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Mannava S, Borah RR, Shamanna BR. Measuring utility values of eye conditions among children in India using the EQ-5D-Y instrument. HEALTH ECONOMICS REVIEW 2024; 14:72. [PMID: 39242433 PMCID: PMC11380325 DOI: 10.1186/s13561-024-00552-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 08/26/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND Vision impairment and blindness are significant global public health challenges, particularly in low- and middle-income countries, where access to eye care services remains limited. India has significantly reduced the prevalence of Blindness and Vision Impairment (VI) over the last two decades. This was achieved with the help of greater investments towards blindness control programs. The use of utility values helps in conducting economic evaluations of various eye health programs and empirically justify investing in these programs. This study aimed to estimate utility values for various childhood eye conditions in central India using the EuroQol-Five-Dimension-Youth (EQ-5D-Y) instrument. METHODS This is a before and after study with data collected at two time points for few participants and at only one time point for others. This study was undertaken at Shri Sadguru Netra Chikitsalaya (SNC) and included children representing central and north India. Participants were randomly sampled in the hospital. After comprehensive eye examination, participants completed the EuroQol-Five-Dimension-Youth (EQ-5D-Y) questionnaire along with EuroQol Visual Analogue Scale (EQ VAS) measurement to elicit their health state for their condition which was repeated after six months post-intervention to measure the change in utility value. We have used Indonesian value set to analyze the preference scores of each dimension of EQ-5D-Y. RESULTS Utility values of 16 eye conditions were estimated at baseline and seven conditions were followed up for post-intervention utility value estimation. There is a statistically significant improvement in the utility values post-intervention amongst six conditions. Blindness and Pediatric cataract had the greatest change (0.23 and 0.2 respectively) in utility value whereas mild Vision Impairment (VI) showed the least change (0.02) in the utility value post-intervention. Blindness had the lowest baseline (0.62) and post-intervention (0.85) utility value. CONCLUSION The utility values estimated in this study showed that generic measures such as EQ-5D-Y may be used to elicit health states for various eye conditions amongst children. These estimates are helpful in undertaking cost-utility analyses of eye health programs and interventions aimed at these eye conditions.
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Affiliation(s)
- Sunny Mannava
- School of Medical Sciences, University of Hyderabad, C.R. Rao Road, Gachibowli, Hyderabad, 500046, Telangana, India
| | - Rishi Raj Borah
- Country Director, Orbis India Country Office, MG Road, Gurugram, 122002, Haryana, India
| | - B R Shamanna
- School of Medical Sciences, University of Hyderabad, C.R. Rao Road, Gachibowli, Hyderabad, 500046, Telangana, India.
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Rowen D, Carlton J, Terheyden JH, Finger RP, Wickramasekera N, Brazier J. Development and Valuation of a Preference-Weighted Measure in Age-Related Macular Degeneration From the Vision Impairment in Low Luminance Questionnaire: A MACUSTAR Report. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:642-654. [PMID: 38369283 DOI: 10.1016/j.jval.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 01/29/2024] [Accepted: 02/08/2024] [Indexed: 02/20/2024]
Abstract
OBJECTIVES This study generates VILL-UI (Vision Impairment in Low Luminance - Utility Index), a preference-weighted measure (PWM) derived from the VILL-33 measure for use in patients with age-related macular degeneration (AMD) and valued to generate United Kingdom and German preference weights. METHODS A PWM consists of a classification system to describe health and utility values for every state described by the classification. The classification was derived using existing data collected as part of the MACUSTAR study, a low-interventional study on AMD, conducted at 20 clinical sites across Europe. Items were selected using psychometric and Rasch analyses, published criteria around PWM suitability, alongside instrument developer views and concept elicitation work that informed VILL-33 development. An online discrete choice experiment (DCE) with duration of the health state was conducted with the United Kingdom and German public. Responses were modeled to generate utility values for all possible health states. RESULTS The classification system has 5 items across the 3 domains of VILL-33: reading and accessing information, mobility and safety, and emotional well-being. The DCE samples (United Kingdom: n = 1004, Germany: n = 1008) are broadly representative and demonstrate good understanding of the tasks. The final DCE analyses produce logically consistent and significant coefficients. CONCLUSIONS This study enables responses to VILL-33 to be directly used to inform economic evaluation in AMD. The elicitation of preferences from both United Kingdom and Germany enables greater application of VILL-UI for economic evaluation throughout Europe. VILL-UI fills a gap in AMD in which generic preference-weighted measures typically lack sensitivity.
