye pathology which cause frustration to the provider for pediatric eye care. The vast majority of information currently available on the costs surrounding pediatric eye care is from a health care spending perspective and does not consider out-of-pocket expenses the families of young children are expected to afford. Glasses break very frequently with activities of these young children and need to be replaced as frequently. This overburdens families and many tend to wait several weeks or months before finances are arranged or insurance benefits kick in. We know refractive errors and amblyopia can run in families, and many times multiple children in the family are also involved in simultaneous pediatric ophthalmology care.
Objectives: The objective of this research was to conduct a systematic review and cost analysis to summarise, from the Ministry of Health perspective, the costs families might incur because of their child’s prescription for refractive errors and amblyopia correction.
Main findings: After screening, 48 records were assessed for eligibility. From these, a final total of 14 studies were found eligible for our quantitative analysis. This review included datasets from the US, UK, Germany, Sweden, India, People’s Republic of China, Singapore and Tanzania. Further, the study design of the included works examined cost analysis, cost-effectiveness analysis, cohort studies, randomised controlled trials, chart review and a cross-sectional study. Diagnosis in the studies included strabismus, amblyopia, anisometropia, esotropia, myopia, congenital cataract and refractive errors. Sample size in the included studies ranged from 48 to 6,904 patients. Annual cost of the glasses per patient in included studies was highest for congenital cataract patients and lowest for refractive error patients. Patients with visual acuity of 20/20 varied from 15.5% to 100%, 20/32 varied from 29.3% to 49.4%, 20/40 from 8.8% to 20.3%. 40% of refractive error patients were not able to afford glasses. Cost of glasses for high refractive error was US$92.67 per utility gained in non-compliant children. The annual cost of glasses for patients with refractive error was 97% less expensive compared to patients with congenital cataract, 94% less expensive compared to amblyopes (mixed), 93% compared to esotropes, 92% compared to patients with strabismus, 89% compared to anisometropes, and 86% compared to myopes. Annual cost of glasses for refractive error patients increased to $55.6 (US dollars) over a five-year time horizon. For esotropia patients, annual cost of glasses per patient increased to $840, for myopes to $410.5, for amblyopes (mixed) to $915.8, for anisometropes to $520.6, and for patients with strabismus to $727.6 over a five-year period. The annual cost for patching increased to $945, $470.45, $395.15, and $75.9 for patients with congenital cataract, amblyopia (mixed), strabismus, and anisometropia, respectively, over a five-year time horizon.
Authors noted that based on findings, the cost of corrective lenses is associated with significant financial burden and thus other means of mitigating costs should be considered. Eyesight problems in children are perceived as low-priority health needs. Thus, educational interventions on substantial visual deficits of not wearing glasses should be offered to families and governmental health agencies.
Inclusion criteria were as follows: 1) publication in English language; 2) pediatric population between the age of 3 and 10 years; 3) publication dates from 2000 and onwards; and 4) journal articles, systematic reviews, meta-analysis, cost analysis, cost-utility analysis, cost-effectiveness analysis, multicentre studies, randomised controlled trials, non-randomised studies, including cohort studies (retrospective, prospective), clinical trials, and comparatives studies. There was no limit set by geography or country where the study was carried out.
For this review, authors used the (PRISMA) guidelines. Literature, including published and unpublished scientific work, was systematically reviewed, and the following bibliographic databases were searched from January 2000 to May 2017: Medline (Ovid and PubMed), Embase (Ovid), BIOSIS Previews (Thomson-Reuters), CINAHL (EBSCO), Health Economic Evaluations Database (HEED), ISI Web of Science (Thomson-Reuters), and the Cochrane Library (Wiley). Database-specific subject headings and key words were employed in the search strategy. Gray literature was identified by searching the conference abstracts of various meetings, including the Canadian Ophthalmology Society meeting, American Association of Pediatric Ophthalmology and Strabismus, American Academy of Ophthalmology annual meeting, European Society of Ophthalmology, and the Association for Research in Vision and Ophthalmology annual meeting. The ProQuest Dissertations and Theses databases and the Canadian Health Research Collection (Ebrary) were also searched for relevant content. Google and other internet search engines were used to search for additional web-based materials and information. The first reviewer extracted data from the included studies, and a second reviewer resolved errors or mistakes, if any, by reviewing the extracted data. Data extracted included study objective, design, location, inclusion and exclusion criteria, data collection technique, data collection period, total patients enrolled in and completed the study, refusal to consent, number of females, patient demographic characteristics, follow-up, diagnosis, cost of prescribed modality for vision correction, secondary cost to vision correction, visual outcome, and compliance Using a Downs and Black checklist, each included article was independently appraised by the two reviewers for quality.
Applicability/external validity: Regarding the external validity, the authors reported significant strength of their review: the included studies had coherent results of improvement in visual outcomes post-treatment. There was heterogeneity between studies. On the other hand, some limitation was acknowledged which need to be taken into account: all studies were included irrespective of their quality, because of the limited number of articles we encountered on this topic. The cost-utility analysis of observational studies is influenced by inherent bias in the included articles. Finally, only studies published in English were included.
Geographic focus: Not discussed.
Summary of quality assessment:
This review was attributed medium confidence because of the following limitations: the search was conducted from January 2000 to May 2017; the authors used the Downs and Black checklist for quality appraisal of each study, but no table was provided to make clear which study is subject to low risk of bias. In addition, authors noted including only 14 studies due to language restriction.