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.

Combination of Grid Laser Photocoagulation and a Single Intravitreal Ranibizumab as an Efficient and Cost-Effective Treatment Option for Macular Edema Secondary to Branch Retinal Vein Occlusion.

Our prospective comparative study of 60 patients aimed to compare the efficacy and feasibility of a single injection ranibizumab versus a single grid laser photocoagulation and versus a combined treatment in macular edema secondary to branch retinal vein occlusion in Asian population. Patients were randomized 1:1:1 (n = 20/group) into grid laser (LAS), the ranibizumab (RAN), and the combination (COM) group. Outcomes were measured as best-corrected visual acuity (BCVA) and central macular thickness (CMT). There were significant differences in mean BCVA between the three groups at 1 week and 1 month (p < 0.05) and in mean CMT at 1 week and 1, 3, 6, and 12 months (p < 0.05). Overall, best results were observed in the combination group. However, the RAN and COM groups achieved very similar results. At 12 months, the CMT in all three groups was decreased compared with baseline (p < 0.05). Our results allow to conclude that the effect of early treatment with a single injection of intravitreal ranibizumab (cost reduction) and the stabilizing effect of grid laser photocoagulation is indeed an effective, feasible, and safe regiment for macular edema secondary to BRVO in Chinese patients, allowing to obviate the need for repeated intravitreal injections and thus reduce the adverse events, therapy duration, patients' malcompliance, and adverse events. A single ranibizumab therapy however is a comparable alternative.

The burden of disease of retinal vein occlusion: review of the literature.

Retinal vein occlusion (RVO) is the second most common cause of vision loss due to retinal vascular disease. A literature review was undertaken to understand the epidemiology, clinical consequence, current practice patterns, and cost of RVO. Pertinent articles were identified by computerized searches of the English language literature in MEDLINE supplemented with electronic and manual searches of society/association proceedings and bibliographies of electronically identified sources. Population-based studies report a prevalence rate of 0.5-2.0% for branch RVO and 0.1-0.2% for central RVO. The 15-year incidence rate is estimated to be 1.8% for branch RVO and 0.2% for central RVO. Patients with RVO report lower vision-related quality of life than those without ocular disease. Available treatment options are limited. Until recently there was no treatment for central RVO. Laser photocoagulation is only recommended for branch RVO in patients who have not experienced severe vision loss. Emerging evidence on the effectiveness of intravitreal anti-vascular endothelial growth factor therapy and dexamethasone intravitreal implant is promising. Information on the treatment patterns and cost of RVO is extremely limited with one retrospective analysis of secondary insurance payment data identified and limited to the United States population only. A better understanding of the economic and societal impact of RVO will help decision makers evaluate emerging medical interventions for this sight-threatening disease.

The quality of pharmacoeconomic evaluations of age-related macular degeneration therapeutics: a systematic review and quantitative appraisal of the evidence.

AIM: To appraise the quality of published pharmacoeconomic studies of therapeutic interventions for age-related macular degeneration (AMD). METHODS: Systematic review of the literature and evaluation of study quality using the Quality of Health Economic Studies instrument. A systematic search of the English-language literature for economic studies of therapeutic interventions for AMD from 1990 to March 2008 was performed. RESULTS: A total of 3637 articles were initially identified. Only 24 met eligibility criteria and were rated using the Quality of Health Economic Studies. The mean quality overall rating was 61.6, with quality scores ranging from 18 to 92. There was a higher mean quality score in the studies designed as clinical trials versus observational type designed studies (mean=74.7(11.4), 52.6 (16.5) respectively, p=0.002) and studies in which the statistical analyses were clearly presented versus studies in which the statistical analyses were not so clear (mean=74.3 (12.3), 53.1 (16.1) respectively, p=0.004). Interestingly, government funded studies exhibited a similar mean quality score to studies that were funded by industry (mean=71.0 (15.1), 61.7 (18.5) respectively, p=0.25). A general linear model was fitted using those independent variables which were significantly associated with quality score. The variables 'study design' and 'statistics presented clearly' were found to be jointly significant and explained nearly 70% of the variation in the dependent variable (R(2)=0.68). CONCLUSIONS: Our analysis reveals that the methodological quality of the health economic analysis of AMD therapeutic interventions in the literature is suboptimal. There is considerable variation in methodological rigour between the articles, and we have identified several attributes that are predictive of study quality.

Assessing the impact of complications on the costs of Type II diabetes.

