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Cost-effectiveness of biennial screening for diabetes related retinopathy in people with type 1 and type 2 diabetes compared to annual screening.

ABSTRACT: OBJECTIVE:Examine the health and economic impact of extending screening intervals in people with Type 2 diabetes (T2DM) and Type 1 diabetes (T1DM) without diabetes-related retinopathy (DR). SETTING:Diabetic Eye Screening Wales (DESW). STUDY DESIGN:Retrospective observational study with cost-utility analysis (CUA) and Decremental Cost-Effectiveness Ratios (DCER) study. INTERVENTION:Biennial screening versus usual care (annual screening). INPUTS:Anonymised data from DESW were linked to primary care data for people with two prior screening events with no DR. Transition probabilities for progression to DR were estimated based on a subset of 26,812 and 1232 people with T2DM and T1DM, respectively. DCER above £20,000 per QALY was considered cost-effective. RESULTS:The base case analysis DCER results of £71,243 and £23,446 per QALY for T2DM and T1DM respectively at a 3.5% discount rate and £56,822 and £14,221 respectively when discounted at 1.5%. Diabetes management represented by the mean HbA1c was 7.5% for those with T2DM and 8.7% for T1DM. SENSITIVITY ANALYSIS:Extending screening to biennial based on HbA1c, being the strongest predictor of progression of DR, at three levels of HbA1c 6.5%, 8.0% and 9.5% lost one QALY saving the NHS £106,075; £58,653 and £31,626 respectively for T2DM and £94,696, £37,646 and £11,089 respectively for T1DM. In addition, extending screening to biennial based on the duration of diabetes?>?6 years for T2DM per QALY lost, saving the NHS £54,106 and for 6-12 and?>?12 years for T1DM saving £83,856, £23,446 and £13,340 respectively. CONCLUSIONS:Base case and sensitivity analyses indicate biennial screening to be cost-effective for T2DM irrespective of HbA1c and duration of diabetes. However, the uncertainty around the DCER indicates that annual screening should be maintained for those with T1DM especially when the HbA1c exceeds 80 mmol/mol (9.5%) and duration of diabetes is greater than 12 years.

SUBMITTER: Thomas RL

PROVIDER: S-EPMC7423794 | biostudies-literature | 2020 Sep

REPOSITORIES: biostudies-literature

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Cost-effectiveness of biennial screening for diabetes related retinopathy in people with type 1 and type 2 diabetes compared to annual screening.

Thomas Rebecca L RL Winfield Thomas G TG Prettyjohns Matthew M Dunstan Frank D FD Cheung Wai-Yee WY Anderson Philippa M PM Peter Rajesh R Luzio Stephen D SD Owens David R DR

The European journal of health economics : HEPAC : health economics in prevention and care 20200508 7

<h4>Objective</h4>Examine the health and economic impact of extending screening intervals in people with Type 2 diabetes (T2DM) and Type 1 diabetes (T1DM) without diabetes-related retinopathy (DR).<h4>Setting</h4>Diabetic Eye Screening Wales (DESW).<h4>Study design</h4>Retrospective observational study with cost-utility analysis (CUA) and Decremental Cost-Effectiveness Ratios (DCER) study.<h4>Intervention</h4>Biennial screening versus usual care (annual screening).<h4>Inputs</h4>Anonymised data ...[more]

