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Tin Yan A. Liu, Lucian V. Del Priore; Regular Optical Coherence Tomography Screening Of Second Eyes Of Patients With Unilateral Exudative Age-related Macular Degeneration: An Incremental Cost-utility Analysis. Invest. Ophthalmol. Vis. Sci. 2011;52(14):5533.
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Prior studies have shown that fellow eyes of patients with unilateral exudative age-related macular degeneration (AMD) are at high risk of converting to exudative AMD. The purpose of this study is to determine the incremental cost-effectiveness of using routine optical coherence tomography (OCT) screening of the fellow eyes of these patients with prompt initiation of treatment if asymptomatic exudation is detected.
Published data on second eye conversion rates, time tradeoff utilities and a threshold of <$50,000 per quality-adjusted-life-year gained are used to determine incremental cost-effectiveness. The usual care group is given anti-VEGF therapy when they are symptomatic and the behavior of visual acuity over time before treatment is modeled by [1/letter lost = 0.1448/ months of disease + 0.0133; Ophthalmology.2009;116:1901-7]. We assume that the experimental group undergoes monthly OCT screening of the fellow eye. 3 separate analyses are done: every-6-week bevacizumab, monthly ranibizumab or quarterly ranibizumab is given once intra/sub-retinal fluid is detected. Only direct costs using Medicare reimbursement rates are included.
The cost effectiveness of screening increases as the cumulative conversion rate from nonexudative to exudative AMD in the fellow eyes increases. The minimum cumulative conversion rate required for cost-effectiveness decreases as the year by which the program needs to be cost-effective increases. For the screening program to be cost-effective, the cumulative conversion rate required using bevacizumab is 32.2 % and 20.4% at 2 and 5 years respectively. Due to its higher cost, monthly ranibizumab treatment does not reach significance until patients are followed for 10 years. If ranibizumab is given quarterly after the first 3 monthly injections, then the cumulative conversion rate required for cost-effectiveness is 36% at 5 years. For comparison, conversion rates observed in the MARINA and ANCHOR trials are 32.1% to 37.3% at 2 years.
Regular OCT screening of the second eyes of patients with unilateral wet AMD is cost effective within 2 years if bevacizumab is used and within 5 years if ranibizumab is given quarterly after the first 3 months, but not if monthly ranibizumab is given continuously after detection of subclinical fluid. Such screening can be expected to lead to better final vision regardless of cost-effectiveness, since virtually all anti-VEGF trials for wet AMD demonstrate that initial visual acuity (VA) is the strongest predictor of final VA.
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