Transcript Economic Evaluation of Toric Intraocular Lens in Cataract

New Toric IOLs Improve
Outcomes and Reduce Costs
Compared to Conventional IOLs
Robert Pineda1, Svetlana Denevich2, Won Chan Lee3,
Curtis Waycaster4, Sarah Pennie3, Chris L. Pashos2
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2
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Massachusetts Eye and Ear Infirmary, Boston, MA
HERQuLES, Abt Bio-Pharma Solutions, Inc., Lexington, MA
HERQuLES, Abt Bio-Pharma Solutions, Inc., Bethesda, MD
Alcon Labs, Fort Worth, TX
Supported by Alcon Labs
S Denevich, WC Lee, S Pennie, and CL Pashos are employees of Abt Bio-Pharma Solutions Inc., an independent research organization. C Waycaster is
an employee of Alcon Labs
Background and Introduction

Approx. 30% of people ≥ 65 are affected by cataracts1
– 15-29% of patients with cataract also have some degree of
astigmatism2

Astigmatism is routinely corrected at the time of cataract
treatment using:
– Corneal surgery and/or
– Implanting a toric intraocular lens (IOL)3


Toric IOLs effectively improve visual acuity and quality of life
in astigmatism patients compared to conventional
monofocal IOLs4,5,6
Medicare does not cover the correction of astigmatism so
the additional costs must be paid by cataract patients
1. Dick, et al. Ophthalmol Clin North Am 2006. 2. American Academy of Ophthalmology. www.aao.org/ppp. 3. Gills. Curr Opin Ophthalmol 2002.
4. Ruhswurm, et al. J Cataract Refract Surg 2000. 5. Mendicute et al. J Cataract Refract Surg 2008. 6. DHHS Ruling 2007.
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Objectives

Our objective was to analyze the economic
value of a toric IOL from the perspective
of cataract patients with astigmatism

We hypothesized that the use of toric IOLs
would prove cost-effective over the longterm through improved uncorrected visual
acuity and reduced spectacle need
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Study Design
A decision analytic cost-effectiveness model was developed using MS Excel®
software
 Data Sources

– Systematic literature review
– Surveys of 60 U.S. practicing cataract/refractive surgeons who
 Performed ≥ 20 cataract procedures per month using conventional or toric IOLs
 Performed ≥ 10 surgical corrections of astigmatism per month
 Practiced for ≥ 2 years & spent ≥ 50% of time in clinical setting

Clinical Inputs
– Distance vision spectacle independence
– Proportion of patients achieving UCVA level ≥ 20/25

Clinical Pathway
– All patients underwent cataract removal
– Some patients could further transition to the second intervention (surgical or nonsurgical) to correct residual refractive cylinder, and to the third intervention (a repeat
refractive surgery) to optimize vision if needed

Outcomes
– Average per patient cost of cataract surgery including the concomitant correction of
astigmatism
– Incremental cost-effectiveness ratio (ICER) of cataract surgery with concomitant
correction of astigmatism
 The effectiveness measure used was the proportion of patients achieving a UCVA level ≥
20/25
 ICER = (Cost A – Cost B)/(proportion ≥ 20/25 A – proportion ≥ 20/25 B)
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Decision Analysis Tree
Cataract surgery
(Intervention A)
Post-cataract correction
(Intervention B)
0.67/0.53/0.63
0.57/0.62/0.58
No further correction required
Glasses
0.10/0.12/0.11
Treatment 1:
Toric IOL
Contact lenses
0.33/0.47/0.37
0.16/0.13/0.16
Distance vision correction required
LVC
0.99/0.99/0.99*
No re-treatment
0.01/0.01/0.01*
Re-treatment required
Cataract patients
age ≥ 65 with
≤3.0 D, for whom
distance vision
correction was
ultimate goal
Treatment 2:
Conv. Monofocal
IOL
without intraoperative refractive
correction
0.82/0.82/0.82*
LVC
ICS (LRI/AK)
CK
No re-treatment
0.14/0.11/0.12
ICS (LRI/AK)
0.18/0.18/0.18*
Re-treatment required
0.75/0.75/0.75*
LVC
ICS (LRI/AK)
CK
No re-treatment
0.04/0.03/0.04
CK
0.25/0.25/0.25*
Re-treatment required
Treatment 3:
Conv. Monofocal
IOL with intraoperative
LRI/PCRI
Re-treatment
(Intervention C)
LVC
ICS (LRI/AK)
CK
Legend
XX/XX/XX = Probability of Treatment 1/ Treatment 2/ Treatment 3
= End node
* The probability of re-treatment after Intervention B was assumed to be the same regardless of the treatment received during Intervention A
Abbreviations: AK=astigmatic keratotomy; CK=Conductive Keratoplasty; ICS=Incision Corneal Surgery; IOL=Intraocular Lens; LRI=Limbal Relaxing
Incision; LVC=Laser Vision Correction; PCRI=Peripheral Corneal Relaxing Incision
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Cost Assessment

