Ophthalmic Surgery, Lasers and Imaging Retina

Clinical Science 

Updated Cost-Effectiveness of Intravitreal Ocriplasmin for Vitreomacular Adhesion and Macular Hole

Tayab Waseem; Colin Reinhart; Alan L. Wagner, MD, FACS; Kapil G. Kapoor, MD, FACS

Abstract

BACKGROUND AND OBJECTIVE:

The purpose of this study is to provide an updated assessment of cost-efficacy of intravitreal ocriplasmin (IVO) for vitreomacular adhesion (VMA) and macular holes (MH).

PATIENTS AND METHODS:

This was a single-center, multiple-physician, institutional review board-approved, retrospective, 15-month cost-effectiveness analysis study (January 2015 to April 2016). Clinical charts and billing records of 247 patients with VMA and MH were reviewed. Patients were divided into group 1 (VMA and MH treated by pars plana vitrectomy [PPV]), group 2 (VMA and MH treated by IVO), and group 3 (VMA treated by IVO). Success rates of interventions in each group were compared, including cost-effectiveness, cost per line-year, and cost per quality-adjusted life-year (QALY).

RESULTS:

Success rates for initial intervention were 98% in group 1, 55.6% in group 2, and 67.7% in group 3. Cost of PPV at our institution was $6,538.00 and cost of IVO (2016) was $3,480.00. Using a cohort-based computer Markov model, the treatment decision tree demonstrated group 1 was less cost-effective, with cost per line of $2,654.39, cost per line-year saved of $185.62, and cost per QALY of $6,187.00. Group 2 was cost-effective with cost per line of $2,456.25, cost per line-year saved of $171.77, and cost per QALY of $5,726.00. The difference in cost-effectiveness showed IVO was more cost-effective than PPV, with a difference in cost per line of $198.14, cost per line-year saved of $13.85, and cost per QALY of $461.00.

CONCLUSIONS:

IVO is a more cost-effective intervention than vitrectomy for the treatment of VMA and MH in the setting of judicious use in appropriate patients. The success rate of IVO in our patient population was greater than currently published rates and most certainly impacted probability of cost-efficacy. Further research targeting optimizing IVO success rate is needed.

[Ophthalmic Surg Lasers Imaging Retina. 2018;49:e240–e248.]

Abstract

BACKGROUND AND OBJECTIVE:

The purpose of this study is to provide an updated assessment of cost-efficacy of intravitreal ocriplasmin (IVO) for vitreomacular adhesion (VMA) and macular holes (MH).

PATIENTS AND METHODS:

This was a single-center, multiple-physician, institutional review board-approved, retrospective, 15-month cost-effectiveness analysis study (January 2015 to April 2016). Clinical charts and billing records of 247 patients with VMA and MH were reviewed. Patients were divided into group 1 (VMA and MH treated by pars plana vitrectomy [PPV]), group 2 (VMA and MH treated by IVO), and group 3 (VMA treated by IVO). Success rates of interventions in each group were compared, including cost-effectiveness, cost per line-year, and cost per quality-adjusted life-year (QALY).

RESULTS:

Success rates for initial intervention were 98% in group 1, 55.6% in group 2, and 67.7% in group 3. Cost of PPV at our institution was $6,538.00 and cost of IVO (2016) was $3,480.00. Using a cohort-based computer Markov model, the treatment decision tree demonstrated group 1 was less cost-effective, with cost per line of $2,654.39, cost per line-year saved of $185.62, and cost per QALY of $6,187.00. Group 2 was cost-effective with cost per line of $2,456.25, cost per line-year saved of $171.77, and cost per QALY of $5,726.00. The difference in cost-effectiveness showed IVO was more cost-effective than PPV, with a difference in cost per line of $198.14, cost per line-year saved of $13.85, and cost per QALY of $461.00.

CONCLUSIONS:

IVO is a more cost-effective intervention than vitrectomy for the treatment of VMA and MH in the setting of judicious use in appropriate patients. The success rate of IVO in our patient population was greater than currently published rates and most certainly impacted probability of cost-efficacy. Further research targeting optimizing IVO success rate is needed.

[Ophthalmic Surg Lasers Imaging Retina. 2018;49:e240–e248.]

