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Publications and Products
The Economics of Diabetes Mellitus:
An Annotated Bibliography
TYPES
OF INTERVENTION
Tertiary
Intervention
Eye
Care
65
TITLE:
Cost Savings Associated with Detection and Treatment of Diabetic Eye Disease.
Javitt, J.C. PharmacoEconomics. 8 (Supplement 1): 33-39. 1995.
OBJECTIVE:
To estimate current and potential savings in the United States and Sweden
from screening and treating retinopathy in persons with diabetes.
CATEGORY:
Tertiary intervention.
Type of
Study: Epidemiological cohort model.
Methodology: Cost-benefit analysis.
Perspective: Societal.
CONCLUSION:
Treatment of retinopathy in patients with diabetes mellitus yields substantial
savings of sight years and money.
RECOMMENDATION:
Eye care for patients with diabetes must emphasize patient identification,
carefully maintained follow-up, and prompt, appropriate treatment.
ABSTRACT:
The author describes the use of the PROPHET modeling system, a program
designed to model the progression of a chronic, irreversible disease,
to estimate savings from recruiting, screening, and treatment programs
for diabetic eye disease. Data from cross-sectional and longitudinal studies
and clinical trials are used in the model. The analysis derives the costs
of screening and treatment from average Medicare charges for 1990; savings
as well as costs are expressed in 1990 U.S. dollars using a discount rate
of 5 percent. An annual federal expenditure of $14,296 is predicted for
blind persons with diabetes under 65 years of age, just $32 (not counting
Medicare, Social Security, income tax exemption) for those 65 and over.
Based on studies by Klein et al. (1987) in Wisconsin, the implementation
rate of eye screening is currently 60 percent. Even at this suboptimal
level, screening and treatment for eye disease in patients with diabetes
generates annual savings of $350 million to the federal budget and 100,000
person-years of sight. Each additional person (beyond the 60 percent level)
enrolled in appropriate screening and treatment is associated with net
lifetime savings of $9,571 (type 1 diabetes) or $973 (type 2 diabetes).
The Swedish Council on Technology Assessment in Health Care repeated this
analysis and found that 60 percent implementation of screening could potentially
save 22 million SEK. Their analysis found that savings associated with
detection and treatment were 10 times greater than costs. The authors
of the present study found that changing the frequency of screening for
patients with no or mild background retinopathy from 1 to 2 years does
not reduce years of sight saved and reduces screening costs if the sensitivity
of eye screening is 80 percent or greater. 3 figures, 43 references.
66
TITLE:
Cost-Benefit Analysis of Diabetic Eye Disease. Matz, H.; Falk, M.; Gottinger,
W.; Kieselbach, G. Ophthalmologica. 210(6): 348-353. 1996.
OBJECTIVE:
To compare the costs of blindness caused by diabetes with the costs of
screening and treatment of retinopathy associated with diabetes.
CATEGORY:
Tertiary intervention.
Type of
Study: Epidemiological cohort model.
Methodology: Cost-benefit analysis.
Perspective: Health care system.
CONCLUSION:
Screening for blindness saves more money than it costs.
RECOMMENDATION:
All patients with diabetes should be screened for retinopathy and optimal
therapy should be initiated.
ABSTRACT:
The authors calculated the cost-benefit of screening and testing of diabetes-associated
eye disease in the state of Tyrol, Austria. Current and new cases of severe
retinopathy (proliferative retinopathy or clinically significant macular
edema) were calculated to be 2,147 and 252, respectively. Without proper
intervention, all 252 persons with incident cases would be expected to
go blind within 10 years, vision could be retained in at least one eye
in 179 cases with proper treatment, and blindness could be delayed an
average of 3 years in patients for whom it is unavoidable. Costs of blindness
included disability payments and allowances; exemptions from telephone,
television, and radio fees; tax exemptions; financial aid based on reduced
earnings and disability; and early retirement pensions. The anticipated
costs of blindness were ATS 19 million overall, of which ATS 14.6 million
was considered preventable, assuming 100 percent ability to diagnose severe
retinopathy and macular edema and 100 percent ability to treat these conditions
at an optimal time. Cost was based on 10-year life expectancy at onset
of severe retinopathy, duration of blindness ranging from 2.5 to 8.5 years,
sex, age, employment status, type of diabetes, and correlation of minimum
retirement age with life expectancy. In Tyrol, 16,913 persons would require
annual eye examinations (cost: ATS 5,191,445) and 2,147 persons would
require examinations 4 times per year (ATS 3,022,547). Laser coagulation
or vitrectomy plus examinations would cost the national health care system
ATS 8,560,089 and private insurance ATS 2,119,566 (only 17.7 percent of
the population has supplemental private insurance). Up to ATS 3.9 million
can be saved through adequate screening and treatment to prevent blindness.
1 figure, 5 tables, 25 references.
67
TITLE:
Cost-Effective Screening for Retinopathy Using a Nonmydriatic Retinal
Camera in a Pre-paid Health-Care Setting. Peters, A.L.; Davidson, M.B.;
Ziel, F.H. Diabetes Care. 16(8): 1193-1195. August 1993.
OBJECTIVE:
To evaluate the effectiveness of a nonmydriatic retinal camera as a screening
tool for serious retinopathy.
CATEGORY:
Tertiary intervention.
Type of
Study: Patient screening.
Methodology: Statistical analysis.
Perspective: Health care system.
CONCLUSION:
The nonmydriatic retinal camera was highly sensitive in detecting serious
retinopathy.
RECOMMENDATION:
The nonmydriatic retinal camera should be considered an easy-to-use, inexpensive
component of screening strategies for retinopathy.
ABSTRACT:
The authors evaluated the effectiveness of the Canon CR4-45 nonmydriatic
retinal camera as a screening tool for retinopathy. Nurse clinicians took
retinal photos of the 522 patients in a diabetes program affiliated with
a health maintenance organization at their initial and annual visits.