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Affiliation(s)
- Donna Rowen
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, England, UK.
| | - Jill Carlton
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, England, UK
| | | | | | - Nyantara Wickramasekera
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, England, UK
| | - John Brazier
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, England, UK
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Gomez-Lumbreras A, Ghule P, Panchal R, Giannouchos T, Lockhart CM, Brixner D. Real-world evidence in the use of Bevacizumab in age-related macular degeneration (ArMD): a scoping review. Int Ophthalmol 2023; 43:4527-4539. [PMID: 37606820 DOI: 10.1007/s10792-023-02853-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 08/05/2023] [Indexed: 08/23/2023]
Abstract
PURPOSE Pharmacological treatments for age-related macular degeneration (ArMD) include anti-vascular endothelial growth factor therapies. Bevacizumab is used off-label, as it has no indication for ArMD. This study aims to identify and describe literature on real-world evidence of bevacizumab (originator or biosimilars) use in ArMD. METHODS A scoping review was conducted in Medline, CINAHL and Embase databases. Studies published in English after September 2017, conducted in USA, including adults (≥ 18 years old) with ArMD who received treatment with bevacizumab for ArMD were included. The review was further limited to peer-reviewed observational studies that quantitatively analyze either clinical or patient-reported outcomes among patients treated with bevacizumab for ArMD. RESULTS The search strategy retrieved 543 studies. After title and abstract screening, a total of 142 studies were selected for full-text review leading to a total of 12 studies qualifying for data charting. All were retrospective studies. Five (41.6%) of the studies had less than 500 eyes included in the analysis, and the rest had over a thousand eyes. All except one study reported clinical outcomes (visual acuity was the main outcome in 8 (66.6%) studies). There were 3 (25%) studies reporting adverse events of bevacizumab intravitreal injections. None of the studies specified using biosimilars for bevacizumab and none mentioned patient-reported outcomes. CONCLUSION The lack of studies aiming to study the patient-reported outcomes as well as the use of biosimilars of bevacizumab in ArMD makes this field a potential for future research. The different exposures and times to follow-up make it difficult to compare results among the selected studies.
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Affiliation(s)
- Ainhoa Gomez-Lumbreras
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, 30S 2000E, Salt Lake City, UT, 84112, USA.
