A longitudinal study to assess the frequency and cost of antivascular endothelial therapy, and inequalities in access, in England between 2005 and 2015

Abstract

ObjectivesHigh-cost antivascular endothelial growth factor (anti-VEGF) medicines for eye disorders challenge ophthalmologists and policymakers to provide fair access for patients while minimising costs. We describe the growth in the use and costs of these medicines and measure inequalities in access.DesignLongitudinal study using Hospital Episode Statistics (2005/2006 to 2014/2015) and hospital prescribing cost reports (2008/2009 to 2015/2016). We used Poisson regression to estimate standardised rates and explore temporal and geographical variations.SettingNational Health Service (NHS) care in England.PopulationPatients receiving anti-VEGF injections for age-related macular degeneration, diabetic macular oedema and other eye disorders.InterventionsHigher-cost drugs (ranibizumab or aflibercept) recommended by the National Institute for Health and Care Excellence or lower-cost drug (bevacizumab) not licensed for eye disorders.Main outcome measuresNational procedure rates and variation between and within clinical commissioning groups (CCGs). Cost of ranibizumab and aflibercept prescribing.ResultsInjection procedures increased by 215% between 2010/2011 and 2014/2015. In 2014/2015 there were 388 031 procedures (714 per 100 000). There is no evidence that the dramatic growth in rates is slowing down. Since 2010/2011 the estimated cost of ranibizumab and aflibercept increased by 247% to £447 million in 2015/2016, equivalent to the entire annual budget of a CCG. There are large inequalities in access; in 2014/2015 procedure rates in a ‘high use’ CCG were 9.08 times higher than in a ‘low use’ CCG. In the South-West of England there was twofold variation in injections per patient per year (range 2.9 to 5.9).ConclusionsThe high and rising cost of anti-VEGF therapy affects the ability of the NHS to provide care for other patients. Current regulations encourage the increasing use of ranibizumab and aflibercept rather than bevacizumab, which evidence suggests is more cost-effective. NHS patients in England do not have equal access to the most cost-effective care.

Intravitreal Injections with Vascular Endothelial Growth Factor Inhibitors: A Practical Approach

“…Since then, the therapeutic indication has been extended to a number of other prevalent retinal diseases, such as retinal vein occlusion, diabetic macular edema, and choroidal neovascularization due to other conditions [6]. Overall, these developments have dramatically changed the number of IVIs performed worldwide: according to records in the American Medical Association Specialty Society Relative Value Scale Update Committee database, the number of injections performed increased more than 500-fold during the period from 2000 to 2012 (from 4500 to 2.3 million injections per year) [7], and similar developments have been reported in the United Kingdom (UK) [8]. Due to population aging in many developed countries, forecasting studies on retinal diseases indicate that we should expect an ever-increasing number of patients who need this treatment [9][10][11].…”

An analysis of the effectiveness outcomes of economic studies evaluating ophthalmic drugs: a systematic review

“…Eye disorders are considerably prevalent and frequently associated with high treatment costs, which could greatly influence the healthcare systems. As well-defined primary outcomes should be used to support the decision-making process in healthcare, evaluating the methodological aspects of cost-effectiveness studies of ophthalmic drugs could be of great value (Freemantle 2001;Orme & Boler 2006;Erie et al 2016;Hollingworth et al 2017;Parikh et al 2017;Holland et al 2017).…”

Longitudinal study of use and cost of subacromial decompression surgery: the need for effective evaluation of surgical procedures to prevent overtreatment and wasted resources

“…In the UK, the National Institute for Health and Care Excellence (NICE) also evaluates the cost-effectiveness of many medicines and does not recommend those which do not provide value. These regulatory processes have their limitations,6 but require robust evidence for the introduction of new treatments. The quality of evidence required to introduce new surgical procedures is not as strict as for medicines,4 5 in part because no specific product such as a drug or device is involved; it can be difficult to categorise procedures as ‘new’ rather than modifications and outcomes may depend on the skill of the practitioner as well as the procedure itself 4.…”