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Treatment of Neovascular Age-Related Macular Degeneration: An Economic Cost-Risk Analysis of Anti-VEGF agents

Published:August 25, 2021DOI:https://doi.org/10.1016/j.oret.2021.08.009

      Abstract

      Objective

      To find the best cost-effective NVAMD treatment to improve vision while avoiding complications. The model is based on a cost-risk tradeoff analysis from policymakers’ perspective.

      Design

      A powerful and flexible simulation models outcomes of 2 years of treatment with the four commonly used anti-VEGF drugs (bevacizumab, ranibizumab, aflibercept, and brolucizumab) across three injection protocols, building on prior findings that these drugs are non-inferior. The model incorporates blinding complications, their management, and associated cost to society. Each option and several “what-if” scenarios were simulated 1,000 times with 100,000 hypothetical patients.

      Participants

      100,000 simulated patients using data from published clinical trials.

      Method

      Case- and eye-specific cost-risk economic analysis.

      Main Outcome Measures

      Costs of NVAMD treatment per patient and number of eyes that become blind due to treatment over 2 years.

      Results

      Using published prices and fees, the injection protocol that follows published clinical studies, results showed that the mean (SD) cost per patient were $16,859 (3.65), $32,949 (3.27), $39,831 (3.80), and $53,056 (2.99) for bevacizumab, brolucizumab, aflibercept, and ranibizumab. The numbers of treated eyes that became blind were 108 (10.18), 694 (26.66), 168 (12.83), and 108 (10.52) respectively. We further provide a lower bound (when all patients are maximally extended) and upper bound (when no patient is extended) to these numbers. For brolucizumab the upper bound is the 2-month interval injection protocol.

      Conclusions

      Taking a policymaking perspective, this study suggests that bevacizumab is the preferred first-line therapy. Recommendation for second-line therapy depends on the extent of the policymaker’s risk-aversion because of the tradeoff between cost and risk of blindness due to treatment. If risk-neutral, the least expensive option (brolucizumab) is preferred. But if moderate to high, then aflibercept or ranibizumab are preferred. Since medical advances and different costs may change our findings, we provide a free application (https://eye-inj.shinyapps.io/calc/) for readers who wish to use different cost structures. Simulating outcomes is an innovative approach, unique in ophthalmology, and presents significant opportunity as it can be easily adapted to different settings (using different costs, risks, and protocols), and to other diseases (e.g., DME), to ultimately improve wide-scale decision-making and use of funds.
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