| | - Priyanka Ghule
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, 30S 2000E, Salt Lake City, UT, 84112, USA
| | - Rupesh Panchal
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, 30S 2000E, Salt Lake City, UT, 84112, USA
- University of Utah Health Plans, Murray, UT, USA
- ZS, 2535 West Hillcrest Drive Suite 100, Thousand Oaks, CA, 91320, USA
| | - Theodoros Giannouchos
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, 30S 2000E, Salt Lake City, UT, 84112, USA
- Department of Health Policy and Organization, School of Public Health, The University of Alabama at Birmingham, Birmingham, AL, 35233, USA
| | - Catherine M Lockhart
- Biologics and Biosimilars Collective Intelligence Consortium, Alexandria, VA, USA
| | - Diana Brixner
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, 30S 2000E, Salt Lake City, UT, 84112, USA
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Oliveira Gonçalves AS, Werdin S, Kurth T, Panteli D. Mapping Studies to Estimate Health-State Utilities From Nonpreference-Based Outcome Measures: A Systematic Review on How Repeated Measurements are Taken Into Account. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:589-597. [PMID: 36371289 DOI: 10.1016/j.jval.2022.09.2477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 09/09/2022] [Accepted: 09/29/2022] [Indexed: 05/06/2023]
Abstract
OBJECTIVES Mapping algorithms are developed using data sets containing patient responses to a preference-based questionnaire and another health-related quality-of-life questionnaire. When data sets include repeated measurements from the same individuals over time, the assumption of observations' independence, required by standard models, is violated, and standard errors are underestimated. This review aimed to identify how studies deal with methodological challenges of repeated measurements, provide an overview of practice to date, and potential implications for future work. METHODS We conducted a systematic literature search of MEDLINE, Cumulative Index to Nursing and Allied Health Literature, specialized databases, and previous systematic reviews. A data template was used to extract, among others, start and target instruments if the data set(s) used for estimation and validation had repeated measurements per patient, used regression techniques, and which (if any) adjustments were made for repeated measurements. RESULTS We identified 278 publications developing at least 1 mapping algorithm. Of the 278 publications, 121 used a data set with repeated measurements, among which 92 used multiple time points for estimation, and 39 selected specific time points to have 1 observation per participant. A total of 36 studies did not account for repeated measurements. An adjustment was conducted using cluster-robust standard errors (21), random-effects models (30), generalized estimating equations (7), and other methods (7). CONCLUSIONS The inconsistent use of methods to account for interdependent observations in the literature indicates that mapping guidelines should include recommendations on how to deal with repeated measurements, and journals should update their guidelines accordingly.
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Affiliation(s)
| | - Sophia Werdin
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland
| | - Tobias Kurth
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Dimitra Panteli
- Department of Health Care Management, Technische Universität Berlin, Berlin, Germany; European Observatory on Health Systems and Policies, Brussels, Belgium
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Valsamis EM, Beard D, Carr A, Collins GS, Brealey S, Rangan A, Santos R, Corbacho B, Rees JL, Pinedo-Villanueva R. Mapping the Oxford Shoulder Score onto the EQ-5D utility index. Qual Life Res 2023; 32:507-518. [PMID: 36169788 PMCID: PMC9911508 DOI: 10.1007/s11136-022-03262-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE In order to enable cost-utility analysis of shoulder pain conditions and treatments, this study aimed to develop and evaluate mapping algorithms to estimate the EQ-5D health index from the Oxford Shoulder Score (OSS) when health outcomes are only assessed with the OSS. METHODS 5437 paired OSS and EQ-5D questionnaire responses from four national multicentre randomised controlled trials investigating different shoulder pathologies and treatments were split into training and testing samples. Separate EQ-5D-3L and EQ-5D-5L analyses were undertaken. Transfer to utility (TTU) regression (univariate linear, polynomial, spline, multivariable linear, two-part logistic-linear, tobit and adjusted limited dependent variable mixture models) and response mapping (ordered logistic regression and seemingly unrelated regression (SUR)) models were developed on the training sample. These were internally validated, and their performance evaluated on the testing sample. Model performance was evaluated over 100-fold repeated training-testing sample splits. RESULTS For the EQ-5D-3L analysis, the multivariable linear and splines models had the lowest mean square error (MSE) of 0.0415. The SUR model had the lowest mean absolute error (MAE) of 0.136. Model performance was greatest in the mid-range and best health states, and lowest in poor health states. For the EQ-5D-5L analyses, the multivariable linear and splines models had the lowest MSE (0.0241-0.0278) while the SUR models had the lowest MAE (0.105-0.113). CONCLUSION The developed models now allow accurate estimation of the EQ-5D health index when only the OSS responses are available as a measure of patient-reported health outcome.
