Eye Care: Dollars and Sense

The 63rd American Academy of Ophthalmology Edward Jackson Memorial Lecture
Delivered by Centre for Eye Research Australia Managing Director Professor Hugh R. Taylor AC

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23rd November 2006

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A transcript of the Edward Jackson Lecture presented by Hugh Taylor in 2006

It is a great honour to be invited to give the 63rd Edward Jackson Lecture. I have enjoyed listening to, and learnt much from, the giants of ophthalmology who have been selected to receive this recognition over the years by the American Ophthalmic Publishing Company and the Academy. I am proud to be the ninth international Jackson Lecturer and the first from Australia. Thank you.

Edward Jackson was a remarkable man. Previous Jackson lecturers including Paul Lichter and Dan Albert have given wonderful descriptions of his life and contributions. For those of you who are not familiar with these, may I recommend them to you.

Jackson was a man of his age. His passion revolved around refraction, an area in which he made lasting contributions. This was at that time when refraction was developing rapidly, much like cataract surgery has over recent years. In Jackson’s time refraction formed the bulk of an ophthalmologist’s practice and provided most of their income. Again, like cataract surgery today. In addition, Jackson was concerned about two major issues that faced the profession, the dissemination of knowledge and professional integrity. Both remain highly relevant today and each still generates considerable passion and debate.

The Priority Given to Vision Loss

Like all ophthalmologists, Jackson instinctively knew the importance of good vision and eye health. He committed his life to the treatment of eye disease and the prevention of blindness. It was his highest priority; it was his calling, as it is ours. As ophthalmologists, we all accept the importance of good vision without question.

In 1980, I was a much younger and less experienced ophthalmologist. I had been asked by the World Health Organization to undertake a review of eye services in Pakistan on behalf of the Government. When I had completed my review I presented it to the Pakistani Minister of Health. He received the report warmly. Then his reservations came; “….but, eye disease is not a priority for me”. As Health Minister, he was faced with many problems; infant mortality and maternal deaths, the provision of primary health care. He had expensive hospitals to run, and the health needs of a million Afghani refugees in Pakistan at that time. I was stumped as to how to make further arguments for improved eye care services.

Since then, I have puzzled over the challenge of how one should rank and prioritize eye care against other competing issues. This is a challenge we all face, both as individual ophthalmologists and as a profession, whether we are working in our own hospitals, or lobbying politicians and policy makers. On every side there is competition for health dollars.

Population-based Evidence

Epidemiologic field studies can provide a wide range of information. In ophthalmology they have provided information about the prevalence and incidence of eye diseases, and disease risk factors. In 1990, when I left Johns Hopkins and returned to Australia there were no coherent data on the magnitude or causes of vision loss. At best, only fragmented reports were available. So, we started the “Melbourne Visual Impairment Project”, a large population-based survey. We wanted to determine the prevalence and causes of vision loss, examine the risk factors for it, and identify barriers to the provision of eye care.

In designing this study I built on the lessons I had learnt from my mentor, Fred Hollows, with whom I had worked in Aboriginal communities in Australia; the work I had done at the Dana Centre on the Chesapeake Bay Waterman Study; our various studies on trachoma and onchocerciasis in Africa and Latin America; and of course the work of my close colleague, Al Sommer, on the East Baltimore Eye Survey.

The Melbourne VIP was a set piece, population-based, epidemiologic study of eye disease. It took five years to complete the first round of the field work that included urban, rural and nursing home samples. Paul Mitchell in Sydney later started the Blue Mountains Eye Study and we were able to share and harmonize some of our survey methodology and later combine some of our analysis.

In many aspects the Melbourne VIP was similar to the other, large population-based studies of eye disease; East Baltimore, Beaver Dam, Rotterdam, Blue Mountains, Barbados, Proyecto Ver and Andra Pradesh. However, our study differed from most other studies in that we did not exclude those aged over 85. Instead, we included even the oldest people, who as it turned out, had even higher rates of vision loss. In addition, our sample was truly representative of the population because it did include urban, rural and institutionalized populations, rather than just those from a single geographic location.

The Prevalence and Causes of Vision Loss

These epidemiologic studies show that the amount of vision loss and eye disease increases dramatically with increasing age. For each decade over the age of 40 the amount of blindness and vision loss increases three-fold.

The studies from different countries show a remarkably consistent picture. Our Australian data were combined with data from other countries to give an estimate for vision loss and eye disease in the US. Even though there may be large differences in ethnic minorities, economic status and health care delivery, the age-specific rates and causes of vision loss and blindness are remarkably consistent in these different Developed Economies.

