A Value-Based Medicine Comparison of Interventions for Subfoveal Neovascular Macular Degeneration Gary C. Brown, MD, MBA, 1,2,3,4 Melissa M. Brown, MD, MBA, 1,3,4,5 Heidi C. Brown, MBA, 1 Sylvia Kindermann, BA, 1 Sanjay Sharma, MD, MBA 1,3,6 Objective: To perform a value-based medicine analysis of clinical trials that evaluate the interventions of laser photocoagulation, intravitreal pegaptanib therapy, and photodynamic therapy (PDT) with verteporfin for the treatment of classic subfoveal choroidal neovascularization. Design: Reference case cost-utility analysis using value-based medicine principles, which use patient- based utility values and standardized, input variable criteria. Participants: Data from participants in the Macular Photocoagulation Study, Pegaptanib for Neovascular Age-Related Macular Degeneration Study, and the Treatment of Age-Related Macular Degeneration with Pho- todynamic Therapy Study. Methods: Visual data were converted to a value-based format using time tradeoff utility analysis values from patients with macular degeneration. Costs were obtained from 2005 Medicare data. Outcomes (quality-adjusted life-years [QALYs]) and costs were discounted at a 3% annual rate. Main Outcome Measures: Interventional QALYs gained, percent improvement in quality of life, and dollars spent per QALY gained. Results: Laser photocoagulation confers a 4.4% (P = 0.03 versus pegaptanib therapy) improvement in quality of life for the reference case, whereas pegaptanib therapy confers a 5.9% improvement and PDT confers an 8.1% (P = 0.0002 versus pegaptanib therapy) improvement. The cost-utility associated with laser photoco- agulation is $8179, that for pegaptanib therapy is $66 978, and that for PDT is $31 544. All sensitivity analyses remain within the conventional standards of cost-effectiveness. Conclusions: Photodynamic therapy confers greater patient value than intravitreal pegaptanib therapy and laser photocoagulation for the treatment of classic subfoveal choroidal neovascularization. Despite the fact that laser photocoagulation is the most cost-effective intervention, both PDT and pegaptanib therapy deliver greater value, and thus are both preferred over laser photocoagulation. Using an economic measure, photodynamic therapy is the preferred treatment among these 3 interventions. Ophthalmology 2007;114:1170 –1178 © 2007 by the American Academy of Ophthalmology. Neovascular, age-related macular degeneration is a serious public health threat, especially with an increasingly aging population as life expectancy increases. 1,2 In addition to the considerable quality-of-life burden caused by the disease, 3 it has been estimated that it produces an annual $5 billion loss to the gross domestic product (GDP) in the United States. 4,5 Therapeutic advances in the arena of neovascular macu- lar degeneration therapy have given the clinician multiple options for treatment of the disease. 6 –14 Currently, value- based medicine information 15,16 is not available that allows the clinician directly to compare the patient-perceived value conferred by these interventions. For example, which provides greater patient value: the improvement in mean long-term vision from 20/500 to 20/320 with laser photocoagulation, 6,7 the improvement in mean long-term vision from 20/320 +2 to 20/160 +2 in eyes treated with photodynamic therapy with verteporfin (PDT), 8 –10 or the improvement from 20/200 +1 to 20/126 -1 in eyes treated with pegaptanib? 11,12 And how do the ad- verse effects associated with each intervention factor into the therapeutic equation? Value-based medicine is the practice of medicine based Originally received: February 8, 2006. Accepted: September 18, 2006. Manuscript no. 2006-173. 1 Center for Value-Based Medicine, Flourtown, Pennsylvania. 2 Retina Service, Wills Eye Hospital, Jefferson Medical College, Philadel- phia, Pennsylvania. 3 Eye Research Institute, Philadelphia, Pennsylvania. 4 Leonard Davis Institute of Health Economics, University of Pennsylva- nia, Philadelphia, Pennsylvania. 5 Department of Ophthalmology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania. 6 Cost-effective Ocular Health Policy Unit, Queens Medical College, King- ston, Canada. Supported in part by the Principals Initiative Research Award, Kingston, Canada, and Premier’s Award for Research Excellence, Kingston, Canada. Correspondence to Gary C. Brown, MD, MBA, Center for Value-Based Medicine, Box 335, Flourtown, PA 19031. E-mail: gbrown@ valuebasedmedicine.com. 1170 © 2007 by the American Academy of Ophthalmology ISSN 0161-6420/07/$–see front matter Published by Elsevier Inc. doi:10.1016/j.ophtha.2006.09.019