Economic burden of blindness and visual impairment in Germany from a societal perspective: a cost-of-illness study

  • Yuliya Chuvarayan
  • Robert P. Finger
  • Juliane Köberlein-NeuEmail author
Original Research



Visual impairment and blindness cause a considerable and increasing economic burden affecting not only persons with vision loss and their families, but also societies. For the majority of countries, there is no solid database that would allow a comprehensive assessment of costs from a societal perspective. The present study was conducted to fill this gap.


To investigate resource utilization of blind or visually impaired people and to assess the economic burden of blindness and visual impairment in Germany.


This cross-sectional cost-of-illness study measures the economic burden of blindness and visual impairment bottom-up and from a societal perspective. Therefore, blind and visually impaired persons were recruited via national self-help organizations (prevalence-based approach) and interviewed regarding their utilized resources using various survey modes (mixed-mode approach). The observation period was 6 months retrospectively. Utilized resources were valued applying standardized unit costs (macro-costing). Calculations for the study population provided direct and indirect costs per person for a period of 6 months. Further cost per category was extrapolated to 1 year for the general population of Germany. Uncertainty of results was addressed applying univariate deterministic sensitivity analyses.


Complete data were collected from 683 participants (54.84% women; average age: 60.28 ± 17.02 years). Decreasing vision was associated with increasing costs (p < 0.001). Most costs were incurred by informal support from relatives, which was the most important resource for coping with everyday life for people with visual loss. Together with assistive/medical devices and loss of productivity due to disability, informal support accounted for 80% of total costs. Extrapolated to Germany, the annual costs of blindness and visual impairment from a societal perspective amounted to € 49.6 billion. Results of the sensitivity analyses and 95% confidence intervals showed a considerable degree of uncertainty.


Visual impairment and blindness may cause enormous overall costs from a societal point of view, as shown here for Germany. Our findings on the costs of blindness and visual impairment in Germany add in a number of different ways to the international evidence. In particular, results show that a large proportion of the costs are not obvious per se as it is caused by self-paid deductibles, productivity loss, early retirement and informal support/care by relatives. Further research should make special efforts to investigate these costs precisely as well as their influence factors.


Blindness Visual impairment Costs Cost of illness Societal perspective 

JEL Classification




The authors thank Fabian Steinbach for his help with the project coordination as well as for the organization of the survey and Verena Maschke for her support during the data entry. Special thanks are due to the DBSV, in particular Volker Lenk, Christiane Moeller and Andreas Bethke, for the enriching discussions and valuable comments in the context of the questionnaire tests as well as the critical revision of the manuscript. The authors also thank the Deutscher Verein der Blinden und Sehbehinderten in Studium und Beruf e.V. (DVBS) (the German association of blinds and visually impaired in studies and occupation registered association), the AMD-Netz NRW e.V. (Alltersabhaengige Makuladegeneration-Netz Nordrhein-Westfalen e.V.) (age-related macular degeneration net North Rhine-Westphalia registered association) and PRO RETINA Germany e.V., which made the dispatch of the study documents through their club magazine possible, the Berufsfoerderungswerk Düren gem. GmbH (engl.: vocational training center of the City Dueren) for their intensive evaluation of the online questionnaire and the SFZ Chemnitz for conducting the personal telephone interviews.


This work was supported by the Jackstaedt-Stiftung and Novartis Pharma GmbH (Grand numbers Date_09072014 and Date_26112014). The funders had no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript. No payment was received by any external funder or outside source for the writing of this manuscript.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Informed consent

The study was approved by the responsible ethics committee of the University of Wuppertal prior to beginning of the study. All participants were informed about anonymity and voluntarily participation. Participants, who chose the paper–pencil or online version of our questionnaire, provided their implicit informed consent during the recruitment phase by agreeing to participate and by sending back the anonymous questionnaire. Respondents answering via personal telephone interview gave explicit informed consent during the recruitment phase by agreeing to participate and providing a telephone number for a re-call. The personally identifying information was not stored and participant responses were anonymized prior to analysis.