PMID: 32385543

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Project description:BackgroundWe aimed to evaluate the cost-effectiveness of an artificial intelligence-(AI) based diabetic retinopathy (DR) screening system in the primary care setting for both non-Indigenous and Indigenous people living with diabetes in Australia.MethodsWe performed a cost-effectiveness analysis between January 01, 2022 and August 01, 2023. A decision-analytic Markov model was constructed to simulate DR progression in a population of 1,197,818 non-Indigenous and 65,160 Indigenous Australians living with diabetes aged ≥20 years over 40 years. From a healthcare provider's perspective, we compared current practice to three primary care AI-based screening scenarios-(A) substitution of current manual grading, (B) scaling up to patient acceptance level, and (C) achieving universal screening. Study results were presented as incremental cost-effectiveness ratio (ICER), benefit-cost ratio (BCR), and net monetary benefits (NMB). A Willingness-to-pay (WTP) threshold of AU$50,000 per quality-adjusted life year (QALY) and a discount rate of 3.5% were adopted in this study.FindingsWith the status quo, the non-Indigenous diabetic population was projected to develop 96,269 blindness cases, resulting in AU$13,039.6 m spending on DR screening and treatment during 2020-2060. In comparison, all three intervention scenarios were effective and cost-saving. In particular, if a universal screening program was to be implemented (Scenario C), it would prevent 38,347 blindness cases, gain 172,090 QALYs and save AU$595.8 m, leading to a BCR of 3.96 and NMB of AU$9,200 m. Similar findings were also reported in the Indigenous population. With the status quo, 3,396 Indigenous individuals would develop blindness, which would cost the health system AU$796.0 m during 2020-2060. All three intervention scenarios were cost-saving for the Indigenous population. Notably, universal AI-based DR screening (Scenario C) would prevent 1,211 blindness cases and gain 9,800 QALYs in the Indigenous population, leading to a saving of AU$19.2 m with a BCR of 1.62 and NMB of AU$509 m.InterpretationOur findings suggest that implementing AI-based DR screening in primary care is highly effective and cost-saving in both Indigenous and non-Indigenous populations.FundingThis project received grant funding from the Australian Government: the National Critical Research Infrastructure Initiative, Medical Research Future Fund (MRFAI00035) and the NHMRC Investigator Grant (APP1175405). The contents of the published material are solely the responsibility of the Administering Institution, a participating institution or individual authors and do not reflect the views of the NHMRC. This work was supported by the Global STEM Professorship Scheme (P0046113), the Fundamental Research Funds of the State Key Laboratory of Ophthalmology, Project of Investigation on Health Status of Employees in Financial Industry in Guangzhou, China (Z012014075). The Centre for Eye Research Australia receives Operational Infrastructure Support from the Victorian State Government. W.H. is supported by the Melbourne Research Scholarship established by the University of Melbourne. The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Project description:ImportanceScreening for diabetic retinopathy is recommended for children with type 1 diabetes (T1D) and type 2 diabetes (T2D), yet screening rates remain low. Point-of-care diabetic retinopathy screening using autonomous artificial intelligence (AI) has become available, providing immediate results in the clinic setting, but the cost-effectiveness of this strategy compared with standard examination is unknown.ObjectiveTo assess the cost-effectiveness of detecting and treating diabetic retinopathy and its sequelae among children with T1D and T2D using AI diabetic retinopathy screening vs standard screening by an eye care professional (ECP).Design, setting, and participantsIn this economic evaluation, parameter estimates were obtained from the literature from 1994 to 2019 and assessed from March 2019 to January 2020. Parameters included out-of-pocket cost for autonomous AI screening, ophthalmology visits, and treating diabetic retinopathy; probability of undergoing standard retinal examination; relative odds of undergoing screening; and sensitivity, specificity, and diagnosability of the ECP screening examination and autonomous AI screening.Main outcomes and measuresCosts or savings to the patient based on mean patient payment for diabetic retinopathy screening examination and cost-effectiveness based on costs or savings associated with the number of true-positive results identified by diabetic retinopathy screening.ResultsIn this study, the expected true-positive proportions for standard ophthalmologic screening by an ECP were 0.006 for T1D and 0.01 for T2D, and the expected true-positive proportions for autonomous AI were 0.03 for T1D and 0.04 for T2D. The base case scenario of 20% adherence estimated that use of autonomous AI would result in a higher mean patient payment ($8.52 for T1D and $10.85 for T2D) than conventional ECP screening ($7.91 for T1D and $8.20 for T2D). However, autonomous AI screening was the preferred strategy when at least 23% of patients adhered to diabetic retinopathy screening.Conclusions and relevanceThese results suggest that point-of-care diabetic retinopathy screening using autonomous AI systems is effective and cost saving for children with diabetes and their caregivers at recommended adherence rates.