The degree of retinopathy as assessed by the reader (a diabetologist)
of the retinal photos was compared with results of examinations of the
patients by retinal specialists. These ophthalmologists used direct and
indirect ophthalmoscopy as well as slit-lamp biomicroscopy. Sensitivity
and specificity values for photo interpretation were based on 189 patients
who had gradable photos for both eyes and a retinal examination report
available. Comparison of any retinopathy noted by the examination with
any retinopathy noted by the reader yielded a sensitivity and specificity
of 85 percent and 93 percent, respectively. The reader occasionally missed
background retinopathy not requiring treatment. If serious retinopathy
was seen on the examination, the reader always noted some retinopathy
(sensitivity: 100 percent; specificity: 82 percent). Results show that
the nonmydriatic retinal camera, which is easy to use and inexpensive,
can be employed as a screening tool for detecting serious retinopathy.
The camera might identify more patients at risk for serious retinopathy
than routine referral for ophthalmologic screening, for which compliance
rates are often poor (74 percent in this study). 1 table, 11 references.
68
TITLE:
Cost-Effectiveness of Alternative Methods for Retinopathy Screening. Lairson,
D.R.; Pugh, J.A.; Kapadia, A.S.; Lorimor, R.J.; Jacobson, J.; Velez, R.
Diabetes Care. 15(10): 1369-1377. October 1992.
OBJECTIVE:
To compare the cost-effectiveness of four approaches to screening for
retinopathy.
CATEGORY:
Tertiary intervention.
Type of
Study: Patient screening.
Methodology: Cost-effectiveness analysis.
Perspective: Health care system.
CONCLUSION:
Screening with retinal photographs in a primary care setting can be cost
effective. Cost per true-positive case was lowest for retinal photography
with dilation.
RECOMMENDATION:
Screening could be offered as an addition to a routine visit in a primary
care clinic or on a separate visit.
ABSTRACT:
The four methods of screening for retinopathy compared were (1) 45-degree
retinal camera photography taken by a physician assistant or nurse practitioner
without pupil dilation (n = 351), (2) the same kind of photography with
pupil dilation (n = 351), (3) direct and indirect funduscopic examination
(dilated pupils) by an ophthalmologist (n = 347), and (4) direct ophthalmoscopic
examination (dilated pupils) by a physician assistant or nurse practitioner
(n = 172). All photographs (methods [1] and [2]) were read by an ophthalmologist.
Positive retinopathy was considered a level of 40 or greater on the modified
Airlie House reference standard. Screening costs were incurred through
Veterans Administration and Department of Defense facilities and included
staff salaries and fringe benefits; equipment (amortized over expected
life); supplies; participants' travel, screening time, and transportation;
space; overhead; and reading fees. Interest rates were set at 8.24 percent,
based on 1989 long-term government bond rates, and overhead costs were
set at 29.7 percent of ambulatory care health system costs. Patient travel
costs were assessed through an interview; wages for unemployed patients
were calculated at $3.35 per hour. Cost-effectiveness was based on the
cost per true-positive test. Sensitivity of methods 1-4, respectively,
was 0.61, 0.81, 0.33, and 0.10; specificity was 0.85, 0.96, 0.99, and
0.99. Total cost (health system plus patient) per exam was $70, $74, $48,
and $31, respectively. The average cost to the health care system only
per case of identified retinopathy was $295 (method 2); $378 (method 1);
$390 (method 3); and $794 (method 4). Adding the patient costs did not
change these rankings. 1 figure, 4 tables, 22 references.
69
TITLE:
Cost-Effectiveness of Alternative Methods for Retinopathy Screening. Wareham,
N.J. Diabetes Care. 16(5): 844. May 1993.
OBJECTIVE:
To point out an issue not raised in an article by Lairson et al. on screening
methods for retinopathy (Diabetes Care. 15:1369-1377. 1992. Abstract
53) and offer calculations of sensitivity, specificity, and cost per true-positive
for the data presented by those authors.
CATEGORY:
Tertiary intervention.
Type of
Study: Patient screening.
Methodology: Cost-effectiveness analysis.
Perspective: Health care system.
CONCLUSION:
The conclusions of cost-effectiveness drawn by Lairson et al. may not
be as strong as presented.
RECOMMENDATION:
None.
ABSTRACT:
The author notes that Lairson et al. did not account for error in their
sensitivity estimates of the four screening tests they compared. He reassesses
their data by applying 95 percent confidence intervals to the sensitivity
and specificity of screening patients with diabetes for retinopathy by
(1) 45-degree retinal photographs without pupil dilation, (2) retinal
photography with pupil dilation, (3) ophthalmologist examination, or (4)
technician examination. The sensitivity (with upper and lower 95 percent
confidence limits) for 1-4 was 0.61 (0.72, 0.50), 0.81 (0.90, 0.72), 0.33
(0.44, 0.22), and 0.07 (0.14, 0), respectively. The specificity for 1-4
was 0.85 (0.89, 0.81), 0.96 (0.99, 0.94), 1.00 (1.00, 0.99), and 0.99
(1.00, 0.97), respectively. System cost per true-positive diagnosis with
these approaches (with upper and lower estimates) was $378 ($463, $330),
$295 ($331, $265), $390 ($581, $294), and $794 (not given, $379), respectively.
Patient cost per true-positive diagnosis was $171 ($209, $144), $139 ($156,
$125), $306 ($454, $230), and $1,009 (not given, $481), respectively.
Because of the overlap in confidence intervals, the author points out
that conclusions in this paper about the cost-effectiveness of these screening
methods are weakened. He also points out that sensitivity is a major determinant
of the cost-effectiveness of screening for retinopathy and states that
including confidence intervals in the estimate of the cost per true-positive
case is critical for making policy decisions. 2 tables, 2 references.
70
TITLE:
Cost-Effectiveness of Current Approaches to the Control of Retinopathy
in Type I Diabetics. Javitt, J.C.; Canner, J.K.; Sommer, A. Ophthalmology.
