OBJECTIVES: The NICE Health Technology Assessment (HTA) found aflibercept to be cost-effective for the treatment of neovascular age-related macular degeneration (nAMD) in the UK, largely due to reduced monitoring visits. This study aimed to compare the costs used in the HTA with a comprehensive real-world cost list (Neutral list) to highlight the importance of including detailed cost assessments in evaluating cost-effectiveness of competing treatments.

METHODS: This mixed-methods study used the Jandhyala Method, combining a structured literature review, expert consultations, and consensus exercises to identify real-world cost items in NHS nAMD treatment. Ten UK-based ophthalmologists provided insights, leading to the development of the nAMD Service Non-Drug Cost Instrument (nAS), which included 217 consensus items in the neutral list. The study compared cost magnitudes using the nAS instrument against the NICE Technology Appraisal (TA800) as well as aflibercept and ranibizumab costs (based on BNF76).

RESULTS: Significant differences were found between TA800 estimates and real-world costs captured by the nAS instrument. TA800 missed substantial costs, especially related to clinic strain and increased workload. Drug costs were found to be just a small proportion of the overall cost of the nAMD service. The nAS instrument showed costs could multiply rapidly when clinic demand exceeded capacity, further exacerbated by the requirement of more frequent monitoring visits. Scenario analysis estimated annual per-patient clinic costs at £845 (within capacity) to £13,960 (under strain - arbitrary 50% increase in resource utilisation), compared to TA800 estimate of £210.

CONCLUSIONS: Current economic evaluations may underestimate real-world costs by overlooking non-drug expenses and clinic strain impacts. This case study illustrates that non-drug costs can significantly outweigh drug costs, and excluding these costs may result in different cost-effectiveness outcomes. Comprehensive cost assessments using Neutral lists are crucial for more accurate economic evaluations, leading to better-informed decision-making in treatment planning and resource allocation for nAMD and similar conditions.