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A cost-effectiveness analysis of femtosecond laser-assisted cataract surgery versus phacoemulsification cataract surgery

Poster Details

First Author: B.Vote AUSTRALIA

Co Author(s):    S. Ewe   R. Abell           

Abstract Details



Purpose:

To perform a comparative cost-effectiveness analysis (CEA) of femtosecond laser-assisted cataract surgery (LCS) using Catalys (Optimedica, Sunnyvale, CA) and conventional phacoemulsification cataract surgery (PCS). Despite the relatively rapid growth in LCS, there is no data on the cost-effectiveness of LCS compared with conventional phacoemulsification cataract surgery (PCS). Measures of improvement in cost-effectiveness with regards to cataract surgery may include: reducing spectacle dependence (through improved refractive outcomes); reducing indirect health care costs related to co-morbidities in the elderly as a result of poor vision; and reducing complications such as corneal decompensation cystoid macular edema, and post-operative endophthalmitis. Incremental Cost Effectiveness Ratio (ICER) calculations allow determination of cost per QALY gained for new technologies compared with established standards of care.

Setting:

Ambulatory Day Surgery Operating Theatre

Methods:

The study design is a retrospective CEA using computer-based econometric modeling. A cost-effectiveness decision tree model that incorporates utility values was constructed to analyze the incremental cost-efficiency and cost-utility of LCS compared to PCS based on a hypothetical cohort of patients undergoing cataract surgery in the better eye (as per convention). This was performed based on a review of the current literature and our direct experience using LCS, with adherence to the reference case scenario recommended by the Panel on Cost-Effectiveness in Health and Medicine. Conservative estimates of complication rates for LCS were used to allow for the most favourable cost-effectiveness analysis. Data was incorporated with time trade-off utility values converted from visual acuity outcomes. Outcome measures included improvements in best-corrected visual acuity converted to quality-adjusted life years (QALYs) in a hypothetical cohort within 1 year after cataract surgery. This was combined with approximate costs in a cost-utility analysis model to determine the incremental cost-effectiveness ratios (ICERs) comparing LCS with PCS. Sensitivity analyses were also conducted by varying inputs into the decision tree model to simulate the impact on the final cost effectiveness results. At current exchange rates, $1AUD is approximately equal to $1 United States Dollar (USD).

Results:

We calculated the overall total weighted average cost of PCS as $3,522.42 and the total weighted average cost of LCS as $4,587,42. Based on simulated complication rates of PCS and LCS (halved) and assuming resultant visual acuity outcome improvement of 5% in uncomplicated cases of LCS, the net utility gain for LCS over PCS was 0.01. The cost-effectiveness based on ICERs gained from LCS was found to be not cost effective at $92,861(Australian dollars spent per QALY) relative to PCS.. The total QALY gain for LCS over PCS was 0.06 units. Hence at current costs, femtosecond laser could not be considered cost-effective based on economic benchmarks. Multivariate sensitivity analyses revealed LCS would need to significantly improve visual outcomes and complication rates over PCS, along with a reduction in the total cost to patient to improve cost effectiveness. If the only demonstrated benefit of LCS was elimination of corneal decompensation through a reduction in phacoemulsification energy, the resultant ICER is equal to $5,052,138/QALY. Modelling a best-case scenario of LCS with excellent visual outcomes i.e 100% of patients achieving BCVA >6/12, zero complications (0%), and a significantly reduced cost to patient (of $300) results in an ICER of $20 000.

Conclusions:

Our study compared the cost effectiveness of PCS and LCS for treatment of age-related cataract based on a systematic review of the literature. With LCS being at its infancy, its costs are known with more certainty that the efficacy. From our sensitivity analyses, we found that while PCS was very effective and highly cost effective (at a cost of $2000-4000 per QALY) compared to no intervention, LCS however was associated with a much higher cost with only very small incremental gain in QALY when compared with PCS. This is also considering that the estimates of improved LCS visual outcomes and reduced postoperative complication rates used in the decision model have been relatively generous in favour of LCS. Even with these generous assumptions, LCS is not cost effective at its current cost to the patient when compared with cost-effectiveness benchmarks and other medical interventions including PCS, irrespective of potential improvements in visual acuity outcomes and complication rates.. A significant reduction in the cost of consumables and therefore overall cost to patient (approximately $300) would increase the likelihood of LCS being considered cost-effective, although this would still only approach marginal cost-effectiveness. It might be hoped that costs should decrease with increased demand and competition, as well as improvements in manufacturing technology and efficiency. A further cost effective analyses comparing manual small incision cataract surgery with LCS and PCS will be a worthwhile follow up in the future. FINANCIAL INTEREST: NONE

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