Incremental cost effectiveness of laser photocoagulation for subfoveal choroidal neovascularization

doi:10.1016/S0161-6420(00)00169-X

Ophthalmology

Volume 107, Issue 7, July 2000, Pages 1374-1380

https://doi.org/10.1016/S0161-6420(00)00169-X Get rights and content

Abstract

Objective

To perform a patient preference-based, incremental cost-effectiveness analysis for laser treatment of subfoveal choroidal neovascularization.

Design

Computer-based econometric modeling.

Methods

The cost effectiveness of laser photocoagulation therapy was compared with the natural course of subfoveal choroidal neovascularization. The model applied long-term visual data from previous clinical trials, utility analysis (which reflects patient perceptions of quality of life associated with a health state), decision analysis with Markov modeling, and the economic principles of present value analysis with discounting to account for the time value of money.

Database

Data from patients eligible for treatment of subfoveal choroidal neovascularization obtained by researchers in the Macular Photocoagulation Study were used for the analysis.

Intervention

Modeled laser therapy for subfoveal choroidal neovasacularization in patients with age-related macular degeneration.

Main outcome measure

Cost per quality-adjusted life-year ($/QALY gained) associated with laser therapy.

Results

Laser photocoagulation therapy for subfoveal choroidal neovascularization, as compared with no treatment, resulted in a mean gain of 0.257 QALYs per treated patient. Using a yearly discount rate of 3% to account for the time value of money and inflation, the resultant $/QALY gained was $5629. Sensitivity analysis used in the cost-effectiveness analysis resulted in a $/QALY gained of $4974 with no gained discount rate and $11,633 with a yearly discount rate of 10%.

Conclusions

The incremental expense of laser therapy for the treatment of subfoveal choroidal neovascularization appears to be highly cost effective. The result, which takes into account patient preference-based utility data, compares quite favorably with other interventional therapies across different medical specialties.

Section snippets

Overview

Software produced by Treeage Inc.14 was used to perform decision analysis15 to simulate the clinical situation involving laser therapy and no therapy for the eyes of patients with subfoveal choroidal neovascularization. Markov modeling, which incorporates matrix algebra to evaluate recurrent risk, was also used in the analysis.16 The microcomputer model takes into account the mortality within the group of patients with subfoveal choroidal neovascular membranes, as well as the treatment results

Decision analysis and Markov modeling

When the utility change attributable to an interventional therapy is multiplied by the time over which the therapy has a benefit or detriment, the number of QALYs gained or lost from the treatment is the result.6, 7, 8, 9, 29 Because the visual acuity as a result of both the natural course of, as well as of laser therapy for, subfoveal choroidal neovascularization varies during the first 4 years of treatment, the number of QALYs gained or lost during this time are shown in Table 3. Of note is

Discussion

The present study found that laser treatment for subfoveal choroidal neovascularization that meets the treatment criteria set forth in the Macular Photocoagulation Study1, 2, 5 appears to be cost effective when compared with other treatment methods in medicine. Although the criteria for cost effectiveness are arbitrary, it has been suggested by Laupacis et al13 that a treatment costing less than $20,000/QALY appears to be cost effective, whereas a treatment costing more than $100,000/QALY is