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Affiliation(s)
- Epaminondas M. Valsamis
- grid.4991.50000 0004 1936 8948Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, OX3 7LD UK
| | - David Beard
- grid.4991.50000 0004 1936 8948Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, OX3 7LD UK
| | - Andrew Carr
- grid.4991.50000 0004 1936 8948Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, OX3 7LD UK
| | - Gary S. Collins
- grid.4991.50000 0004 1936 8948Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Centre for Statistics in Medicine, University of Oxford, Oxford, OX3 7LD UK
| | - Stephen Brealey
- grid.5685.e0000 0004 1936 9668Department of Health Sciences, York Trials Unit, University of York, York, YO10 5DD UK
| | - Amar Rangan
- grid.5685.e0000 0004 1936 9668Department of Health Sciences, York Trials Unit, University of York, York, YO10 5DD UK
| | - Rita Santos
- grid.5685.e0000 0004 1936 9668Centre for Health Economics, University of York, York, YO10 5DD UK
| | - Belen Corbacho
- grid.5685.e0000 0004 1936 9668Department of Health Sciences, York Trials Unit, University of York, York, YO10 5DD UK
| | - Jonathan L. Rees
- grid.4991.50000 0004 1936 8948Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, OX3 7LD UK
| | - Rafael Pinedo-Villanueva
- grid.4991.50000 0004 1936 8948Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, OX3 7LD UK
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Franklin M, Enrique A, Palacios J, Richards D. Psychometric assessment of EQ-5D-5L and ReQoL measures in patients with anxiety and depression: construct validity and responsiveness. Qual Life Res 2021; 30:2633-2647. [PMID: 33835414 PMCID: PMC8034045 DOI: 10.1007/s11136-021-02833-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Generic health measures have been questioned for quantifying mental-health-related outcomes. In patients with anxiety and/or depression, our aim is to assess the psychometric properties of the preference-based EQ-5D-5L (generic health) and ReQoL-UI (recovery-focussed quality of life) for economic evaluation against the PHQ-9 (depression) and GAD-7 (anxiety). EQ-5D-5L anxiety/depression item and ReQoL-10 are also assessed. METHODS A 2:1 (intervention: control) randomised controlled trial collected measures at baseline and 8 weeks post baseline; in the intervention arm, data were also collected 3, 6, 9, and 12-months post baseline. EQ-5D-5L preference-based scores were obtained from the value set for England (VSE) and 'cross-walked' EQ-5D-3L United Kingdom (UK) value set scores. ReQoL-UI preference-based scores were obtained from its UK value set as applied to seven ReQoL-10 items. EQ-5D-5L and ReQoL measures' construct validity and responsiveness were assessed compared against PHQ-9 and GAD-7 scores and group cut-offs. RESULTS 361 people were randomised to intervention (241) or control (120). ReQoL-UI/-10 had better construct validity with depression severity than the EQ-5D-5L (VSE/cross-walk scores), which had relatively better construct validity with anxiety severity than the ReQoL-UI/-10. Across all intervention-arm time-points relative to baseline, responsiveness was generally better for EQ-5D-5L (VSE in particular) than ReQoL-UI, but worse than ReQoL-10. CONCLUSION There is insufficient evidence to recommend the ReQoL-UI over EQ-5D-5L for economic evaluations to capture anxiety severity. However, there may be rationale for recommending the ReQoL-UI over the EQ-5D-5L to capture depression severity given its better construct validity, albeit poorer responsiveness, and if recovery-focussed quality of life relative to condition-specific symptomology is the construct of interest.
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Affiliation(s)
- Matthew Franklin
- Health Economics and Decision Science (HEDS), School of Health and Related Research (ScHARR), University of Sheffield, West Court, 1 Mappin Street, Sheffield, S1 4DT, UK.
