The Cost of Vision Loss in Canada: Full Report (Word)

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The cost of vision loss in Canada

Report by Access Economics Pty Limited for the

CNIB and the Canadian

Ophthalmological Society

The cost of vision loss in Canada

CONTENTS

Glossary of acronyms ........................................................................................................... i

Executive summary .............................................................................................................. ii

1.

2.

3.

4.

Background ................................................................................................................. 1

1.1

Definitions ............................................................................................................................ 1

1.1.1

Better eye, worse eye 2

1.2

1.1.2

Severity definitions used in this report 2

Main causes of impairment .................................................................................................. 3

1.2.1

1.2.2

1.2.3

1.2.4

1.2.5

Age related macular degeneration (AMD)

Cataract

Diabetic retinopathy

Glaucoma

Refractive error (RE) and other causes of vision loss

3

4

6

8

10

Estimating prevalence .............................................................................................. 15

2.1

Population data ..................................................................................................................15

2.2

2.1.1

2.1.2

Age, gender and growth

Ethnicity

15

19

Data sources for prevalence of vision loss ........................................................................23

2.2.1

2.2.2

Population-based eye studies

Canadian self-reported survey data

24

24

2.3

2.2.3

Data from Canadian journal articles and research studies 32

Prevalence rates for VL .....................................................................................................36

2.3.1

2.3.2

2.3.3

White population VL

Aboriginals and Visible Minorities (AVM) VL

Cataract-induced VL in AVM

36

39

40

2.3.4

2.3.5

VL caused by AMD, Glaucoma and RE in AVM

Diabetes and DR in the AVM population

44

48

2.4

2.3.6

Summary of VL in AVM populations 50

Summary ............................................................................................................................51

Health system expenditure ....................................................................................... 62

3.1

Total expenditure on ‘vision care’ ......................................................................................62

3.2

3.3

Expenditure on particular eye disorders ............................................................................63

Total health system expenditure ........................................................................................66

3.3.1

3.3.2

Health system expenditure, top down

Health system expenditure, bottom up

66

67

Other financial costs ................................................................................................. 69

4.1

Productivity losses .............................................................................................................69

4.1.1

Employment participation 69

While every effort has been made to ensure the accuracy of this document, the uncertain nature of economic data, forecasting and analysis means that Access Economics Pty Limited is unable to make any warranties in relation to the information contained herein. Access Economics Pty Limited, its employees and agents disclaim liability for any loss or damage which may arise as a consequence of any person relying on the information contained in this document.

The cost of vision loss in Canada

5.

6.

4.1.2

4.1.3

4.1.4

Absenteeism from paid and unpaid work

Presenteeism

Premature mortality

70

71

72

4.2

4.1.5

Funeral costs 72

DWL from transfers ............................................................................................................72

4.2.1

4.2.2

Lost taxation revenue

Social security payments

72

74

4.3

4.2.3

Deadweight losses 75

Care and other assistance .................................................................................................76

4.4

Aids and devices ................................................................................................................78

4.4.1

4.4.2

4.4.3

4.4.4

4.4.5

4.4.6

4.4.7

4.4.8

Canes and accessories

Writing aids/stationery

Variable speed tape recorders

Computer voice synthesizer software

Electronic Braille display systems

Talking time pieces

Sunglasses with non-corrective lenses

Hand held magnifiers

82

82

79

79

81

81

81

81

4.4.9

4.4.10

4.4.11

Video magnifiers/CCTVs

Screen magnification software

82

83

83 Other aids for the sight impaired

4.5

4.4.12

Summary of aids and devices 84

Summary of other financial costs .......................................................................................86

Burden of disease ..................................................................................................... 87

5.1

Willingness to pay and the value of a life year ...................................................................87

5.2

5.1.1

5.1.2

Measuring burden: DALYs, YLLs and YLDs

Willingness to pay and the value of a statistical life year

87

87

Burden of disease from vision loss ....................................................................................89

5.2.1

5.2.2

Disability weights

Deaths from VL

89

90

5.3

5.2.3

5.2.4

Years of life lost due to disability

Years of life due to premature death

90

90

Total DALYs due to VL ......................................................................................................91

Summary .................................................................................................................... 93

Appendix A: EDPRG prevalence tables ............................................................................ 96

Appendix B: Prevalence projections by age, gender and disease ............................... 100

References ........................................................................................................................ 106

The cost of vision loss in Canada

FIGURES

Figure 1-1: Vision problems among Canadian seniors (% of age group)

Figure 1-2: Prevalence of AMD by age and gender in whites (% population)

Figure 1-3: Prevalence of cataract by age and gender in whites (% population)

Figure 1-4: Rates of cataract surgery by age

Figure 1-5: Prevalence of DR by age and gender in whites (% population)

Figure 1-6: Prevalence of glaucoma by age and gender in whites(% population)

Figure 1-7: Prevalence of myopia by age and gender in whites (% population)

Figure 1-8: Prevalence of hyperopia by age and gender in whites (% population)

Figure 1-9: Prevalence of hyperopia across countries by age, gender and source study

(% population)

Figure 1-10: Prevalence of myopia across countries by age, gender and source study

(% population)

Figure 2-1: Prevalence and incidence approaches to cost measurement

Figure 2-

2: Canadian population by age (’000 people), 2006 and 2031

Figure 2-3: White and AVM populations, 2006-2032 (% total)

Figure 2-4: Aboriginals and Visible Minorities, 1981-2017, selected years (% population)

Figure 2-5: Age distribution of non-white males (% population), 2001

Figure 2-6: Age distribution of non-white females (% population), 2001

Figure 2-

7: Ethnic composition of Canadian population compared to Australia’s

Figure 2-8: Prevalence of seeing disabilities by age and gender (2001)

Figure 2-9: Uncorrected VL, by ethnicity, age and gender (% population)

Figure 2-10: Under corrected VL from myopia, by ethnicity, age and gender (% population)

Figure 2-11: Under corrected VL from hyperopia, by ethnicity, age and gender (% population)

Figure 2-12: Canadians unable to see clearly at any distance or at all, by ethnicity, age and gender (% population)

Figure 2-13: Cataract prevalence, by ethnicity, age and gender (% population)

Figure 2-14: Glaucoma, by ethnicity, age and gender (% population)

Figure 2-15: Causes of VL in Prince George, Canada

Figure 2-16: Myopia in Chinese children in Canada and Hong Kong

Figure 2-17: Causes of blindness by ethnicity (US)

Figure 2-18: Probability of developing VL after contracting selected diseases, by ethnicity

Figure 2-19: Prevalence rates of VL, by ethnicity and cause, 2007

Figure 2-20: Prevalence of VL, by cause, 2007-2032

Figure 2-21: Prevalence of VL by gender, 2007 to 2032

13

27

27

14

15

16

20

46

52

53

54

6

8

10

11

11

1

4

5

21

22

22

23

25

26

28

29

30

33

34

39

The cost of vision loss in Canada

Figure 2-22: Projections of VL, by ethnicity, 2007 to 2032

Figure 2-23: Relative share of total VL, by ethnicity, 2007 to 2032

Figure 3-1: Canadian health system expenditure, 2007 (% of total)

Figure 3-2: Expenditure on vision care, Canada, 1975-2007

Figure 4-1: DWL of taxation

Figure 4-2: Comparison of assistance with activities of daily living between study groups

Figure 5-1: Loss of wellbeing due to VL (DALYs), by age and gender, 2007

Figure 6-1: Financial costs of VL, by type of cost (% total)

Figure 6-2: Financial costs of VL, by bearer (% total)

54

55

62

63

76

77

91

94

94

TABLES

Table 2

–1: Canadian population projections, males (‘000), 2006-2031, selected years

Table 2

–2: Canadian population projections, females (‘000), 2006-2031, selected years

Table 2

–3: Ethnic composition of Canadian population (% total), 2001

Table 2

–4: Prevalence of diabetes, by age and gender, 2005 (%)

Table 2

–5: CCHS prevalence of eye diseases in AVM

Table 2

–6: Causes of blindness in CNIB clients (2007)

Table 2

–7: Prevalence of POAG among the Eskimo (%)

Table 2

–8: Prevalence of diabetes among Canadian Aboriginal peoples (1991)

Table 2

–9: Prevalence of blindness by cause, 2006 to 2031 (% population)

Table 2

–10: causes of VL, by disease, in white populations

Table 2

–11: Prevalence of VL due to AMD, by severity (% of age group)

Table 2

–12: Prevalence rates for VL from cataracts, by age and severity (%)

Table 2

–13: Prevalence rates for vision impairment (<6/12) from DR, and proportion by stage of vision loss

Table 2

–14: Proportion of people with glaucoma by age and severity (%)

Table 2

–15: Prevalence rates for VL from RE, by age and severity (%)

Table 2

–16: Estimated VL prevalence in Canadian whites by disease and age

Table 2

–17: Prevalence of VL in US whites with cataracts (2000)

Table 2

–18: Prevalence of VL in US blacks with cataracts (2000)

Table 2

–19: Prevalence of VL in US Hispanics with cataracts (2000)

Table 2

–20: Prevalence of VL in US ‘Other’ with cataracts (2000)

Table 2

–21: Relative risk of developing VL from cataracts, by race

Table 2

–22: Prevalence of VL in whites with cataract, by age

Table 2

–23: Prevalence of VL in non- whites with cataract, by age

Table 2

–24: Prevalence of cataract-induced VL in Canadian AVM, by age

36

36

37

37

32

33

35

35

17

18

19

31

40

41

41

41

37

38

38

39

42

42

43

44

The cost of vision loss in Canada

Table 2

–25: Prevalence of eye diseases by ethnicity, US, 2000

Table 2

–26: Causes of VL by ethnicity

Table 2

–27: Prevalence of VL, by ethnicity and cause, US, 2000

Table 2

–28: Prevalence (%) of VL within specified diseases, by ethnicity

Table 2

–29: Relative risk of VL by eye disease, non-whites to whites

Table 2

–30: Prevalence of eye diseases in whites

Table 2

–31: Fraction of whites with each eye disease who have VL, by age and gender

(%)

Table 2

–32: prevalence of VL within disease groups, non-whites

Table 2

–33: Prevalence of VL in AVM

Table 2

–34: Under corrected VL in AVM

Table 2

–35: Prevalence of VL from DR within diabetic AVM groups

Table 2

–36: Prevalence of diabetes in AVM population, 2005 (%)

Table 2

–37: Estimated prevalence of DR-induced VL in AVM

Table 2

–38: Prevalence of VL in AVM by age, gender and disease

Table 2

–39: Prevalence of VL, by cause and ethnicity, 2007

Table 2

–40: All vision loss, by age, gender and ethnicity, 2007

Table 2

–41: Cataract vision loss, by age, gender and ethnicity, 2007

Table 2

–42: DR vision loss, by age, gender and ethnicity, 2007

Table 2

–43: Glaucoma vision loss, by age, gender and ethnicity, 2007

Table 2

–44: AMD vision loss, by age, gender and ethnicity, 2007

Table 2

–45: RE/Other vision loss, by age, gender and ethnicity, 2007

Table 3

–1: Total expenditure on certain eye procedures, 2004-05

Table 3

–2: Drug expenditure on nervous system and sense organ disorders, 1998

Table 3

–3: Expenditure on nervous system and sense organ disorders (1998)

Table 3

–4: Frequency of selected hospital procedures (2001)

Table 3

–5: Rebates for certain ophthalmological procedures in Ontario (2006)

Table 3

–6: Average treatment costs for neovascular AMD (2005)

Table 3

–7: Estimated VL health system expenditure (top down), 2007

Table 4

–1: Estimated AWE, by age and gender, 2007

Table 4

–2: percentage of population employed, by age and gender

Table 4

–3: Provincial sales taxes

Table 4

–4: Income sources (CNIB)

Table 4

–5: VL-related social security payments and beneficiaries

Table 4

–6: Excess usage of social security payments

Table 4

–7: Annual direct AMD non-medical related utilisation costs per person (2005$)

Table 4

–8: Canes/accessories for the blind (2000-01$)

Table 4

–9: Writing and stationery items (2000-01$)

Table 4

–10: Talking time pieces (2000-01$)

44

45

45

45

46

46

65

66

67

70

70

64

64

64

65

77

79

81

82

73

74

75

75

58

59

60

61

51

52

56

57

47

47

48

49

49

49

50

The cost of vision loss in Canada

Table 4

–11: Sunglasses with non-corrective lenses (2000-01$)

Table 4

–12: Hand held magnifiers (2000-01$)

Table 4

–13: Other stationery (2000-01$)

Table 4

–14: Large button telephones (2000-01$)

Table 4

–15: Summary of aids and devices (2000-01$)

Table 4

–16: Estimates of additional aids and devices

Table 4

–17: Summary of other financial costs of VL, 2007

Table 5

–1: Value of a statistical life in Canadian studies ($ million)

Table 5

–2: Estimated years of healthy life lost due to disability (YLD), 2007 (DALYs)

Table 5

–3: Years of life lost due to premature death (YLL) due to VL, 2007

Table 5

–4: Net cost of lost wellbeing, $million, 2007

Table 6

–1: VL, total costs by type of cost and bearer, 2007

82

82

83

84

85

86

86

89

90

90

92

93

The cost of vision loss in Canada

GLOSSARY OF ACRONYMS

AMD

AVM

AWE

BMES

CACS

CCHS

CCTV

CERA

CIHI

CNIB

COS

DALY

DR

DWL

EDPRG

GST

HST

ICES

MVIP

NGS

NHEX

NPHS

PALS

POAG

PST

RE

UK

US

UV

VL

VSL(Y) age related macular degeneration

Aboriginal and Visible Minorities

Average Weekly Earnings

Blue Mountains Eye Study

Comprehensive Ambulatory Classification System

Canadian Community Health Survey closed circuit television

Centre for Eye Research Australia

Canadian Institute for Health Information

CNIB

Canadian Ophthalmological Society

Disability Adjusted Life Year diabetic retinopathy deadweight loss

Eye Disease Prevalence Research Group

Goods and Services Tax

Harmonized Sales Tax

Institute for Clinical Evaluative Sciences

Melbourne Visual Impairment Project

National Grouping System

National Health Expenditure database

National Population Health Survey

Participation and Activity Limitation Survey

Primary Open Angle Glaucoma

Provincial Sales Taxes refractive error

United Kingdom

United States ultraviolet vision loss

Value of a Statistical Life (Year) i

The cost of vision loss in Canada

EXECUTIVE SUMMARY

This report estimates the cost of vision loss (VL) in Canada, utilising a prevalence-based approach. Direct health system expenditures on visually impairing eye conditions are included, as well as other financial costs (such as productivity losses) and the value of the loss of healthy life (measured in Disability Adjusted Life Years or DALYs).

Prevalence of vision loss

A variety of data sources were used to construct a model of Canadian VL by age, gender, ethnicity, severity and type.

In 2007, there were an estimated 816,951 Canadians with

VL

.

Of this total, 780,534 (95.5%) were white and 36,416 (4.5%) were Aboriginals and

Visible Minorities (AVM).

‘Refractive Error and Other’ is the main source of VL for the white population (68.1% of the total), and cataract is the main cause of VL in AVM (36.1% of the total) 1 .

For whites, the second largest source of VL is cataract (15.5%) and, for the AVM population, DR is the second largest source (24.4% of the total).

AVM have lower prevalence of VL for all diseases other than DR, largely due to lower prevalence of eye diseases at equivalent ages to whites, a younger age profile, and less likelihood of developing VL once they have contracted a given eye disease.

AMD

Cataract

DR

Glaucoma

RE/Other

P

REVALENCE OF

VL,

BY CAUSE AND ETHNICITY

, 2007

All ethnicities White AVM

Number % total Number % total Number % total

89,241

133,836

29,920

24,937

539,236

10.9%

16.4%

3.7%

3.1%

66.0%

84,641

120,685

20,992

22,565

531,650

10.8%

15.5%

2.7%

2.9%

68.1%

4,380

13,151

8,928

2,373

7,586

12.0%

36.1%

24.5%

6.5%

20.8%

All VL 817,171 100.0% 780,534 100.0% 36,417 100.0%

ii

1

‘Other’ represents minor diseases – ie,

not

the ‘big five’ of cataract, diabetic retinopathy (DR), age-related macular degeneration (AMD), glaucoma, or refractive error (RE)

. ‘Other’ diseases have not been the subject of population eye health studies.

The cost of vision loss in Canada

P

REVALENCE RATES OF

VL,

BY CAUSE AND ETHNICITY

, 2007

3.5%

3.0%

2.5%

All races

White

AVM

3.0%

2.5%

1.6%

2.0%

2.0%

1.5%

4.5%

4.0%

3.5%

3.0%

2.5%

2.0%

1.5%

1.0%

0.5%

0.0%

1.0%

0.5%

0.0%

0.3%

0.3%

0.4%

0.1%

0.5%

0.1%

0.2%

0.1%

0.1%

0.1%

0.0%

AMD Cataract DR

0.1%

Glaucoma RE/Other All VI

0.6%

The prevalence of VL is projected to almost double in absolute numbers, and increase from

2.5% of the population in 2007 to 4.0% in 2032.

VL affects women more than men, reflecting greater longevity in females. In 2007, females accounted for 58.4% of VL; by 2032, this will have fallen slightly to 56.3%.

Despite the fact that the AVM share of the total population is rapidly increasing, the increase in this group’s share of VL at the end of the projection period is less than commensurate, partly due to AVM having a considerably younger age profile than the white population with no substantial aging over the forecast period.

P

REVALENCE OF

VL,

BY CAUSE

, 2007-2032

All VI

Glaucoma

Cataracts

AMD

DR

RE/Other iii

iv

The cost of vision loss in Canada

Costs

In 2007, the

financial cost of VL was $15.8 billion

. Of this:

$8.6 billion (54.6%) was direct health system expenditure;

$4.4 billion (28.0%) was productivity lost due to lower employment, absenteeism and premature death of Canadians with VL;

$1.8 billion (11.1%) was the DWL from transfers including welfare payments and taxation forgone;

$0.7 billion (4.4%) was the value of the care for people with VL; and

$305 million (1.9%) was other indirect costs such as aids and home modifications and the bring-forward of funeral costs.

Additionally,

the value of the lost wellbeing (disability and premature death) was a further $11.7 billion

.

Burden of disease

Health system costs

Productivity costs

Carer costs

Other Indirect costs

Deadweight losses

Transfers

Total financial costs

Total costs including burden of disease

Burden of disease

Health system costs

Productivity costs

Carer costs

Other Indirect costs

Deadweight losses

Transfers

Total financial costs

Total costs including burden of disease

VL,

TOTAL COSTS BY TYPE OF COST AND BEARER

, 2007

Individuals

11,710

1,499

2,847

0

61

0

-917

3,490

Family/

Friends

0

413

62

0

0

0

0

474

Federal

Government

Provincial

Governments

Total cost ($ million)

0

388

886

218

0

0

917

2,409

0

5,670

619

0

61

0

0

6,350

Employers

80

0

61

0

0

0

0

141

15,200 141

14,334

1,835

3,485

0

74

0

-1,122

4,272

18,606

474 2,409 6,350

Cost per person with visual impairment ($)

0

0

0

505

76

0

0

581

0

475

1,084

267

0

0

1,122

2,948

0

6,941

757

0

74

0

0

7,773

581 2,948 7,773

0

0

98

0

74

0

0

172

172

Society/

Other

0

1,081

0

62

61

1,757

0

2,960

2,960

0

1,323

0

76

74

2,151

0

3,624

3,624

Total

11,710.4

8,637.9

4,431.4

692.8

304.9

1,757.0

0

15,824

27,534

14,334

10,573

5,424

848

373

2,151

0

19,370

33,704

In per capita terms, this amounts to a financial cost of $19,370 per person with VL per annum. Including the value of lost wellbeing, the cost is $33,704 per person per annum.

The cost of vision loss in Canada

F

INANCIAL COSTS OF

VL,

BY TYPE OF COST

(%

TOTAL

)

Indirect Costs

1.9%

Carer Costs

4.4%

DWL

11.1%

Productivity Costs

28.0%

Health System Costs

54.6%

Individuals with VL bear 22.1% of the financial costs, and their families and friends bear a further 3.0%. Federal government bears 15.2% of the financial costs (mainly through taxation revenues forgone and welfare payments). Provincial governments bear 40.1% of the costs, reflecting the nature of Canada’s Federal system, while employers bear 0.9% and the rest of society bears the remaining 18.7%.

If the burden of disease (lost wellbeing) is included, individuals bear 55.2% of the costs and

Provincial governments bear 23.1% while the Federal government bears a lesser 8.7%, with family and friends 1.7%, employers 0.5% and others in society 10.8%.

F

INANCIAL COSTS OF

VL,

BY BEARER

(%

TOTAL

)

Society/Other

18.7%

Individuals

22.1%

Employers

0.9%

Family/Friends

3.0%

Federal Government

15.2%

Provincial

Governments

40.1%

v

The cost of vision loss in Canada

Finally, an important finding from this analysis was the observation that, for an advanced

Western nation, Canada has a serious deficienc y in eye health data. CNIB’s Health

Economic Statement (

http://www.costofblindness.org/media/health-state.asp

) observes that, with respect to blindness and vision loss, there is

‘strong argument for saying that

Canada has the worst record of supporting research of all the G8 countries

’. The importance of good eye health to Canadians is shown from survey data in the same document revealing that two-thirds of Canadians would cash in all their savings or sell everything they owned to save their eyesight. With a rapidly aging population, it is high time for a Canadian population eye health study to monitor incidence, prevalence and morbidity outcomes and economic impacts more robustly in the future.

Access Economics

12 December 2008

vi

The cost of vision loss in Canada

1.

BACKGROUND

This report estimates the cost of vision loss (VL) in Canada, utilising a prevalence-based approach. Direct health system expenditures on visually impairing eye conditions are included, as well as other financial costs (such as productivity losses) and the value of the loss of healthy life (measured in Disability Adjusted Life Years or DALYs).

1.1

DEFINITIONS

Statistics Canada (2004a) reported that the majority (51%) of Canadians had some form of

‘vision problem’ in 2003, while Statistics Canada (2001) found that that 2.5% had a ‘visual disability’. A ‘vision problem’ is not considered a visual disability if it can be corrected

(eg, with glasses or contact lenses for refractive error - RE). Figure 1-1 shows the

differences between the two categories within age and gender cohorts for Canadian seniors

(people aged 65 years or older), where prevalence is understandably higher (70%-90%).

F

IGURE

1-1: V

ISION PROBLEMS AMONG

C

ANADIAN SENIORS

(%

OF AGE GROUP

)

50%

40%

30%

20%

10%

0%

100%

90%

80%

70%

60%

Male, uncorrected

Male, corrected

Female, uncorrected

Female, corrected

Y e a rs o f a ge

Source: Statistics Canada (2004a).

In this report, the term ‘vision loss’ rather than ‘visual disability’ will be used.

Vision loss

is broadly defined as a limitation in one or more functions of the eye or visual system, most commonly impairment of visual acuity (sharpness or clarity of vision), visual fields (the ability to detect objects to either side or above or below the direction in which the person is looking) and colour vision.

1

2

The cost of vision loss in Canada

Normal vision is recorded as 20/20 in the Imperial system used in Canada (6/6 in metric), which means that a person can see at 20 feet (6 meters) what a person with normal vision can see at 20 feet. Degrees of VL are measured similarly, where the first number in the measure is the furthermost distance at which the person can clearly see an object and the second number is the distance at which a person with normal vision could see the same object. For example, 20/40 vision means that the person can clearly see at 20 feet (but not more) an object that a person with unimpaired vision could see at 40 feet (but not more).

The

Blind Persons Regulations, Consolidated Regulations of Canada 1978 (Chapter 371A)

2

states that ‘a person shall be considered legally blind whose central acuity does not exceed

20/200 in the better eye with correcting lenses’. This means that if a person with their glasses on can see the big 'E' on a Snellen eye chart, but none of the other optotypes, for legal purposes they are considered blind and are eligible for certain government tax credits as well as concessions from some retailers and other service providers. The Canadian definition of legal blindness also includes ‘or a visual field extent of less than 20 degrees in diameter horizontally’.

1.1.1

B

ETTER EYE

,

WORSE EYE

VL can differ from one eye to the other (asymmetrical vision loss). As a result of this, prevalence rates can be reported for either the better or the worse eye in terms of the extent of vision loss. Asymmetrical vision loss, however, has little impact on function or disability, and indeed, it is often only when vision loss becomes bilateral that it is identified and treated.

When reporting prevalence rates, better eye measures would provide conservative estimates, while worse eye measures may tend to overstate costs and impairment.

In this study, the conservative approach has thus been to report VL prevalence for the better eye.

1.1.2

S

EVERITY DEFINITIONS USED IN THIS REPORT

Best corrected visual acuity (BCVA) is defined as the best possible vision a person can achieve with corrective lenses measured in terms of Snellen lines on an eye chart.

Common definitions for visual acuity used in Canada (Jutai et al, 2006), and in this report are as follows.

Blindness

is defined as BCVA of 20/200 or worse (

≤6/60) in the better-seeing eye.

Vision loss

is defined as BCVA less than 20/40 (<6/12) in the better-seeing eye. It thus comprises blindness and low vision.

Low vision

is defined as VL that is not blindness, and is categorized as:

mild

VL

– BCVA worse than 20/40 (<6/12) but better than or equal to 20/60

(6/18) in the better-seeing eye; and

moderate

VL

– BCVA worse than 20/60 (<6/18) but better than or equal to

20/200 (6/60) in the better-seeing eye.

2

http://www.amdcanada.com/template.php?section=4&lang=eng&subSec=3d&content=4_3 (accessed 28 March

2008)

1.2

MAIN CAUSES OF IMPAIRMENT

The cost of vision loss in Canada

1.2.1

A

GE RELATED MACULAR DEGENERATION

(AMD)

AMD is an incurable eye disease and a leading cause of blindness in elderly people. The macula is the part of the retina that enables central vision and the seeing of fine detail.

Damage to the macula is characterized by a ‘black spot’ – losing the centre of the picture. In

‘early AMD,’ small yellow deposits called

drusen

form under the macula. Vision is usually lost with more advanced stages of AMD. There are two types of ‘late AMD’.

Dry (geographic/atrophic):

In around one third of cases of late AMD, the macula thins. Vision loss is directly related to the location and amount of retinal thinning, but the progress of dry AMD is slower than that of the ‘wet’ type. There is no known treatment or cure for the ‘dry’ type of AMD.

Wet (exudative/neovascular):

Two thirds of those with late AMD have this type.

Abnormal blood vessels grow under the retina and macula; these vessels bleed and leak fluid, causing the macula to bulge or lift up. Vision loss may be rapid and severe.

Thermal laser surgery may be used in the early stages and may prevent severe eye damage for some patients.

Photodynamic laser therapy with verteporfin

provides an improvement over thermal laser treatment, but does not preclude recurrence, so that at best it slows the rate of vision loss.

Causes of AMD are not well understood, but may include age and a genetic component, with family history increasing the risk of AMD three to four times. People who smoke are twice as likely to develop AMD. People who have a family history of AMD and smoke are up to 144 times more likely to develop the disease. In summary, in most cases there is no effective prevention of or treatment for AMD. Because AMD is painless, usually progresses slowly and generally occurs in one eye first, it may be difficult to self-detect AMD early (Access

Economics, 2006).

Current treatments for AMD, such as photodynamic therapy, are limited both in terms of their ability to retard progression of disease and thus loss of vision, as well as only being effective for a proportion of people with neovascular AMD. However, emerging therapies have the potential to enhance the efficacy and coverage of treatment options for people with AMD.

Anti-angiogenesis is a treatment that aims to block the process of angiogenesis in neovascular AMD. Theoretically this will retard progression of neovascular AMD and reduce its recurrence. Anti-angiogenesis treatments include: o

Pegaptanib (Macugen). This requires six weekly injections in the affected eye over a period of at least two years. Pegaptanib has been shown to retard the progression of wet AMD. o

Ranibizumab (Lucentis) is new treatment, shown to be effective in both retarding the progression of wet AMD and restoring some vision to a significant number of patients. o

Bevacizumab (Avastin) has been fairly widely used

‘off label’ for AMD, although it is not indicated for this condition. As yet, no extensive head to head clinical trials have been conducted comparing bevacizumab and ranibizumab with respect to both safety and efficacy.