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Conversely, if the vision in one eye decreases to no light perception, the weighted decrease in utility also should be accounted for in the overall utility outcome. With diseases affecting one eye or both eyes, first-eye and second-eye models have been used and the weighted results integrated into a combined-eye model.3,16,25–27 The first-eye model calculates interventional utility gain as described in the current study.
To present ophthalmic patient time-tradeoff vision utilities for quantifying vision-related quality-of-life when the fellow eye still has good vision. These utilities are important for performing reliable cost-utility analyses.
Consecutive time-tradeoff vision utilities were obtained from ophthalmic patients with good vision (20/20–20/25) in one eye and vision ranging from 20/20 to no light perception in the fellow eye over a 15-year period from 2000 through 2014.
Five hundred eighty-six ophthalmic participant interviews from Wills Eye Hospital, New York Eye and Ear Hospital, and ophthalmology office practices in Pennsylvania and New Jersey.
Participants underwent a full ophthalmic examination, after which time-tradeoff vision utilities were obtained by personal interview by the authors using a standardized, validated instrument.
Time-tradeoff vision utilities.
Mean time-tradeoff vision utilities were as follows in participants with good vision (20/20–20/25) in at least one eye and the following visions in the fellow eyes: no light perception, 0.79; counting fingers to light perception, 0.87; 20/200 to 20/400, 0.88; 20/60 to 20/100, 0.88; 20/30 to 20/50, 0.87; and 20/20 to 20/25, 0.94.
In people with good vision (20/20–20/25) in one eye, the associated mean time-tradeoff vision utility is a remarkably consistent 0.87 to 0.88 when vision in the fellow eye ranges from 20/30 to light perception. Vision of 20/20 to 20/25 in the fellow eye results in a significantly higher associated utility of 0.94 (P < 0.01), whereas vision of no light perception in the fellow eye results in a significantly lower utility of 0.079 (P < 0.01). These utilities are important for calculating reliable patient value (quality-adjusted life-year) gains in ophthalmic cost-utility analysis populations in which there is unilateral and bilateral disease involvement.
Cost-effectiveness of bevacizumab and ranibizumab for newly diagnosed neovascular macular degeneration
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Finally, when each parameter was simultaneously varied in a probabilistic sensitivity analysis, as-needed bevacizumab was preferred in nearly two-thirds of the simulations by using a WTP of $100 000/QALY; monthly bevacizumab was preferred in another 18% to 20% of simulations. Previous cost-effectiveness analyses have compared some older treatments for neovascular AMD, such as FALP,13,43,44 PDT with verteporfin,13,45–49 pegaptanib,13,15–17 or ranibizumab,14,18–20 with supportive care, or compared PDT with verteporfin versus pegaptanib or ranibizumab.15,19,21–23 Little, however, has been known about the relative cost effectiveness of the 2 most commonly used interventions today.
We sought to determine the most cost-effective treatment for patients with newly diagnosed neovascular macular degeneration: monthly or as-needed bevacizumab injections, or monthly or as-needed ranibizumab injections.
Cost-effectiveness analysis.
Hypothetical cohort of 80-year-old patients with newly diagnosed neovascular macular degeneration.
Using a mathematical model with a 20-year time horizon, we compared the incremental cost-effectiveness of treating a hypothetical cohort of 80-year-old patients with newly diagnosed neovascular macular degeneration using monthly bevacizumab, as-needed bevacizumab, monthly ranibizumab, or as-needed ranibizumab. Data came from the Comparison of Age-related macular degeneration Treatment Trial (CATT), the Medicare Fee Schedule, and the medical literature.
Costs, quality-adjusted life-years (QALYs), and incremental costs per QALY gained.
Compared with as-needed bevacizumab, the incremental cost-effectiveness ratio of monthly bevacizumab is $242 357/QALY. Monthly ranibizumab gains an additional 0.02 QALYs versus monthly bevacizumab at an incremental cost-effectiveness ratio of >$10 million/QALY. As-needed ranibizumab was dominated by monthly bevacizumab, meaning it was more costly and less effective. In sensitivity analyses assuming a willingness to pay of $100 000/QALY, the annual risk of serious vascular events would have to be ≥2.5 times higher with bevacizumab than that observed in the CATT trial for as-needed ranibizumab to have an incremental cost-effectiveness ratio of <$100 000/QALY. In another sensitivity analysis, even if every patient receiving bevacizumab experienced declining vision by 1 category (e.g., from 20/25–20/40 to 20/50–20/80) after 2 years but every patient receiving ranibizumab retained their vision level, as-needed ranibizumab would have an incremental cost-effectiveness ratio of $97 340/QALY.
Even after considering the potential for differences in risks of serious adverse events and therapeutic effectiveness, bevacizumab confers considerably greater value than ranibizumab for the treatment of neovascular macular degeneration.
Cost-effectiveness of ranibizumab for the treatment of neovascular age-related macular degeneration in germany: Model analysis from the perspective of germany's statutory health insurance system
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Background: In clinical trials, ranibizumab has been associated with stabilization and even improvement of visual acuity among patients with neovascular agerelated macular degeneration (AMD), but its use is also associated with considerable costs.
Objective: The aim of this work was to compare ranibizumab with best supportive care or photodynamic therapy (PDT) for AMD by means of economic costutility and cost-effectiveness analysis from the perspective of Germany's Statutory Health Insurance System.
Methods: Visual acuity data from the Anti-VEGF (vascular endothelial growth factor) Antibody for the Treatment of Predominantly Classic Choroidal Neovascularization in AMD (ANCHOR) and Minimally Classic/Occult Trial of the Anti-VEGF Antibody Ranibizumab in the Treatment of Neovascular AMD (MARINA) studies were applied, based on a ranibizumab dose of 0.5 mg. A Markov model simulated visual acuity and costs over 10 years (discounted at 3%). The base-case analysis assumed 5 injections per year over 2 years. Treatment costs were based on year-2008 euros (using German prices) and recommendations for procedure reimbursement from a public health insurance perspective. To assess cost-effectiveness, costs per year of legal blindness avoided (ie, vision-year gained [VYG]) and per quality-adjusted life-year (QALY) were calculated. The model assumed each patient's affected eye had better sight than the other eye, and the 2 comparators against which ranibizumab treatment was assessed were best supportive care and PDT. The robustness of the results was investigated in a univariate sensitivity analysis of all relevant parameters and a multivariate probabilistic sensitivity analysis. The multivariate 95% CIs for incremental cost-effectiveness ratios were obtained by conducting 1000 Monte Carlo simulations.
Results: Compared with best supportive care, costs per VYG for ranibizumab were €6767 in occult choroidal neovascularization (CNV) and €6020 in minimally classic CNV. In classic CNV, costs were €5734/VYG for ranibizumab compared with supportive care and €778/VYG for ranibizumab compared with PDT. Costs per QALY for ranibizumab treatment for occult, minimally classic CNV, and classic CNV were €22,320, €22,538, and €25,036, respectively, and €3294 for classic CNV compared with PDT. Results were sensitive to the cost of blindness, injection frequency, and duration. The multivariate 95% CIs for the incremental costeffectiveness ratios were €14,438 to €41,110/QALY for occult CNV, €13,463 to €43,614/QALY for minimally classic CNV, and €15,634 to €51,106/QALY for classic CNV.
Conclusion: In this model analysis using costs and clinical trial data from Germany, ranibizumab appeared to be a cost-effective treatment option for all angiographic subtypes of neovascular AMD, from the perspective of Germany's Statutory Health Insurance System.
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^☆: Supported in part by the Retina Research and Development Fund, Philadelphia, Pennsylvania, and the Principal’s Initiative Research Fund, Kingston, Ontario, Canada.

