Modelling lifetime cost consequences of toric compared with standard IOLs in cataract surgery of astigmatic patients in four European countries

Figures & data

Figure 1. Scheme of the toric model.

Table 1. Results of the clinical trial comparing toric IOL and monofocal IOL and of the European survey.

Study description	Toric IOL n=256	Monofocal IOL n=261	European survey n=408
	Randomised clinical trial, toric versus monofocal, mainly unilateral, small group of bilateral implantation		Observational survey of patients after cataract surgery, all patients monofocal, bilateral implantation Main objective: refraction resource utilisation
Rate of re-intervention*	1.6%	0%
Do not wear spectacles*	5.4%	9.10%
Wear spectacles*	94.6%	90.9%
Some of the time	67.6%	36.4%
Half of the time	18.9%	18.2%
Most of the time	2.7%	9.1%
All of the time	5.4%	27.3%
Type of spectacles^†			France	Germany	Italy	Spain
With reading spectacles only	74.3%	30.0%	12.0%	39.0%	24.7%	47.3%
With distance spectacles only	0.0%	0.0%	3.6%	2.4%	17.1%	8.8%
With reading and distant spectacles	0%	5.0%	8.4%	6.5%	24.8%	24.6%
With bifocal spectacles	17.1%	50.0%	12.0%	17.1%	14.0%	7.0%
With other spectacles (multifocal)	8.6%	15.0%	64.0%	35.0%	19.4%	12.3%

*Estimated on the all population (unilateral and bilateral).

^†Estimated on the bilateral implanted population (toric: 37, monofocal: 22).

Table 2. Unit costs (societal) according to country and type of resource consumed (€).

Item	France	Germany	Italy	Spain
Cataract surgery
Surgery	1,145.9^a	1,250.0^b	1,106.0^c	1,050.0^d
Spectacles with toric IOL^e	487.7	255.8	249.3	214.6
Spectacles with monofocal IOL^f	657.2	400.0	393.4	292.0
Unit cost of cleaning	3.0	3.0	3.0	3.0
Visit
Ophthalmologist	25.0^g	57.8^h	100.0^i	60.0^j
Optometrist	–	0.0	0.0	40.0
Mean cost per km
Visit/implant	0.39^k	0.27^l	0.31^m	0.46^n
Optic centre	0.31^k	0.23^l	0.31^m	0.45^m
Cost of work/hour^p	24.7	26.2	21.39	14.8

^aPMSI (DRG) 2004 database. National cost database (ENC) and private cost database 1999 (inflated).

^bDRG tariffs 2006.

^cNew National DRG Tariff 2006 & Alcon. In Italy the DRG varies according to the different Italian regions and ranges between €800 and a maximum of €1,400 (Alcon).

^dDRG tariffs 2006 & Alcon. In Spain, cataract surgery costs vary between €900 and €1200 approximately (Alcon).

^eCost of spectacles from societal perspective calculated from dedicated spectacles survey 2006 combined with distribution of patients according to type of spectacles (Clinical Study – Alcon).

^fCost of spectacles for society perspective calculated from dedicated spectacles survey 2006.

^gCCAM Classification Communes des Actes Médicaux.

^hThe National Association of Statutory Health Insurance Physicians.

ⁱNational Ambulatory Tariff for specialist's outpatient visit.

^jAverage cost of ophthalmologist visit (varying by region).

^kAaverage cost of 1 km by bus: €0.10/km based on ticket price of €1.40 divided by mean number of km; by car: €0.40/km; by train: €0.19/km SNCF €0.19/km; by taxi: €0.90/km – Taxis-de-France – based on Tariff A (10:00 to 17:00 h) = €0.70 + fixed €1.8.

^lMobilCheck Deutsche Bahn, ADAC average cost of 1 km by bus: €0.20/km (assumption same tariff system as for train); by car: €0.41/km; by train: €0.20/km; by taxi: €1.10/km.

^mAverage cost of 1 km by bus: €1.10/km (assumption same tariff system as for train); by car: €0.4/km; by train: €0.10/km; UI €1.70/km;

ⁿConsumers EROSKI n°92, Oct 2005. Average cost of 1 km by bus: €0.37/km (assumption same tariff system as for train); by car: €0.36/km; by train: €0.31/km; by taxi: €1.80/km.

^oHourly earnings estimated from the European Union Statistical Office which published the hourly costs related to workforce in Europe.

Table 3. Average time (years) with and without spectacles in the Markov model period according to toric, monofocal implants and countries.