Project description:Aims/hypothesisIn this study we examined the cost-effectiveness of three different screening strategies for diabetic retinopathy: using a personalised adaptive model, annual screening (fixed intervals), and the current Dutch guideline (stratified based on previous retinopathy grade).MethodsFor each individual, optimal diabetic retinopathy screening intervals were determined, using a validated risk prediction model. Observational data (1998-2017) from the Hoorn Diabetes Care System cohort of people with type 2 diabetes were used (n = 5514). The missing values of retinopathy grades were imputed using two scenarios of slow and fast sight-threatening retinopathy (STR) progression. By comparing the model-based screening intervals to observed time to develop STR, the number of delayed STR diagnoses was determined. Costs were calculated using the healthcare perspective and the societal perspective. Finally, outcomes and costs were compared for the different screening strategies.ResultsFor the fast STR progression scenario, personalised screening resulted in 11.6% more delayed STR diagnoses and €11.4 less costs per patient compared to annual screening from a healthcare perspective. The personalised screening model performed better in terms of timely diagnosis of STR (8.8% less delayed STR diagnosis) but it was slightly more expensive (€1.8 per patient from a healthcare perspective) than the Dutch guideline strategy.Conclusions/interpretationThe personalised diabetic retinopathy screening model is more cost-effective than the Dutch guideline screening strategy. Although the personalised screening strategy was less effective, in terms of timely diagnosis of STR patients, than annual screening, the number of delayed STR diagnoses is low and the cost saving is considerable. With around one million people with type 2 diabetes in the Netherlands, implementing this personalised model could save €11.4 million per year compared with annual screening, at the cost of 658 delayed STR diagnoses with a maximum delayed time to diagnosis of 48 months.

Project description:BackgroundDiabetic retinopathy (DR) is a significant global public health and economic burden. DR accounts for approximately 15-17% of all cases of total blindness in the USA and Europe. Telemedicine is a new intervention for DR screening, however, there is not enough evidence to support its cost-effectiveness. The aim of this study is to review the most recent published literature on economic evaluations of telemedicine in DR screening and summarize the evidence on the cost-effectiveness of this technology.MethodsA systematic search of PubMed, Embase and Google Scholar for relevant articles published between January 2010 and January 2020. Studies were included if they met the following criteria: (1) recruited subjects with either type 1, type 2 diabetes (2) evaluated telemedicine technology (3) patients underwent primary screening for DR (4) compared a telemedicine-based intervention with standard care (5) performed an economic evaluation or provided sufficient data for evaluating the cost-effectiveness of the technology used.ResultsOf 2238 articles screened, seven studies were included. Four of the studies were conducted in developed countries: The United States, Singapore and two studies in Canada. Three studies were conducted in developing countries: India, Brazil and South Africa. The patient populations in all studies were diabetic patients over the age of 18, previously not screened for DR. All seven studies used a telemedicine program which included capturing a retinal image and subsequently transmitting it to an ocular imaging center to assess the severity of DR. All studies compared telemedicine to a standard screening method for DR, including the option of no screening as standard of care. Although telemedicine requires initial and maintenance costs, it has the potential to provide significant cost savings by increasing patients' working ability, increasing independent living ability, increasing quality of life and reducing travel costs.ConclusionsDiabetic retinopathy telemedicine technology has the potential to provide significant cost savings, especially in low-income populations and rural patients with high transportation costs.

Project description:BackgroundRetinopathy is a common complication of diabetes mellitus that if detected early by regular retinal examinations can be treated; thus, blindness can be delayed or prevented. Providing high-quality retinal screening is difficult, especially in rural and remote areas. Canada's First Nations population has a higher prevalence of diabetes and is, in general, more geographically isolated than the broader Canadian population. We modelled the cost-effectiveness of retinopathy screening by travelling retina specialists versus retinal photography with a portable digital camera in an isolated First Nations cohort with diabetes.MethodsThe 2 screening programs were modelled to run concurrently for 5 years, with outcomes evaluated over 10 years. To construct economic models for the population of Cree individuals living in the western James Bay area of northern Ontario, we used available data on the prevalence of diabetes in the area and estimates of the incidence of retinopathy derived from the published literature. We compared the screening models and calculated total costs, visual outcome, costs per sight-year saved and costs per quality-adjusted life year (QALY). We also estimated the costs of implementing a screening program for all First Nations individuals in Ontario with diabetes and no access to an ophthalmologist.ResultsFrom the perspective of the health care system the camera program was preferable to the specialist-based program. Over 10 years, 67 v. 56 sight years were saved, compared with no screening, at costs of 3900 Canadian dollars v. 9800 Canadian dollars per sight year and 15,000 Canadian dollars v. 37,000 Canadian dollars per QALY. Generalizing these results to the province of Ontario, the camera system could allow most isolated First Nations people with diabetes to be screened for 5 years for approximately 1.2 million Canadian dollars.InterpretationA portable retinal camera is a cost-effective means of screening for diabetic retinopathy in isolated communities of at-risk individuals.