AIMS/HYPOTHESIS: 'The Cost of Diabetes in Europe - Type II (CODE-2) study' provides the first coordinated attempt to assess the total costs of managing people with Type II (non-insulin-dependent) diabetes mellitus in Europe. Type II diabetes is associated with a number of serious long-term complications, which are a major cause of morbidity, hospitalisation and mortality in diabetic patients. METHODS: Patients were divided into four broad categories defining their complication status in terms of no complications, one or more microvascular complications, one or more macrovascular complications or one or more of each microvascular and macrovascular complication. The prevalence of complications and associated costs were assessed retrospectively for 6 months. RESULTS: In total, 72% of patients in the CODE-2 study had at least one complication, with 19% having microvascular only, 10% having macrovascular only and 24% of the total having both microvascular and macrovascular complications. Of patients with microvascular complications, 28% had neuropathy, 20% renal damage, 20% retinopathy and 6.5% required treatment for eye complications. Among the patients with macrovascular complications, 18% had peripheral vascular disease, 17% angina, 12% heart failure and 9% had myocardial infarction. Percutaneous transluminal coronary angioplasty, coronary artery bypass graft or stroke occurred in 3%, 4% and 5% of the patients, respectively. In patients with both microvascular and macrovascular complications, the total cost of management was increased by up to 250% compared to those without complications. CONCLUSION/INTERPRETATION: Complications have a substantial impact on the costs of managing Type II diabetes. This study has confirmed that the prevention of diabetic complications will not only benefit patients, but potentially reduce overall healthcare expenditure.

Continuous computer simulation analysis of the cost-effectiveness of screening and treating diabetic retinopathy.

This paper analyzes the cost-effectiveness of screening and treating diabetic retinopathy (DR) by simulating the disease progress continuously with existing data. A new computer simulation based on Monte Carlo techniques and logistic transformation follows cohorts from diabetes onset until death in five care scenarios. For younger-onset patients, ophthalmic care reduces the prevalence of blindness by 52% or greater while savings in disability facilities and production losses surpass direct costs. For older-onset patients, less favorable results appear. Financial benefits surpass costs for juvenile-onset patients. For other patients, the net costs of ophthalmic care seem lower than in other health care programs.

Assessing the costs and benefits of medical research: the diabetic retinopathy study.

Significant amounts of scarce resources are devoted to medical research, but there have been few attempts to assess whether the benefits to society of these investments exceed the costs. A method for undertaking such an assessment has been developed and applied retrospectively to the Diabetic Retinopathy Study, a major clinical trial funded by the National Eye Institute from 1972-1981. It was estimated that the trial, which cost $10.5 million, generated a net saving of $2816 million to society ($231 million when the costs of lost production are excluded) (1982 prices) and a gain to patients of 279,000 vision years. This approach could be applied prospectively in considering priorities for medical research, in conjunction with traditional criteria such as the scientific merit of the proposal and the capabilities of the investigators. The key factors affecting the economic returns from medical research are the prevalence, incidence and economic burden of the disease in question, the costs and effectiveness of the medical intervention concerned, the likely impact of the clinical trial on clinical practice and the likely timespan of benefits from knowledge obtained during the trial.

Endoscopic therapy of bleeding peptic ulcers: a cost-benefit analysis.

Endoscopic hemostatic therapies have become increasingly popular and appear capable of controlling hemorrhage from peptic ulcers and reducing the need for surgery, but many physicians are unsure that the efficacy justifies the cost. In order to study this clinically and economically important issue, we developed a mathematical model to analyze the economics of endoscopic therapy of bleeding peptic ulcers. Endoscopic therapy appears capable of reducing direct hospital costs only when selectively applied to those patients with the highest risk of requiring surgery. Sensitivity analysis identifies efficacy, treatment cost, and the rebleeding rate in untreated patients as the most critical variables affecting the cost of interventional endoscopy. Using neodymium: YAG laser photocoagulation as an example, interventional endoscopy can be cost-effective for treating selected patients with bleeding peptic ulcers. Should other hemostatic devices such as the heater probe and bipolar electrocoagulator prove to be as effective as the laser, even greater cost savings could be achieved.

Diabetic retinopathy - need and demand for photocoagulation and its cost-effectiveness: evaluation based on services in the United Kingdom.

Photocoagulation services in the two Regions, north of the River Thames, treated 6,589 cases of diabetic retinopathy (including an annual incidence of 309 cases) or 20% of the estimated total need for photocoagulation. Sixty-one percent of diabetic retinopathy patients have disease in both eyes. It is cheaper to treat a patient with diabetic retinopathy than to look after a blind person for one year. Hence, adequate training in the identification and early treatment of diabetic retinopathy requiring photocoagulation is urgent.