Figure 1-2 shows the prevalence of AMD by gender among whites, based on an international

meta-analysis of these ethnicities by the Eye Disease Prevalence Research Group

– EDPRG

(Congdon et al, 2004a). Details of the source studies used by the EDPRG are provided in

3

4

12%

10%

8%

6%

4%

2%

0%

The cost of vision loss in Canada

Appendix A, and include studies from the United States (US), West Indies, Australia and the

Netherlands.

14%

F

IGURE

1-2: P

REVALENCE OF

AMD

BY AGE AND GENDER IN WHITES

(%

POPULATION

)

White Female

White Male

Years of age

Note: See Appendix A for underlying data.

Source: Congdon et al (2004a) and Access Economics (2006).

1.2.2

C

ATARACT

A cataract is a cloudy area in the eye's lens that forms when proteins clump together. Over time, the cataract may grow larger and cloud more of the lens, making it hard to see. The most common symptoms are blurry vision, problems with light, ‘faded’ colours, double or multiple vision and the need for frequent changes in glasses or contact lenses.

The four main types of cataract are age related (most common), congenital, secondary

(eg, due to diabetes or steroid use) and traumatic (eg, due to eye injury). Causes of cataract are still uncertain, although age, smoking, diabetes and ultraviolet (UV) exposure have been shown to increase risk. Detection is through an eye examination including a visual acuity test (eye chart test) and pupil dilation (where the pupil is widened with eye drops to allow the eye care professional to see more of the lens and look for other eye problems).

Cataract surgery may be indicated to improve vision, with the cloudy lens removed and replaced with a substitute lens. Surgery is safe and very effective, with almost all people having better vision and improved quality of life afterward, and only a small percentage experiencing complications such as infection, bleeding or inflammation. Cataract surgery is generally performed as same-day surgery without general aesthetic, with a six week total recovery period.

The cost of vision loss in Canada

Figure 1-3 shows the prevalence of cataract by age, gender and ethnicity.

F

IGURE

1-3: P

REVALENCE OF CATARACT BY AGE AND GENDER IN WHITES

(%

POPULATION

)

50%

40%

30%

20%

10%

0%

80%

70%

60%

White Female

White Male

Years of age

Note: See Appendix A for underlying data.

Source: Congdon et al (2004a) and Access Economics (2006).

5

The cost of vision loss in Canada

Taylor (2001) shows that, in Australia, rates of cataract surgery double with each decade of

life. Figure 1-4 shows rate of cataract by age group. While younger people have lower rates

of cataract surgery than older cohorts, because there are fewer people in the oldest cohorts

3

, the average age of cataract surgery in Canada is 74 years

4

.

Conversely, while surgery rates increase in older cohorts, prevalence of cataract increases faster still, leading to higher rates of VL in the oldest of the old.

F

IGURE

1-4: R

ATES OF CATARACT SURGERY BY AGE

Source: Taylor (2001).

1.2.3

D

IABETIC RETINOPATHY

Diabetic retinopathy (DR) is a complication of diabetes mellitus, usually affecting both eyes, wherein microaneurysms develop on the tiny blood vessels inside the retina. As the disease progresses, some blood vessels that nourish the retina are blocked, causing vision loss through either proliferative retinopathy or macular edema.

6

Left

: Normal vision.

Right

: The same scene as it might be viewed by a person with DR.

DR often has no early symptoms. Sometimes the person sees specks of blood, or spots,

‘floating’ in their vision. Diagnosis can be made via a visual acuity test (eye chart test), dilated eye examination, retinal photography and/or fluorescein angiogram. Macular edema

3

There are over ten times as many Canadian septuagenarians as nonagenarians.

4

Canadian Ophthalmological Society, correspondence of 11 April 2008.

The cost of vision loss in Canada is treated with focal laser surgery, which stabilizes vision and reduces the risk of vision loss by 50%.

Proliferative retinopathy is treated with scatter laser surgery that, while it can worsen peripheral, colour and/or night vision, can save the rest of a person’s sight. If bleeding is severe and persistent, a

vitrectomy

may be necessary, where blood and gel are removed from the centre of the eye and replaced with a salt solution, under local or general anesthetic.

Although both laser treatment and vitrectomy can effectively reduce vision loss they do not cure DR, and the patient remains at risk for new bleeding. Multiple treatments may be necessary.

To prevent the onset and progression of DR (and the need for surgery), people with diabetes should control their levels of blood sugar, blood pressure and blood cholesterol. Early diagnosis and treatment can prevent almost all severe vision loss. The earlier treatment is

received, the more likely it is to be effective. Prevalence is shown in Figure 1-5.

7

The cost of vision loss in Canada

F

IGURE

1-5: P

REVALENCE OF

DR

BY AGE AND GENDER IN WHITES

(%

POPULATION

)

8%

7%

6%

5%

4%

3%

2%

1%

0%

White Female

White Male

Years of age

Note: See Appendix A for underlying data.

Source: Congdon et al (2004a) and Access Economics (2006).

1.2.4

G

LAUCOMA

Glaucoma is a group of diseases that, while initially asymptomatic, can damage the eye's optic nerve and result in blindness. The optic nerve comprises nerve fibers that connect the retina with the brain. In the front of the eye is a space called the

anterior chamber

– clear fluid flows in and out of this space, leaving the chamber at the angle where the cornea and iris meet. When the fluid reaches the angle, it flows through a spongy meshwork, like a drain, and leaves the eye.

Primary open-angle glaucoma (POAG),

the most common type, occurs when, for unknown reasons, the fluid passes too slowly through the meshwork drain. As the fluid builds up, the pressure inside the eye rises. Unless the pressure at the front of the eye is controlled, it can damage the optic nerve and cause vision loss. Although people can see objects clearly in front of them, they miss things to the side and out of the corner of their eye. Peripheral vision may deteriorate without treatment, like looking through a tunnel, until there is no vision left.

8

Left

: Normal vision.

Right

: The same scene as it might be viewed by a person with glaucoma.

The cost of vision loss in Canada

Other less common types of glaucoma include:

Closed-angle glaucoma

,

in which the fluid at the front of the eye is blocked from reaching the angle, resulting in a sudden increase in pressure, pain, redness and blurred vision. Immediate (medical emergency) laser surgery is required to clear the blockage and protect sight.

Congenital glaucoma

, occurring in children born with defects in the angle of the eye that slow fluid drainage, causing cloudy eyes, sensitivity to light and excessive tearing.

Prompt surgery provides an excellent chance of saving vision.

Secondary glaucoma

, which

develops as a complication of other medical conditions, such as surgery, advanced cataract, eye injuries, certain eye tumours, uveitis (eye inflammation), diabetes or the use of corticosteroid drugs. Treatment includes medicines and laser or conventional surgery.

Increased risk for glaucoma occurs with age, family history and ethnicity. Glaucoma is detected through an eye examination including visual acuity, visual field, tonometry and optic nerve examination.

Although there is no cure for glaucoma, early diagnosis and treatment may help protect eyes against serious vision loss and blindness. Treatments include:

Eye drops

(very common)

– eye drops taken several times a day can lower pressure by helping fluid drain from the eye or causing the eye to make less fluid. Rare side effects include headaches or eye irritation.

Laser surgery

(‘laser trabeculoplasty’) – helps fluid drain from the eye by burning holes in the meshwork with a high-energy light beam. The effects of laser surgery wear off so that, after two years, the pressure increases again in more than half of all patients. Repeating laser surgery is often not useful.

Conventional surgery

– can make a new opening for the fluid to leave the eye. Such surgeries are often performed after eye drops and laser surgery have failed to control pressure. Surgery is around 80-90% effective at lowering pressure. However, if the new drainage opening closes, a second operation may be needed. Conventional surgery works best in the absence of other previous eye surgery.

Possible side effects of glaucoma surgery include cataract, inflammation or infection inside the eye, and swelling of blood vessels behind the eye

– all of which are treatable. In some cases, vision may worsen after surgery.

9

10

The cost of vision loss in Canada

F

IGURE

1-6: P

REVALENCE OF GLAUCOMA BY AGE AND GENDER IN WHITES

(%

POPULATION

)

5%

4%

3%

2%

1%

0%

8%

7%

6%

White Female

White Male

Years of age

Note: See Appendix A for underlying data.

Source: Congdon et al (2004a) and Access Economics (2006).

1.2.5

R

EFRACTIVE ERROR

(RE)

AND OTHER CAUSES OF VISION LOSS

A large part of remaining vision loss is caused by RE. Less common conditions such as neuro-ophthalmic disorders, retinitis pigmentosa and other retinal conditions account for the remaining prevalence of VL and blindness.

As noted above, RE is the most frequent yet most easily correctible source of eye problems in Canada, occurring when optical defects result in light not focusing properly on the retina.

Myopia

(near-sightedness with blurry distant vision) and

hyperopia

(farsightedness with close objects blurry) are the most well-known RE. Most infants have some degree of hyperopia, although vision usually normalizes by six years of age. Most myopia occurs later during adolescence. The extent of RE is measured in

diopters

. Other common forms of REs include

astigmatism

(uneven focus) and

presbyopia

(age related problem with near focus).

Myopia is a very common disorder. Prevalence is greater in women through age 60, after which rates become more comparable between genders. Myopia affects more whites than other races, and is generally less frequent with age, Hyperopia is less common, but prevalence generally increases with age. It is also most frequent in Whites.

Prevent

Blindness America (2002:12)

Almost all RE can be corrected by eyeglasses or contact lenses. Refractive surgery is another alternative treatment, but one not without risk.

Figure 1-7 and Figure 1-8 highlight that RE is less common in males than females. Myopia

tends to decrease with age, whereas hyperopia increases. (Older black males have

The cost of vision loss in Canada significantly less of either condition than other groups

– hyperopia is over 18 times more prevalent in older white females than equally aged black males.)

15%

10%

5%

0%

35%

30%

25%

20%

F

IGURE

1-7: P

REVALENCE OF MYOPIA BY AGE AND GENDER IN WHITES

(%

POPULATION

)

50%

45%

40%

White Female

White Male

Years of age

Note: See Appendix A for underlying data.

Source: Congdon et al (2004a) and Access Economics (2006). Note: Myopia = (-1.00 diopters or worse).

F

IGURE

1-8: P

REVALENCE OF HYPEROPIA BY AGE AND GENDER IN WHITES

(%

POPULATION

)

30%

25%

20%

White Female

White Male

15%

10%

5%

0%

Years of age

Note: See Appendix A for underlying data.

Source: Congdon et al (2004a) and Access Economics (2006). Note: Hyperopia = (+3.00 diopters or worse).

11

The cost of vision loss in Canada

RE is the most common source of VL in Western countries; Figure 1-9 and Figure 1-10 show that population-based eyes studies demonstrate little variance in the prevalence of hyperopia and myopia in white populations across countries with similar cultures and income levels.

12

The cost of vision loss in Canada

F

IGURE

1-9: P

REVALENCE OF HYPEROPIA ACROSS COUNTRIES BY AGE

,

GENDER AND SOURCE STUDY

(%

POPULATION

)

Prevalence of hyperopia of +3 diopters or greater in white persons (A) and black and Hispanic persons (B). BES= Baltimore Eye Study; BDES=Beaver Dame Eye Study;

BMES=Blue Mountains Eye Study; RS=Rotterdam Study; Melbourne VIP = Melbourne Visual Impairment Project; Proyecto VER=Vision Evaluation and Research.

Source: Congdon et al (2004b).

13

The cost of vision loss in Canada

F

IGURE

1-10: P

REVALENCE OF MYOPIA ACROSS COUNTRIES BY AGE

,

GENDER AND SOURCE STUDY

(%

POPULATION

)

14

Prevalence of myopia of -1 diopter or less in white persons (A) and black and Hispanic persons (B). BES= Baltimore Eye Study; BDES=Beaver Dame Eye Study; BMES=Blue

Mountains Eye Study; RS=Rotterdam Study; Melbourne VIP = Melbourne Visual Impairment Project; Proyecto VER=Vision Evaluation and Research.

Source: Congdon et al (2004b).

The cost of vision loss in Canada

2.

ESTIMATING PREVALENCE

Prevalence approaches to cost estimation, for a given health condition, measure the number of people with that given condition (in this case VL) in a base period (in this case calendar year 2007) and the costs associated with treating them, as well as other financial and nonfinancial costs (productivity losses, carer burden, loss of quality of life) in that year, due to the condition. This report adopts a prevalence approach to cost measurement rather than an incidence approach, as the data sources lend themselves to utilization of such an approach, and for consistency with other studies of the cost of VL (eg, in Australia, Japan and the US).

Figure 2-1 depicts the difference between a prevalence approach (areas A+B+C in Figure

2-1) and an incidence approach, the latter estimating the present value of the lifetime costs of new cases of VL in 2005 (area C plus the present value of C* in Figure 2-1). Consider

person A, who first experienced VL and its impacts in 1990 and continued to experience them until death in 2005. This person would be included in a prevalence approach (but not in an incidence approach), although only the costs incurred in 2005 would be included (ie, A but not A*, where A includes the present value of premature mortality costs if the death was premature). Person B developed VL during the late 1990s and experiences impairment and its impacts through to 2008 (with costs of B+B*+B**, shaded in blue); she also would be counted (but only costs of B) using a prevalence approach, but not using an incidence approach. Person C (shaded in red) is newly diagnosed with VL in 2005 and his costs in

2005 (C) would be included in a prevalence approach but not future costs (C*).

F

IGURE

2-1: P

REVALENCE AND INCIDENCE APPROACHES TO COST MEASUREMENT

1990 2006 2010

To estimate the number of cases of VL in the population, epidemiological data on prevalence rates are applied to population data. Ideally for projections, the number of cases of VL should be stratified by gender, age, ethnicity, severity (mild and moderate VL and blindness) and cause (A

MD, cataract, DR, glaucoma, RE and ‘other’). A first step is thus to assimilate population data by gender, age and ethnicity, for 2007 and subsequent years (next section).

2.1

POPULATION DATA

2.1.1

A

GE

,

GENDER AND GROWTH

Statistics Canada (2006) reports that Canada has the second youngest population in the

G8

5

. In 2006, around one in seven Canadians (13.7%)

6

was aged 65 years or older and

Statistics Canada (2006) projects that by 2031 these ‘senior citizens’ will account for around

5

The Group of Eight represents the world’s largest industrialised economies: US, UK, Russia, France, Germany,

Italy, Japan and Canada.

6

Statistics Canada 2006 Census Online, www.statcan.ca (Cat, No, 97-551-XCB2006005).

15

2,000

1,500

1,000

500

0

The cost of vision loss in Canada

one quarter of the population (Figure 2-2)

7

. Thus, as many eye diseases are age related, the overall prevalence of VL will increase over the medium term.

These projections were compiled using data from the 2001 Census. Although 2006

Census data have recently become available for that year, population projections by five year age-gender cohorts are not yet provided by Statistics Canada from the 2006

Census. Accordingly, this report uses

Statistics Canada’s existing projections

8

.

F

IGURE

2-2: C

ANADIAN POPULATION BY AGE

(’000

PEOPLE

), 2006

AND

2031

3,000

2006

2031

2,500

Age group (years)

Source: Statistics Canada (2006).

16

7

Statistics Canada (2006) makes projections for the entire Canadian population out to 2031, with special data requests available out to 2056. Projections presented here are from the medium growth, medium immigration scenario (scenario 3).

8

This also enables consistency with the other vision health projections (Buhrmann, forthcoming).

Age group

0

–4

5

–9

10

–14

15

–19

20

–24

25

–29

30

–34

35

–39

40

–44

45

–49

50

–54

55

–59

60

–64

65

–69

70

–74

75

–79

80

–84

85

–89

90

–94

95

–99

100+

Total

The cost of vision loss in Canada

T

ABLE

2

–1:

C

ANADIAN POPULATION PROJECTIONS

,

MALES

(‘000),

2006-2031,

SELECTED YEARS

2006

868

943

1,068

1,109

1,153

1,125

1,122

1,183

1,357

1,335

1,170

1,029

778

591

490

387

249

115

38

7

1

16,116

2007

872

927

1,054

1,121

1,154

1,138

1,128

1,181

1,322

1,353

1,206

1,038

833

613

490

396

255

123

39

8

1

16,251

2008

875

917

1,037

1,130

1,152

1,152

1,139

1,179

1,279

1,372

1,241

1,054

879

641

495

402

263

131

40

8

1

16,386

2009

876

914

1,020

1,131

1,153

1,165

1,154

1,175

1,241

1,386

1,268

1,081

919

670

504

405

270

138

41

8

1

16,520

2010

879

911

1,002

1,123

1,161

1,173

1,169

1,173

1,217

1,384

1,294

1,114

958

699

515

407

278

143

44

9

1

16,654

2011

884

911

982

1,113

1,171

1,178

1,183

1,172

1,210

1,362

1,321

1,144

991

732

531

409

286

148

48

9

1

16,787

2016

914

928

952

1,029

1,176

1,199

1,238

1,236

1,202

1,220

1,350

1,295

1,107

936

662

449

307

175

64

12

1

17,451

2021

931

960

971

1,001

1,095

1,206

1,263

1,294

1,268

1,216

1,215

1,327

1,256

1,050

852

567

344

192

77

17

2

18,102

Source: Statistics Canada (2006).

2026

929

979

1,004

1,022

1,069

1,129

1,275

1,322

1,329

1,284

1,214

1,198

1,291

1,197

964

736

440

220

87

21

2

18,711

2031

913

980

1,026

1,057

1,092

1,105

1,203

1,338

1,360

1,346

1,282

1,199

1,171

1,235

1,105

841

579

288

103

24

3

19,249

17

18

Age group

0

–4

5

–9

10

–14

15

–19

20

–24

25

–29

30

–34

35

–39

40

–44

45

–49

50

–54

55

–59

60

–64

65

–69

70

–74

75

–79

80

–84

85

–89

90

–94

95

–99

100+

Total

The cost of vision loss in Canada

T

ABLE

2

–2:

C

ANADIAN POPULATION PROJECTIONS

,

FEMALES

(‘000),

2006-2031,

SELECTED YEARS

2006

829

900

1,017

1,056

1,100

1,101

1,101

1,168

1,342

1,337

1,194

1,054

806

637

554

491

389

228

99

26

4

16,431

2007

832

885

1,001

1,067

1,103

1,115

1,110

1,165

1,309

1,351

1,229

1,067

863

660

555

495

392

241

102

27

4

16,571

2008

834

876

986

1,075

1,102

1,129

1,121

1,162

1,268

1,366

1,260

1,087

912

689

560

497

395

253

104

29

4

16,709

2009

834

873

970

1,075

1,105

1,141

1,138

1,157

1,232

1,376

1,284

1,117

956

718

571

497

397

263

108

30

4

16,848

2010

835

871

954

1,067

1,115

1,148

1,154

1,156

1,207

1,373

1,306

1,152

1,000

748

583

497

402

269

114

32

4

16,986

2011

841

870

934

1,058

1,124

1,152

1,172

1,155

1,199

1,350

1,330

1,183

1,037

782

600

498

406

274

121

33

5

17,123

2016

868

883

907

978

1,128

1,178

1,225

1,227

1,188

1,211

1,345

1,320

1,165

1,007

739

544

417

291

148

42

6

17,815

2021

885

912

921

952

1,051

1,186

1,255

1,283

1,263

1,203

1,211

1,336

1,302

1,134

955

674

460

303

160

52

8

18,507

Source: Statistics Canada (2006).

2026

883

931

953

968

1,028

1,113

1,268

1,317

1,321

1,278

1,204

1,207

1,321

1,270

1,080

875

576

341

170

58

10

19,172

2031

868

931

973

1,001

1,046

1,094

1,200

1,333

1,357

1,338

1,281

1,202

1,197

1,292

1,214

996

753

432

196

63

11

19,780

The cost of vision loss in Canada

2.1.2

E

THNICITY

Canada is a racially diverse country. While

‘white’ Europeans make up the great majority of the population (82%), the 2001 Census data showed that Aboriginals (North American Indians, Metis and Inuit) comprised 5% while

‘Visible Minorities’ comprised 13% (East Asians – mainly Chinese),

South Asians

– mainly Indians, and blacks and other migrant groups

9

(Table 2

–3).

Ethnicity

T

ABLE

2

–3:

E

THNIC COMPOSITION OF

C

ANADIAN POPULATION

(%

TOTAL

), 2001

% of population

Aboriginal

Chinese and other East Asian

South Asian

Black

Other

White

Source: Statistics Canada, topic-based tabulations 95F0363XCB2001004 and 97F0011XCB2001003.

Note: Shares may not sum to 100% due to rounding.

4.6%

4.1%

3.1%

2.2%

4.1%

81.7%

While at present whites outnumber Aboriginal and Visible Minorities (AVM) by four to one, by the

end of the projection period (2032) whites only outnumber AVM by two to one (Figure 2-3)

10

.

9

For consistency with Statistics Canada data, the term ‘Aboriginal’ is used in this report and ‘North American Indians’ is used rather than ‘First Nations’. For the same reason, ‘black’ is used instead of Caribbean Canadian or African Canadian, and ‘white’ is used instead of European or Caucasian.

10

Statistics Canada makes projections for the population as a whole to 2031, and by race to 2017. Access Economics has extended these trends to 2032, as that represents 25 years after the base year (2007)

19

The cost of vision loss in Canada

F

IGURE

2-3: W

HITE AND

AVM

POPULATIONS

, 2006-2032 (%

TOTAL

)

White Aboriginals and Visible Minorities

90

80

70

60

50

40

30

20

10

0

Source: Statistics Canada (2005a, 2005b, 2006).

Statistics Canada (2005a and 2005b) makes projections for Aboriginal and, separately, Visible

Minorities populations to 2017.

However, both populations’ shares of the Canadian total have been growing in a fairly linear manner

– due to high migration (Visible Minorities) and high birth rates

(Aboriginal peoples). Out to 2017, official projections maintain these trends (Figure 2-4). Access

Economics has extended the same trends from 2018 through to 2032.

20

The cost of vision loss in Canada

F

IGURE

2-4: A

BORIGINALS AND

V

ISIBLE

M

INORITIES

, 1981-2017,

SELECTED YEARS

(%

POPULATION

)

25%

20%

15%

10%

5%

Visible Minorities (%)

Trend

Aboriginal Peoples

Trend

0%

1981 1986 1991 1996 2001 2006 2011 2017

In Canada, demographic aging is less of an issue for non-white populations. Aboriginals in particular have a young age profile (over 60% are under 30 years old), although the East Asian

population is fairly evenly spread across all age groups (Figure 2-5 and Figure 2-6).

Statistics Canada (2005b) publishes an age-gender profile for Aboriginal peoples at the beginning, middle and end (2017) of its projections. In the absence of further data, Access Economics has assumed that the 2017 profile is maintained through to 2032. This errs on the side of conservatism, as the Aboriginal population might age between 2017 and 2032, which would increase the prevalence of VL.

Statistics Canada (2005a) does not publish an age-gender profile for its Visible Minorities projections. However, given most of the growth in this population occurs through immigration, it could reasonably be expected to maintain a similar age-gender profile to that which it has at present.

The age-gender profile (as well as total numbers) for whites was estimated as a residual after subtracting Aboriginal and Visible Minorities (AVM) projections from Statistics Canada (2006) total population projections.

21

8%

7%

6%

5%

4%

3%

2%

1%

0%

The cost of vision loss in Canada

F

IGURE

2-5: A

GE DISTRIBUTION OF NON

-

WHITE MALES

(%

POPULATION

), 2001

East Asian

South Asian

Black

Other Visible Minority

Aboriginal

Age group (years)

4%

3%

2%

1%

0%

8%

Source: Statistics Canada, topic-based tabulations 95F0363XCB2001004 and 97F0011XCB2001003.

F

IGURE

2-6: A

GE DISTRIBUTION OF NON

-

WHITE FEMALES

(%

POPULATION

), 2001

7%

6%

East Asian

South Asian

Black

Other Visible Minority

Aboriginal

5%

Age group (years)

Source: Statistics Canada, topic-based tabulations 95F0363XCB2001004 and 97F0011XCB2001003.

22

The cost of vision loss in Canada

It is noteworthy that there is a strong concordance between the ethnic compositions of Canada and

Australia (Figure 2-7). Australia is also similar to Canada in culture and standard of living

11

, and has similar principles and values underlying its health system.

F

IGURE

2-7: E

THNIC COMPOSITION OF

C

ANADIAN POPULATION COMPARED TO

A

USTRALIA

S

100

90

80

70

60

Canada

Australia

50

40

30

20

10

0

European Asian Aboriginal Black / Other /

Islander Mixed

Note: ‘Black / Islander’ for Canada refers to blacks (72% of whom have Caribbean island heritage) and to Pacific islanders for Australia. Australian data are 2006, Canadian data are 2001

.

Source: Statistics Canada (2004b) and Statistics Canada Online Topic Based Tabulations, www.statcan.ca

(Cat No

97F0010XCB2001004) and, Australian Bureau of Statistics, Australia Year Book 2007 (Cat No 1301.0).

2.2

DATA SOURCES FOR PREVALENCE OF VISION LOSS

A variety of data sources were reviewed to estimate prevalence of VL stratified by age, gender, ethnicity, severity (mild and moderate VL and blindness) and cause (AMD, cataract, DR, glaucoma,

RE and ‘other’). Since this level of granularity is not available from any single Canadian epidemiological data source, various data sources were combined in order to ensure that Canadian aggregates were used wherever possible, with credible alternative sources used where there were found to be data gaps.

Three types of data sources were used.

Population-based eye studies

. These are the gold standard, where the degree, type and cause of VL are assessed by experts over a large sample of people. However, because such

11

In 2006, according to World Bank statistics Australia’s per capita income was $US 36,000, where Canada’s was

$US 36,200 (see

http://web.worldbank.org/WBSITE/EXTERNAL/DATASTATISTICS

).

23

The cost of vision loss in Canada studies require large amounts of time, money and equipment, they are very rare, and none have been conducted in Canada, although data from the EDPRG eye studies (Appendix A) were utilised where appropriate.

Canadian surveys

. These large scale collections assemble data from, typically, tens of thousands of respondents, across all ages, genders, ethnicities and geographic areas. The down side is that they are self-diagnosed and self-reported, and thus may suffer a substantial degree of error. Another issue is that publicly available data are usually highly aggregated.

Relevant studies in Canada include the Canadian Community Health Survey (CCHS), the

National Population Health Survey (NPHS)

– a longitudinal study, and the Participation and

Activity Limitation Survey (PALS)

12

.

Canadian journal articles and research studies

. These often provide a great deal of detail, but only in relation to a small subject area

– eg, myopia among children of Chinese immigrants, or use of visual support services by the poor in a particular city, for example.

Extensive literature searching has only uncovered a handful of such studies conducted in

Canada. Examples include:

Cheng et al (2007) on the prevalence of myopia in Chinese-Canadian children;

Hanley et al (2005) on complications of diabetes (including DR) among Aboriginal

Canadians;

Meddings et al (1998) on the relationship between the development of cataract at a young age and socioeconomic status in British Columbia;

Chang et al (1999) on AMD in Chinese-Canadians; and

Iskedjian et al (2003) on the costs of treating patients with glaucoma in Canada.

2.2.1

P

OPULATION

-

BASED EYE STUDIES

Population-based eye studies in the US, Australia and the Netherlands show that the prevalence of

VL and its underlying eye diseases do not vary greatly between white populations in these countries.

Accordingly, data from these studies form the basis of estimates for the white Canadian population.

However, these population studies also show significant differences in VL prevalence between given racial groups (eg, East Asian and black) living in wealthy countries (such as Canada) and those living in poorer countries (eg, China, Barbados). Accordingly, wherever possible, data for non-white groups are sourced from Canadian surveys and journal articles (see the following sections).

2.2.2

C

ANADIAN SELF

-

REPORTED SURVEY DATA

While data from national health surveys are self diagnosed and self reported, they may still be a reasonably good indicator of overall VL, and some major eye diseases.

 People generally know they have vision problems. The Canadian Ophthalmological Society’s

(2006) eye examination guidelines note that less than 1% of the population are unaware of having decreased vision. The exception is glaucoma, where only half of those with the condition are aware of it.

Surveys may be a reasonably accurate diagnostic tool. Djafair et al (2003) conducted an interesting evaluation of survey questionnaires as a diagnostic tool. Administering typical survey questions to over 500 patients in a Canadian hospital (whose VL was also able to be

12

Neither the PALS or the CCHS are published in hard copy, but selected data can be tabulated from these surveys at the

Statistics Canada website (www.statcan.ca)

24

The cost of vision loss in Canada clinically assessed) resulted in a sensitivity of 82.6% and a specificity of 88.9% for best corrected VL.