Project description:BACKGROUND:In patients who have had type 1 diabetes for 5 years, current recommendations regarding screening for diabetic retinopathy include annual dilated retinal examinations to detect proliferative retinopathy or clinically significant macular edema, both of which require timely intervention to preserve vision. During 30 years of the Diabetes Control and Complications Trial (DCCT) and its longitudinal follow-up Epidemiology of Diabetes Interventions and Complications (EDIC) study, retinal photography was performed at intervals of 6 months to 4 years. METHODS:We used retinal photographs from the DCCT/EDIC study to develop a rational screening frequency for retinopathy. Markov modeling was used to determine the likelihood of progression to proliferative diabetic retinopathy or clinically significant macular edema in patients with various initial retinopathy levels (no retinopathy or mild, moderate, or severe nonproliferative diabetic retinopathy). The models included recognized risk factors for progression of retinopathy. RESULTS:Overall, the probability of progression to proliferative diabetic retinopathy or clinically significant macular edema was limited to approximately 5% between retinal screening examinations at 4 years among patients who had no retinopathy, 3 years among those with mild retinopathy, 6 months among those with moderate retinopathy, and 3 months among those with severe nonproliferative diabetic retinopathy. The risk of progression was also closely related to mean glycated hemoglobin levels. The risk of progression from no retinopathy to proliferative diabetic retinopathy or clinically significant macular edema was 1.0% over 5 years among patients with a glycated hemoglobin level of 6%, as compared with 4.3% over 3 years among patients with a glycated hemoglobin level of 10%. Over a 20-year period, the frequency of eye examinations was 58% lower with our practical, evidence-based schedule than with routine annual examinations, which resulted in substantial cost savings. CONCLUSIONS:Our model for establishing an individualized schedule for retinopathy screening on the basis of the patient's current state of retinopathy and glycated hemoglobin level reduced the frequency of eye examinations without delaying the diagnosis of clinically significant disease. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others; DCCT/EDIC ClinicalTrials.gov numbers, NCT00360893 and NCT00360815 .).

Project description:BackgroundDiabetic eye complications are the leading cause of visual loss among working-aged people. Pharmacy-based teleophthalmology has emerged as a possible alternative to in-person examination that may facilitate compliance with evidence-based recommendations and reduce barriers to specialized eye care. The objective of this study was to estimate the cost-effectiveness of mobile teleophthalmology screening compared with in-person examination (primary care) for the diabetic population residing in semiurban areas of southwestern Ontario.MethodsA decision tree was constructed to compare in-person examination (comparator program) versus pharmacy-based teleophthalmology (intervention program). The economic model was designed to identify patients with more than minimal diabetic retinopathy, manifested by at least 1 microaneurysm at examination (modified Airlie House classification grade of ≥ 20). Cost-effectiveness was assessed as cost per case detected (true-positive result) and cost per case correctly diagnosed (including true-positive and true-negative results).ResultsThe cost per case detected was $510 with in-person examination and $478 with teleophthalmology, and the cost per case correctly diagnosed was $107 and $102 respectively. The incremental cost-effectiveness ratio was $314 per additional case detected and $73 per additional case correctly diagnosed. Use of pharmacologic dilation and health care specialists' fees were the most important cost drivers.InterpretationThe study showed that a compound teleophthalmology program in a semiurban community would be more effective but more costly than in-person examination. The findings raise the question of whether the benefits of pharmacy-based teleophthalmology in semiurban areas, where in-person examination is still available, are equivalent to those observed in remote communities. Further study is needed to investigate the impact of this program on the prevention of severe vision loss and quality of life in a semiurban setting.

Dataset Information

Cost-effectiveness of biennial screening for diabetes related retinopathy in people with type 1 and type 2 diabetes compared to annual screening.

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Cost-effectiveness of biennial screening for diabetes related retinopathy in people with type 1 and type 2 diabetes compared to annual screening.

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