Cost-utility analysis of cataract surgery in the United States for the year 2018

Global estimates on the number of people blind or visually impaired by cataract: a meta-analysis from 2000 to 2020

BACKGROUND

To estimate global and regional trends from 2000 to 2020 of the number of persons visually impaired by cataract and their proportion of the total number of vision-impaired individuals.

METHODS

A systematic review and meta-analysis of published population studies and gray literature from 2000 to 2020 was carried out to estimate global and regional trends. We developed prevalence estimates based on modeled distance visual impairment and blindness due to cataract, producing location-, year-, age-, and sex-specific estimates of moderate to severe vision impairment (MSVI presenting visual acuity <6/18, ≥3/60) and blindness (presenting visual acuity <3/60). Estimates are age-standardized using the GBD standard population.

RESULTS

In 2020, among overall (all ages) 43.3 million blind and 295 million with MSVI, 17.0 million (39.6%) people were blind and 83.5 million (28.3%) had MSVI due to cataract blind 60% female, MSVI 59% female. From 1990 to 2020, the count of persons blind (MSVI) due to cataract increased by 29.7%(93.1%) whereas the age-standardized global prevalence of cataract-related blindness improved by -27.5% and MSVI increased by 7.2%. The contribution of cataract to the age-standardized prevalence of blindness exceeded the global figure only in South Asia (62.9%) and Southeast Asia and Oceania (47.9%).

CONCLUSIONS

The number of people blind and with MSVI due to cataract has risen over the past 30 years, despite a decrease in the age-standardized prevalence of cataract. This indicates that cataract treatment programs have been beneficial, but population growth and aging have outpaced their impact. Growing numbers of cataract blind indicate that more, better-directed, resources are needed to increase global capacity for cataract surgery.

Economic evaluations in cataract surgery: a narrative review

Economic evaluations are tools for assessing emerging technologies and a complement for decision-making in healthcare systems. However, this topic may not be familiar for doctors and academics, who may be confused when interpreting the results of studies using these tools. Cataract is a disease which has received special attention in healthcare systems due to its high incidence, the great impact that it could have on patients' quality of life, and the fact that it can be definitively solved in almost all cases through cataract surgery. Historically, economic evaluations in cataract surgery have been conducted for many purposes by simply assessing whether the surgery is cost-effective for specific questions related to the implantation of multifocal intraocular lenses, surgical techniques, optimizing assessments, preventing diseases or complications, etc. Moreover, although there are systematic reviews about cataract surgery and narrative reviews introducing the concept of economic evaluations, as far as we know, no previous study has been conducted that synthesizes and integrates evidence coming from both fields. Thus, the purpose of this narrative review is to introduce doctors and academics to economic evaluation tools, to describe how these have been historically applied to cataract surgery, and to provide special considerations for the correct interpretation of economic studies.

Comparison of current relative value unit-based prices and utility between common surgical procedures, including orthopedic surgeries, in South Korea

BACKGROUND

The medical pricing system strongly influences physicians' job satisfaction and patient health outcomes. This study aimed to investigate the current relative value unit (RVU)-based pricing and utility of patients in commonly performed surgical procedures in South Korea.

METHODS

Fifteen common surgical procedures were selected from OECD statistics, and three additional orthopedic procedures were examined. The current pricing of each surgical procedure was retrieved from the Korea National Health Insurance Service, and the corresponding utilities were obtained as quality-adjusted life year (QALY) gains from previous studies. The relationship between the current prices (RVUs) and the patients' utility (incremental QALY gains/year) was analyzed. Subgroup analysis was performed between fatal and non-fatal procedures and between orthopedic and non-orthopedic procedures.

RESULTS

A significant negative correlation (r = - 0.558, p < 0.001) was observed between RVU and incremental QALY among all 18 procedures. The fatal subgroup had a significantly higher RVU than the non-fatal subgroup (p < 0.05), while the former had a significantly lower incremental QALY than the latter (p < 0.001). Orthopedic procedures showed higher incremental QALY values than non-orthopedic procedures, but they did not show higher prices (RVU).

