A Cost Effectiveness Analysis of Intravitreal Aflibercept for the Prevention of Progressive Diabetic Retinopathy

Cost-effectiveness Analysis of Digital Therapeutics for Amblyopia

PURPOSE

To evaluate the cost-utility of Luminopia (Luminopia, Inc) and CureSight (NovaSight, Ltd) as therapy for amblyopia compared with current common amblyopic treatments such as glasses, atropine drops, and patching.

DESIGN

Cost analysis based on data from published randomized control trials (RCTs).

SUBJECTS

Data from Luminopia, CureSight, and atropine RCTs.

METHODS

A cost-utility analysis was performed using patient preference-based time trade-off utility values from previous literature. Costs for eye examinations were calculated using reimbursement data; device costs for duration of treatment were provided by sales representatives of Luminopia and CureSight. All treatments were inclusive of the cost of eyeglasses. Visual acuity (VA) and stereoacuity outcomes were extrapolated from the RCTs for atropine, Luminopia, and CureSight. A quality-adjusted life-year (QALY) was calculated by multiplying utility gain, a value correlated with VA gain, by length of time of benefit.

MAIN OUTCOME MEASURES

Cost, cost per QALY, and cost per stereoacuity gain.

RESULTS

The cost to treat amblyopia with glasses alone for 12 weeks was $514. The cost of treating with patching for 12 weeks was $540 and with atropine for 16 weeks was $652, whereas the cost of treating with Luminopia or CureSight for 12 weeks was $1951 and $1564 or $1814, respectively. Treatment with glasses alone or patching for 12 weeks resulted in a cost per QALY gained of $427 and $101, respectively. Atropine treatment for 16 weeks resulted in a cost per QALY gained of $151. The cost per QALY for 12-week Luminopia treatment was $618 versus $368 or $427 for 12-week CureSight treatment and $314 or $354 for 16-week CureSight treatment (P < 0.05). Cost per stereoacuity gain for 12-week treatment duration was $6421/log arcsec (glasses), $1801/log arcsec (patching), and $3007/log arcsec or $3488/log arcsec (CureSight).

CONCLUSIONS

Treatment of amblyopia with Luminopia or CureSight is cost-effective in comparison with established willingness-to-pay thresholds and can provide a viable treatment option, especially for those who are unable to tolerate patching or atropine penalization. Cost-effectiveness values based on VA gain of Luminopia and CureSight were comparable.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

A systematic review of the cost-effectiveness of anti-VEGF drugs for the treatment of diabetic retinopathy

Background

Non-proliferative and proliferative diabetic retinopathy are common complications of diabetes and a major cause of sight loss. Anti-vascular endothelial growth factor drugs represent a treatment option for people with diabetic retinopathy and are routinely used to treat various other eye conditions. However, anti-vascular endothelial growth factor drugs are expensive relative to current care options, and it is unclear whether this additional cost is justified when the immediate risk of vision loss is lower compared to patients with more aggressive ophthalmological conditions.

Objective

To systematically review the evidence supporting the cost-effectiveness of alternative treatments for diabetic retinopathy.

Methods

A systematic review of all comparative cost-effectiveness studies evaluating any treatment for diabetic retinopathy was conducted. Bibliographic searches were carried out to identify studies reporting on the cost-effectiveness of treatments for diabetic retinopathy; the latest searches were conducted on 28 April 2023. Included studies were synthesised narratively and evaluated with reference to UK decision-making. Studies were grouped by population into non-proliferative diabetic retinopathy and proliferative diabetic retinopathy.

Results

The review identified five studies in the proliferative diabetic retinopathy population, all of which examined the cost-effectiveness of anti-vascular endothelial growth factor treatments compared to pan-retinal photocoagulation. Results of these studies suggest that anti-vascular endothelial growth factor treatments offer some additional benefits in terms of preserved visual acuity but also incur substantial additional costs relative to pan-retinal photocoagulation. Most authors agreed that the additional costs outweigh the limited benefits, especially in certain patient subgroups without pre-existing oedema. As most of the identified evidence considered a US perspective, it is unclear how these results would translate to a UK setting. Two studies were identified in the non-proliferative diabetic retinopathy population. There was limited evidence to support the early use of anti-vascular endothelial growth factor treatment. However, one UK study suggested that early treatment of non-proliferative diabetic retinopathy with pan-retinal photocoagulation is cost-effective compared to delayed pan-retinal photocoagulation.

