Cost-effectiveness of fluocinolone acetonide implant versus systemic therapy for noninfectious intermediate, posterior, and panuveitis

Abstract

Objective: To evaluate the 3-year incremental cost-effectiveness of fluocinolone acetonide implant versus systemic therapy for the treatment of noninfectious intermediate, posterior, and panuveitis.

Design: Randomized, controlled, clinical trial.

Participants: Patients with active or recently active intermediate, posterior, or panuveitis enrolled in the Multicenter Uveitis Steroid Treatment Trial.

Methods: Data on cost and health utility during 3 years after randomization were evaluated at 6-month intervals. Analyses were stratified by disease laterality at randomization (31 unilateral vs 224 bilateral) because of the large upfront cost of the implant.

Main outcome measures: The primary outcome was the incremental cost-effectiveness ratio (ICER) over 3 years: the ratio of the difference in cost (in United States dollars) to the difference in quality-adjusted life-years (QALYs). Costs of medications, surgeries, hospitalizations, and regular procedures (e.g., laboratory monitoring for systemic therapy) were included. We computed QALYs as a weighted average of EQ-5D scores over 3 years of follow-up.

Results: The ICER at 3 years was $297,800/QALY for bilateral disease, driven by the high cost of implant therapy (difference implant - systemic [Δ]: $16,900; P < 0.001) and the modest gains in QALYs (Δ = 0.057; P = 0.22). The probability of the ICER being cost-effective at thresholds of $50,000/QALY and $100,000/QALY was 0.003 and 0.04, respectively. The ICER for unilateral disease was more favorable, namely, $41,200/QALY at 3 years, because of a smaller difference in cost between the 2 therapies (Δ = $5300; P = 0.44) and a larger benefit in QALYs with the implant (Δ = 0.130; P = 0.12). The probability of the ICER being cost-effective at thresholds of $50,000/QALY and $100,000/QALY was 0.53 and 0.74, respectively.

Conclusions: Fluocinolone acetonide implant therapy was reasonably cost-effective compared with systemic therapy for individuals with unilateral intermediate, posterior, or panuveitis but not for those with bilateral disease. These results do not apply to the use of implant therapy when systemic therapy has failed or is contraindicated. Should the duration of implant effect prove to be substantially >3 years or should large changes in therapy pricing occur, the cost-effectiveness of implant versus systemic therapy would need to be reevaluated.

Figure 1

Percentage of total cost attributable to implant, procedure, uveitis medication, ocular medication, other medication, and hospitalization over three years of follow-up for individuals randomized to systemic (left) or implant (right) therapy for individuals with bilateral (a) and unilateral (b) disease.

Figure 1

Percentage of total cost attributable to implant, procedure, uveitis medication, ocular medication, other medication, and hospitalization over three years of follow-up for individuals randomized to systemic (left) or implant (right) therapy for individuals with bilateral (a) and unilateral (b) disease.

Figure 2

Bootstrap estimates of the variability of the components of the incremental cost effectiveness ratio comparing implant and systemic therapy for individuals with (a) bilateral uveitis and (b) unilateral uveitis. The black dot represents the pairing of the estimated difference in cost and quality adjust life years (QALYs) based upon the observed data. The grey x's represent the bootstrap replicates. The upper left (systemic) and lower right (implant) quadrants represent scenarios for which one therapy is dominant.

Figure 2

Bootstrap estimates of the variability of the components of the incremental cost effectiveness ratio comparing implant and systemic therapy for individuals with (a) bilateral uveitis and (b) unilateral uveitis. The black dot represents the pairing of the estimated difference in cost and quality adjust life years (QALYs) based upon the observed data. The grey x's represent the bootstrap replicates. The upper left (systemic) and lower right (implant) quadrants represent scenarios for which one therapy is dominant.

Figure 3

A plot of the probability that implant therapy is cost-effective versus the threshold of dollars per quality adjusted life year (QALY) used to define cost-effectiveness for bilateral (black) and unilateral (grey) disease. The probability of being cost-effective is included for the standard thresholds, $50,000/QALY (triangle) and $100,000/QALY (square).