0.06% 0.06% 0.09% 0.12% 0.14% 0.14% 0.18% 0.22% 0.23% 0.24% 0.26% 0.31% 0.33%

0.61% 0.61%

0.96% 1.3% 1.4%

1.9% 2.0%

2.1% 2.4%

3.7%

0% 1% 2% 3% 4%

Switzerland UK

Japan China

Canada France

Israel Austria

Spain Australia Lithuania

USA Mexico

Thailand Brazil India

Nepal Chile

Paraguay Guatemala

Nigeria Ethiopia

South Africa

0.09% 0.21% 0.30% 0.32% 0.33% 0.38% 0.40% 0.40% 0.7% 0.8%

1.3% 4.6%

5.3% 5.4% 5.4%

6.7% 7.1%

9.3% 10.1%

13.2%

0% 5% 10% 15% 20%

UK Canada France Austria

Switzerland Japan

Australia Israel Spain

Lithuania USA

Mexico Paraguay

Chile India

Nepal Brazil

South Africa China

Nigeria Ethiopia*

Data Collection •  Collected data on the retail prices for all classes of topical

glaucoma medications and prices for a patient to undergo laser trabeculoplasty and trabeculectomy surgery on a single eye for countries throughout the world

•  Pricing data for each country was obtained from medication pricing lists and fee schedules published on government websites, drug pricing databases, academic publications, and/or personal communications with ophthalmologists practicing in the country of interest

•  If different prices were obtained from multiple sources in a country, prices were averaged and reported as mean values

Data Analysis •  Prices adjusted for inflation and purchasing power parity

exchange rates (example: The Economist’s “Big Mac Index”)

•  Prices for each class of topical medications were multiplied to

obtain a yearly drug cost to treat both eyes, assuming that a 2.5 mL bottle lasts 1 month with once-daily dosing, 5 ml bottle lasts 1 month with twice-daily dosing, etc.

•  Prices were divided by median annual household income of each country (obtained from published Gallup, Inc. polling data) to calculate the price percentage relative to annual median household income (HHI)

RESULTS

Comparing the Cost of Glaucoma Medications, Laser Trabeculoplasty, and Incisional Surgery in Countries Around the World

Peter Y. Zhao, MD1; Raheem Rahmathullah2; Alan L. Robin, MD1,3, Joshua D. Stein, MD, MS1,4,5

1Department of Ophthalmology and Visual Sciences, W.K. Kellogg Eye Center, University of Michigan, Ann Arbor, MI; 2International Eye Foundation, Kensington, MD; 3Department of Ophthalmology and School of International Health, Johns Hopkins University, Baltimore, MD;

4Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; 5Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI

Unit Prices ($/ml) for Topical Glaucoma Medications

DISCUSSION

REFERENCES We would especially like to thank the many ophthalmologists and administrators worldwide who provided a significant portion of the local pricing data included in this study. 1.  Tham YC, Li X, Wong TY, Quigley HA, Aung T, Cheng CY. Global prevalence of glaucoma and projections of

glaucoma burden through 2040: a systematic review and meta-analysis. Ophthalmology. Nov 2014;121(11):2081-2090.

2.  Kesselheim AS, Avorn J, Sarpatwari A. The High Cost of Prescription Drugs in the United States: Origins and Prospects for Reform. JAMA. Aug 23-30 2016;316(8):858-871.

3.  Measuring medicine prices, availability, affordability, and price components. 2nd ed. Switzerland: World Health Organization and Health Action International; 2008. Available at: http://www.who.int/medicines/areas/access/medicines_prices08/en/

4.  Gallup, Inc. Countries Ranked by Median Self-Reported Per-Capita and Household Income; 2013. Available at http://www.gallup.com/poll/166211/worldwide-median-household-income-000.aspx

BACKGROUND •  Glaucoma is one of the leading causes of blindness •  Projected to affect 110 million people worldwide by 2040 •  Treatment options for glaucoma include 1) topical medications

2) laser trabeculoplasty 3) incisional glaucoma surgery •  Availability, accessibility, and cost of these different

interventions can have a dramatic effect on patient management decisions

•  Little is known about how prices of these various therapeutic interventions vary among countries throughout the world.

PURPOSE •  To determine the prices of different classes of topical

glaucoma medicat ions, laser trabeculoplasty, and trabeculectomy for countries worldwide

•  To compare costs of different glaucoma treatment options between countries relative to the median annual household income in each country

•  To determine the extent by which the price ratio between a brand name and generic formulation of latanoprost vary among countries worldwide

Price of 1 Year Supply of Eye Drops Relative to Median Annual Household Income (MHI)

Key Findings: •  There is considerable country-to-country variation

in the prices of topical medications, laser trabeculoplasty, and trabeculectomy

•  Generic timolol was the cheapest topical glaucoma medication in all countries studied, but in 7 countries, it costs ≥ 1% of median annual household income

•  The United States has some of the highest prices for glaucoma treatments and the highest price ratio of brand name to generic latanoprost

•  Overall, glaucoma therapies may be more expensive for the average resident of a developing country than for the average resident of a developed country

Questions? Please contact Peter Zhao, MD (zhaope@med.umich.edu)

