Does quality-of-life with DME therapies have a price?


In DME patients with worse baseline visual acuity, aflibercept and ranibizumab provided more of a quality-of-life improvement-yet aflibercept had an associated higher cost.

Take-home: In DME patients with worse baseline visual acuity, aflibercept and ranibizumab provided more of a quality-of-life improvement-yet aflibercept had an associated higher cost.

Reviewed by Bryon K. Hong, MD

In diabetic macular edema (DME) patients with worse visual acuity, intravitreal agents aflibercept (Eylea, Regneron) and ranibizumab (Lucentis, Genentech) had higher quality-of-life benefits compared with bevacizumab (Avastin, Genentech). However, ranibizumab had a slightly greater gain in DME patients with better visual acuity, with an associated lower cost compared to aflibercept.

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Bryan K. Hong, MD, presented these conclusions based on a value-based medicine analysis of research from the Diabetic Retinopathy Clinical Research Network, Protocol T (Years 1 and 2), which compares aflibercept, ranibizumab, and bevacizumab in a randomized manner.1,2  Protocol T tracked the efficacy of the various agents as well as the average number of injections for patients.

Dr. Hong, MD, is a vitreoretinal fellow at the Wills Eye Hospital, Thomas Jefferson University, Philadelphia.

Dr. Hong’s work is based on methodology developed by Gary Brown, MD, and Melissa Brown, MD, both of Thomas Jefferson University, who were able to assign time-trade off utilities to specific visual acuity levels, thereby allowing the comparison of value-based efficacy across all medical specialties in a way that is understandable by the public.3,4,5

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Value-based medicine considers patient value gain and financial value gain by looking at factors, such as quality of life (QOL), length of life, adverse effects, benefits, and patient opinions.

QOL issue

Previous research carried out by Drs. Brown has found that cataract surgery leads to a 20% increase in QOL.6 To put that in context, selective serotonin reuptake inhibitor medications for depression lead to a 21.6% increase in QOL, the glaucoma medication timolol leads to a 19.9% increase in QOL, and statins offer a 4% to 6% QOL increase.

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Using a last-observation, carried-forward method on the average diabetic patient with a life expectancy of about 17 years from time of enrollment, Dr. Hong found an 18.2% QOL gain with aflibercept, a 12.6% gain with bevacizumab, and a 15.9% gain with ranibizumab in DME patients with a visual acuity between 20/50 and 20/320. This group was considered the “worse VA” group.

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In the group with a visual acuity between 20/32 and 20/40 (considered the “better VA” group), the QOL gains were less dramatic-5.9%, 5.2%, and 6.4% with aflibercept, bevacizumab, and ranibizumab, respectively.  

QOL versus cost

Although aflibercept demonstrated QOL gains for the worse VA group, that also came at a higher cost of $63,223. That compared with $2,528 for bevacizumab and $40,364 for ranibizumab.

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The study concluded that though aflibercept and ranibizumab are both cost-effective over 17 years in the treatment of DME and yield comparable gains in QOL, Ranibizumab is more cost-effective due to its lower cost.

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“The conclusions of studies like this one are easily misinterpreted by policy makers,” Dr. Hong pointed out in a joint statement with Dr. Gary Brown. “It is important to understand that the ‘most cost-effective’ treatment is not necessarily what is best for the patient. The treatment that affords the highest patient-value should be the preferred treatment, and only when two treatments appear to be comparable should a cost-efficacy analysis be used to decide which is more economical for third-party payer with limited resources.” 


1. Diabetic Retinopathy Clinical Research Network, et al. Aflibercept, bevacizumab, or ranibizumab for diabetic macular edema. N Eng J Med. 2015;26:1193-1203.

2. Wells JA, Glassman AR, Ayala AR, et al. Aflibercept, bevacizumab, or ranibizumab for diabetic macular edema: Two-year results from a comparative effectiveness randomized clinical trial. Ophthalmology. 2016 Feb 27. [Epub ahead of print]

3. Brown GC. Vision and quality of life. Trans Am Ophthalmol Soc 1999;97:473-512.

4. Brown MM, Brown GC, Sharma S, Kistler J, Brown H. Utility values associated with blindness in an adult population. Br J Ophthalmol 2001;85:327-331.

5. Brown MM, Brown GC, Sharma S. Evidence-Based to Value-Based Medicine, Chicago, AMAPress, 2005.

6. Brown GC, Brown MM, Menezes A, Busbee BG, Lieske HB, Lieske PA. Cataract surgery cost-utility revisited in 2012. A new economic paradigm. Ophthalmology. 2013;120:2367-76.


Bryan K. Hong, MD



Gary Brown, MD



This article was adapted for Dr. Hong’s presentation at the 2015 American Academy of Ophthalmology meeting.

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