Cost Analysis of Intravitreal Aflibercept vs Vitrectomy With Panretinal Photocoagulation for Vitreous Hemorrhage From Proliferative Diabetic Retinopathy

Recent advances in the management of proliferative diabetic retinopathy

PURPOSE OF REVIEW

The prevalence of diabetic retinopathy continues to rise. This review highlights advances in imaging, medical, and surgical management of proliferative diabetic retinopathy (PDR) in recent years.

RECENT FINDINGS

Ultra-widefield fluorescein angiography has been shown to better characterize which patients have predominantly peripheral lesions and who may advance to more advanced forms of diabetic retinopathy. This was well demonstrated in DRCR Retina Network's Protocol AA. Protocol S demonstrated that antivascular endothelial growth factor (VEGF) treatment alone can be useful in the management of select PDR patients - particularly those without high-risk features. However, a growing body of literature highlights how lapse in care is a significant concern in PDR patients, and tailoring one's approach to treatment based on patient needs is recommended. In patients with high-risk features or where there is concern for lost-to-follow-up, incorporation of panretinal photocoagulation in the treatment paradigm is recommended. Protocol AB highlighted how patients with more advanced disease may benefit from earlier surgical intervention for earlier visual recovery but that continued anti-VEGF treatment may result in similar visual outcomes over a longer period. Finally, earlier surgical intervention for PDR without vitreous hemorrhage (VH) or retinal detachment is being considered a potential option to minimize treatment burden.

SUMMARY

Recent advances in imaging, as well as medical and surgical treatment options for PDR, have provided a deeper understanding of PDR management, which can be optimized for the individual patient.

A Caveat about Financial Incentives for Anti-Vascular Endothelial Growth Factor Therapy for Diabetic Retinopathy

PURPOSE

To highlight the financial incentive to the physician of choosing an intravitreal anti-VEGF based strategy for treatment of non-proliferative and proliferative diabetic retinopathy and its possible risks to the patient and costs to the healthcare system.

DESIGN

Perspective, with retrospective cost and profit analysis METHODS: Review and synthesis of selected literature on the treatment of diabetic retinopathy, with interpretation of activity- and time-based costing of an intravitreal aflibercept strategy for diabetic retinopathy. Data from the DRCR Retina Network Protocols W and AB and from the PANORAMA trial are used to illustrate the potential financial incentive underlying such a treatment strategy.

RESULTS

Physician treatment algorithms for diabetic vitreous hemorrhage and non-proliferative diabetic retinopathy may be influenced by the substantial financial incentives intravitreal aflibercept strategies present despite functional equivalence with alternative, less profitable, strategies. For example, pursuing an intravitreal aflibercept based strategy for diabetic vitreous hemorrhage presents a 76% increased profit over pars plana vitrectomy with laser, with equivalent functional outcomes. For non-proliferative diabetic retinopathy, preventative aflibercept injections represent a potential 414% increase in profit over observation and an increased cost of $12164 to $17542 over two years per patient, with no improvement in visual function. These findings demonstrate that there may be misaligned financial incentives in the management of diabetic retinopathy.

CONCLUSIONS

While anti-VEGF therapy is a useful tool in the management of proliferative diabetic retinopathy and diabetic macular edema, we believe physicians should avoid overreliance on anti-VEGF injections in the treatment of diabetic retinopathy. Retina specialists should be cognizant of the limitations, costs and risks of anti-VEGF monotherapy and prophylactic therapy, and of the imperative to avoid bias towards financially remunerative practice patterns when equally effective alternatives exist.