| | - Angel Enrique
- Cinical Research & Innovation, SilverCloud Health, Dublin, Ireland, UK
- E-mental Health Research Group, School of Psychology, University of Dublin, Trinity College, Dublin, Ireland, UK
| | - Jorge Palacios
- Cinical Research & Innovation, SilverCloud Health, Dublin, Ireland, UK
- E-mental Health Research Group, School of Psychology, University of Dublin, Trinity College, Dublin, Ireland, UK
| | - Derek Richards
- Cinical Research & Innovation, SilverCloud Health, Dublin, Ireland, UK
- E-mental Health Research Group, School of Psychology, University of Dublin, Trinity College, Dublin, Ireland, UK
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Pennington B, Alshreef A, Flight L, Metry A, Poku E, Hykin P, Sivaprasad S, Prevost AT, Vasconcelos JC, Murphy C, Kelly J, Yang Y, Lotery A, Williams M, Brazier J. Cost Effectiveness of Ranibizumab vs Aflibercept vs Bevacizumab for the Treatment of Macular Oedema Due to Central Retinal Vein Occlusion: The LEAVO Study. PHARMACOECONOMICS 2021; 39:913-927. [PMID: 33900585 PMCID: PMC8298346 DOI: 10.1007/s40273-021-01026-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/30/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND We aimed to assess the cost effectiveness of intravitreal ranibizumab (Lucentis), aflibercept (Eylea) and bevacizumab (Avastin) for the treatment of macular oedema due to central retinal vein occlusion. METHODS We calculated costs and quality-adjusted life-years from the UK National Health Service and Personal Social Services perspective. We performed a within-trial analysis using the efficacy, safety, resource use and health utility data from a randomised controlled trial (LEAVO) over 100 weeks. We built a discrete event simulation to model long-term outcomes. We estimated utilities using the Visual-Functioning Questionnaire-Utility Index, EQ-5D and EQ-5D with an additional vision question. We used standard UK costs sources for 2018/19 and a cost of £28 per bevacizumab injection. We discounted costs and quality-adjusted life-years at 3.5% annually. RESULTS Bevacizumab was the least costly intervention followed by ranibizumab and aflibercept in both the within-trial analysis (bevacizumab: £6292, ranibizumab: £13,014, aflibercept: £14,328) and long-term model (bevacizumab: £18,353, ranibizumab: £30,226, aflibercept: £35,026). Although LEAVO did not demonstrate bevacizumab to be non-inferior for the visual acuity primary outcome, the three interventions generated similar quality-adjusted life-years in both analyses. Bevacizumab was always the most cost-effective intervention at a threshold of £30,000 per quality-adjusted life-year, even using the list price of £243 per injection. CONCLUSIONS Wider adoption of bevacizumab for the treatment of macular oedema due to central retinal vein occlusion could result in substantial savings to healthcare systems and deliver similar health-related quality of life. However, patients, funders and ophthalmologists should be fully aware that LEAVO could not demonstrate that bevacizumab is non-inferior to the licensed agents.
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Affiliation(s)
- Becky Pennington
- School of Health and Related Research, University of Sheffield, Sheffield, UK.
