The State of Economic Evaluation in Vision Research—Adding a fourth for bridge

When I was invited to act as guest editor for this special issue of Ophthalmic Epidemiology I was told that among my duties would be to prepare an accompanying editorial. As I considered what words of wisdom concerning the economics of vision that I might share with you readers, two anecdotes came to mind.

The first concerns a conversation I had with my mother as I was completing my doctoral studies in 2001. My graduate degree was in health services research with a concentration in economic evaluation, something that never fit into an easy description when my parent’s friends inquired as to what their eldest son did for a living. Mom and Dad normally defaulted to “he is a college professor, and does some sort of research ….” Lacking an understanding of my chosen profession only added to my parents concern about the stability of my employment. As I completed my doctoral studies, I was honored to be offered a position in the Department of Ophthalmology and Visual Sciences at Washington University School of Medicine. When I called my mother with the news, her response was “How many years will you have a job? What happens when you have finished answering all the economic questions about eyes?” I confidently assured her that there were enough questions surrounding vision that I would have a long and fruitful career.

The second anecdote concerns the challenge that my mentors faced in guiding a protégé through a unique niche of research. I was privileged to work under the supervision of Dr Mae Gordon, and the chairmanship of Dr Michael Kass, both highly respected clinical trialists who led the highly influential Ocular Hypertension Treatment Study (OHTS).^1,2 Mike, while recognizing the importance of the questions I was investigating, was often bemused at the prospect of giving me direction. Once as we were reviewing the paper presenting the economic evaluation of the OHTS study,³ he expressed frustration concerning who we might ask to review our work prior to submission, saying “If you put everyone who works in your field around a table, you would need a fourth to play bridge!”—His words were prophetic. A few months later when I was at the World Glaucoma Congress in Singapore I found myself sharing coffee with Kevin Frick from the Wilmer Eye Institute and Bloomberg School of Public Health at Johns Hopkins and Gisella Kobelt from the University of Lund---both highly respected economic researchers who built careers looking at vision problems. At the table with us was a highly regarded ocular epidemiologist from Australia. As I surveyed the table, Dr. Kass's words came back to me and I laughed. When my colleagues asked what was so funny, I shared the story of Mike's comments and and turning to our friend from Australia said “…apparently, you get to be the dummy!”

These anecdotes came to mind as I assembled these articles for two reasons: (1) They demonstrate that my mother has nothing to fear concerning a lack of important policy questions to be explored concerning the economics in vision; and, (2) there are a lot more people doing this work than sat at that table in Singapore. The six excellent articles we offer here represent four different countries, are the product of authors who are presenting economic research in vision for the first time, and employ a diverse array of methodological approaches. Two papers present traditional cost-effectiveness studies. Kawasaki and colleagues provide a study of screening for diabetic retinopathy in Japan employing a Markov model estimated using Monte Carlo methods;⁴ while Ma and colleagues examine treatment for retinal detachment employing bootstrapping methods to evaluate areas of uncertainty.⁵ We have two articles examining patient preferences for vision function and services in India. Polack and colleagues examine utilities related to diabetic retinopathy, finding that blindness is a much worse problem for sufferers in India than is typically reported in developed nations.^6,7 Radhakrishnan and colleagues look at patient preferences for cataract surgery using willingness-to-pay methods.⁸ They make a very compelling case that some will find controversial – the provision of free cataract surgery in India may paradoxically reduce the availability of cataract extraction by crowding out surgeons who would be willing to provide low cost surgery, but cannot obtain funding to provide free services. Finally, we have two cost-of-care studies. Galor and colleagues present a study of the association of sociodemographic factors and the cost of eye care in the United States,⁹ and Griffith and colleagues examine the cost associated with a faith-based eye program in Zambia.¹⁰

These articles join a veritable explosion of vision-related economic research conducted over the past decade. My mother’s fears to the contrary, much work remains to be done, and let me offer a few recommendations for future research. First, there is considerable work to be done in properly measuring the impact of vision on quality of life using preference-based measures.¹¹ Current methods for estimating quality adjusted life years (QALYs), when applied properly, do not adequately capture the impact of vision loss (or conversely, improvement) on quality of life and thus likely underestimate the impact of vision interventions. Second, while there have been a number of studies done to examine the economic impact of population-based screening for eye disease in adults, all have been specific to one disease (e.g. glaucoma, macular degeneration) and thus miss the synergy of screening for multiple diseases in the primary care setting. Furthermore, none have been based on validated population-based models of prevalence and progression. These deficiencies must be addressed if we are to properly inform policymakers of the value of vision screening. Third, the plethora of choices of intraocular lenses to cataract patients in the United States offer a unique opportunity to examine the impact of patient preferences for treatment and visual function in a shared decision-making setting. Finally, Exploring this provides a unique opportunity to contribute to our understanding of the role of patient preferences and shared decision making in a clinical setting, there is an urgent need to apply the principles of economic evaluation and preference assessment in developing sustainable models of screening and treatment in nations where there is a scarcity of vision care services. Radhakrishnan and co-authors raise this point in their article,⁸ and it is an argument that deserves to be highlighted. Developing nations, particularly those experiencing rapid growth such as India, China, and the nations of southeast Asia and Central America have an opportunity to leverage their internal resources to improve vision for their citizens and in doing so, feed their economic growth. To do so they must first move beyond a charity model and engage local entrepreneurship and resources. Transdisciplinary research employing experts in vision, economic evaluation, implementation and entrepreneurship will support such development. There are few areas better prepared than the vision community to successfully implement such research models.

I am very proud of the work that has been done in our field over the past decade. But as with many of fields of research, the players change over time. Among our little band sitting around the table in Singapore, Dr Frick has taken an administrative role so as to engage his remarkable talent as an educator, and Dr Kobelt has broadened her scope to bring her talents to other fields of medicine. While I still do occasional work in vision, I have moved from academic life to the private sector. It is very reassuring to see in this issue of Ophthalmic Epidemiology that the talent in our field now fills far more than a single bridge table. Indeed, we could have a good-sized tournament if we so wished. Thus we can all be certain that the coming decade will be filled with new and exciting insights from investigators committed to providing better access to vision care for all.

Declaration of Interest

The author reports no conflict of interest. The author alone is responsible for the content and writing of this article.