96(2): 255-264. February 1989.
OBJECTIVE:
To estimate the benefits (in terms of preservation of vision) and attendant
costs of screening, diagnosis, follow-up, and treatment of retinopathy
in patients with type 1 diabetes.
CATEGORY:
Tertiary intervention.
Type of
Study: Epidemiological cohort model.
Methodology: Cost-benefit analysis.
Perspective: Societal.
CONCLUSION:
Screening, diagnosis, follow-up, and treatment of retinopathy in patients
with type 1 diabetes resulted in a cost of $966 per person-year of sight
saved, which is only 14 percent of the direct cost to the federal government
of a year of blindness-related disability.
RECOMMENDATION:
The federal government should fund eye care for patients with type 1 diabetes
to avoid the higher cost of disability from blindness.
ABSTRACT:
The authors used a computer model to analyze the benefits (in terms of
preservation of vision) and attendant costs of screening, diagnosis, follow-up,
and treatment of retinopathy in patients with juvenile-onset type 1 diabetes.
Screening recommendations were taken from the Public Health Committee
of the American Academy of Ophthalmology. Current charges for screening
and treatment of retinopathy were compared with current federal budgetary
expenses for blindness-induced disability under the Social Security Disability
program. Incidence, disease progression, and mortality data were drawn
from several population-based studies. The computer model, based on a
Monte Carlo simulation, was run for a hypothetical cohort of 31,000 patients
with type 1 diabetes beginning at age 12.5 years and followed over a 60-year
period. Model inputs were based on published reports of cross-sectional
and disease incidence studies, clinical trials, and U.S. statistics. The
model predicted that by age 60, background retinopathy would have developed
in 98 percent of the cohort, macular edema in 42 percent, and proliferative
retinopathy in 72 percent. Despite appropriate screening and treatment,
ultimately 28 percent of the cohort, according to the model, would suffer
severe vision loss. Over the 60 years, costs for ophthalmologic examinations,
focal laser treatment, and panretinal photocoagulation were $91.0 million,
$26.0 million, and $44.0 million, respectively. A total of 92,700 person-years
of sight could be saved at the end of 60 years by the application of screening
and panretinal photocoagulation. The cost of screening and panretinal
photocoagulation per person-year of sight saved was $966, which is only
14 percent of the direct cost ($6,900) to the federal government of a
year of blindness-related disability payments. 8 figures, 2 tables, 35
references.
71
TITLE:
Cost-Effectiveness of Detecting and Treating Retinopathy. Javitt, J.C.;
Aiello, L.P. Annals of Internal Medicine. 124 (1 Part 2): 164-169.
January 1, 1996.
OBJECTIVE:
To determine from the perspective of health insurers the cost-effectiveness
of ophthalmologic screening and treatment to prevent vision loss for patients
with diabetes.
CATEGORY:
Tertiary intervention.
Type of
Study: Epidemiological cohort model.
Methodology: Cost-utility analysis.
Perspective: Health care system.
CONCLUSION:
Ophthalmologic screening and treatment of eye disease in patients with
diabetes is a highly cost-effective approach to preventing blindness in
people with diabetes.
RECOMMENDATION:
Implementation of current guidelines regarding eye examinations for people
with diabetes should be encouraged.
ABSTRACT:
Detection and treatment of diabetic eye disease has been shown to result
in cost savings. Prevention of diabetes-related blindness, on a cost-effectiveness
basis, ranks above other medical interventions commonly provided. The
PROPHET system, based on Monte Carlo simulation, was used to model the
progression of proliferative retinopathy. Monte Carlo simulation, which
uses random number generation, allows for a simple, probability-based
solution of complex disease progression processes over time. Screening
and treatment costs were derived from average Medicare charges in 1990,
using a discount rate of 5 percent. Previous reports suggest that over
413,200 person-years of sight are currently saved, and over 710,800 person-years
of sight could be saved, if all patients with diabetes had appropriate
ophthalmologic screening and treatment. The cost of implementing currently
recommended guidelines for screening and treatment of retinopathy was
calculated to be $1,757 per person-year of sight saved. The cost per quality-adjusted
life-year (QALY) associated with detecting and treating diabetic eye disease
was found to range from $1,996 per QALY for those with type 1 diabetes
to $3,530 per QALY for those with type 2 diabetes who do not require insulin.
Overall cost of detecting and treating disease in patients with diabetes
was $3,190 per QALY. Despite the high level of efficacy, clinical effectiveness,
and cost-effectiveness, screening and treatment for diabetic eye disease
are not universally practiced. Recommendations for annual dilated-eye examinations of patients with diabetes have now been included in the Health
Plan Employer Data and Information Set (HEDIS II) quality guidelines adopted
throughout the managed care industry. 1 figure, 4 tables, 55 references.
72
TITLE:
Cost-Effectiveness of Strategies for Detecting Retinopathy. Dasbach, E.J.;
Fryback, D.G.; Newcomb, P.A.; Klein, R.; Klein, B.E. Medical Care.
29(1): 20-39. January 1991.
OBJECTIVE:
To evaluate the cost-effectiveness of six different strategies for providing
ophthalmologic care to patients with diabetes.
CATEGORY:
Tertiary intervention.
Type of
Study: Epidemiological cohort model.
Methodology: Cost-effectiveness analysis.
Perspective: Health care system.
CONCLUSION:
Screening for retinopathy is generally cost effective in younger-onset
patients and in those older-onset patients who take insulin.
RECOMMENDATION:
None.
ABSTRACT:
The authors used data from the Wisconsin Epidemiologic Study of Retinopathy
to create simulation models of the natural progression of retinopathy
and the effects of detecting and treating retinopathy on this process.
Data were modeled (by the Markov process) for three groups of 1,000 patients:
younger-onset patients (under age 30 years at diagnosis) with diabetes
for 5 years or more, older-onset patients (age 30 years or over at diagnosis)
who required insulin, and older-onset patients who did not take insulin.
