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Deloitte Access Economics was commissioned by the NCBI (National Council for the Blind of Ireland) to estimate the economic impact of vision impairment (VI) and blindness in the Republic of Ireland (ROI), including costs to the health care system (direct costs), other financial costs to society such as the inability to work due to vision loss (indirect costs), and the burden of vision loss on individuals’ wellbeing.
Deloitte Access Economics also conducted cost effectiveness analyses of three eye-care interventions:
- eye screening for people with diabetes in the ROI;
- eye screening for the elderly in the ROI; and
- reducing cataract surgery waiting lists in the ROI.
Burden of disease study
This report comprises the following estimates:
- the numbers of people with mild VI (6/18 ≤ visual acuity [VA] < 6/12), moderate VI (6/60 ≤ VA < 6/18), and blindness (VA < 6/60), by primary cause;
- the costs of VI and blindness to the health care system based on Irish data (or international data using price adjustments between countries);
- the value of lost production/employment due to VI and blindness;
- the cost of informal care provided to people with VI and blindness
- the tax inefficiency associated with public funding of health care for people with VI and blindness (known as deadweight welfare loss [DWL]);
- the burden of VI and blindness on individuals, measured using disability adjusted life years (DALYs), which includes healthy years of life lost due to disability (YLD) and life lost due to premature death (YLL) associated with VI;
- projections of the above outcomes to the year 2020.
These estimates are reported for the years 2010, 2015 and 2020 and all cost results are expressed in 2010 euros.
The numbers of blind people in the ROI were derived from the NCBI register, with an adjustment for the likely extent of under registration. The numbers of people with mild and moderate VI in the ROI were estimated by applying to these data international figures on the relative prevalence of mild/moderate VI to blindness. These prevalence figures were estimated to 2020 by applying ROI population projections (CSO, 2008).
Table i reports the numbers of people with VI or blindness (and associated prevalence rates) in the ROI in 2010. This study indicates that 224,832 people are vision impaired or blind in 2010. Of these, 157,156 have mild VI, 54,681 have moderate VI and 12,995 are blind. The numbers of people with VI and blindness are predicted to increase with population growth. There are projected to be 271,996 people with mild/moderate VI or blindness by 2020.
Table i: Prevalence of VI and blindness (% of all ages population) in the ROI
Source: Deloitte Access Economics calculations
Health care system costs of VI and blindness were estimated using Irish public hospital activity data (ESRI, 2010). In the absence of published Irish cost data, the costs per bed day were imputed using Australian costs and relative health care prices, following a published methodology (Access Economics 2010b, Wimo et al, 2006). DWL was calculated using the proportion of health care costs funded by the Irish government through taxation, and a 57% ‘marginal cost of public funds’ or tax inefficiency rate (Kleven and Kreiner, 2003).
The health burden of VI and blindness on individuals was calculated using published disability weights from the Netherlands (Stouthard et al, 1997) and the estimated numbers of people with mild VI (weight 0.02), moderate VI (weight 0.17) and blindness (weight 0.43) reported above. These weights have previously been applied in international studies of the burden of VI and blindness (Access Economics, 2004; 2006; 2008a; 2008b; 2009; 2010b; Begg et al, 2007; Mathers et al 1999).
Annual numbers of deaths due to VI were estimated using published mortality rates by age in the ROI, and the relative mortality risk (2.34) in people with a VA less than 6/12 (Access Economics, 2010a). The calculation of deaths accounted for the small proportion of excess deaths specifically attributable to VI (1.38%).
Productivity losses due to VI and blindness were calculated using the human capital method, which values time off work due to VI and blindness using average wages as a proxy for the value of production. These calculations used National Disability Survey (NDS) data on the number of people unable to work due to a seeing disability (CSO, 2010d).
Informal care costs were also estimated using NDS data on the number of people with a seeing disability that receive (unpaid) assistance from friends or relatives. Following standard methodologies, the value of carer time was proxied by GDP per capita.
The results of the burden of disease study are summarised in Table ii. Where data permit, detailed results are presented by VI cause and severity in the main report. The results indicate that 224,832 people are vision impaired in 2010. The health care system costs of VI and blindness total €116.8 million in 2010. Other costs in 2010 total nearly €269.3 million, including an expected DWL of €104.4 million, productivity loss of €56.7 million and an informal care cost of €108.3 million. In total the financial cost of VI and blindness is estimated to be €386.1 million.