Introduction

Vitreomacular adhesion (VMA) can be characterized as the adhesion of the posterior hyaloid to the center of the fovea, with detached vitreous around the macula.1,2 This can lead to a vitreomacular traction syndrome with focal anteroposterior traction on a small region encompassing the macula and optic nerve disc, potentially leading to macular hole (MH) formation and sometimes significant vision loss.1,2 Pars plana vitrectomy (PPV) has been the cornerstone for the treatment of clinically significant VMA, vitreomacular traction (VMT), and MH for years. With microincisional sutureless techniques and increasingly smaller gauge vitrectomy consoles, PPV has the benefit of high success rates (consistently above 90% in varying studies) while still maintaining a low risk rate.2,3 As we review with patients, however, the risks are still not zero and can include retinal tear, retinal detachment, hemorrhage, and cataract progression, which could require a second surgery to optimize vision. Additionally, although more evidence continues to evolve the technique of macular surgery beyond strict face-down positioning, this is still a significant component of the postoperative treatment at many centers and is not without challenge and risk.3,4

In fall 2012, the U.S. Food and Drug Administration approved ocriplasmin (Jetrea; ThromboGenics, now Oxurion, Leuven, Belgium) for the treatment of symptomatic VMT. Ocriplasmin is a recombinant protease with activity against two components of the vitreoretinal interface: fibronectin and laminin. By targeting dissolution of these proteins, the protease intends to achieve posterior detachment of the vitreous.5

The novelty of ocriplasmin has introduced significant controversy into the decision-making tree for vitreoretinal surgeons. At face value, intravitreal ocriplasmin (IVO) propels forward with a significant upper hand, given it may achieve a similar outcome, without requiring a surgical procedure, which intrinsically means no anesthesia, no extra visit to the surgery center, no postoperative healing course, and, if applicable, no face-down positioning. Since its introduction, there have been concerns about whether this outcome truly is similar, how successful the medication is at achieving its desired outcome, and whether there are some safety concerns that need to be addressed. Additionally, a critical component to add to this discussion is one of cost. When ocriplasmin works, has a desired clinical outcome, and obviates the need for surgery, it is a huge win for the patient but also a huge win for the health care system, as the significant costs of retinal surgery, potential cataract surgery, anesthesia, and postoperative medication and multiple postoperative visits were eliminated. When ocriplasmin does not work, the cost outcomes are less flattering, as a relatively expensive medication that costs a few thousand dollars left us right back at square one with proceeding with the surgical intervention that was the gold standard. Whereas multiple studies have subsequently attempted to break this down and suggest that ocriplasmin either increases or decreases the efficacy of an ultimate vitreoretinal surgery, the apparent consensus is that it places us squarely where we started, not a step back nor forward.

One study has previously attempted to examine this quandary: evaluating the win-loss balance in a patient pool of ocriplasmin and determining if this was ultimately cost-effective.6 With the initial study, the determination was that intravitreal ocriplasmin was not a cost-effective option in 2014.7 Since then, we have learned significantly more from the OASIS and ORBIT studies and other studies applying real-world data points. Improved patient selection has improved success rates of IVO significantly. In a changing health care system that increasingly demands our cost awareness, it is critical that we re-examine this: Is intravitreal ocriplasmin cost-effective now? The aim of this study is to determine if ocriplasmin is a cost-effective method for the treatment of VMT and MH.

Patients and Methods

The database spanned 15 months, and data were collected on 247 patients. Patient charts were cross-referenced with optical coherence tomography (OCT) scans to confirm the presence of MH and VMA. The database was then cross-referenced with the billing records for patients, and total costs of PPV and IVO between 2014 and 2016 were calculated.

Cost of PPV at Wagner Macula and Retina Center (WMRC) was determined from surgical procedure ($3,032.00), hospital utilization ($2,185.00), anesthesia ($1,080.00), OCT ($91.00), and office visit ($150.00) for a total cost of $6,538.00 (Tables 1a and 1b). Cost of IVO at WMRC from 2014 to 2015 was determined from ocriplasmin injection ($5,253.00), saline flush ($201.00), OCT ($91.00), and office visit ($150.00) for a total cost of $5,695.00 (Table 1a). Cost of IVO at WMRC in 2016 was determined from ocriplasmin injection ($3,037.55), saline flush ($201.00), OCT ($91.00), and counseling ($150.00) for a total cost of $3,479.55.00 (Table 1b). Cost decisions were determined from the 2014–2015 and 2016 billing codes of each procedure.