Conclusions

Overall, there is a dearth of cost-effectiveness evidence considering the UK context. The identified studies raised doubts about the cost-effectiveness of anti-vascular endothelial growth factor treatments for proliferative diabetic retinopathy. No conclusions can be made regarding the cost-effectiveness of anti-vascular endothelial growth factor treatments for non-proliferative diabetic retinopathy. Future research should focus on developing rigorous model-based cost-effectiveness analyses integrating all available evidence.

Funding

This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR132948.

Utility Assessment of Follow-up Evaluation for Commotio Retinae

Purpose: To perform an outcome-and-cost analysis of follow-up visits and associated imaging in patients presenting to the Massachusetts Eye and Ear (MEE) emergency department with commotio retinae. Methods: This retrospective consecutive case series comprised consecutive patients presenting to the emergency department from January 1, 2020, to January 1, 2022, who were diagnosed with contusion or other injuries of the eye or orbit (International Classification of Diseases, 10th edition, codes S05.1 and S05.8). Cost analysis was performed using Medicare fee data and previously described methods. Costs considered included follow-up examinations, optical coherence tomography (OCT), and fundus photography. Results: Of the 490 patients presenting to the emergency department, 201 had findings of commotio retinae on examination and were included in this study. Of the 201 patients with initial commotio retinae, 142 (70.6%) returned for follow-up. OCT was performed in 34% of patients and fundus photography in 33%. A total of 254 follow-up visits were conducted. Four patients (2.8%) had retinal tears on follow-up, with only 1 (0.7%) developing a retinal detachment. Complications requiring intervention were always heralded by worsening symptoms. The total cost of follow-up was $60,436 for the cohort and $425.60 per patient. Conclusions: Patients with commotio retinae infrequently develop retinal complications and have a high rate of loss to follow-up. Significant resources are dedicated to following up and imaging patients with commotio retinae. Our results underscore the low utility in multiple follow-up visits among asymptomatic patients.

Anti-Vascular Endothelial Growth Factor Drugs Compared With Panretinal Photocoagulation for the Treatment of Proliferative Diabetic Retinopathy: A Cost-Effectiveness Analysis

OBJECTIVES

This study aimed to evaluate the cost-effectiveness of anti-vascular endothelial growth factor drugs (anti-VEGFs) compared with panretinal photocoagulation (PRP) for treating proliferative diabetic retinopathy (PDR) in the United Kingdom.

METHODS

A discrete event simulation model was developed, informed by individual participant data meta-analysis. The model captures treatment effects on best corrected visual acuity in both eyes, and the occurrence of diabetic macular edema and vitreous hemorrhage. The model also estimates the value of undertaking further research to resolve decision uncertainty.

RESULTS

Anti-VEGFs are unlikely to generate clinically meaningful benefits over PRP. The model predicted anti-VEGFs be more costly and similarly effective as PRP, generating 0.029 fewer quality-adjusted life-years at an additional cost of £3688, with a net health benefit of -0.214 at a £20 000 willingness-to-pay threshold. Scenario analysis results suggest that only under very select conditions may anti-VEGFs offer potential for cost-effective treatment of PDR. The consequences of loss to follow-up were an important driver of model outcomes.

CONCLUSIONS

Anti-VEGFs are unlikely to be a cost-effective treatment for early PDR compared with PRP. Anti-VEGFs are generally associated with higher costs and similar health outcomes across various scenarios. Although anti-VEGFs were associated with lower diabetic macular edema rates, the number of cases avoided is insufficient to offset the additional treatment costs. Key uncertainties relate to the long-term comparative effectiveness of anti-VEGFs, particularly considering the real-world rates and consequences of treatment nonadherence. Further research on long-term visual acuity and rates of vision-threatening complications may be beneficial in resolving uncertainties.

A Cost-Effectiveness Analysis of Pegcetacoplan for the Treatment of Geographic Atrophy

PURPOSE

To evaluate the cost-effectiveness of the treatment of geography atrophy (GA) with intravitreal pegcetacoplan and to identify utility-measurement surrogates.

