Minimally Invasive Glaucoma Surgery: A Budget Impact Analysis and Evaluation of Patients' Experiences, Preferences, and Values.

Background: Glaucoma is a condition that causes progressive damage to the optic nerve, which can lead to visual impairment and irreversible blindness. There is a spectrum of current treatments for glaucoma that aim to reduce intraocular pressure (IOP), including pharmacotherapy (eye drops), laser therapy, and the more invasive option of filtration surgery. A new class of treatments called minimally invasive glaucoma surgery (MIGS) may reduce IOP and offer a better safety profile than more invasive procedures. We conducted a budget impact analysis of MIGS for adults with glaucoma from the perspective of the Ontario Ministry of Health and Long-Term Care. We also conducted interviews with people with glaucoma and family members of people with glaucoma to determine patient preferences and values surrounding glaucoma and its treatment options, including MIGS. We completed this work to complement a health technology assessment conducted in collaboration with the Canadian Agency for Drugs and Technologies in Health (CADTH).

Methods: We analyzed the budget impact of publicly funding MIGS in adults with glaucoma in Ontario. We derived costs from the collaborative health technology assessment.¹ We assumed MIGS may be used in three subgroups: (1) MIGS in combination with cataract surgery as a replacement for cataract surgery alone in people with mild to moderate glaucoma; (2) MIGS alone as a replacement for other glaucoma treatments in people with mild to moderate glaucoma; and (3) MIGS (alone or in combination with cataract surgery) to replace filtration surgery (alone or in combination with cataract surgery) in people with advanced to severe glaucoma. We estimated the budget impact over 5 years for two possible uptake scenarios: a slow rate of uptake and a fast rate of uptake. To contextualize the lived experience of glaucoma and treatments for glaucoma, we also interviewed people with glaucoma and family members of people with glaucoma, some of whom had experience with surgical procedures such as MIGS and some of whom did not.

Results: Assuming a slow uptake scenario, the annual budget impact of publicly funding MIGS in Ontario over the next 5 years ranges from $1 million in year 1 to $18 million in year 5. Assuming a fast uptake scenario, the annual budget impact of publicly funding MIGS in Ontario over the next 5 years ranges from $6 million in year 1 to $70 million in year 5. The budget impact varies depending on the proportion of people in each of the three subgroups described above. Introducing a new MIGS billing code may reduce the overall expenditures. Interview participants felt that less invasive surgical procedures, such as MIGS, could control glaucoma progression with minimal side effects and recovery time needed.

Conclusions: We estimate that publicly funding MIGS in Ontario would result in additional costs over the next 5 years; however, this may depend on the populations using MIGS and if uptake is restricted or controlled. For the people with glaucoma we spoke with, avoiding blindness was their paramount concern, and MIGS was perceived as an effective treatment option with minimal side effects and recovery time required.