Total costs
– FY 2008 Medicare physician and ambulatory surgical facility fee
reimbursement amounts
– Patient out-of-pocket costs

Cost components
– Short term costs (1st year post cataract removal): costs of
procedures (cataract and refractive surgery), cost of one year of
wearing glasses/contact lenses
– Long term costs (all years following the 1st year post cataract
removal): cost associated with glasses/contact lens wear

Cost Calculation
– Costs were assessed through 1st year post cataract surgery and
over an average remaining lifetime
 Remaining lifetime was estimated at 17 years, based on the average life
expectancy for a general US population at 65 years of age1
– Lifetime costs combined the 1st year costs and the costs over
remaining lifetime
– The lifetime costs were discounted at 3% annually
1. CDC. US Life tables 2008.
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Unit Costs
Medical Costs of Services, Procedures and Devices per Patient1,2,3
Cost components
Patient
Cost
Total
Cost
Cataract treatment options
Toric IOL
Conventional IOL without intra-operative refractive correction
Conventional monofocal IOL with intra-operative LRI/PCRI
$ 1,750
$ 823
$ 1,544
$ 5,040
$ 4,113
$ 4,834
Follow-up intervention to optimize vision
Glasses (over 1st year post cataract surgery)
Glasses (over each of the following years post cataract surgery)
Contacts (over 1st year post cataract surgery)
Contacts (over each of the following years post cataract surgery)
LVC spectrum procedures
ICS
CK
$ 59
$ 313
$ 198
$ 335
$ 4,085
$ 721
$ 3,092
$ 297
$ 313
$ 319
$ 335
$ 4,085
$ 721
$ 3,092
Abbreviations: AK=astigmatic keratotomy; CK=Conductive Keratoplasty; ICS=Incision Corneal Surgery; IOL=Intraocular Lens; LRI=Limbal Relaxing Incision;
LVC=Laser Vision Correction; PCRI=Peripheral Corneal Relaxing Incision
1. Alcon Labs Inc. 2008. 2. AMA 2008. 3. CMS 2008.
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Results – Average Costs per Patient

Toric IOL yielded better clinical outcomes than the conventional IOL with and
without intra-operative refractive correction: 67%, 63%, and 53% of patients
achieved spectacle independence, and 53%, 48%, and 44% of patients had
UCVA ≥20/25, respectively.
 Toric IOLs incurred the highest first year costs compared to the other two
treatment options. However, once life time costs were accrued the Toric
provided an average cost savings to patients.
Total Cost of Cataract and Follow-up Astigmatism Correction Treatments
8000
$7343
$7578
$7477
Legend
3387
Treatment Arms:
1. Toric IOL
2. Conventional Monofocal IOL
with glasses
3. Conventional Monofocal IOL
with LRI/PCRI
Cost (US 2008 $$)
7000
6000
$5529
$4678
5000
4000
$5365
3379
3000
3379
3408
3388
3408
3964
4170
14
25
4090
2000
1000
2150
1270
0
1
1
2
2
First Year
First-Year
Medicare payments
Patient payments
1977
3
3
Lifetime
Life-Time
6
3
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Results – Cost-Effectiveness

In the first year, both astigmatism-correcting cataract treatments were costineffective compared to the conventional monofocal IOL with glasses/contacts.

