Abstract
This economic evaluation study compares the costs of intravitreal injections of aflibercept, 2 mg, vs pars plana vitrectomy plus panretinal photocoagulation for nonclearing vitreous hemorrhage secondary to proliferative diabetic retinopathy.
The DRCR Retina Network recently reported findings from their trial Protocol AB,1 wherein they investigated the effect of initial treatment with intravitreal injections of aflibercept, 2 mg, vs pars plana vitrectomy (PPV) plus panretinal photocoagulation (PRP) for nonclearing vitreous hemorrhage secondary to proliferative diabetic retinopathy.1 They found no statistically significant differences in visual acuity between these treatment strategies for the primary outcome, the mean change in visual acuity over 24 weeks, or a secondary end point, the mean change at 104 weeks. Given that visual acuity outcomes were not superior in one group vs the other, we evaluated the cost-effectiveness of each strategy under Medicare, the largest insurance payer in the US, as a factor to consider when choosing between these alternative treatment approaches.
Methods
A literature search capturing all studies from January 2008 to December 2020 was performed to find preexisting calculations of total Medicare reimbursement for intravitreal aflibercept, including both medication and administration costs, and combined PPV plus PRP. Then, the mean number of PPV plus PRP procedures was calculated from the original Protocol AB report supplement1 by totaling the number of reported surgeries and dividing by the number of participants. Because other factors, such as adverse events, cataract extraction (31% vs 27%), and tractional detachment repair (12% vs 13%), did not differ significantly between the treatment groups, their cost differences were excluded from this analysis. The costs of postoperative medications were not considered because they were not standardized. The costs of office visits (including postoperative visits), in-office testing, indirect costs (such as caregiver costs), and geographic factors that may modulate Medicare reimbursement were also not included. Then, these total costs of each administration of therapy were calculated using the Medicare reimbursement values, using Excel version 2103 (Microsoft). Data collection occurred within the past 2 years.
Results
Protocol AB included 205 participants (205 eyes) (mean [SD] age, 57 [11] years; 115 men [56.1%]). Including medication and administration costs, intravitreal aflibercept, 2 mg, cost a mean of $1953.2 Mean total costs for PPV plus PRP performed in facility settings (ie, in a hospital) and nonfacility settings (ie, in an ambulatory surgical center) were $4796 and $3145, respectively.3 The initial aflibercept group required means (SDs) of 8.9 (4.6) injections and 0.45 (0.70) PPVs over 104 weeks. The initial PPV plus PRP group required means (SDs) of 2.3 (4.3) injections and 1.18 (0.47) PPVs, including initial PPVs, over 104 weeks. Using these values, initial PPV plus PRP saved a mean (SD) of $9389 ($12 946) over 104 weeks when performed in a facility and a mean (SD) of $10 594 ($12 580) when performed in a nonfacility setting, compared with the initial aflibercept group (Table).
Table. Calculations to Compare Costs Over 104 Weeks Between Initial Intravitreous Aflibercept vs Pars Plana Vitrectomy (PVP) Plus Panretinal Photocoagulation (PRP) in Participants With Nonclearing Diabetic Vitreous Hemorrhage, Based on Medicare Reimbursements.
| Relevant outcome | Value |
|---|---|
| Holekamp et al,2 2019 | |
| Aflibercept base case vial cost, mean, $ | 1850 |
| Intravitreal administration cost, mean, $ | 103 |
| Lin et al,3 2018 | |
| Total facility costs for PPV plus PRP, mean, $ | 4796a |
| Total nonfacility costs for PPV plus PRP, mean, $ | 3145a |
| Antoszyk et al (Protocol AB),1 2020 | |
| Aflibercept group treatments over 104 wk, mean (SD) | |
| Injections | 8.9 (4.6) |
| Vitrectomies | 0.45 (0.70)b |
| PPV plus PRP group treatments over 104 wk, mean (SD) | |
| Injections | 2.3 (4.3) |
| Vitrectomies | 1.18 (0.47)b |
| Treatment costs, mean (SD), $ | |
| With facility costs | |
| Initial aflibercept group | 19 540 (9591) |
| Initial PPV plus PRP group | 10 151 (8695) |
| Cost savingsc | 9389 (12 946) |
| With nonfacility costs | |
| Initial aflibercept group | 18 797 (9250) |
| Initial PPV plus PRP group | 8203 (8527) |
| Cost savingsc | 10 594 (12 580) |
The costs of surgery included the surgical fees, professional fees (including anesthesiologist fees), and facility fees.3 The term facility indicates a hospital-based facility, while the term nonfacility indicates an office-based clinical service, including surgery performed in an ambulatory surgery center.
The mean number of vitrectomies per patient was calculated by totaling the number of vitrectomies divided by the total participants in the group, including the second, third, and fourth vitrectomies over the 2-year period, as reported in the article supplement of Antoszyk et al.1
Cost savings for the initial PPV plus PRP group over the initial aflibercept group.
Discussion
While the PPV plus PRP–first strategy was not shown to have superior visual acuity outcomes compared with the aflibercept-first strategy for nonclearing vitreous hemorrhage in proliferative diabetic retinopathy, this analysis shows the therapeutic cost of performing a surgical intervention first is about half that of initial medical therapy. It is difficult to extrapolate these results across the US health system, because the incidence of nonclearing vitreous hemorrhage from proliferative diabetic retinopathy is unknown, to our knowledge.
We acknowledge potential advantages to an aflibercept-first strategy for selected patients, such as those not healthy enough for an operative procedure. Furthermore, Protocol AB only studied participants up to 104 weeks; the cost analysis and visual acuity results may differ beyond this period, when the rate of injections could increase or decrease. Finally, it is possible that intravitreal bevacizumab, which is substantially less costly than aflibercept, may have economic advantages compared with PPV plus PRP first. However, a cost analysis of an intravitreal bevacizumab–first strategy cannot be done, because such a strategy, to our knowledge, has not been studied. Differential visual acuity outcomes when comparing bevacizumab with aflibercept have been shown with diabetic macular edema4 and macular edema secondary to central retinal vein occlusion.5 Given the financial disadvantages, transience of aflibercept’s effects, and potential consequences of noncompliance with follow-up in the clinical practice setting, we believe clinicians should strongly consider these findings when recommending a treatment strategy for patients similar to those enrolled in Protocol AB.6
References
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