The six strategies modeled for ophthalmologic care were annual or biannual
use of ophthalmoscopy, annual or biannual use of fundus photography through
physiologic pupil dilation (the nonmydriatic camera), and annual or biannual
use of fundus photography through pharmacologic pupil dilation (mydriatic).
Effectiveness was based on sight years saved with intervention. Each strategy
was modeled over 10 and 60 years, with costs remaining constant; savings
in years and costs were discounted by 5 percent to represent their present
value. Except for the older-onset group not taking insulin, net savings
for annual or biannual screening by all methods were substantial; for
10 years they ranged from $877,656 to $997,462 in the younger-onset cohort
and from $19,043 to $71,986 in the older-onset group taking insulin. The
younger-onset group (10-year model) saved more than 200 sight years by
any of the strategies; the older-onset groups taking insulin saved 45
to 59 years; and those not taking insulin, 14 to 19 years. Sixty-year
results were similar to those for 10 years; an exception was that the
younger-onset cohort gained considerably more sight years and cost savings.
Annual screening with fundus photography using the mydriatic camera was
the most effective of the six screening strategies; however, the gain
in effectiveness was small compared with annual screening with the nonmydriatic
camera or with an ophthalmoscope. 7 figures, 5 tables, 32 references.
73
TITLE:
Cost-Effectiveness of the Screening and Treatment of Retinopathy. What
Are the Costs of Underutilization? Fendrick, A.M.; Javitt, J.C.; Chiang,
Y.P. International Journal of Technology Assessment in Health Care.
8(4): 694-707. Fall 1992.
OBJECTIVE:
To determine whether screening and treating retinopathy is cost effective
in Sweden.
CATEGORY:
Tertiary intervention.
Type of
Study: Epidemiological cohort model.
Methodology: Cost-effectiveness analysis.
Perspective: Health care system.
CONCLUSION:
Annual photographic screening to detect early signs of retinal disease
combined with laser photocoagulation treatment of macular edema and retinopathy
leads to improved health outcomes in terms of years of sight saved and
also to decreased medical expenditures.
RECOMMENDATION:
None.
ABSTRACT:
A computer model (PROPHET) was used to simulate the health and economic
outcomes of an annual screening program for retinal disease in a group
of patients with type 1 diabetes in Sweden. Many Swedish patients with
type 1 diabetes do not receive optimal eye care because physicians have
inconsistent practice patterns, are inexperienced in performing the eye
exam, and lack knowledge of screening recommendations. Screening for retinopathy
and macular edema before high-risk lesions become worse is the key to
preventing vision loss. The study looked at 750 patients newly diagnosed
with diabetes over a 60-year life span. Fundus photography (3 fields per
eye) was used as the screening method and photocoagulation (panretinal
for proliferative retinopathy and focal retinal for macular edema) was
employed to treat eye disease. The model predicted that background retinopathy,
a preclinical state, would be present in 98 percent of the patients after
60 years of diabetes. Macular edema and proliferative retinopathy were
predicted to occur in more than 50 percent of the patients in that period.
The number of person-years of vision preserved by annual screening was
closely linked to patient compliance with screening recommendations. The
model revealed that with a compliance rate of 70 percent, more than 45,000
screening exams were performed over the 60-year study period and 2,306
years of vision were saved. Without screening and treatment, 6,500 years
of sight would be lost. The model showed that with a screening compliance
rate of 60 to 100 percent, net savings, including the costs of screening
and treatment, would range from $3.7 to $6 million (U.S. dollars). Although
the program was costly in the beginning, its net cost decreased over time
as the years of sight saved accrued and treatment sessions decreased.
Sensitivity analysis was performed to evaluate variables for which there
was uncertainty. In this model, screening compliance rates correlated
positively with improved clinical and economic outcomes. 5 figures, 3
tables, 64 references.
74
TITLE:
Detecting and Treating Retinopathy in Patients with Type I Diabetes
Mellitus: A Health Policy Model. Javitt, J.C.; Canner, J.K.; Frank,
R.G.; Steinwachs, D.M.; Sommer, A. Ophthalmology. 97(4): 483-494
(discussion: 494-495). April 1990.
OBJECTIVE:
To estimate the medical and economic implications to the federal government
of several screening and treatment strategies for retinopathy in patients
with type 1 diabetes.
CATEGORY:
Tertiary intervention.
Type of
Study: Epidemiological cohort model.
Methodology: Cost-benefit analysis.
Perspective: Societal.
CONCLUSION:
All five retinopathy screening and treatment strategies resulted in cost
savings to the federal government.
RECOMMENDATION:
Public health policy must consider the enormous medical and economic benefits
that can be realized by detecting and treating diabetic eye disease.
ABSTRACT:
The authors used a cost-benefit model to evaluate the average net savings
to the federal government of retinopathy screening and treatment in patients
with type 1 diabetes. Using a PROPHET simulation system, the authors analyzed
outcomes for a hypothetical cohort of 31,000 patients developing the disease
at age 12.5 years; these values represent annual incidence and average
age of onset for this disorder in the United States. Five screening strategies
involving various schedules of dilated ophthalmoscopy with and without
full fundus photographs were tested: (1) ophthalmoscopy (with the eyes
dilated) every 2 years, (2) annual ophthalmoscopic exam, (3) ophthalmoscopic
exam annually for patients with no retinopathy, every 6 months for those
with retinopathy, (4) annual ophthalmoscopic exam with full fundus photography,
and (5) annual ophthalmoscopic exam with fundus photographs for patients
with no retinopathy, an exam and photos every 6 months for those with
retinopathy. The discount rate was set at 5 percent; potential savings
(in 1986 dollars) were based on the amounts paid by the federal government
for blindness-related disability ($6,300 annually in the model). Undiscounted
screening and treatment costs for the five strategies varied from $89.2
million to $290.3 million. All of the strategies resulted in substantial
net annual savings to the federal government, ranging from $62.1 million
to $108.6 million. The model predicted a clear medical and economic advantage
for the strategy of dilated ophthalmoscopy performed annually, then semiannually
upon diagnosis of retinopathy. This strategy had the second highest government
savings (annual ophthalmoscopy only had the highest), but saved several
thousand more person-years of sight than annual ophthalmoscopy. Positive
returns were seen for all five strategies at discount rates below 10 percent.
