Financial Return-on-Investment of Ophthalmic Interventions
The term societal costs includes all forms of medical costs. The costs that comprise societal costs include direct medical costs, direct nonmedical costs and indirect costs. A discussion of each follows below.
A list of direct medical costs is shown in Table 1 . The direct medical costs are most typically costs expended for an intervention. For example, when ranibizumab is utilized to improve vision, there are costs expended, including those for the drug, physician costs for examination and injection, and diagnostic testing costs, such as for optical coherence tomography and/or intravenous fluorescein angiography. It is estimated that hospital cost in 2014 will comprise 30.5% of all healthcare costs, whereas physician costs will account for approximately 20.4% of all healthcare costs, and drug costs are estimated to comprise 8.9% of the national healthcare expenditure.
There are, however, direct medical costs that are saved by, rather than expended for, an intervention. Javitt et al. showed, in a Medicare population, that when vision decreases, the costs for depression, injury, skilled nursing facilities (SNFs), nursing homes and other as yet unidentified costs all rise. Thus, improvement in vision or prevention of vision loss can save dollars that would otherwise be spent on depression, injury, SNFs, nursing homes and the unidentified costs. These costs saved by the direct medical costs expended for an intervention accrue against the direct medical costs expended for that intervention, and thus can be viewed as negative costs. A list of these negative costs associated with improvement in vision/prevention of vision loss is shown in Table 2 . All are adjusted to 2013 US real dollars using the Medicare Care component of the Consumer Price Index.
The major costs within this group are caregiver costs. Residence costs, such as the costs of moving to a new home costs and changing to a new home to live because of vision loss are also included within this category. Transportation costs incurred because of vision loss are encompassed within this grouping as well. Among these latter costs are those to travel to shop, to go to a physician's office, to travel for pleasure and so forth.
Schmier et al. studied the caregiver costs associated with vision loss. In this analysis, they found that 72.3% of caregiver costs were unpaid, either given by spouses, other family members or friends. Nonetheless, these are still considered as costs because those who give free care would otherwise be able to enter the paid job market. The time spend on free caregiving was costed at the national hourly wage level. These authors noted that yearly caregiver costs began to rise dramatically when the vision decreased to the 20/80 level of worse in the better-seeing eye (Table 3). When the vision decreased to the 20/250 level or worse in the better-seeing eye, inflation-adjusted caregiver costs rose to over a remarkable US$58 000 per year. Included among the endeavors that those with at least 20/250 vision are often unable to perform are shopping for food and other necessities, cleaning the home, repairing the home, taking medications, preparing food, reading the mail, taking care of personal finances and paying bills, performing personal hygiene and others (M.M. Brown, G.C. Brown, H.B. Lieske et al., unpublished observation).
Included among these costs are those related to employment, as well as those related to volunteering for unpaid endeavors. Despite the fact that volunteering is unpaid, it is typically costed at the average hourly wage because this time could have been otherwise used for theoretical paid endeavors.
The US Census Bureau periodically conducts Household Economic Studies on disabled Americans, the most recent of which is Americans with Disabilities: 2010. These analyses report on how many people have disabilities, as well as the incidence of employment within these cohorts and the median monthly salary for each disability cohort and combined cohorts.
People with vision loss and other serious disabilities have a decreased incidence of employment referent to those without physical or mental limitations (Table 4). They also receive decreased salary referent to a person who has no disabilities. The average person with mild bilateral vision loss has a 43.9% incidence of employment, versus 34% for a person with severe bilateral vision loss and 79.1% for an age-matched person with no disability. The median monthly salary for a person with mild vision loss is US$2207 and that for severe vision loss is US$2564, versus US$2724 for an age-matched person with no disability. Overall, the average person with mild vision loss with mild vision loss makes 45% that of the age-matched working person with no disability, whereas the average person with severe vision loss makes only 40.5% that of the average age-matched person with no disability (Table 4). The average person with a mild hearing disability fares better financially than the average person with mild vision loss, while the average person with severe hearing loss fares poorer financially than the average person with severe vision loss (Table 4).