Supplementary material

10198_2019_1115_MOESM1_ESM.docx (205 kb)
Supplementary material 1 (DOCX 205 kb)
10198_2019_1115_MOESM2_ESM.docx (26 kb)
Supplementary material 2 (DOCX 26 kb)
10198_2019_1115_MOESM3_ESM.docx (28 kb)
Supplementary material 3 (DOCX 27 kb)
10198_2019_1115_MOESM4_ESM.docx (17 kb)
Supplementary material 4 (DOCX 17 kb)
10198_2019_1115_MOESM5_ESM.docx (28 kb)
Supplementary material 5 (DOCX 27 kb)
10198_2019_1115_MOESM6_ESM.docx (21 kb)
Supplementary material 6 (DOCX 20 kb)
10198_2019_1115_MOESM7_ESM.docx (88 kb)
Supplementary material 7 (DOCX 88 kb)


  1. 1.
    Chakravarthy, U., Biundo, E., Saka, R.O., Fasser, C., Bourne, R., Little, J.-A.: The economic impact of blindness in Europe. Ophthalmic Epidemiol. 24(4), 239–247 (2017). Google Scholar
  2. 2.
    Finger, R.P., Fimmers, R., Holz, F.G., Scholl, H.P.N.: Incidence of blindness and severe visual impairment in Germany: projections for 2030. Invest. Ophthalmol. Vis. Sci. 52(7), 4381–4389 (2011). Google Scholar
  3. 3.
    Finger, R.P., Fimmers, R., Holz, F.G., Scholl, H.P.N.: Prevalence and causes of registered blindness in the largest federal state of Germany. Br. J. Ophthalmol. 95(8), 1061–1067 (2011). Google Scholar
  4. 4.
    Schwander, B.: Early health economic evaluation of the future potential of next generation artificial vision systems for treating blindness in Germany. Health economics Rev. 4(1), 27 (2014). Google Scholar
  5. 5.
    Kawasaki, R., Akune, Y., Hiratsuka, Y., Fukuhara, S., Yamada, M.: Cost-utility analysis of screening for diabetic retinopathy in Japan: a probabilistic Markov modeling study. Ophthalmic Epidemiol. 22(1), 4–12 (2015). Google Scholar
  6. 6.
    Köberlein, J., Beifus, K., Schaffert, C., Finger, R.P.: The economic burden of visual impairment and blindness: a systematic review. BMJ Open 3(11), e003471 (2013). Google Scholar
  7. 7.
    Cruess, A.F., Zlateva, G., Xu, X., Soubrane, G., Pauleikhoff, D., Lotery, A., Mones, J., Buggage, R., Schaefer, C., Knight, T., Goss, T.F.: Economic burden of bilateral neovascular age-related macular degeneration: multi-country observational study. Pharm. Econ. 26(1), 57–73 (2008). Google Scholar
  8. 8.
    Hirneiß, C., Kampik, A., Neubauer, A.S.: Volkswirtschaftliche Kosten von Augenerkrankungen (Macroeconomic costs of eye diseases). Der Ophthalmol. 111(5), 420–427 (2014). Google Scholar
  9. 9.
    Oeverhaus, M., Hirche, H., Esser, J., Eckstein, A., Schaperdoth-Gerlings, B.: Evaluation der Versorgungssituation von Sehbehinderten. Signifikante Unterschiede zwischen Jung und Alt (Evaluation of the medical treatment situation of the visually impaired: significant differences between young and old). Der Ophthalmol. (2018). Google Scholar
  10. 10.
    Kaczmirek, L., Wolff, K.G.: Survey design for visually impaired and blind people. In: Stephanidis, C. (ed.) Universal access in human-computer interaction. 4th International Conference on Universal Access in Human-Computer Interaction, UAHCI 2007, held as part of HCI International 2007, Beijing, China, July 22–27, 2007; proceedings, Part 1: Coping with diversity. Lecture notes in computer science, vol. 4554, pp. 374–381. Springer, Berlin (2007)Google Scholar
  11. 11.
    Lamoureux, E.L., Chou, S.L., Larizza, M.F., Keeffe, J.E.: The reliability of data collection periods of personal costs associated with vision impairment. Ophthalmic Epidemiol. 13(2), 121–126 (2006). Google Scholar
