Retinal Treatments Don’t Just Cost the Price on the Package

STOCKHOLM — Ophthalmologists are often cornered into choosing one retinal treatment over another but not necessarily because it’s the best overall option for the patient in the long run, explained experts here at the American Society of Retina Specialists (ASRS) 2024 Annual Meeting. They presented data on the broader societal and economic impacts of retinal treatments, revealing hidden costs that challenge current cost-effectiveness models.

“In an ideal world, we would not have to consider financial constraints,” explained Linda A. Lam, MD, professor of clinical ophthalmology at the University of Southern California, Los Angeles, speaking to Medscape Medical News. “But in America, many retina specialists are often forced to use certain therapies before the patient can be switched to a potentially more effective therapy due to cost constraints provided by the insurer.”

On the other side, ophthalmologists sometimes opt for more frequent, more expensive treatments, even though they may be only slightly more effective than more convenient, cheaper ones.

“Ideally, we would consider factors such as the patient’s ability to come to the appointment easily,” she said. “If a patient is elderly and doesn’t have transportation, it would be better to start the patient on a longer-term therapy.”

“The increased treatment burden for more frequent injections and clinical visits offsets the benefits over time,” Lam explained.

The Hidden Costs of Treatment

Ella Leung, MD, a vitreoretinal surgeon at Georgia Retina, explained that most cost-effectiveness studies focus primarily on direct medical costs, such as injections, tests, and clinic operations. However, the true costs of treatment extend beyond medical expenses for patients with poor vision. These patients often need a caretaker to accompany them to appointments and face reduced productivity due to missed work. Leung explained that “[it] can be difficult for younger, working age, diabetic patients to return for more frequent injections.”

She presented the results of a study commissioned by the ASRS health economics committee. The study looked at the societal costs and incremental cost-utility ratios for the treatment of diabetic macular edema (DME) when following the bevacizumab-first DRCR protocol AC vs more expensive real-world anti-VEGF treatment regimens.

Using a decision-analytic model that analyzed costs over 2 years, it found that even though patients achieved slightly better visual outcomes with the bevacizumab-first arm of the trial, the increased treatment burden from more frequent injections and clinical visits offset the benefits over time.

More specifically, the societal formal and informal healthcare and non-healthcare costs were 14% higher in the bevacizumab-first arm.

Also, the incremental cost-utility ratio for the bevacizumab-first protocol vs real-world treatments was $84,214 per quality-adjusted life year (QALY), exceeding typical societal willingness-to-pay thresholds of $50,000.

If applied to all 1.1 million US patients with DME, the bevacizumab-first approach could increase societal costs by $19 billion over 2 years compared with current real-world strategies.

“The societal perspective provides a more comprehensive view of all the costs incurred by treatments, not just for the healthcare system and insurance companies but also for our patients, their caretakers, the workforce, and society as a whole,” Leung told Medscape Medical News.

“Physicians can use the longer-acting, more efficacious drugs, even though they’re more expensive because it can be cost-effective,” she added.

Geographic Atrophy (GA) Treatment Costs

Utility studies in ophthalmology have traditionally examined functional endpoints, most commonly visual acuity. However, the two US Food and Drug Administration–approved treatments for GA, avacincaptad pegol (ACP) and pegcetacoplan (PEG), have not demonstrated benefits in visual acuity but instead slow the progress of the condition.

Function is a difficult endpoint to measure in GA, so new ways involving anatomical endpoints are needed to look at the cost-benefit ratio of these drugs, said Lam.

Researchers introduced a novel metric of “cost-per-area of GA spared” to analyze GA treatment costs. They utilized data from the GATHER2 and DERBY/OAKS clinical trials for ACP and PEG, respectively, basing costs on 2022 Medicare reimbursement rates in Miami, Florida. The study examined monthly and every-other-month treatment regimens, creating 2-year and lifetime models for patients in facility settings.

Over 2 years, treating with ACP costs about $67,400 for monthly dosing and $50,200 for every-other-month dosing.

When looking at how much it costs to delay GA progression with ACP, the every-other-month schedule was more cost-effective than the monthly schedule ($57,100 vs $119,000 per square millimeter, respectively).

For patients with GA not yet affecting central vision, ACP was generally lesser cost-effective than PEG, especially with monthly dosing. The costs per square millimeter were $650,000 vs $322,000 for the monthly dosing and $245,000 vs $205,000 for the every-other-month dosing of ACP vs PEG, respectively.

The lifetime cost per QALY was more than $1 million vs about $537,000 for the monthly dosing of ACP vs PEG, respectively. The lifetime projections for every-other-month dosing were $618,000 for ACP and $313,000 for PEG.

The study’s findings imply that reducing the frequency of treatment could lead to substantial cost savings without compromising treatment effectiveness.

“Every-other-month treatment is more cost-effective because there’s really a lack of substantial efficacy gain relative to the increased costs with the more frequent dosing,” explained Hasenin Al-khersan, MD, a retina specialist at Retina Consultants of Texas in Houston, who was involved in the study, speaking to Medscape Medical News.

“Our study gives physicians an idea of the relative cost-effectiveness of these similar complement inhibitors,” he said. “However, a doctor’s decision to use a particular medication is multifactorial. It cannot and should not be solely based on cost. Physicians must consider each patient’s specific clinical context in making their decision about which drug to use. This study offers clinicians one additional data point to consider in the overall decision analysis.”

Lam, Leung, and Al-khersan had no relevant financial relationships to disclose.

Manuela Callari is a freelance science journalist specializing in human and planetary health. Her words have been published in The Medical Republic, Rare Disease Advisor, The Guardian, MIT Technology Review, and others.