Study Strengths: •  Used combination of data sources to obtain local prices of

glaucoma treatment in over 20 countries •  Compared exchange-rate-adjusted prices across different

countries and used median annual household income to estimate financial burden of treatment

Study Limitations: •  No universal, reliable, and open data source exists for

comparing local pricing information •  Prices may vary significantly between different regions

within each country and government pricing data may not reflect retail pricing

•  Study does not address the availability of eye drops, ophthalmic lasers, or surgical equipment, or availability of surgeons for laser treatment or surgery

•  Varying availability of health insurance to cover cost of these different interventions in different countries

•  Assumed a bottle of eye drops contains same number of drops; may be differences based on manufacturer

Conclusions and Implications: •  More worldwide monitoring of glaucoma drug pricing is

needed in order to determine where patients may be at increased risk of vision loss due to prohibitively high costs associated with treatment

•  More research is needed to examine whether laser procedures or incisional surgery could be more cost-effective interventions in countries where topical medications are very expensive or difficult for patients to get access to them

Price of Laser Trabeculoplasty Relative to MHI

METHODS

Price of Trabeculectomy Relative to MHI

Research supported by:

*For Ethiopia (30.8%), graph bar length was truncated

Generic Latanoprost Generic Timolol

World Map of Countries Studied (Total 23)

Price Ratio of Brand Name Xalatan to Generic Latanoprost

Countries Studied Created with mapchart.net

PGA BB AA CAI BB+PGA BB+AA BB+CAI Americas (7) Brazil $11.11 $0.80 $4.09 $3.26 $14.02 $7.89 $5.96 Canada $2.98 $0.97 $0.93 $1.75 $3.54 $3.30 $1.92 Chile $14.20 $1.80 $12.18 $8.81 $17.83 $12.13 $12.68 Guatemala NA $3.09 NA NA NA NA $12.89 Mexico $18.96 $0.67 $8.62 $7.92 $22.99 $13.08 $3.66 Paraguay $11.82 $2.11 $4.63 NA NA NA $5.66 USA $19.69 $2.30 $5.89 $6.35 NA $32.23 $11.16

Europe (7) Austria $3.90 $2.68 $1.46 $1.34 $6.83 $2.68 $3.90 France $3.26 $1.56 $1.27 $1.56 $4.00 $4.41 $1.95 Israel $4.22 $0.96 NA $1.77 $4.93 $4.08 $2.23 Lithuania $3.49 $0.56 $1.65 $1.37 $4.69 $3.24 $1.91 Spain $5.27 $0.89 $1.78 $1.25 $4.36 $4.12 $2.95 Switzerland $6.69 $1.13 $4.30 $3.45 $10.02 $5.93 $4.94 UK $1.00 $0.33 $0.58 $0.61 $1.30 $2.90 $0.71

Africa (3) Ethiopia $16.73 $0.65 $5.96 $6.98 NA NA NA Nigeria $13.76 $1.09 NA $6.42 NA NA NA South Africa $17.10 $3.38 $9.24 $6.50 $19.27 $10.89 $10.51

Asia & Pacific (6) China $16.47 $0.14 NA $4.27 NA NA NA India $5.29 $0.40 $1.78 $2.77 $4.31 $2.32 $3.02 Japan $4.37 $1.04 $4.39 $2.89 $11.80 NA $6.16 Nepal $6.60 $0.66 $3.30 $3.30 NA NA NA Thailand $5.60 $0.75 $1.60 $7.46 $15.52 $7.63 $10.25 Australia $6.83 $2.09 $3.00 $2.86 $10.31 $3.69 $3.43 Unit prices reflect lowest-cost medication (may be generic or brand name) available in each drug class PGA = prostaglandin analogue; BB = topical beta blocker; AA = alpha agonist; CAI = topical carbonic anhydrase inhibitor; NA = either pricing information not available or medication class not available within that country

1.0 1.0 1.0 1.0 1.0 1.0

1.1 1.1

1.4 1.4

1.6 1.7

2.0 2.1

2.9 3.5

0.0 1.0 2.0 3.0 4.0

UK France

Australia Israel Spain

Austria South Africa

Lithuania Brazil

Nigeria Japan

Switzerland Canada

Chile India USA

0.16% 0.24% 0.31% 0.38% 0.47% 0.50% 0.59% 0.67% 0.76%

1.3% 1.6% 1.6% 1.6%

2.2% 2.5% 2.5%

3.2% 3.4%

5.1% 8.7%

9.2% 11.4%

0% 2% 4% 6% 8% 10% 12%

Switzerland Israel Brazil

Canada France

UK Australia

Austria Mexico

Spain Lithuania Ethiopia

USA China

Thailand Japan

Paraguay Nepal Chile

South Africa Nigeria

India

1.1% 1.2% 1.4% 1.7%

2.7% 3.2%

3.6% 4.1% 4.2% 4.5% 4.8% 5.0% 5.3%

6.5% 6.6%

8.0% 8.8%

11.2% 12.0%

16.4% 16.4%

17.7% 18.3%

0% 5% 10% 15% 20% Canada

Australia Switzerland

Austria Guatemala

Lithuania Brazil

Mexico UK

Israel France

Thailand Chile USA

Japan Spain

Paraguay Nepal

Ethiopia South Africa

Nigeria China India