title: Cost-effectiveness of Descemet's stripping endothelial keratoplasty versus penetrating keratoplasty.
abstract: OBJECTIVE
  Selective endothelial transplantation in the form of Descemet's stripping endothelial keratoplasty (DSEK) is rapidly replacing traditional full-thickness penetrating keratoplasty (PK) for endothelial disease. An incremental cost-effectiveness analysis was performed to determine whether the benefits of DSEK are worth the additional costs.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  Patients at the Singapore National Eye Center, a tertiary eye center in Singapore, with Fuchs' dystrophy or bullous keratopathy who underwent either PK or DSEK.
  
  
  METHODS
  Patients underwent either PK (n = 171) or DSEK (n = 93) from January 2001 through December 2007. Data were collected from inpatient and outpatient notes corresponding to the time immediately before the procedure to up to 3 years after.
  
  
  METHODS
  Improvements in best spectacle-corrected visual acuity were used to calculate the increase in quality-adjusted life years (QALYs) 3 years after the procedure. This was combined with hospital charges (a proxy for costs) to determine incremental cost-effectiveness ratios (ICERs) comparing PK with no intervention and DSEK with PK.
  
  
  RESULTS
  Three-year charges for DSEK and PK were $7476 and $7236, respectively. The regression-adjusted improvement in visual acuity for PK relative to no intervention was -0.613 logarithm of the minimum angle of resolution (logMAR) units (P<0.001), and for DSEK relative to PK, it was -0.199 logMAR units (P = 0.045). The regression-adjusted marginal gain in utility for PK relative to no intervention was 0.128 QALYs (P<0.001) and for DSEK relative to PK was 0.046 QALYs (P = 0.031). This resulted in ICERs of $56 409 per QALY for PK relative to no intervention and $5209 per QALY for the more expensive DSEK relative to PK.
  
  
  CONCLUSIONS
  If the goal is to maximize societal health gains given fixed resources, DSEK should be the preferred strategy. For a fixed budget, it is possible to achieve greater QALY gains by providing DSEK to as many patients as possible (and nothing to others), rather than providing PK.
authors.affiliation: Duke-NUS Graduate Medical School, Singapore, Republic of Singapore. Electronic address: saideep.bose@duke.edu.
authors.forename: Saideep
authors.initials: S
authors.lastname: Bose
authors.affiliation: Singapore National Eye Center, Singapore, Republic of Singapore; Singapore Eye Research Institute, Singapore, Republic of Singapore.
authors.forename: Marcus
authors.initials: M
authors.lastname: Ang
authors.affiliation: Singapore National Eye Center, Singapore, Republic of Singapore; Singapore Eye Research Institute, Singapore, Republic of Singapore; Department of Ophthalmology, National University Health Systems, Singapore, Republic of Singapore; Department of Clinical Sciences, Duke-NUS Graduate Medical School, Singapore, Republic of Singapore.
authors.forename: Jodhbir S
authors.initials: JS
authors.lastname: Mehta
authors.affiliation: Singapore National Eye Center, Singapore, Republic of Singapore.
authors.forename: Donald T
authors.initials: DT
authors.lastname: Tan
authors.affiliation: Duke-NUS Graduate Medical School, Singapore, Republic of Singapore.
authors.forename: Eric
authors.initials: E
authors.lastname: Finkelstein
mesh_terms: D000368:Aged; D001768:Blister / Q000191:economics / Q000601:surgery; D003316:Corneal Diseases / Q000191:economics / Q000601:surgery; D003362:Cost-Benefit Analysis; D057111:Descemet Stripping Endothelial Keratoplasty / Q000191:economics*; D005006:Ethnicity; D005260:Female; D005500:Follow-Up Studies; D005642:Fuchs' Endothelial Dystrophy / Q000191:economics / Q000601:surgery; D017048:Health Care Costs; D006801:Humans; D007431:Intraoperative Complications; D015948:Keratoplasty, Penetrating / Q000191:economics*; D008297:Male; D011183:Postoperative Complications; D019057:Quality-Adjusted Life Years; D012189:Retrospective Studies; D014792:Visual Acuity / Q000502:physiology