Elhusseiny AM, Yannuzzi NA, Smiddy WE. Cost Analysis of Pneumatic Retinopexy versus Pars Plana Vitrectomy for Rhegmatogenous Retinal Detachment. Ophthalmol Retina 2019;3:956–961
Rhegmatogenous retinal detachment (RRD) may result in significant and permanent vision loss. Many studies have looked at outcomes of various surgical techniques in achieving single surgical success. Recently, the Pneumatic Retinopexy (PR) versus Vitrectomy (PPV) for the Management of Primary Rhegmatogenous Retinal Detachment Outcomes Randomized Trial (PIVOT), compared the safety and efficacy of PR and PPV for repair of RRD involving the superior 8 clock hours in both phakic and pseudophakic eyes. Using the PIVOT data, Elhusseiny et al. performed a cost-utility analysis between PR and PPV for the management of RRD. Costs, lifetime usefulness, and lifetime cost per quality-adjusted life year (QALY) for the treatment of RRD with PR or PPV were calculated.
In PIVOT, primary anatomic success was achieved in 80.8% of eyes in the PR group compared with 93.2% in the PPV group. The average postoperative best-corrected visual acuities in the PR and PPV groups were 20/25 and 20/ 32 at 12 months, respectively. Total modeled costs included initial costs for either PPV or PR as well as anticipated additional costs for cataract extraction, secondary PPV for recurrent RRD, and PPV for epiretinal membrane, macular hole, or endophthalmitis, as reported in the PIVOT trial. Medicare fee data for 2019 Centers for Medicare and Medicaid Services were applied to calculate the costs (in 2019 United States dollars) associated with each treatment.
The total imputed costs (all in 2019 United States dollars) for primary repair of RRD in facility (hospitals) and nonfacility settings (office and ambulatory surgical centers) were $4451 and $2456, respectively, in the PR group and $7108 and $4514, respectively, in the PPV group. The estimated lifetime QALYs gained were 5.9 and 5.4 in the PR and PPV groups, respectively. The cost per QALY for facility and nonfacility settings was $751 and $414, respectively, in the PR group and $1312 and $833, respectively, in the PPV group.
Overall, this was a well-designed study based on the robust data from PIVOT, which is the only prospective randomized trial evaluating PR versus PPV. Both surgical approaches are highly cost-effective. For comparison, previously reported acceptable rates per QALY can range from $50,000 to $100,000. However, this analysis is highly dependent on the primary success rate of PR. A reduction in single procedure success of PR can lead to a worse cost utility, although it would still likely be favorable.
When choosing between PPV versus PR in the treatment of RRD, considerations should include the type of pathology, likelihood of single surgery success, lens status, patient compliance with positioning, and operating room availability. Although cost-utility typically isn’t weighed heavily in the decision process, it should be comforting to know that both are highly cost effective.
Daniel Su, MD
Retina Vitreous Associates Medical Group
Los Angeles, CA