BLOG: Cost-effectiveness of cross-linking
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As a cornea specialist, I have no doubt about the clinical value of cross-linking.
Many patients and their families would say that no cost is too high to help preserve their vision and ocular health. But from a health economics standpoint, it is also important to know whether the individual and societal benefits of an intervention such as cross-linking outweigh its costs. The answer, according to a recent paper, is a resounding “yes.”
Using a discrete-event simulation model that has been widely employed to gauge the cost-effectiveness of medical interventions, researchers determined that iLink cross-linking with Photrexa Viscous, Photrexa and the KXL system (Glaukos), compared with conventional treatment, was associated with an average per-patient lifetime savings of more than $8,600 in direct medical costs. In addition, there was an estimated national savings of between $150 million to $736 million per year (depending on estimated prevalence of keratoconus) and an increase in quality-adjusted life years that showed greater benefits with earlier intervention.
The modeling study simulated outcomes for both eyes of 2,000 individual patients, using data from the U.S. multicenter phase 3 pivotal trials that led to FDA approval of iLink to define the characteristics of the preoperative population. Outcomes data from the pivotal trials and data from the published literature on the natural history of keratoconus were used to account for a variety of factors affecting disease progression, such as the impact of age on the rate of disease progression. Rates of anticipated adverse events associated with penetrating keratoplasty (graft rejection/failure, cataract, glaucoma) were also derived from the literature.
The outputs of the model show two major drivers of economic value: reduction in the rate of PK and less time spent in the advanced stages of keratoconus, which affect the complexity of lens fit, work productivity and quality of life. The outcomes of the simulation suggest that cross-linking would reduce the rate of PK by 26%, with patients spending 28 fewer years in the advanced stages of keratoconus. All in all, this simulation suggested that cost-effectiveness would be achieved within 2 years and cost savings in less than 5 years.
Scenario analyses varying the baseline age show that the earlier we intervene with iLink, the better the value (greater cost savings and more QALY gained). Aligning with what we know to be true clinically, there is substantial benefit to identifying patients earlier and treating them sooner (Figure 1). Furthermore, the model confirms for payers that cross-linking is very much worth covering. That’s good news because we need all payers to provide access to this technology and to adequately reimburse physicians for treating individuals with progressive keratoconus, especially younger patients.
Cross-linking has previously been shown to be cost-effective in countries with national health care systems, but this is the first study to evaluate cost-effectiveness in the U.S. It shows that even here, in the relatively high-cost U.S. market, cross-linking is a good investment by the health care system.
What this relatively conservative analysis leaves out is also worth considering. The study factors in actual costs and productivity over patients’ lifetime, but it cannot really take into account many other difficult-to-quantify benefits: psychological advantages of not worrying about keratoconus progression or feeling “damaged”; less frequent monitoring and fewer restrictions on activity; and the potential socioeconomic gains, academic achievement and career success for people who are not limited by poor eyesight. If we consider all these factors, the true burden of leaving progressive keratoconus untreated may be even greater than the model can capture.
- References:
- Caro JJ, et al. Expert Rev Pharmacoecon Outcomes Res. 2016;doi:10.1586/14737167.2016.1165608.
- Lindstrom RL, et al. J Med Econ. 2021;doi:10.1080/13696998.2020.1851556.
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