Conversely, while rates between races are reasonably similar within the CCHS and within the

EDPRG data (Congdon et al, 2004a), they do tend to be quite different to each other. (As noted above, the approach adopted herein is to use EDPRG data for Canadian whites, and Statistics

Canada data for the AVM population.) The only disease for which AVM prevalence is similar to US whites is glaucoma, which is the disease least likely to be selfdiagnosed as most people don’t know they have it. Cataract rates in US whites are some three times higher than in Canadian AVM.

Refractive error rates for US whites are around ten times or more higher than Canadian AVM rates

– when both are assessed on a best-corrected basis. Moreover the age patterns (for both races) are reversed in CCHS data (increasing with age, where EDPRG data shows decreases with age). As eye health questions are optional for CCHS participants, the data also has a number of gaps due to responses being too small to be statistically valid &/or not contravene privacy regulations.

2.2.2.1 P

ARTICIPATION AND

A

CTIVITY

L

IMITATION

S

URVEY

(PALS, 2001)

The PALS asks respondents the following questions.

With your glasses or contact lenses, do you have any difficulty seeing ordinary newsprint?

Have you been diagnosed by an eye specialist as being legally blind?

Besides glasses or contact lenses, do you use any other aids or specialized equipment for persons who are blind or visually impaired eg, magnifiers or Braille reading materials?

Figure 2-8 shows the prevalence of seeing disabilit

ies according to this source’s definition, differing

somewhat from Statistics Canada (2004a) (recall Figure 1-1).

16%

F

IGURE

2-8: P

REVALENCE OF SEEING DISABILITIES BY AGE AND GENDER

(2001)

Male

Female

14%

14.9%

12%

11.5%

10%

8%

6.0%

6%

4%

2.5%

3.3%

3.4%

2%

0.4%

0.7%

0.9%

0%

0.12%

0.13%

0.42%

0.44%

0.24%

0.38%

0.4%

0-4 5-9 10-14 15-24 25-44

Age group (years)

45-64

Source: Statistics Canada Online PALS (2001) www.statcan.ca.

65-74 75+

25

2.2.2.2

The cost of vision loss in Canada

C

ANADIAN

C

OMMUNITY

H

EALTH

S

URVEY

(2005)

AND

N

ATIONAL

P

OPULATION

H

EALTH

S

URVEY

(NPHS)

A major limitation for our purposes is that PALS does not provide any information about ethnicity.

The CCHS in contrast collects detailed data about ethno-cultural identities and background.

Unfortunately, in its publicly available form, the CCHS amalgamates this into only two categories

‘White’ and ‘Other’.

The CCHS classified respondents as (under corrected) hyperopic if they could not see well enough to read ordinary newsprint (with glasses); and (under corrected) myopic if they could not recognise a friend across the street (with glasses). The CCHS also asked respondents if they cou ld see at all (ie, blindness), but this was amalgamated in the category ‘myopic and hyperopic and/or blind’.

Figure 2-9 shows that in Canada, non-whites have a higher degree than whites of uncorrected VL in

younger years, but generally lower rates in older age. This pattern is also apparent for VL from best corrected

myopia

(Figure 2-10) and for Canadians

unable to see clearly at any distance or at all

(Figure 2-12). There is a generally higher prevalence of VL from under corrected

hyperopia

among

non-whites (Figure 2-11).

F

IGURE

2-9: U

NCORRECTED

VL,

BY ETHNICITY

,

AGE AND GENDER

(%

POPULATION

)

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

White Female

White Male

Non-white Female

Non-white Male

Years of age

Source: Statistics Canada CCHS public use microdata files.

26

The cost of vision loss in Canada

F

IGURE

2-10: U

NDER CORRECTED

VL

FROM MYOPIA

,

BY ETHNICITY

,

AGE AND GENDER

(%

POPULATION

)

8%

7%

6%

5%

4%

3%

2%

1%

0%

White Female

White Male

Non-white Female

Non-white Male

Years of age

Source: Statistics Canada CCHS public use microdata files.

Note: Data for non-white males over 65 not supplied.

F

IGURE

2-11: U

NDER CORRECTED

VL

FROM HYPEROPIA

,

BY ETHNICITY

,

AGE AND GENDER

(%

POPULATION

)

6%

5%

4%

White Female

White Male

Non-white Female

Non-white Male

3%

2%

1%

0%

Years of age

Source: Statistics Canada CCHS public use microdata files.

27

The cost of vision loss in Canada

F

IGURE

2-12: C

ANADIANS UNABLE TO SEE CLEARLY AT ANY DISTANCE OR AT ALL

,

BY ETHNICITY

,

AGE

AND GENDER

(%

POPULATION

)

8%

7%

6%

5%

4%

3%

2%

1%

0%

White Female

White Male

Non-white Female

Non-white Male

Years of age

Source: Statistics Canada CCHS public use microdata files.

While elderly male non-whites continue to fit the pattern by having lower

cataract

prevalence

13

than their white contemporaries, there is a divergence for older non-white women, who have the highest

cataract prevalence (Figure 2-13).

13

The CCHS only reports cataract prevalence, not VL from cataract.

28

The cost of vision loss in Canada

F

IGURE

2-13: C

ATARACT PREVALENCE

,

BY ETHNICITY

,

AGE AND GENDER

(%

POPULATION

)

45%

40%

35%

30%

25%

20%

15%

10%

5%

0%

White Female

White Male

Non-white Female

Non-white Male

Years of age

Source: Statistics Canada CCHS public use microdata files.

Over most age ranges, it is non-white males who have the highest rates of

glaucoma

14

(Figure

2-14). Another important fact to note with glaucoma is that its prevalence appears to be increasing in

Canada. Data from various CCHSs and NPHSs compiled by Peruccio et al (2007) show that the prevalence of glaucoma in Canadians over the age of 20 years increased by 64% between 1994 and 2003. Moreover, this is not just due to population aging, as the same trend can be seen within each age group

– and in fact the increase is highest in those under 50 years. Some of this increase can be ascribed to improved diagnosis over this period. A similar trend is evident in diabetes, and

thus presumably DR (see discussion around Table 2

–4).

14

The CCHS only reports prevalence of glaucoma, not of VL from glaucoma

29

The cost of vision loss in Canada

F

IGURE

2-14: G

LAUCOMA

,

BY ETHNICITY

,

AGE AND GENDER

(%

POPULATION

)

14%

12%

10%

8%

6%

4%

2%

0%

White Female

White Male

Non-white Female

Non-white Male

Years of age

Source: Statistics Canada CCHS public use microdata files.

Diabetic Retinopathy

causes around 600 new cases of blindness in Canada each year

15

. Despite acknowledging that DR is ‘the leading cause of adult blindness in Canada’

16

Statistics Canada does not collect any information on this disease. (The CCHS asks people with diabetes if they have had an eye examination where their pupils were dilated but does not provide the results of these tests.)

However, it is possible to derive the prevalence of VL from DR from the CCHS in conjunction with another Statistics Canada publication: Wilkins and Park (1996) calculated from the 1994-95 NPHS that people with diabetes were almost twice as likely as those without (odds ratio of 1.72) to have a vision limitation. Most of this is likely to refer to DR, although Canadians with diabetes also have higher rates of cataract and glaucoma than those without (James et al, 1997). Thus an upper limit for prevalence of VL from DR could be calculated by taking each age-gender cohort in the diabetic

population (from Table 2

–4) and assigning it 1.72 times the VL prevalence experienced by that

cohort in the general population. (This is discussed in more detail in section 2.3.5)

15

Public Health Agency of Canada,

National Diabetes Fact Sheet 2007

, http://www.phac-aspc.gc.ca/ccdpccpcmc/diabetes-diabete/english/pubs/ndfs-fnrd07-eng.html

16

http://www.statcan.ca/english/research/82-619-MIE/2005002/sequelae.htm

(accessed 3 Feb 2008)

30

The cost of vision loss in Canada

Age

T

ABLE

2

–4:

P

REVALENCE OF DIABETES

,

BY AGE AND GENDER

, 2005 (%)

Male Female All

12-14

15-19

20-24

25-34

35-44

45-54

55-64

65-74

75+

Total

0.3

0.9

0.9

2.1

5.0

11.8

17.3

16.8

0.3

0.7

1.2

1.9

4.0

8.5

12.3

13.1

0.3

0.3

0.8

1.1

2.0

4.5

10.1

14.6

14.6

5.3 4.4 4.9

Source: Statistics Canada

http://www40.statcan.ca/l01/cst01/health53b.htm

One important fact to note with diabetes is that it is growing faster than population growth.

Moreover, this growth is not just due to population aging either, as the prevalence of diabetes has increased significantly within every age-gender cohort (by an average of over 50% in the decade to

2005, potentially due to increasing rates of obesity and other risk factors). Again, as with glaucoma, the highest increases in prevalence are in the younger ages. This could have significant implications for the prevalence of blindness in Canada over the next 25 years. However, in the interests of conservatism, age-gender prevalence rates were modelled to remain constant in the future.

A summary of eye disease prevalence in AVM groups from the 2005 CCHS is contained in Table 2

5. As noted above, for the white Canadian population, studies in the EDRPG dataset are used.

The CCHS does not report the prevalence of either AMD or DR. DR, however, can be estimated

indirectly (and is done so in Section 2.3.5, covering VL caused by DR in AVM groups). The

prevalence of AMD in Canadian AVMs is assumed to be the same as the average prevalence in non-white Americans (from Congdon et al, 2004a).

31

The cost of vision loss in Canada

Males

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

Females

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

T

ABLE

2

–5:

CCHS

PREVALENCE OF EYE DISEASES IN

AVM

Cataract

0.0%

0.4%

0.0%

0.2%

0.3%

0.1%

1.9%

2.0%

4.4%

11.7%

13.2%

22.9%

16.0%

21.0%

20.99%

20.99%

Glaucoma

0.00%

0.05%

0.00%

0.15%

0.82%

0.56%

0.64%

1.18%

4.45%

1.85%

6.26%

9.53%

5.70%

5.99%

5.99%

5.99%

Hyperopia

0.47%

1.31%

0.00%

0.00%

0.00%

0.83%

0.40%

1.46%

2.52%

1.48%

2.24%

2.53%

2.82%

2.45%

2.45%

2.45%

Myopia

0.00%

0.00%

0.80%

0.00%

0.00%

0.32%

0.00%

0.10%

0.92%

0.62%

3.40%

2.16%

2.26%

2.64%

2.64%

2.64%

0.00%

0.05%

0.09%

0.43%

0.28%

0.56%

0.19%

1.41%

3.46%

10.05%

21.14%

34.68%

36.80%

41.99%

41.99%

41.99%

0.18%

0.00%

0.00%

0.25%

0.18%

0.50%

0.21%

0.99%

0.65%

2.34%

2.08%

3.07%

11.50%

2.95%

2.95%

2.95%

0.00%

0.18%

2.19%

1.42%

1.53%

1.63%

1.25%

3.20%

5.15%

3.02%

0.88%

0.31%

3.20%

3.19%

3.19%

3.19%

0.00%

0.00%

0.00%

0.98%

0.00%

0.00%

0.39%

0.00%

1.00%

0.87%

0.95%

3.17%

3.24%

2.55%

2.55%

2.55%

AMD

0.24%

0.39%

0.64%

1.06%

1.75%

2.88%

4.69%

7.55%

7.55%

0.50%

0.70%

0.97%

1.34%

1.85%

2.57%

3.59%

5.02%

5.02%

Note: Figures in italics contain no data in original, and are interpolated from relative changes between cohorts in the same ethnicity or gender.

Source: Source: Statistics Canada CCHS public use microdata files, Congdon et al (2004a).

2.2.3

2.2.3.1

D

ATA FROM

C

ANADIAN JOURNAL ARTICLES AND RESEARCH STUDIES

C

ANADIAN POPULATION STUDIES

Maberley et al (2006) conducted an analysis of all ophthalmological records (around 2,500, of which

962 were suitable) in Prince George, a medium-sized Canadian city, over a five year period. They concluded that ‘The overall prevalence of low vision and blindness in Canada are in keeping with

32

The cost of vision loss in Canada data from large population-based studies fro

m other developed nations’. As Figure 2-15 shows,

cataract, visual pathway disorders

17

and AMD were the leading causes of VL in this study.

F

IGURE

2-15: C

AUSES OF

VL

IN

P

RINCE

G

EORGE

, C

ANADA

Glaucoma

3%

Other (iris, trauma, lid)

5%

DR

7%

Cataract

29%

Refractive

8%

Cornea / conjunctiva

11%

AMD

13%

Visual pathway

12%

Other retinal causes

12%

Source: Maberley et al (2006).

CNIB has a database of its clients that can also be used to derive an estimate of the causes of

blindness in Canada (Table 2

–6), assuming that registering with CNIB is equally likely for all causes

of blindness. The fact that the elderly blind may have difficulty registering may represent a source of bias, however.

AMD

DR

Glaucoma

Other

Total

T

ABLE

2

–6:

C

AUSES OF BLINDNESS IN

CNIB

CLIENTS

(2007)

Cause

Persons (‘000)

50.2

7.5

7.6

49.2

114.5

Source: CNIB

2.2.3.2 C

HINESE

C

ANADIANS

Chang et al (1999) reports in a study of 20,000 patients presenting for fluorescein angiography that the rate of

AMD

in Chinese Canadians (30.4%) was over twice as high as in white Canadians

17

Visual pathway disorders (ICD10 H446-H48) are conditions which impede the visual pathway. Occasionally acute vision loss is caused by homonymous hemianopia and, more rarely, cortical blindness.

33

The cost of vision loss in Canada

(14.6%). From this, it may be plausible to assume that AMD in Chinese-Canadians is twice as high as the overall population estimate provided by Maberley et al (2006).

Cheng et al (2007) report that Chinese Canadian children aged six years have a prevalence rate of

myopia

of 22.4%, which is several times the prevalence reported by Robinson (1999) for Canadian six year olds in general of 6.4%. Cheng et al (2007) also report that the prevalence of myopia among Chinese children in Canada is broadly similar to earlier findings from Chinese children in

China (Hong Kong)

– Figure 2-16. The assumption is made that Chinese-Canadian teenagers have the same rates of myopia as do their counterparts in China in Figure 2-16. However, this appears to

decline in later years; Wong (2006) records that Chinese in China over the age of 40 and 60 years have myopia prevalence of 22.9% and 19.4% respectively.

F

IGURE

2-16: M

YOPIA IN

C

HINESE CHILDREN IN

C

ANADA AND

H

ONG

K

ONG

100

90

80

70

60

50

40

30

20

10

Canada 2003

Hong Kong 1996

Hong Kong 2000

Hong Kong 2001

0

5 6 7 8 9 10

Age (years)

11 12 13 14 15

Source: Cheng et al (2007).

If nature dominates nurture for the Canadian Chinese population, as well as having twice the rate of

AMD, it is also possible that Chinese Canadians may have twice the rate of

DR

. The 2001 PALS found that 17.4% of Canadians who have diabetes report a seeing disability. Wong et al (2006) found that 35% of the Chinese population in Taiwan with diabetes have a seeing disability. The

Institute for Clinical Evaluative Sciences - ICES (Glazier et al, 2007) note that in the US, African and

Hispanic populations have twice the rate of diabetes as do whites; diabetes among Asian Americans is higher than in whites and rising faster than in other ethnic groups; and that in the United Kingdom

(UK), South Asians have at least three times the rate of diabetes as the white population.

2.2.3.3 A

BORIGINALS

Data availability for VL in North American Indians, Metis and Inuit is also scarce. Hanley et al (2005) found 23.3% of North American Indian diabetics in remote communities had DR, with similar figures

34

The cost of vision loss in Canada also being reported by Maberley et al (2002). This is around a third higher than for the general population (albeit lower than the Chinese figures). ICES (Glazier et al, 2007) note that the prevalence of diabetes in Aboriginal communities in Ontario (13%) was three times higher than for the non-indigenous population.

Van Rens et al (1988) reported remarkably high levels of POAG in Eskimo women in Alaska (Table

2

–7). Similarly, Adams and Adams (1974) reported that the prevalence of POAG in Canadian Inuit

women was up to 40 times that in non-Inuit women.

Age (years)

<49

50-59

60-69

70+

T

ABLE

2

–7:

P

REVALENCE OF

POAG

AMONG THE

E

SKIMO

(%)

Males Females

3.1

2.6

3.7

0.5

Source: Van Rens et al (1988).

3.6

11.8

11.8

1.2

Young et al (2000) state that Canada’s North American Indians have a ‘high prevalence of serious and untreated diabetic retinopathy’.

18

Health Canada (2002b) reports that 25% of Mohawks who have had diabetes for ten years also have DR.

T

ABLE

2

–8:

P

REVALENCE OF DIABETES AMONG

C

ANADIAN

A

BORIGINAL PEOPLES

(1991)

3

2

1

0

5

4

9

8

7

6

Total

Aboriginal

On-Reserve Off-Reserve

North

American

North

American

Indians Indians

Total North

American

Indians

Metis Inuit

18

They cite Ross and Flick (1991) as their source, but this article does not appear to be electronically available.

35

The cost of vision loss in Canada

Source: Health Canada (2002b).

2.2.3.4

BLINDNESS

Buhrmann et al (forthcoming) estimate the prevalence of blindness by cause in Canada out to 2031, by applying the breakdown from Congdon et al (2004a) to Statistics Canada’s (total) population projections for selected years.

T

ABLE

2

–9:

P

REVALENCE OF BLINDNESS BY CAUSE

, 2006

TO

2031 (%

POPULATION

)

2.3

Cause

AMD

DR

Glaucoma

Other

Total

2006 2011 2016 2021

0.4

0.0

0.1

0.2

0.7

0.4

0.0

0.1

0.2

0.5

0.0

0.1

0.2

0.5

0.1

0.1

0.2

0.7 0.7 0.8

Source: Buhrmann et al (forthcoming).

PREVALENCE RATES FOR VL

2026

0.5

0.1

0.1

0.2

0.9

2031

0.6

0.1

0.1

0.2

1.0

2.3.1

W

HITE POPULATION

VL

As noted above, there have not yet been any major population eye health studies conducted in

Canada. Thus, for Canadian whites, the choice falls to using self-diagnosed and self-reported data from the CCHS, or using data from American or Australian eye health studies. Australian data

(Centre for Eye Research Australia, 2005)

19

is preferred for two reasons. First, Australian VL data for each disease is available by age cohort, which is essential for working with population projections. Second

– and potentially reflecting similar ethnic mix and health systems – the

Australian proportion of total VL caused by each of the major diseases is significantly closer to

Canada’s than the US data (Table 2–10). As the table shows, the proportion of VL caused by

cataract in the US is more than three times higher than in Canada, whereas the ratio between

Canada and Australia is around 1.30 to 1.00 At the other end of the scale, the proportion of VL due to RE and other is more than five times smaller in the US than it is Canada, whereas the ratio between Australia and Canada is around 1.39 to 1.00.

T

ABLE

2

–10:

CAUSES OF

VL,

BY DISEASE

,

IN WHITE POPULATIONS

Disease US Canada Australia

Cataract

Glaucoma

DR

AMD

RE/Other

59.2%

3.3%

4.9%

22.9%

9.7%

18.6%

7.0%

7.0%

16.3%

51.3%

Sources: US (Congdon et al, 2004a), Canada (Maberley et al, 2006), Australia (CERA, 2005)

14.3%

2.9%

1.6%

10.1%

71.2%

19

These data have been published in a number of journal articles, including Taylor, Pezzullo and Keeffe (2006)

36

The cost of vision loss in Canada

Australian VL

Access Economics (2007) used data from the MVIP to determine the prevalence of VL caused by

AMD

(Table 2

–11). Severity was measured according to the better seeing eye (noting that with

AMD it can become the worse one over time). For Canada, the distribution between mild, moderate and severe VL from AMD and by age are based on these data, as it was considered likely that AMD incidence and progression follows a similar pathway in Canada.

T

ABLE

2

–11:

P

REVALENCE OF

VL

DUE TO

AMD,

BY SEVERITY

(%

OF AGE GROUP

)

Age

0-69

70-74

75-79

80-84

85-89

90+

40+

Mild

0.00

0.17

0.00

1.00

2.13

3.15

0.10

Moderate

0.00

0.00

0.87

1.00

4.26

6.29

0.33

Source: Access Economics (2007).

Severe

0.00

0.17

0.00

1.00

3.19

4.72

0.13

The Centre for Eye Research Australia (CERA, 2005) estimated the prevalence of VL caused by

cataract

in Australia, also from the MVIP (Table 2

–12). For Canada, as with AMD, the distribution

between mild, moderate and severe VL from cataract and by age are based on these data.

T

ABLE

2

–12:

P

REVALENCE RATES FOR

VL

FROM CATARACTS

,

BY AGE AND SEVERITY

(%)

Age

40-49

50-59

60-69

70-79

80-89

90+

Total VL (<20/40)

0.0%

0.0%

0.1%

1.4%

6.6%

15.2%

Source: CERA (2005).

VL by severity Total

Mild (6/12 to 6/18) 60.2%

Moderate (<6/18 to 6/60) 26.7%

Severe (>6/60) 13.0%

Access Economics (2008c, forthcoming) provides estimates of the prevalence of VL caused by

DR

(Table 2

–13), based on combined data from the MVIP and Blue Mountains Eye Study (BMES). For

Canada, the distribution between mild, moderate and severe VL from DR and by age are again based on these data.

T

ABLE

2

–13:

P

REVALENCE RATES FOR VISION IMPAIRMENT

(<6/12)

FROM

DR,

AND PROPORTION BY

STAGE OF VISION LOSS

Age

40-49

50-59

60-69

70-79

80-89

90+

Total VL (<20/40)

0.0%

0.0%

0.2%

0.1%

0.5%

0.6%

VL by severity

Mild (6/12 to 6/18)

Moderate (<6/18 to 6/60)

Severe (>6/60)

Total

30.6%

47.8%

21.6%

(a) Prevalence based on combined data from the MVIP and BMES. (b) Stages of vision loss based on MVIP.

Source: Access Economics (2008c).

Access Economics (2008b) estimated the prevalence of VL caused by

POAG

, by degrees of

severity, from the MVIP and the BMES (Table 2

–14). For Canada, the distribution between mild,

moderate and severe VL from glaucoma and by age are once again based on these data.

37

The cost of vision loss in Canada

T

ABLE

2

–14:

P

ROPORTION OF PEOPLE WITH GLAUCOMA BY AGE AND SEVERITY

(%)

Age Group

0-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

Mild Moderate

0.0

0.2

0.4

0.5

1.2

1.7

2.2

0.0

1.7

2.8

3.7

8.4

11.5

15.1

1.1 7.7

Source: Based on combined data from the MVIP and BMES.

Severe

0.0

2.9

2.6

3.3

1.8

2.5

4.8

20.6

Most people with glaucoma in developed countries are unaware they have the disease (Canadian

Ophthalmological Society, 2007). Even among those regularly visiting eye professionals, the probability of diagnosis depends on the severity of the condition. Hence, the more severe forms have the highest (diagnosed) prevalence.

Wong et al (2004) examined the presence of undiagnosed glaucoma in people who had visited an eye care provider in the previous year using MVIP data. They found that 81% of possible cases, 72% of probable cases and 59% of definite cases of glaucoma were previously undiagnosed by the eye care provider.

CERA (2005) estimated the prevalence of VL caused by

RE

in Australia from the MVIP (Table 2

15). For Canada, the relativities between mild, moderate and severe VL from RE and by age are

based on these data, as it is likely that RE incidence and progression follows a similar pathway in

Canada.

T

ABLE

2

–15:

P

REVALENCE RATES FOR

VL

FROM

RE,

BY AGE AND SEVERITY

(%)

Age Total VL (<20/40) VL by severity Total

40-49

50-59

60-69

70-79

80-89

90+

0.5%

1.8%

3.9%

7.8%

13.0%

7.9%

Source: CERA (2005).

Mild (6/12 to 6/18)

Moderate (<6/18 to 6/60)

Severe (>6/60)

83.4%

14.6%

2.0%

In addition to the above breakdowns by severity, CERA (2005) also gives an overall prevalence of

VL caused by each major eye disease, which is used as the basis for the prevalence of VL by cause

for Canadian whites (Table 2

–16).

38

The cost of vision loss in Canada

T

ABLE

2

–16:

E

STIMATED

VL

PREVALENCE IN

C

ANADIAN WHITES BY DISEASE AND AGE

Cataract DR Glaucoma AMD RE Other

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

0.00%

0.08%

0.01%

0.16%

0.73%

2.37%

5.49%

8.71%

15.17%

0.00%

0.09%

0.12%

0.16%

0.16%

0.10%

0.44%

0.78%

0.68%

0.58%

0.00%

0.16%

0.20%

0.34%

1.52%

1.32%

1.23%

Source CERA (2005).

0.00%

0.00%

0.00%

0.00%

0.08%

0.22%

1.70%

2.31%

8.77%

12.97%

0.71%

0.29%

1.05%

2.62%

2.51%

5.38%

6.30%

9.87%

13.13%

12.80%

7.86%

0.18%

0.14%

0.52%

0.17%

0.25%

0.43%

0.64%

0.78%

0.92%

3.75%

2.44%

2.3.2

A

BORIGINALS AND

V

ISIBLE

M

INORITIES

(AVM) VL

There are severe data problems in estimating the prevalence of VL among Canada’s AVM populations. While the CCHS collects the prevalence of eye diseases, by age, for the AVM population, it does not collect data on the causes of VL. Moreover, the prevalence data are not

disaggregated by race, despite known differences between races (Figure 2-17). There have been

some international population eye health studies covering the causes of VL in non-whites, but the races (blacks and Hispanics) co vered were not representative of Canada’s AVM population (blacks are 2% of the Canadian population, and Hispanic does not rate a category in the Canadian census).

Moreover the data is not available by age-cohort which, given how greatly the incidence of VL varies by age, makes it very difficult to map to Canada’s AVM population.

F

IGURE

2-17: C

AUSES OF BLINDNESS BY ETHNICITY

(US)

Source: Congdon et al (2004a).

Access Economics

’ approach has been to estimate from international sources the likelihood that a non-white person who has an eye disease will develop VL, and apply that ratio to the CCHS

39

The cost of vision loss in Canada prevalence of that disease in

Canada’s AVM population. The next few paragraphs illustrate the concepts involved using illustrative round numbers.

Suppose, for example, that 25% of the US non-white population who have cataract will also have VL from that disease. Suppose further, that 10,000 Canadian AVM have cataract. Then - if making the assumption that the share of non-whites with cataract who have VL is similar on both sides of the border - there are an estimated 2,500 (=10,000 * 25%) AVM who suffer VL because of their cataracts.

Prevalence rates of cataract by age group among Canadian AVM are known and Congdon et al

(2004a) reports that, in America, if a white and a non-white both have cataract, the white is more likely to suffer VL from the disease (for illustrative purposes, suppose twice as likely). Assuming that

American, Australian and Canadian whites are similar in this relative risk, then if 80% of 80 year old

(Australian) whites with cataract have VL, it follows that half as many (40%) of Canadian non-whites

(Canadian) with cataract will have VL. So if the CCHS reports that there are 1,000 80 year old

Canadian AVM with cataract, 400 of them (=1,000 * 40%) are estimated to have VL.

2.3.3

C

ATARACT

-

INDUCED

VL

IN

AVM

Because there are multiple races and multiple diseases, this section works through one disease in detail

– cataract – using actual data, and other disease prevalence rates are similarly calculated.

Using the NEI disease prevalence (http://www.nei.nih.gov/eyedata/tables.asp) and 2000 US Census data (http://factfinder.census.gov/), an estimated 7.47% of the white population had cataract (Row A,

Table 2

–17). Access Economics (2006) shows that 2.79% of white Americans had VL (Row B).

Congdon et al (2004a) show that 59.2% of this total VL was caused by cataract (Row C). Thus, the prevalence of cataract-induced VL was 1.65% (59.2% times 2.79%) of the white population (Row D).

Thus, it can be deduced that 22.1% (1.65/7.47) of whites who have cataract will also have VL from those cataracts (Row E).

