title: Modelling cost effectiveness in neovascular age-related macular degeneration: the impact of using contrast sensitivity vs. visual acuity.
abstract: BACKGROUND
  The cost utility of treatments of age-related macular degeneration (AMD) is commonly assessed using health state transition models defined by levels of visual acuity. However, there is evidence that another measure of visual function, contrast sensitivity, may be better associated with utility than visual acuity. This paper investigates the difference in cost effectiveness resulting from models based on visual acuity and contrast sensitivity using the example of bevacizumab (Avastin) for neovascular AMD. The implications of the choice of outcome on structural uncertainty in the model are investigated.
  
  
  METHODS
  Health state transition Markov models based on levels of visual acuity and contrast sensitivity are used to represent the costs, health utilities and outcomes of the Avastin for choroidal neovascular age-related macular degeneration (ABC) trial. Health states are associated with costs and utilities based on literature values. Treatment outcomes from the ABC trial are used to predict transitions between states in both models. Total costs and quality-adjusted life-years (QALYs) are calculated for a cohort of patients treated over a defined number of model cycles.
  
  
  RESULTS
  Over a 5-year time horizon, a contrast sensitivity model predicts a statistically significant (p < 0.05) 25% greater QALY gain than the visual acuity model based on 10,000 Monte Carlo simulations. Bevacizumab is more effective and less costly than the comparator in the contrast sensitivity model and the visual acuity model.
  
  
  CONCLUSIONS
  There is considerable structural uncertainty associated with the choice of outcome for modelling the cost effectiveness of AMD treatments. Bevacizumab has a higher incremental QALY gain and more favourable incremental cost-effectiveness ratio when cost effectiveness is assessed using contrast sensitivity outcomes compared with using visual acuity outcomes. Previous cost-effectiveness analyses may have underestimated the cost effectiveness of anti-vascular endothelial growth factor (anti-VEGF) therapy.
authors.affiliation: Institute of Ophthalmology, University College London, 11-43 Bath Street, London, EC1V 9EL, UK, thomas.butt.10@ucl.ac.uk.
authors.forename: Thomas
authors.initials: T
authors.lastname: Butt
authors.forename: Praveen J
authors.initials: PJ
authors.lastname: Patel
authors.forename: Adnan
authors.initials: A
authors.lastname: Tufail
authors.forename: Gary S
authors.initials: GS
authors.lastname: Rubin
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D020533:Angiogenesis Inhibitors / Q000191:economics / Q000627:therapeutic use; D061067:Antibodies, Monoclonal, Humanized / Q000191:economics / Q000627:therapeutic use; D000068258:Bevacizumab; D015350:Contrast Sensitivity; D003362:Cost-Benefit Analysis; D016527:Drug Costs; D005260:Female; D017048:Health Care Costs; D006801:Humans; D008268:Macular Degeneration / Q000188:drug therapy / Q000191:economics*; D008297:Male; D008390:Markov Chains; D018803:Models, Economic; D019057:Quality-Adjusted Life Years; D014792:Visual Acuity
chemical_list: D020533:Angiogenesis Inhibitors; D061067:Antibodies, Monoclonal, Humanized; D000068258:Bevacizumab