Cost Assessment of Treatment Scenarios From 2014 to 2015

Table 1A:

Cost Assessment of Treatment Scenarios From 2014 to 2015

Cost Assessment of Treatment Scenarios in 2016

Table 1B:

Cost Assessment of Treatment Scenarios in 2016

The WMRC patient population was separated into three distinct groups: VMA and MH treated by PPV initially, VMA and MH treated by IVO initially, and VMA treated by IVO initially. Success and failure rates for the pharmacologic (IVO) and surgical treatment (PPV) of VMA, as well as MH and VMA, were determined by examination of patients' OCT data for resolved VMA and closure of MH. The 98% single surgical success rate was calculated from 189 patients with VMA and MH. The second surgical success was computed to be 75% from four patients who failed initial surgical intervention. Pharmacologic success rates were calculated to be 67.7% for 31 patients with VMA and 55.6% for 28 patients with VMA and MH. Surgical intervention following IVO failure had success rates of 90% for 10 patients with VMA and 81.82% for 11 patients with VMA and MH. An average of 2.5 lines were saved from initial successful PPV and IVO procedures. Quality-adjusted life-years (QALY) were calculated using a previously published formula. The QALYs per line-year of vision saved was determined using the factor 0.03.8

The clinical scenarios performed within WMRC were arranged into decision trees (Figures 1a and 1b). Surgical intervention scenario 1 included PPV success, PPV failure followed by PPV success, PPV failure (unresolved), and PPV failure followed by PPV failure (unresolved). Intravitreal injection of ocriplasmin scenario 2 included IVO success, IVO failure followed by PPV success, IVO failure (unresolved), and IVO failure followed by PPV failure (unresolved). The decision trees were then reviewed using a Markov weighted probabilistic cost model for cost-effective analysis. The decision to use the weighted probabilistic cost model was made based on the high success rate (98%) of the initial PPV procedure in the WMRC patient population and the negligible complication rates within the population.

Decision trees of treatment scenarios 1 and 2 for vitreomacular traction (VMT) with full-thickness macular hole (FTMH). Scenario 1 (VMT + FTMH) utilized PPV for first line treatment and second line treatment if the VMT with FTMH failed to resolve. Scenario 2 (VMT + FTMH) utilized ocriplasmin for first line treatment and PPV as a second line treatment if the VMT with FTMH failed to resolve.

Figure 1a.

Decision trees of treatment scenarios 1 and 2 for vitreomacular traction (VMT) with full-thickness macular hole (FTMH). Scenario 1 (VMT + FTMH) utilized PPV for first line treatment and second line treatment if the VMT with FTMH failed to resolve. Scenario 2 (VMT + FTMH) utilized ocriplasmin for first line treatment and PPV as a second line treatment if the VMT with FTMH failed to resolve.

Decision trees of treatment scenario 2 for vitreomacular traction (VMT) without full-thickness macular hole. Scenario 2 (VMT) utilized Ocriplasmin for first-line treatment and pars plana vitrectomy as second line treatment if the VMT failed to resolve.

Figure 1b.

Decision trees of treatment scenario 2 for vitreomacular traction (VMT) without full-thickness macular hole. Scenario 2 (VMT) utilized Ocriplasmin for first-line treatment and pars plana vitrectomy as second line treatment if the VMT failed to resolve.

The calculations and analysis were performed with Microsoft Excel software (Microsoft, Redmond, WA). Male and female life expectancies were averaged to be 14.3 years from the actuarial tables of the Social Security Administration. This was determined from the mean age of the WMRC patient population of 71.2 years of age.

Results

Cost decisions were determined from the billing codes at WMRC from 2014–2015 for the IVO and PPV protocols, and the updated 2016 cost of IVO was incorporated into the statistical model.

Scenario 1: With the 2014–2015 WMRC PPV Cost

The weighted probability model with an initial success rate of 98% for PPV determined the overall cost outcome for scenario 1 to be $6,635.97 (Table 3a). The modeled cost for scenario 1 in the 2014–2015 calculations determined the cost per line was $2,654.39, cost per line-year saved was $185.62, and cost per QALY was $6,187.00 (Table 2a).

