GLAUCOMA OVERBURDEN

With the number of patients with glaucoma-related pathologies predicted to increase significantly over the next few years, there is a pressing need for health services to work towards creating high-quality, high-volume and cost-effective glaucoma care for all citizens, according to Anja Tuulonen MD, PhD.

“The overburden of glaucoma services demands a reappraisal of current management strategies. We know that the possibilities of care, demand for services and costs are increasing much more than the available resources, regardless of how our healthcare systems are financed. I believe it is our role as health practitioners to try to make wise decisions in this situation,” she told delegates attending her keynote lecture at the 2015 Congress of the European Society of Ophthalmology (SOE) in Vienna, Austria.

The basic task of glaucoma care is to promote the well-being of patients, said Prof Tuulonen, insisting that practitioners need to be aware that the decisions they make in everyday clinical practice impact, for better or worse, on the quality and cost of healthcare.

Prof Tuulonen, CEO of Tays Eye Centre, Tampere University Hospital, Tampere, Finland, noted that many problems stem from different interpretations as to what constitutes “high-quality” healthcare.

“One definition of excellence is to provide patients with only the care that they need at the optimum time in the most appropriate setting. Another version is that we should be aiming to serve everything to everybody including all new interventions entering the market,” she said.

Faced with ageing populations worldwide, the stark reality for all healthcare systems is to find ways to make their systems more cost-effective. This raises many questions for glaucoma experts in terms of the right approach to adopt in the face of increasing demands: when is the right time to intervene?; should all patients be systematically screened?; what treatments should be used?; and so forth.

To highlight the way such choices translate to a national level, Prof Tuulonen cited the examples of Denmark and Finland, both of which have 5.4million inhabitants. From 2002 to 2007, Finland treated one-third more patients with glaucoma compared to Denmark. Finland also spent more on glaucoma medications compared to Denmark.

“The question is, was Finland overtreating or was Denmark undertreating its patients? For decades we have known that there are enormous variations in performance within and between countries. These variations are produced by everyday clinical decision-making, they are also probably sometimes in conflict with professional ethics, and we do not talk about them a lot,” she said.

Based on the World Health Organisation’s 1948 definition of health as “complete physical, mental and social well-being”, most people alive would be defined as sick most of the time, said Prof Tuulonen. A new and more relevant definition of health, suggested by the British Medical Journal, is “the ability to adapt and self-manage in the face of social, physical and emotional challenges during our lifetimes”.

Efforts have been made in some countries to cut down on waste and target health resources more wisely. In the USA, for instance, there has been the ‘choosing wisely’ campaign to help patients choose evidence-based care and avoid tests and procedures which are not truly necessary, she said.

FUNDAMENTAL CHANGES

There are two approaches to making glaucoma care more cost-effective: making the existing system work better, or by changing the system in more fundamental ways.

The experience of the UK in introducing a national guideline for glaucoma illustrates the side-effects of intrinsically sincere intentions, said Prof Tuulonen.

“The National Institute for Health and Care Excellence (NICE) guidelines for glaucoma in 2008 sought to find patients earlier and follow them more frequently, resulting in suffocating the healthcare system: in some areas it led to a 600 per cent increase in referrals, no gain in finding new glaucoma cases, and a reduction in accuracy in detecting abnormal optic disc,” she added.

More targeted screening programmes for older populations may prove more effective, said Prof Tuulonen, as well as closer follow-up of patients who are deemed to be high-risk.

Advances in tele-ophthalmology applications and home screening devices, as well as other technological innovations, could foresee fundamental changes and help healthcare systems to do more with less money in the future, she said.

“Sustainable glaucoma care means preventing visual disability, producing a feeling of well-being, dealing with a chronic disease or disability with allocated resources and taking into account other eye diseases. To do this we need a paradigm shift. As Einstein said, we cannot solve our problems with the same thinking which created them,” she concluded.

Anja Tuulonen: anja.tuulonen@pshp.fi