Screening and treatment were cost-saving if the value of a year of sight
saved was $2,500 or more. Little advantage was demonstrated in adding
routine fundus photography to screening exams. 3 figures, 8 tables, 41
references.
75
TITLE:
Detecting and Treating Retinopathy in Patients with Type I Diabetes Mellitus:
Savings Associated with Improved Implementation of Current Guidelines.
Javitt, J.C.; Aiello, L.P.; Bassi, L.J.; Chiang, Y.P.; Canner, J.K. Ophthalmology.
98(10): 1565-1573 (discussion: 1574). October 1991.
OBJECTIVE:
To estimate the net federal budgetary savings that might be attained with
increased enrollment of patients with type 1 diabetes into appropriate
ophthalmologic care.
CATEGORY:
Tertiary intervention.
Type of
Study: Epidemiological cohort model.
Methodology: Cost-benefit analysis.
Perspective: Societal.
CONCLUSION:
At current levels of screening and treatment implementation, it is less
expensive to provide preventive eye care for patients with type 1 diabetes
than to support subsequent disability. Because each 10 percent improvement
in implementation over current levels would save $16.5 million annually,
significant recruitment efforts could be undertaken without diminishing
returns.
RECOMMENDATION:
Public education should be expanded so that all possible patients are
recruited into appropriate screening strategies, and primary care physicians
must be enlisted to identify patients so that strict ophthalmologic follow-up
may be instituted.
ABSTRACT:
The authors analyzed the net federal budgetary savings achieved under
current American Academy of Ophthalmology screening and treatment conditions
for retinopathy in patients with type 1 diabetes and estimated savings
that might be obtained by increased enrollment of patients into appropriate
ophthalmologic care. A PROPHET modeling system, based on Monte Carlo techniques,
was used to analyze events and costs. Disease data in the model were derived
primarily from reports of cross-sectional studies and clinical trials.
Screening and treatment costs were derived from average Medicare charges
in 1990. The authors expressed costs and savings in 1990 U.S. dollars
with a discount rate of 5 percent. They estimated that 60 percent of patients
with type 1 diabetes receive retinopathy treatment and screening that
meets American Academy of Ophthalmology guidelines. At this level, 47,374
person-years of sight are salvaged and $101.0 million saved annually.
The model predicts that for every additional 10 percent of patients who
enter screening, more than 7,966 person-years of sight and $16.5 million
in further annual savings would be realized. With 100 percent screening,
79,236 person-years of sight and $167.0 million would be saved annually.
Current American Academy of Ophthalmology guidelines recommend initiating
retinopathy screening 5 years after diagnosis of type 1 diabetes. The
additional annual financial burden of beginning screening upon diagnosis
would be $3.03 million. However, the yearly increase in expense would
be recovered totally if less than 1 additional patient were recruited
to screening from every 56 patients with diabetes. The model predicts
a loss of $17.4 million and 5,961 person-years of sight if treatment of
retinopathy is delayed 1 year. 8 figures, 3 tables, 41 references.
76
TITLE:
Detection of Sight-Threatening Diabetic Eye Disease. Leese, G.P.; Broadbent,
D.M.; Harding, S.P.; Vora, J.P. Diabetic Medicine. 13(10): 850-853.
October 1996.
OBJECTIVE:
To review the feasibility and costs of screening methods to detect asymptomatic
eye disease in patients with diabetes in the United Kingdom.
CATEGORY:
Tertiary intervention.
Type of
Study: Patient screening.
Methodology: Cost analysis.
Perspective: Societal.
CONCLUSION:
Community-based screening programs employing fundus photography or slit-lamp
biomicroscopy may offer a cost-effective alternative to ophthalmological
screening for eye diseases in patients with diabetes.
RECOMMENDATION:
Formal research-based measurements of the effectiveness of alternative
eye disease screening methods are needed, and health services purchasers
must be persuaded to implement cost-effective community-based screening
programs.
ABSTRACT:
The authors review the status of screening for sight-threatening eye disease
among patients with diabetes in the United Kingdom and assess the feasibility
of alternatives to ophthalmological examinations. Because the number of
ophthalmologists in the United Kingdom is not sufficient to allow screening
of all patients, other options must be considered. Screening for retinopathy
and other eye diseases at hospital-based clinics, at general practice
clinics, in optometry practices, and by mobile fundus photography is discussed.
The per-patient cost of screening by direct ophthalmoscopy has been estimated
at £ 13 when performed by community-based optometrists, £ 15
by general practitioners, and £ 27 by hospital physicians. Costs
of fundus photography by a mobile unit have been estimated at between
£ 10 and £ 23 per patient versus £ 19 per screen if the
camera is maintained within a hospital. When using a mobile van, overall
costs per potentially sight-saving treatment have been estimated by other
researchers at £ 700 to £ 1,000. Screening by fundus photography
has been demonstrated to be more cost effective than ophthalmoscopy because
of its greater sensitivity. Screening costs must be evaluated in comparison
with the costs of supporting a blind person in the community, which were
estimated in 1981 to be £ 3,500 per year. 42 references.
77
TITLE:
Evaluation of Argon Laser Treatment of Retinopathy and Its Diffusion in
The Netherlands. Vondeling, H. Health Policy. 23(12): 97111. January
1993.
OBJECTIVE:
To review studies on argon laser treatment for retinopathy, including
its cost-effectiveness; to discuss the diffusion of this technology.
