Stereotactic Radiotherapy (SRT) for nAMD shows 65% probability of cost-effectiveness at 4 years, despite worse BCVA.
Background
Neovascular age-related macular degeneration (nAMD) is a leading cause of vision loss, typically managed with frequent intravitreal anti-VEGF injections. While effective, these injections pose treatment burden, risks, and may not fully address the underlying disease. Stereotactic radiotherapy (SRT) offers a potential alternative to reduce injection frequency and associated costs. This study evaluates the health economic impact and patient-reported outcomes of SRT in the context of the STAR trial, specifically using the EQ-5D vision bolt-on to better capture vision-related quality of life.
Study Design
This study utilized data from the UK STAR trial, a randomized, double-masked, sham-controlled device trial. Participants with chronic active nAMD were randomized to receive either 16-Gray SRT (n=274) or double-masked sham SRT (n=137). Both groups received pro re nata ranibizumab for two years, followed by two years of routine care. Researchers compared mean BCVA, EQ-5D-5L, and Visual Function Questionnaire-25 (VFQ-25) scores across the three levels of the EQ-5D vision bolt-on. An economic evaluation estimated the cost-effectiveness of SRT from a UK national health service perspective over two and four years, using prospective data on EQ-5D-5L and eye-related direct healthcare use.
Results
Participants reporting vision problems on the EQ-5D vision bolt-on had significantly worse BCVA, EQ-5D-5L, and VFQ-25 scores compared to those without. EQ-5D utilities (with and without the bolt-on) increased with BCVA but showed weaker correlations than VFQ-25 composite scores. Quality-adjusted life years (QALYs) did not differ significantly between treatment groups, with or without the bolt-on. The economic evaluation suggested that SRT would reduce healthcare costs by £404 (95% CI: -£1282 to £2092) per patient at a four-year time horizon. The probability of SRT plus anti-VEGF being cost-effective at a £20,000 per QALY threshold was 65% at a four-year time horizon. Sensitivity analyses confirmed the robustness of these findings. Importantly, the original STAR trial found SRT resulted in worse BCVA in Years 3 and 4.
Key Findings
- Participants reporting vision problems on the
EQ-5D vision bolt-onhad significantly worseBCVA,EQ-5D-5L, andVFQ-25scores. - SRT reduced healthcare costs by £404 per patient over four years (95% CI: -£1282 to £2092).
- The probability of SRT being cost-effective at a £20,000 per
QALYthreshold was 65% at four years. QALYsdid not significantly differ between SRT and sham groups, with or without the vision bolt-on.
Why It Matters
Stereotactic radiotherapy (SRT) presents a potentially cost-effective strategy for managing nAMD, offering a reduction in healthcare costs and anti-VEGF injection burden, despite a trade-off in long-term visual acuity. This finding is crucial for healthcare systems seeking to optimize resource allocation while maintaining patient outcomes. The EQ-5D vision bolt-on proved valuable in capturing vision-specific quality of life, enhancing the precision of economic evaluations for ophthalmic conditions. While QALYs didn't significantly differ, the cost reduction and probability of cost-effectiveness suggest SRT could be a viable option, particularly in contexts where frequent injections are a major burden. Further research is needed to balance the cost savings with the observed decline in BCVA in later years.
namd
stereotactic-radiotherapy
cost-effectiveness
quality-of-life
eq-5d
vision