T

ABLE

2

–17:

P

REVALENCE OF

VL

IN

US

WHITES WITH CATARACTS

(2000)

Factor

A. Prevalence of cataract

B. Prevalence of VL

C. Proportion of VL caused by cataract

D. Prevalence of cataract-induced VL (C*B)

E. Percent of cataract population who have VL (D/A)

Sources: Access Economics (2006), Congdon et al (2004a).

%

7.47%

2.79%

59.2%

1.65%

22.1%

For blacks, the same data show that 6.42% of the black population had cataract (Row A, Table 2

18). Access Economics (2006) shows that 2.28% of black Americans had VL (Row B). Congdon et

al (2004a) show that 50.9% of this total VL was caused by cataract (Row C). Thus, the prevalence of cataract-induced VL was 1.16% (50.9% times 2.79%) of the black population (Row D) and it can be deduced that 18.1% (1.16/6.42) of blacks who have cataract will also have VL from those cataracts (Row E).

40

The cost of vision loss in Canada

T

ABLE

2

–18:

P

REVALENCE OF

VL

IN

US

BLACKS WITH CATARACTS

(2000)

Factor %

A. Prevalence of cataract

B. Prevalence of VL

C. Proportion of VL caused by cataract

D. Prevalence of cataract-induced VL (C*B)

E. Percent of cataract population who have VL (D/A)

6.42%

2.28%

50.9%

1.16%

18.1%

Sources: Access Economics (2006), Congdon et al (2004a).

For Hispanics, the data record that 6.96% of the Hispanic population had cataract (Row A, Table 2

19). Access Economics (2006) shows that 1.96% of Hispanic Americans had VL (Row B).

Congdon et al (2004a) show that 46.7% of this total VL was caused by cataract (Row C). Thus, the prevalence of cataract-induced VL was 0.91% (46.7% times 1.96%) of the Hispanic population (Row

D) and it can be deduced that 13.1% (0.91/6.96) of Hispanics who have cataract will also have VL from those cataracts (Row E).

T

ABLE

2

–19:

P

REVALENCE OF

VL

IN

US H

ISPANICS WITH CATARACTS

(2000)

Factor %

A. Prevalence of cataract

B. Prevalence of VL

C. Proportion of VL caused by cataract

D. Prevalence of cataract-induced VL (C*B)

E. Percent of cataract population who have VL (D/A)

6.96%

1.96%

46.7%

0.91%

13.1%

Sources: Access Economics (2006), Congdon et al (2004a).

Finally, for other races, according to the data, 6.96% of the remaining population of other races had

cataract (Row A, Table 2

–20). Access Economics (2006) shows that 2.15% of ‘other’ Americans

had VL (Row B). Congdon et al (2004a) show that 52.3% of this total VL was caused by cataract

(Row C). Thus, the prevalence of cataract-induced VL was 1.12% (52.3% times 2.15%) of the remainder of the population (Row D) and it can be deduced that 16.2% (1.12/6.96) of other races who have cataract will also have VL from those cataracts (Row E).

T

ABLE

2

–20:

P

REVALENCE OF

VL

IN

US

‘O

THER

WITH CATARACTS

(2000)

Factor %

A. Prevalence of cataract

B. Prevalence of VL

C. Proportion of VL caused by cataract

D. Prevalence of cataract-induced VL (C*B)

E. Percent of cataract population who have VL (D/A)

6.96%

2.15%

52.3%

1.12%

16.2%

Sources: Access Economics (2006), Congdon et al (2004a).

Drawing this together, it is possible to estimate how much less likely the average non-white is to

develop VL after contracting cataracts than is the average white (Table 2

–21). Weighting the three

non-white races (black, Hispanic and

‘other’) by their respective shares of the Canadian AVM population (blacks 12%, Latin Americans

20

4%,

‘other’ 84%) yields the result that 16.3% of Canadian

20

As noted above, the Canadian census does not include the category ‘Hispanic’; ‘Latin American’ is used as a proxy.

41

The cost of vision loss in Canada

AVM with cataract will have VL from their cataracts (Row E). This in turn indicates that an AVM person with cataract is only 74% as likely to develop VL as is a white person with cataract (Row F).

T

ABLE

2

–21:

R

ELATIVE RISK OF DEVELOPING

VL

FROM CATARACTS

,

BY RACE

Race/Ethnic group

A. Whites (

Table 2

–17

)

B. Blacks (

Table 2

–18

)

C. Hispanic (

Table 2

–19

)

D. Other (

Table 2

–20

)

E. Non-white weighted average

Prevalence of VL in those with cataract

22.1%

18.1%

13.1%

16.2%

16.3%

Share of Canadian

AVM population

12%

4%

84%

F. Ratio average non-white to white (E/A) 0.74

Source: Derived from previous tables.

Having derived above that, over the whole population, an AVM person with cataract is around threequarters as likely to have VL as a white person, this is then applied to the fraction of whites with

cataracts who have VL (Column C in Table 2

–22). The latter, in turn, is derived from the prevalence

of cataract-induced VL (from Table 2

–16, reproduced as Column A in Table 2–22) and from the

prevalence of cataract as a disease in whites (from the Australian Bureau of Statistics, 2006,

Column B below).

T

ABLE

2

–22:

P

REVALENCE OF

VL

IN WHITES WITH CATARACT

,

BY AGE

Age

35-39

40-44

45-49

A. Prevalence of cataract

0.2%

0.2%

0.5%

B. Prevalence of cataract induced VL

0.0%

0.0%

0.0%

C. Fraction of those with cataracts who have

VL (B/A)

0.0%

0.0%

0.0%

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

0.5%

1.5%

1.5%

5.1%

5.1%

13.2%

13.2%

19.9%

19.9%

0.0%

0.1%

0.0%

0.2%

0.7%

2.4%

5.5%

8.7%

15.2%

Sources: CERA (2005), Australian Bureau of Statistics (2006).

0.0%

5.5%

0.7%

3.2%

14.2%

17.9%

41.5%

43.8%

76.2%

The likelihood that a non-white with cataract will develop VL (Column C in Table 2

–23) can then be

derived from the fraction of whites with cataracts who have VL (from Table 2

–22, reproduced as

Column A in Table 2

–23) and the relative risk between whites and non-whites (from Table 2–21,

reproduced as Column B).

42

Age

The cost of vision loss in Canada

T

ABLE

2

–23:

P

REVALENCE OF

VL

IN NON

-

WHITES WITH CATARACT

,

BY AGE

A. Fraction of whites with cataracts who have

VL

0.0%

0.0%

0.0%

B. Relative risk of developing VL from cataract (nonwhite/white)

0.74

0.74

0.74

C. Fraction of non-whites with cataracts who have

VL (A*B)

0.0%

0.0%

0.0%

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

0.0%

5.5%

0.7%

3.2%

14.2%

17.9%

41.5%

43.8%

76.2%

Source: derived from Tables 2-21 and 2-22.

0.74

0.74

0.74

0.74

0.74

0.74

0.74

0.74

0.74

Finally, having derived how likely a non-white with cataract is to develop VL (Table 2

–23), it remains

to ascertain how many non-whites have cataract. This information is provided by the CCHS (Table

2

–5) and reproduced as Column A in Table 2–24. Multiplying the number of AVM with cataract

(Column A) by their chance of having VL (Column B) gives the prevalence of VL from cataract in the

AVM population by age group. For example, if 22.9% of AVM aged between 70 and 74 have cataract, and 10.5% of these develop VL, then around 2.4% of AVM in this age group will have VL caused by cataract.

0.0%

4.1%

0.5%

2.3%

10.5%

13.2%

30.5%

32.2%

56.1%

43

The cost of vision loss in Canada

T

ABLE

2

–24:

P

REVALENCE OF CATARACT

-

INDUCED

VL

IN

C

ANADIAN

AVM,

BY AGE

Males

35-39

40-44

A Prevalence of cataract in nonwhites

0.3%

0.1%

B Fraction of nonwhites with cataracts who have VL

0.0%

0.0%

C Prevalence of cataract-induced

VL in non-whites

(A*B)

0.0%

0.0%

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

Females

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

0.3%

0.6%

0.2%

1.4%

3.5%

10.0%

21.1%

34.7%

36.8%

42.0%

42.0%

42.0%

1.9%

2.0%

4.4%

11.7%

13.2%

22.9%

16.0%

21.0%

21.0%

21.0%

Source: Derived from above tables and data from the CCHS.

0.0%

0.0%

0.0%

0.0%

4.1%

0.5%

2.3%

10.5%

13.2%

30.5%

32.2%

56.1%

0.0%

0.0%

4.1%

0.5%

2.3%

10.5%

13.2%

30.5%

32.2%

56.1%

2.3.4

VL

CAUSED BY

AMD, G

LAUCOMA AND

RE

IN

AVM

The exercise in the previous section can be repeated for VL in AVM caused by the other major eye diseases, except DR, which is dealt with by a different method, using solely Canadian data, in

Section 2.3.5. Table 2

–25 reports the prevalence of each eye disease in each non-white group from

the NEI dataset (weighted by 2000 Census age cohorts, as above).

T

ABLE

2

–25:

P

REVALENCE OF EYE DISEASES BY ETHNICITY

, US, 2000

A. AMD

B. Cataract

C. Glaucoma

D. RE/Other

White

0.8%

7.5%

0.7%

16.7%

Black

0.4%

6.4%

1.6%

8.6%

Hispanic

0.4%

7.0%

0.9%

10.7%

Other

0.4%

7.0%

1.0%

10.9%

Source: US Census 2000

(

http://factfinder.census.gov/servlet/STTable?_bm=y&-geo_id=01000US&qr_name=ACS_2006_EST_G00_S0101&-ds_name=ACS_2006_EST_G00_

)

EDPRG

(

http://www.nei.nih.gov/eyedata/tables.asp

)

0.0%

0.0%

0.0%

0.0%

0.1%

0.1%

0.5%

3.6%

4.9%

12.8%

13.5%

23.5%

0.0%

0.0%

0.2%

0.1%

0.3%

2.4%

2.1%

6.4%

6.8%

11.8%

44

The cost of vision loss in Canada

The prevalence of VL caused by each eye disease is derived from Congdon et al (2004a), which

reports both the total prevalence of VL for each race in the US (Row E in Table 2

–27) and the percentage of this VL which is caused by each major disease (Table 2

–26). The prevalence of VL by disease is then derived as per cataract in the previous section, presented in Table 2

–28.

A. AMD

B. Cataract

C. Glaucoma

D. RE/Other

T

ABLE

2

–26:

C

AUSES OF

VL

BY ETHNICITY

21

White

22.9%

59.2%

3.3%

9.7%

Black

3.2%

50.9%

14.3%

17.0%

Hispanic

14.3%

46.7%

7.6%

18.5%

Source: Congdon et al (2004a).

Other

13.5%

52.3%

8.4%

15.1%

T

ABLE

2

–27:

P

REVALENCE OF

VL,

BY ETHNICITY AND CAUSE

, US, 2000

White Black Hispanic Other

A. AMD

B. Cataract

C. Glaucoma

D. RE/Other

E. Sum

0.64%

1.65%

0.09%

0.27%

2.79%

0.07%

1.16%

0.33%

0.39%

2.28%

Source: Access Economics (2006), Table 2

–26.

0.28%

0.91%

0.15%

0.36%

1.96%

0.29%

1.12%

0.18%

0.32%

2.15%

T

ABLE

2

–28:

P

REVALENCE

(%)

OF

VL

WITHIN SPECIFIED DISEASES

,

BY ETHNICITY

A. AMD

B. Cataract

C. Glaucoma

D. RE/Other

White Black Hispanic

95.2

22.1

14.0

1.6

17.4

18.1

20.1

4.5

Source: Derived from Table 2

–25 and Table 2–27.

63.2

13.1

16.7

3.4

Other

69.5

16.2

17.9

3.0

Extending the above analysis across ethnicities and diseases, Figure 2-18 shows the variance in the

probability of VL across diseases and ethnic groups. For example, AMD appears to have a significantly greater likelihood of causing VL in whites than in blacks, while RE is more likely to cause VL in blacks than whites. This may possibly be due to genetic factors or to socioeconomic factors governing access to medical care (and thus detection and treatment).

21

DR is not included as it is calculated separately in Section 2.3.5. Rates are white 5%, black 15%, Hispanic 13%, other

11%.

45

The cost of vision loss in Canada

F

IGURE

2-18: P

ROBABILITY OF DEVELOPING

VL

AFTER CONTRACTING SELECTED DISEASES

,

BY

ETHNICITY

100.0

90.0

80.0

70.0

60.0

50.0

40.0

30.0

20.0

10.0

0.0

White

Black

Hispanic

Other

Cataract Glaucoma DR RE/Other

Source: Derived from EDPRG (Congdon et al, 2004a) and US Census data.

AMD

As with the methodology for cataract, the relative risk of VL from a particular disease is compared between whites and each other group and a weighted average is developed using the population

weights for each group among the Canadian AVM total (Table 2

–29).

T

ABLE

2

–29:

R

ELATIVE RISK OF

VL

BY EYE DISEASE

,

NON

-

WHITES TO WHITES

Disease

A. AMD

B. Cataract

C. Glaucoma

D. RE/Other

Relative Risk

1.52

0.74

1.29

1.96

Source: Derived from previous tables and Canadian Census data.

To derive an age breakdown for the relative risks for the non-white population, data on prevalence of each disease were used from the Australian Bureau of Statistics (2006) and the Australian Institute

of Health and Welfare (2005) (Table 2

–30).

T

ABLE

2

–30:

P

REVALENCE OF EYE DISEASES IN WHITES

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

Age AMD

0.1%

0.3%

0.3%

0.8%

0.8%

1.1%

1.1%

3.7%

3.7%

6.3%

6.3%

Cataract

0.2%

0.5%

0.5%

1.5%

1.5%

5.1%

5.1%

13.2%

13.2%

19.9%

19.9%

Glaucoma

0.2%

0.8%

0.8%

1.3%

1.3%

2.4%

2.4%

6.3%

6.3%

7.2%

7.2%

RE/Other

43.9%

77.4%

77.4%

70.9%

70.9%

52.8%

52.8%

54.1%

54.1%

51.2%

51.2%

Source: Australian Bureau of Statistics (2006), Australian Institute of Health and Welfare (2005).

46

The cost of vision loss in Canada

Recall that the prevalence of VL in whites by cause was shown in Table 2

–16. Using that prevalence

and the prevalence of each disease (Table 2

–30) gives the fraction of VL caused by that disease

(Table 2

–31) for each five-year age cohort in the white population.

T

ABLE

2

–31:

F

RACTION OF WHITES WITH EACH EYE DISEASE WHO HAVE

VL,

BY AGE AND GENDER

(%)

Age

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

AMD

0.0%

0.0%

0.0%

7.4%

20.2%

45.4%

61.5%

100.0%

100.0%

Cataract

0.0%

0.0%

0.0%

5.5%

0.7%

3.2%

14.2%

17.9%

41.5%

43.8%

76.2%

Glaucoma

0.0%

0.0%

0.0%

0.0%

0.0%

6.7%

8.2%

5.4%

24.3%

18.3%

17.0%

Note: AMD prevalences in 85 years and older capped at 100%

Source: Congdon et al (2004a), Access Economics (2007).

RE/Other

2.0%

0.6%

2.0%

3.9%

3.9%

11.0%

13.1%

19.7%

26.0%

32.3%

20.1%

Combining the fractions in Table 2

–31 with the relative risks (non-white to white) from Table 2–29

leads to the prevalence of VL within disease groups in non-whites as per Table 2

–32.

T

ABLE

2

–32:

PREVALENCE OF

VL

WITHIN DISEASE GROUPS

,

NON

-

WHITES

40-44

Age

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

AMD

0.0%

0.0%

0.0%

10.5%

28.6%

64.4%

87.3%

100.0%

100.0%

Cataract

0.0%

0.0%

0.0%

4.1%

0.5%

2.3%

10.5%

13.2%

30.5%

32.2%

56.1%

Source: Derived from previous tables.

Glaucoma

0.0%

0.0%

0.0%

0.0%

0.0%

8.7%

10.6%

7.0%

31.2%

23.5%

21.8%

RE/Other

4.0%

1.1%

4.0%

7.7%

7.6%

21.5%

25.7%

38.6%

50.8%

63.3%

39.4%

Using this with the prevalence of eye disease in AVM from CCHS data (Table 2

–5) results in the

prevalence of VL from that disease (Table 2

–33).

47

The cost of vision loss in Canada

Males

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

Females

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

T

ABLE

2

–33:

P

REVALENCE OF

VL

IN

AVM

AMD

AMD

0.00%

0.00%

0.00%

0.14%

0.53%

1.66%

3.13%

5.02%

5.02%

0.00%

0.00%

0.00%

0.11%

0.50%

1.85%

4.09%

7.55%

7.55%

Cataract

0.00%

0.00%

0.00%

0.18%

0.06%

0.31%

2.40%

2.11%

6.41%

6.76%

11.77%

Cataract

0.00%

0.00%

0.00%

0.14%

0.05%

0.49%

3.63%

4.85%

12.82%

13.52%

23.54%

Glaucoma

0.00%

0.00%

0.00%

0.00%

0.00%

0.54%

1.01%

0.40%

1.87%

1.41%

1.31%

RE/Other

0.05%

0.00%

0.06%

0.27%

0.16%

1.22%

1.21%

1.96%

2.59%

3.22%

2.01%

Glaucoma

0.00%

0.00%

0.00%

0.00%

0.00%

0.18%

0.33%

0.80%

0.92%

0.69%

0.64%

RE/Other

0.06%

0.02%

0.13%

0.47%

0.30%

0.39%

0.89%

2.48%

2.92%

3.63%

2.26%

2.3.5

D

IABETES AND

DR

IN THE

AVM

POPULATION

The above methods cannot be fully used for DR in the Canadian AVM population, because the

CCHS does not report on the prevalence of DR in AVM. However, there are sufficient Canadian data from other sources to estimate age-gender prevalence of DR using an alternate methodology discussed in this section.

Data from various Canadian publications enable an estimate of VL from DR in the AVM population to be calculated directly (rather than having to rely on non-Canadian EDPRG data.) Statistics

Canada’s

Health Report

(Wilkins and Park, 1996) shows that the prevalence of VL among Canadian diabetics is 72% higher than in the general population. However, as Access Economics (2008c) notes, diabetics also have higher rates of cataract, glaucoma and macular edema, with the result that the prevalence of DR in diabetics is roughly equivalent to the combined prevalence of these three other diseases in diabetics. Thus, it was assumed that half of the increased rate of VL (36%) is due to DR (rather than the other three associated eye diseases). Increasing the 2005 CCHS

figures for the prevalence of under corrected VL in the AVM population (Table 2

–34) by 36% enabled an estimate of the prevalence of DR-induced VL among diabetics in this population (Table

2

–35).

48

The cost of vision loss in Canada

T

ABLE

2

–34:

U

NDER CORRECTED

VL

IN

AVM

Age

20-24

25-34

35-44

45-54

55-64

65-74

75+

Male

1.3%

0.4%

0.6%

0.2%

1.7%

1.7%

3.7%

Female

1.0%

3.9%

1.4%

1.0%

3.1%

2.0%

4.7%

Source: Statistics Canada, CCHS public use microdata files.

T

ABLE

2

–35:

P

REVALENCE OF

VL

FROM

DR

WITHIN DIABETIC

AVM

GROUPS

Age Male Female

20-24

25-34

35-44

45-54

55-64

65-74

75+

1.8%

0.5%

0.8%

0.3%

2.3%

2.3%

5.0%

Source: Derived from Table 2

–34.

1.4%

5.3%

1.9%

1.3%

4.2%

2.8%

6.4%

Although the CCHS does not provide an estimate of diabetic prevalence in the AVM population,

ICES (Glazier et al, 2007) reports that rates of diabetes among First Nation groups in Ontario are among the highest in the world, and are some three times higher than for the rest of the population.

ICES also reports that diabetes in Ontario’s South Asian population is three times the general population. They also note the prevalence of diabetes in black Americans is twice as high as the general population, which might reasonably be assumed to apply also to black Canadians. Finally,

ICES reports that the prevalence of diabetes in Toronto neighbourhoods is strongly correlated with the percentage of the population from Visible Minorities. Taken together, Access Economics has conservatively assumed that the rate of diabetes in the AVM population is twice that of the white

population. Statistics Canada publishes rates of diabetes for the general population (Table 2

–4).

Doubling these rates thus yields an estimate of the prevalence of diabetes in the AVM population

(Table 2

–36).

T

ABLE

2

–36:

P

REVALENCE OF DIABETES IN

AVM

POPULATION

, 2005 (%)

Age Male Female All

12-14

15-19

20-24

25-34

35-44

45-54

55-64

65-74

75+

Total

0.0%

0.6%

1.8%

1.8%

4.2%

10.0%

23.6%

34.6%

33.6%

10.6%

0.0%

0.6%

1.4%

2.4%

3.8%

8.0%

17.0%

24.6%

26.2%

8.8%

0.6%

0.6%

1.6%

2.2%

4.0%

9.0%

20.2%

29.2%

29.2%

9.8%

Source: As per Table 2

–4, and ICES (Glazier et al, 2007).

49

The cost of vision loss in Canada

Multiplying the prevalence of diabetes in the AVM population (Table 2

–36) by the prevalence of VL in the AVM diabetic population (Table 2

–35) provides the prevalence of AVM diabetics who have

DR-induced VL (Table 2

–37).

20 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 to 74

75 and older

T

ABLE

2

–37:

E

STIMATED PREVALENCE OF

DR-

INDUCED

VL

IN

AVM

Male

0.03%

0.01%

0.03%

0.03%

0.55%

0.80%

1.69%

Source: Derived from earlier tables.

Female

0.02%

0.13%

0.07%

0.11%

0.71%

0.68%

1.67%

2.3.6

S

UMMARY OF

VL

IN

AVM

POPULATIONS

Combining the prevalence of VL from DR (Table 2

–37) with the prevalence estimates for the other

eye diseases (Table 2

–33) enables a completion of the estimates of VL by disease for the whole

AVM population (Table 2

–38). As noted above, the CCHS does not report VL by disease, only the

prevalence of the diseases. However, it does report the total number of AVM who have under-

corrected VL (Table 2

–34). Self-reported VL for AVM was 0.8% for males and 2.0% for females.

The estimates here, derived from ratios of diagnosed VL between races, are 0.5% for AVM males,

and 0.7% for AVM females (Table 2

–40).

50

Males

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

Female

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

The cost of vision loss in Canada

T

ABLE

2

–38:

P

REVALENCE OF

VL

IN

AVM

BY AGE

,

GENDER AND DISEASE

AMD

0.00%

0.00%

0.00%

0.11%

0.50%

1.85%

4.09%

7.55%

7.55%

Cataract

0.00%

0.00%

0.00%

0.18%

0.06%

0.31%

2.40%

2.11%

6.41%

6.76%

11.77%

DR

0.03%

0.03%

0.03%

0.55%

0.55%

0.80%

0.80%

1.69%

1.69%

1.69%

1.69%

Glaucoma

0.00%

0.00%

0.00%

0.00%

0.00%

0.54%

1.01%

0.40%

1.87%

1.41%

1.31%

RE/Other

0.05%

0.00%

0.06%

0.27%

0.16%

1.22%

1.21%

1.96%

2.59%

3.22%

2.01%

AMD

0.00%

0.00%

0.00%

0.14%

0.53%

1.66%

3.13%

5.02%

5.02%

Cataract

0.00%

0.00%

0.00%

0.14%

0.05%

0.49%

3.63%

4.85%

12.82%

13.52%

23.54%

DR

0.07%

0.11%

0.11%

0.71%

0.71%

0.68%

0.68%

1.67%

1.67%

1.67%

1.67%

Glaucoma

0.00%

0.00%

0.00%

0.00%

0.00%

0.18%

0.33%

0.80%

0.92%

0.69%

0.64%

RE/Other

0.06%

0.02%

0.13%

0.47%

0.30%

0.39%

0.89%

2.48%

2.92%

3.63%

2.26%

2.4

SUMMARY

A variety of data sources were used to construct a model of Canadian VL by age, gender, ethnicity, severity and type. There was found to be little difference in the prevalence of visually impairing eye conditions among white populations in US, Australian and European population eye health studies, so these studies (Congdon et al, 2004a and CERA, 2005) were used to estimate the prevalence of

VL for white Canadians.

For AVM, self-reported data from the CCHS were used to estimate the prevalence of cataract, glaucoma and RE, with supplementation from Canadian academic studies and journal articles for

DR and AMD, since these conditions are not covered in the CCHS. DR was estimated from other

Canadian sources and AMD was estimated from the average prevalence rates for non-whites in the

US. The risk of VL within each disease for AVM was derived from the risk for non-whites in the US.

These data show that differences in the rates of VL from

‘disease x’ are related to differences in prevalence of that disease across ethnicities as well as differences in access to treatment and genetic factors that may affect progression of VL. Since the self-reported data do not distinguish between mild and medium levels of VL, the severity distribution is assumed to be the same for AVM as for whites (by disease).

In total,

there were an estimated 816,951 Canadians with VL in 2007

(Table 2

–39).

Of this total, 780,534 (95.5%) were white and 36,417 (4.5%) were AVM.

RE / Other is the main source of VL for the white population (68% of the total), and cataract is the main cause of VL in AVM (36% of the total).

51

The cost of vision loss in Canada

For whites the second largest source of VL is cataract (15.5%) and, for the AVM population,

DR is the second largest source (24.5% of the total).

22

AVM have lower prevalence of VL for all diseases other than DR (Figure 2-19), largely due to

lower prevalence of eye diseases at equivalent ages to whites, a younger age profile, and less likelihood of developing VL once they have contracted a given eye disease.

T

ABLE

2

–39:

P

REVALENCE OF

VL,

BY CAUSE AND ETHNICITY

, 2007

AMD

Cataract

DR

Glaucoma

RE/Other

All ethnicities White AVM

Number % total Number % total Number % total

89,241

133,836

29,920

24,937

539,236

10.9%

16.4%

3.7%

3.1%

66.0%

84,641

120,685

20,992

22,565

531,650

10.8%

15.5%

2.7%

2.9%

68.1%

4,380

13,151

8,928

2,373

7,586

12.0%

36.1%

24.5%

6.5%

20.8%

All VL 817,171 100.0% 780,534 100.0% 36,417 100.0%

Note: For corresponding prevalence rates, see Table 2

–40 to Table 2–45.

F

IGURE

2-19: P

REVALENCE RATES OF

VL,

BY ETHNICITY AND CAUSE

, 2007

3.5%

All races

White

AVM

3.0%

3.0%

2.5%

2.5%

2.0%

2.0%

1.6%

1.5%

1.0%

0.5%

0.0%

0.3%

0.3%

0.4%

0.1%

0.5%

0.1%

0.2%

0.1%

0.1%

0.1%

0.1%

0.0%

AMD Cataract DR

0.1%

Glaucoma RE/Other All VI

0.6%

Note: Estimates are raw prevalence rates, not age-standardised, so low AVM figures reflect low average age.

The prevalence of VL is projected to increase from 2.5% of the population in 2007 to 4.0% in 2032

(Figure 2-20). In terms of numbers of people, there are projected to be almost twice as many

22

As noted earlier, Canadian Aboriginals have some of the highest rates of diabetes in the world, and Asians have some three to six times the diabetes prevalence of whites.

52

The cost of vision loss in Canada

Canadians with VL in 25 years than in 2007, with VL from cataract, AMD and glaucoma all projected to increase by more than 100% over the next 25 years (114%, 113% and 117% respectively).

Detailed tables underlying the projections in this section may be found in Appendix B. Summaries

for 2007 are provided in Table 2

–40 through to Table 2–45 at the end of this section.

F

IGURE

2-20: P

REVALENCE OF

VL,

BY CAUSE

, 2007-2032

4.5%

4.0%

3.5%

3.0%

2.5%

2.0%

1.5%

1.0%

0.5%

0.0%

All VI

Glaucoma

Cataracts

AMD

DR

RE/Other

VL affects women more than men (Figure 2-21), reflecting greater longevity in females now and in

the future. In 2007, females accounted for 58.4% of VL, by 2032, this will have fallen slightly to

56.3%.