  12. 12.
    Deutsches Institut für medizinische Dokumentation und Information (DIMDI): ICD-10-GM Kapitel VII Krankheiten des Auges und der Augenanhangsgebilde (H00–H59) (ICD-10-GM Chapter VII Diseases of the eye and its appendages (H00-H59)) (2015)Google Scholar
  13. 13.
    Bundesministerium für Arbeit und Soziales: Anlage » Versorgungsmedizinische Grundsätze « zu § 2 der Verordnung zur Durchführung des § 1 Abs.1 und 3, des § 30 Abs.1 und des § 35 Abs.1 des Bundesversorgungsgesetzes (Annex “Medical Care Principles” to § 2 of the Ordinance on the Implementation of § 1 paras 1 and 3, § 30 paras 1 and § 35 paras 1 of the Federal Medical Care Act) (2018)Google Scholar
  14. 14.
    Köberlein-Neu, J., Seifert, A., Himmelsbach, I.: Selbstberichtetes Sehvermögen in der (gerontologischen) Versorgungsforschung und -praxis – ein Plädoyer zur Öffnung (Self-reported vision in (gerontological) health services research and practice-an opening plea). Der Ophthalmol. 115(10), 818–825 (2018). Google Scholar
  15. 15.
    Lange, C.: Ergebnisse der Studie “Gesundheit in Deutschland aktuell 2012” (Facts and figures. Results of the study “Health in Germany Current 2012”). Beiträge zur Gesundheitsberichterstattung des Bundes. Robert-Koch-Inst, Berlin (2014)Google Scholar
  16. 16.
    Robert Koch-Institut: Blindheit und Sehbehinderung (Blindness and visual impairment). Robert Koch-Institut, Berlin (2017)Google Scholar
  17. 17.
    Finger, R.P.: Blindheit in Deutschland: dimensionen und Perspektiven (Blindness in Germany: dimensions and perspectives). Der Ophthalmol. 104(10), 839–844 (2007). Google Scholar
  18. 18.
    Neumann, P.J., Sanders, G.D., Russell, L.B., Siegel, J.E., Ganiats, T.G. (eds.): Cost effectiveness in health and medicine. Oxford University Press, New York (2017)Google Scholar
  19. 19.
    LimeSurvey GmbH: Referenzen und Auszeichnungen. Accessed 13 Jan 2019
  20. 20.
    Krauth, C., Hessel, F., Hansmeier, T., Wasem, J., Seitz, R., Schweikert, B.: Empirische Bewertungssätze in der gesundheitsökonomischen Evaluation – ein Vorschlag der AG Methoden der gesundheitsökonomischen Evaluation (AG MEG) (Empirical standard costs for health economic evaluation in Germany – a proposal by the working group methods in health economic evaluation). Gesundheitswesen 67(10), 736–746 (2005). Google Scholar
  21. 21.
    Bock, J.-O., Brettschneider, C., Seidl, H., Bowles, D., Holle, R., Greiner, W., König, H.H.: Ermittlung standardisierter Bewertungssätze aus gesellschaftlicher Perspektive für die gesundheitsökonomische Evaluation (Calculation of standardised unit costs from a societal perspective for health economic evaluation). Gesundheitswesen 77(1), 53–61 (2015). Google Scholar
  22. 22.
  23. 23.
    Kastaun, S., Brown, J., Brose, L.S., Ratschen, E., Raupach, T., Nowak, D., Cholmakow-Bodechtel, C., Shahab, L., West, R., Kotz, D.: Study protocol of the German Study on Tobacco Use (DEBRA): a national household survey of smoking behaviour and cessation. BMC Public Health 17(1), 378 (2017). Google Scholar
  24. 24.
    Deb, P., Norton, E.C.: Modeling Health Care Expenditures and Use. Annu. Rev. Public Health 39, 489–505 (2018). Google Scholar
  25. 25.
    Briggs, A.H., O’Brien, B.J., Blackhouse, G.: Thinking outside the box: recent advances in the analysis and presentation of uncertainty in cost-effectiveness studies. Annu. Rev. Public Health 23, 377–401 (2002). Google Scholar
