Advertisement

Cost Evaluation of Early Vitrectomy versus Panretinal Photocoagulation and Intravitreal Ranibizumab for Proliferative Diabetic Retinopathy

      Purpose

      To evaluate costs and cost-utility of early vitrectomy (pars plana vitrectomy [PPV]) compared with panretinal photocoagulation (PRP) and intravitreal ranibizumab (IVR) for proliferative diabetic retinopathy (PDR) without diabetic macular edema.

      Design

      A decision analysis model of cost-utility.

      Participants

      There were no participants.

      Methods

      A decision analysis was based on results from the Diabetic Retinopathy Clinical Research Network Protocol S comparing treatment of PRP with IVR (0.3 mg) in PDR without incident macular edema to model the total 2-year costs and outcomes for each treatment scenario. These values were compared with the 2-year hypothetical costs of early PPV for PDR. Centers for Medicare and Medicaid Services data were used to calculate associated modeled costs in a hospital/facility-based and nonfacility setting. Cost-utility was calculated on the basis of the preserved visual utility and estimated life years remaining. In addition, costs for lifetime treatment were modeled for all scenarios and used to calculate lifetime quality-adjusted life years (QALY) costs for each scenario. Sensitivity analyses were performed to evaluate the impact of the model’s assumptions.

      Main Outcome Measures

      Cost of treatment, utility, and cost per QALY.

      Results

      The modeled cost per QALY of treatment for PDR for 2 years of utility in the facility (nonfacility) setting was $163 988 ($102 559) in the PRP group, $436 992 ($326 424) in the IVR group, and $181 144 ($107 965) in the PPV group. Sensitivity analysis showed that both IVR and PPV groups would have equivalent costs per QALY over the first 2 years if 78% (facility) and 80% (nonfacility) of patients in the PPV group required additional treatment with IVR (at the dose of 10.1 injections as in Protocol S). Beyond 2 years, the cost per QALY in the facility (nonfacility) setting was calculated as $61 695 ($21 752) in the PRP group, $338 348 ($239 741) in the IVR group, and $63 942 ($22 261) in the PPV group.

      Conclusions

      Early PPV as a strategy for treatment of PDR without macular edema demonstrates cost-utility similar to management with PRP and more favorable cost-utility compared with IVR in the short term. This advantage over IVR continues when lifetime costs are factored.

      Abbreviations and Acronyms:

      CPT (Current Procedural Terminology), DME (diabetic macular edema), DRS (Diabetic Retinopathy Study), IVR (intravitreal ranibizumab), PDR (proliferative diabetic retinopathy), PPV (pars plana vitrectomy), PRP (panretinal photocoagulation), QALY (quality-adjusted life years), RVU (relative value unit), VEGF (vascular endothelial growth factor)
      To read this article in full you will need to make a payment

      Subscribe:

      Subscribe to Ophthalmology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Lee R.
        • Wong T.Y.
        • Sabanayagam C.
        Epidemiology of diabetic retinopathy, diabetic macular edema and related vision loss.
        Eye Vis (Lond). 2015; 2: 17
      1. Photocoagulation treatment of proliferative diabetic retinopathy. Clinical application of Diabetic Retinopathy Study (DRS) findings, DRS Report Number 8. The Diabetic Retinopathy Study Research Group.
        Ophthalmology. 1981; 88: 583-600
      2. Preliminary report on effects of photocoagulation therapy. The Diabetic Retinopathy Study Research Group.
        Am J Ophthalmol. 1976; 81: 383-396
        • Stefansson E.
        The therapeutic effects of retinal laser treatment and vitrectomy. A theory based on oxygen and vascular physiology.
        Acta Ophthalmol Scand. 2001; 79: 435-440
        • Avery R.L.
        Regression of retinal and iris neovascularization after intravitreal bevacizumab (Avastin) treatment.
        Retina. 2006; 26: 352-354
        • Spaide R.F.
        • Fisher Y.L.
        Intravitreal bevacizumab (Avastin) treatment of proliferative diabetic retinopathy complicated by vitreous hemorrhage.
        Retina. 2006; 26: 275-278
        • Filho J.A.
        • Messias A.
        • Almeida F.P.
        • et al.
        Panretinal photocoagulation (PRP) versus PRP plus intravitreal ranibizumab for high-risk proliferative diabetic retinopathy.
        Acta Ophthalmol. 2011; 89: e567-e572
        • Gross J.G.
        • Glassman A.R.
        • et al.
        • Writing Committee for the Diabetic Retinopathy Clinical Research N
        Panretinal photocoagulation vs intravitreous ranibizumab for proliferative diabetic retinopathy: a randomized clinical trial.
        JAMA. 2015; 314: 2137-2146
        • Sivaprasad S.
        • Prevost A.T.
        • Vasconcelos J.C.
        • et al.
        Clinical efficacy of intravitreal aflibercept versus panretinal photocoagulation for best corrected visual acuity in patients with proliferative diabetic retinopathy at 52 weeks (CLARITY): a multicentre, single-blinded, randomised, controlled, phase 2b, non-inferiority trial.
        Lancet. 2017; 389: 2193-2203
        • Elman M.J.
        • Aiello L.P.
        • et al.
        • Diabetic Retinopathy Clinical Research Network
        Randomized trial evaluating ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema.
        Ophthalmology. 2010; 117: 1064-1077.e35
        • Maturi R.K.
        • Glassman A.R.
        • Liu D.
        • et al.
        Effect of adding dexamethasone to continued ranibizumab treatment in patients with persistent diabetic macular edema: a DRCR Network Phase 2 Randomized Clinical Trial.
        JAMA Ophthalmol. 2018; 136: 29-38
        • Bressler S.B.
        • Qin H.
        • Melia M.
        • et al.
        Exploratory analysis of the effect of intravitreal ranibizumab or triamcinolone on worsening of diabetic retinopathy in a randomized clinical trial.
        JAMA Ophthalmol. 2013; 131: 1033-1040
        • Javadzadeh A.
        The effect of posterior subtenon methylprednisolone acetate in the refractory diabetic macular edema: a prospective nonrandomized interventional case series.
        BMC Ophthalmol. 2006; 6: 15
      3. Early vitrectomy for severe proliferative diabetic retinopathy in eyes with useful vision. Clinical application of results of a randomized trial–Diabetic Retinopathy Vitrectomy Study Report 4. The Diabetic Retinopathy Vitrectomy Study Research Group.
        Ophthalmology. 1988; 95: 1321-1334
      4. Early vitrectomy for severe vitreous hemorrhage in diabetic retinopathy. Two-year results of a randomized trial. Diabetic Retinopathy Vitrectomy Study report 2. The Diabetic Retinopathy Vitrectomy Study Research Group.
        Arch Ophthalmol. 1985; 103: 1644-1652
      5. Early vitrectomy for severe proliferative diabetic retinopathy in eyes with useful vision. Results of a randomized trial–Diabetic Retinopathy Vitrectomy Study Report 3. The Diabetic Retinopathy Vitrectomy Study Research Group.
        Ophthalmology. 1988; 95: 1307-1320
      6. Early vitrectomy for severe vitreous hemorrhage in diabetic retinopathy. Four-year results of a randomized trial: Diabetic Retinopathy Vitrectomy Study Report 5.
        Arch Ophthalmol. 1990; 108: 958-964
        • da R.L.D.
        • Ribeiro J.A.
        • Costa R.A.
        • et al.
        Intraoperative bleeding during vitrectomy for diabetic tractional retinal detachment with versus without preoperative intravitreal bevacizumab (IBeTra study).
        Br J Ophthalmol. 2009; 93: 688-691
        • Rizzo S.
        • Genovesi-Ebert F.
        • Di Bartolo E.
        • et al.
        Injection of intravitreal bevacizumab (Avastin) as a preoperative adjunct before vitrectomy surgery in the treatment of severe proliferative diabetic retinopathy (PDR).
        Graefes Arch Clin Exp Ophthalmol. 2008; 246: 837-842
        • Yeoh J.
        • Williams C.
        • Allen P.
        • et al.
        Avastin as an adjunct to vitrectomy in the management of severe proliferative diabetic retinopathy: a prospective case series.
        Clin Exp Ophthalmol. 2008; 36: 449-454
        • Ishikawa K.
        • Honda S.
        • Tsukahara Y.
        • Negi A.
        Preferable use of intravitreal bevacizumab as a pretreatment of vitrectomy for severe proliferative diabetic retinopathy.
        Eye (Lond). 2009; 23: 108-111
        • Berrocal M.H.
        • Acaba L.A.
        • Acaba A.
        Surgery for diabetic eye complications.
        Curr Diab Rep. 2016; 16: 99
        • Fujii G.Y.
        • De Juan Jr., E.
        • Humayun M.S.
        • et al.
