Objective
Anti-vascular endothelial growth factor therapies have revolutionized the treatment of clinically significant diabetic macular (CSDME); yet these agents are expensive, and whether they are cost-effective is unclear. The purpose of this study is to determine the most cost-effective treatment option for patients with newly diagnosed CSDME: focal laser photocoagulation alone (L), focal laser plus intravitreal ranibizumab (L+R), focal laser plus intravitreal bevacizumab (L+B), or focal laser plus intravitreal triamcinolone (L+T) injections.
Design
Cost effectiveness analysis
Participants
Hypothetical cohort of 57 year old patients with newly-diagnosed CSDME.
Methods
Using a Markov model with a 25-year time horizon, we compared the incremental cost-effectiveness of treating patients with newly-diagnosed CSDME using L, L+R, L+B, or L+T. Data came from the DRCRnet randomized controlled trial, the Medicare Fee Schedule, and the medical literature.
Main Outcome Measures
Costs, quality-adjusted life years (QALYs), and incremental costs per QALY gained.
Results
Compared with L, the incremental cost-effectiveness of L+R and L+B were $89,903/QALY and $11,138/QALY, respectively. L+T was dominated by L. A probabilistic sensitivity analysis demonstrated, at a willingness-to-pay (WTP) of $50,000/QALY, that L was approximately 70% likely to be the preferred therapy over L+R and L+T. However, at a WTP of $100,000/QALY, more than 90% of the time, L+R therapy was the preferred therapy, compared with L and L+T. In the probabilistic sensitivity analysis, L+B was found to be the preferred therapy over L and L+T for any WTP value above $10,000/QALY. Sensitivity analyses revealed that the annual risk of cerebrovascular accident would have to be at least 1.5% higher with L+B than with L+R for L+R to be the preferred treatment. In another sensitivity analysis, if patients require < 8 injections per year over the remainder of the 25-year time horizon, L+B would cost less than $100,000/QALY, whereas L+R would be cost-effective at a WTP of $100,000/QALY if patients require fewer than 0.45 injections per year after year 2.
Conclusion
With bevacizumab and ranibizumab assumed to have equivalent effectiveness and similar safety profiles when used in the management of CSDME, bevacizumab therapy confers the greatest value among the different treatment options for CSDME.