Calculations From 2014 to 2015 Cost Per Line, Cost Per Line-Year Saves, and QALY

Table 2A:

Calculations From 2014 to 2015 Cost Per Line, Cost Per Line-Year Saves, and QALY

Weighted Probability Model Outcomes From 2014 to 2015

Table 3A:

Weighted Probability Model Outcomes From 2014 to 2015

Scenario 2: With the 2014–2015 WMRC IVO Cost

The weighted probability model with an initial success rate of 55.6% for IVO determined the overall cost outcome for scenario 1 to be $8,421.06 (Table 3a). The modeled cost for scenario 2 in the 2014–2015 calculations determined the cost per line was $3,368.43, cost per line-year saved was $235.55, and cost per QALY was $7,852.00 (Table 2a). When the initial success rate of IVO was increased to 86% within the model, the cost outcome for scenario 1 was reduced to $6,599.07 (Figures 2a and 2b). This allowed the IVO procedure to become cost-effective; however, the alternative to determine cost-effectiveness was a reduction in cost in IVO.

Probability weighted cost versus average percent success in 2014 to 2015: The 2014 to 2015 intravitreal ocriplasmin cost at a 55.6% success rate was $8,421.06, whereas the 2014 to 2015 pars plana vitrectomy cost at a 98% success rate was $6,636.97. To achieve cost effectiveness in the 2014 to 2015 probability weighted model at $6,599.07, the success rate would need to increase to 86%.

Figure 2a.

Probability weighted cost versus average percent success in 2014 to 2015: The 2014 to 2015 intravitreal ocriplasmin cost at a 55.6% success rate was $8,421.06, whereas the 2014 to 2015 pars plana vitrectomy cost at a 98% success rate was $6,636.97. To achieve cost effectiveness in the 2014 to 2015 probability weighted model at $6,599.07, the success rate would need to increase to 86%.

Probability weighted cost versus average percent success in 2016: The 2016 intravitreal ocriplasmin (IVO) cost at a 55.6% success rate was $6,340.61, whereas the 2016 pars plana vitrectomy cost at a 98% success rate was $6,636.97. The 2016 IVO cost reduction achieved cost effectiveness with a success rate of 55.6%.

Figure 2b.

Probability weighted cost versus average percent success in 2016: The 2016 intravitreal ocriplasmin (IVO) cost at a 55.6% success rate was $6,340.61, whereas the 2016 pars plana vitrectomy cost at a 98% success rate was $6,636.97. The 2016 IVO cost reduction achieved cost effectiveness with a success rate of 55.6%.

Scenario 1: With Updated 2016 PPV Cost

The weighted probability model with an initial success rate of 98% for PPV determined the overall cost outcome for scenario 1 to be $6,635.97 (Table 3b). The modeled cost for scenario 1 in the 2016 calculations determined the cost per line was $2,654.39, cost per line-year saved was $185.62, and cost per QALY was $6,187.00 (Table 2b).

Calculations of 2016 Cost Per Line, Cost Per Line-Year Saves, and QALY

Table 2B:

Calculations of 2016 Cost Per Line, Cost Per Line-Year Saves, and QALY

Weighted Probability ModelOutcomes in 2016

Table 3B:

Weighted Probability ModelOutcomes in 2016

Scenario 2: With Updated 2016 IVO Cost

The weighted probability model with an initial success rate of 55.6% for IVO determined the overall cost outcome for scenario 1 to be $6,140.61 (Table 3b). The modeled cost for scenario 2 in the 2016 calculations determined the cost per line was $2,456.25, cost per line-year saved was $171.77, and cost per QALY was $5,726.00 (Table 2b). The updated 2016 cost of IVO resulted in IVO becoming a cost-effective intervention for VMT with full-thickness macular hole (FTMH) for the WMRC patient population.