CONCLUSIONS

This paradoxical relationship between current prices and patient utility is attributed to the higher pricing of surgical procedures for fatal and urgent conditions. Orthopedic surgery has been found to be a cost-effective treatment strategy. These findings could contribute to a better understanding of the potential role of incremental QALY in pursuing value-based purchasing or reasonable modification of the current medical fee schedule.

Sociodemographic Disparities in Preoperative Visual Acuity and Cataract Surgery Utilization in the San Francisco Bay Area

OBJECTIVE

We examined whether cataract surgery utilization and preoperative visual acuity were associated with patient-specific factors, including ocular findings and comorbidities, general biomedical factors, and/or sociodemographic factors.

DESIGN

Retrospective, cross-sectional study.

SUBJECTS, PARTICIPANTS, AND/OR CONTROLS

We reviewed the electronic health records of patients from 2012 to 2022 who were examined and followed for at least 2 years by an eye care provider at University of California San Francisco Health (UCSF Health) and who had cataract in at least one eye associated with best-corrected visual acuity of 20/25 or worse. Data include ocular factors (e.g., best-corrected visual acuity, lens opacity grade, diagnoses of glaucoma, and/or age-related macular degeneration), biomedical comorbidities, and sociodemographic factors including race/ethnicity, health insurance coverage, primary language spoken, and social vulnerability index.

METHODS

Logistic and multivariate regression analyses.

MAIN OUTCOME MEASURES

We examined cataract surgery utilization and preoperative best-corrected visual acuity.

RESULTS

Compared to White and Asian patients, Black patients had the lowest rates of cataract surgery utilization and the poorest mean preoperative visual acuities, with Hispanic patients following in second place in both categories. However, when the analysis controlled for sociodemographic and biomedical factors, Medicaid insurance and speaking Chinese as a primary language emerged as significant associations. In addition, higher cataract surgery utilization rates were associated with worse preoperative best-corrected visual acuity, a concurrent diagnosis of glaucoma, and a concurrent diagnosis of macular degeneration. Worse preoperative visual acuity was associated with Spanish or Chinese language preference, Medicaid status, and glaucoma diagnosis; poorer preoperative visual acuity was only weakly correlated with increased social vulnerability.

CONCLUSIONS

After adjusting for other biomedical and sociodemographic variables, having Medicaid insurance and being a non-English speaker were the factors most notably associated with reduced cataract surgery utilization and poorer preoperative visual acuity. Health insurance and language barriers, as well as other biomedical and sociodemographic factors, may explain a large proportion of the racial disparities in both cataract surgery utilization and preoperative visual acuity observed among Black and Hispanic patients. Chinese-speaking patients with limited English proficiency are a vulnerable subgroup that exhibits lower rates of cataract surgery utilization and higher degrees of visual loss prior to undergoing cataract surgery compared to other Asian patients.

Prevention Surpasses Treatment: 5-year Follow-Up, Cost-Utility, and Cost-Benefit of Zeaxanthin Therapy for Neovascular Age-Related Macular Degeneration

INTRODUCTION

Oral administration of zeaxanthin (Zx) 20 mg daily in patients with unilateral neovascular age-related macular degeneration (nAMD) treated with triple therapy (photodynamic therapy/intravitreal bevacizumab/intravitreal dexamethasone) reduced fellow-eye 2-year nAMD incidence from 23 to 6% (p = 0.02) in a prior clinical trial. We questioned the long-term benefit and thus analyzed case-control 5-year patient data of trial participants and additional participants with 5-year follow-up, also performing cost-utility and cost-benefit analyses.

METHODS

Consecutive, unilateral nAMD patient outcomes for those taking 20 mg Zx supplementation orally for ≥ 5 years were compared with the Comparison of AMD Treatments Trials (CATT) 5-year historical controls for fellow-eye nAMD conversion. Eleven-year mean life expectancy, cost-utility and cost-benefit models were undertaken employing a 3% discount rate and 2020 US real dollars.

