Trial-based Cost-effectiveness Analysis of Descemet Endothelial Thickness Comparison Trial Therapeutic Exploratory Study, A Randomized Trial Comparing Ultrathin Descemet Stripping Automated Endothelial Keratoplasty With Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To evaluate the cost-effectiveness of ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) compared with Descemet membrane endothelial keratoplasty (DMEK) for treatment of primary corneal endothelial dysfunction. METHODS: A 12-month trial-based cost-effective analysis was performed using data from a double-masked comparative effectiveness trial in which patients were randomized to UT-DSAEK (n = 25) or DMEK (n = 25). Costs were assessed from societal and third-party payer perspectives and adjusted to 2023 US dollars. Effectiveness was measured in quality-adjusted life years (QALYs) derived from improvements in visual acuity (VA) and Visual Function Questionnaire. Incremental cost-effectiveness ratios (ICERs) were calculated for each perspective and outcome measure. Deterministic sensitivity analysis was used. RESULTS: From the societal perspective, DMEK had higher mean costs than UT-DSAEK ($16,736 ± 2385 vs. $16,191 ± 1879), resulting in an incremental cost of $545. From the third-party payer perspective, DMEK's incremental cost was $378. DMEK had a higher VA-based QALY than UT-DSAEK (0.889 ± 0.03 vs. 0.847 ± 0.05). The resulting ICERs were $12,783 (societal) and $8869 (third-party payer) per QALY gained below the $50,000 willingness-to-pay threshold, indicating that DMEK is cost-effective when using VA-based utilities. In contrast, VFQ-based QALYs showed no difference between groups, and DMEK remained more costly, resulting in negative ICERs and dominance of UT-DSAEK. However, this result should be interpreted cautiously given the limited power of VFQ. CONCLUSIONS: The cost-effectiveness of DMEK versus UT-DSAEK depends on outcome measure. DMEK appears cost-effective based on VA-based utilities, whereas UT-DSAEK is favored using VFQ. These results highlight the importance of outcome measure in economic evaluations.