The cost-effectiveness of initiating ranibizumab therapy in eyes with neovascular AMD with good vision: an economic model using real-world outcomes

Objectives: To evaluate the cost-effectiveness of immediate treatment with ranibizumab in patients with neovascular age-related macular degeneration (nAMD) with good (better than 6/12) starting visual acuity compared with current UK clinical guidance of waiting until vision falls below 6/12 to begin treatment, using real-world outcomes data. Design: A patient-level health economic state transition model based on levels of visual acuity in the better seeing eye was constructed to simulate the costs and consequences of treating patients with nAMD with ranibizumab. Setting: The model took the perspective of the UK National Health Service (NHS). Participants: The model was populated with real-world outcomes and resource use from a prospective multicentre national nAMD database study containing 92 976 ranibizumab treatment episodes. Interventions: Two treatment approaches were compared: immediate intervention with 0.5 mg ranibizumab pro re nata, PRN (on detection of nAMD) or delayed intervention (waiting until vision fell to 6/12 before beginning treatment). Main outcome measures: Quality-adjusted life years (QALYs) for health states and healthcare costs were accrued for each strategy, and an incremental cost-effectiveness ratio (ICER) was calculated. One-way and probabilistic sensitivity analyses were employed to test the uncertainty of the model. Results: Over a 2-year time horizon, based on 10 000 Monte Carlo simulations, the early treatment arm accumulated 1.59 QALYs and 8469.79 pound cost. The delayed treatment arm accumulated 1.35 QALYs and 7460.21 pound cost. The central ICER estimate was 4251.60 pound. Conclusions: A model based on real-world data is likely to be a realistic reflection of the health gains and resource use of ranibizumab for nAMD in the UK NHS. Initiating treatment immediately with ranibizumab PRN regimen is a cost-effective strategy compared with current guidance of initiating treatment at a level of 6/12 or worse vision.