| | - Abualbishr Alshreef
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Laura Flight
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Andrew Metry
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Edith Poku
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Philip Hykin
- NIHR Moorfields Biomedical Research Centre, London, UK
| | | | - A Toby Prevost
- Nightingale-Saunders Clinical Trials and Epidemiology Unit at King's Clinical Trials Unit, King's College London, London, UK
| | - Joana C Vasconcelos
- Nightingale-Saunders Clinical Trials and Epidemiology Unit at King's Clinical Trials Unit, King's College London, London, UK
| | - Caroline Murphy
- King's Clinical Trials Unit at King's Health Partners, King's College London, London, UK
| | - Joanna Kelly
- King's Clinical Trials Unit at King's Health Partners, King's College London, London, UK
| | - Yit Yang
- Wolverhampton Eye Infirmary, Wolverhampton, UK
| | - Andrew Lotery
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Michael Williams
- Centre for Medical Education, Queen's University of Belfast, Belfast, UK
| | - John Brazier
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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Sivaprasad S, Netuveli G, Wittenberg R, Khobragade R, Sadanandan R, Gopal B, Premnazir L, Conroy D, Srinath J, Ramakrishnan R, George S, Sahasranamam VI. Complex interventions to implement a diabetic retinopathy care pathway in the public health system in Kerala: the Nayanamritham study protocol. BMJ Open 2021; 11:e040577. [PMID: 34183333 PMCID: PMC8240569 DOI: 10.1136/bmjopen-2020-040577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Using a type 2 hybrid effectiveness-implementation design, we aim to pilot a diabetic retinopathy (DR) care pathway in the public health system in Kerala to understand how it can be scaled up to and sustained in the whole state. METHODS AND ANALYSIS Currently, there is no systematic DR screening programme in Kerala. Our intervention is a teleophthalmology pathway for people with diabetes in the non-communicable disease registers in 16 family health centres. The planned implementation strategy of the pathway will be developed based on the discrete Expert Recommendations for Implementing Change taxonomy. We will use both quantitative data from a cross-sectional study and qualitative data obtained from structured interviews, surveys and group discussions with stakeholders to report the effectiveness of the DR care pathway and evaluation of the implementation strategy.We will use logistic regression models to assess crude associations DR and sight-threatening diabetic retinopathy and fractional polynomials to account for the form of continuous covariates to predict uptake of DR screening. The primary effectiveness outcome is the proportion of patients in the non-communicable disease register with diabetes screened for DR over 12 months. Other outcomes include cost-effectiveness, safety, efficiency, patient satisfaction, timeliness and equity. The outcomes of evaluation of the implementation strategies include acceptability, feasibility, adoption, appropriateness, fidelity, penetration, costs and sustainability. Addition of more family health centres during the staggered initial phase of the programme will be considered as a sign of acceptability and feasibility. In the long term, the state-wide adoption of the DR care pathway will be considered as a successful outcome of the Nayanamritham study. ETHICS AND DISSEMINATION The study was approved by Indian Medical Research Council (2018-0551) dated 13 March 2019. Study findings will be disseminated through scientific publications and the report will inform adoption of the DR care pathway by Kerala state in future. TRIAL REGISTRATION NUMBER ISRCTN28942696.
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Affiliation(s)
- Sobha Sivaprasad
- Medical Retina Department, NIHR Moorfields Biomedical Research Centre, Moorfields Eye Hospital, London, UK
- Vision Sciences, UCL, London, UK
| | - Gopalakrishnan Netuveli
- Institute of Connected Communities, University of East London-Duncan House Campus, London, UK
| | - Raphael Wittenberg
- Nuffield Department of Primary Health Care Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - Rajan Khobragade
- Directorate of Health, Government of Kerala, Thiruvananthapuram, India
| | - Rajeev Sadanandan
- Directorate of Health, Government of Kerala, Thiruvananthapuram, India
| | - Bipin Gopal
- Non-Communicable Diseases Department, Directorate of Health Services, Government Medical College Thiruvananthapuram, Thiruvananthapuram, India
| | - Lakshmi Premnazir
- Directorate of Health Services, Government Medical College Thiruvananthapuram, Thiruvananthapuram, India
| | | | - Jyotsna Srinath
- Institute of Connected Communities, University of East London-Duncan House Campus, London, UK
| | | | - Simon George
