Cost-Effectiveness Analysis of Intracameral Cefuroxime Use for Prophylaxis of Endophthalmitis after Cataract Surgery

doi:10.1016/j.ophtha.2009.03.014

Ophthalmology

Volume 116, Issue 10, October 2009, Pages 1887-1896.e1

https://doi.org/10.1016/j.ophtha.2009.03.014 Get rights and content

Objective

To evaluate the cost-effectiveness of intracameral cefuroxime for postoperative endophthalmitis prophylaxis, and to determine the efficacy threshold necessary for alternative antibiotics to attain cost-effective equivalence with intracameral cefuroxime.

Design

Cost-effectiveness analysis.

Participants

We study a hypothetical cohort of 100 000 patients undergoing cataract surgery as a part of the cost analysis.

Methods

A cost-effectiveness model was constructed to analyze different antibiotic prophylactic regimens for postoperative endophthalmitis with intracameral cefuroxime as our base case. Efficacy was defined as the absolute reduction in rate of infection from background rate of infection, which was sourced from the literature. Antibiotic cost data were derived from the Red Book 2007 edition, and salary data were taken from the United States Bureau of Labor Statistics. Multivariate sensitivity analysis assessed the performance of antibiotic options under different scenarios.

Main Outcome Measures

Cost per case of endophthalmitis prevented; theoretical maximal cost-effectiveness; efficacy threshold necessary to achieve cost-effective equivalence with intracameral cefuroxime; ratio indicating how many times more effective or less expensive alternative antibiotics would have to be to achieve cost-effective equivalence with intracameral cefuroxime.

Results

The cost-effectiveness ratio for intracameral cefuroxime is $1403 per case of postoperative endophthalmitis prevented. By comparison, the least expensive topical fluoroquinolone in our study, ciprofloxacin, would have to be >8 times more effective than intracameral cefuroxime to achieve cost-effective equivalence. The most expensive topical fluoroquinolones studied, gatifloxacin and moxifloxacin, would have to be ≥19 times more effective than intracameral cefuroxime to achieve cost-effective equivalence. A sensitivity analysis reveals that even in the worst case scenario for intracameral cefuroxime efficacy and with a 50% reduction in the cost of 4th-generation fluoroquinolones, gatifloxacin and moxifloxacin would have to be ≥9 times more effective than intracameral cefuroxime to achieve cost-effective equivalence.

Conclusions

Administration of intracameral cefuroxime is relatively cost-effective in preventing endophthalmitis after cataract surgery. Owing to their high costs, many commonly used topical antibiotics are not cost-effective compared with intracameral cefuroxime, even under optimistic assumptions about their efficacy.

Financial Disclosure(s)

The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Section snippets

Overview

Our model and analysis were constructed to determine the cost-effectiveness of preventing postoperative endophthalmitis using several methods of antibiotic prophylaxis. In this section, we will use estimates of the incidence rate of endophthalmitis after surgery assuming the use of (1) intracameral cefuroxime 1 mg/0.1 mL, (2) subconjunctival cefazolin 100 mg/mL, (3) topical gatifloxacin 0.3% (Zymar; Allergan Inc., Irvine, CA), (4) topical moxifloxacin 0.5% (Vigamox; Alcon Laboratories Inc.,

Cost-Effectiveness

For each of the 11 prophylactic regimens, results for the base case scenario are given in Table 2. The second column gives the estimated net cost (including both treatment and endophthalmitis averted) if the regimen is applied to a hypothetical cohort of 100 000 eyes. Intracameral cefuroxime yields net cost savings of approximately $480 000 in the cohort due to endophthalmitis averted (an expected 45 cases would still occur). None of the fluoroquinolones were cost saving, even assuming that all

Discussion

Because clinical trials and efficacy data are lacking for many antibiotics commonly used in cataract surgery, in this study we investigate the role of cost as a potential factor in choosing a specific antibiotic for the prevention of endophthalmitis. To our knowledge, this is the first study to analyze the cost-effectiveness of different antibiotic options used to prevent endophthalmitis after cataract surgery. Because there are at least 2 large, prospective, peer-reviewed, clinical studies of

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Cited by (52)