RESULTS

Among 227 consecutive patients with nAMD/Zx-supplementation, 202 (90%) had 5-year follow-up. The fellow-eye nAMD 5-year conversion incidence using a Kaplan-Meier cumulative event estimate was 22% (49/227), versus 48% (167/348) with CATT control data (p < 0.0001). An 11-year cost-utility model with estimates for years 6-11 demonstrated a 0.42 (7.7%) QALY (quality-adjusted life-year) gain, including 3 months of life saved per patient due to decreased nAMD fellow-eye conversion. This yielded a direct ophthalmic medical cost perspective, incremental cost-utility ratio (CUR) of -$576/QALY and a societal cost perspective CUR of -$125,071/QALY. Zx supplementation for all 2020 US unilateral nAMD cases would have theoretically saved society, primarily patients, $6.0 billion over 11 years, a 1531% return on investment (ROI), or 31.3% annual ROI, on Zx costs.

CONCLUSIONS

Oral zeaxanthin supplementation for unilateral nAMD patients appears to decrease fellow-eye long-term incidence and is cost-effective and financially rewarding. It is dominant vs. no supplementation in patients presenting with unilateral nAMD.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT01527435.

Role of Chondroitin Sulfate Proteoglycan 5 in Steroid-Induced Cataract

Steroid-induced cataracts (SIC) are defined as cataracts associated with the administration of corticosteroids. Long-term glucocorticoid treatment for inflammatory diseases reportedly increases the risk of SIC, and steroids can induce cataracts by disrupting ocular growth factor balance or homeostasis. In this study, we verified the effect of chondroitin sulfate proteoglycan 5 (CSPG5) using dexamethasone (dexa)-treated human lens epithelial (HLE-B3) cells and the lens epithelium from the anterior capsule of SIC patients obtained during cataract surgery. CSPG5 expression increased in the lens epithelium of SIC patients. The downregulation of CSPG5 suppressed the dexa-induced epithelial-mesenchymal transition (EMT)-related protein expression and motility in HLE-B3 cells. The disruption of the transcription factors EZH2 and B-Myb downregulated CSPG5, dexa-induced fibronectin expression, and cell migration in HLE-B3 cells, reaffirming that CSPG5 expression regulates EMT in lens epithelial cells. Taken together, these results indicate that the steroid-induced effects on lens epithelial cells are mediated via alterations in CSPG5 expression. Therefore, our study emphasizes the potential of CSPG5 as a therapeutic target for the prevention and treatment of SIC.

Economic Evaluation of Cataract: A Systematic Mapping Review

INTRODUCTION

The purpose of this article was to ascertain the existing literature and find the gaps in economic evaluations of cataracts.

METHODS

Systematic methods were used to search and collect the published literature on economic evaluations of cataracts. A mapping review of studies published in the following bibliographical databases was performed: the National Library of Medicine (PubMed), EMBASE, Web of Science (WOS), and the Central of Reviews and Dissemination (CRD) database. A descriptive analysis was conducted and relevant studies were classified into different groups.

RESULTS

Among 984 studies screened, 56 studies were included in the mapping review. Four research questions were answered. There has been a progressive increase of publications during the last decade. The majority of the included studies were published by authors from institutions in the USA and UK. The most commonly investigated area was cataract surgery followed by intraocular lenses (IOLs). The studies were classified into different categories according to the main outcome evaluated, such as comparisons between different surgical techniques, costs of the cataract surgery, second eye cataract surgery costs, quality of life gain after cataract surgery, waiting time of cataract surgery and costs, and cataract evaluation, follow-up, and costs. In the IOL classification, the most frequently studied area was the comparison between monofocal and multifocal IOLs, followed by the comparison between toric and monofocal IOLs.

CONCLUSIONS

Cataract surgery is a cost-effective procedure compared with other non-ophthalmic and ophthalmic interventions and surgery waiting time is an important factor to consider because vision loss has a huge and broad-ranging impact on society. Numerous gaps and inconsistencies are found among the studies included. For this reason, there is a need for further studies according to the classification described in the mapping review.

