JAMA Ophthalmology, August 2016
Ross et al., on behalf of the Diabetic Retinopathy Clinical Research Network (DRCR.net), examined the incremental cost-effectiveness ratios (ICERs) of aflibercept, bevacizumab, and ranibizumab for the treatment of diabetic macular edema (DME). They found that the visual acuity (VA) benefits of aflibercept and ranibizumab translate into modest quality-of-life improvements but at a high cost relative to bevacizumab, with ICERs substantially higher than $100,000, a frequently cited threshold for cost-effectiveness.
Post hoc analysis of efficacy, safety, and resource utilization data was performed at 1-year follow-up from the DRCR.net Comparative Effectiveness Trial. The study included 624 participants (mean age, 60.6 years): 209 in the aflibercept group, 207 in the bevaciz-umab group, and 208 in the ranibiz-umab group. These data were used to calculate cost-effectiveness for 1 year for each of the anti-VEGF agents, and mathematical modeling was used to project 10-year cost-effectiveness.
Overall, during 1 year, the ICERs of aflibercept and ranibizumab compared with bevacizumab were $1,110,000 per quality-adjusted life-year (QALY) and $1,730,000 per QALY, respectively.
During 10 years, they were $349,000 and $603,000 per QALY, respectively. Compared with ranibizumab, aflibercept’s ICER was $648,000 per QALY at 1 year and $203,000 per QALY at 10 years. For the subgroup with worse baseline vision, the 10-year ICERs of aflibercept and ranibizumab compared with bevacizumab were $287,000 and $817,000 per QALY, respectively. For all participants, treatment costs of aflibercept and ranibizumab would need to decrease by 69% and 80%, respectively, to reach a cost-effectiveness threshold of $100,000 per QALY compared with bevacizumab during a 10-year horizon; for the subgroup with worse baseline vision, the costs would need to decrease by 62% and 84%, respectively.
The researchers concluded that aflibercept and ranibizumab are not cost-effective compared with bevacizumab. From a societal perspective, bevacizumab as first-line therapy for DME would confer the greatest value; however, these findings highlight the challenges faced by physicians, patients, and policy makers when safety and efficacy results are at odds with cost-effectiveness results.
The original article can be found here.