Quantifying Conflict of Interest in the Choice of Anti-VEGF Agents

Abstract

Purpose To quantify the economic incentives associated with the choice of anti-VEGF drugs for retinal diseases. Methods An economic model was created based on the distribution of use and number of injections of bevacizumab (B), versus aflibercept or ranibizumab (AR); published Medicare reimbursement rates; published rebates; estimated unreimbursed drug use; estimated use of drug company samples; and published costs-of-drugs. Differential economic incentives associated with the choice of drugs were calculated over a range of distributions of drug use. Results The splits in drug choice ranged from 92% AR/8% B to 31% AR/69% B, and in annual injection numbers from 2000 to 6000 with a median of 4000 in one 5-person retina service. Assumed values for rebates were 1% for drug company rebate, 1% for group purchasing organization rebate, and 5 for number of unreimbursed injections per year. The differential economic incentive of a 92% AR/8% B split compared to a 31% AR/69% B split for the median annual number of injections was $266, 893. Conclusion Using real-world data, the economic incentive associated with a choice of more expensive anti-VEGF drugs is large. Accounting for unreimbursed drug use and the cost of additional staff required to manage expensive drug inventory does not nullify the incentive. To what degree this financial incentive influences ophthalmologists’ choice of drugs is unknown, but not trivial. Financial disclosure of the conflicts of interest in the drugs recommended for treatment should be discussed with patients.

Do published trial results influence physician prescribing patterns? Intravitreal antivascular endothelial growth factor usage by the United States Ophthalmologists before and after Protocol T study

“…When compared with ranibizumab, on the contrary, the cost of aflibercept would need to be reduced by 18% for all patients, by 9% for those with worse baseline vision and by 28% for those with better baseline vision to reach the same threshold [18]. In addition, payments and reimbursements for anti-VEGF injections have been decreasing in recent years, as evidenced in the current study and in previous reports [23]. Although the priority of ophthalmologists should always be the patient's well being and visual outcome first, the financial reward for prescribing a brand-name medication, through insurance reimbursement, company-promoted rebate programmes or physician-industry interactions, which have been shown to be associated with increased brand-name medication use, may further influence the use of aflibercept over bevacizumab [24].…”

Review and analysis of history and utilization of panretinal photocoagulation and ranibizumab after publication of protocol S

“…Additionally, treatment with ranibizumab was associated with a lower likelihood of posttreatment complications, including vitreous hemorrhage, retinal detachment, and neovascular glaucoma compared to treatment with PRP [22]. Furthermore, the existence of financial benefit in the form of rebates with use of anti-VEGF injection therapy might be associated with the nationwide increase in ranibizumab utilization observed [24]. These factors may all play a role in the uptake of ranibizumab by providers.…”

A Caveat About Financial Incentives for Anti-Vascular Endothelial Growth Factor Therapy for Diabetic Retinopathy

“…15,17 This study represents a lower bound for aflibercept profitability, as it does not take into account other differential economic benefits such as differential inventory reimbursement, volume rebates from wholesalers or drug companies, which range from 1% to 3.5%, and rebates which can accrue when medications are purchased with a credit card, typically 2%. 14,18 An initial PPV+PRP strategy has durable benefit and is more economically efficient to the healthcare system, without an increase in adverse events or need for cataract surgery. 2,7…”