53

The cost of vision loss in Canada

F

IGURE

2-21: P

REVALENCE OF

VL

BY GENDER

, 2007

TO

2032

1,000

900

800

700

600

500

400

300

200

100

0

Males Females

2007 2010 2015 2020 2025 2032

While the AVM share of the total population is rapidly increasing (recall Figure 2-3), the rise in this

group’s share of VL at the end of the projection period is smaller than their increase in population share (Figure 2-23). This is partly due to AVM having a considerably younger age profile than the white population. It is also due to the assumption that the Visible Minorities population

– which is mostly growing through migration

– is not aging over the forecast period

23

.

1,600

F

IGURE

2-22: P

ROJECTIONS OF

VL,

BY ETHNICITY

, 2007

TO

2032

1,400

1,200

1,000

800

600

400

200

0

White

AVM

100,000

90,000

80,000

70,000

60,000

50,000

40,000

30,000

20,000

10,000

0

2007 2010 2015 2020 2025 2032

23

This assumption is necessary as Statistics Canada does not disaggregate its growth forecasts for Visible Minorities by age cohorts. However, it is plausible.

54

The cost of vision loss in Canada

4.8%

4.7%

4.6%

4.5%

4.4%

4.3%

4.2%

F

IGURE

2-23: R

ELATIVE SHARE OF TOTAL

VL,

BY ETHNICITY

, 2007

TO

2032

5.1% 96%

5.0%

White

AVM

96%

4.9% 95%

95%

95%

95%

95%

95%

95%

95%

2007 2010 2015 2020 2025 2032

55

The cost of vision loss in Canada

T

ABLE

2

–40:

A

LL VISION LOSS

,

BY AGE

,

GENDER AND ETHNICITY

, 2007

Prevalent cases

Males White AVM Total

Prevalence rate

Males White AVM Total

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

All Males

Female

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

All

Females

All

Persons

Total

345

205

9,469

5,166

17,390

29,942

23,148

0

49

347

0

0

0

37,979

44,041

75,270

94,066

85,336

54,101

476,854

816,951

24

24

87

9,577

5,028

16,924

28,842

22,096

36,555

38,920

59,237

0

0

86

0

0

60,526

42,877

19,296

340,097

AVM

345

205

389

271

487

1,568

1,182

0

49

347

0

0

0

1,715

3,895

4,232

4,114

1,760

1,213

21,771

36,417

24

24

87

207

64

173

1,102

805

2,207

3,112

2,380

0

0

86

0

0

2,540

1,146

690

14,646

White

9,080

4,895

0

0

16,903

28,374

21,967

36,264

40,146

71,038

0

0

0

0

0

0

89,952

83,576

52,888

455,083

780,534

0

9,369

0

0

4,964

16,752

27,740

21,291

34,347

35,808

56,857

0

0

0

0

0

57,986

41,730

18,606

325,451

Female

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

All

Females

All

Persons

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

All Males

0.00%

0.00%

0.00%

0.00%

0.00%

0.00%

0.00%

0.00%

0.89%

0.43%

1.66%

2.99%

2.92%

6.38%

8.19%

15.51%

24.15%

36.04%

40.26%

2.5%

0.00%

0.00%

0.00%

0.00%

0.03%

0.01%

0.01%

0.03%

0.08%

0.03%

0.09%

0.99%

0.77%

2.98%

5.92%

8.00%

16.65%

19.11%

28.81%

0.5%

0.00%

0.00%

0.00%

0.00%

0.01%

0.00%

0.00%

0.01%

0.72%

0.37%

1.40%

2.78%

2.65%

5.97%

7.94%

14.95%

23.70%

34.75%

41.06%

2.1%

White

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.9%

0.4%

1.7%

3.0%

2.9%

6.4%

8.2%

15.5%

24.1%

36.0%

40.3%

3.4%

3.0%

AVM

0.0%

0.0%

0.0%

0.0%

0.0%

0.1%

0.1%

0.1%

0.1%

0.1%

0.2%

1.3%

1.1%

1.9%

6.1%

11.5%

21.5%

25.4%

31.0%

0.7%

0.6%

Total

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.7%

0.4%

1.4%

2.8%

2.7%

5.8%

7.9%

15.2%

24.0%

35.4%

40.6%

2.9%

2.5%

56

The cost of vision loss in Canada

Female

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

All

Females

All

Persons

T

ABLE

2

–41:

C

ATARACT VISION LOSS

,

BY AGE

,

GENDER AND ETHNICITY

, 2007

Prevalent cases

Males

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

White

3,173

8,692

13,186

10,086

7,010

783

78

873

0

0

0

0

0

0

0

0

0

0

0

AVM

1,261

626

978

375

334

198

63

229

0

0

0

0

0

0

0

0

0

0

0

Total

980

141

1,102

0

0

0

0

4,434

9,319

14,164

10,462

7,344

0

0

0

0

0

0

0

Prevalence rate

Males

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

White

0.0%

0.0%

0.0%

0.0%

0.1%

0.0%

0.2%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.7%

2.4%

5.5%

8.7%

15.2%

AVM

0.0%

0.0%

0.0%

0.0%

0.2%

0.1%

0.3%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

2.4%

2.1%

6.4%

6.3%

13.9%

All Males 43,882 4,063 47,945 All Males 0.3% 0.1%

White

0

801

0

0

80

921

3,557

10,860

20,455

20,201

19,927

0

0

0

0

0

0

0

0

76,803

120,685

AVM

0

166

0

0

58

450

2,334

1,791

2,458

969

861

0

0

0

0

0

0

0

0

9,088

13,151

Total

0

967

0

0

138

1,371

5,892

12,651

22,914

21,170

20,788

0

0

0

0

0

0

0

0

85,891

133,836

Female

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

All

Females

All

Persons

White

0.0%

0.0%

0.0%

0.0%

0.1%

0.0%

0.2%

0.7%

2.4%

5.5%

8.7%

15.2%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.6%

0.5%

AVM

0.0%

0.0%

0.0%

0.0%

0.1%

0.1%

0.5%

3.6%

4.9%

12.8%

14.0%

22.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.3%

0.2%

Total

0.0%

0.0%

0.0%

0.0%

0.1%

0.0%

0.2%

1.1%

2.6%

5.8%

8.8%

15.6%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.5%

0.4%

Total

0.0%

0.0%

0.0%

0.0%

0.1%

0.0%

0.2%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.9%

2.4%

5.5%

8.5%

15.6%

0.3%

57

The cost of vision loss in Canada

Female

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

All

Females

All

Persons

T

ABLE

2

–42:

DR

VISION LOSS

,

BY AGE

,

GENDER AND ETHNICITY

, 2007

Prevalent cases

Males

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

White

0

881

0

0

1,130

1,141

879

447

1,623

1,881

792

270

0

0

0

0

0

0

0

AVM

87

87

55

53

610

575

593

421

503

258

94

48

0

86

24

24

0

0

0

Total

87

87

55

933

1,740

1,717

1,472

869

2,125

2,138

886

318

0

86

24

24

0

0

0

Prevalence rate

Males

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

White

0.0%

0.0%

0.0%

0.1%

0.1%

0.2%

0.2%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.1%

0.4%

0.8%

0.7%

0.6%

AVM

0.0%

0.0%

0.0%

0.0%

0.6%

0.6%

0.8%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.8%

1.7%

1.7%

1.6%

2.0%

All Males 9,043 3,517 12,560 All Males 0.1% 0.1%

White

889

1,155

0

0

1,177

928

502

2,028

2,917

1,586

768

0

0

0

0

0

0

0

0

11,950

20,992

AVM

206

232

224

842

794

616

435

49

347

345

205

0

0

0

0

616

320

120

61

5,411

8,928

Total

206

232

1,112

1,997

1,971

1,544

937

49

347

345

205

0

0

0

0

2,643

3,237

1,706

829

17,360

29,920

Female

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

All

Females

All

Persons

White

0.0%

0.0%

0.0%

0.1%

0.1%

0.2%

0.2%

0.1%

0.4%

0.8%

0.7%

0.6%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.1%

0.1%

AVM

0.1%

0.1%

0.1%

0.1%

0.7%

0.7%

0.7%

0.7%

1.7%

1.7%

1.7%

1.6%

0.0%

0.0%

0.0%

0.0%

0.0%

0.1%

0.1%

0.2%

0.1%

Total

0.0%

0.0%

0.0%

0.1%

0.2%

0.2%

0.2%

0.2%

0.5%

0.8%

0.7%

0.6%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.1%

0.1%

Total

0.0%

0.0%

0.0%

0.1%

0.2%

0.2%

0.2%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.2%

0.5%

0.8%

0.7%

0.7%

0.1%

58

The cost of vision loss in Canada

Female

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

All

Females

All

Persons

T

ABLE

2

–43:

G

LAUCOMA VISION LOSS

,

BY AGE

,

GENDER AND ETHNICITY

, 2007

Prevalent cases

Males

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

White

879

1,246

3,643

1,533

568

0

885

0

0

0

0

0

0

0

0

0

0

0

0

AVM

0

0

402

0

0

0

0

532

118

285

78

37

0

0

0

0

0

0

0

Total

0

0

1,288

0

0

0

0

1,410

1,364

3,928

1,611

605

0

0

0

0

0

0

0

Prevalence rate

Males

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

White

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.2%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.2%

0.3%

1.5%

1.3%

1.2%

AVM

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.5%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

1.0%

0.4%

1.9%

1.3%

1.5%

All Males 8,753 1,453 10,206 All Males 0.1% 0.0%

White

0

935

985

0

0

0

0

1,556

5,651

3,069

1,615

0

0

0

0

0

0

0

0

13,812

22,565

AVM

0

164

209

0

0

0

0

297

177

50

24

0

0

0

0

0

0

0

0

920

2,373

Total

0

1,099

1,194

0

0

0

0

1,853

5,828

3,119

1,639

0

0

0

0

0

0

0

0

14,731

24,937

Female

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

All

Females

All

Persons

White

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.2%

0.2%

0.3%

1.5%

1.3%

1.2%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.1%

0.1%

AVM

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.2%

0.3%

0.8%

0.9%

0.7%

0.6%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

Total

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.2%

0.2%

0.4%

1.5%

1.3%

1.2%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.1%

0.1%

Total

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.2%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.3%

0.3%

1.5%

1.3%

1.3%

0.1%

59

The cost of vision loss in Canada

Female

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

All

Females

All

Persons

T

ABLE

2

–44:

AMD

VISION LOSS

,

BY AGE

,

GENDER AND ETHNICITY

, 2007

Prevalent cases

Males

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

White

436

968

6,236

5,537

0

0

10,157

5,996

0

0

0

0

0

0

0

0

0

0

0

AVM

0

83

264

551

624

420

214

0

0

0

0

0

0

0

0

0

0

0

0

Total

0

519

1,232

6,787

6,161

10,577

6,210

0

0

0

0

0

0

0

0

0

0

0

0

Prevalence rate

Males

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

White

0.0%

0.0%

0.0%

0.0%

0.0%

0.1%

0.2%

1.7%

2.3%

8.8%

13.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

AVM

0.0%

0.0%

0.0%

0.0%

0.0%

0.1%

0.5%

1.9%

4.1%

7.0%

8.9%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

All Males 29,330 2,156 31,486 All Males 0.2% 0.1%

White

0

461

1,085

7,791

8,590

20,342

17,043

0

0

0

0

0

0

0

0

0

0

0

0

55,311

84,641

AVM

0

128

341

611

600

360

184

0

0

0

0

0

0

0

0

0

0

0

0

2,225

4,380

Total

0

589

1,427

8,402

9,190

20,702

17,227

0

0

0

0

0

0

0

0

0

0

0

0

57,536

89,022

Female

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

All

Females

All

Persons

White

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.1%

0.2%

1.7%

2.3%

8.8%

13.0%

0.4%

0.3%

AVM

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.1%

0.5%

1.7%

3.1%

5.2%

4.7%

0.1%

0.1%

Total

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.1%

0.3%

1.7%

2.3%

8.6%

12.9%

0.3%

0.3%

Total

0.0%

0.0%

0.0%

0.0%

0.0%

0.1%

0.3%

1.7%

2.4%

8.6%

13.2%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.2%

60

The cost of vision loss in Canada

Female

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

All

Females

All

Persons

T

ABLE

2

–45:

RE/O

THER VISION LOSS

,

BY AGE

,

GENDER AND ETHNICITY

, 2007

Prevalent cases

Males

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

White

9,369

4,964

0

0

15,871

25,828

20,072

31,274

0

0

0

0

0

0

30,341

39,060

33,739

19,163

4,762

AVM

0

120

9

120

294

167

900

634

582

395

179

57

0

0

0

0

0

0

0

Total

0

9,490

4,973

15,991

26,122

20,239

32,174

30,975

39,642

34,134

19,342

4,819

0

0

0

0

0

0

0

Prevalence rate

Males

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

White

0.0%

0.9%

0.4%

1.6%

2.8%

2.8%

5.8%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

6.9%

10.7%

14.0%

16.5%

10.3%

AVM

0.0%

0.0%

0.0%

0.1%

0.3%

0.2%

1.2%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

1.2%

2.0%

2.6%

3.0%

2.4%

All Males 234,443 3,457 237,900 All Males 1.8% 0.1%

White

9,080

4,895

16,015

26,418

20,709

33,020

34,017

48,803

52,338

38,378

13,535

0

0

0

0

0

0

0

0

297,207

531,650

AVM

184

39

263

560

330

358

575

917

559

260

83

0

0

0

0

0

0

0

0

4,129

7,586

Total

9,264

4,934

16,278

26,978

21,039

33,378

34,592

49,720

52,897

38,638

13,617

0

0

0

0

0

0

0

0

301,336

539,236

Female

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

All

Females

All

Persons

White

0.0%

0.9%

0.4%

1.6%

2.8%

2.8%

5.8%

6.9%

10.7%

14.0%

16.5%

10.3%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

2.2%

2.0%

AVM

0.0%

0.1%

0.0%

0.1%

0.5%

0.3%

0.4%

0.9%

2.5%

2.9%

3.8%

2.1%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.1%

0.1%

Total

0.0%

0.7%

0.4%

1.3%

2.5%

2.4%

5.1%

6.2%

10.0%

13.5%

16.0%

10.2%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

1.8%

1.6%

Total

0.0%

0.7%

0.4%

1.3%

2.5%

2.4%

5.3%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

6.3%

10.0%

13.4%

15.7%

10.3%

1.5%

61

The cost of vision loss in Canada

3.

HEALTH SYSTEM EXPENDITURE

After ascertaining the prevalence of VL from the various eye disorders, costs to the Canadian economy can be calculated. Financial costs included direct health system expenditure (medicines, surgery, lenses, and so on) and indirect costs (for example, lower levels of employment for visually impaired people and time spent by caregivers for people with VL).

While available data from Canada are not sufficient t o uniformly adopt a ‘top-down’ approach (that is, national expenditure on all forms of treatment for visually impairing eye conditions

) or ‘bottom-up’ estimates (known costs and quantities of specific eye care procedures), using a combination approach enables a reasonable estimate of total health system expenditure.

3.1

TOTAL EXPENDITURE ON

‘VISION CARE’

The Canadian Institute for Health Information (CIHI) tracks health expenditure on its National Health

Expenditure (NHEX) database, including expenditure on

‘vision care’. The vision care category includes expenditures for the professional services of optometrists and dispensing opticians, as well as expenditures for eyeglasses and contact lenses. Expenditure on vision care was nearly

$3.5 billion in 2007 24

, representing 2.2% (Figure 3-1) of all health system expenditure ($160.1 billion

in 2007).

F

IGURE

3-1: C

ANADIAN HEALTH SYSTEM EXPENDITURE

, 2007 (%

OF TOTAL

)

Other Health Spending

6.1%

Administration

3.6%

Public Health

5.8% Hospitals

28.4%

Capital

4.6%

Drugs

16.8%

Other Institutions

10.4%

Other Professional Services

8.6%

Vision Care

2.2%

Physicians

13.4%

Source: CIHI NHEX.

Apart from differentiating the services of particular types of health professionals (eg, optometrists), the NHEX does not divide expenditure by disease category.

24

Expenditure for 2007 ($3,483m) was still a provisional forecast at time of drafting.

62

The cost of vision loss in Canada

Expenditure on health care in Canada has been growing rapidly

– considerably faster than Gross

Domestic Product. After adjusting for inflation, health care spending grew at an average annual real rate of 3.8% between 1975 and 1991, by 0.8% per annum from 1991 to 1996 and by 5.1% from

1996 to 2003. However, expenditure on vision care has risen even faster, rising from 1.8% of the

total in 1975 to 2.2% in 2007 (Figure 3-2).

F

IGURE

3-2: E

XPENDITURE ON VISION CARE

, C

ANADA

, 1975-2007

10,000 1,000,000

100,000

1,000

Vision Care

Services

Total

10,000

100 1,000

Source: CIHI NHEX.

NHEX data from earlier years (before 2007) provides more detail than are currently available for

2007. Total health system expenditure reported by the NHEX for Canada was $141.2 billion in 2005.

The majority of this, $99.1 billion (or 70.1%) was publicly funded, with the remaining $42.2 billion

(29.9%) privately funded.

The NHEX reports that in 2005, nearly all Canadian public expenditure (93.6%) came from

Provincial and Territory governments. Only 4.3% came from the Federal Government, with municipal go vernments and worker’s compensation funds comprising the remaining 2.1%.

Households accounted for the majority (58.1%) of total private expenditure on health care in Canada in 2005. Private health insurance entities constituted 29.2%, and ‘other’ (including hospital nonpatient revenue, capital expenditures for privately owned facilities and health research) made up the remaining 12.7%.

Expenditure on vision care totalled $3.19 billion in 2005. In 2003 when the total was $2.64 billion, the NHEX showed that private spending on vision care in Canada was $2.44 billion, whereas public spending only amounted to $200 million. Of private expenditure, households contributed

$1.91 billion and private health insurance $0.53 million.

3.2

EXPENDITURE ON PARTICULAR EYE DISORDERS

While ‘vision care’ is only a small component of overall health system expenditure on visually impairing conditions, it can be supplemented from other sources. In a number of cases, detailed

63

The cost of vision loss in Canada information about the costs of certain eye procedures are available. Less frequently, numbers of eye procedures performed are also available. Where both are available, ‘bottom up’ calculations of expenditure can be estimated.

CIHI’s National Grouping System (NGS) attempts to provide reasonably comparable and consistent statistics on the utilization, cost and distribution of physicians’ services for which payment was made on a fee-for-service basis by provincial and territorial medical care insurance plans. CIHI (2007)

data on eye examinations and cataract surgery summed to around $144 million in 2004-05 (Table

3

–1). Assuming expenditure on these procedures has risen by the same amount as total health

system expenditure, this figure would have risen to $153 million by 2007.

T

ABLE

3

–1:

T

OTAL EXPENDITURE ON CERTAIN EYE PROCEDURES

, 2004-05

Procedure

Eye Examinations

Cataract Surgery

Total

Number

373,148

284,523

657,671

Average $/case

$41.44

$452.30

$219.15

Expenditure $m

$15.5

$128.7

$144.2

Source: CIHI (2007). Note $/case is derived from the other two columns.

Additionally, some partial information is available on drug expenditure from Health Canada (2002a)

The Economic Burden of Illness in Canada 1998

. Drug expenditure on two categories of eye disorders

– glaucoma and conjunctiva disorders – totalled $143.2 million in 1998 (Table 3–2). Given

the NHEX shows expenditure on drugs has increased by 214% since then, proportionally, this figure

in 2007 would be $307 million (Table 3

–3).

T

ABLE

3

–2:

D

RUG EXPENDITURE ON NERVOUS SYSTEM AND SENSE ORGAN DISORDERS

, 1998

$m

Disorder

Glaucoma

Conjunctiva disorders

Ear infections

Parkinson’s disease

Other nervous system and sense organ disorders

Sub-total for nervous system and sense organ disorders

54.7

88.5

92.7

24.1

276.4

536.4

Total for all diseases 12,385.2

Source: Health Canada (2002a).

Health Canada (2002a) gives a breakdown of the ICD-

10 block ‘Nervous System and Sense Organ

Disorders’, of which vision conditions are a major component. Unfortunately Health Canada were

unable to supply more detailed data than as provided in Table 3

–3, to isolate the vision component.

T

ABLE

3

–3:

E

XPENDITURE ON NERVOUS SYSTEM AND SENSE ORGAN DISORDERS

(1998)

Hospital Care

Drugs

Physician Care

Research

Total

$m % of total health system expenditure

1,425.6

536.4*

824.8

35.7

2,822.5

5.20%

4.30%

7.10%

0.20%

3.36%

Source: Health Canada (2002a). * Matches the Table 3-2 sub-total.

64

The cost of vision loss in Canada

CIHI (2005)

Exploring the 70/30 Split: How Canada’s Health System is Financed

, provides quite detailed information on the costs of a selected range of hospital procedures. The only procedure listed there relevant to VL

– ‘Retinal procedures’ – averaged $2,538 in 2003 (around half the cost of most procedures). Charts in the same document show that these costs can be broken down to

provincial level. The CIHI website shows a casemix spreadsheet with the following reporting (Table

3

–4) of eye operations by volume in 2000-01. This, together with the above data on cost of retinal

procedures, allows an estimate of the cost and quantity of retinal procedures (4,126 cases in

2000/01). A more detailed breakdown of hospital expenditures is not possible.

T

ABLE

3

–4:

F

REQUENCY OF SELECTED HOSPITAL PROCEDURES

(2001)

25

Case Mix Description Volume FY00/01

Retinal procedures

Orbital procedures

Lens insertion

Other ophthalmic dx

Major eye infections

Other intraocular procedures

Other ophthalmic proc

Extraocular procedures

Iris and lens procedures

Hyphema

4,126

2,889

1,284

1,134

847

715

492

289

110

95

Source: CIHI secure.cihi.ca/cihiweb/en/downloads/Casemix_ICDimpact_AppA_CMG_02_03.xls

For specialist consultations, data on Medicare rebates are available for some provinces. Rebates for ophthalmological procedures from the Ontario Ministry of Health and Long-

Term Care’s

Schedule of Benefits for Physician Services 2006

are shown in Table 3

–5. However, for these data

to be useful there is also a need to know the numbers of each procedure performed.

T

ABLE

3

–5:

R

EBATES FOR CERTAIN OPHTHALMOLOGICAL PROCEDURES IN

O

NTARIO

(2006)

Ophthalmological Listing Cost ($)

A235 Consultation

A935 Special surgical consultation (see General Preamble GP17)

A236 Repeat consultation

A233 Specific assessment

A234 Partial assessment

A237 Periodic Oculo-visual Assessment

A115 Major eye examination

A230 Orthoptic assessment

A250 Retinopathy of prematurity assessment

A252 Initial vision rehabilitation assessment

A251 Special ophthalmologic assessment

Source: Ontario Ministry of Health and Long-

Term Care’s

Schedule of Benefits for Physician Services 2006

.

71.30

132.50

45.85

42.15

22.45

42.15

42.15

25.00

120.00

240.00

120.00

25

COS advise that it is ‘totally unbelievable’ that there are four times as many retinal procedures as lens insertions (and in

Australia it is more like the other way round). Accordingly, information from this table is regarded as unreliable and not utilized for final costings. It is still included, however, as part of the census of information available from official sources in

Canada.

65

The cost of vision loss in Canada

Cruess et al (2007) provide a comprehensive coverage of the average costs involved in treating

AMD

in Canada (Table 3

–6), which can be used with prevalence data to estimate the total cost of

AMD.

Treatment

T

ABLE

3

–6:

A

VERAGE TREATMENT COSTS FOR NEOVASCULAR

AMD (2005)

Cost ($)

Verteporfin, one eye only

Simultaneous verteporfin treatment, both eyes

Intravitreal coriscosteroids, per eye

Photodynamic therapy with intravitreal steroid injection

Source: Cruess et al (2007).

$2,112

$2,266

$183

$308

Ray et al (2005) provide costs for both

cataract

surgery and retinal laser treatment for

DR

in

Canada of $1,323 and $709 in 2003. Interestingly, these procedures were substantially less expensive in Canada than the same operations in Australia - $2,061 and $2,237 respectively.

26

Iskedjian et al (2003) conducted an Ontario-based costing analysis of

glaucoma

in Canada and estimated the total cost of procedures associated with the treatment of glaucoma to be $344 for mild, $420 for moderate, and $511 for severe forms of glaucoma in 2001. These estimates included the cost of the procedure itself, physician’s fee, assistant’s fee, and the anaesthetist’s fee. Costs associated with hospital resources and medications were not included.

3.3

TOTAL HEALTH SYSTEM EXPENDITURE

3.3.1

H

EALTH SYSTEM EXPENDITURE

,

TOP DOWN

This top down estimate relies primarily on two sources:

Economic Burden of Illness in Canada 1998

and CIHI’s

Health Canada’s 2002 publication

The

National Health Expenditure Database

(NHEX), and is calculated as outlined below.

Total health system expenditure in 2007 was $160.1 billion dollars. Expenditure on

‘nervous system and sense disorders

’ in 1998 was 3.36% (from Table 3–3) of health system

expenditure (Health Canada, 2002a). However, health system expenditure as defined in this source only covers hospitals, physicians, drugs and research. Assuming nervous system and sense disorders are also responsible for the same ratio (3.36%) of the total health system expenditure reported for 2007 by the NHEX ($160.1 billion) then total health system expenditure on nervous system and sense disorders in 2007 would be $5.38 billion. This provides an upper limit on expenditure on VL (for the above categories).

Health Canada (2002a) does not provide any further breakdowns, except for drugs (Table 3

2). Within drugs there are a number of subcategories that can be attributable to VL (noting that the category

‘other’ accounts for the majority of expenditure). Specifically, expenditure on glaucoma and conjunctiva disorders can be attributed to VL, ear infections to other sense organ disorders, and Parkinson

’s to nervous system disorders. Thus represented, VL accounts for 55.1% of such drug expenditure as it is able to be attributed to separately identified categories; other sense organ disorders (ear infections) account for 35.7% and nervous system disorders

(Parkinson’s) account for 9.3%. It is assumed that expenditure in

‘other’ would have the same distribution between these identifiable categories.

26

In the original article, all costs were in Euros, converted to Canadian dollars at then prevailing exchange rates.

66

The cost of vision loss in Canada

Assuming that, if VL accounts for 55.1% of all drug expenditure on

‘nervous system and sense disorders

’ then VL would also account for the same proportion of health system expenditure on nervous system and sense disorders, and 55.1% of $5.38 billion equals $2.97 billion. This provides an upper limit for VL expenditure under the hospital, research, physicians and drug categories.

The NHEX also provides explicit expenditure for the professional services category under

‘Vision Care’,

27

which includes optometrists, ophthalmologists, glasses and contact lenses, of

$3.48 billion. Adding vision care to the $5.38 billion estimate of expenditure on hospitals, physicians, drugs and research yields a total of $6.45 billion in 2007.

The NHEX further shows that expenditure on

‘Other institutions’ is composed of nursing homes (90%) and mental institutions (10%). Access Economics (2006) calculated that 3.0% of US nursing home patients had been institutionalized due to VL. Thus, 2.7% (=3.0% * 90%) of the total

‘other institutions’ of $16.7 billion (NHEX) is estimated to be due to VL, or

$448.8 million.

This still leaves an amount to be calculated for public health, administration, capital, and other expenditure ‘not elsewhere classified’. These categories collectively account for 20% of total

health system expenditure (Figure 3-1). Thus, given the categories already calculated account

for 80% of health system expenditure, these remaining categories are equivalent to a quarter of those already calculated (=20% / 80%), or $1.7 billion

Thus, a top down estimate of health system expenditure on VL in Canada for 2007 is

$8.64 billion.

T

ABLE

3

–7:

E

STIMATED

VL

HEALTH SYSTEM EXPENDITURE

(

TOP DOWN

), 2007

Type of cost Total ($m)

Hospital

Physicians

Pharmaceuticals

Vision Care (optometry, ophthalmology and lenses)

Research

Other Institutions

Other (capital, public health, administration, other institutions and professional services)

Total

1,497.7

866.5

563.5

3,483.7

37.5

444.8

1,740.3

$8,637.9

3.3.2

H

EALTH SYSTEM EXPENDITURE

,

BOTTOM UP

For a bottom up approach, estimates were undertaken for each of the five major eye diseases, either for total expenditure, or by the categories covered under the top-down approach, but for each individual disease.

For

AMD,

Cruess et al (2008) estimated the total to society of AMD in Canada was $1.12 billion in

2005. For the average patient, medical costs accounted for over three quarters of this figure

(76.7%) and non-medical costs (primarily aids, equipment and carers) the remainder (23.3%).