Discussion

In this study, a 15-month period was analyzed to determine the cost-effectiveness of ocriplasmin for patients with symptomatic VMA and MH. As with most studies, the subgroups of a model or assumptions made can significantly alter conclusions reached, even when using the same data set. Both the 2014 study and the 2016 study used the phase 3 MIVI-TRUST trials to create their models, and the two studies had opposite opinions. In our study, instead of reusing the same data set with a different model, we opted to use a separate data set from the WMRC clinic. The data set spanned 15 months and considered 247 patients. Like most models, our model has its limitations. Similar to the 2014 study, our model did not include an observational arm, in which there are patients who have spontaneous resolution of VMAs.6 This arm of the study has its own disadvantages. Whereas 11% of patients may have resolution without treatment, 65% of patients lost at least 2 Snellen lines of vision in the same time frame.

The models used for our study displayed the success rate of each procedure within the WMRC population. These success and failure rates of each procedure were used to establish the cohort-based computer model used for the analysis (Figure 1a). The 2014–2015 procedural costs generated an overall difference that favored scenario 1 by approximately $1,785.09, with a superior cost per line ($714.04), cost per line-year saved ($49.93), and cost per QALY ($1,665.00). The statistical model produced a threshold percent success (86%) of IVO needed to accommodate the differences in price between the two procedures (Table 3a), congruent with previous reports.7

The 2016 procedural cost placed within the statistical model yielded an overall cost of $6,140.61, which was $495.36 lower than scenario 1 overall (Table 3b), resulting in a superior cost-effectiveness of scenario 2, superior cost per line ($198.14), cost per line-year saved ($13.85), and cost per QALY ($461.00). The statistical model thus showed cost-effectiveness for intravitreal ocriplasmin for symptomatic VMA and MH in the 2016 subset analysis after procedural cost reduction.

Although cost-effectiveness is an important part of the puzzle, a simple literature review will reveal that the answer is still not clear for when to use ocriplasmin.9,10,11,12 Many studies have looked at “real-world” rates of ocriplasmin and the rates of MH closure. The difference between success rates is due to targeted subgroups. The review published by Song and Smiddy evaluated 13 of the 14 clinical trials ocriplasmin was enrolled on and concluded that patients with macular holes less than 250 μm, a lack of epiretinal membrane (ERM), and a smaller length of VMA were more likely to have a positive prognosis.11

The MIVI-TRUST study showed that there was a 26.5% rate of VMA release with ocriplasmin versus a 10.1% release rate with a saline injection. A more in-depth look at the data shows that eyes without ERM had a four-fold higher rate of release and patients with MH had a higher rate of closure. The OASIS study subsequently showed a 41.7% rate of VMA release with its modified inclusion criteria.13 The phase 4 ORBIT study that evaluated real-world efficacy of ocriplasmin showed a 42.5% success rate of VMA resolution at day 28, but in the subset of patients that truly had no ERM, the success rate was 49.5%.14 The WMRC VMT population had a higher ocriplasmin success rate of 67.7%, whereas the VMT with MH population had a higher rate of closure with an initial ocriplasmin success rate of 55.6%.

In 2014, Chang and Smiddy suggested that ocriplasmin is not a cost-effective method and that PPV should remain the primary treatment procedure.6 The study used a Markov model of cost-effectiveness and utility to examine the MIVI-TRUST data. However, two essential determinants were changed within the WMRC study that significantly affected the outcome of cost-effectiveness: procedural cost and procedural success rate. The total cost of ocriplasmin was reduced from the $5,760.00 in 2014 during the Chang and Smiddy study to $3,479.55 in 2016 for the WMRC study.6 This was an approximate 40% reduction in total cost. The procedural success rate used in the Chang and Smiddy study also reflected the MIVI-TRUST study, which was significantly lower than the 67.7% and 55.6% success rates of the WMRC population. With these changes within the weighted probabilistic cost model, it was determined that ocriplasmin was a more cost-effective procedure.

In 2016, a group in the United Kingdom used a cohort-based computer simulation model to determine if ocriplasmin is a cost-effective treatment option for VMT.12 This study used a U.K. payer perspective and divided the cost-effectiveness into mutually exclusive subgroups: VMT without ERM or FTMH, VMT with ERM but no FTMH, and VMT with FTMH. The study, like the study published by Chang, used data from the phase 3 MIVI-TRUST trials to determine disease state transition probabilities. The cohort-based computer simulation model revealed that ocriplasmin was a cost-effective procedure for VMT but not VMT with MH. This outcome occurred because the cohort-based computer simulation model that was utilized had the same limitations as the Markov model of cost-effectiveness. The models were utilizing the same sample population from the MIVI-TRUST trials that determined procedural success rates. The 2016 study was also using outdated procedural cost much like the 2014 study.