- Ophthalmology Department, Regional Institute of Ophthalmology, Government Medical College, Thiruvananthapuram, India
| | - Vasudeva Iyer Sahasranamam
- Ophthalmology Department, Regional Institute of Ophthalmology, Government Medical College, Thiruvananthapuram, India
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Hykin P, Prevost AT, Sivaprasad S, Vasconcelos JC, Murphy C, Kelly J, Ramu J, Alshreef A, Flight L, Pennington R, Hounsome B, Lever E, Metry A, Poku E, Yang Y, Harding SP, Lotery A, Chakravarthy U, Brazier J. Intravitreal ranibizumab versus aflibercept versus bevacizumab for macular oedema due to central retinal vein occlusion: the LEAVO non-inferiority three-arm RCT. Health Technol Assess 2021; 25:1-196. [PMID: 34132192 PMCID: PMC8287375 DOI: 10.3310/hta25380] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Licensed ranibizumab (0.5 mg/0.05 ml Lucentis®; Novartis International AG, Basel, Switzerland) and aflibercept (2 mg/0.05 ml Eylea®; Bayer AG, Leverkusen, Germany) and unlicensed bevacizumab (1.25 mg/0.05 ml Avastin®; F. Hoffmann-La Roche AG, Basel, Switzerland) are used to treat macula oedema due to central retinal vein occlusion, but their relative clinical effectiveness, cost-effectiveness and impact on the UK NHS and Personal Social Services have never been directly compared over the typical disease treatment period. OBJECTIVE The objective was to compare the clinical effectiveness and cost-effectiveness of three intravitreal antivascular endothelial growth factor agents for the management of macula oedema due to central retinal vein occlusion. DESIGN This was a three-arm, double-masked, randomised controlled non-inferiority trial. SETTING The trial was set in 44 UK NHS ophthalmology departments, between 2014 and 2018. PARTICIPANTS A total of 463 patients with visual impairment due to macula oedema secondary to central retinal vein occlusion were included in the trial. INTERVENTIONS The participants were treated with repeated intravitreal injections of ranibizumab (n = 155), aflibercept (n = 154) or bevacizumab (n = 154). MAIN OUTCOME MEASURES The primary outcome was an increase in the best corrected visual acuity letter score from baseline to 100 weeks in the trial eye. The null hypothesis that aflibercept and bevacizumab are each inferior to ranibizumab was tested with a non-inferiority margin of -5 visual acuity letters over 100 weeks. Secondary outcomes included additional visual acuity, and imaging outcomes, Visual Function Questionnaire-25, EuroQol-5 Dimensions with and without a vision bolt-on, and drug side effects. Cost-effectiveness was estimated using treatment costs and Visual Function Questionnaire-Utility Index to measure quality-adjusted life-years. RESULTS The adjusted mean changes at 100 weeks in the best corrected visual acuity letter scores were as follows - ranibizumab, 12.5 letters (standard deviation 21.1 letters); aflibercept, 15.1 letters (standard deviation 18.7 letters); and bevacizumab, 9.8 letters (standard deviation 21.4 letters). Aflibercept was non-inferior to ranibizumab in the intention-to-treat population (adjusted mean best corrected visual acuity difference 2.23 letters, 95% confidence interval -2.17 to 6.63 letters; p = 0.0006), but not superior. The study was unable to demonstrate that bevacizumab was non-inferior to ranibizumab in the intention-to-treat population (adjusted mean best corrected visual acuity difference -1.73 letters, 95% confidence interval -6.12 to 2.67 letters; p = 0.071). A post hoc analysis was unable to demonstrate that bevacizumab was non-inferior to aflibercept in the intention-to-treat population (adjusted mean best corrected visual acuity difference was -3.96 letters, 95% confidence interval -8.34 to 0.42 letters; p = 0.32). All per-protocol population results were the same. Fewer injections were required with aflibercept (10.0) than with ranibizumab (11.8) (difference in means -1.8, 95% confidence interval -2.9 to -0.8). A post hoc analysis showed that more bevacizumab than aflibercept injections were required (difference in means 1.6, 95% confidence interval 0.5 to 2.7). There were no new safety concerns. The model- and trial-based cost-effectiveness analyses estimated that bevacizumab was the most cost-effective treatment at a threshold of £20,000-30,000 per quality-adjusted life-year. LIMITATIONS The comparison of aflibercept and bevacizumab was a post hoc analysis. CONCLUSION The study showed aflibercept to be non-inferior to ranibizumab. However, the possibility that bevacizumab is worse than ranibizumab and aflibercept by 5 visual acuity letters cannot be ruled out. Bevacizumab is an economically attractive treatment alternative and would lead to substantial cost savings to the NHS and other health-care systems. However, uncertainty about its relative effectiveness should be discussed comprehensively with patients, their representatives and funders before treatment is considered. FUTURE WORK To obtain extensive patient feedback and discuss with all stakeholders future bevacizumab NHS use. TRIAL REGISTRATION Current Controlled Trials ISRCTN13623634. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 38. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Philip Hykin