        A new 25-gauge instrument system for transconjunctival sutureless vitrectomy surgery.
        Ophthalmology. 2002; 109: 1807-1813
        • Fujii G.Y.
        • De Juan Jr., E.
        • Humayun M.S.
        • et al.
        Initial experience using the transconjunctival sutureless vitrectomy system for vitreoretinal surgery.
        Ophthalmology. 2002; 109: 1814-1820
        • Eckardt C.
        Transconjunctival sutureless 23-gauge vitrectomy.
        Retina. 2005; 25: 208-211
        • Khan M.A.
        • Shahlaee A.
        • Toussaint B.
        • et al.
        Outcomes of 27 gauge microincision vitrectomy surgery for posterior segment disease.
        Am J Ophthalmol. 2016; 161: 36-43.e1-2
        • Haller J.A.
        • Qin H.
        • et al.
        • Diabetic Retinopathy Clinical Research Network Writing Committee
        Vitrectomy outcomes in eyes with diabetic macular edema and vitreomacular traction.
        Ophthalmology. 2010; 117: 1087-1093.e3
        • Harbour J.W.
        • Smiddy W.E.
        • Flynn Jr., H.W.
        • Rubsamen P.E.
        Vitrectomy for diabetic macular edema associated with a thickened and taut posterior hyaloid membrane.
        Am J Ophthalmol. 1996; 121: 405-413
        • Lewis H.
        • Abrams G.W.
        • Blumenkranz M.S.
        • Campo R.V.
        Vitrectomy for diabetic macular traction and edema associated with posterior hyaloidal traction.
        Ophthalmology. 1992; 99: 753-759
        • Lin J.
        • Chang J.S.
        • Smiddy W.E.
        Cost evaluation of panretinal photocoagulation versus intravitreal ranibizumab for proliferative diabetic retinopathy.
        Ophthalmology. 2016; 123: 1912-1918
        • Centers for Medicare and Medicaid Services
        Physician Fee Schedule.
        (Available at:)
        • Centers for Medicare and Medicaid Services
        Ambulatory Surgical Center (ASC) Payment.
        (Available at:)
        • Centers for Medicare and Medicaid Services
        Addendum B. Final OPPS Payment by HCPCS Code for CY 2017, January 2017.
        (Available at:)
        • Yannuzzi N.A.
        • Chang J.S.
        • Brown G.C.
        • Smiddy W.E.
        Cost-utility of evaluation for posterior vitreous detachment and prophylaxis of retinal detachment.
        Ophthalmology. 2018; 125: 43-50
        • Chang J.S.
        • Smiddy W.E.
        Cost-effectiveness of retinal detachment repair.
        Ophthalmology. 2014; 121: 946-951
        • Sonnenberg F.A.
        • Beck J.R.
        Markov models in medical decision making: a practical guide.
        Med Decis Making. 1993; 13: 322-338
        • Brown M.M.
        • Brown G.C.
        • Sharma S.
        • Landy J.
        Health care economic analyses and value-based medicine.
        Surv Ophthalmol. 2003; 48: 204-223
        • Social Security
        Actuarial Life Table. Period Life Table, 2011.
        (Available at:)
        https://www.ssa.gov/oact/STATS/table4c6.html
        Date accessed: October 22, 2017
        • Centers for Medicare and Medicaid Services
        2017 ASP Drug Pricing Files.
        (Available at:)
        • Smiddy W.E.
        Relative cost of a line of vision in age-related macular degeneration.
        Ophthalmology. 2007; 114: 847-854
      7. Comprehensive Adult Medical Eye Evaluation- 2015.
        (Available at:)
        • Bhavsar A.R.
        • Torres K.
        • Glassman A.R.
        • et al.
        Evaluation of results 1 year following short-term use of ranibizumab for vitreous hemorrhage due to proliferative diabetic retinopathy.
        JAMA Ophthalmol. 2014; 132: 889-890
        • Beaulieu W.T.
        • Bressler N.M.
        • Melia M.
        • et al.
        Panretinal photocoagulation versus ranibizumab for proliferative diabetic retinopathy: patient-centered outcomes from a randomized clinical trial.
        Am J Ophthalmol. 2016; 170: 206-213
        • Hutton D.W.
        • Stein J.D.
        • Bressler N.M.
        • et al.
        Cost-effectiveness of intravitreous ranibizumab compared with panretinal photocoagulation for proliferative diabetic retinopathy: secondary analysis from a diabetic retinopathy clinical research network randomized clinical trial.
        JAMA Ophthalmol. 2017; 135: 576-584
        • Pendergast S.D.
        Vitrectomy for diabetic macular edema associated with a taut premacular posterior hyaloid.
        Curr Opin Ophthalmol. 1998; 9: 71-75
        • Smiddy W.E.
        • Feuer W.
        Incidence of cataract extraction after diabetic vitrectomy.
        Retina. 2004; 24: 574-581
        • Holekamp N.M.
        • Bai F.
        • Shui Y.B.
        • et al.
        Ischemic diabetic retinopathy may protect against nuclear sclerotic cataract.
        Am J Ophthalmol. 2010; 150: 543-550.e1
        • Khuthaila M.K.
        • Hsu J.
        • Chiang A.
        • et al.
        Postoperative vitreous hemorrhage after diabetic 23-gauge pars plana vitrectomy.
        Am J Ophthalmol. 2013; (63. e1-2): 757-763
        • Eifrig C.W.
        • Scott I.U.
        • Flynn Jr., H.W.
        • et al.
        Endophthalmitis after pars plana vitrectomy: incidence, causative organisms, and visual acuity outcomes.
        Am J Ophthalmol. 2004; 138: 799-802
        • Zarbin M.A.
        • Dunger-Baldauf C.
        • Haskova Z.
        • et al.
        Vascular safety of ranibizumab in patients with diabetic macular edema: a pooled analysis of patient-level data from randomized clinical trials.
        JAMA Ophthalmol. 2017; 135: 424-431
        • Kakinoki M.
        • Sawada O.
        • Sawada T.
        • et al.
        Effect of vitrectomy on aqueous VEGF concentration and pharmacokinetics of bevacizumab in macaque monkeys.
        Invest Ophthalmol Vis Sci. 2012; 53: 5877-5880