Cataract is the leading cause of preventable blindness worldwide, and cataract extraction with intraocular lens (IOL) implantation is the leading surgical procedure performed in many countries. Adoption of new surgical technologies, which vary in costs and effectiveness, has important implications for allocation of healthcare dollars.
A Markov computer simulation model was developed to compare lifetime effectiveness and costs of 5 surgical strategies: conventional phacoemulsification (with a basic/monofocal IOL—standard-of-care in most settings), manual small-incision surgery with a basic/monofocal IOL, femtosecond-laser-assisted phacoemulsification with a basic/monofocal IOL, phacoemulsification with a toric IOL (“premium” IOL that corrects astigmatism), and phacoemulsification with a multifocal IOL (“premium” IOL that provides both distance and near vision).
Inputs and treatment effects were derived from randomized clinical trials. Modeled complications included inflammation, infection, and intraoperative complications. Costs were assessed from a societal perspective, including treatment-related costs, caregiver time, and costs of low vision. Quality-of-life weights were computed based on changes in visual acuity. The primary outcome measure was quality-adjusted life years (QALYs). Deterministic sensitivity analyses were performed on model inputs across a wide range of assumptions.
In our base case scenario, phacoemulsification with a multifocal IOL achieved the greatest lifetime benefit, gaining 0.86 QALYs at additional lifetime cost of $5,834 compared to conventional phacoemulsification—an incremental cost-effectiveness ratio (ICER) of $6,810 per QALY gained. Femtosecond-laser-assisted phacoemulsification and phacoemulsification with a toric IOL each achieved greater effectiveness at higher cost than conventional phacoemulsification, but at insufficient value to be cost-effective options (extended dominance). Manual small-incision surgery was less effective than the other options, with overall lifetime cost greater than conventional phacoemulsification. When femtosecond-laser-assisted phacoemulsification was evaluated assuming an optimized multifocal toric IOL, it was preferred to all other options (ICER of $1,523 per QALY gained over conventional phacoemulsification). Results were highly sensitive to quality-of-life for astigmatism and presbyopia, and to fine visual discrimination (reflecting visual needs, particularly relevant in resource-poor settings).
In lifetime model-based analysis, phacoemulsification with premium IOLs may be more cost-effective than conventional phacoemulsification. If femtosecond-laser-assisted phacoemulsification can be performed with an optimal toric multifocal IOL, it becomes the most cost-effective option. Findings vary based on cataract severity, visual needs, and the value of obviating patients’ need for glasses; however, new technologies offer cost-effective additional benefit over standard-of-care.