Value-Based Medicine® pharmacoeconomics, as applied to AMD interventions and those across all of medicine, signals a new era of quality in the healthcare arena. The information is important to patients, physicians, Pharmacy & Therapeutic Committees [63], insurers, Pharmacy Benefit Managers, and those in public positions who allocate healthcare resources.

The advantages of Value-Based Medicine® pharmacoeconomic analyses for AMD and other interventions include the facts they:

•Integrate all benefits and adverse events associated with a drug to demonstrate its overall conferred value.

•Integrate patient quality-of-life preferences (utilities) often ignored in clinical trial primary outcomes.

•Allow physicians to better understand what patients consider most relevant so higher quality care can be provided.

•Identify drugs with superior value, as well as those with negligible value.

and other interventions [48, 4955–58, 62], as well as the costs expended for that value [23]. It ushers in a new era of superior care for medicine as it takes evidence-based medicine outcomes to a higher level of quality by integrating patient preferences, at the same time it facilitates the most efficient use of healthcare resources.

The Future

Pharmacoeconomics has already had an impact on the use of retinal pharmacologic agents [1–23], a phenomenon that will only become more pronounced in the near future as the USA adopts cost-utility principles with the creation of the Patient Centered Outcomes Research Institute [31]. Pharmacoeconomic cost-utility principles are currently used in public policy in the UK, Canada, and Australia, and will be adopted in other countries as well. Why? Because there is no other instrument available that can integrate qual-

coeconomics provides an information system which allows all stakeholders the ability to appreciate the human value conferred by AMD drugs

Research Group [65] suggests that 1.7 million new cases of atrophic macular degeneration and 1,65,000 new cases of neovascular AMD develop

in the United States annually. Prevalence data show there are approximately 7.5 million cases of atrophic AMD and 1.2 million cases of neovascular AMD in the USA any time [64, 65].

Employment and Wage Loss

Data on disability and employment from the Bureau of Labor and Statistics demonstrate those with mild visual loss (<20/40 in the better eye) are employed at a rate 56% that of people with normal vision and those with severe visual loss (<20/200 in better eye) are employed only 39% as often as those with normal vision [66]. Furthermore, people with mild visual loss earn 30% less than those with normal vision, and those with severe visual loss earn 38% less than those with normal vision [66]. Consequently, the average person with mild visual loss earns 39% that of a person with normal vision, while the average person with severe visual loss earns only 24% that of a person with normal vision.

Pearl

The average person with mild vision loss (<20/40) earns 39% as much as their counterpart with normal vision, while the average person with severe vision loss (£20/200) earns 24% that of their counterparts with normal vision.

Gross Domestic Product (GDP)

The GDP, or Gross Domestic Product [67], is the sum of all final goods and services produced within the national borders annually. Brown and colleagues [15] calculated that atrophic AMD in the USA, diminishes salaries, employment, and consumption, and therefore the GDP of the country, by approximately $26.1 billion annually (adjusted to year 2010 real dollars). Neovascular AMD in the USA decreases the GDP by approximately $5.8 billion annually. The total annual cost (in 2010 real dollars) to the GDP, the latter which is often considered a measure of the

overall wealth of the country, is therefore ($26.1 + $5.8 =) $31.9 billion [15]. The financial loss due to wage loss from untreated AMD comprises approximately 0.22% of the entire 2010 US GDP of $14.75 trillion [67].

Pearl

Untreated, atrophic AMD causes wage loss of $26.1 billion annually, while neovascular AMD cause a $5.1 billion annual wage loss. Thus, AMD costs the economy, and therefore the GDP (Gross Domestic Product), $31.8 billion annually in real 2010 US dollars.

Other Costs

In addition to direct ophthalmologic medical costs, there are other direct costs associated with AMD and visual loss. Among the direct, nonophthalmologic medical costs are those associated with: (1) increased depression, (2) increased injury, (3) increased subacute nursing facility (SNF) costs, (4) increased nursing home costs, and (5) as yet unidentified costs associated with visual loss [68]. As per the work of Javitt and colleagues [68], the annual sum of these costs is greater than $12,700 (2010 US real dollars) for people with <20/400 vision in the better eye (World Health Organization definition of blindness), more than $8,200 for those with <20/200 in the better seeing eye (US definition of legal blindness) and more than $4,300 for those with vision <20/40 in the better eye.

The direct nonmedical costs include primarily transportation costs, the cost of shelter and caregiver costs, with the latter the greatest cost. Schmier and colleagues [69] have shown that caregiver costs for people with AMD increase as vision in the better-seeing eye decreases. The costs (adjusted to year 2010 real dollars) from the Schmier study [69] are shown in Table 10.10. Remarkably, caregiver costs exceed $58,000 per year for AMD patients whose vision in the betterseeing eye is 20/250 or worse.