Cost-utility analysis of commonly used anti-glaucoma interventions for mild-to-moderate primary open-angle glaucoma patients in rural and urban China

Abstract

Objective: An increasing number of studies have explored the clinical effects of antiglaucoma surgical procedures; however, economic evidence was scarce. We aimed to compare the cost-effectiveness between maximal medical treatment (MMT) and commonly used surgical procedures (trabeculectomy, Ahmed glaucoma valve implantation, gonioscopy-assisted transluminal trabeculotomy and ab interno canaloplasty).

Design and setting: A Markov model study.

Participants: A hypothetical cohort of 100 000 patients with mild-to-moderate primary open-angle glaucoma (POAG).

Outcomes: Data were obtained from public sources. The main outcomes were incremental cost-utility ratios (ICURs) using quality-adjusted life-years (QALYs). Sensitivity analyses were conducted to verify the robustness and sensitivity of base-case results.

Main results: Both cumulative costs and QALYs gained from surgical procedures (US$6045-US$13 598, 3.33-6.05 QALYs) were higher than those from MMT (US$3117-US$6458, 3.14-5.66 QALYs). Compared with MMT, all surgical procedures satisfied the cost-effectiveness threshold (lower than US$30 501 and US$41 568 per QALY gained in rural and urban settings, respectively). During the 5-year period, trabeculectomy produced the lowest ICUR (US$21 462 and US$15 242 per QALY gained in rural and urban settings, respectively). During the 10-year-follow-up, trabeculectomy still produced the lowest ICUR (US$13 379 per QALY gained) in urban setting; however, gonioscopy-assisted transluminal trabeculotomy (US$19 619 per QALY gained) and ab interno canaloplasty (US$18 003 per QALY gained) produced lower ICURs than trabeculectomy (US$19 675 per QALY gained) in rural areas. Base-case results were most sensitive to the utilities and costs of initial treatment and maintenance.

Conclusions: The long-term cost-effectiveness of commonly used surgical procedures could be better than the short-term cost-effectiveness for mild-to-moderate POAG patients in China. Health economic studies, supported by more rigorous structured real-world data, are needed to assess their everyday cost-effectiveness.

Keywords: Health economics; Public health; SURGERY.

Figure 1

Healthcare pathways of different treatments for patients with mild-to-moderate primary open-angle glaucoma. Patients who entered the model were in a mild or moderate state of POAG and may have previously received the maximal medical treatment or antiglaucoma surgery. In the first year, patients received initial treatment, follow-up and management of complications. During the follow-up years, patients with successful surgery received regular follow-up and management of late complications, while patients with failed surgery received maximal medical treatment. POAG, primary open-angle glaucoma.

Figure 2

Deterministic one-way sensitivity analysis for surgical procedures compared with maximal medical treatment at the 10-year follow-up. Costs are given in US dollars. The top five parameters that caused the greatest impact on ICURs are listed. We performed a deterministic one-way sensitivity analysis for surgical procedures (TRAB, AGV implantation, GATT and ABiC) compared with maximal medical treatment at the 10-year follow-up for rural (A–D) and urban (E–H) settings. Intervention was considered cost-effective when the cost was less than three times the per capita GDP (US$41 568 for urban patients, US$30 501 for rural patients) and highly cost-effective when the cost was less than one times the per capita GDP (US$13 856 for urban patients, US$10 167 for rural patients). AGV, Ahmed glaucoma valve; ABiC, ab interno canaloplasty; GATT, gonioscopy-assisted transluminal trabeculotomy; GDP, gross domestic product; ICURs, incremental cost–utility ratios; MIGS, minimally invasive glaucoma surgery; QALY, quality-adjusted life-year; TRAB, trabeculectomy.