Vitamin D Supplementation and the Incidence of Cataract Surgery in Older Australian Adults

PURPOSE

Observational studies suggest that higher serum 25-hydroxy vitamin D (25(OH)D) concentration may be associated with lower risk of cataract. However, no randomized controlled trials have assessed the effect of vitamin D supplementation on the incidence of cataract. We aimed to assess whether vitamin D supplementation reduces the incidence of cataract surgery.

DESIGN

We conducted an ancillary study of the D-Health Trial, a randomized, double-masked, placebo-controlled trial of monthly vitamin D conducted from 2014 through 2020 within the Australian general population.

PARTICIPANTS

We invited 421 207 men and women 60 to 84 years of age to participate; including an additional 1896 volunteers, 40 824 expressed interest. Those with hypercalcemia, hyperparathyroidism, kidney stones, osteomalacia, or sarcoidosis or those who were taking more than 500 international units (IU) supplemental vitamin D per day were excluded. A total of 21 315 were randomized, and 1390 participants did not fulfil the eligibility criteria for this analysis (linked data available, no cataract within first 6 months), leaving 19 925 included. The median follow-up was 5 years.

METHODS

Participants took 60 000 IU of vitamin D₃ (n = 10 662) or placebo (n = 10 653) orally once per month for a maximum of 5 years.

MAIN OUTCOME MEASURES

The primary outcome for this analysis was the first surgical treatment for cataract, ascertained through linkage to universal health insurance records and hospital data.

RESULTS

Among 19 925 participants eligible for this analysis (mean age, 69.3 years; 46% women) 3668 participants (18.4%) underwent cataract surgery during follow-up (vitamin D: n = 1841 [18.5%]; placebo: n = 1827 [18.3%] ). The incidence of cataract surgery was similar between the two groups (incidence rate, 41.6 and 41.1 per 1000 person-years in the vitamin D and placebo groups, respectively; hazard ratio, 1.02; 95% confidence interval, 0.95-1.09). In prespecified subgroup analyses, the effect of vitamin D supplementation on the incidence of cataract surgery was not modified by age, sex, body mass index, predicted serum 25(OH)D concentration, or ambient ultraviolet radiation.

CONCLUSIONS

Routinely supplementing older adults who live in an area with a low prevalence of vitamin D deficiency with high-dose vitamin D is unlikely to reduce the need for cataract surgery.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Cost-Effectiveness of Preoperative Topical Antibiotic Prophylaxis for Endophthalmitis Following Cataract Surgery

PURPOSE

To determine the cost-effectiveness of preoperative topical antibiotic prophylaxis for the prevention of endophthalmitis following cataract surgery.

DESIGN

Cost-effectiveness analysis using a decision-analytic microsimulation model.

METHODS

Preoperative topical antibiotic prophylaxis vs no-prophylaxis costs and effects were projected over a life-time horizon for a simulated cohort of 500 000 adult patients (≥18 years old) requiring cataract surgery in theoretical surgical centers in the United States. Efficacy and cost (2021 US dollars) values were obtained from the literature and discounted at 3% per year.

RESULTS

Based on inputted parameters, the mean incidence of endophthalmitis following cataract surgery for preoperative topical antibiotic prophylaxis vs no-prophylaxis was 0.034% (95% CI 0%-0.2%) and 0.042% (95% CI 0%-0.3%), respectively-an absolute risk reduction of 0.008%. The mean life-time costs for cataract surgery with prophylaxis and no-prophylaxis were $2486.67 (95% CI $2193.61-$2802.44) and $2409.03 (95% CI $2129.94-$2706.69), respectively. The quality-adjusted life-years (QALYs) associated with prophylaxis and no-prophylaxis were 10.33495 (95% CI 7.81629-12.38158) and 10.33498 (95% CI 7.81284-12.38316), respectively. Assuming a cost-effectiveness criterion of ≤$50 000 per QALY gained, the threshold analyses indicated that prophylaxis would be cost-effective if the incidence of endophthalmitis after cataract surgery was greater than 5.5% or if the price of the preoperative topical antibiotic prophylaxis was less than $0.75.

