The clinical effectiveness and cost-effectiveness of screening for open angle glaucoma:A systematic review and economic evaluation

Objectives: To assess whether open angle glaucoma (OAG) screening meets the UK National Screening Committee criteria, to compare screening strategies with case finding, to estimate test parameters, to model estimates of cost and cost-effectiveness, and to identify areas for future research. Data sources: Major electronic databases were searched up to December 2005. Review methods: Screening strategies were developed by wide consultation. Markov submodels were developed to represent screening strategies. Parameter estimates were determined by systematic reviews of epidemiology, economic evaluations of screening, and effectiveness (test accuracy, screening and treatment). Tailored highly sensitive electronic searches were undertaken. Results: Most potential screening tests reviewed had an estimated specificity of 85% or higher. No test was clearly most accurate, with only a few, heterogeneous studies for each test. No randomised controlled trials (RCTs) of screening were identified. Based on two treatment RCTs, early treatment reduces the risk of progression. Extrapolating from this, and assuming accelerated progression with advancing disease severity, without treatment the mean time to blindness in at least one eye was approximately 23 years, compared to 35 years with treatment. Prevalence would have to be about 3-4% in 40 year olds with a screening interval of 10 years to approach cost-effectiveness. It is predicted that screening might be cost-effective in a 50-year-old cohort at a prevalence of 4% with a 10-year screening interval. General population screening at any age, thus, appears not to be cost-effective. Selective screening of groups with higher prevalence (family history, black ethnicity) might be worthwhile, although this would only cover 6% of the population. Extension to include other at-risk cohorts (e.g. myopia and diabetes) would include 37% of the general population, but the prevalence is then too low for screening to be considered cost-effective. Screening using a test with initial automated classification followed by assessment by a specialised optometrist, for test positives, was more cost-effective than initial specialised optometric assessment. The cost-effectiveness of the screening programme was highly sensitive to the perspective on costs (NHS or societal). In the base-case model, the NHS costs of visual impairment were estimated as £669. If annual societal costs were £8800, then screening might be considered cost-effective for a 40-year-old cohort with 1% OAG prevalence assuming a willingness to pay of £30,000 per quality-adjusted life-year. Of lesser importance were changes to estimates of attendance for sight tests, incidence of OAG, rate of progression and utility values for each stage of OAG severity. Cost-effectiveness was not particularly sensitive to the accuracy of screening tests within the ranges observed. However, a highly specific test is required to reduce large numbers of false-positive referrals. The findings that population screening is unlikely to be cost-effective are based on an economic model whose parameter estimates have considerable uncertainty, in particular, if rate of progression and/or costs of visual impairment are higher than estimated then screening could be cost-effective. Conclusions: While population screening is not cost-effective, the targeted screening of high-risk groups may be. Procedures for identifying those at risk, for quality assuring the programme, as well as adequate service provision for those screened positive would all be needed. Glaucoma detection can be improved by increasing attendance for eye examination, and improving the performance of current testing by either refining practice or adding in a technology-based first assessment, the latter being the more cost-effective option. This has implications for any future organisational changes in community eye-care services. Further research should aim to develop and provide quality data to populate the economic model, by conducting a feasibility study of interventions to improve detection, by obtaining further data on costs of blindness, risk of progression and health outcomes, and by conducting an RCT of interventions to improve the uptake of glaucoma testing. © Queen's Printer and Controller of HMSO 2007. All rights reserved.

The effect of socio-economic deprivation on severity of glaucoma at presentation

OBJECTIVE: To evaluate the influence of socio-economic factors on severity of glaucoma at presentation

METHODS: All newly diagnosed glaucoma patients at the University Hospitals-NHS, Aberdeen and South Glasgow University Hospitals-NHS, in 2006, were included. Glaucoma was severe at presentation if there was a repeatable visual-field loss with a mean deviation index greater than 12 dB in the Humphreys visual fields test or an absolute paracentral scotoma within the central 5 degrees of the visual fields. Home address was used to determine the Scottish Index of Multiple Deprivation (SIMD) rank. The SIMD rank, demographics and severity of glaucoma at presentation were investigated using general linear modelling.

RESULTS: There were 48 patients with severe glaucoma and 74 patients with non-severe glaucoma. In four, the severity could not be determined. Severity of glaucoma at presentation was significantly associated with SIMD rank, being most severe in patients from areas with the lowest ranks (p = 0.026). Age was a significant factor (p = 0.024), with severe glaucoma being more common in elderly patients.

CONCLUSIONS: Age and socio-economic deprivation were associated with severity of glaucoma at presentation, with patients from areas of higher socio-economic deprivation presenting with more advanced glaucoma.

Fabricating Economic Development

This paper is concerned with the institutions of Irish economics; it is structured around two arguments each of which links to the thesis presented in Garvin’s Preventing the future (2004). Overall it will be demonstrated that Irish economics was shaped by intellectual trends experienced within economic thought globally as well as the social considerations that were peculiar to Ireland. The evidence presented indicates that firstly while Economic Development mattered to the Irish economy it did not matter for the reasons that most writers have suggested it did. It is argued for instance that much of the literature, regardless of academic discipline, presents the publication of Economic Development in 1958 as analogous to a “big bang” event in the creation of modern Ireland. However, such a “big bang” perspective misrepresents the sophistication of economic debates prior to Whitaker’s report as well as distorting the interpretation of subsequent developments. The paper secondly, by drawing on the contents of contemporary academic journals, reappraises Irish economic thinking before and after the publication of Economic Development. It is argued that an economically “liberal” approach to Keynesianism, such as that favoured by TK Whitaker and George O’Brien, lost out in the 1960s to a more interventionist approach: only later did a more liberal approach to macroeconomic policy triumph. The rival approaches to academic economics were in turn linked to wider debates on the influence of religious authorities on Irish higher education. Academic economists were particularly concerned with preserving their intellectual independence and how a shift to planning would keep decisions on resource allocation out of the reach of conservative political and religious leaders.

Committing to Economic Openness in Ireland: The Importance of Domestic Institutional Capabilities

This chapter sets out to explain the factors behind Ireland's exceptional period of economic growth from the early 1990s to the mid 2000s. It suggests that an unbending commitment to economic openness and an on-going effort to establish quality domestic institutions were the main drivers of the so-called ‘Celtic tiger’ phenomenon. The commitment to economic openness manifested itself in the relentless search for inward investment and a willingness to accept deep forms of European integration. Building domestic institutional capabilities involved adopting new-classical macroeconomic policies, creating a robust system of social partnership and reforming the educational system. The two factors positively interacted with each other to create dynamic effects.

The relationship between spatial planning and economic competitiveness: the ‘path to economic nirvana’ or a ‘dangerous obsession’?

This paper offers a contribution to contemporary studies of spatial planning. In particular, it problematises the relationship between neoliberal competitiveness and spatial planning. Neoliberal competitiveness is a hegemonic discourse in public policy as it (allegedly) provides the ‘path to economic nirvana’. However, commentators have critiqued its theoretical underpinnings and labelled it a ‘dangerous obsession’ for policy makers. Another set of literatures argues that spatial planning can be understood as a form of ‘neoliberal spatial governance’ and read in a ‘postpolitical’ framework that ‘privileges competitiveness’. Synthesising these debates this paper critically analyses the application and operationalisation of neoliberal competitiveness in Northern Ireland and Belfast. In focusing on this unique case study—a deeply divided society with a turbulent history—the paper takes the debate forward in arguing that rather than offering the ‘path to economic nirvana’ neoliberal competitiveness is a ‘postpolitical strategy’ and represents a ‘dangerous obsession’ for spatial planning.