Types of Costs
The term societal costs includes all forms of medical costs. The costs that comprise societal costs include direct medical costs, direct nonmedical costs and indirect costs. A discussion of each follows below.
Direct Medical Costs
A list of direct medical costs is shown in Table 1 . The direct medical costs are most typically costs expended for an intervention. For example, when ranibizumab is utilized to improve vision, there are costs expended, including those for the drug, physician costs for examination and injection, and diagnostic testing costs, such as for optical coherence tomography and/or intravenous fluorescein angiography. It is estimated that hospital cost in 2014 will comprise 30.5% of all healthcare costs, whereas physician costs will account for approximately 20.4% of all healthcare costs, and drug costs are estimated to comprise 8.9% of the national healthcare expenditure.
There are, however, direct medical costs that are saved by, rather than expended for, an intervention. Javitt et al. showed, in a Medicare population, that when vision decreases, the costs for depression, injury, skilled nursing facilities (SNFs), nursing homes and other as yet unidentified costs all rise. Thus, improvement in vision or prevention of vision loss can save dollars that would otherwise be spent on depression, injury, SNFs, nursing homes and the unidentified costs. These costs saved by the direct medical costs expended for an intervention accrue against the direct medical costs expended for that intervention, and thus can be viewed as negative costs. A list of these negative costs associated with improvement in vision/prevention of vision loss is shown in Table 2 . All are adjusted to 2013 US real dollars using the Medicare Care component of the Consumer Price Index.
Direct Nonmedical Costs
The major costs within this group are caregiver costs. Residence costs, such as the costs of moving to a new home costs and changing to a new home to live because of vision loss are also included within this category. Transportation costs incurred because of vision loss are encompassed within this grouping as well. Among these latter costs are those to travel to shop, to go to a physician's office, to travel for pleasure and so forth.
Schmier et al. studied the caregiver costs associated with vision loss. In this analysis, they found that 72.3% of caregiver costs were unpaid, either given by spouses, other family members or friends. Nonetheless, these are still considered as costs because those who give free care would otherwise be able to enter the paid job market. The time spend on free caregiving was costed at the national hourly wage level. These authors noted that yearly caregiver costs began to rise dramatically when the vision decreased to the 20/80 level of worse in the better-seeing eye (Table 3). When the vision decreased to the 20/250 level or worse in the better-seeing eye, inflation-adjusted caregiver costs rose to over a remarkable US$58 000 per year. Included among the endeavors that those with at least 20/250 vision are often unable to perform are shopping for food and other necessities, cleaning the home, repairing the home, taking medications, preparing food, reading the mail, taking care of personal finances and paying bills, performing personal hygiene and others (M.M. Brown, G.C. Brown, H.B. Lieske et al., unpublished observation).
Indirect Medical Costs
Included among these costs are those related to employment, as well as those related to volunteering for unpaid endeavors. Despite the fact that volunteering is unpaid, it is typically costed at the average hourly wage because this time could have been otherwise used for theoretical paid endeavors.
The US Census Bureau periodically conducts Household Economic Studies on disabled Americans, the most recent of which is Americans with Disabilities: 2010. These analyses report on how many people have disabilities, as well as the incidence of employment within these cohorts and the median monthly salary for each disability cohort and combined cohorts.
People with vision loss and other serious disabilities have a decreased incidence of employment referent to those without physical or mental limitations (Table 4). They also receive decreased salary referent to a person who has no disabilities. The average person with mild bilateral vision loss has a 43.9% incidence of employment, versus 34% for a person with severe bilateral vision loss and 79.1% for an age-matched person with no disability. The median monthly salary for a person with mild vision loss is US$2207 and that for severe vision loss is US$2564, versus US$2724 for an age-matched person with no disability. Overall, the average person with mild vision loss with mild vision loss makes 45% that of the age-matched working person with no disability, whereas the average person with severe vision loss makes only 40.5% that of the average age-matched person with no disability (Table 4). The average person with a mild hearing disability fares better financially than the average person with mild vision loss, while the average person with severe hearing loss fares poorer financially than the average person with severe vision loss (Table 4).
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