CATEGORY:
Tertiary intervention.
Type of
Study: Patient screening.
Methodology: Review of studies.
Perspective: Societal.
CONCLUSION:
Screening for and treating retinopathy is cost effective.
RECOMMENDATION:
None.
ABSTRACT:
Clinical trial evidence indicates that immediate argon laser treatment
can prevent blindness and stabilize retinopathy for at least 10 years
in 70 percent of cases. Drummond et al. (1990) analyzed the U.S. Retinopathy
Study and found a net savings from the trial for U.S. society over 22
years of laser photocoagulation of $2,816 million (including $2,585 million
in lost production). Another model (Javitt and coworkers), for patients
with type 1 diabetes, predicted a cost (in 1986 dollars) of $966 per person-year
of vision saved from proliferative retinopathy and $1,118 per person-year
of central acuity saved from macular edema; in contrast, average annual
federal payments to eligible blind recipients were $6,900. A model of
screening practices indicated that the most cost-effective method is dilated
ophthalmoscopy performed annually for patients without retinopathy and
every 6 months for those with retinopathy. Proper screening of 60 percent
of persons with type 1 diabetes would result in annual savings of 47,374
person-years of sight and $101 million. In The Netherlands, the number
of argon lasers increased from 10 prior to 1978 to 111 in 1992. Change
in clinical practice in The Netherlands could have been implemented more
quickly with more active governmental support. Adequate screening for
diabetic eye disease is being promoted by the American Academy of Ophthalmology,
the U.S. National Eye Institute, the World Health Organization, and the
International Diabetes Federation. Further studies are needed to document
accurately the cost-effectiveness of screening and early treatment programs.
3 figures, 21 references.
78
TITLE:
The Evaluation of Mobile Screening for Retinopathy. Thompson, C.; Leese,
G. Scottish Medical Journal. 40(1): 5-7. February 1995.
OBJECTIVE:
To overview the use of mobile screening for retinopathy.
CATEGORY:
Tertiary intervention.
Type of
Study: Patient screening.
Methodology: Review of studies.
Perspective: Health care system.
CONCLUSION:
Mobile retinal cameras, which offer the chance to expand eye screening
for retinopathy, particularly to remote and rural areas, should be considered
a valuable addition to current methods.
RECOMMENDATION:
None.
ABSTRACT:
The authors review previous studies on screening for retinopathy in the
United Kingdom. The ideal screening program for retinopathy, which has
yet to be determined, should be technically accurate, cost effective,
and applicable to the whole population. Mobile screening in the community
is a possible alternative for patients who do not attend diabetes clinics
and may be particularly valuable in remote rural areas, where fewer people
attend specialty diabetes clinics or receive a regular ophthalmic examination.
In the great majority of cases, mydriatic drops (to increase pupil size)
are not required for the retinal cameras used. An evaluation of a rural
mobile screening program (in Tayside) for persons with diabetes found
that 20 percent of those not attending diabetic clinics had retinopathy,
and 6.5 percent needed urgent ophthalmological assessment. It has been
estimated that a comprehensive screening program that included detection,
referral, treatment, and follow-up would reduce new blindness by 10 percent
in persons under 70 years. A recent multicenter study on screening found
the cost of diagnosis per true-positive case of sight-threatening retinopathy
to be 33 to £ 1,079 when the screener was a general practitioner,
£ 497 for a mobile community-based retinal camera, £ 1,546 for
a hospital-based retinal camera, £ 1,028 for opticians, and £
1,033 for hospital physicians. In the Tayside program, the cost to screen
a patient was £ 10; the cost per case of newly discovered sight-threatening
retinopathy was £ 50. The cost per patient receiving laser therapy
for retinopathy was £ 1,000. A screening service's cost-effectiveness
depends on the prior probability of detecting significant retinopathy;
after the initial impact of the mobile camera it may drop because of the
low annual incidence of this problem. The development of a strategy for
identifying high-risk groups has been advocated. 24 references.
79
TITLE:
Local Survey of Optometrists about Dilated Funduscopic Examinations for
Patients with Diabetes: Making Use of Phone Book Yellow-Page Listings.
Foster, D.T.; Wylie-Rosett, J.; Walker, E.A. Diabetes Educator.
22(6): 605-608. November-December 1996.
OBJECTIVE:
To assess the knowledge, attitudes, and practices of optometrists in the
Bronx, New York, area related to providing dilated funduscopic examination
for patients with diabetes.
CATEGORY:
Tertiary intervention.
Type of
Study: Patient management.
Methodology: Telephone survey.
Perspective: Health care system.
CONCLUSION:
Dilated funduscopic examinations were available at a relatively modest
cost in over half of the optometry practices listed in the NYNEX yellow
pages for the Bronx.
RECOMMENDATION:
Information is needed concerning how to increase education about dilated
fundoscopic examinations in medically underserved areas such as the South
Bronx. Campaigns to increase the rate of dilated funduscopy among patients
with diabetes should consider how optometrists interact with the medical
care system to achieve early detection of retinopathy and other diabetes-related
eye problems.
ABSTRACT:
The authors surveyed optometrists listed in the Bronx, New York, NYNEX
yellow pages. Telephone interviews were conducted with 23 of the 31 optometry
practices listed. Dilated funduscopic examinations were performed by 13
of the 23 practices. The primary contraindication to performing dilated
funduscopy cited by respondents who performed the examination was narrow-angle
glaucoma; hypertension was also mentioned as a contraindication (it is
not considered one per se, and this problem is frequently associated with
diabetes). Estimates by optometrists of the percentage of patients with
diabetes who knew of the need for dilated funduscopy examinations ranged
from 2 percent in the South Bronx to 25 percent for Westchester County
(New York) practices. Billing charges for a general examination ranged
from $12 to $55. The billing charge for dilated funduscopy ranged from
no additional charge to a $27 extra charge. Of the 23 practices, Medicaid
payment for examinations was accepted by 22, credit card by 20, and Medicare
by 18. Performing dilated funduscopy could be a recruitment strategy for
optometrists and might increase the number of patients who get this examination
annually. 2 tables, 12 references.
