COST-EFFECTIVENESS OF TREATMENT OPTIONS FOR DIABETIC MACULAR EDEMA

Purpose: Diabetic macular edema is a leading cause of progressive visual disability in patients with diabetic eye disease. Five treatment options are commonly used in clinical practice, though no clear consensus exists on which is most effective or cost-effective. We assessed the cost-effectiveness of treatment options for diabetic macular edema to provide guidance for clinical practice.

Methods: We developed a Markov model of diabetic macular edema, considering five treatment options (anti-VEGF injections, triamcinolone injections, laser treatment, laser with anti-VEGF injections, and laser with triamcinolone injections) along with observation alone. Inputs and treatment effects were derived primarily from the major relevant randomized clinical trials (ETDRS, RESTORE, and DRCR.net). We also used model calibration to match trial data on the number and timing of treatments. Costs included caregiver time and long-term costs of blindness. Quality-of-life weights were computed based on loss of visual acuity. Treatment was administered over a one year period, and the model run over a lifetime horizon, considering all outcomes from a societal perspective. We performed sensitivity analyses on all model inputs.

Results: Under our base-case assumptions, laser with anti-VEGF injections was the most effective regimen, gaining 1.1 QALYs and costing $14,856 more than laser with triamcinolone ($13,486 per QALY), the next most effective strategy. Observation, laser alone, and triamcinolone alone were dominated across a wide range of parameter values and assumptions; however, variation in utilities for visual acuity yielded anti-VEGF injections alone as the preferred strategy (dominating laser with anti-VEGF injections) in some scenarios. However, the absolute difference in quality of life between anti-VEGF injections alone and laser with anti-VEGF injections was small – ranging from <0.01 to 0.04 QALYs. 

Conclusions: Anti-VEGF injections, with or without laser, improved health outcomes and provided good value for money compared to other treatment options for diabetic macular edema. While anti-VEGF injections do appear consistently preferable to laser, triamcinolone, or observation, drawing conclusions about the relationship between combined laser/anti-VEGF injections and anti-VEGF injections alone is not currently possible, as the difference is small and hinges upon assigned utility values. A high degree of certainty regarding appropriate visual acuity utilities would thus be required to definitively determine the additional value from laser.