A longitudinal study to assess the frequency and cost of antivascular endothelial therapy, and inequalities in access, in England between 2005 and 2015

Abstract

Objectives: High-cost antivascular endothelial growth factor (anti-VEGF) medicines for eye disorders challenge ophthalmologists and policymakers to provide fair access for patients while minimising costs. We describe the growth in the use and costs of these medicines and measure inequalities in access.

Design: Longitudinal study using Hospital Episode Statistics (2005/2006 to 2014/2015) and hospital prescribing cost reports (2008/2009 to 2015/2016). We used Poisson regression to estimate standardised rates and explore temporal and geographical variations.

Setting: National Health Service (NHS) care in England.

Population: Patients receiving anti-VEGF injections for age-related macular degeneration, diabetic macular oedema and other eye disorders.

Interventions: Higher-cost drugs (ranibizumab or aflibercept) recommended by the National Institute for Health and Care Excellence or lower-cost drug (bevacizumab) not licensed for eye disorders.

Main outcome measures: National procedure rates and variation between and within clinical commissioning groups (CCGs). Cost of ranibizumab and aflibercept prescribing.

Results: Injection procedures increased by 215% between 2010/2011 and 2014/2015. In 2014/2015 there were 388 031 procedures (714 per 100 000). There is no evidence that the dramatic growth in rates is slowing down. Since 2010/2011 the estimated cost of ranibizumab and aflibercept increased by 247% to £447 million in 2015/2016, equivalent to the entire annual budget of a CCG. There are large inequalities in access; in 2014/2015 procedure rates in a 'high use' CCG were 9.08 times higher than in a 'low use' CCG. In the South-West of England there was twofold variation in injections per patient per year (range 2.9 to 5.9).

Conclusions: The high and rising cost of anti-VEGF therapy affects the ability of the NHS to provide care for other patients. Current regulations encourage the increasing use of ranibizumab and aflibercept rather than bevacizumab, which evidence suggests is more cost-effective. NHS patients in England do not have equal access to the most cost-effective care.

Keywords: England; drug costs; geography; macular degeneration; macular edema; vascular endothelial growth factor A.

Figure 1

Office of Population, Censuses and Surveys codes used to identify antivascular endothelial growth factor injections: 2014/2015. Note: 2479 eye injection procedures were excluded due to combination with X93.2 or X93.3 high-cost drug codes.

Figure 2

Directly standardised intravitreal injection procedure rates, England, 2005/2006–2014/2015. APC, admitted patients care; HES, Hospital Episode Staristics; OP, outpatient.

Figure 3

Percentage of total eye injection procedures in Hospital Episode Statistics admitted patients care for different primary diagnoses, England, 2008/2009–2014/2015. AMD, age-related macular degeneration; RVO, retinal vein occlusion; due to very small numbers of procedures for myopic choroidal neovascularisation (≤10 per year), this was included in ‘Other’.

Figure 4

Hospital prescribing costs for ranibizumab and aflibercept, 2008/2009 to 2015/2016.

Figure 5

(A) Indirectly age-sex-deprivation-ethnicity standardised procedure ratios for combined eye injection procedures (OPCS-4: C794 and C893) by CCG in England, 2014/2015. (B) Indirectly age-sex-deprivation-ethnicity standardised patient ratios for combined eye injection procedures (OPCS-4: C794 and C893) by CCG in England, 2014/2015. CCG, clinical commissioning group; OPCS, Office of Population, Censuses and Surveys.

Figure 6

(A) Indirectly standardised procedure ratios for combined eye injection procedures by Middle Layer Super Output Areas (MSOA) in SW England, 2014/2015. (B) Indirectly standardised patient ratios for combined eye injection procedures by MSOA in SW England, 2014/2015. Note: Major hospitals marked including those in National Health Service (NHS) Trusts providing 100+ procedures. CCG, clinical commissioning group.