DESIGN

Cost analysis based on data from a published study.

SUBJECTS

None; based on data from published sham control compared with 2 treatment groups in the index study.

METHODS

Costs were based on 2022 Medicare reimbursement data. Specific outcomes were extrapolated from the DERBY and OAKS trials. Assumptions were made for the lifetime analysis based on a theoretical logistic growth model of the atrophy.

OUTCOME MEASURES

Cost, cost utility, cost per quality-adjusted life-year, and cost per area of GA (in US$).

RESULTS

The costs to treat GA in every month (EM) and every-other-month (EOM) treatment groups over the 2 years as reported were $70 000 and $34 600, respectively. The costs per area of delaying GA for 2 years in all patients were $87 300/mm2 (EM) and $49 200/mm2 (EOM), and in initially extrafoveal patients, $53 900/mm2 (EM) and $32 100/mm2 (EOM). The costs per day of delaying GA for 2 years were $295 (EM) and $170 (EOM); the marginal cost (EM vs. EOM) per retinal pigment epithelium cell saved was $30. The modeled lifetime costs were $350 000 (EM) and $172 000 (EOM), or $309 000/mm2 (EM) and $180 000 (EOM) /mm2. The modeled time to 95% atrophy at 13 years was delayed by 2.5 years (EM) and 2.1 years (EOM). The costs/quality-adjusted life-year gained based on modeled visual loss with 95% atrophy were $706 000 (EM) and $397 000 (EOM).

CONCLUSION

Treatment of GA with intravitreal pegcetacoplan EOM was more cost effective than EM. Treatment of extrafoveal lesions yielded greater utility than the treatment of the entire group. As atrophy progression approaches an upper limit, the marginal cost/benefit ratios increase.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Aflibercept Monotherapy versus Bevacizumab-First for Diabetic Macular Edema: A Cost Analysis Based on Diabetic Retinopathy Clinical Research Network Protocol AC Results

PURPOSE

To calculate the costs of treatment for diabetic macular edema with bevacizumab-first (step therapy) compared with aflibercept monotherapy.

DESIGN

Cost analysis of the treatment arms based on a published study.

SUBJECTS

None.

METHODS

Published results from the Diabetic Retinopathy Clinical Research Network protocol AC were used to assess costs. Data incorporated in the usage and outcome model included the frequency of injections, medication type, visits, and imaging. Costs were modeled based on the 2022 Medicare reimbursement data for both facility (hospital-based) and nonfacility settings in Miami. Outcomes were similar in protocol AC so were not differentially studied. Results were extrapolated so as to estimate lifetime (17 years for the age of the cohort).

MAIN OUTCOME MEASURES

Cost of treatment options.

RESULTS

Over the 2 years reported in the protocol AC, the cost required to treat in the facility (nonfacility setting) was $42 000 ($32 000) in the aflibercept monotherapy group and $29 000 ($22 000) in the bevacizumab-first group. Extrapolated modeled lifetime costs were $158 000 ($136 000) and $125 000 ($103 000), respectively. The total cost with bevacizumab-first was 33% lower at year 2 and 21% lower at year 17 compared with aflibercept monotherapy. Savings per year for the 2 years results were $6500 ($5000) in the facility (nonfacility) setting. For the extrapolated 17 years model, annual savings were $1900 ($1900) in the facility (nonfacility) setting. The professional fees accounted for a minority of overall costs; in contrast, medication costs accounted for 82% of the total costs for the aflibercept monotherapy and 73% in the bevacizumab-first group at 2 years. Our model predicted an additional 15% lifetime cumulative savings if patients still not meeting the threshold criteria after switching to aflibercept were placed back on bevacizumab, and a similar degree of improvement if those on not meeting threshold criteria on aflibercept monotherapy were switched to bevacizumab.

CONCLUSIONS

Medication is the dominant driver of the total expenses associated with the treatment of diabetic macular edema. Although cost savings are realized with bevacizumab-first step therapy, the magnitude was not as much as might be intuited, probably because of the high (70%) incidence of patients switching to aflibercept within protocol AC.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.