CONCLUSIONS

General use of preoperative topical antibiotic prophylaxis is not cost-effective compared with no-prophylaxis for the prevention of endophthalmitis following cataract surgery. Preoperative topical antibiotic prophylaxis, however, would be cost-effective at a higher incidence of endophthalmitis and/or a substantially lower price for prophylaxis.

Development Pattern of Medical Device Technology and Regulatory Evolution of Cataract Treatment

To prevent regulation from becoming an obstacle to healthcare technological innovation, regulation should evolve as new healthcare technologies are developed. Although regulation is closely related to healthcare technology development, there are few studies that view healthcare technological advances from the multi-layered perspective of papers, patents, and clinical research and link this with regulatory evolution. Therefore, this study tried to develop a new method from a multi-layer perspective and draw regulatory implications based on it. This study applied this method to intraocular lens (IOLs) for cataract treatment and detected four major healthcare technologies and two recent healthcare technologies. Moreover, it discussed how current regulations evaluate these technologies. The findings provide implications for healthcare technological advances and the evolutionary direction of regulation through the example of IOLs for cataract treatment. This study contributes to the development of theoretical methods for co-evolution with regulations based on healthcare technology innovation.

An update on immediate sequential bilateral cataract surgery

PURPOSE OF REVIEW

The aim of this study was to present an overview of recent publications and opinions in the field of same-day bilateral cataract surgery.

RECENT FINDINGS

A Cochrane review was published comparing immediate sequential bilateral cataract surgery (ISBCS) and delayed sequential bilateral cataract surgery (DSBCS) with regard to safety outcomes, costs and cost-effectiveness. In addition, several large database studies provided more information on incidences of rare complications such as unilateral and bilateral endophthalmitis rates.

SUMMARY

Recently available evidence showed that ISBCS is an effective and cost-effective alternative to DSBCS. Nonetheless, additional (randomized) registry studies, randomized controlled trials and cost-effectiveness studies are needed to evaluate bilateral endophthalmitis rates, refractive outcomes and cost-effectiveness of ISBCS compared with DSBCS.

Advanced Retina Implants

PURPOSE

To discuss the role of advanced retinal implants in retinitis pigmentosa and age-related macular degeneration.

DESIGN

Presented by Mark S. Humayun as the Charles Schepen's Lecture on the Retina Subspecialty Day of the American Academy of Ophthalmology in 2021.

PARTICIPANTS

The details of subjects, participants, and controls are provided in the references pertaining to each study.

METHODS

Review of published literature and clinical trials.

MAIN OUTCOME MEASURES

Visual and anatomic outcomes from retinal implants.

RESULTS

Retinal implants have been researched over the past few decades, and some have been advanced into the clinic. Two types of implants-bioelectronic and stem cell-based-have shown promising results in restoring some level of vision in patients with inherited retinal degeneration and geographic atrophy. These implants differ in their constructions, locations of implantation, and safety profiles. The results from some of these retinal implants have shown signs of efficacy, and 1 retinal implant, the Argus II, has been approved by the United States Food and Drug Administration.

CONCLUSIONS

Careful consideration of the design of the implant and associated surgical techniques are necessary to obtain a stable and effective long-term interface between the implant and the retina.

The Cost-Effectiveness of a Telemedicine Screening Program for Diabetic Retinopathy in New York City

Background

A telemedicine screening initiative was implemented by the Montefiore Health System to improve access to eyecare for a multi-ethnic, at-risk population of diabetic patients in a largely underserved urban community in the Bronx, New York. This retrospective, cross-sectional analysis evaluates the societal benefit and financial sustainability of this program by analyzing both cost and revenue generation based on current standard Medicare reimbursement rates.

Methods

Non-mydriatic fundus cameras were placed in collaboration with a vendor in eight outpatient primary care sites throughout the Montefiore Health Care System, and data was collected between June 2014 and July 2016. Fundus photos were electronically transmitted to a central reading center to be systematically reviewed and coded by faculty ophthalmologists, and patients were subsequently scheduled for ophthalmic evaluation based upon a predetermined treatment algorithm. A retrospective chart review of 2251 patients was performed utilizing our electronic medical record system (Epic Systems, Verona WI). Revenue was projected utilizing standard Medicare rates for our region while societal benefit was calculated using quality adjusted life years (QALY).

