Elsevier

Ophthalmology

Volume 121, Issue 4, April 2014, Pages 936-945
Ophthalmology

Original article
Cost-Effectiveness of Bevacizumab and Ranibizumab for Newly Diagnosed Neovascular Macular Degeneration

https://doi.org/10.1016/j.ophtha.2013.10.037Get rights and content

Purpose

We sought to determine the most cost-effective treatment for patients with newly diagnosed neovascular macular degeneration: monthly or as-needed bevacizumab injections, or monthly or as-needed ranibizumab injections.

Design

Cost-effectiveness analysis.

Participants

Hypothetical cohort of 80-year-old patients with newly diagnosed neovascular macular degeneration.

Methods

Using a mathematical model with a 20-year time horizon, we compared the incremental cost-effectiveness of treating a hypothetical cohort of 80-year-old patients with newly diagnosed neovascular macular degeneration using monthly bevacizumab, as-needed bevacizumab, monthly ranibizumab, or as-needed ranibizumab. Data came from the Comparison of Age-related macular degeneration Treatment Trial (CATT), the Medicare Fee Schedule, and the medical literature.

Main Outcome Measures

Costs, quality-adjusted life-years (QALYs), and incremental costs per QALY gained.

Results

Compared with as-needed bevacizumab, the incremental cost-effectiveness ratio of monthly bevacizumab is $242 357/QALY. Monthly ranibizumab gains an additional 0.02 QALYs versus monthly bevacizumab at an incremental cost-effectiveness ratio of >$10 million/QALY. As-needed ranibizumab was dominated by monthly bevacizumab, meaning it was more costly and less effective. In sensitivity analyses assuming a willingness to pay of $100 000/QALY, the annual risk of serious vascular events would have to be ≥2.5 times higher with bevacizumab than that observed in the CATT trial for as-needed ranibizumab to have an incremental cost-effectiveness ratio of <$100 000/QALY. In another sensitivity analysis, even if every patient receiving bevacizumab experienced declining vision by 1 category (e.g., from 20/25–20/40 to 20/50–20/80) after 2 years but every patient receiving ranibizumab retained their vision level, as-needed ranibizumab would have an incremental cost-effectiveness ratio of $97 340/QALY.

Conclusions

Even after considering the potential for differences in risks of serious adverse events and therapeutic effectiveness, bevacizumab confers considerably greater value than ranibizumab for the treatment of neovascular macular degeneration.

Section snippets

Study Design

We developed a Markov model to capture the total costs and HRQL for patients with newly diagnosed neovascular AMD under 4 treatment options: monthly bevacizumab injections, as-needed bevacizumab injections, monthly ranibizumab injections, and as-needed ranibizumab injections. A societal perspective was taken to encompass all parties affected by the treatment choice: patients, providers, and payers. The model followed a hypothetical cohort of patients aged 80 years (the mean age for neovascular

Base Model

Over 20 years, the expected costs for a single patient with newly diagnosed neovascular AMD receiving monthly bevacizumab, as-needed bevacizumab, monthly ranibizumab, and as-needed ranibizumab were $79 771, $65 267, $257 496, and $163 694, and the QALYs for a patient receiving these treatments were 6.66, 6.60, 6.68, and 6.64, respectively. The ICER of monthly bevacizumab over as-needed bevacizumab was $242 357/QALY. The ICER of monthly ranibizumab over as-needed bevacizumab was

Discussion

As health care policymakers aim to curtail rising health care costs, treatments that confer the greatest relative value must be identified. Using data from CATT, we find that, compared with as-needed dosing of bevacizumab, the ICERs of monthly bevacizumab and monthly ranibizumab for neovascular AMD are $242 357/QALY and $10 708 377/QALY, respectively. Furthermore, as-needed ranibizumab was dominated by as-needed bevacizumab, meaning that as-needed ranibizumab is more costly and less effective.

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    Supplemental material is available at www.aaojournal.org

    This research has been accepted as a thesis for the American Ophthalmological Society.

    Financial Disclosures: The authors have no proprietary or commercial interest in any of the materials discussed in this article. Paul P. Lee, MD, JD, is a consultant to Genentech; however, this company was not involved in the conception, design, or conduct of this study.

    Funding/support: National Eye Institute K23 Mentored Clinician Scientist Award (1K23EY019511-01); Grant Number P30DK092926 from the National Institute of Diabetes and Digestive and Kidney Diseases; Research to Prevent Blindness “Physician Scientist” Award; and an unrestricted grant from Research to Prevent Blindness.

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