The distribution and causes of vision loss today are vastly different from 100 years ago when Edward Jackson was in practice. Then ophthalmia neonatum and corneal infection, and injury in young adults were the leading causes of blindness. The average life expectancy was about 40 years and most blindness was seen in young people. Nowadays, in Australia and the US, over 80% of those with vision loss are over the age of 65.

Today, half the blindness in Australia and other Developed Countries is due to Age-Related Macular Degeneration and just five conditions account for three quarters of vision loss. The “Big Five” of the ophthalmic jungle are: AMD, cataract, diabetic eye disease, glaucoma and under-corrected refractive error.

Similarly with vision impairment (that is less than 20/40) the same five conditions cause three quarters of the vision loss, although here under-corrected refractive error is of much greater importance.

When asked what health condition they fear most, one third of people will identify blindness, another third will identify cancer, and a third will identify a wide range of other ailments or fears. However, although the development of blindness is something that is feared, most people regard blindness and vision loss to be so rare that they are unlikely to be affected. Similarly, most health planners and policy-makers also regard vision loss to be of little importance or priority. This is why I was stumped in my argument with the Minister of Health about the importance of vision loss. People have recognized neither the frequency with which vision loss occurs, nor its impact.

The Impact of Vision Loss

Over the last few years, studies in Australia and elsewhere have shown that even relatively small degrees of visual impairment can have a major impact on the quality and the length of life. The critical level of vision is that required for an unrestricted driving licence. People with less than 20/40 have a significantly increased risk of falls, fractures, depression and death. They have a substantial loss of social independence, and they are likely to be admitted to nursing homes three years earlier, than those with normal vision. Even this relatively moderate reduction in vision prevents people from enjoying healthy and independent ageing.

The Costs of Vision Loss

More recently, we have analysed the economic impact and cost of vision loss in Australian communities. We found that vision loss and its costs had been totally overlooked.

Throughout the following analyses I have used Australian dollars. The exchange rate is usually about $US0.75 to $AU1.00. International dollars are used to compare the Relative Purchasing Power Parity of a currency in its own country. In these terms, the Australian dollar is very nearly equivalent to the US Dollar. For all intents, we can talk dollar for dollar per person. The difference is that the US population is 14 times larger than Australia’s.

We were surprised to discover that vision loss is the seventh leading cause of disability in Australia. It causes nearly 3% of the national total of years of life lost due to disability. It has a similar impact to that of diabetes or coronary heart disease, and has a much greater impact than conditions such as breast cancer, prostate cancer, or HIV/AIDS. The loss of well-being and premature death associated with vision loss costs Australia $ 4.8 billion each year.

Data published this year on the Global Burden of Disease show that world-wide, vision loss in aggregate ranks as the sixth most important cause of disability.

We found that the indirect costs of vision loss are $3.2 billion. The indirect costs include the loss of earnings, the cost of carers, low vision aids and other costs.

The direct health costs for eye disorders total $1.8 billion per year. Direct costs include hospital care, outpatient and office visits, optometry costs, drugs and other direct medical expenses. Of these, cataract surgery is the single largest direct health cost.

Everyone will develop cataract. Four out of 10 people over the age of 60 have at least some cataract. In Australia 10% have already had surgery. Last year, 180,000 cataract operations were performed. This gives a Cataract Surgery Rate of 9000 per million people per year. This is even higher than the rate quoted in the US of about 7000.

The direct health costs for vision disorders rank seventh in Australia. The direct costs for vision loss exceed those of arthritis, stroke or depression. In fact, vision disorders cost as much as diabetes and asthma combined.

Altogether, the total cost of vision loss in Australia last year was nearly $10 billion. But this is only part of the story. This is the current situation, what will happen in the future?

Our community is aging. This is linked to our increasing life expectancy and falling birth rate. The number of people in Australia over the age of 65 will double in the next 20 years, at the same time the overall population will only increase by about 20%. This is due to the baby boomers aging. The US and other Developed Countries face the same issue.

This means that the number of Australians with vision impairment will almost double over the next 20 years to nearly 800,000.

The costs of eye care will increase much faster than population growth because of the increasing proportion of older people. In fact, the costs will more than double by 2020. National health policy makers and health planners need to take vision loss seriously. It already has huge and broad-ranging impacts on our society and these will continue to grow in the coming years.

However, these data provide us with a crystal ball to see the future. We should be well placed to plan and manage this developing problem because we now have the evidence base.

