Cost-effectiveness of corneal collagen cross-linking for keratoconus in district general hospital settings in the United Kingdom

Abstract Purpose Keratoconus is a bilateral corneal ectasia occurring in adolescence or early adulthood. Collagen crosslinking is being used as an option to halt disease progression. However, still many district general hospitals lack the equipment of performing this rather straightforward procedure. The aim of this study is to assess how cost-effectiveness of crosslinking when performed in district units compares to crosslinking in tertiary centers. Methods A Markov model was constructed consisting of two different cohorts. One cohort included patients having crosslinking in district units, while the second included patients that were initially examined in district hospitals but then they were referred to tertiary centers in order to have the same treatment. Data for the first cohort were derived from audit data in our department, whereas for the tertiary cohort we used already published data. Sensitivity analyses were performed to examine the robustness of our results. Results In the base case, crosslinking performed in district general hospitals proved to be more effective and less costly compared to crosslinking in tertiary units. Assuming a lifelong efficacy of crosslinking, this leads to an extra cost of £238,782.33/QALY, whereas assuming a 10-year efficacy crosslinking in district general hospitals saves £1,062,962.96/QALY. In any case, crosslinking in district units remains cost effective compared to the NHS willingness-to-pay ratio of £30000/QALY. Decision making is unaffected by the initial disease severity, the proportion of bilateral cases treated and the discount rate of the utilities and the costs. Conclusion Collagen crosslinking when performed in district general hospitals is more effective and less costly for the healthcare system. Coordinated actions should be taken in order to equip even more district units with all the necessary equipment so that patients can be treated locally rather than be referred to tertiary centers.