Results

Of the 2251 patient charts reviewed, 791 patients (35.1%) were seen by Montefiore ophthalmologists within a year of the original screening date. Estimated revenue generated by these visits was $276,800, with the majority from the treatment of retinal disease ($208,535), and the remainder from other ophthalmic conditions detected in the fundus photos ($68,265). There was a societal benefit of 14.66 quality adjusted life years (QALYs) with an estimated value of $35,471/QALY.

Conclusion

This telemedicine initiative was successful in identifying many patients with diabetic retinopathy and other ophthalmic conditions who may otherwise not have been formally evaluated. Our analysis demonstrates the program to generate a downstream revenue of nearly $280K with a cost benefit below <50% of the threshold of $100,000/QALY, and therefore cost-effective in marginalized communities.

Utilization of Crowdfunding for Cataract and LASIK Procedures

PURPOSE

To study the nature of crowdfunding campaigns for common ophthalmologic procedures.

METHODS

Cross sectional, retrospective study of campaigns on GoFundMe.com from January 1st, 2021 to July 31st, 2021. All domestic and international campaigns referring to cataract and intraocular lens placement or LASIK procedures, excluding those with non-ophthalmologic conditions or campaigns for multiple conditions. Descriptive analysis of campaigns including condition, country of origin of patient, total and median value raised, total and median value sought, age of the patient, funding goal met, insurance status when possible. Total and median funds raised and sought, international versus domestic campaigns, success rate for campaigns, percent of campaigns involving children, percent of campaigns mentioning insurance.

RESULTS

137 campaigns were identified, 67.9% (93/137) were for cataract and 32.1% (44/137) were for LASIK. 13.1% (18/137) of campaigns were international. 7.3% (10/137) campaigns were successful at reaching funding goals. Of successful campaigns, 70.0% (7/10) were for cataract and 30.0% (3/10) were for LASIK. Total value raised (in USD) was $131,763, where $106,593 was for cataract and $25,170 was for LASIK. The median value sought overall was $5,000, where the median sought for cataract procedures was $5,000 and the median for LASIK was $4,000. The median value raised was $395. 5.8% (8/137) of campaigns mentioned minors. 12.5% (1/8) of campaigns for children or minors successfully met funding goals compared to 7.0% (9/129) adult campaigns. The total funds raised for children or minors was $9,224 with a goal of $41,050. The total funds raised for adults was $122,539 out of a goal of $775,617. 14.6% (20/137) campaigns mentioned insurance coverage, of which 85% (17/20) were for cataract and 15.0% (3/20) were for LASIK. Premium lenses (toric, multifocal, etc.) were mentioned in 1.1% of cataract campaigns (1/93) as being cost prohibitive.

CONCLUSIONS

Crowdfunding is ineffective as a means for patients to raise funds for ophthalmic procedures. The broad range of financial requests within campaigns indicates a large patient knowledge gap in cost for procedures.

The carbon footprint of cataract surgery in a French University Hospital

PURPOSE

To assess the carbon footprint of cataract surgery in a French university hospital.

SETTING

Operating room of Cochin University Hospital, Paris, France.

DESIGN

Single-center component analysis.

METHODS

One day of surgery was used as a reference. Greenhouse gases (GHG) related to patient and staff transportation were calculated based on the distance travelled and the means of transportation used. The annual consumption of energy (heating and electricity) of our building was converted in kg equivalent of carbon dioxide (CO₂eq), and the principle of proportionality was used to calculate what was used for a single cataract procedure. GHG emissions related to the life cycle assessment (LCA) of the equipment used and the sterilization process were calculated.