The findings of this study suggest that intravitreal ocriplasmin is a more cost-effective intervention than vitrectomy for the treatment of symptomatic VMA and MH in the setting of judicious use in appropriate patients. IVO is also less invasive than surgery, and the overall treatment burden can be significantly reduced for IVO patients given it allows sidestepping preoperative, intraoperative, and postoperative steps. The success rate of IVO in our patient population was greater than previously published rates in literature, which may reflect more optimal patient selection or anatomic differences. The success rates most certainly impacted the weighted probability model of cost-efficacy, and further research targeting optimizing IVO success rates is needed to better elucidate its optimal role for therapeutic intervention.

References

  1. Shechtman DL, Dunbar MT. The expanding spectrum of vitreomacular traction. Optometry. 2009;80(12):681–687. doi:10.1016/j.optm.2009.07.014 [CrossRef]
  2. Johnson MW. Posterior vitreous detachment: Evolution and complications of its early stages. Am J Ophthalmol. 2010;149(3);371–382.e1. doi:10.1016/j.ajo.2009.11.022 [CrossRef]
  3. Madgula IM, Costen M. Functional outcome and patient preferences following combined phaco-vitrectomy for macular hole without prone posturing. Eye (Lond). 2007;22(8):1050–1053. doi:10.1038/sj.eye.6702835 [CrossRef]
  4. Iezzi R, Kapoor KG. No face-down positioning and broad internal limiting membrane peeling in the surgical repair of idiopathic macular holes. Ophthalmology. 2013;120(10):1998–2003. doi:10.1016/j.ophtha.2013.06.001 [CrossRef]
  5. Stalmans P, Benz M, Gandorfer A, et al. MIVI-TRUST Study Group. Enzymatic vitreolysis with ocriplasmin for vitreomacular traction and macular holes. N Engl J Med. 2012;367(7):606–615. doi:. doi:10.1056/NEJMoa1110823 [CrossRef]
  6. Chang JS, Smiddy WE. Cost evaluation of surgical and pharmaceutical options in treatment for vitreomacular adhesions and macular holes. Ophthalmology. 2014;121(9):1720–1726. doi:10.1016/j.ophtha.2014.03.029 [CrossRef]
  7. Mastropasqua R, Di Antonio L, Ciciarelli V, Aharrh-Gnama A, Rispoli M, Carpineto P. Comparison of guided and unguided ocriplasmin injection for the treatment of vitreomacular traction: A preliminary study. J Ophthalmol. 2016;2016:6521304. doi:10.1155/2016/6521304 [CrossRef]
  8. Brown MM, Brown GC, Sharma S, Landy J. Health care economic analyses and value-based medicine. Surv Ophthalmol. 2003;48(2):204–223. doi:10.1016/S0039-6257(02)00457-5 [CrossRef]
  9. Dimopoulos S, Bartz-Schmidt K, Gelisken F, Januschowski K, Ziemssen F. Rate and timing of spontaneous resolution in a vitreomacular traction group: Should the role of watchful waiting be re-evaluated as an alternative to ocriplasmin therapy?Br J Ophthalmol. 2015;99(3):350–353. doi:10.1136/bjophthalmol-2014-304961 [CrossRef]
  10. Song SJ, Smiddy WE. Ocriplasmin for symptomatic vitreomacular adhesion: An evidence-based review of its potential. Core Evid. 2014;9:51–59.
  11. Stein JD, Zacks DN, Grossman D, Grabe H, Johnson MW, Sloan FA. Adverse events after pars plana vitrectomy among Medicare beneficiaries. Arch Ophthalmol. 2009;127(12):1656–1663. doi:10.1001/archophthalmol.2009.300 [CrossRef]
  12. Bennison C, Stephens S, Lescrauwaet B, Van Hout B, Jackson TL. Cost-effectiveness of ocriplasmin for the treatment of vitreomacular traction and macular hole. J Mark Access Health Policy. 2016;4.
  13. Dugel PU, Tolentino M, Feiner L, Kozma P, Leroy A. Results of the 2-year ocriplasmin for treatment for symptomatic vitreomacular adhesion including macular hole (OASIS) randomized trial. Ophthalmology. 2016;123(10):2232–2247. doi:10.1016/j.ophtha.2016.06.043 [CrossRef]
  14. Kapoor KG. Efficacy and safety outcomes for ocriplasmin intravitreal injection from multiple prospective clinical trials (MIVI-TRUST, OASIS, and ORBIT). Presented at: Retina Society. ; September 14, 2016. ; San Diego, CA. .

