Gary C. Brown

The burden of age-related macular degeneration: A value-based analysis

Purpose of review The quality-of-life loss and the financial consequences associated with age-related macular degeneration are assessed. Recent findings The quality-of-life loss associated with macular degeneration is markedly underestimated by the general public, nonophthalmic physicians, and ophthalmologists who treat patients with this condition. Mild age-related macular degeneration causes a 17% decrement in the quality of life of the average patient, similar to that encountered with moderate cardiac angina or symptomatic human immunodeficiency virus syndrome. Moderate age-related macular degeneration causes a 40% decrease in the average patients quality of life, similar to that associated with severe cardiac angina or renal dialysis. Very severe age-related macular degeneration causes a large 63% decrease in the average patients quality of life, similar to that encountered with end-stage prostatic cancer or a catastrophic stroke that leaves a person bedridden, incontinent and requiring constant nursing care. The return on investment is high for both treatment with current age-related macular degeneration therapies and the research costs invested in the development of age-related macular degeneration treatment modalities. Summary Age-related macular degeneration is a major public health problem that has a devastating effect upon patients and marked adverse financial consequences for the economy.

Triple combination therapy and zeaxanthin for the treatment of neovascular age-related macular degeneration: an interventional comparative study and cost-effectiveness analysis

BackgroundReports of triple combination therapy for neovascular age-related macular degeneration (AMD) suggest a benefit, as do reports for zeaxanthin. An interventional comparative study was thus undertaken to evaluate the efficacy of triple combination therapy with and without zeaxanthin, as well as the economic viability of the therapies.MethodsThe cases of 543 consecutive eyes of 424 patients with subfoveal choroidal neovascularization (CNV) secondary to AMD were reviewed. All eyes were treated with triple combination therapy (triple therapy) consisting of: (1) reduced-fluence photodynamic therapy with verteporfin, (2) intravitreal bevacizumab and (3) intravitreal dexamethasone. Therapy was repeated as necessary. One cohort of patients was also given supplementation with 20xa0mg of oral zeaxanthin (Zx) daily.ResultsThe triple therapy group without Zx received a mean of 2.8 treatment cycles and 87xa0% of patients had stable or improved vision at 24xa0months. In the triple therapy group with Zx, the mean number of treatment cycles was 2.1, with 83xa0% of patients having stable or improved vision at 24xa0months. At 24xa0months, CNV developed in 12.5xa0% of fellow eyes treated with triple therapy alone; CNV developed in 6.25xa0% of eyes treated with triple therapy with Zx (pxa0=xa00.03). An average cost-utility analysis revealed that triple therapy was cost-effective with a cost-utility ratio of

Vascular Occlusive Disease

26,574/QALY, while triple therapy with Zx was more cost-effective with an average cost-utility ratio of

The comparative effectiveness and cost-effectiveness of ranibizumab for neovascular macular degeneration revisited

19,962/QALY. The incremental cost-utility analysis assessing the addition of Zx to triple therapy disclosed Zx supplementation was very cost-effective at

A Value-Based Medicine cost-utility analysis of genetic testing for neovascular macular degeneration.

5302/QALY. When it was assumed that triple therapy with Zx reduced fellow eye CNV development by 30.3xa0%, the incremental cost-utility dropped to (−

The Economics of Age-Related Macular Degeneration

6332/QALY), indicating that adding Zx to triple therapy yielded greater patient value, and was also less expensive than using triple therapy alone.ConclusionsTriple therapy is comparatively effective and cost-effective. Considerably less treatment is needed than reported in monotherapy studies. The addition of oral Zx appears to further reduce the treatment cycles required, and possibly reduce the risk of CNV development in the fellow eye.

Evidence-based to value-based medicine

A complicated well-regulated balance exists between the thrombosis and fibrinolysis systems. This chapter will cover the two main categories of retinal vascular occlusive disease (RVOD): central (CVO) or branch retinal vein occlusion (BVO) and central (CAO) or branch retinal artery occlusion (BAO). This chapter will not address the overall diagnostic evaluation of patients with retinal vascular disease. Patients with CAO/BAO should be evaluated by their medical doctor for common underlying causes such as ipsilateral carotid disease and heart disease. Patients with bilateral, simultaneous CVO/BVO of course should be evaluated for common causes of hypercoagulable states such as Waldenstrom’s or multiple myeloma. Basic evaluation should include a medical review of systems, testing for high blood pressure and diabetes for all patients, and sedimentation rate, carotid Doppler and cardiac sonogram should always be obtained for retinal arterial disease (RAO). After a basic evaluation, many patients with RAO or retinal venous disease (RVO) are said to have idiopathic conditions. In recent years, there have been a large number of papers citing possible associations of RAO and RVO with abnormalities of plasma proteins. Are these associations real? Which should be considered and looked for in which patients? It will be some years before we can offer clear guidance on this subject, and there is a strong need for large prospective studies with contemporaneous well-matched control groups. Until these studies are available, in this chapter we summarize the pertinent literature and offer some thoughts on whether and how patients with RAO and RVO who do not have obvious causes after a “basic” evaluation should be worked up.

Retinal Artery Obstruction

AbstractBackgroundnTo compare a near decade of follow-up, newer control cohort data, use of both the societal and third party insurer cost perspectives, and integration of unilateral/bilateral therapy on the comparative effectiveness and cost-effectiveness of intravitreal ranibizumab therapy for neovascular, age-related macular degeneration (AMD).MethodsValue-Based Medicine®, 12-year, combined-eye model, cost-utility analysis employing MARINA and HORIZON clinical trial data. Preference-based comparative effectiveness outcomes were quantified in (1) QALY (quality-adjusted life-year) gain, and (2) percent improvement in quality-of-life, while cost-effectiveness outcomes were quantified in (3) the cost-utility ratio (CUR) and financial return-on-investment (ROI) to society.ResultsUsing MARINA and HORIZON trial data and a meta-analysis control cohort after 24xa0months, ranibizumab therapy conferred a combined-eye patient value (quality-of-life) gain of 16.3%, versus 10.4% found in 2006. The two-year direct ophthalmic medical cost for ranibizumab therapy was

VALUE-BASED MEDICINE AND OPHTHALMOLOGY: AN APPRAISAL OF COST-UTILITY ANALYSES

46,450, a 33.8% real dollar decrease from 2006. The societal cost perspective CUR was −

Method of quantifying loss of quality of life resulting from personal injury for tort cases

242,920/QALY, indicating a