Subtracting non-medical costs proportionally leaves health system expenditure of $858.7 million. As

27

For total health system expenditure, the NHEX divides

Professional Services is divided into two subcategories ‘Vision

Care’ and ‘Other’.

67

The cost of vision loss in Canada these estimates apply to 2005, allowing for cumulative inflationary increases of 4.7% yields a total for 2007 health system expenditure of

$898.9 million

.

For

RE

, given this is the only form of VL correctable by lenses, the assumption was made most of the NHEX category

‘vision care’ would be attributable to RE. Conversely, it was also assumed that

RE required little in the way of hospital care, physicians, drugs or the other categories in Table 3

–7.

Thus, expenditure on RE would be around

$3.48 billion

.

For

glaucoma

, following the methodology adopted in the top-down approach, the ratio of glaucoma drug expenditure to total nervous drug expenditure (10.2

%) was assumed to hold for glaucoma’s share of total

‘nervous system and sense organ disorders’ health system expenditure. Nervous system and sense disorders in turn were (3.36%) of total health system expenditure. This yields a total of

$549 million

for glaucoma.

Total expenditure on

cataract

surgery is estimated at $136.6 million, taking the $128.7 million in

2004-05 from Table 3

–1 and allowing for inflation to 2007. Assuming that most such surgery takes

place in hospitals, then given hospitals account for 28.4% of total health system expenditure, if the same ratio holds for cataract, total health system expenditure for cataract would be $481 million.

For

diabetic retinopathy (DR)

, given there is only one frequency of procedure number, which COS advise is not plausible, costs are assumed to be the same as the average for the other diseases

($6,875 per person per year), which for the total of 29,920 people with VL from DR, gives a total of

$205.71 million.

Thus, estimating from the bottom up, total health system expenditure on VL was $5.62 billion in

Canada in 2007. As with the top-down estimate, this figure needs to be scaled up to account for factors such as capital expenditure, research, public health and other unallocated health expenditure. For consistency, the same mark-up (25.2%) is used, giving a

total bottom-up estimate of $7.04 billion.

3.3.2.1 S

UMMARY

The bottom-up estimate above is around 18.5% lower than the top-down estimate derived earlier.

Most of this difference would be due to the fact that the bottom-up estimate only includes the

‘big five

’ eye diseases (cataract, DR, glaucoma, AMD, RE). For example, Maberley et al (2006) in their study of VL in one Canadian city found that 12% of VL was caused by visual pathway disease

(which is not included in the bottom up estimates).

Accordingly, while Access Economics has a preference to err on the side of caution, in this case the top-down estimate is considered more reliable. Thus

the total cost of VL-related health expenditure in Canada is estimated as $8,637.9 million in 2007

. This equates to $10,570 per person with VL per annum.

68

The cost of vision loss in Canada

4.

OTHER FINANCIAL COSTS

In addition to health system costs, VL also imposes a number of other important financial costs on society and the economy, including the following.

Productivity losses

of people with VL comprise those from lower employment participation, absenteeism and/or premature mortality.

Carer costs

comprise the value of care services provided in the community primarily by informal carers and not captured in health system costs.

Other costs

comprise the cost of aids, home modifications and other pertinent financial costs not captured elsewhere.

Transfer costs

comprise the deadweight loss (DWL) associated with government transfers such as taxation revenue forgone, welfare and disability payments.

It is important to make the economic distinction between real and transfer costs.

Real costs

use up real resources, such as capital or labour, or reduce the econ capacity to produce goods and services. omy’s overall

Transfer payments

involve payments from one economic agent to another that do not use up real resources eg, a disability support pension or taxation revenue.

Data on other financial costs are drawn from a variety of sources eg, the literature (focusing on

Canadian literature but sometimes supplemented by other international material).

4.1

PRODUCTIVITY LOSSES

Productivity losses are the cost of production that is lost when people with VL are unable to work because of the condition. They may work less than they otherwise would (either being employed less, being absent more often or being less productive while at work) or they may die prematurely.

This represents a real cost to the Canadian economy. Access Economics adopts a human capital approach to measurement of productivity losses in developed countries.

4.1.1

E

MPLOYMENT PARTICIPATION

Some insight into the employment impact of VL is provided by CNIB (2005). A survey of people living with vision loss found that the employment rate among those of working age was only 24.7% compared to 67.6% for the general population of the same age (Table 4

–2). The chances of being employed are thus almost two-thirds (64%) lower for someone who is visually impaired. In addition to 24.7% who were employed, 49.2% listed themselves as unemployed, while the remaining 26.1% were ‘retired’ or ‘other’ and are assumed to be not participating in the labour force. Thus, of those actively participating in the labour force, 67% of people with VL describe themselves as unemployed. Of those who were employed, 63% were working full time, but only 29% had a permanent position. Alternate data from the 2001 PALS indicates that the employment rate among those with VL was 32%. Given the PALS survey has a larger sample size than the CNIB survey, the former is preferred. On PALS data, people with VL are around half as likely to be employed as those with full sight (53% lower).

This reduced employment result was then combined with employment rates for each respective agegender group (Table 4

–2) to calculate, from the number of people with VL in that age group, how many would be unemployed. The lost productivity for those unemployed due to VL was then

69

The cost of vision loss in Canada

Age

15-19

20-24

25-34

35-44

45-54

55-59

60-64

65+

Total

measured by the average weekly earnings (AWE) of $855.06 that they would have otherwise been earning (Table 4

–1).

28

T

ABLE

4

–1:

E

STIMATED

AWE,

BY AGE AND GENDER

, 2007

Male Female Persons

$264.49

$576.08

$926.61

$926.61

$1,096.00

$1,096.00

$1,095.09

$1,095.09

$1,036.21

$192.03

$493.65

$686.58

$686.58

$670.28

$670.28

$681.15

$681.15

$645.82

$227.35

$537.13

$817.92

$817.92

$897.63

$897.63

$890.38

$890.38

$855.06

Source: Derived from Statistics Canada

Employment, Earnings and Hours,

Cat No 72-002-XIB.

T

ABLE

4

–2:

PERCENTAGE OF POPULATION EMPLOYED

,

BY AGE AND GENDER

Age Male Female

15-19 years

20-24 years

25-34 years

35-44 years

45-54 years

55-64 years

45%

73%

86%

88%

85%

64%

49%

70%

78%

79%

78%

51%

Source: Statistics Canada, Labor force characteristics by age and sex http://www40.statcan.ca/l01/cst01/labor20a.htm

The annual cost of

lost earnings due to reduced employment is thus estimated as

$4.06 billion

in 2007.

4.1.2

A

BSENTEEISM FROM PAID AND UNPAID WORK

In addition to workforce separation, people with VL may be absent from work more often as a result of their impairment. Our literature search was unable to locate published works on such absenteeism rates for people with VL in Canada.

However, Access Economics (2006) calculated (from the National Health Interview Survey-Disability data set) that in the US, VL was shown to result in an additional 4.1 days off work per annum. This estimate could also be applied to Canada, noting it is small ($155 per person with VL) relative to the productivity cost associated with lower workforce participation.

In cases of absenteeism, employers often choose to make up lost production through overtime employment of another employee that attracts a premium on the ordinary wage. The overtime premium represents lost employer profits. On the other hand, the overtime premium also indicates how much an employer is willing to pay to maintain the same level of production. Thus, if overtime employment is not used, the overtime premium also represents lost employer profits due to lost

28

As Statistics Canada does not break down AWE for each age-gender group, these were estimated from the distribution

in Australia, due to the similarities (see footnote 11).

70

The cost of vision loss in Canada production. While productivity remains at the same level, the distribution of income between wages and profits changes

29

. For this study it is assumed that the overtime rate is 40%

30

.

According to traditional microeconomic theory (in particular the work of Gary Becker in the 1960s), people will work until they are indifferent between the marginal value of the income earned relative to the personal value of the time sacrificed that could be used for unpaid domestic work or leisure.

However no-one else tends to value the individual's leisure similarly. The typical approach to overcome this problem is to value leisure time at a discounted proportion of earnings which takes into account taxes that reduce the effective income from work and restrictions on the amount of time that can be used for work (for both biological and governmental regulation reasons). Access

Economics assumes that visually impaired people incur the same loss of time from unpaid work

(‘leisure’) as from paid work, but that the value of this time is 30% of paid work.

Based on these parameters and the AWE for each age-gender group, Access

Economics estimates that in 2007,

the total cost of absenteeism due to VL is

$231.7 million

. Of this, $22.8 million is the workplace absenteeism cost borne by the employee, $122.5 million is the workplace absenteeism cost borne by the employer, and

$86.5 million is the value of absenteeism from unpaid work.

4.1.3

P

RESENTEEISM

VL can also affect a person’s ability to work effectively while at work. Presenteeism can be estimated by multiplying the number of days worked with VL by the percentage reduction in effectiveness on days worked with VL. Workers with VL must have productivity reasonably close to their sighted counterparts; otherwise they would not continue to be employed. With the right equipment, they should be just as productive as anyone else. However, the CNIB survey found that around three-quarters (73.8%) of workers with VL indicated that their workplace was taking some measures to accommodate them; mostly in the form of adapted equipment, flexible scheduling and modified responsibilities. Around a quarter (23.5%) indicated that they did not receive job accommodation measures that they needed, with the greatest unmet need being for adaptive computers. Daum et al (2004) in a study of productivity and visual status in the US found that vision loss reduced productivity in the workforce by between 2.5% and 28.9%. Taking a simple average of an 15.7% reduction in productivity, and applying this to the 23.5% of VL workers without proper equipment, yields an estimated overall lower productivity for VL workers of 3.7%.

Such a low level of productivity highlights the significant impact of VL on employment outcomes.

Given these results, Access Economics estimates that in 2007,

the total cost of

‘presenteeism’ (lower productivity while at work) due to VL is $133.9 million

.

29

While the opportunity cost of any overtime employment of another employee is implicitly taken into account through the overtime premium, this methodology does not allow for the choice to use salaried or part-time employees to make up the production at ordinary or no additional wage costs. However given that workers are assumed to value their leisure time at

30% of their earnings, the difference in estimated economic costs if this choice is taken into account would be small

– the only difference would be that ‘society’ would incur these costs rather than the ‘employer’.

30

Based on the lower bound of workplace injuries literature - NOHSC assumed an overtime rate of 40% (Access

Economics 2004b).

71

The cost of vision loss in Canada

4.1.4

P

REMATURE MORTALITY

The production loss arising from premature mortality associated with VL through falls and depression is calculated as the expected remaining lifetime earnings multiplied by the number of people who died prematurely who would otherwise have been employed. As discussed in Section

5.2.2, the estimated number of deaths due to VL is 313. Since most (98%) of these deaths are in

the 75+ age group where employment rates are low, lifetime earnings lost are not large.

The estimated annual cost due to lost productivity from premature death due to

VL is $3.4 million in 2007

.

Premature death also leads to additional search and hiring costs for replacement workers. These are estimated as the number of people with VL who die prematurely (by age and gender) multiplied by their chance of being employed multiplied by the search and hiring cost brought forward three years (the search and hiring cost is estimated as 26 weeks at AWE and the three year bring forward reflects average staff turnover rates). Since premature mortality costs are very low, these costs are tiny.

In 2007, additional search and hiring costs are estimated at only $9,040 for people with VL

, based on the present value of bringing forward three years of average cost of staff turnover (26 weeks at AWE).

4.1.5

F

UNERAL COSTS

The ‘additional’ cost of funerals borne by family and friends of people with VL is based on the additional likelihood of death associated with VL in the period that the person experiences it.

However, some people (particularly older people) would have died during this time anyway.

Eventually everyone must die and thus incur funeral expenses

– so the true cost is the cost brought forward (adjusted for the likelihood of dying anyway in a given year). The most recent official data on funeral costs from are from 1991 (Statistics Canada, 1998), at which point an average funeral cost around $3,510. Updating this to allow for inflation to 2007 yields a current cost of $4,301. (This roughly accords with the figure from the Australian Bureau of Transport and Road Economics

(2000), which after allowing for inflation and conversion to Canadian dollars, equates to $3,541.)

The

bring forward of funeral costs

associated with premature death for people with VL is estimated at around

$1.1 million in 2007.

4.2

DWL FROM TRANSFERS

Lost taxation revenue is considered a transfer payment, rather than an economic cost. However, raising additional taxation revenue does impose real efficiency costs on the Canadian economy, known as DWLs. Besides the cost of administering the taxation system costs, DWLs arise from the distortionary impact of taxes on workers’ work and consumption choices.

4.2.1

L

OST TAXATION REVENUE

Reduced earnings due to reduced workforce participation, absenteeism and premature death will also have an effect on taxation revenue collected by Canadian Governments. As well as forgone income (personal) taxation, there will also be a fall in indirect (consumption) tax, as those with lower incomes spend less on the consumption of goods and services.

72

The cost of vision loss in Canada

Personal income tax forgone is a product of the average personal income tax rate and the forgone income. With VL and lower income, there will be less consumption of goods and services, estimated up to the level of the disability pension. Without VL, it is assumed that consumption would comprise (on average) virtually all household income - based on Statistics Canada reports that

Canadians only save 3% of their income (Chawla and Wannell, 2005). The indirect tax forgone is estimated as a product of the forgone consumption and the average indirect tax rate.

The (Federal) Canadian Goods and Services Tax (GST) rate is 5%, however most Provinces also levy separate sales taxes. In fact in Canada there are three types of sales taxes: provincial sales taxes or PST, the federal Goods and Services Tax or GST, and the Harmonized Sales Tax or HST.

Every province except Alberta implements a Provincial Sales Tax or HST. The Yukon Territory,

Northwest Territories and Nunavut do not have any type of regional sales tax.

The HST is used in certain provinces to combine the federal GST and the PST into a single, blended, sales tax. Currently, there is a 13% HST in the provinces of New Brunswick,

Newfoundland, and Nova Scotia. The HST is collected by the Canada Revenue Agency, which then remits the appropriate amounts to the participating provinces.

Separate PST are collected in the provinces of British Columbia, Saskatchewan, Manitoba, Ontario,

Quebec, and Prince Edward Island. Goods to which the tax is applied vary by province, as do the rates. Moreover, for those provinces whose provincial sales tax is applied to the combined cost and

GST, provincial revenues decline or increase with respective changes in the GST.

T

ABLE

4

–3:

P

ROVINCIAL SALES TAXES

Province

Alberta

British Columbia

Saskatchewan

Manitoba

Ontario

Quebec

Prince Edward Island

Rate

0

7%

5%

7%

8%

7.5%

10%

Notes

Alcohol 10%

Alcohol 10%

Lodging 5%

Alcohol and entertainment at restaurants 10%

Alcohol at retail stores 12%

Also applied to Federal GST, so effectively 7.875%

Also applied to Federal GST, so effectively 10.5%

Source: www.taxtips.ca

From these sources it is possible to estimate taxation revenue forgone due to VL. Both Federal and

Provincial direct taxes have progressive rates. For a Canadian on the average income of $40,082, total Federal income tax would be $6,166 at an average rate of 15.4%. Given the multiplicity of

Provincial direct taxes, Quebec was chosen as being representative as it has one of the largest populations and its tax rates are roughly mid range. A Quebecois on an income of $40,082 would pay $2,551 in direct taxes at an average tax rate of 6.4%. These average taxation rates are sourced from the Canadian Revenue Authority.

For indirect taxes, although Federal GST is 5%, the numerous Provincial indirect taxes (Table 4

–3)

mean that, again, Quebec is selected as a representative Province, with its effective indirect tax of

7.875%.

Personal income tax forgone is then calculated as the product of the average personal income tax rate (21.8%) and the forgone income. With VL and lower income, there will be less consumption of goods and services, with the indirect taxation rate estimated as 12.9%.

73

The cost of vision loss in Canada

Around $1.75 billion in lost potential tax revenue is estimated to be incurred in

2007

, due to the reduced productivity of people with VL.

Lost taxation revenue is considered a transfer payment, rather than an economic cost per se.

4.2.2

S

OCIAL SECURITY PAYMENTS

The CNIB (2005) study on the needs of blind or visually impaired people briefly covered their sources of income.

The CNIB study encompassed 352 adult client participants nation-wide with VL. Of these, 61% were female (213), and 39% were male (139), while 57% of adult participants were working age (21

–64), and 43% were seniors (65+).

The most frequent source of income for all adult client participants was some form of government income supplement program (federal or provincial). However, unsurprisingly there were age related differences in the programs that were providing benefits. The vast majority of senior participants reported receiving a federal pension (91%), compared to only 26% of working age participants. Conversely, 41% of working age participants reported receiving provincial disability benefits, compared to only 6% of seniors. Income from employment was low overall (12% for all adult consumer participants), and again age made a difference. Of working age participants 24% reported income from employment or self-employment, compared to 2% of seniors. Seniors were more likely to report receiving a private pension

(31%) than were working age participants (8%). Table 4

–4 provides an overview of income

sources for adult participants.

Income Source

Federal pension*

T

ABLE

4

–4:

I

NCOME SOURCES

(CNIB)

All

54%

Working Age

26%

Seniors

91%

Provincial disability benefits

Private pension

Private income

Employment

Spousal support

Self-employment

Family support

Other

26%

18%

13%

12%

8%

4%

2.3%

8%

41%

8%

8%

19%

9.5%

5.4%

3%

8%

* Federal pensions included Old Age Pension, Disability Pension, and Veterans Pension.

Source: CNIB (2005).

6%

31%

19%

1%

5%

1.3%

1.3%

8%

Publicly available data exist for social security spending and recipients in Canada

– reported by

Human Resources and Social Development Canada as part of its

Social Security Statistics Canada and Provinces 1978-79 to 2002-03

.

31

Selected payments that people with VL may access are

presented in Table 4

–5 – these data refer to aggregate payments to all recipients rather than

payments to people with VL only.

31

See:

http://www.hrsdc.gc.ca/en/cs/sp/sdc/socpol/tables/page02.shtml

(accessed Wednesday 6 February, 2008).

74

The cost of vision loss in Canada

T

ABLE

4

–5:

VL-

RELATED SOCIAL SECURITY PAYMENTS AND BENEFICIARIES

Old age security

Veterans' and civilians' disability pensions

Canada and Quebec pension plans

Employment assistance for persons with disabilities

Provincial welfare programs

Total payments

($000)

20,464,192

1,473,118

3,330,019

378,318

20,552,751

Beneficiaries

(number)

3,941,039

164,805

340,116

$/beneficiary

5,193

8,939

9,791

Total 46,198,398

Source: Human Resources and Social Development Canada, Social Security Statistics Canada and Provinces 1978-79 to

2002-03.

The data from Table 4

–5 can be used to calculate the excess number of people with VL who receive

payment relative to population norms. These excess usage rates can then be multiplied by the average payment rates to estimate the social security payments for people with VL.

CNIB (2005) did not include unemployment benefits as a source of income for the visually impaired. Presumably then, working age people with VL are either employed or on disability pension.

Income Source

T

ABLE

4

–6:

E

XCESS USAGE OF SOCIAL SECURITY PAYMENTS

Working

Age

Usage % of total population

Excess usage

VL working age pop

VL who get benefit

Pop who get benefit

%

Attributable to VL

Federal pension*

Provincial disability benefits

26%

41%

2%

8%

24.4%

32.8%

209,122

209,122

54,372

85,740

504,921

2,577,363

10.8%

3.3%

4.2.3

D

EADWEIGHT LOSSES

The welfare payments calculated immediately above are, like taxation revenue losses, not themselves economic costs but rather a financial transfer from taxpayers to the income support recipients. The real resource cost of these transfer payments is only the associated DWL.

DWLs refer to the costs of administering welfare pensions and raising additional taxation revenues.

For any given fiscal position, invalid and sickness benefits must be financed through taxation.

Although welfare payments and forgone taxation are not real costs (so should not be included in the estimation of total costs), it is still worthwhile estimating them as that helps us understand how the total costs of VL are shared between the taxpayer, the individual and other financiers.

DWL is the loss of consumer and producer surplus, as a result of the imposition of a distortion to the equilibrium (society preferred) level of output and prices. Taxes alter the price and quantity of goods sold compared to what they would be if the market were not distorted, and thus lead to some

diminution in the value of trade between buyers and sellers that would otherwise be enjoyed (Figure

4-1).

75

The cost of vision loss in Canada

F

IGURE

4-1: DWL

OF TAXATION

Price ($)

Price plus Tax

Taxation Revenue

Price

Deadweight Loss (cost of raising taxation revenue)

Supply

Demand

Output

Actual Quantity

Supplied

Potential Quantity

Supplied

Usher (2002) estimates the DWL of raising revenue in Canada at 20.2%.

Access Economics estimates that around

$1.75 billion in DWL is incurred in 2007

, due to the additional taxation required to replace that forgone due to lost productivity of people with VL and welfare payments. Of this, $1.2 billion is a result of the governmentfinanced component of health system expenditures, $348 million is due to taxation revenue forgone and $185 million is due to welfare expenditures.

4.3

CARE AND OTHER ASSISTANCE

Carers are people who provide informal care to others in need of assistance or support. Most informal carers are family or friends of the person receiving care. Carers may take time off work to accompany people with VL to medical appointments, stay with them in hospital, or care for them at home. Carers may also take time off work to undertake many of the unpaid tasks that the person with VL would do if they did not have VL and were able to do these tasks.

A recent study focusing on AMD only rather than overall VL calculated the burden of neovascular

AMD in the Canadian population (Cruess et al, 2007). This cross-sectional, observational analysis was conducted in relation to self-reported functional health, wellbeing and disease burden among elderly subjects in Canada with (n=67) and without (n=99) neovascular AMD.

Subjects with neovascular AMD reported significantly worse vision-related functioning and overall wellbeing than controls (adjusted mean scores on the NEI-VFQ-25

32

: 48.0 vs. 87.5) and significantly more depression symptoms than controls (Hospital Anxiety and Depression Scale:

5.8 vs. 4.3). The annual neovascular AMD cost per patient was $11,334, which is over eight

32

National Eye Institute Visual Functioning Questionnaire

http://www.nei.nih.gov/resources/visionfunction/vfq_ia.pdf

(25 questions). See, for example,

76

The cost of vision loss in Canada

 times that of elderly subjects without neovascular AMD ($1,412). Over half of the neovascular

AMD costs were direct medical costs.

Subjects with neovascular AMD also reported more than twice the need for assistance with daily activities compared with controls (19% vs. 9%). This allows us to calculate the excess care required by people with AMD relative to the rest of the population

– by taking the difference between the two figures.

F

IGURE

4-2: C

OMPARISON OF ASSISTANCE WITH ACTIVITIES OF DAILY LIVING BETWEEN STUDY GROUPS

19%

Neovascular AMD Control group

13%

9%

4%

3%

2%

5%

1%

3%

4% 4%

5%

0%

2%

Daily activities overall

Home care Other transportation

Administrative tasks

Self care Transportation for health care

Leisure activities

Source: Cruess et al (2007).

Cruess et al (2007) also reported unit costs for non-medical related costs of AMD with data sourced from the Canadian Management Information Systems database. These data relate to people with

AMD only rather than people with VL as a whole.

The main unit cost categories were direct vision-related medical costs, direct non vision-related medical costs, and direct non-medical costs (living in government-sponsored assisted living facilities, assistance received for daily activities, and social benefits received). Given that other health-related costs data sources have already been identified in this study (see Sections 3 and 4), the most useful data from Cruess et al (2007) related to the non-medical costs.

After collecting the unit costs, annual utilisation costs were then calculated by multiplying the number of units consumed by the unit cost. Overall, people with AMD had much higher non-medical costs ($2,553.25) which included home care/living assistance compared to the control group

($601.02).

T

ABLE

4

–7:

A

NNUAL DIRECT

AMD

NON

-

MEDICAL RELATED UTILISATION COSTS PER PERSON

(2005$)

Direct non medical related utilisation costs per person

Total living situation related costs

Total costs of assistance for daily activities received

Total

Source: Cruess et al (2007).

AMD Control

$240.68 $0.00

$2,312.57 $601.02

$2,553.25 $601.02

77

The cost of vision loss in Canada

Cruess (2007) provides an overview of carer costs for AMD ($2,553.25 per person per annum) and for an age-matched control group ($601.02). Thus, the difference between the two groups

($1,952.23 pa) is the cost of care that is specific to AMD. Access Economics has assumed that additional care is not due to having a particular eye disease as such, so much as to the VL caused by that disease. AMD’s disability weight (0.235) is 1.6 times higher than the average disability weight across all eye diseases (0.145). So, factoring down, the expected care costs for people with

VL

– above their fully sighted counterparts – would be $1,208.99 per person per year.

Thus, for the total visually impaired population of 0.82 million, annual carer costs attributable to VL is

$0.63 billion.

Rehabilitation and library costs

According to CNIB, the cost of provision of rehabilitation services for people with vision loss in 2007 was $32.8 million. In addition, the cost of special library services for people with vision loss was

$7.4 million. Only 23% of these funds are provided by government. The rest is provided by support from the public.

Also, there are two other significant organizations providing services in Quebec

– the Institut

Nazareth et Louis Braille and MAB-Mackay (the Montreal Association for the Blind and the Mackay

Rehabilitation Centre). Financial information from most recent annual reports on their websites

33 suggests costs relating to these organisations are estimated as $12.8 million and $8.8 million respectively in 2007.

In total, the rehabilitation and library costs are estimated as $61.8 million and total cost of care is estimated as $0.693 billion.

4.4

AIDS AND DEVICES

People who are visually impaired or blind require a variety of devices, special equipment and home modifications to function adequately and to enhance their quality of life.

The greater need for devices and home modifications due to VL and blindness has been established in international studies (for example, Brezin, 2005; Access Economics, 2004a).

In the Australian study, the cost of devices and modifications was estimated as A$318 to

A$571 per visually impaired person on average in 2004. The French study estimated only additional utilization, not costs.

Two sets of supports are provided for people with low vision and those who are blind because of the different needs of these two populations. For people who are blind, support primarily involves assistance using non-visual sensory data. For those with low vision, supports primarily involve magnifying or enlarging, brightening and enhancing contrast in visual displays or cues.

CNIB is the primary source for devices for the visually impaired and, as a result, prices reported are from CNIB price lists for the period 2000-01, weighted by the number of items sold of each of the brands/models available. Volumes of sales were reported in the December 2003

Price Survey of

Assistive Devices and Supports for Persons with Disabilities

produced by the Department of Human

Resources and Social Development.

33

http://www.mab.ca/ and http://www.inlb.qc.ca/apropos/ra2006-2007.aspx#s11

78

The cost of vision loss in Canada

These data are inflated to 2007 by Consumer Price Inflation and population growth. They provide a good indication of the types of aids and modifications used, as well as the volume in which they are used across Canada and their price.

4.4.1

C

ANES AND ACCESSORIES

Two different brands/types of canes were priced

—a mobility (way-finding) cane and a support cane.

Each is available in three identically priced models. In 2000, 1,278 canes were sold at an average price of $21.78.

The mobility cane folds, comes with a rubber tip grip bottom, handle and connecting elastics.

The average price for the 626 mobility canes sold was $20.00.

The support cane is made of moulded plastic, has a height adjustment and a rubber tip grip bottom. A total of 652 of these were purchased at an average price of $23.50. These types of cane can also be used by some people with mobility limitations.

In addition, three frequently purchased accessories were priced.

Replacement cane elastics for the folding mobility canes

$0.30 each.

—163 were purchased at a price of

Roller tips used for some types of mobility canes (the cane slides on a ball bearing allowing continuous contact with the ground, providing an alternative method for way finding

—a sweeping motion rather than the more common tapping motion)

—163 of these were purchased at $11.00 each.

Flip-up ice spikes which replace grip bottoms on support canes

—166 were purchased at a price of $8.80 each.

T

ABLE

4

–8:

C

ANES

/

ACCESSORIES FOR THE BLIND

(2000-01$)

Product Number sold per year

Average price

Cost per year (in

2000-01)

Canes

Way Finding Canes

Support Canes

Accessories

For Way finding Canes:

Replacement cane plastics

Roller Tips

For Support Canes:

1,278

626

652

163

163

$21.78 $27,834.84

$20.00 $12,520.00

$23.50 $15,322.00

$0.30

$11.00

$48.90

$1,793.00

Ice Spikes (flip-up)

Sub total

166

1,770

$8.80

n/a

Note: Numbers may not sum exactly due to rounding.

