iStent for Adults With Glaucoma: A Health Technology Assessment

Ontario Health
Record ID 32018000727
English
Original Title: iStent for people with open angle glaucoma
Authors' objectives: This health technology assessment examines the evidence for the effectiveness, safety, cost- effectiveness, budget impact, and patient preferences of iStent for adults with glaucoma.
Authors' results and conclusions: Results: Comparing iStent with pharmacotherapy, there may be no difference in comparative clinical effectiveness (GRADE: Very low to Low). There was uncertainty around the comparative clinical effectiveness of iStent compared with filtration surgery and of iStent plus cataract surgery compared with a different MIGS procedure plus cataract surgery (GRADE: Very low). iStent with cataract surgery may improve comparative clinical effectiveness (reduced intraocular pressure and number of medications) compared with cataract surgery alone (GRADE: Low). iStent may be cost-effective compared with pharmacotherapy (incremental cost-effectiveness ratios [ICER]: $14,120–$25,596/quality-adjusted life-year [QALY]; 60%–76% and 65%–100% of iterations cost- effective at willingness-to-pay values of $50,000/QALY and $100,000/QALY, respectively). iStent with cataract surgery may not be cost-effective compared with cataract surgery alone (ICERs: $108,934– $112,380/QALY; 17%–46% and 46%–68% of iterations cost-effective at willingness-to-pay values of $50,000/QALY and $100,000/QALY, respectively). iStent may not be cost-effective compared with filtration surgery (iStent was less effective and more expensive than filtration surgery). These estimates are influenced by the long-term effectiveness of iStent. The iStent device costs approximately $1,250 (for two iStent or iStent inject devices). Based on a recent analysis by Quebec’s Institut national d’excellence en santé et en services sociaux (INESSS) and our previous analysis on MIGS, publicly funding iStent may reduce some spending on glaucoma medication but, overall, iStent is likely to lead to additional costs for the public health care system. In Ontario, publicly funding MIGS over 5 years is estimated to cost a total of $40 million if uptake is slow (25,000 people) and $199 million, if uptake is fast (100,000 people). In Quebec, publicly funding iStent over 3 years is estimated to cost a total of $29 million (15,000 people). People with glaucoma with whom we spoke reported that pharmacotherapy can be challenging and that they relied on trust in their physician to determine if surgery was necessary to avoid potential consequences of glaucoma, such as blindness. Those who received MIGS procedures found it beneficial, with minimal side effects and recovery time. However, they were often unaware what type of MIGS procedure they received, so they could not specifically comment on iStent. Conclusions: We are uncertain about the comparative clinical effectiveness of iStent compared with filtration surgery, as well as iStent combined with cataract surgery versus other MIGS procedures combined with cataract surgery. There may be no difference in the comparative clinical effectiveness of iStent compared with pharmacotherapy. iStent combined with cataract surgery may improve clinical effectiveness (mainly intraocular pressure and number of medications) when compared with cataract surgery alone. In some instances, iStent may be cost-effective (i.e., when compared with pharmacotherapy) but in other instances it may not be cost-effective (i.e., when iStent combined with cataract surgery is compared with cataract surgery alone or when iStent is compared with filtration surgery). Publicly funding iStent may reduce some spending on pharmacotherapy but, overall, is likely to lead to additional costs for the public health system. People with glaucoma reported that pharmacotherapy adherence could be challenging, and that avoiding blindness was their main priority for treatment. Experiences with MIGS procedures were positive, although patients were unable to comment on iStent specifically.
Authors' recomendations: Ontario Health, based on guidance from the Ontario Health Technology Advisory Committee, recommends publicly funding iStent in combination with cataract surgery for adults with mild to moderate glaucoma that cannot be well controlled with pressure-lowering medications
Authors' methods: We summarized two health technology assessments recently completed in Canada. In addition, we summarized new evidence we identified through expert consultation and scoping of the literature. We reported the quality of the body of clinical evidence as reported by the included health technology assessments, according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria.
Details
Project Status: Completed
Year Published: 2021
Requestor: OHTAC/Ministry of Health
English language abstract: An English language summary is available
Publication Type: Full HTA
Country: Canada
Province: Ontario
Pubmed ID: 34422143
MeSH Terms
  • Glaucoma, Open-Angle
  • Intraocular Pressure
  • Minimally Invasive Surgical Procedures
  • Glaucoma Drainage Implants
  • Stents
  • Glaucoma
Keywords
  • Glaucoma
  • istent
  • health technology assessment
  • cost-effectiveness
  • patient preferences
Contact
Organisation Name: Ontario Health
Contact Address: 130 Bloor Street West, 10th Floor
Contact Name: Nancy Sikich
Contact Email: OH-HQO_hta-reg@ontariohealth.ca
Copyright: © Queen’s Printer for Ontario, 2021
This is a bibliographic record of a published health technology assessment from a member of INAHTA or other HTA producer. No evaluation of the quality of this assessment has been made for the HTA database.