View full text

Incremental cost effectiveness of laser photocoagulation for subfoveal choroidal neovascularization☆

Abstract

Objective

Design

Methods

Database

Intervention

Main outcome measure

Results

Conclusions

Section snippets

Overview

Decision analysis and Markov modeling

Discussion

Am J Ophthalmol

Ophthalmology

Laser photocoagulation of subfoveal neovascular lesions in age-related macular degeneration

Arch Ophthalmol

Laser photocoagulation of subfoveal neovascular lesions of age-related macular degeneration. Updated findings from two clinical trials

Arch Ophthalmol

Submacular surgery. Are randomized trials necessary? [editorial]

Arch Ophthalmol

Photodynamic therapy of subfoveal choroidal neovascularization in age-related macular degeneration with verteporfinone-year results of 2 randomized clinical trials—TAP report

Arch Ophthalmol

Subfoveal neovascular lesions in age-related macular degeneration. Guidelines for evaluation and treatment in the Macular Photocoagulation Study

Arch Ophthalmol

Utilities and quality-adjusted life years

Int J Technol Assess Health Care

Evidence-based medicine, utilities, and quality of life [review]

Curr Opin Ophthalmol

Evidence-based medicine and cost-effectiveness

J Health Care Finance

Cost-effectiveness of warfarin and aspirin for prophylaxis of stroke in patients with nonvalvular atrial fibrillation

JAMA

Vision and quality-of-life

Trans Am Ophthalmol Soc

Evidence-Based Medicine Working Group. Users’ guides to the medical literature. XIII. How to use an article on economic analysis of clinical practice. A. Are the results of the study valid?

JAMA

Evidence-Based Medicine Working Group. Users’ guides to the medical literature. XIII. How to use an article on economic analysis of clinical practice. B. What are the results and will they help me in caring for my patients?

JAMA

How attractive does a new technology have to be to warrant adoption and utilization? Tentative guidelines for using clinical and economic evaluations

Can Med Assoc J