The health burden of VI and blindness in the ROI is estimated to be 18,537 DALYs in 2010. The economic valuation of this disease burden (using the reported value of a statistical life year = €94,794) is nearly €1.76 billion.
The burden of disease is projected to increase with population growth.
Table ii: Summary of the burden of vision impairment and blindness in the ROI
|Prevalence of VI (number)||224,832||246,773||271,996|
|Health care system costs (€ million)||116.75||127.42||136.80|
|Lost production (€ million)||56.72||60.61||63.74|
|Informal care (€ million)||108.25||118.14||126.83|
|Deadweight welfare losses (€ million)||104.37||113.57||121.62|
|Total financial cost (€ million)||386.09||419.73||449.00|
|Economic value of DALYs (€ million)||1,757.16||1,972.11||2,224.37|
Source: Deloitte Access Economics calculations. All costs expressed in 2010 euros.
The results of this study demonstrate the substantial economic impacts of VI and blindness in the ROI. In 2010, the cost to the health care system alone is estimated to be €116.8 million, whilst the total financial cost to society is €386.1 million. These costs could potentially be reduced through coordinated care strategies to reduce the prevalence, incidence and progression of sight loss in the ROI. Without intervention, these costs will continue to increase with population growth.
The health impacts of VI and blindness to affected individuals are equivalent to a burden of 18,537 DALYs in 2010. Using published data on the valuation of life, this burden is valued at nearly €1.76 billion. The health burden of VI and blindness is also forecast to increase over time without increased intervention.
Cost effectiveness analyses
The second part of this report presents the cost effectiveness of three potential (hypothetical) eye care interventions. These analyses are conducted from two perspectives. The health care perspective only includes the costs (and cost savings) to the health care system in the ROI from implementing the interventions. The societal perspective also includes the DWL associated with the government funding each intervention through taxation.
The first intervention was an educational program targeted at people aged 70 years and over, consisting of messages and advertisements through national and regional television and radio stations, national and regional newspapers, and alternative publications such as magazines and online media outlets. The education program was assumed to increase the uptake of eye tests in the elderly population. Intervention costs were derived from a similar educational campaign in Australia (Müller et al, 2007) and the cost of screening tests in the ROI. The analysis included treatment costs for people diagnosed with VI through screening. The cost effectiveness of the screening program was estimated to be €17,738 per DALY averted under a societal perspective, and €11,974 per DALY averted under a health care perspective.
The second intervention was an eye screening program for people with diabetes. This would target people in the ROI aged 10 years and older with registered diabetes and deliver free eye tests via an annual, mobile screening service. The service could pick up other eye conditions in addition to diabetic retinopathy. The intervention costs included retinal photography and three-stage grading with internal and external quality assurance, derived from a similar program in Dublin (HSE and Irish College of Ophthalmologists, 2008). Again, the analysis included treatment costs for people diagnosed with VI through screening. The cost effectiveness of the screening program was estimated to be €9,090 per DALY averted under a societal perspective, and €6,031 per DALY averted under a health care perspective.
Both screening programs are highly cost effective according to World Health Organisation (WHO) thresholds for the cost per DALY averted (WHO, 2011).
The third intervention was government initiatives to improve the efficiency and capacity of cataract surgery services in public hospitals. These initiatives were assumed to reduce the waiting time for cataract surgery by 50% (i.e. double the annual volume of cataract surgeries) in line with a Canadian cataract surgery efficiency program (Boisjoly et al, 2010). The costs of the intervention included:
- bringing forward surgeries;
- increasing capacity (beds, theatres etc) in public hospitals to perform more surgeries;
- increasing the number of ophthalmic surgeons trained in cataract surgery (training and recruitment costs);
- investing in better technology to undertake cataract surgery more efficiently; and
- DWL associated with government funding of these costs.
Since no data were identified to estimate these key intervention costs, rather than estimating the cost effectiveness of this intervention, the CEA estimated the highest intervention cost for which the initiative would be considered cost effective under WHO thresholds.
Under a health care perspective, an initiative to reduce cataract surgery waiting lists would be considered highly cost effective if it costed less than €1,869,916, and cost effective if it costed between €1,869,916 and €5,445,733.
The societal perspective for this intervention also included reductions in informal care and productivity losses due to less time living with cataracts and VI. Under a societal perspective, the initiative would be considered highly cost effective if it costed less than €1,280,538, and cost effective if it costed between €1,280,538 and €3,558,320.
Deloitte Access Economics