Cost-Effectiveness of Preoperative Topical Antibiotic Prophylaxis for Endophthalmitis Following Cataract Surgery
2023, American Journal of Ophthalmology
Citation Excerpt :
However, other studies have previously explored the cost-effectiveness of other prophylactic measures for cataract surgery. Sharifi and associates44 indicated a cost-effectiveness ratio of $1403 per case for the use of intracameral cefuroxime, whereas topical fluoroquinolone would have had to be at least 8 times as effective as preventing infection to achieve the same cost-effectiveness. Leung and associates45 found similar results in a cost-effectiveness analysis comparing intracameral moxifloxacin and perioperative topical antibiotic prophylaxis with perioperative topical antibiotics alone, concluding that adjunctive intracameral moxifloxacin was more effective on the basis of QALYs.
To determine the cost-effectiveness of preoperative topical antibiotic prophylaxis for the prevention of endophthalmitis following cataract surgery.
Cost-effectiveness analysis using a decision-analytic microsimulation model.
Preoperative topical antibiotic prophylaxis vs no-prophylaxis costs and effects were projected over a life-time horizon for a simulated cohort of 500 000 adult patients (≥18 years old) requiring cataract surgery in theoretical surgical centers in the United States. Efficacy and cost (2021 US dollars) values were obtained from the literature and discounted at 3% per year.
Based on inputted parameters, the mean incidence of endophthalmitis following cataract surgery for preoperative topical antibiotic prophylaxis vs no-prophylaxis was 0.034% (95% CI 0%-0.2%) and 0.042% (95% CI 0%-0.3%), respectively—an absolute risk reduction of 0.008%. The mean life-time costs for cataract surgery with prophylaxis and no-prophylaxis were $2486.67 (95% CI $2193.61-$2802.44) and $2409.03 (95% CI $2129.94-$2706.69), respectively. The quality-adjusted life-years (QALYs) associated with prophylaxis and no-prophylaxis were 10.33495 (95% CI 7.81629-12.38158) and 10.33498 (95% CI 7.81284-12.38316), respectively. Assuming a cost-effectiveness criterion of ≤$50 000 per QALY gained, the threshold analyses indicated that prophylaxis would be cost-effective if the incidence of endophthalmitis after cataract surgery was greater than 5.5% or if the price of the preoperative topical antibiotic prophylaxis was less than $0.75.
General use of preoperative topical antibiotic prophylaxis is not cost-effective compared with no-prophylaxis for the prevention of endophthalmitis following cataract surgery. Preoperative topical antibiotic prophylaxis, however, would be cost-effective at a higher incidence of endophthalmitis and/or a substantially lower price for prophylaxis.
Ocular toxicity after inadvertent overdose of intracameral cefuroxime during cataract surgery
2021, Archivos de la Sociedad Espanola de Oftalmologia
Describir los efectos de la inyección de cefuroxima intracameral a una dosis más alta de la recomendada en cirugía de catarata.
Estudio retrospectivo de 8 ojos de 8 pacientes operados de catarata en un mismo día que recibieron 12,5 mg/0,1 ml de cefuroxima intracameral de forma inadvertida al finalizar la cirugía, por un error en la dilución. A todos los pacientes se les realizó un seguimiento oftalmológico estrecho durante 6 meses.
Todos los pacientes presentaron una inflamación marcada del segmento anterior con edema corneal que se resolvió en todos los casos (entre 5 días y 3 meses). A los 6 meses de seguimiento se constató una diferencia significativa en el recuento endotelial corneal de dichos ojos al compararlo con el ojo contralateral (p = 0,038), siendo < 1000 cels/mm² en 3 casos. Tres pacientes (37,5%) presentaron un edema macular precoz, dejando como secuela permanente la disrupción de la capa elipsoidal a nivel subfoveal en uno de los casos. Uno de los pacientes desarrolló una neuropatía óptica con defecto pupilar aferente asociado.
Aunque la inyección de cefuroxima en cámara anterior a dosis de 1 mg/0,1 ml ha demostrado disminuir la incidencia de endoftalmitis, su sobredosificación puede tener efectos oculares potencialmente perjudiciales tanto en el segmento anterior como en el posterior.
To describe intracameral toxic effects of cefuroxime at a higher dose than recommended in cataract surgery.
Retrospective study of 8 eyes of 8 patients who inadvertently received 12.5 mg/0.1 ml of intracameral cefuroxime due to a dilution error, at the end of the cataract surgery. All patients underwent a strict ophthalmology follow-up for 6 months.
All patients presented with a marked anterior segment inflammation with corneal oedema that resolved completely in all cases (between 5 days and 3 months). At 6 months of follow-up a statistically significant difference was found in the corneal endothelial cell density when compared with the fellow eye (P = .038), being < 1000 cells/mm² in 3 cases. Three patients (37.5%) showed early macular oedema, with subfoveal ellipsoid layer disruption in one case as a permanent sequel. One patient developed an optic neuropathy with associated afferent pupillary defect.