The Costs of Eye Care

Most vision loss now can be prevented or treated, usually by highly cost-effective measures. An intervention is cost-effective if it costs less than three times Gross Domestic Product per capita to avert the loss of one Quality Adjusted Life Year or QALY (an economic measure of a year of good health). However, if an intervention costs less than one GDP per capita, $37,000 per QALY, it is very cost effective. Cataract surgery costs less than $3,000 per QALY, and that makes it extraordinarily cost-effective. Screening for diabetic retinopathy, even in rural and remote areas, is also highly cost-effective at less than $20,000 per QALY.

It has been shown over and over again; prevention is much better than cure. We must reverse the projected increase in prevalence, cost and the loss of well-being caused by vision loss. There are three measures to accomplish this, and they are quite straightforward.

First, we must prevent the vision loss that we can prevent. We need appropriately resourced, long-term promotion of eye health to reduce vision loss from causes that are already known and avoidable. The Vision Initiative in Victoria is an example of this. The National Eye Health Program (NEHEP) of the National Eye Institute is another good model. Similar efforts are needed elsewhere. We need to ensure that people have the appropriately timed eye examinations, and simple preventative measures are promoted, like smoking reduction and UV-B protection.

Second, we must treat the eye diseases that we can treat. We need to provide adequate funding for eye care services for the treatable eye conditions, and also provide low vision support services to those whose vision loss cannot be reversed. It is both unconscionable and uneconomical to have people on long waiting lists for cataract surgery. We must increase our capacity to handle these conditions now, and build the capacity needed to manage the increasing workload of the future.

Last year we costed a package of 14 specific interventions to eliminate avoidable vision loss in Australia. For each dollar spent, the country would save five dollars. We have shown that preventing and treating eye disease actually saves money.

Third, there must be a substantial increase in funding for research into the causes of vision loss and blindness that at present, cannot be either prevented or treated. This is especially true for conditions such as macular degeneration and glaucoma.

Age-related macular degeneration (AMD) affects one person in four over the age of 60, but the prevalence of AMD increases dramatically in the oldest age groups, and for those in their 90’s, nearly two-thirds will have at least early macular degeneration and nearly 20% are blind. AMD is strongly linked to cigarette smoking and more recently to genes for several complement factors.

But, despite recent advances for most people, there is still no effective prevention or treatment. However, if we could slow the progression of macular degeneration by just 10%, we could save an average of $250 million each year for the next 20 years.

This provides a very strong argument for additional funding for research to slow the progression of AMD.

Dollars and Sense

At long last, we are able to discuss priorities with health bureaucrats and policy makers, and Ministers of Health, in a way I could not do when I first met the Minister of Health in Pakistan, all those years ago. We now have the information that is required, to place the needs for eye care in perspective, and to compare it with other health priorities. We can quantify and rank the impact of vision loss and the cost of not addressing it. Armed with these data we can now effectively answer the Ministerial “but....” response.

In November 2005, the Australian governments presented the National Eye Health Framework that incorporates and endorses many of these ideas in a five point plan.

This is the first time Australia has had a national plan and in May this year the Australian Government committed $14 million to eye health promotion. Of course, the next challenge will be to translate these plans into action.

Although most of the information I have referred to is from Australia, there are many similarities with the situation in the US and other developed countries. We have had the unique opportunity to do these analyses within Australia, as we had access to good data on all the factors involved; including the epidemiology of eye disease, the population structure, the total national health care costs and employment costs; and the impact of vision loss both on quality of life and in economic terms. But having performed this detailed analysis in one jurisdiction such as Australia, the cost of vision loss in other countries can be extrapolated by looking at the ratio of costs, such as those within eye care, or the relative ranking of eye-care costs and other health conditions.

We believe that these data, on the economic impact of vision loss, will be broadly useful in helping to argue the importance of eye care. They will help give it, the priority that Edward Jackson instinctively knew it should have.

A body of work such as this is clearly the result of the contributions of many people. I want to recognize and thank the mentors who have guided me, Gerard Crock, Fred Hollows, and three previous Jackson Lecturers, Ed Maumenee and Arnall Patz, and my good friend and colleague Al Sommer.

A large team of people at the Centre for Eye Research Australia and the Department of Ophthalmology at the University of Melbourne have worked on these projects.

But I want to particularly thank Cathy McCarty and Mylan van Newkirk for their contributions to the Visual Impairment Project, Jill Keeffe for her great work on the impact of low vision and Jill and Lynne Pezzullo (Access Economics) for their work on the health economic analyses.

Finally I must recognize the strong and ongoing support of my wife Elizabeth and my family. They have been tolerant, supportive, loving and long suffering.