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A longitudinal study to assess the frequency and cost of antivascular endothelial therapy, and inequalities in access, in England between 2005 and 2015
  1. William Hollingworth1,
  2. Tim Jones2,
  3. Barnaby C Reeves3,
  4. Tunde Peto4
  1. 1 Department of Population Health Sciences, University of Bristol, Bristol, UK
  2. 2 NIHR CLAHRC West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
  3. 3 Clinical Trials Evaluation Unit, Department of Translational Sciences, University of Bristol, Bristol, UK
  4. 4 School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
  1. Correspondence to Dr William Hollingworth; william.hollingworth{at}


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.

  • vascular endothelial growth factor A
  • drug costs
  • macular degeneration
  • macular edema
  • England
  • geography

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  • Contributors WH initiated and designed the study, contributed to the data analysis and interpretation of data, and drafted and revised the paper. He is guarantor. TJ contributed to the study design, cleaned and analysed the data, contributed to the interpretation of data, and revised the draft paper. BCR and TP contributed to the interpretation of data and revised the draft paper. All authors approved the final version of the paper. All authors had full access to all of the data in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Funding WH and TJ receive funding from the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) West.

  • Disclaimer The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.