Although 1 mg/0.1 ml of intracameral cefuroxime has been shown to reduce the incidence of endophthalmitis, its overdose can have potentially toxic eye effects in both anterior and posterior segments.
Cefuroxime (Aprokam®) in the Prophylaxis of Postoperative Endophthalmitis After Cataract Surgery Versus Absence of Antibiotic Prophylaxis: A Cost-Effectiveness Analysis in Poland
2020, Value in Health Regional Issues
Citation Excerpt :
In the Sharifi et al study49 (Linertova et al36 published the same results) and in the Rodriguez-Caravaca et al study,11 a cefuroxime solution prepared at the hospital pharmacy was analyzed. All publications showed its cost-effectiveness (in Sharifi et al,49 savings resulting from the use of prophylaxis outweighed the costs of drug administration; in Rodriguez-Caravaca et al,11 the potential savings were €1176.7 for every 182 patients with intracameral cefuroxime prevention). We also found results from a French clinical center study, which showed that administering Aprokam could save €63 500 per 10 000 cases of cataract surgery (Bertholom et al).50
The analysis aims to assess the cost-effectiveness of cefuroxime (Aprokam®) in the prophylaxis of postoperative endophthalmitis (POE) after cataract surgery compared with the absence of antibiotic prophylaxis from the National Health Fund perspective in Poland.
We performed a cost-effectiveness and cost-utility analysis using the decision tree and Markov model, respectively, for patients after cataract surgery. The efficacy of Aprokam was 0.21 (95% confidence interval [CI], 0.08-0.55) and is based on the results of the European Society of Cataract and Refractive Surgery study. According to the epidemiological data from Poland, the risk of POE is 0.377%. The costs associated with the Aprokam administration and POE treatment costs were included. We determined the utilities of the health states in the model depending on visual loss due to POE. To determine the uncertainty of estimates parameters, a one-way deterministic and probabilistic sensitivity analysis were performed.
Using Aprokam allows avoiding 0.003 POEs per patient. The benefit from the intervention is 0.0007 quality-adjusted life years per patient in the lifetime horizon. The total costs of prophylaxis are higher at about €1.70. The cost of avoiding one POE (incremental cost-effectiveness ratio) is about €569.85. The estimated incremental cost-effectiveness utility ratio is equal to €2427.72/quality-adjusted life-years, and it is significantly lower than the cost-effectiveness threshold in Poland in 2019 (about 7.5% of the threshold). In all scenarios of performed one-way sensitivity analyses, Aprokam is cost-effective.
In Poland, the use of Aprokam is cost-effective, with the estimated incremental cost-utility ratio significantly lower than the cost-effectiveness threshold.
Prescribing Patterns and Costs Associated with Postoperative Eye Drop Use in Medicare Beneficiaries Undergoing Cataract Surgery
2020, Ophthalmology
To determine costs and prescribing patterns of postoperative eye drops for cataract surgery and estimate potential savings of generic or therapeutic drug substitutions.
Retrospective, cross-sectional analysis.
Medicare beneficiaries aged ≥65 years with Part D coverage who underwent cataract surgery in 2016.
Medicare Part D claims were used to extract information on eye drop prescriptions that were filled during the postoperative period of cataract surgery. Savings from generic or therapeutic drug substitutions were estimated for brand medications.
Total cost of postoperative eye drops for cataract surgery and physician and patient factors associated with medication cost.
Postoperative eye drops were prescribed in 2016 to 88% of 591 733 Medicare beneficiaries who underwent cataract surgery during that calendar year, with brand medications accounting for 57.5% of prescription volume. The overall cost totaled more than $167 million, 76.5% of which was attributable to use of brand medications. The mean costs of medications were $228 and $324 for those undergoing 1 and 2 surgeries, respectively. Topical antibiotics (89%) were the most commonly prescribed drug class by volume, followed by topical steroids (86%) and nonsteroidal anti-inflammatory drugs (66%), and accounted for 26%, 37%, and 36% of the total cataract surgery eye drop cost, respectively. Use of therapeutic and generic alternatives could have resulted in cost savings of as much as $118 million, or 70% of the total cost of postoperative eye drops. In adjusted analysis, patient factors associated with increased eye drop cost included older age, female gender, and race or ethnicity. Physician characteristics associated with increased eye drop cost included female gender, greater number of years in practice, practicing in metropolitan versus nonmetropolitan areas, and practicing in the Northeast versus the South and in the South versus the Midwest.
The cost to the Centers for Medicare and Medicaid Services for eye drops prescribed for postoperative use after cataract surgery in 2016 was approximately $170 million. In the absence of evidence of clinical superiority of expensive versus less costly options, substantial opportunity exists to improve the value of care delivered to Medicare beneficiaries.