80
TITLE:
Meeting the Challenge of Diabetic Blindness in the 90's. Yeo, K.; Fan,
R.; Yong, V. Singapore Medical Journal. 34(2): 128-130. April 1993.
OBJECTIVE:
To describe a 5-year screening and education program for diabetes.
CATEGORY:
Tertiary intervention.
Type of
Study: Patient screening.
Methodology: Statistical analysis.
Perspective: Health care system.
CONCLUSION:
Blindness from retinopathy is largely preventable.
RECOMMENDATION:
Institute a nationwide program of screening and treatment for diabetes.
ABSTRACT:
The prevalence of diabetes in Singapore is rising, and retinopathy is
a leading cause of blindness among Singapore adults. Hospital-based screening
efforts in Singapore will reach only a small percentages of those with
diabetes. Most Singapore patients with diabetes are treated in primary-level
services (general practitioners, outpatient departments), where direct
ophthalmoscopy is widely available. This approach, however, has important
technical limitations. Many persons with diabetes do not know that diabetes
might cause blindness, and those with good vision are often not motivated
to seek a fundal examination. If blindness can be prevented in 10 percent
of the people in Singapore who have diabetes, cost savings will be significant.
A nationwide screening program for public education in diabetes; training
of medical staff, nursing personnel, and volunteers; and providing adequate
treatment and follow-up facilities are suggested to reduce blindness from
diabetes, with initial screening targeting high-risk groups. As a first
step, the authors suggest establishing a centralized screening clinic
in a hospital or diabetic center coupled with a mobile screening service.
They project that 16,800 patients can be screened the first year, with
10 percent increments each year, for a total of 102,564 patients for 5
years. The cost of these two programs is estimated at $150,000 (Singapore
dollars) for the first year, with equipment accounting for the major expenditure
in that year. The cost of screening is not excessive and is much below
the cost of treating late-stage retinopathy and rehabilitating blind patients.
The loss of economically productive persons with diabetes must also be
considered. Education can be carried out through mobile exhibits, mass
media, talks and seminars, and a diabetes education exhibit in the screening
center. Additional laser facilities would have to be made available to
treat patients with sight-threatening retinopathy. 8 references.
81
TITLE:
Mobile Retinal Photography: A Means of Screening for Retinopathy in Aboriginal
Communities. Karagiannis, A.; Newland, H. Australian and New Zealand
Journal of Ophthalmology. 24(4):333-337. November 1996.
OBJECTIVE:
To determine whether interpretable fundus photographs of the eye could
be taken by specially trained aboriginal health workers in a mobile screening
setting.
CATEGORY:
Tertiary intervention.
Type of
Study: Patient screening.
Methodology: Quality review.
Perspective: Health care system.
CONCLUSION:
Of the 390 photographs taken of 47 patients known to have diabetes, 371
slides were of sufficient clarity to interpret for retinopathy. However,
158 of the 371 slides were suboptimal.
RECOMMENDATION:
Mobile retinal photography carried out by aboriginal health workers as
part of routine health visits could be an efficient, practical approach
to eye screening of aboriginal diabetes patients living in remote areas
and of monitoring patients with existing retinopathy.
ABSTRACT:
The prevalence of diabetes in the aboriginal community in Australia is
estimated to be up to 15 percent. Aborigines and Torres Strait Islanders
living in remote areas of Australia and New Zealand have limited access
to screening services for retinopathy. The investigators describe a pilot
study to train aboriginal health workers to take fundus photographs of
the eyes of aborigines with diabetes during routine health clinic visits.
The health workers received 2 weeks of training from an ophthalmic photographer;
1 week took place on-site in an aboriginal community. The photographer
then supervised the health workers on 2 clinic visits in a 6-month period
in the community during which the health workers carried out dilated-eye
examinations in 47 known diabetes patients. The health workers took an
average of 8 photographs per patient (range: 4 to 27), for a total of
390 slides. A retinal specialist compared the slides with baseline photographs
taken by the ophthalmic photographer at the beginning of each clinic visit
and graded them for quality and interpretability. Nineteen slides, representing
11 patients, could not be read; 371 slides were of sufficient quality
to detect significant eye disease. The unit cost per photograph was $1.00
(Australian dollars), not including the cost of the equipment, services
of the retinal specialist, or mobile screening vehicle. 2 figures, 14
references.
82
TITLE:
Ophthalmic Screening for Diabetics: The Importance of Physician-Ophthalmologist
Collaboration in the Prevention of Blindness. Chew, S.J.; Hart, P.M.;
Ang, B.C.; Lim, A. Singapore Medical Journal. 31(1): 26-29. February
1990.
OBJECTIVE:
To evaluate the efficacy and cost-effectiveness of a screening program
for retinopathy involving the coordination of primary physician and ophthalmologist
services.
CATEGORY:
Tertiary intervention.
Type of
Study: Patient screening.
Methodology: Statistical analysis.
Perspective: Health care system.
CONCLUSION:
The screening program accurately identified patients with varying degrees
of retinopathy at a reasonable cost.
RECOMMENDATION:
Screening for retinopathy based on fundus photography performed by primary
care physicians and interpreted by ophthalmologists should be considered
an accurate, cost-effective strategy for blindness prevention in patients
with diabetes.
ABSTRACT:
The screening program, which was offered in Singapore, included Polaroid
fundus photography, noncontact tonometry, and blood pressure measurement,
with primary care physicians and ophthalmologists equally responsible
for patient care. Screening examinations took place at a retinal clinic,
and photographs were reviewed and discussed with patients by a retinal
specialist. During the first 6 months of the program, 428 patients with
known diabetes were screened; retinopathy was detected in 161 eyes (18.8
percent). The prevalence of retinopathy was closely associated with duration
of diabetes; age of onset was of lesser importance. Of the 161 eyes with
retinopathy, 60 percent exhibited only background changes; sight-threatening
retinopathy was found in 7.6 percent of all cases (59 of 856 eyes). Background
retinopathy occurred in 22.5 percent of eyes among patients with type
1 diabetes and 9.7 percent of eyes among patients with type 2 diabetes.