$1,460.80

$31,144.70

4.4.2

W

RITING AIDS

/

STATIONERY

Writing and reading for the blind primarily uses the Braille system of embossed dot patterns. Braille embossers are devices designed to produce Braille writing on paper. They can be as simple as slates/frames and stylus or manual, Braille typewriters such as the Perkins Brailler. However, there are also more advanced computerized brailing devices such as the Mountbatten Brailler. There are also high speed computer Braille printers.

79

The cost of vision loss in Canada

4.4.2.1 B

RAILLE

S

LATES

/F

RAMES AND

S

TYLUSES

Braille slates/frames and stylus systems are used to manually emboss Braille dots. Braille slates are part of a frame such that a two-line slate can be stepped down a page with a hinge system to give a whole page of Braille. Plastic slates are lighter than metal ones but tend to have a lower life expectancy. Frames without hinges only work with a fixed size of paper, but are very popular as a highly portable note-taking device.

The stylus handle design significantly affects ease of use. The easier to use, large handle styluses, however, are less convenient to carry.

The weighted average price of the 16 slates commonly purchased at CNIB is $56.61. A total of 790 basic four-line plastic slates were sold at $6.50. However, this was the minimum price slate

– and prices varied to a maximum of $158.50 for a 28-line, full page, heavy duty metal slate.

The average price of the six CNIB styluses available at CNIB is $6.00. The ‘Erasable’ stylus is priced at $21.50.

4.4.2.2 B

RAILLE

T

YPEWRITERS

The average price of the five manual Perkins Braillers sold at CNIB is $1,393.20. The electric

Perkins Brailler is priced at $1,750.

4.4.2.3 N

OTE TAKERS

Note takers are computerized devices which have either standard or Braille-input keyboards. They usually have built-in speech output and/or Braille displays. They may be either palmtop or laptop devices. Standard-key note takers are used by persons with vision impairment, Braille note takers by persons who are blind.

Common features that come with note takers include word processing, diary, telephone directory, database and communications functions, and plugs which allow the user to connect peripheral devices such as printers, modems and Braille embossers.

The note taker available at CNIB provides a Braille-input keyboard and Braille display/computer output at a price of $5,365.

4.4.2.4 C

OMMON

S

TATIONERY

Three types of Braille paper were priced. Each is rawhide tag manila and regular weight, and contains approximately 250 sheets per package. The average price paid for 1,094 purchases of the best selling Braille paper was $24.34.

In addition, CNIB sells a number of Braille calendars. In 2000-01, 532 were sold at a price of $2.00.

80

The cost of vision loss in Canada

T

ABLE

4

–9:

W

RITING AND STATIONERY ITEMS

(2000-01$)

Product

Braille Paper (250 sheet package)

8.5 x 11 inches

11 x 11 inches

Computer paper, 12.5 x 11 Cerlox

Number sold per year

1,094

560

322

212

Average price

Cost per year (in

2000-01)

$24.34 $26,627.96

$14.25 $7,980.00

$17.75 $5,715.50

$61.00 $12,932.00

Embossing Sheets

Braille Calendar

1,319

532

$3.00

$2.00

$3,957.00

$1,064.00

Total 2,945 n/a $36,783.50

Note: Numbers may not sum exactly due to rounding.

4.4.3

V

ARIABLE SPEED TAPE RECORDERS

A total of 12 cassette recorders were available from CNIB at an average price of $263.33. Prices varied from a minimum of $62.50 for a portable to $528.50 for a large, desk-top model. Most prices were near or at the overall average.

4.4.4

C

OMPUTER VOICE SYNTHESIZER SOFTWARE

Five types of common computer software used by people who are blind are available from CNIB.

Three of these convert data from either a file or a screen display to voice.

The average price of this software was $1,328.33. Two also included scanning capacity and convert written documents to computer files, as well as providing a voice synthesizer. The average price of these two packages was $1,795. These software packages can also be used with electronic Braille display systems (see next sub-section).

4.4.5

E

LECTRONIC

B

RAILLE DISPLAY SYSTEMS

An electronic Braille display system is a device designed to present computer screen text as Braille.

A Braille display uses a series of electronic ‘pins’, which are either in the up or down position. Text on the screen is displayed as Braille through the pattern of up and down pins. Braille displays make excellent computer access devices for Braille-literate persons but are very expensive. The model available at CNIB is priced at $18,708.

4.4.6

T

ALKING TIME PIECES

Three types of time pieces were priced

—talking clocks, wrist watches and a talking key chain. All prices include batteries.

A total of 1,406 talking clocks were purchased in 2000 at an average price of $20.65. The cost of the four different devices ranged from a low of $14.95 to a high of $28.50.

In 2000, a total of 4,650 talking wrist watches were purchased, at an average price of $19.24. Four different brands were commonly sold, varying from a price of $9.00 to a high of $65.00. Price varies considerably with watch style and features. For example, the more expensive watches have a gold or silver casing and choice of alarm sounds, while the lower range watches are encased in plastic.

81

The cost of vision loss in Canada

Talking time-keeping key chains cost an average of $11.00 and in 2000, 1,652 were sold.

T

ABLE

4

–10:

T

ALKING TIME PIECES

(2000-01$)

Product Number sold per year

Average price

Cost per year

(in 2000-01)

Talking clocks

Talking wrist watches

Talking key chain

Total

1,278

4,650

1,652

$21.78

$19.24

$11.00

$27,834.84

$89,466.00

$18,172.00

7,580 n/a

Note: Numbers may not sum exactly due to rounding.

$135,472.84

4.4.7

S

UNGLASSES WITH NON

-

CORRECTIVE LENSES

A total of 4,570 regular sunglasses were sold by CNIB in 2000 at an average price of $12.35.

Sunglasses with UV protection were most popular. A total of 3,544 pairs were sold in 2000 at an average price of $13.00. The remaining 631 pairs of regular sunglasses were sold at $8.00.

T

ABLE

4

–11:

S

UNGLASSES WITH NON

-

CORRECTIVE LENSES

(2000-01$)

Product Number sold per year

Average price

Cost per year

(in 2000-01)

Sunglasses with UV protection

Regular sunglasses

Total

3,544

631

4,175

$13.00

$8.00

n/a

$46,072.00

$5,048.00

$51,120.00

4.4.8

H

AND HELD MAGNIFIERS

Magnifiers vary in strength and can come with small lights or ‘illuminators’. The average price of the

4,531 magnifiers sold in the year 2000 by CNIB was $33.70. At one end of the spectrum in this group are simply-designed, light, plastic magnifiers, which are priced in the $9.50-$14.50 range. At the other end are more solidly built models with glass lenses and/or illuminators, which are priced in the $43.50 to $50.00 range.

Magnifying sheets were also priced. These are plastic covers that fit over and magnify book or newspaper pages. A total of 2,180 sheets were sold in 2000 at a price of $2.20.

T

ABLE

4

–12:

H

AND HELD MAGNIFIERS

(2000-01$)

Product Number sold Average per year price

Cost per year (in 2000-01)

Magnifiers/hand readers

Total

4,521

4,521

$33.70

n/a

$152,357.70

$152,357.70

4.4.9

V

IDEO MAGNIFIERS

/CCTV

S

Screen magnifiers enlarge what is displayed on a computer monitor so people with vision problems can read the text on the screen. Closed Circuit Televisions (CCTVs) are devices that use a camera

82

The cost of vision loss in Canada to magnify printed text and images placed under it. These are then presented enlarged on a television screen or computer monitor.

CNIB has two electronic video magnifiers that connect to an ordinary TV. The black and white only magnifier is priced at $1,119, while the colour model costs $1,499. CNIB also has a number of full

CCTV systems, which include the monitor and TV screen and which can be connected to a computer. The average price of the black and white CCTVs offered is $2,875 and the colour CCTVs have an average price of $4,348.

4.4.10

S

CREEN MAGNIFICATION SOFTWARE

Screen magnification software significantly enlarges screen text and graphics to a size that a vision impaired users can easily view. CNIB offers two such products at an average price of $814.50

4.4.11

O

THER AIDS FOR THE SIGHT IMPAIRED

4.4.11.1 S

TATIONERY

Three different writing pads with bolded lines were priced. These pads include 100 white sheets of black thick lined writing paper. In total, 1,200 pads were purchased in 2000, each at $3.80. In addition, 10,829 large print calendars were purchased at a price of $2.00.

T

ABLE

4

–13:

O

THER STATIONERY

(2000-01$)

Product Number sold per year

Average price

Cost per year

(in 2000-01)

Writing pads

Large print calendars

Total

1,200

10,829

12,029

$3.80

$2.00

n/a

$4,560.00

$21,658.00

$26,218.00

4.4.11.2 L

ARGE BUTTON TELEPHONES

Two prices for large button telephones with high sales volumes were obtained from CNIB price list.

The first model phone also has speaker phone capacity. A total of 244 of these phones were sold in

2000 at a price of $33.00.

The second phone provides features for persons who are also hearing impaired

—a hearing aid attachment and an adjustable very loud ringer. In 2000, 226 of these were sold at $70.00.

83

The cost of vision loss in Canada

T

ABLE

4

–14:

L

ARGE BUTTON TELEPHONES

(2000-01$)

Product Number sold per year

Average price

Cost per year

(in 2000-01)

Phone with speaker phone capacity

Phone for hearing impaired

Total

244

226

470

$33.00

$70.00

n/a

$8,052.00

$15,820.00

$23,872.00

4.4.12

S

UMMARY OF AIDS AND DEVICES

Overall, available CNIB data on prices and volumes show that there was around $456,968.74 spent

on vision impairment-related aids and devices (Table 4

–15) in 2000-01. In today’s dollars that would

equate to around $524,046.72 (after inflating by the Consumer Price Index).

84

The cost of vision loss in Canada

T

ABLE

4

–15:

S

UMMARY OF AIDS AND DEVICES

(2000-01$)

Product Number sold per year

Average price

Cost per year

(in 2000-01)

Canes

Way Finding Canes

Support Canes

Accessories for Way Finding Canes

Replacement cane plastics

Roller Tips

Accessories for Support Canes

Ice Spikes (flip-up)

Sub total

1,278

626

652

163

163

166

1,770

790 Braille slates

Braille Paper (250 sheet package)

8.5 x 11 inches

11 x 11 inches

Computer paper, 12.5 x 11

Cerlox

Embossing Sheets

Braille Calendar

Sub total

1,094

560

322

212

1,319

532

2,945

Talking clocks

Talking Wrist Watches

Talking Key Chain

Sub total

Magnifiers/Hand Readers

3.5-4.4X magnifier

5X

–11X magnifier w/light

Sub total

Sunglasses with UV protection

Regular sunglasses

Sub total

Writing pads

Large print calendars

Sub total

Phone with speaker phone capacity

Phone for hearing impaired

Sub total

Total

1,278

4,650

1,652

7,580

244

226

470

4,521

1,514

1,076

4,521

3,544

631

4,175

1,200

10,829

12,029

$61.00

$3.00

$2.00

n/a

$21.78

$19.24

$11.00

n/a

$33.70

$32.52

$43.50

n/a

$13.00

$8.00

n/a

$3.80

$2.00

n/a

$21.78

$20.00

$23.50

$0.30

$11.00

$8.80

n/a

$6.50

$24.34

$14.25

$17.75

$33.00

$70.00

n/a

$27,834.84

$12,520.00

$15,322.00

$48.90

$1,793.00

$1,460.80

$31,144.70

$5,135.00

$26,627.96

$7,980.00

$5,715.50

$12,932.00

$3,957.00

$1,064.00

$36,783.50

$27,834.84

$89,466.00

$18,172.00

$135,472.84

$152,357.70

$49,235.28

$46,806.00

$152,357.70

$46,072.00

$5,048.00

$51,120.00

$4,560.00

$21,658.00

$26,218.00

$8,052.00

$15,820.00

$23,872.00

$456,968.74

The above data are supplemented by estimates of volumes data on: Braille slates/frames and styluses; Braille typewriters; note takers; variable speed tape recorders; computer voice synthesiser

85

The cost of vision loss in Canada software; electronic Braille display systems; video magnifiers/CCTVs; and screen magnification software. Volume data were estimated by using US usage per person data from Access Economics

(2006).

These additional devices added $15.1 million for CNIB clients, resulting in an overall total for CNIB aids and modifications of $15.6 million.

T

ABLE

4

–16:

E

STIMATES OF ADDITIONAL AIDS AND DEVICES

Product Number sold per year

Average price

Cost per year

(in 2000-01)

Stylus

Erasable stylus

Braille typewriter

Note takers

Variable speed tape recorders

Computer voice synthesisers

Electronic Braille display systems

Video magnifiers (black and white)

CCTVs (black and white)

Screen magnification software

Total

Total (inflated to 2007$)

835

835

835

835

835

281

281

281

281

281

6

21.5

1750

5365

263.33

1328.33

18708

1119

2875

814.5

$5,012

$17,959

$1,461,742

$4,481,282

$219,955

$372,977

$5,252,954

$314,200

$807,261

$228,701

$13,162,042

$15,094,084

Using an active CNIB client base of 42,000 people this translates to $371.86 per person with VL.

4.5

Multiplying this by the number of people with VL gives us a

total cost of aids and modifications of $303.9 million

. This cost has been allocated equally between individuals, family and friends, government, employment and society / other (health insurance entities).

SUMMARY OF OTHER FINANCIAL COSTS

In total,

the non-health related financial costs of VL are estimated to be around

$7.1 billion in 2007

.

T

ABLE

4

–17:

S

UMMARY OF OTHER FINANCIAL COSTS OF

VL, 2007

Productivity costs

Carer costs

Aids and modifications, funerals

DWL

Total other financial costs

$ million

4431

693

305

,1,757

7,186

86

The cost of vision loss in Canada

5.

BURDEN OF DISEASE

The main cost of VL is the loss of wellbeing and quality of life that it entails. Access Economics adopts ‘burden of disease’ methodology in order to quantify this substantial cost component. This methodology was developed by the World Health Organization, the World Bank and Harvard

University to comprehensively measure mortality and disability from diseases, injuries and risk factors in 1990, projected to 2020 (Murray and Lopez, 1996). The approach is non-financial, where pain, suffering and premature mortality are measured in terms of Disability Adjusted Life Years

(DALYs), with 0 representing a year of perfect health and 1 representing death (the converse of a

QALY or ‘quality-adjusted life year’ where 1 represents perfect health). The DALY approach has been successful in avoiding the subjectivity of individual valuation and is capable of overcoming the problem of comparability between individuals and between nations. This report treats the value of a life year as equal throughout the lifespan.

5.1

WILLINGNESS TO PAY AND THE VALUE OF A LIFE YEAR

5.1.1

M

EASURING BURDEN

: DALY

S

, YLL

S AND

YLD

S

In the last decade a non-financial approach to valuing human life has been derived, where loss of wellbeing and premature mortality

– called the ‘burden of disease and injury’ – are measured in terms of Disability Adjusted Life Years, or DALYs. This approach was developed by the World

Health Organization (WHO), the World Bank and Harvard University for a study that provided a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in

1990, projected to 2020 (Murray and Lopez, 1996). Methods and data sources are detailed further in

Murray et al (2001) and the WHO continues to revisit the estimates for later years.

A DALY of 0 represents a year of perfect health, while a DALY of 1 represents death. Other health states are attributed values between 0 and 1 as assessed by experts on the basis of literature and other evidence of the quality of life in relative health states. For example, the

disability weight

of 0.18 for a broken wrist can be interpreted as losing 18% of a person’s quality of life relative to perfect health, because of the inflicted injury. Total DALYs lost from a condition are the sum of the mortality and morbidity components

– the Year(s) of Life Lost due to premature death (YLLs) and the Year(s) of healthy life Lost due to Disability (YLDs).

The DALY approach has been successful in avoiding the subjectivity of individual valuation and is capable of overcoming the problem of comparability between individuals and between nations, although some nations have subsequently adopted variations in weighting systems, for example age-weighting for older people. This report treats the value of a life year as equal throughout the lifespan.

As these approaches are not financial, they are not directly comparable with most other cost and benefit measures. In public policy making, it is often desirable to apply a monetary conversion to ascertain the cost of an injury, disease or fatality or the value of a preventive health intervention, for example, in cost benefit analysis. Such financial conversions tend to utilise ‘willingness to pay’ or risk-based labour market studies as described in the next section.

5.1.2

W

ILLINGNESS TO PAY AND THE VALUE OF A STATISTICAL LIFE YEAR

The burden of disease as measured in DALYs can be converted into a dollar figure using an estimate of the

Value of a ‘Statistical’ Life

(VSL). As the name suggests, the VSL is an estimate of the value society plac es on an anonymous life. Since Schelling’s (1968) discussion of the

87

The cost of vision loss in Canada economics of life saving, the economic literature has focused on

willingness to pay

(WTP)

– or, conversely, willingness to accept (WTA)

– measures of mortality and morbidity, in order to develop estimates of the VSL.

Estimates may be derived from observing people’s choices in situations where they rank or trade off various states of wellbeing (loss or gain) either against each other or for dollar amounts eg, stated choice models of people’s WTP for interventions that enhance health or WTA poorer health outcomes or the risk of such states. Alternatively, risk studies use evidence of market trade-offs between risk and money, including numerous labour market and other studies (such as installing smoke detectors, wearing seatbelts or bike helmets and so on).

The extensive literature in this field mostly uses econometric analysis to value mortality risk and the

‘hedonic wage’ by estimating compensating differentials for on-the-job risk exposure in labour markets; in other words, determining what dollar amount would be accepted by an individual to induce him/her to increase the probability of death or morbidity by a particular percentage. Viscusi and Aldy (2002), in a summary of mortality studies, find the VSL ranges between US$4 million and

US$9 million with a median of US$7 million (in year 2000 US dollars), similar but marginally higher than the VSL derived from studies of US product and housing markets. They also review a parallel literature on the implicit value of the risk of non-fatal injuries.

Weaknesses in the WTP approach, as with human capital approaches to valuing life and wellbeing, are that there can be substantial variation between individuals. Extraneous influences in labour markets such as imperfect information, income/wealth or power asymmetries can cause difficulty in correctly perceiving the risk or in negotiating an acceptably higher wage in wage-risk trade off studies, for example.

As DALYs are enumerated in years of life rather than in whole lives it is necessary to calculate the

Value of a ‘Statistical’ Life Year (VSLY)

based on the VSL. This is done using the formula:

34

VSLY = VSL / Σ i=0,…,n-1

(1+r) i

Where: n = years of remaining life, and

r = discount rate.

Clearly there is a need to know

n

(the years of remaining life), and to determine an appropriate value for

r

(the discount rate). There is a substantial body of literature, which often provides conflicting advice, on the appropriate mechanism by which costs should be discounted over time, properly taking into account risks, inflation, positive time preference and expected productivity gains. In reviewing the literature, Access Economics (2008) found the most common rate used to discount healthy life was 3%, perhaps the most eminent sources being Nordhaus, 2002 (Yale); Murphy and

Topel, 2005 (University of Chicago); Cutler and Richardson, 1998 (Harvard); WHO, 2002; Aldy and

Viscusi, 2006). This report assumes a discount rate for future streams of health in Canada of 3%.

Further it is assumed that on average people have 40 years of life remaining.

35

34

The formula is derived from the definition:

VSL = ΣVSLYi/(1+r)^ i where i=0,1,2….n where VSLY is assumed to be constant (i.e. no variation with age).

35

This assumption relates to the average years of life remaining for people included in VSL studies, not the years of life remaining for people with VL.

88

The cost of vision loss in Canada

Access Economics (2008a) identified 16 Canadian VSL studies (Table 5

–1). Converting the study

findings into 2007 Canadian dollars, the average of VSL estimates was $4.66 million

36

. A discount rate of 3% was applied to calculate the 2007 Canadian VSLY at $195,837.

Authors

Belhadji

Meng and

Smith

Transport

Canada

Krupnick et al.

T

ABLE

5

–1:

V

ALUE OF A STATISTICAL LIFE IN

C

ANADIAN STUDIES

($

MILLION

)

Year Currency

1994 CAD

Study Area

Lowest estimate

Highest estimate

Single/ average estimate

1.2

VSL in

2007

$CAN

1.6

1990 USD

Transport

Occupational

Risk 1.2 2.1

1996 USD

2000 CAD

Transport 0.4 3.2 1.8

2.5

2.7

2.9

Viscusi

Alberini et al.

Alberini et al.

Meng and

Smith

Hara

Associates

Miller

Martinello and Meng

Dionne and

Lanoie

2005 USD

2002 USD

2002 USD

1999 USD

2000 USD

2000 USD

1992 USD

2002 CAD

Health

Occupational

Risk

Occupational

Risk

Occupational

Risk

Occupational

Risk

Health

Mixed

Occupational

Risk

3.9

0.5

1.3

1.7

2.1

4.7

0.9

3.7

5.7

3.1

2.4

2.4

2.4

2.4

2.4

2.5

3.1

4.7

3.0

3.3

3.3

3.4

3.5

3.6

5.1

5.3

Meng

Vodden et al.

Cousineau et al.

Bellavance et al.

Average

1989 USD

1994 CAD

1991 USD

2007 USD

Mixed

Occupational

Risk

Occupational

Risk

Occupational

Risk

Mixed

4.0

6.1

4.8

9.2

7.6

7.9

8.0

11.2

4.7

5.2

BURDEN OF DISEASE FROM VISION LOSS

5.2.1

D

ISABILITY WEIGHTS

Disability weights for mild, moderate and severe VL are based on the Dutch weights from the global burden of disease study (Murray and Lopez, 1996). These are:

36

Figures converted to $2007 Canadian using OECD Purchasing Power Parity rates. One additional study (Lanoie et al,

1995) was rejected as an outlier beyond reasonable parameters, given its VSL estimate was $37.5 million.

89

The cost of vision loss in Canada

0.020 for mild VL;

0.170 for moderate impairment; and

0.430 for severe impairment (blindness).

Section 1.2 presents the distribution of severity for each of the major eye diseases. To derive a total

for Canada, these individual disease distributions were weighted by their overall prevalence. This yields an average disability weighting for Canadian VL of 0.093.

The burden of disease is thus calculated on a prevalence basis from the prevalence estimates from

Section 2.4, together with disability weights, for the year 2007.

5.2.2

D

EATHS FROM

VL

The Australian Institute of Health and Welfare (Begg et al, 2007) estimates that in Australia in 2003, the visually impaired population numbered 510,761, and that the number of deaths due to that VL was 163. Given the number of visually impaired persons in Canada in 2007 is 817,171 on a pro-rata basis, the expected number of deaths caused by VL was 261.

5.2.3

Y

EARS OF LIFE LOST DUE TO DISABILITY

Based on the disability weight outlined above and the total number of people experiencing VL, the

YLD for VL has been calculated by gender (Table 5

–2), for the year 2007.

In total, YLD for VL was an estimated 75,891 DALYs in 2007.

T

ABLE

5

–2:

E

STIMATED YEARS OF HEALTHY LIFE LOST DUE TO DISABILITY

(YLD), 2007 (DALY

S

)

Estimated disability weight Prevalence YLD

Males

Females

0.093

0.093

340,097

476,854

31,572

44,268

5.2.4

Y

EARS OF LIFE LOST DUE TO PREMATURE DEATH

.

Based on the relative risk of mortality due to VL outlined above, it is estimated that there are around

261 deaths per year due to VL

. YLL were estimated from the age-gender distribution of deaths by the corresponding YLL for the age of death in the Standard Life Expectancy Table (West Level 26) with a discount rate of 3% and no age weighting.

In total, YLL for VL was an estimated 1,467 DALYs in 2007.

Males

Females

Persons

T

ABLE

5

–3:

Y

EARS OF LIFE LOST DUE TO PREMATURE DEATH

(YLL)

DUE TO

VL, 2007

15-29

0

0

0

30-39

0

0

0

40-49

4

2

6

50-59

22

15

37

60-69

58

38

96

70-79

181

153

334

80+

359

635

993

Total

623

844

1,467

90

The cost of vision loss in Canada

5.3

TOTAL DALYS DUE TO VL

The overall loss of wellbeing due to VL is estimated as 77,306 DALYs.

Figure 5-1 illustrates the YLD and YLL components by age and gender. The greatest impact of VL

is in old age, reflecting the physiology of VL and higher YLD due to the large number of Canadians with VL in this cohort.

F

IGURE

5-1: L

OSS OF WELLBEING DUE TO

VL (DALY

S

),

BY AGE AND GENDER

, 2007

16,000

14,000

12,000

Female YLL

Male YLL

Female YLD

Male YLD

10,000

8,000

6,000

4,000

2,000

0

Age Groups

Multiplying the number of DALYs by the VSLY ($195,837) provides an estimate of the dollar value of the loss of wellbeing due to VL.

The estimated gross cost of lost wellbeing from VL is $15.2 billion in 2007.

Bearing in mind that the wage-risk studies underlying the calculation of the VSL take into account all known personal impacts

– suffering and premature death, lost wages/income, out-of-pocket personal health costs and so on

– the estimate of $15.2 billion should be treated as a ‘gross’ figure.

However, costs specific to VL that are unlikely to have entered into the thinking of people in the source wage/risk studies should not be netted out (e.g. publicly financed health spending, care

provided voluntarily). The results after netting out are presented in Table 5

–4.

91

The cost of vision loss in Canada

T

ABLE

5

–4:

N

ET COST OF LOST WELLBEING

, $

MILLION

, 2007

Gross cost of wellbeing

Less health costs borne out-of-pocket

Less individual production losses net of tax

Less other indirect costs borne out-of-pocket

Plus transfers to people with VL

Net cost of lost wellbeing

The estimated net cost of lost wellbeing from VL is $11.7 billion in 2007.

15,200

1,499

2,847

61

917

11,710

92

The cost of vision loss in Canada

6.

SUMMARY

In 2007, the

financial cost of VL was $15.8 billion

(Table 6

–1). Of this:

$8.6 billion (54.6%) was direct health system expenditure;

$4.4 billion (28.0%) was productivity lost due to lower employment, absenteeism and premature death of Canadians with VL;

$1.8 billion (11.1%) was the DWL from transfers including welfare payments and taxation forgone;

$0.7 billion (4.4%) was the value of the care for people with VL; and

$305 million (1.9%) was other indirect costs such as aids and home modifications and the bring-forward of funeral costs.

Additionally,

the value of the lost wellbeing (disability and premature death) was a further

$11.7 billion

.

T

ABLE

6

–1:

VL,

TOTAL COSTS BY TYPE OF COST AND BEARER

, 2007

Burden of disease

Health system costs

Productivity costs

Carer costs

Other Indirect costs

Deadweight losses

Transfers

Total financial costs

Total costs including burden of disease

Individuals

11,710

1,499

2,847

0

61

0

-917

3,490

Family/

Friends

0

413

62

0

0

0

0

474

Federal

Government

Provincial

Governments

Total cost ($ million)

0

388

886

218

0

0

917

2,409

0

5,670

619

0

61

0

0

6,350

Employers

80

0

61

0

0

0

0

141

Society/

Other

0

1,081

0

62

61

1,757

2,960

0

Total

11,710.4

8,637.9

4,431.4

692.8

304.9

1,757.0

0

15,824

Burden of disease

Health system costs

Productivity costs

Carer costs

Other Indirect costs

Deadweight losses

Transfers

Total financial costs

Total costs including burden of disease

15,200

14,334

1,835

3,485

0

74

0

-1,122

4,272

18,606

474 2,409 6,350

Cost per person with visual impairment ($)

0

0

0

505

76

0

0

581

0

475

1,084

267

1,122

2,948

0

0

0

6,941

757

0

74

0

0

7,773

581 2,948 7,773

141

0

0

98

0

74

0

0

172

172

2,960

0

1,323

0

76

74

2,151

0

3,624

3,624

27,534

14,334

10,573

5,424

848

373

2,151

0

19,370

33,704

In per capita terms, this amounts to a financial cost of $19,370 per person with VL per annum.

Including the value of lost wellbeing, the cost is $33,704 per person per annum.

The shares by each type of financial cost are illustrated in Figure 6-1, while the financial cost shares by bearer are shown in Figure 6-2.