RESULTS

The LCA of disposable items accounted for 59.49kg (73.32%) of CO₂eq for each procedure. A single procedure generated 2.83±0.10kg of waste. The average CO₂eq produced by the transportation of the patients to and from our center, adjusted for one procedure, was 7.26±6.90kg (8.95%) of CO₂eq. The CO₂eq produced by the sterilization of the phacoemulsifier handpiece was 2.12kg (2.61%). The energy consumption of the building and staff transportation accounted for the remaining CO₂eq emissions, 0.76kg (0.93%) and 0.08kg (0.10%) respectively. Altogether, the carbon footprint of one cataract procedure in our center was 81.13kg CO₂eq - the equivalent of an average car driving 800km.

CONCLUSION

Our data provide a basis to quantify cataract surgery as a source of GHG and suggests that reductions in emissions can be achieved.

Opportunities to Reduce Potential Bias in Ophthalmic Cost-Utility Analysis

IMPORTANCE

Select research methods in cost-utility analysis (incremental cost-effectiveness analysis) might potentially bias against patient value (quality-adjusted life-year [QALY]) gain and cost-effectiveness associated with common ophthalmic interventions in disabled, elderly, and African American populations.

OBJECTIVE

To ascertain whether using nonpatient vision utilities and/or a maximum limit model constraining vision utility gain to the systemic comorbidity utility level biases against ophthalmic cost-utility outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation predominantly used data from the Center for Value-Based Medicine database to perform preference-based comparative effectiveness and cost-utility analyses for cataract surgery and intravitreal ranibizumab therapy for neovascular age-related macular degeneration (NVAMD) using vision utilities acquired from patients with ophthalmic disease (ophthalmic patient utilities) and from surrogate individuals (nonophthalmic patient vision utilities) with and without integrating systemic comorbidity utility limits on vision utility gain. Ophthalmic patient data were collected from January 1, 2000, to December 31, 2016, and analyzed from April 1 to July 1, 2020.

INTERVENTIONS

Cost-utility analysis with 3% discount rate in 2018 US dollars.

MAIN OUTCOMES AND MEASURES

QALY gains and dollars expended per QALY gain (the cost-utility ratio).

RESULTS

A total of 309 participants in the nonophthalmic patient cohort and 505 patients in the ophthalmic patient cohort were included. A reference case of first-eye cataract surgery using ophthalmic patient vision utilities and no systemic comorbidity utility limits yielded a 2.574 (34.2%) QALY gain vs observation. Substituting nonophthalmic patient utilities resulted in a 1.502 (15.5%) QALY gain, whereas using the 0.76 patient systemic comorbidity utility to limit cataract surgery vision utility gain yielded a 1.337 (17.8%) QALY gain. Using both nonophthalmic patient utilities and systemic comorbidity utility limits yielded a 0.839 (8.7%) QALY gain. The substitutions decreased cataract surgery cost-effectiveness by 71.3% (95% CI, 70.6%-72.1%) for nonophthalmic patient utilities, 92.5% (95% CI, 51.9%-133.1%) for patient systemic comorbidity utility, and 206.8% (95% CI, 202.6%-211.2%) for both. The NVAMD ranibizumab therapy reference case yielded a 1.339 (26.1%) QALY gain. Similar substitutions resulted in QALY gains of 1.164 (22.7%) for nonophthalmic patient utilities while reducing cost-effectiveness by 16.4%, 1.001 (19.5%) for systematic-limiting comorbidity utility while reducing cost-effectiveness by 33.8%, and 0.971 (18.9%) for both while reducing cost-effectiveness by 37.9%.

CONCLUSIONS AND RELEVANCE

Using nonophthalmic patient vision utilities and/or the maximum limit model of limiting patient utility gains to the population systemic comorbidity utility level resulted in large decreases in patient value (QALY) gain and cost-effectiveness for common ophthalmic interventions. Ophthalmologists should realize these phenomena and consider correcting the potential discrimination against disabled, elderly, and African American populations. This negative potential bias could theoretically result in beneficial intervention denial, less research dollars, curbed therapeutic advances, and decreased interventional reimbursement.

