Cost-effectiveness of Intravitreous Ranibizumab Compared With Panretinal Photocoagulation for Proliferative Diabetic Retinopathy: Secondary Analysis From a Diabetic Retinopathy Clinical Research Network Randomized Clinical Trial

Abstract

Importance: The Diabetic Retinopathy Clinical Research Network Protocol S randomized clinical trial results suggest that ranibizumab is a reasonable treatment alternative to panretinal photocoagulation (PRP) when managing proliferative diabetic retinopathy (PDR), with or without concomitant baseline diabetic macular edema (DME). However, ranibizumab injections are costly. Thus, it would be useful to examine the relative cost-effectiveness of these 2 treatment modalities.

Objective: To evaluate incremental cost-effectiveness ratios of 0.5-mg ranibizumab therapy vs PRP for PDR.

Design, setting, and participants: Preplanned secondary analysis using efficacy, safety, and resource utilization data through 2 years of follow-up at 55 US sites for 213 adults with PDR. Data were collected from February 2012 to January 2015.

Interventions: Intravitreous 0.5-mg ranibizumab at baseline and as frequently as every 4 weeks based on a structured retreatment protocol or PRP at baseline for PDR. Eyes in both groups could receive ranibizumab for concomitant DME.

Main outcomes and measures: Incremental cost-effectiveness ratios of ranibizumab compared with PRP evaluated within 2 prespecified subgroups for the study eye: with baseline vision-impairing (Snellen equivalent 20/32 or worse) DME and without baseline vision-impairing DME.

Results: The study included 305 adults with PDR, the mean age was 52 years, 44% were women, and 52% were white. Of the 46 participants with PDR and vision-impairing DME at baseline, 21 were assigned to the ranibizumab group and 25 to the PRP group (plus ranibizumab for DME). Among the remaining participants without baseline vision-impairing DME, 80 and 87 were in the ranibizumab and PRP groups, respectively. For participants with and without baseline vision-impairing DME, the incremental cost-effectiveness ratios of ranibizumab therapy compared with PRP were $55 568/quality-adjusted life-year and $662 978/quality-adjusted life-year, respectively, over 2 years.

Conclusions and relevance: Over 2 years, compared with PRP, 0.5-mg ranibizumab as given in this trial is within the $50 000/quality-adjusted life-year to $150 000/quality-adjusted life-year range frequently cited as cost-effective in the United States for eyes presenting with PDR and vision-impairing DME, but not for those with PDR without vision-impairing DME.

Trial registration: Clinicaltrials.gov Identifier: NCT01489189.

Conflict of interest statement

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Bressler reports grants from Bayer, Novartis, Regeneron, and Roche outside the submitted work. Dr Browning reports grants from Regeneron, Alcon, Genentech, Novartis, Ohr, Alimera, and Aerpio outside the submitted work. Dr Glassman reports grants from the National Institutes of Health during the conduct of the study and grants and nonfinancial support from Genentech outside the submitted work. Dr Hutton reports grants from Jaeb Center for Health Research during the conduct of the study. Dr Jampol reports grants from the National Eye Institute. A complete list of all DRCR.net investigator financial disclosures can be found at http://www.drcr.net. No other disclosures were reported.

Figures

Figure 1.. Two-Way Sensitivity Analysis Verifying Cost of Anti–Vascular Endothelial Growth Factor (VEGF) and Cost of Panretinal Photocoagulation (PRP) for Persons With and Without Vision-Impairing Diabetic Macular Edema (DME) at Baseline

Colors represent the incremental cost-effectiveness ratios. Although there are no official thresholds of cost-effectiveness in the United States, generally, interventions costing less than $50 000 to $150 000 would be considered cost-effective. ICER indicates incremental cost-effectiveness ratios.

Figure 2.. Cost-effectiveness Acceptability Curve

Lines represent the probability ranibizumab was cost-effective (y-axis) at willingness-to-pay for quality-adjusted life-year (QALY) gains (x-axis).