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Photodynamic therapy for macular degeneration

Clinical bottom line

Health economic analyses taking the perspective of the UK NHS shows that photodynamic therapy is cost effective for people with wet-type age related macular degeneration. Cost effectiveness is best for those with milder forms of the disease and with reasonable visual acuity, and higher in those with lesser visual acuity. Earlier treatment is more cost-effective than waiting.


Background

The UK has a fourth hurdle body called the National Institute of Clinical Excellence (NICE link to PDF). This body examined clinical and cost effectiveness of new technologies, amongst other things. It has declared that photodynamic therapy for wet type age related macular degeneration is cost-effective, and health authorities should provide the treatment. In many cases they do not, and wait until people have more severe disease.

Cost effectiveness analyses

Two cost effectiveness analyses reported in 2004 [1, 2]. Both took the perspective of the NHS in the UK, that is of third party payer, and without any societal or social costs of care being included. The studies used data from a large randomised trial of photodynamic therapy, with a five to seven year window.

The broad conclusions of both were the same, that the cost per vision year gained, or cost per quality adjusted life year gained were lower for people with better than worse visual acuity. A broad perspective incorporating other NHS costs and social care costs suggest that over the long term photodynamic therapy is a reasonable value for money.

Real world use of photodynamic therapy

A prospective cohort study of photodynamic therapy followed 48 patients after photodynamic therapy [3]. At 12 months, 72% lost less than three lines of visual acuity, and although there were decreases in some quality of life measures, patients were significantly less anxious and more independent outdoors at 12 months. This is in keeping with the randomised trials.

Age-related macular degeneration and self-care

A fourth study examined 199 people with macular degeneration in Belfast [4]. It looked for relationships between visual assessment and ability to care for themselves, and others. It found that people with good visual health status and visual functioning were more likely to be able to care for themselves and others, and that there was a strong relationship between self-reported visual functioning.

Comment

People with better vision reduces the costs of care in older people, and treatments that maintain vision at higher levels are likely to reap benefits through prevention of institutionalisation of visually impaired people and their dependants. Neither of these costs was counted against the costs of photodynamic therapy for wet-type macular degeneration in the two health economic analyses.

Even without these costs, the health economics of photodynamic therapy were favourable, and showed better cost effectiveness with early treatment in people with wet-type macular degeneration with better visual acuity. That means earlier treatment is better, and more cost effective. In places like the UK where this therapy is rationed despite fourth hurdle guidance to the contrary, this emphasises that delay wastes money and makes people worse, both in visual health terms and in overall quality of life.

References

  1. C Hopley et al. Cost utility of photodynamic therapy for predominantly classic neovascular age related macular degeneration. British Journal of Ophthalmology 2004 88: 982-987.
  2. DH Smith et al. Cost effectiveness of photodynamic therapy with verteporfin for age related macular degeneration: the UK case. British Journal of Ophthalmology 2004 88: 1107-1112.
  3. AM Armbrecht et al. A prospective study of visual function and quality of life following PDT in patients with wet age related macular degeneration British Journal of Ophthalmology 2004 88: 1270-1273.
  4. MR Stevenson et al. Reduced vision in older adults with age related macular degenration interferes with ability to care for self and impairs role as carers. British Journal of Ophthalmology 2004 88: 1125-1130.