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Robert Finger, Arthur Hsueh, Jill Keeffe, Robyn Guymer; Optimizing cost-effectiveness analyses of treatments for neovascular age-related macular degeneration using real-life data. Invest. Ophthalmol. Vis. Sci. 2013;54(15):4388.
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To assess cost-effectiveness (CE) of anti-VEGF treatment for neovascular age-related macular degeneration (nv AMD) from a healthcare payer’s perspective, using long-term data from routine medical practice in Australia.
200 patients undergoing long-term (>1 year) anti-VEGF treatment for nvAMD were included and costs for services assigned based on Medicare Australia rebates. Three Markov models (MM) were created to reflect impact of anti-VEGF treatment on 1. better eye and 2. treated eye VA and 3. vision states combining both eye VA using TreeAge software, based on our real life data. Vision-related utilities were based on a large (n>1300) reference sample interviewed using the Vision and Quality of Life multi-attribute utility instrument. Costs and rewards were discounted at 3.5%/year and final results tested in probabilistic sensitivity analyses.
Mean treatment duration was 37 (±13) months and mean injections were 21(±11;7 in year 1-3, 6 in year 4, 5 in year 5). VA in the treated eye improved from baseline to last follow-up (+7 ltrs; 49 to 56 ltrs, p<0.001) and remained stable in the better eye (-3 ltrs; 66 to 63 ltrs, p=0.001). 40% of patients were treated in both eyes during year 1, and 50% by year 5. Treatment costs were highest in the first year (A$18,296 ± 7,991), and lower for uniocular (A$16,123±6,757) than for binocular treatment ($21,487±8,610). Based on these data MMs ran for 5 years, with all treatment assumed to be with ranibizumab (A$ 1976.36). Cost-effectiveness was A$17,155/QALY for better eye, 17,812/QALY for treated eye and 17,243/QALY for both eye vision state models, with the both eye vision state MM generating most QALYs (1.80 compared to 1.74 in MM1 and 1.70 in MM2).
All modeling approaches arrived at CE estimates well below the cut-off of $50,000/QALY commonly accepted to be cost-effective. Using treated eye VA led to a low estimate of treatment effects and high costs, whereas using better eye VA led to a medium estimate of treatment effect and the lowest cost. Using both eyes’ VA (in vision states) most accurately reflects clinical reality with a necessity to treat both eyes in a considerable proportion of patients and led to the highest estimate of treatment impact with a medium cost estimate. Economic evaluations of bilateral ocular disease and its treatments should take both eyes’ VA into account.
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