Supplementation of cataract patients with multifocal intraocular lenses involves an additional financial investment when compared to the corresponding monofocal supplementation, which usually is not funded by German health care insurers. In the context of recent resource allocation discussions, however, the cost effectiveness of multifocal cataract surgery could become an important rationale. Therefore an evidence-based estimation of its cost effectiveness was carried out.
Three independent meta-analyses were implemented to estimate the gain in uncorrected near visual acuity and best corrected visual acuity (vision lines) as well as the predictability (fraction of patients without need for reading aids) of multifocal supplementation. Study reports published between 1995 and 2004 (English or German language) were screened for appropriate key words. Meta effects in visual gain and predictability were estimated by means and standard deviations of the reported effect measures. Cost data were estimated by German DRG rates and individual lens costs; the cost effectiveness of multifocal cataract surgery was then computed in terms of its marginal cost effectiveness ratio (MCER) for each clinical benefit endpoint; the incremental costs of multifocal versus monofocal cataract surgery were further estimated by means of their respective incremental cost effectiveness ratio (ICER). An independent meta-analysis estimated the complication profiles to be expected after monofocal and multifocal cataract surgery in order to evaluate expectable complication-associated additional costs of both procedures; the marginal and incremental cost effectiveness estimates were adjusted accordingly. A sensitivity analysis comprised cost variations of +/- 10 % and utility variations alongside the meta effect estimate's 95 % confidence intervals.
Total direct costs from the health care insurer's perspective were estimated 3363 euro, associated with a visual meta benefit in best corrected visual acuity and near visual acuity of 5.1 lines (95 % confidence interval 3.8 - 6.4 lines) and 6.1 lines (4.7 - 7.5 lines), respectively, and a meta predictability estimate of 81 % (72 - 89 %). The mean MCER for best corrected visual acuity results became 659 euro per gained visual acuity line (sensitivity range 473 - 973 euro). For near visual acuity, a mean MCER of 555 euro (sensitivity range 404 - 787 euro) per gained visual line was found. In terms of incremental costs, multifocal cataract surgery implied an additional mean investment of 63 euro (sensitivity range 0 - 234 euro) per additionally gained near visual acuity line, and 5 euro (0 - 18 euro) per additionally gained percentage point in predictability, when compared to monofocal cataract surgery as the standard treatment. The meta-analysis on complication profiles revealed posterior capsule opacification (meta incidence 20 %) and vitreous loss (meta incidence 2 %) as the complications to be expected most frequently. The cost adjustment for expectable complication patterns after multifocal cataract surgery implied total direct costs of 3491 euro, resulting in marginal costs of 576 euro per line (sensitivity range 419 - 817 euro per line) gained in near visual acuity and 684 euro per line (491 - 1011 euro per line) gained in best corrected visual acuity.
Bearing incremental costs of 63 euro per additionally gained vision line (near visual acuity) in mind, multifocal cataract surgery comprises a cost effective alternative to the monofocal standard treatment.