Cost Assessment of Treatment Scenarios From 2014 to 2015

Scenario 1 Billing Codes PPV; PPV-PPV Hospital Utilization Anesthesia OCT Counseling Total Cost
a. PPV success 67042: Vitrectomy membranectomy macular hole $3,032.00 $2,185.00 $1,080.00 $91.00 $150.00 $6,538.00
b. PPV failure, PPV success 67042: Vitrectomy membranectomy macular hole; 67042 $6,064.00 $4,370.00 $2,160.00 $182.00 $300.00 $13,076.00
c. PPVfailure (unresolved) 67042: Vitrectomy membranectomy macular hole $3,032.00 $2,185.00 $1,080.00 $91.00 $150.00 $6,538.00
d. PPV failure, PPV failure (unresolved) 67042: Vitrectomy membranectomy macular hole; 67042 $6,064.00 $4,370.00 $2,160.00 $182.00 $300.00 $13,076.00
Scenario 2 Billing Codes IVO; IVO - PPV Saline Flush OCT Counseling Total Cost
a. IVO success J7316: Jetrea injection, ocriplasmin, 0.125 mg $5,253.00 $201.00 $91.00 $150.00 $5,695.00
b. IVO failure, PPV success J7316: Jetrea injection, ocriplasmin, 0.125 mg; 67042 $9,334.00 $201.00 $182.00 $300.00 $10,017.00
c. IVO failure(un-resolved) J7316: Jetrea injection, ocriplasmin, 0.125 mg $5,253.00 $201.00 $91.00 $150.00 $5,695.00
d. IVO failure, PPV failure (un-resolved) J7316: Jetrea injection, ocriplasmin, 0.125 mg; 67042 $9,334.00 $201.00 $182.00 $300.00 $10,017.00

Cost Assessment of Treatment Scenarios in 2016

Scenario 1 Billing Codes PPV; PPV-PPV Hospital Utilization Anesthesia OCT Counseling Total Cost
a. PPV success 67042: Vitrectomy membranectomy macular hole $3,032.00 $2,185.00 $1,080.00 $91.00 $150.00 $6,538.00
b. PPV failure, PPV success 67042: Vitrectomy membranectomy macular hole; 67042 $6,064.00 $4,370.00 $2,160.00 $182.00 $300.00 $13,076.00
c. PPV failure (unresolved) 67042: Vitrectomy membranectomy macular hole $3,032.00 $2,185.00 $1,080.00 $91.00 $150.00 $6,538.00
d. PPV failure, PPV failure (unresolved) 67042: Vitrectomy membranectomy macular hole; 67042 $6,064.00 $4,370.00 $2,160.00 $182.00 $300.00 $13,076.00
Scenario 2 Billing Codes IVO; IVO - PPV Saline Flush OCT Counseling Total Cost
a. IVO success J7316: Jetrea injection, ocriplasmin, 0.125 mg $3,037.55 $201.00 $91.00 $150.00 $3,479.55
b. IVO failure, PPV success J7316: Jetrea injection, ocriplasmin, 0.125 mg; 67042 $9,334.55 $201.00 $182.00 $300.00 $10,017.55
c. IVO failure (unresolved) J7316: Jetrea injection, ocriplasmin, 0.125 mg $3,037.55 $201.00 $91.00 $150.00 $3,479.55
d. IVO failure, PPV failure (unresolved) J7316: Jetrea injection, ocriplasmin, 0.125 mg; 67042 $9,334.55 $201.00 $182.00 $300.00 $10,017.55

