For patients with polypoidal choroidal vasculopathy (PCV), intravitreal anti-vascular endothelial growth factor (anti-VEGF) combination therapy has been shown to be cost-saving relative to monotherapy in a clinical trial setting. However, whether this also applies to real-world settings is unclear. We aim to compare the real-world functional outcomes and cost-effectiveness of intravitreal anti-VEGF combination therapy relative to monotherapy, to investigate whether combination therapy is truly cost-saving.
We used a Markov model to simulate a hypothetical cohort of PCV patients treated at Singapore National Eye Centre. Model parameters were informed by coarsened exact matched estimates of a two-year retrospective study of patients who initiated treatment in 2015. Treatment options included intravitreal aflibercept, bevacizumab, or ranibizumab, as monotherapy or in combination with full-fluence verteporfin photodynamic therapy.
The two-year logMAR letters gains were significant for combination therapy ( + 10.6, P = 0.006) but not monotherapy (−2.2, P = 0.459). Over 20 years, a PCV patient would cost the health system SGD 48,790 under monotherapy and SGD 61,020 under combination therapy. Quality-adjusted life-years (QALYs) were estimated to be 7.41 for monotherapy and 7.80 for combination therapy. The incremental cost-effectiveness ratio of combination therapy was SGD 31,460/QALY, which is less than the common willingness-to-pay threshold of per capita gross domestic product of Singapore (SGD 88,990/QALY). Sensitivity analysis showed that combination therapy remained incrementally cost-effective, but not cost-saving.
Our study shows that combination therapy is good value for money but is likely to increase costs when applied in real-world settings.
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We thank Wee Siang Tay and Wei Han Melvin Wong for excellent research assistance.
This work was supported by Duke-NUS Medical School and Singapore Eye Research Institute.
The authors declare no competing interests.
Ethics approval statement
This research was conducted in accordance with the Declaration of Helsinki and the local Institutional Review Board (studies 2009/788/A and R697/47/2009). Patients’ individual informed consent was exempted due to the retrospective nature of the study and use of anonymized clinical data. Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.
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Chay, J., Fenner, B.J., Finkelstein, E.A. et al. Real-world cost-effectiveness of anti-VEGF monotherapy and combination therapy for the treatment of polypoidal choroidal vasculopathy. Eye (2021). https://doi.org/10.1038/s41433-021-01856-9