A Value-Based Medicine Comparison of Interventions for Subfoveal Neovascular Macular Degeneration
Received 8 February 2006; accepted 18 September 2006. published online 23 February 2007.
Objective
To perform a value-based medicine analysis of clinical trials that evaluate the interventions of laser photocoagulation, intravitreal pegaptanib therapy, and photodynamic therapy (PDT) with verteporfin for the treatment of classic subfoveal choroidal neovascularization.
Design
Reference case cost-utility analysis using value-based medicine principles, which use patient-based utility values and standardized, input variable criteria.
Participants
Data from participants in the Macular Photocoagulation Study, Pegaptanib for Neovascular Age-Related Macular Degeneration Study, and the Treatment of Age-Related Macular Degeneration with Photodynamic Therapy Study.
Methods
Visual data were converted to a value-based format using time tradeoff utility analysis values from patients with macular degeneration. Costs were obtained from 2005 Medicare data. Outcomes (quality-adjusted life-years [QALYs]) and costs were discounted at a 3% annual rate.
Main Outcome Measures
Interventional QALYs gained, percent improvement in quality of life, and dollars spent per QALY gained.
Results
Laser photocoagulation confers a 4.4% (P = 0.03 versus pegaptanib therapy) improvement in quality of life for the reference case, whereas pegaptanib therapy confers a 5.9% improvement and PDT confers an 8.1% (P = 0.0002 versus pegaptanib therapy) improvement. The cost-utility associated with laser photocoagulation is $8179, that for pegaptanib therapy is $66978, and that for PDT is $31544. All sensitivity analyses remain within the conventional standards of cost-effectiveness.
Conclusions
Photodynamic therapy confers greater patient value than intravitreal pegaptanib therapy and laser photocoagulation for the treatment of classic subfoveal choroidal neovascularization. Despite the fact that laser photocoagulation is the most cost-effective intervention, both PDT and pegaptanib therapy deliver greater value, and thus are both preferred over laser photocoagulation. Using an economic measure, photodynamic therapy is the preferred treatment among these 3 interventions.
1Center for Value-Based Medicine, Flourtown, Pennsylvania.
2Retina Service, Wills Eye Hospital, Jefferson Medical College, Philadelphia, Pennsylvania.
3Eye Research Institute, Philadelphia, Pennsylvania.
4Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.
5Department of Ophthalmology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
6Cost-effective Ocular Health Policy Unit, Queens Medical College, Kingston, Canada.
Correspondence to Gary C. Brown, MD, MBA, Center for Value-Based Medicine, Box 335, Flourtown, PA 19031.
Manuscript no. 2006-173.
Supported in part by the Principals Initiative Research Award, Kingston, Canada, and Premier’s Award for Research Excellence, Kingston, Canada.
ABSTRACT