Calculations From 2014 to 2015 Cost Per Line, Cost Per Line-Year Saves, and QALY

Total Cost
Initial Procedure Second Procedure Lines Saved Years Remaining Success Rate Frequency Cost Per Line Cost Per Line-Year Saved Cost Per QALY
PPV N/A 2.5 14.3 98% 85.8% $2,615.00 $182.88 $6,096.00
Ocri N/A 2.5 14.3 56% 7% $2,304.00 $161.12 $5,371.00
Ocri PPV 2.5 14.3 33% 4.2% $4,919.00 $344.00 $11,467.00
PPV PPV 2.5 14.3 1% 0.9% $5,230.40 $365.76 $12,192.07
Scenario 1 2.5 14.3 99% 86.6% *$2,654.39 *$185.62 *$6,187.00
Scenario 2 2.5 14.3 88.9% 11.1% *$3,368.43 *$235.55 *$7,852.00

Calculations of 2016 Cost Per Line, Cost Per Line-Year Saves, and QALY

Total Cost
Initial Procedure Second Procedure Lines Saved Years Remaining Success Rate Frequency Cost Per Line Cost Per Line-Year Saved Cost Per QALY
PPV N/A 2.5 14.3 98% 85.8% $2,615.00 $182.88 $6,096.00
Ocri N/A 2.5 14.3 56% 7% $2,304.00 $161.12 $5,371.00
Ocri PPV 2.5 14.3 33% 4.2% $4,919.00 $344.00 $11,467.00
PPV PPV 2.5 14.3 1% 0.9% $5,230.40 $365.76 $12,192.07
Scenario 1 2.5 14.3 99% 86.6% *$2,654.39 *$185.62 *$6,187.00
Scenario 2 2.5 14.3 88.9% 11.1% *$3,368.43 *$235.55 *$7,852.00

Weighted Probability Model Outcomes From 2014 to 2015

Scenario 1 Scenario 2
5% 11,194.98 11,453.72
10% 10,949.71 11,154.05
15% 10,704.46 10,854.38
20% 10,459.23 10,554.71
25% 10,214.02 10,255.04
30% 9,968.82 9,955.37
35% 9,723.64 9,655.70
40% 9,478.48 9,356.03
45% 9,233.34 9,056.36
50% 8,988.22 8,756.69
55% 8,743.11 8,457.02
2014–2015 IVO* 55.6% 8,713.70 *8,421.06
60% 8,498.03 8,157.35
65% 8,252.96 7,857.68
70% 8,007.91 7,558.02
75% 7,762.88 7,258.38
80% 7,517.87 6,958.68
85% 7,272.87 6,659.01
Cost-Effective IVO** 86% 7,223.88 **6,599.07
90% 7,027.90 6,359.34
95% 6,782.90 6,059.67
2014–2015 PPV* 98% *6,635.97 5,879.87
100% 6,538.00 5,760.00

Weighted Probability ModelOutcomes in 2016

Scenario 1 Scenario 2
5% 11,194.98 9,173.27
10% 10,949.70 8,873.60
15% 10,704.46 8,573.93
20% 10,459.23 8,274.26
25% 10,214.02 7,974.59
30% 9,968.82 7,674.92
35% 9,723.64 7,375.25
40% 9,478.48 7,075.58
45% 9,233.34 6,775.91
50% 8,988.22 6,476.24
55% 8,743.11 6,176.57
Current IVO* 55.6% 8,713.70 *6,140.61
60% 8,498.03 5,876.90
65% 8,252.96 5,577.23
70% 8,007.91 5,277.57
75% 7,762.88 4,977.90
80% 7,517.87 4,678.23
85% 7,272.87 4,378.56
90% 7,027.90 4,078.89
95% 6,782.97 3,779.22
Current PPV* 98% *6,635.97 3,599.42
100% 6,538.00 3,479.55
Authors

From Eastern Virginia Medical School, Norfolk, Virginia (TW, CR, ALW); and Wagner Macula and Retina Center, Virginia Beach, Virginia (ALW, KGK).

This paper was presented at the Association for Research in Vision and Ophthalmology annual meeting in May 2017.

The authors report no relevant financial disclosures.

The authors would like to thank William McPheat, PhD, MBA, for his expert consultation and Maxwell Wagner, MS, for his assistance in collecting data.

Address correspondence to Kapil G. Kapoor, MD, FACS, Wagner Macula and Retina Center, 5520 Greenwich Road, Suite 204, Virginia Beach, VA 23462; email: kaps2003@gmail.com.

Received: September 07, 2017
Accepted: April 25, 2018

10.3928/23258160-20181203-14

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