  26. 26.
    Briggs, A.H., Gray, A.M.: Handling uncertainty in economic evaluations of healthcare interventions. BMJ (Clin. Res. Ed.) 319(7210), 635–638 (1999). Google Scholar
  27. 27.
    Porz, G., Scholl, H.P.N., Holz, F.G., Finger, R.P.: Methoden zur Ermittlung persönlicher Krankheitskosten am Beispiel retinaler Erkrankungen (Methods for estimating personal costs of disease using retinal diseases as an example). Der Ophthalmol. 107(3), 216–220 (2010). Google Scholar
  28. 28.
    Mauschitz, M.M., Li, J.Q., Larsen, P.P., Köberlein-Neu, J., Holz, F.G., Breteler, M.M.B., Finger, R.P.: Epidemiology of severe visual impairment and blindness of old people in Germany. Der Ophthalmol. 116(2), 201–212 (2019). Google Scholar
  29. 29.
    Gibbert, J., Müller, D., Fauser, S., Stock, S.: Krankheitskosten der altersbedingten Makuladegeneration. Systematischer Review zur Entwicklung eines Kostentagebuchs (Cost of illness of age-related macular degeneration. Systematic review on the development of a costs diary). Der Ophthalmol. 110(6), 528–536 (2013). Google Scholar
  30. 30.
    Pauleikhoff, D., Scheider, A., Wiedmann, P., Gelisken, F., Scholl, H.P.N., Roider, I., Mohr, A., Zlateva, G., Xu, X.: Neovaskuläre altersabhängige Makuladegeneration in Deutschland. Beinträchtigung der Lebensqualität und ihre finanziellen Auswirkungen (Neovascular age-related macular degeneration in Germany. Encroachment on the quality of life and the financial implications). Der Ophthalmol. 106(3), 242–251 (2009). Google Scholar
  31. 31.
    Pezzullo, L., Streatfeild, J., Simkiss, P., Shickle, D.: The economic impact of sight loss and blindness in the UK adult population. BMC Health Serv. Res. 18(1), 63 (2018). Google Scholar
  32. 32.
    Taylor, H.R., Pezzullo, M.L., Keeffe, J.E.: The economic impact and cost of visual impairment in Australia. Br. J. Ophthalmol. 90(3), 272–275 (2006). Google Scholar
  33. 33.
    Roberts, C.B., Hiratsuka, Y., Yamada, M., Pezzullo, M.L., Yates, K., Takano, S., Miyake, K., Taylor, H.R.: Economic cost of visual impairment in Japan. Arch. Ophthalmol. 128(6), 766–771 (2010). (Chicago, Ill.: 1960) Google Scholar
  34. 34.
    Frick, K.D., Gower, E.W., Kempen, J.H., Wolff, J.L.: Economic impact of visual impairment and blindness in the United States. Arch. Ophthalmol. 125(4), 544–550 (2007). (Chicago, Ill.: 1960) Google Scholar
  35. 35.
    Gesundheitsbezogene Selbsthilfe in Deutschland—Entwicklungen, Wirkungen, Perspektiven (SHILD): Aktuelles SHILD-Modul 4: Transfer der Ergebnisse (11/2017-heute) (Current SHILD module 4: Transfer of results (11/2017-today)) (2017)Google Scholar
  36. 36.
    Lafuma, A., Brezin, A., Fagnani, F., Mimaud, V., Mesbah, M., Berdeaux, G.: Nonmedical economic consequences attributable to visual impairment: a nation-wide approach in France. Eur. J Health Econ. 7(3), 158–164 (2006). Google Scholar
  37. 37.
    Andersen, R.M.: Revisiting the behavioral model and access to medical care. Does it matter? J. Health. Soc. Behav. 36(1), 1 (1995). Google Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Center for Health Economics and Health Services Research, Schumpeter School of Business and EconomicsUniversity of WuppertalWuppertalGermany
  2. 2.Department of OphthalmologyUniversity of BonnBonnGermany

Personalised recommendations