Time	France		Germany		Italy		Spain
	Toric	Monofocal	Toric	Monofocal	Toric	Monofocal	Toric	Monofocal
Time without spectacles	1.0	1.6	0.9	1.5	1.0	1.5	1.0	1.6
Time with spectacles	15.0	14.4	13.5	12.9	14.5	14.0	14.6	14.0
Reading spectacles	11.2	1.7	10.1	5.1	10.9	3.5	10.9	6.6
Other spectacle types	3.8	12.7	3.4	7.8	3.6	10.5	3.7	7.4
Life time	16.0		14.4		15.5		15.6

Table 4. Average resources per patient consumed in the Markov model period according to toric, monofocal implants and countries.

Resource	France		Germany		Italy		Spain
	Toric	Monofocal	Toric	Monofocal	Toric	Monofocal	Toric	Monofocal
Number of re-interventions	0.016	—	0.016	—	0.016	—	0.016	—
Number of spectacles	6.9	6.7	7.1	6.8	7.9	7.5	7.3	7.0
Number of reading spectacles	5.1	0.8	5.3	2.7	5.9	1.9	5.5	3.3
Number of other spectacles	1.8	5.9	1.8	4.1	2.0	5.6	1.8	3.7
Number of units purchased for spectacle cleaning	39.2	37.6	22.4	21.5	34.2	32.8	15.1	14.5
Visits to ophthalmologist/ optometrist to correct visual acuity	6.9	6.7	7.1	6.8	7.9	7.5	7.3	7.0
Transportation ophthalmologist (km)	521.4	503.7	216.8	209.8	495.9	479.6	406.0	392.8
Transportation optic centre (km)	660.9	634.4	426.8	409.7	874.3	839.2	795.9	763.8
Time spent to care for visual acuity	59.7	58.6	55.1	54.5	61.6	60.8	54.4	53.9

Table 5. Cost consequences (€) according to toric and monofocal IOLs per country from the societal perspective – discount rate 3%.

	France		Germany		Italy		Spain
	Toric	Monofocal	Toric	Monofocal	Toric	Monofocal	Toric	Monofocal
Surgery including IOL	2,291.8	2,291.8	2,500.0	2,500.0	2,212.0	2,212.0	2,100.0	2,100.0
Re-intervention	26.7	0	28.5	0	24.8	0	21.8	0
Spectacles	2,654.7	3,408.6	1,455.9	2,161.8	1,545.7	2,315.4	1,241.8	1,608.4
Spectacle cleaning	89.4	85.9	52.3	50.2	78.5	75.4	34.7	33.3
Visit to correct visual acuity	135.3	129.7	290.2	278.0	509.8	488.6	304.9	292.1
Transportation	325.2	313.7	126.0	121.4	336.0	323.6	432.0	416.1
Total excluding time spent	5,523.1	6,229.7	4,452.9	5,111.4	4,706.8	5,415.0	4,135.2	4,449.9
Time spent	1,365.7	1,350.8	1,366.7	1,354.6	1,221.6	1,207.3	762.3	755.8
Total including time spent	6,888.8	7,580.5	5,819.6	6,466.0	5,928.4	6,622.3	4,897.5	5,205.7
Difference*	–691.7	Ref	–646.4	Ref	–693.9	Ref	–308.2	Ref

*The difference represents the savings realised with the toric lenses in comparison to a monofocal IOL. If a toric price premium (on the top of the DRG) equals the calculated difference, implanting a toric IOL would be cost neutral.

Table 6. Cost consequences (€) according to toric and monofocal IOLs per country from the societal perspective – discount rate 0%.

	France		Germany		Italy		Spain
	Toric	Monofocal	Toric	Monofocal	Toric	Monofocal	Toric	Monofocal
Surgery including IOL	2,291.8	2,291.8	2,500.0	2,500.0	2,212.0	2,212.0	2,100.0	2,100.0
Re-intervention	26.7	0	28.5	0	24.8	0	21.8	0
Spectacles	3,406.4	4,375.5	1,833.5	2,723.4	1,977.8	2,963.5	1,585.9	2,054.8
Clean spectacles	117.5	112.8	67.3	64.6	102.5	98.5	45.2	43.5
Visit to correct visual acuity	173.6	166.4	365.4	350.3	652.2	625.3	398.3	373.2
Transportation	407.8	393.1	156.7	150.9	424.8	408.8	544.9	524.4
Total without time spent	6,423.8	7,339.6	4,951.4	5,789.2	5,394.1	6,308.1	4,696.1	5,095.9
Time spent	1,465.9	1,447.1	1,442.9	1,427.6	1,318.2	1,300.0	805.5	797.3
Total including time spent	7,889.7	8,786.7	6,394.3	7,216.8	6,712.3	7,608.1	5,501.6	5,893.2
Difference*	-897.0	Ref	-822.5	Ref	-895.8	Ref	-391.6	Ref

*The difference represents the savings realised with the toric lenses in comparison to a monofocal IOL. If a toric premium (on the top of the DRG) equals the calculated difference, implanting a toric IOL would be cost neutral.