Once lifetime costs were considered, the Toric IOL proved the better value
compared to either a conventional monofocal IOL with LRI/PCRI or a
conventional monofocal IOL with glasses/contacts. Toric ICERs were lower
(better) due to a larger proportion of patients achieving an uncorrected visual
acuity of ≥ 20/25
Incremental cost
of treatment*
ICER per patient
with UCVA
≥ 20/25*
Incremental cost
of treatment*
First Year
ICER per patient
with UCVA
≥ 20/25*
Lifetime
Toric IOL
Total costs
Patient costs
$ 851
$ 880
$ 9,768
$ 10,099
$ -235.15
$ -206.29
$- 2,699
$ -2,368
CM IOL with intraoperative LRI/PCRI
Total costs
Patient costs
$ 687
$ 707
$ 16,567
$ 17,060
$ -100
$ -80
$ -2,417
$ -1,925
*CM IOL without intra-operative refractive correction was used as a baseline comparator
CM=conventional monofocal; ICER = Incremental Cost Effectiveness Ratio; IOL=Intraocular Lens; LRI=Limbal Relaxing Incision;
PCRI=Peripheral Corneal Relaxing Incision
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Sensitivity Analysis


To test the robustness of the model results, we varied the cost of toric IOL to account for possible cost range
Proportion of patients achieving distance vision independence was also varied to account for possible better
and worse outcomes as identified in clinical studies.
Parameter
Patient cost of cataract surgery with toric IOL
Probability of distance vision spectacle
independence with toric IOL

Best-case
scenario value
Default model value
Worse-case
scenario value
$750 per eye
$825 per eye
$1,000 per eye
90%
67%
50%
All best-case scenarios indicated better value (negative ICER) with the toric IOL compared to that obtained
with default model values. Results were more sensitive to the change in distance vision spectacle
independence than in the cost of the toric IOL. Result sensitivity was greatest when the probability of
distance vision spectacle independence and toric IOL cost were modified simultaneously.
Best-case:
ICERs with toric IOL vs.
conventional monofocal IOL
Worse-case:
ICERs with toric IOL vs.
conventional monofocal IOL
$750 per eye
$2,90
0
$1,000 per
eye
+$20
1
Spectacle independence
90%
$15,0
00
50%
+$12,
670
Simultaneous modifying
of both parameters
$750 per eye
90%
$17,5
00
$1,000 per
eye 50%
+$16,
000
Cost of toric IOL
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Conclusion

The Toric IOL is the economically dominant treatment for the correction
of astigmatism in cataract patients compared to conventional monofocal
IOLs with either glasses or intra-operative refractive surgery.

Nearly all of the cost savings afforded by the Toric IOL are accrued by
the patient.

These results may be informative to physicians and patients regarding
the value and long-term benefits of the toric IOL to treat cataract with
preexisting astigmatism.

Future research quantifying lost productivity and other intangible costs
of wearing glasses/lenses is warranted to ensure that the outcomes of
alternative treatments are as comprehensively evaluated as possible.

Our findings should be cautiously applied to patients who require
correction of more than three diopters or patients whose likelihood of
becoming distance vision spectacle independent is low.
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References
Alcon Laboratories Inc. 2008 Market Scope Reports. Alcon data on file.
American Academy of Ophthalmology. Cataract in the Adult Eye, Preferred Practice Pattern. Available at:
www.aao.org/ppp Accessed June, 2007. www.aao.org/ppp
American Medical Association. CPT Code/Relative Value Search. Available at:
https://catalog.amaassn.org/Catalog/cpt/cpt_search.jsp?_requestid=18642?checkXwho=done,
Accessed August, 2008.
Center for Disease Control and Prevention. US Life tables. Available at:
http://www.cdc.gov/nchs/data/hus/hus07.pdf#027. Accessed August, 2008.
Center for Medicare and Medicaid Services. Ambulatory Surgical Payments. Available
at:http://www.cms.hhs.gov/ASCPayment/01_Overview.asp . Accessed August, 2008.
Department of Health and Human Services. Ruling No. CMS-1536-R. Jan.22, 2007.
Dick HB, Dell S. Single optic accommodative intraocular lenses. Ophthalmol Clin North Am 2006; 19(1):10724.
Gills JP. Treating astigmatism at the time of cataract surgery. Curr Opin Ophthalmol 2002; 13(1):2-6.
Mendicute J, Irogoyen C, Aramberri J, Ondarra A, Montes-Mico R. Foldable toric intraocular lens for
astigmaticsm correction in cataract patients. J Cataract Refract Surg 2008; 34(4):601-607.
Ruhswurm I, Scholz U, Zehetmayer M, Hanselmayer G, Vass C, Skorpik C. Astigmatism correction with a
foldable toric intraocular lens in cataract patients. J Cataract Refract Surg 2000; 26(7):1022-1027.
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