High profits may incentivize using anti-VEGF therapy over surgery for diabetic retinopathy

Despite apparently equivalent therapeutic outcomes, intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy offers significantly higher financial reward for physicians over pars plana vitrectomy (PPV), which could lead to bias in choosing the most appropriate treatment for diabetic retinopathy.

Study design

A retrospective cost and profit analysis of selected literature, including two years of data from the DRCR Network Protocols W and AB as well as the PANORAMA trial, assessed the potential benefits and financial incentives of an intravitreal aflibercept–based therapy versus PPV for diabetic retinopathy without macular edema (DME) using mean profitability per procedure minute for primary comparison.

Outcomes

The DRCR Network Protocol AB demonstrated equivalence in mean visual acuity outcomes for the treatment of diabetic vitreous hemorrhage with PPV and laser versus serial aflibercept injections. An initial PPV with laser strategy was shown to have durable benefit and cost savings in comparison to serial injections. When analyzing costs, the authors calculated surgical profit to the physician as $8.14/minute for PPV with laser, whereas intravitreal injection profit is $14.35/minute. Similarly, both PANORAMA and DRCR Protocol W investigated the use of anti-VEGF injections to prevent progression to proliferative diabetic retinopathy or DME. Both found no visual acuity benefit to using anti-VEGF injections preventatively for either condition, yet practice profits increased by as much as 414% when physicians opted for a preventative injection approach.

Limitations

The authors compared the costs of surgery versus aflibercept injections for diabetic vitreous hemorrhage. However, financial analysis should include calculations with bevacizumab as well, which is a more cost-effective alternative to aflibercept. In addition, there should be consideration of the potential complications of surgery. Finally, it would be helpful to understand whether retina specialists are actually using anti-VEGF medications for prevention of progression to DME or proliferative diabetic retinopathy.

Clinical significance

With the steady decline in surgical reimbursement rates, a physician’s financial incentive to continue with intravitreal injections rather than pursue surgery must be considered. These pressures may paradoxically increase the overall cost of healthcare by driving more practices towards intravitreal injections rather than surgery for diabetic vitreous hemorrhage. In addition, prevention strategies with regular intravitreal injections incur added risk of endophthalmitis with little additional benefit to the patient. This is why preventive injections have not in general become standard of care in the retina community.