- National Institute for Health Research Moorfields Biomedical Research Centre, London, UK
- Institute of Ophthalmology, University College London, London, UK
| | - A Toby Prevost
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Sobha Sivaprasad
- National Institute for Health Research Moorfields Biomedical Research Centre, London, UK
- Institute of Ophthalmology, University College London, London, UK
| | - Joana C Vasconcelos
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Caroline Murphy
- King's Clinical Trials Unit at King's Health Partners, King's College London, London, UK
| | - Joanna Kelly
- King's Clinical Trials Unit at King's Health Partners, King's College London, London, UK
| | - Jayashree Ramu
- National Institute for Health Research Moorfields Biomedical Research Centre, London, UK
| | - Abualbishr Alshreef
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Laura Flight
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Rebekah Pennington
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Ellen Lever
- King's Clinical Trials Unit at King's Health Partners, King's College London, London, UK
| | - Andrew Metry
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Edith Poku
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Yit Yang
- The Eye Infirmary, New Cross Hospital, Wolverhampton, UK
| | - Simon P Harding
- Eye and Vision Science, University of Liverpool, and St Paul's Eye Unit, Royal Liverpool University Hospitals, Liverpool, UK
| | - Andrew Lotery
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Usha Chakravarthy
- Department of Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - John Brazier
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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Huygens SA, Versteegh MM, Vegter S, Schouten LJ, Kanters TA. Methodological Challenges in the Economic Evaluation of a Gene Therapy for RPE65-Mediated Inherited Retinal Disease: The Value of Vision. PHARMACOECONOMICS 2021; 39:383-397. [PMID: 33604870 PMCID: PMC8009797 DOI: 10.1007/s40273-021-01003-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/23/2021] [Indexed: 05/10/2023]
Abstract
The emergence of gene therapies challenge health economists to evaluate interventions that are often provided to a small patient population with a specific gene mutation in a single dose with high upfront costs and uncertain long-term benefits. The objective of this study was to illustrate the methodological challenges of evaluating gene therapies and their implications by discussing four economic evaluations of voretigene neparvovec (VN) for the treatment of RPE65-mediated inherited retinal disease. The checklist for economic evaluations of gene therapies of Drummond et al. was applied to the economic evaluations of VN performed by US Institute for Clinical and Economic Review, two country adaptations of the company model in the UK and the Netherlands, and another US publication. The main differences in methodological choices and their impact on cost-effectiveness results were assessed and further explored with sensitivity analyses using the Dutch model. To enable comparison between the economic evaluations, costs were converted to US dollars. Different methodological choices were made in the economic evaluations of VN resulting in large differences in the incremental cost-effectiveness ratio varying from US$79,618 to US$643,813 per QALY. The chosen duration of treatment effect, source of utility values, discount rate and model structure had the largest impact on the cost-effectiveness. This study underlines the findings from Drummond et al. that standard methods can be used to evaluate gene therapies. However, given uncertainty about (particularly long-term) outcomes of gene therapies, guidance is required on the acceptable extrapolation of treatment effect of gene therapies and on how to handle the uncertainty around this extrapolation in scenario and sensitivity analyses to aid health technology assessment research and align submissions of future gene therapies.
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Affiliation(s)
- Simone A Huygens
- Institute for Medical Technology Assessment (iMTA), Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - Matthijs M Versteegh
- Institute for Medical Technology Assessment (iMTA), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | | | - Tim A Kanters
- Institute for Medical Technology Assessment (iMTA), Erasmus University Rotterdam, Rotterdam, The Netherlands
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