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Randomized Controlled Trial
. 2023 Mar 1;141(3):268-274.
doi: 10.1001/jamaophthalmol.2022.6142.

Cost-effectiveness of Aflibercept Monotherapy vs Bevacizumab First Followed by Aflibercept If Needed for Diabetic Macular Edema

David W Hutton  1 , Adam R Glassman  2 , Danni Liu  2 , Jennifer K Sun  3 ; DRCR Retina Network
Collaborators, Affiliations
Randomized Controlled Trial

Cost-effectiveness of Aflibercept Monotherapy vs Bevacizumab First Followed by Aflibercept If Needed for Diabetic Macular Edema

David W Hutton et al. JAMA Ophthalmol. .

Abstract

Importance: The DRCR Retina Network Protocol AC showed no significant difference in visual acuity outcomes over 2 years between treatment with aflibercept monotherapy and bevacizumab first with switching to aflibercept for suboptimal response in treating diabetic macular edema (DME). Understanding the estimated cost and cost-effectiveness of these approaches is important.

Objective: To evaluate the cost and cost-effectiveness of aflibercept monotherapy vs bevacizumab-first strategies for DME treatment.

Design, setting, and participants: This economic evaluation was a preplanned secondary analysis of a US randomized clinical trial of participants aged 18 years or older with center-involved DME and best-corrected visual acuity of 20/50 to 20/320 enrolled from December 15, 2017, through November 25, 2019.

Interventions: Aflibercept monotherapy or bevacizumab first, switching to aflibercept in eyes with protocol-defined suboptimal response.

Main outcomes and measures: Between February and July 2022, the incremental cost-effectiveness ratio (ICER) in cost per quality-adjusted life-year (QALY) over 2 years was assessed. Efficacy and resource utilization data from the randomized clinical trial were used with health utility mapping from the literature and Medicare unit costs.

Results: This study included 228 participants (median age, 62 [range, 34-91 years; 116 [51%] female and 112 [49%] male; 44 [19%] Black or African American, 60 [26%] Hispanic or Latino, and 117 [51%] White) with 1 study eye. The aflibercept monotherapy group included 116 participants, and the bevacizumab-first group included 112, of whom 62.5% were eventually switched to aflibercept. Over 2 years, the cost of aflibercept monotherapy was $26 504 (95% CI, $24 796-$28 212) vs $13 929 (95% CI, $11 984-$15 874) for the bevacizumab-first group, a difference of $12 575 (95% CI, $9987-$15 163). The aflibercept monotherapy group gained 0.015 (95% CI, -0.011 to 0.041) QALYs using the better-seeing eye and had an ICER of $837 077 per QALY gained compared with the bevacizumab-first group. Aflibercept could be cost-effective with an ICER of $100 000 per QALY if the price per dose were $305 or less or the price of bevacizumab was $1307 per dose or more.

Conclusions and relevance: Variability in individual needs will influence clinician and patient decisions about how to treat specific eyes with DME. While the bevacizumab-first group costs still averaged approximately $14 000 over 2 years, this approach, as used in this study, may confer substantial cost savings on a societal level without sacrificing visual acuity gains over 2 years compared with aflibercept monotherapy.

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Conflict of interest statement

Conflict of Interest Disclosures: Mr Glassman reported receiving grants from the National Institutes of Health during the conduct of the study and grants from Regeneron outside the submitted work. Ms Liu reported receiving grants from the National Institutes of Health during the conduct of the study and grants from Regeneron and Roche outside the submitted work. Dr Sun reported receiving grants from JDRF, Physical Sciences, Kalvista, Novartis, Janssen Pharmaceuticals, Genentech/Roche, Novo Nordisk, and Boehringer Ingelheim; nonfinancial support from Optovue, Boston Micromachines, Merck, Novo Nordisk, Adaptive Sensory Technologies, Genentech/Roche, and Novartis; and personal fees from the American Medical Association and American Diabetes Association outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Utility Over Time
Quality of life was mapped to visual acuity letter score in the participant’s better-seeing eye at each visit using data from Brown et al, with a more detailed view shown in the inset. Error bars represent the 95% CIs.
Figure 2.
Figure 2.. Tornado Diagram of 1-Way Sensitivity Analysis
The diagram shows how the incremental cost-effectiveness ratio on the horizontal axis varies as the individual parameter assumptions (on the vertical axis) vary between the high and low ranges (shown in Table 1). Quality of life was mapped to visual acuity (VA) letter score in the participant’s better-seeing eye at each visit using data from Brown et al. OCT indicates optical coherence tomography.
Figure 3.
Figure 3.. Sensitivity to Cost of Treatment per Dose
The lines show the incremental cost-effectiveness ratio (ICER) of aflibercept vs bevacizumab first (vertical axis) at the varying costs of aflibercept and bevacizumab (horizontal axis). An ICER less than $100 000 per quality-adjusted life-year (QALY) is commonly considered meaningful for determining cost-effectiveness in the US.,,,, Quality of life was mapped to visual acuity letter score in the participant’s better-seeing eye at each visit using data from Brown et al.
See this image and copyright information in PMC

References

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