93

The cost of vision loss in Canada

F

IGURE

6-1: F

INANCIAL COSTS OF

VL,

BY TYPE OF COST

(%

TOTAL

)

DWL

11.1%

Indirect Costs

1.9%

Carer Costs

4.4%

Productivity Costs

28.0%

Health System Costs

54.6%

Individuals with VL bear 22.1% of the financial costs, and their families and friends bear a further

3.0%. Federal government bears 15.2% of the financial costs (mainly through taxation revenues forgone and welfare payments). Provincial governments bear 40.1% of the costs, reflecting the nature of Canada’s Federal system, while employers bear 0.9% and the rest of society bears the remaining 18.7%.

If the burden of disease (lost wellbeing) is included, individuals bear 55.2% of the costs and

Provincial governments bear 23.1% while the Federal government bears a lesser 8.7%, with family and friends 1.7%, employers 0.5% and others in society 10.8%.

F

IGURE

6-2: F

INANCIAL COSTS OF

VL,

BY BEARER

(%

TOTAL

)

Society/Other

18.7%

Individuals

22.1%

Employers

0.9%

Family/Friends

3.0%

Federal Government

15.2%

Provincial

Governments

40.1%

94

The cost of vision loss in Canada

As well as cost information, an important finding from this analysis was the observation that, for an advanced Western nation, Canada has a serious deficiency in eye health data. CNIB’s Health

Economic Statement (

http://www.costofblindness.org/media/health-state.asp

) observes that, with respect to blindness and vision loss

, there is ‘strong argument for saying that Canada has the worst record of supporting research of all the G8 countries’. The importance of good eye health to

Canadians is shown from survey data in the same document revealing that two-thirds of Canadians would cash in all their savings or sell everything they owned to save their eyesight. With a rapidly aging population, it is high time for a Canadian population eye health study to monitor incidence, prevalence and morbidity outcomes and economic impacts more robustly in the future.

95

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85+

The cost of vision loss in Canada

APPENDIX A: EDPRG PREVALENCE TABLES

Recognizing the need for national estimates of VL, Prevent Blindness America and the National Eye

Institute invited the principal investigators of several population-based vision studies to a meeting in

Fort Lauderdale, Florida, in May 2001, to standardize disease definitions and methods of data reporting so that available data from many of these studies might be analysed together.

Prevalence of eye disease and associated blindness and low vision were calculated based on studies from the US, Western Europe, the West Indies and Australia. The number of individuals with each disease and the total number in the respective populations were provided in five year age increments by age, gender and ethnicity for the adult population from each of the studies.

Prevalence rates were then combined using a meta-analysis technique for reducing the overall variance of the pooled rate.

T

ABLE

A-1: S

OURCE STUDIES FOR

EDRPG

DATA

Study and location B/VL RE AMD Cataract DR Glaucoma

Baltimore Eye Survey, US

Barbados Eye Studies, West Indies

Beaver Dam Eye Study, US

BMES, Australia

MVIP, Australia

Proyecto Vision Evaluation Research, US

Rotterdam Eye Study, The Netherlands

Salisbury Eye Evaluation Project, US

B W

W

W

W

H

W

B W

B W

W

H

W

B W

B

W

W

W

W

B W

B

W

W

W

B W

Note: B = Black, H = Hispanic, W = White, B/VL = Blindness / VL

Source: Congdon et al (2004a).

B

W

W

W

H

B W

W

W

W

H

W

Age

T

ABLE

A-2: P

REVALENCE OF

AMD

BY AGE

,

GENDER AND WHITE

/

BLACK

(%

POPULATION

)

White Female White Male Black Female Black Male

0.2

0.2

0.4

0.7

1.5

3.2

6.8

13.6

0.3

0.4

0.6

1.1

2.1

3.9

6.9

12.0

0.9

1.1

1.4

1.7

2.1

2.5

2.9

3.3

0.2

0.4

0.6

0.9

1.5

2.4

3.8

5.9

96

The cost of vision loss in Canada

Age

T

ABLE

A-3: P

REVALENCE OF CATARACT BY AGE

,

GENDER AND WHITE

/

BLACK

(%

POPULATION

)

White Female White Male Black Female Black Male

40-49

50-54

55-59

60-64

65-69

70-74

75-79

80+

1.8

5.0

9.4

16.8

27.5

40.8

54.5

72.9

2.8

4.9

8.2

13.8

22.4

34.0

47.2

67.2

2.2

7.3

12.8

20.0

28.5

37.4

46.1

58.2

1.7

4.5

7.6

11.9

17.5

24.1

31.3

43.3

Age

T

ABLE

A-4: P

REVALENCE OF

DR

BY AGE

,

GENDER AND WHITE

/

BLACK

(%

POPULATION

)

White Female White Male Black Female Black Male

40-49

50-54

55-59

60-64

65-69

70-74

75-79

80+

18-39

40-49

50-64

65-74

75+

1.1

1.9

3.3

5.3

5.2

0.7

1.5

4.2

7.6

5.3

0.8

1.9

6.3

6.8

5.8

0.6

1.9

4.3

4.2

4.9

Age

T

ABLE

A-5: P

REVALENCE OF

G

LAUCOMA BY AGE

,

GENDER AND WHITE

/

BLACK

(%

POPULATION

)

White Female White Male Black Female Black Male

0.8

0.9

1.0

1.2

1.6

2.2

3.3

6.9

0.4

0.6

0.8

1.2

1.7

2.3

3.2

5.5

2.3

3.0

3.5

4.1

4.8

5.6

6.5

8.3

1.5

2.2

2.9

3.7

4.8

6.2

7.9

11.6

97

The cost of vision loss in Canada

Age

T

ABLE

A-6: P

REVALENCE OF

M

YOPIA BY AGE

,

GENDER AND WHITE

/

BLACK

(%

POPULATION

)

White Female White Male Black Female Black Male

40-49

50-54

55-59

60-64

65-69

70-74

75-79

80+

46.4

30.3

23.7

19.4

16.8

15.5

15.2

16.8

37.0

26.2

22.0

19.4

17.9

17.5

18.0

21.1

18.4

13.2

11.4

10.3

9.8

9.9

10.4

12.7

22.5

16.3

13.1

10.4

8.1

6.3

4.9

3.1

Age

T

ABLE

A-7: P

REVALENCE OF

H

YPEROPIA BY AGE

,

GENDER AND WHITE

/

BLACK

(%

POPULATION

)

White Female White Male Black Female Black Male

40- 49

50-54

55-59

60-64

65-69

70-74

75-79

80 +

40-49

50-54

55-59

60-64

65-69

70-74

75-79

80+

3.7

7.4

10.5

14.1

17.9

21.6

24.7

28.0

3.6

6.4

8.7

11.4

14.2

17.1

19.9

23.5

3.1

5.4

7.1

8.9

10.6

12.0

13.1

13.6

2.2

3.3

3.8

3.9

3.8

3.3

2.6

1.5

Age

T

ABLE

A-8: P

REVALENCE OF ALL

VL

BY AGE

,

GENDER AND WHITE

/

BLACK

(%

POPULATION

)

White Female White Male Black Female Black Male

0.3

0.4

0.5

0.7

1.2

2.3

4.8

24.1

0.3

0.3

0.4

0.6

1.0

1.9

4.0

20.2

0.1

0.4

0.7

1.3

2.4

4.2

7.0

15.1

0.3

0.7

1.2

2.2

3.8

6.4

10.4

23.7

98

The cost of vision loss in Canada

Age

T

ABLE

A-9: P

REVALENCE OF MILD

VL

BY AGE

,

GENDER AND WHITE

/

BLACK

(%

POPULATION

)

White Female White Male Black

40-49

50-54

55-59

60-64

65-69

70-74

75-79

80 +

0.2

0.2

0.3

0.4

0.7

1.3

2.8

12.3

0.1

0.2

0.2

0.3

0.6

1.0

2.2

9.5

0.0

0.1

0.3

0.6

1.2

2.3

3.8

7.7

T

ABLE

A-10: P

REVALENCE OF MODERATE

VL

BY AGE

,

GENDER AND WHITE

/

BLACK

(%

POPULATION

)

Age White Female White Male Black

40-49

50-54

55-59

60-64

65-69

70-74

75-79

80 +

40-49

50-54

55-59

60-64

65-69

70-74

75-79

80 +

0.1

0.1

0.1

0.2

0.3

0.5

1.1

4.9

0.1

0.1

0.1

0.1

0.2

0.4

0.9

3.8

0.0

0.1

0.1

0.3

0.5

0.9

1.5

3.1

Age

T

ABLE

A-11: P

REVALENCE OF BLINDNESS BY AGE

,

GENDER AND WHITE

/

BLACK

(%

POPULATION

)

White Female White Male Black Female Black Male

0.1

0.1

0.1

0.2

0.2

0.4

0.9

6.8

0.1

0.1

0.1

0.2

0.2

0.4

0.9

6.8

0.1

0.2

0.3

0.4

0.7

1.1

1.7

4.2

0.3

0.5

0.8

1.3

2.0

3.2

5.1

12.8

99

The cost of vision loss in Canada

APPENDIX B: PREVALENCE PROJECTIONS BY AGE, GENDER

AND DISEASE

T

ABLE

B-1: A

LL

VL

BY AGE AND GENDER

, 2007-2032

SELECTED YEARS

(

PEOPLE

)

2007

28,842

22,096

36,555

38,920

59,237

60,526

42,877

19,296

340,097

2.1%

41.6%

0

0

0

0

49

347

345

205

9,469

5,166

17,390

29,942

23,148

37,979

44,041

75,270

94,066

85,336

54,101

476,854

2.9%

58.4%

0

0

0

0

86

24

24

87

9,577

5,028

16,924

0

0

0

0

135

371

369

292

19,046

10,193

34,315

58,784

45,245

74,534

82,961

134,507

154,591

128,212

73,397

816,951

2.49%

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

Total males

% of males

% of total prevalence

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

Total females

% of females

% of total prevalence

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

Total persons

% of total population

2010

30,861

25,511

41,772

40,874

60,658

65,860

49,695

22,356

369,458

2.2%

42.0%

0

0

0

0

53

381

377

223

8,388

5,202

18,376

32,271

26,902

43,143

46,199

75,476

96,399

95,603

60,609

509,602

3.0%

58.0%

0

0

0

0

93

26

26

94

8,465

5,090

18,076

0

0

0

0

147

407

403

318

16,853

10,292

36,452

63,132

52,413

84,915

87,073

136,134

162,258

145,298

82,965

879,059

2.63%

2015

35,009

28,515

54,331

50,178

64,591

72,030

61,082

27,469

424,576

2.5%

42.8%

0

0

0

0

61

442

435

256

7,904

4,429

18,850

36,151

30,400

56,520

56,063

79,852

99,527

108,488

68,785

568,162

3.2%

57.2%

0

0

0

0

108

31

30

108

8,009

4,278

18,808

2020

36,928

32,472

61,212

65,545

80,323

78,328

70,652

31,774

485,355

2.7%

43.3%

0

0

0

0

70

512

502

295

7,997

4,239

15,750

37,614

34,116

64,140

73,219

97,566

106,756

117,435

74,469

634,679

3.5%

56.7%

0

0

0

0

124

35

35

125

8,056

4,076

15,672

2025

32,110

34,337

70,126

74,498

106,150

98,929

80,104

36,029

559,828

3.0%

43.7%

0

0

0

0

81

589

579

340

8,149

4,343

14,869

32,816

35,531

72,227

83,586

128,058

131,653

128,081

81,229

722,129

3.8%

56.3%

0

0

0

0

143

41

40

144

8,194

4,128

14,856

0

0

0

0

169

473

465

364

15,912

8,707

37,658

71,159

58,915

110,851

106,241

144,443

171,557

169,570

96,254

992,738

2.86%

0

0

0

0

195

547

537

420

16,053

8,315

31,421

74,541

66,587

125,352

138,764

177,889

185,084

188,087

106,243

1,120,033

3.10%

0

0

0

0

224

630

619

484

16,342

8,470

29,725

64,925

69,868

142,353

158,084

234,208

230,582

208,185

117,258

1,281,957

3.43%

0

0

0

0

270

762

749

587

15,806

8,672

30,475

63,620

59,987

143,616

187,186

286,541

323,928

284,515

159,390

1,566,103

4.01%

2032

31,493

29,488

71,676

89,502

130,352

140,017

113,655

51,054

684,941

3.6%

43.7%

0

0

0

0

98

712

701

413

7,902

4,471

15,320

32,127

30,500

71,940

97,684

156,188

183,910

170,860

108,336

881,162

4.5%

56.3%

0

0

0

0

172

49

48

174

7,903

4,200

15,155

100

The cost of vision loss in Canada

T

ABLE

B-2: VL

FROM

AMD

BY AGE AND GENDER

, 2007-2032

SELECTED YEARS

(

PEOPLE

)

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

Total males

% of males

% of total prevalence

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

Total females

% of females

% of total prevalence

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

Total persons

% of total population

1,427

8,402

9,190

20,702

17,227

57,536

0

589

0

0

0

0

0

0

0

0

0

0

0

0

0.3%

64.6%

0

1,108

0

0

2,659

15,189

15,351

31,279

23,437

89,022

0.27%

0

0

0

0

0

0

0

0

0

0

2007

519

1,232

6,787

0

0

0

0

0

0

0

0

6,161

10,577

6,210

31,486

0.2%

35.4%

0

0

0

0

0

1,826

8,951

9,777

26,315

21,889

69,615

0

857

0

0

0

0

0

0

0

0

0

0

0

0

0.4%

62.9%

0

1,619

0

0

3,416

16,413

17,155

41,366

30,730

110,700

0.32%

0

0

0

0

0

0

0

0

0

0

2015

762

1,591

7,462

0

0

0

0

0

0

0

0

7,377

15,051

8,841

41,084

0.2%

37.1%

0

0

0

0

0

1,511

8,441

9,436

23,193

19,300

62,546

0

666

0

0

0

0

0

0

0

0

0

0

0

0

0.4%

64.1%

0

1,257

0

0

2,815

15,414

16,148

35,445

26,495

97,573

0.29%

0

0

0

0

0

0

0

0

0

0

2010

591

1,304

6,973

0

0

0

0

0

0

0

0

6,712

12,251

7,195

35,027

0.2%

35.9%

0

0

0

0

0

2,341

10,926

10,513

28,477

23,675

76,908

0

977

0

0

0

0

0

0

0

0

0

0

0

0

0.4%

61.6%

0

1,839

0

0

4,385

20,175

18,574

45,888

33,901

124,761

0.35%

0

0

0

0

0

0

0

0

0

0

2020

861

2,044

9,249

0

0

0

0

0

0

0

0

8,061

17,411

10,226

47,853

0.3%

38.4%

0

0

0

0

0

0

1,104

0

0

0

0

0

0

0

0

0

0

2,675

14,304

12,938

31,053

25,806

87,880

0

0

0.5%

60.7%

0

2,092

0

0

5,003

26,452

23,053

50,796

37,402

144,797

0.39%

0

0

0

0

0

0

0

0

0

0

2025

987

2,327

12,148

0

0

0

0

0

0

0

0

10,115

19,743

11,596

56,917

0.3%

39.3%

0

0

0

0

0

2032

1,027

2,799

14,909

0

0

0

0

0

0

0

0

14,179

27,961

16,435

77,309

0.4%

40.1%

0

0

0

0

0

0

1,140

0

0

0

0

0

0

0

0

0

0

3,144

17,443

18,004

41,440

34,465

115,636

0

0

0.6%

59.9%

0

2,167

0

0

5,943

32,351

32,183

69,402

50,900

192,945

0.49%

0

0

0

0

0

0

0

0

0

0

101

The cost of vision loss in Canada

T

ABLE

B-3: VL

FROM CATARACT BY AGE AND GENDER

, 2007-2032

SELECTED YEARS

(

PEOPLE

)

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

Total males

% of males

% of total prevalence

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

Total females

% of females

% of total prevalence

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

Total persons

% of total population

0

0

0

0

2,101

318

2,800

11,012

22,374

39,034

35,836

31,793

145,268

0.44%

0

0

0

0

0

0

0

158

1,547

6,301

12,810

23,614

23,716

23,288

92,480

0.5%

0

1,046

0

0

0

0

0

0

0

0

0

0

63.7%

2010

0

0

1,055

160

1,254

4,711

9,564

15,420

12,121

8,505

52,789

0

0

0

0

0

0

0

0

0

0.3%

36.3%

0

0

0

0

1,947

279

2,473

10,325

21,970

37,077

31,632

28,133

133,836

0.41%

0

0

0

0

0

0

0

138

1,371

5,892

12,651

22,914

21,170

20,788

85,891

0.5%

0

967

0

0

0

0

0

0

0

0

0

0

64.2%

2007

0

0

980

141

1,102

4,434

9,319

14,164

10,462

7,344

47,945

0

0

0

0

0

0

0

0

0

0.3%

35.8%

0

0

0

0

2,385

365

3,577

13,308

23,932

41,544

41,841

36,903

163,856

0.47%

0

0

0

0

0

0

0

182

1,969

7,581

13,715

24,641

26,949

26,457

102,673

0.6%

0

1,180

0

0

0

0

0

0

0

0

0

0

62.7%

2015

0

0

1,205

183

1,608

5,727

10,217

16,903

14,893

10,446

61,183

0

0

0

0

0

0

0

0

0

0.4%

37.3%

0

0

0

0

2,335

455

4,637

19,228

38,284

55,824

51,464

45,032

217,259

0.58%

0

0

0

0

0

0

0

225

2,550

10,912

21,597

32,627

31,930

31,328

132,307

0.7%

0

1,139

0

0

0

0

0

0

0

0

0

0

60.9%

2025

0

0

1,196

230

2,087

8,316

16,687

23,197

19,534

13,704

84,952

0

0

0

0

0

0

0

0

0

0.5%

39.1%

0

0

0

0

2,542

417

4,071

16,831

29,351

45,037

46,459

40,773

185,482

0.51%

0

0

0

0

0

0

0

207

2,251

9,534

16,672

26,616

29,233

28,689

114,448

0.6%

0

1,247

0

0

0

0

0

0

0

0

0

0

61.7%

2020

0

0

1,295

210

1,821

7,298

12,678

18,421

17,227

12,084

71,034

0

0

0

0

0

0

0

0

0

0.4%

38.3%

0

0

0

0

2,400

460

4,882

22,902

46,801

77,754

70,148

61,081

286,428

0.73%

0

0

0

0

0

0

0

226

2,692

12,897

26,318

45,067

42,468

41,688

172,519

0.9%

0

1,163

0

0

0

0

0

0

0

0

0

0

60.2%

2032

0

0

1,237

234

2,190

10,005

20,483

32,688

27,680

19,393

113,910

0

0

0

0

0

0

0

0

0

0.6%

39.8%

102

The cost of vision loss in Canada

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

Total males

% of males

% of total prevalence

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

Total females

% of females

% of total prevalence

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

Total persons

% of total population

T

ABLE

B-4: VL

FROM

DR

BY AGE AND GENDER

, 2007-2032

SELECTED YEARS

(

PEOPLE

)

0

2,493

2,595

2,196

1,208

2,931

3,474

2,174

1,057

0

61

0

0

442

435

256

254

289

1,245

21,112

0.1%

57.2%

0

4,658

4,820

4,292

2,333

5,342

6,039

3,428

1,506

0

169

0

0

473

465

364

362

358

2,290

36,897

0.11%

2015

0

2,164

2,225

2,096

1,124

2,411

2,566

1,254

449

0

108

31

30

0

0

108

108

69

1,045

15,786

0.1%

42.8%

0

2,177

2,255

1,738

1,006

2,704

3,334

1,911

929

0

53

381

377

0

0

223

223

252

1,184

18,746

0.1%

57.7%

0

4,060

4,212

3,403

1,940

4,917

5,664

2,934

1,296

0

147

407

403

0

0

318

317

312

2,182

32,509

0.10%

2010

0

1,883

1,957

1,665

933

2,212

2,330

1,023

367

94

94

60

998

0

93

26

26

0

0

13,763

0.1%

42.3%

0

1,997

1,971

1,544

937

2,643

3,237

1,706

829

0

49

347

345

0

0

205

206

232

1,112

17,360

0.1%

58.0%

0

3,737

3,688

3,015

1,805

4,769

5,376

2,591

1,147

0

135

371

369

0

0

292

293

287

2,045

29,920

0.09%

2007

0

1,740

1,717

1,472

869

2,125

2,138

886

318

87

87

55

933

0

86

24

24

0

0

12,560

0.1%

42.0%

0

2,719

2,954

2,515

1,507

3,545

3,749

2,363

1,149

0

70

0

0

512

502

295

293

333

1,123

23,630

0.1%

57.0%

0

5,081

5,505

4,904

2,904

6,497

6,556

3,814

1,669

0

195

0

0

547

537

420

417

413

2,012

41,471

0.11%

2020

0

2,362

2,551

2,389

1,397

2,953

2,807

1,451

519

0

124

35

35

0

0

125

124

79

889

17,840

0.1%

43.0%

0

2,697

3,198

2,854

1,726

4,529

4,599

2,585

1,257

0

81

0

0

589

579

340

338

384

1,122

26,877

0.1%

56.9%

0

4,989

5,970

5,594

3,322

8,318

8,115

4,231

1,847

0

224

0

0

630

619

484

481

475

1,978

47,277

0.13%

2025

0

2,292

2,772

2,740

1,596

3,789

3,516

1,647

590

0

143

41

40

0

0

144

143

91

856

20,400

0.1%

43.1%

2032

0

2,467

2,706

2,977

1,923

4,639

4,913

2,310

822

0

172

49

48

0

0

174

173

110

888

24,373

0.1%

43.1%

0

2,946

3,197

3,057

2,045

5,514

6,362

3,428

1,667

0

98

0

0

712

701

413

410

465

1,217

32,230

0.2%

56.9%

0

5,413

5,903

6,034

3,968

10,153

11,275

5,738

2,489

0

270

0

0

762

749

587

584

575

2,104

56,603

0.15%

103

The cost of vision loss in Canada

T

ABLE

B-5: VL

FROM

G

LAUCOMA BY AGE AND GENDER

, 2007-2032

SELECTED YEARS

(

PEOPLE

)

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

Total males

% of males

% of total prevalence

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

Total females

% of females

% of total prevalence

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

Total persons

% of total population

0

1,614

1,525

0

0

0

0

0

0

0

0

0

0

0

0

2,018

6,145

3,965

2,083

17,349

0.1%

57.1%

0

3,469

3,348

3,520

10,834

6,255

2,943

30,368

0.09%

0

0

0

0

0

0

0

0

0

0

0

0

2015

0

0

1,855

1,824

1,502

0

0

4,689

2,291

860

13,020

0

0

0

0

0

0

0

0

0

0.1%

42.9%

0

1,245

1,260

0

0

0

0

0

0

0

0

0

0

0

0

1,880

5,965

3,495

1,836

15,680

0.1%

58.3%

0

2,705

2,766

3,282

10,241

5,360

2,537

26,891

0.08%

0

0

0

0

0

0

0

0

0

0

0

0

2010

0

0

1,460

1,506

1,402

0

0

4,276

1,865

701

11,211

0

0

0

0

0

0

0

0

0

0.1%

41.7%

0

1,099

1,194

0

0

0

0

0

0

0

0

0

0

0

0

1,853

5,828

3,119

1,639

14,731

0.1%

59.1%

0

2,386

2,605

3,217

9,755

4,730

2,244

24,937

0.08%

0

0

0

0

0

0

0

0

0

0

0

0

2007

0

0

1,288

0

0

1,410

1,364

3,928

1,611

605

10,206

0

0

0

0

0

0

0

0

0

0.1%

40.9%

0

1,836

1,971

0

0

0

0

0

0

0

0

0

0

0

0

2,450

6,581

4,290

2,253

19,381

0.1%

56.3%

0

3,944

4,268

4,311

11,693

6,940

3,248

34,403

0.10%

0

0

0

0

0

0

0

0

0

0

0

0

2020

0

0

2,107

2,297

1,860

0

0

5,112

2,650

995

15,021

0

0

0

0

0

0

0

0

0

0.1%

43.7%

0

2,072

2,251

0

0

0

0

0

0

0

0

0

0

0

0

3,165

8,126

4,677

2,457

22,749

0.1%

55.8%

0

4,489

4,872

5,607

14,561

7,683

3,585

40,797

0.11%

0

0

0

0

0

0

0

0

0

0

0

0

2025

0

0

2,417

2,621

2,441

0

0

6,435

3,005

1,129

18,047

0

0

0

0

0

0

0

0

0

0.1%

44.2%

0

4,692

5,794

6,852

20,441

10,494

4,873

53,147

0.14%

0

0

0

0

0

0

0

0

0

0

0

0

0

2,109

2,639

0

0

0

0

0

0

0

0

0

0

0

0

3,857

11,379

6,243

3,280

29,507

0.1%

55.5%

2032

0

0

2,584

3,155

2,996

0

0

9,062

4,251

1,593

23,641

0

0

0

0

0

0

0

0

0

0.1%

44.5%

104

The cost of vision loss in Canada

T

ABLE

B6: VL

FROM

RE

BY AGE AND GENDER

, 2007-2032

SELECTED YEARS

(

PEOPLE

)

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

80-84

85-89

90+

Total males

% of males

% of total prevalence

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

Total females

% of females

% of total prevalence

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

Total persons

% of total population

0

16,536

9,980

34,270

56,971

47,884

74,750

68,540

90,147

91,171

65,724

20,845

576,817

1.73%

0

0

0

0

0

0

0

29,048

24,489

37,948

36,121

49,641

54,050

43,288

15,256

320,149

1.9%

8,165

4,950

17,193

0

0

0

0

0

0

0

0

55.5%

2010

0

17,078

27,923

23,395

36,802

32,419

40,506

37,121

22,435

5,589

256,668

8,371

5,030

0

0

0

0

0

0

0

1.6%

44.5%

0

18,753

9,907

32,269

53,100

41,278

65,552

65,567

89,362

87,032

57,980

18,436

539,236

1.64%

0

0

0

0

0

0

0

26,978

21,039

33,378

34,592

49,720

52,897

38,638

13,617

301,336

1.8%

9,264

4,934

16,278

0

0

0

0

0

0

0

0

55.9%

2007

0

15,991

26,122

20,239

32,174

30,975

39,642

34,134

19,342

4,819

237,900

9,490

4,973

0

0

0

0

0

0

0

1.5%

44.1%

0

15,551

8,349

35,368

64,116

53,731

97,893

83,835

95,236

95,986

76,680

24,172

650,917

1.87%

0

0

0

0

0

0

0

32,477

27,623

49,883

43,923

52,237

55,491

49,086

17,299

357,414

2.0%

7,649

4,140

17,605

0

0

0

0

0

0

0

0

54.9%

2015

0

17,763

31,639

26,108

48,010

39,912

42,999

40,495

27,594

6,873

293,503

7,901

4,209

0

0

0

0

0

0

0

1.7%

45.1%

0

15,862

7,996

27,748

57,601

63,443

125,542

125,659

155,547

129,029

94,010

29,391

831,827

2.23%

0

0

0

0

0

0

0

28,979

32,108

63,647

66,021

84,462

73,363

57,836

20,381

452,316

2.4%

7,811

3,959

13,748

0

0

0

0

0

0

0

0

54.4%

2025

0

14,000

28,622

31,334

61,895

59,638

71,084

55,665

36,174

9,011

379,511

8,051

4,037

0

0

0

0

0

0

0

2.1%

45.6%

0

15,636

7,902

29,409

66,918

60,665

110,594

110,376

117,555

103,224

84,986

26,652

733,916

2.03%

0

0

0

0

0

0

0

33,647

30,954

56,561

57,867

63,972

59,297

53,073

18,703

400,310

2.2%

7,704

3,905

14,626

0

0

0

0

0

0

0

0

54.5%

2020

0

14,783

33,271

29,711

54,033

52,508

53,583

43,927

31,913

7,949

333,606

7,932

3,997

0

0

0

0

0

0

0

1.9%

45.5%

0

15,222

8,097

28,371

55,806

53,624

125,841

148,580

190,383

182,275

128,734

40,047

976,979

2.50%

0

0

0

0

0

0

0

28,018

27,077

62,943

76,960

103,057

103,099

77,281

27,235

531,271

2.7%

7,492

4,007

14,103

0

0

0

0

0

0

0

0

54.4%

2032

0

14,268

27,788

26,547

62,898

71,620

87,326

79,176

51,454

12,812

445,709

7,730

4,090

0

0

0

0

0

0

0

2.3%

45.6%

105

The cost of vision loss in Canada

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