Health Research and Policy

Research in Progress Seminar (RIP)

Date: October 10, 2012
Time: 1:30 pm - 3:00 pm
Location: CHP/PCOR Conference Room
117 Encina Commons, Room 119, Stanford
Speaker: Dr. Suzann Pershing
AHRQ Fellow in Health Care Research and Health Policy
Title: Cost-Effectiveness of Treatment for Diabetic Macular Edema: Ranibizumab, Triamcinolone, and Laser Therapies


Objective: Diabetic macular edema (DME) is a leading cause of progressive visual disability. No clear consensus exists on which DME treatment is most effective or cost-effective. We performed a cost-effectiveness analysis to inform clinical practice.

Design: A Markov computer simulation for diabetic macular edema, considering lifetime effectiveness and costs of five treatments administered for one year (anti-VEGF injections, triamcinolone injections, laser treatment, laser with anti-VEGF injections, and laser with triamcinolone injections), as well as clinical observation alone.

Participants: A simulated cohort of patients with diabetic macular edema.

Methods: Inputs and treatment effects were derived from major randomized clinical trials (ETDRS, RESTORE, and The model was calibrated to match trial data for the number and timing of treatments. Modeled complications included cataract, glaucoma, and endophthalmitis. Costs included treatment provision and clinical care as well as caregiver time and long-term costs of blindness. Quality-of-life weights were computed based on changes in visual acuity. We performed deterministic and probabilistic sensitivity analyses on all model inputs.

Main Outcome Measures: Discounted, quality adjusted life year (QALY) gains and incremental cost effectiveness ratios (ICER), expressed as cost per QALY gained, relative to the next best treatment all considered from a societal perspective.

Results: Laser with anti-VEGF injection had the greatest lifetime effectiveness, gaining 1.1 QALYs and costing $14,856 more than laser with triamcinolone ($13,486 per QALY), the next most effective strategy. Observation, laser alone, and triamcinolone alone each cost more and were less effective across a wide range of assumptions. However, under some scenarios with alternative QALY decrements for for visual acuity loss, anti-VEGF monotherapy became the preferred strategy. Even so, the absolute difference in quality of life gains for anti-VEGF injections alone and laser with anti-VEGF injections was small ranging from <0.01 to 0.04 QALYs.

Conclusions: Anti-VEGF injections, with or without laser, improve health outcomes and are cost-effective compared to other treatments for diabetic macular edema. The choice of anti-VEGF monotherapy versus combination therapy with laser may ultimately depend upon individual patient preferences.

Please note: All research in progress seminars are off-the-record. Any information about methodology and/or results are embargoed until publication.
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