Drug delivery to the eye anterior chamber by intraocular lenses: An in vivo concentration estimation model
2018, European Journal of Pharmaceutics and Biopharmaceutics
Citation Excerpt :
This drug delivery route offers numerous advantages, namely ease of procedure and patient compliance, however, it presents low bioavailability (1–5%) due to rapid precorneal clearance [7–9]. A cost-effectiveness analysis of POE prophylaxis reported that topical application of antibiotics was among the most expensive options, compared with intracameral or subconjunctival delivery routes [10]. Nonsteroidal anti-inflammatory drugs (NSAIDs) are also prescribed postoperatively for management of the inflammatory response and prevention of cystoid macular edema (CME) [11].
Drug loaded intraocular lenses have been proposed as an alternative to the conventional post-cataract removal prophylaxis through topical drug administration, since the drug or combination of drugs released from the lenses are delivered directly to the target site. In this work, a mathematical model to estimate the concentration of drug released from such lenses in the eye aqueous humor was developed. To attain these estimated concentration profiles, partition and effective diffusivity coefficients for the specific lens material were obtained from standard in vitro release experiments. The model was validated by comparing the predicted aqueous humor concentrations with those obtained in in vivo studies where hydrophilic acrylic intraocular lens loaded with an antibiotic (moxifloxacin) were implanted in rabbits. Subsequently, other partition and effective diffusivity values were determined for levofloxacin, diclofenac and ketorolac in the same hydrophilic acrylic and in a second material, a silicone hydrogel. Predicted drug concentrations in the aqueous humor allowed an initial screening and evaluation of the most promising system for post-cataract removal prophylaxis, with the hydrophilic acrylic material presenting promising results, especially for moxifloxacin and diclofenac controlled release.
Intracameral moxifloxacin for endophthalmitis prophylaxis after cataract surgery: Cost-effectiveness analysis
2018, Journal of Cataract and Refractive Surgery
To determine the cost-effectiveness of intracameral moxifloxacin compared with traditional antibiotic prophylaxis in preventing endophthalmitis after cataract surgery.
Theoretical surgical center in the United States.
Evaluation of technology.
The incremental cost-effectiveness ratios (ICER) and incremental cost-utility ratios (ICUR) were calculated for patients having cataract surgery with traditional antibiotic prophylaxis (perioperative topical antibiotics) compared with perioperative topical antibiotics with intracameral moxifloxacin. The base case was a healthy binocular 73-year-old man having first-eye cataract surgery. The incidences and costs were derived from PubMed English literature searches, Medicare reimbursement rates, and average wholesale prices. All costs and benefits were adjusted 3% per annum and for inflation to 2017 United States dollars. Deterministic and probabilistic sensitivity analyses were performed to assess uncertainty.
Compared with traditional prophylaxis, an adjuvant 500 μg intracameral moxifloxacin (for $20) was cost-saving from a societal perspective in the base case; in probabilistic sensitivity analyses, all the values were within the societal willingness-to-pay threshold of $50 000/quality-adjusted-life-years (QALYs), and 6142 (61%) of 10 000 iterations were cost-saving. From a healthcare sector perspective, intracameral moxifloxacin was cost-effective, with an ICUR of $8275/QALY. In cases with posterior capsule tears, a $20 intracameral moxifloxacin was cost-saving.
From a societal perspective in the U.S., a topical perioperative antibiotic with a 500 μg intracameral moxifloxacin costing $22 dollars or less was cost-effective and cost-saving. From a healthcare sector perspective, a $20 intracameral moxifloxacin was cost-effective but not cost-saving. Adjuvant intracameral moxifloxacin had greater effectiveness in improving QALYs than topical antibiotics.

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: Manuscript no. 2008-1301.

Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Supported in part by an unrestricted grant from That Man May See, San Francisco, CA, an unrestricted grant from Research to Prevent Blindness, New York, NY, and by a Core Grant For Vision Research (NIH P30 EY002162).

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Original articleCost-Effectiveness Analysis of Intracameral Cefuroxime Use for Prophylaxis of Endophthalmitis after Cataract Surgery

Objective

Design

Participants

Methods

Main Outcome Measures

Results

Conclusions

Financial Disclosure(s)

Section snippets

Overview

Cost-Effectiveness

Discussion

Ophthalmology

Am J Ophthalmol

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J Cataract Refract Surg

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J Cataract Refract Surg

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Original article
Cost-Effectiveness Analysis of Intracameral Cefuroxime Use for Prophylaxis of Endophthalmitis after Cataract Surgery