Original Research
7 January 2014

Cost-Effectiveness of Treatment of Diabetic Macular Edema

Publication: Annals of Internal Medicine
Volume 160, Number 1

Abstract

Background:

Macular edema is the most common cause of vision loss among patients with diabetes.

Objective:

To determine the cost-effectiveness of different treatments of diabetic macular edema (DME).

Design:

Markov model.

Data Sources:

Published literature and expert opinion.

Target Population:

Patients with clinically significant DME.

Time Horizon:

Lifetime.

Perspective:

Societal.

Intervention:

Laser treatment, intraocular injections of triamcinolone or a vascular endothelial growth factor (VEGF) inhibitor, or a combination of both.

Outcome Measures:

Discounted costs, gains in quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs).

Results of Base-Case Analysis:

All treatments except laser monotherapy substantially reduced costs, and all treatments except triamcinolone monotherapy increased QALYs. Laser treatment plus a VEGF inhibitor achieved the greatest benefit, gaining 0.56 QALYs at a cost of $6975 for an ICER of $12 410 per QALY compared with laser treatment plus triamcinolone. Monotherapy with a VEGF inhibitor achieved similar outcomes to combination therapy with laser treatment plus a VEGF inhibitor. Laser monotherapy and triamcinolone monotherapy were less effective and more costly than combination therapy.

Results of Sensitivity Analysis:

VEGF inhibitor monotherapy was sometimes preferred over laser treatment plus a VEGF inhibitor, depending on the reduction in quality of life with loss of visual acuity. When the VEGF inhibitor bevacizumab was as effective as ranibizumab, it was preferable because of its lower cost.

Limitation:

Long-term outcome data for treated and untreated diseases are limited.

Conclusion:

The most effective treatment of DME is VEGF inhibitor injections with or without laser treatment. This therapy compares favorably with cost-effective interventions for other conditions.

Primary Funding Source:

Agency for Healthcare Research and Quality.

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Supplemental Material

Supplement. Cost-Effectiveness of Treatment of DME

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Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 160Number 17 January 2014
Pages: 18 - 29

History

Published online: 7 January 2014
Published in issue: 7 January 2014

Keywords

Authors

Affiliations

Suzann Pershing, MD, MS
From Stanford Health Policy, Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University, Stanford, California; Byers Eye Institute at Stanford University, Stanford University School of Medicine, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and University of Minnesota School of Public Health, Minneapolis, Minnesota.
Eva A. Enns, MS, PhD
From Stanford Health Policy, Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University, Stanford, California; Byers Eye Institute at Stanford University, Stanford University School of Medicine, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and University of Minnesota School of Public Health, Minneapolis, Minnesota.
Brian Matesic, BS
From Stanford Health Policy, Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University, Stanford, California; Byers Eye Institute at Stanford University, Stanford University School of Medicine, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and University of Minnesota School of Public Health, Minneapolis, Minnesota.
Douglas K. Owens, MD, MS
From Stanford Health Policy, Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University, Stanford, California; Byers Eye Institute at Stanford University, Stanford University School of Medicine, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and University of Minnesota School of Public Health, Minneapolis, Minnesota.
Jeremy D. Goldhaber-Fiebert, PhD
From Stanford Health Policy, Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University, Stanford, California; Byers Eye Institute at Stanford University, Stanford University School of Medicine, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and University of Minnesota School of Public Health, Minneapolis, Minnesota.
This material was presented at the 34th Annual Meeting of the Society of Medical Decision Making, Phoenix, Arizona, 17–19 October 2012.
Disclaimer: The contents of this article are solely the responsibility of the authors and do not necessarily represent the views of the National Institutes of Health, Agency for Healthcare Research and Quality, or U.S. Department of Veterans Affairs. Discussion of DRCR.net data, as cited in this publication, is by the authors and is in no way affiliated or endorsed by DRCR.net. Additional data provided by DRCR.net is not an indication that DRCR.net has made any statement on the validity of these analyses or interpretations.
Acknowledgment: The authors thank Dr. Mark S. Blumenkranz for guidance and manuscript review.
Financial Support: By grant T32-HS000028 from the Agency for Healthcare Research and Quality and a National Institutes of Health National Institute on Aging Career Development Award (K01 AG037593-01A1; Dr. Goldhaber-Fiebert, principal investigator). Dr. Owens was supported by the U.S. Department of Veterans Affairs. This research was also supported in part by the Office of the Dean, Stanford Medical School, Stanford Society of Physician Scholars.
Reproducible Research Statement: Study protocol, statistical code, and data set: Available from Dr. Pershing (e-mail, [email protected]).
Corresponding Author: Suzann Pershing, MD, MS, 2452 Watson Court, Palo Alto, CA 94303; e-mail, [email protected].
Current Author Addresses: Dr. Pershing: 2452 Watson Court, Palo Alto, CA 94303.
Dr. Enns: University of Minnesota, Division of Health Policy and Management, MMC 729 Mayo, Campus Mail Code 8729A, 420 Delaware Street SE, Minneapolis, MN 55455.
Mr. Matesic: 316 Grant Avenue, Palo Alto, CA 94306.
Dr. Owens and Goldhaber-Fiebert: Stanford University, Center for Health Policy and Center for Primary Care and Outcomes Research, 117 Encina Commons, Stanford, CA 94305.
Author Contributions: Conception and design: S. Pershing, J.D. Goldhaber-Fiebert, D.K. Owens.
Analysis and interpretation of the data: S. Pershing, E.A. Enns, J.D. Goldhaber-Fiebert.
Drafting of the article: S. Pershing,
Critical revision of the article for important intellectual content: S. Pershing, E.A. Enns, J.D. Goldhaber-Fiebert, D.K. Owens.
Final approval of the article: S. Pershing, E.A. Enns, J.D. Goldhaber-Fiebert, D.K. Owens, B. Matesic.
Provision of study materials or patients:
Statistical expertise: S. Pershing, E.A. Enns, J.D. Goldhaber-Fiebert.
Obtaining of funding:
Administrative, technical, or logistic support:
Collection and assembly of data: S. Pershing.

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Suzann Pershing, Eva A. Enns, Brian Matesic, et al. Cost-Effectiveness of Treatment of Diabetic Macular Edema. Ann Intern Med.2014;160:18-29. [Epub 7 January 2014]. doi:10.7326/M13-0768

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