A Mechanistic Review of β-Carotene, Lutein, and Zeaxanthin in Eye Health and Disease

Carotenoids are natural lipid-soluble antioxidants abundantly found as colorful pigments in fruits and vegetables. At least 600 carotenoids occur naturally, although about 20 of them, including β-carotene, α-carotene, lycopene, lutein, zeaxanthin, meso-zeaxanthin, and cryptoxanthin, are detectable in the human blood. They have distinct physiological and pathophysiological functions ranging from fetal development to adult homeostasis. β-carotene is a precursor of vitamin A that essentially functions in many biological processes including vision. The human macula lutea and eye lens are rich in lutein, zeaxanthin, and meso-zeaxanthin, collectively known as macular xanthophylls, which help maintain eye health and prevent ophthalmic diseases. Ocular carotenoids absorb light from the visible region (400-500 nm wavelength), enabling them to protect the retina and lens from potential photochemical damage induced by light exposure. These natural antioxidants also aid in quenching free radicals produced by complex physiological reactions and, consequently, protect the eye from oxidative stress, apoptosis, mitochondrial dysfunction, and inflammation. This review discusses the protective mechanisms of macular xanthophylls in preventing eye diseases such as cataract, age-related macular degeneration, and diabetic retinopathy. Moreover, some preclinical animal studies and some clinical trials are discussed briefly to understand carotenoid safety and efficacy.

Cost-Utility Analysis of VEGF Inhibitors for Treating Neovascular Age-Related Macular Degeneration

PURPOSE

To perform 11- and 2-year health care sector (ophthalmic) and societal cost perspective reference case, cost-utility analyses comparing bevacizumab, ranibizumab, and aflibercept monotherapies for neovascular age-related macular degeneration (NVAMD).

DESIGN

Cost-utility analysis.

METHODS

The authors performed 11-year and 2-year ophthalmic and societal cost perspective, cost-utility analyses comparing bevacizumab, ranibizumab, and aflibercept monotherapies for neovascular age-related macular degeneration (NVAMD). We employed patient utilities, bilateral outcomes, 2018 U.S. dollars, vision-related mortality, a Medicare fee schedule, and CATT (Comparison of Age-Related Macular Degeneration Treatments) study and VIEW (VEGF Trap-Eye: Investigation of Efficacy and Safety in Wet AMD) trial. Cochrane data were also used.

SETTING

Center for Value-Based Medicine. Patient/study population: patients with NVAMD.

INTERVENTION

Cost-utility analyses using published data. Data-modeled 10-year vision outcomes were modeled forward to year 11.

MAIN OUTCOME MEASUREMENT

These included cost-utility ratios (CURs), costs, and quality-adjusted life-years (QALYs) gained. $100,00/QALY was considered the US cost-effectiveness upper limit.

RESULTS

Bevacizumab and ranibizumab each conferred an 11-year, 1.339 QALY gain versus observation. Aflibercept conferred a 1.380 QALY gain. Aflibercept conferred greater QALY gain for less cost than ranibizumab but was not cost-effective compared to bevacizumab ($1,151,451/QALY incremental CUR). The average ophthalmic cost perspective CUR for bevacizumab was $11,033/QALY, $79,600/QALY for ranibizumab, and $44,801/QALY for aflibercept. Eleven-year therapies saved a 1.0 year-of-life loss without treatment from the 11.0-year life expectancy. Early treatment was 138%-149% more cost-effective than late treatment. Two-year therapy prevented a 1-month-of-life loss, and revealed bevacizumab, ranibizumab, and aflibercept conferred 0.141, 0.141, and 0.164 QALY gains, respectively, with corresponding average CURs of $40,371/QALY, $335,726/QALY, and $168,006/QALY, respectively.

CONCLUSIONS

From an ophthalmic (medical) cost perspective, bevacizumab, ranibizumab, and aflibercept NVAMD monotherapies were all cost-effective over 11 years, with bevacizumab 6.21× more cost-effective than ranibizumab and 3.06× more cost-effective than aflibercept. Two-year modeling revealed bevacizumab was cost-effective, whereas ranibizumab and aflibercept were not. Early treatment was critical for obtaining optimal vision and cost-effectiveness, as is long-term follow-up and adherence to treatment.