Proliferative retinopathy was 10 times more prevalent in the eyes of patients
with type 1 than in the eyes of patients with type 2 diabetes. Patients
were charged S$6.00 for the screening service, which included the cost
of photography. 7 tables, 5 references.
83
TITLE:
Opportunities for Cost Reduction in Retinopathy Treatment: Case Study
From Mexico. Phillips, M.; del Rio, I.; Quiroz, H. Bulletin of the
Pan American Health Organization. 28(1): 50-61. March 1994.
OBJECTIVE:
To measure the costs of treating eye problems in patients with diabetes,
to find out who bears these costs, and to determine how cost reduction
could be accomplished.
CATEGORY:
Tertiary intervention.
Type of
Study: Patient management.
Methodology: Cost analysis.
Perspective: Societal.
CONCLUSION:
The cost of treating eye problems was quite high, and the individual patient
bore most of the costs for treatment. Reducing the number of visits could
substantially lower the economic impact on patients.
RECOMMENDATION:
Further research is needed to clarify the benefits gained by patients
who have photocoagulation laser therapy.
ABSTRACT:
A randomized study was conducted at the Hospital for the Prevention of
Blindness in Mexico City to determine the costs of treating patients with
diabetes who had retinopathy. Clinical records of a random sample of 69
patients were used to collect data on demographic and socioeconomic variables,
diabetes treatment, initial eye diagnosis, and the amount and type of
eye treatment provided by the hospital from 1985 to 1991. The cost of
the resources used for each type of treatment provided was determined.
Patient interviews provided information about treatment-associated costs
incurred by patients and those accompanying them. The average age of patients
was 59 years; most were poor and had little formal education. All lacked
private health insurance and none was reimbursed for medical care expenses
incurred. The cost of treatment per patient over 5 years was $630; the
patient and family paid 83 percent of the cost. Fees accounted for 45
percent of patient costs, other direct expenses (e.g., travel and accommodations)
made up another 45 percent, and lost income accounted for 10 percent.
Suggestions for reducing patient costs without lowering quality of care
included shortening waiting time, increasing the strength of laser treatments
to decrease number of visits needed, completing more procedures in a single
visit, revising the policy on fluoroangiography, and educating patients
and at-risk relatives accompanying them about the need for early detection
and treatment of eye problems. 5 tables, 13 references.
84
TITLE:
Practical Community Screening for Retinopathy Using the Mobile Retinal
Camera: Report of a 12 Centre Study. British Diabetic Association Mobile
Retinal Screening Group. Also, Population-based Screening for Retinopathy:
A Promising Start (Comment). Greenwood, R.H. Diabetic Medicine.
13(11):925-926, 946-952. November 1996.
OBJECTIVE:
To report the progress of a project involving the use of mobile units
equipped with retinal cameras to provide eye screening services to diabetes
patients in 12 health districts in the United Kingdom.
CATEGORY:
Tertiary intervention.
Type of
Study: Patient screening.
Methodology: Statistical analysis.
Perspective: Health care system.
CONCLUSION:
The mobile units performed 64,905 screenings; analysis of 42,803 screenings
found 2,400 referrals for further evaluation, of which 516 resulted in
immediate laser therapy for sight-threatening disease. During subsequent
years of this multiyear project, the number of patients referred and those
needing laser therapy declined.
RECOMMENDATION:
Mobile eye screening programs should be designed to fit the specific needs
of each district, retinal photographers should be personable and well
trained, and close liaisons with local ophthalmologists should be established.
ABSTRACT:
In 1989, the British Diabetic Association initiated a mobile eye screening
program designed to reduce morbidity from diabetic eye disease, the leading
cause of blindness in working-age adults. Twelve health centers, representing
urban and rural areas, participated in the program. The vans were equipped
with retinal cameras, and each center was responsible for training an
operator/driver, determining how the screening service would be used in
the district, and setting up systems for reporting results. Most screenings
(76.5 percent) were carried out in primary care settings; the remainder
were carried out in hospital-based settings. The average cost per patient
screened and per patient treated was £ 13.11 and £ 1,110, respectively.
Patient acceptance of the screening process was high, and in 10 of 12
districts financial responsibility for the program has been taken over
by hospital trusts or district health authorities. The investigators conclude
that the use of mobile vans for retinal screening is cost effective and
efficient. An accompanying "Comment" notes that performance
standards need to be developed by a central organization such as the British
Diabetic Association before the program can be implemented on a wider
scale. A table of proposed standards developed by the British Diabetic
Association Retinal Screening Group is presented in the original article.
The article also includes an appendix listing reports from district units.
7 tables, 1 appendix, 19 references in principal article; 15 references
in Comment.
85
TITLE:
Preventive Eye Care in People with Diabetes Is Cost-Saving to the Federal
Government: Implications for Health Care Reform. Javitt, J.C.; Aiello,
L.P.; Chiang, Y.; Ferris, F.L.; Canner, J.K. III; Greenfield, S. Diabetes
Care. 17(8): 909-917. August 1994.
OBJECTIVE:
To estimate savings to the federal government from screening and treatment
of retinopathy in patients with type 2 diabetes.
CATEGORY:
Tertiary intervention.
Type of
Study: Epidemiological cohort model.
Methodology: Cost-benefit analysis.
Perspective: Societal.
CONCLUSION:
Improvement in ophthalmologic screening of patients with type 2 diabetes
will reduce vision loss and save money for the federal government.
RECOMMENDATION:
Eye care for patients with type 2 diabetes must emphasize patient identification,
careful follow-up, and prompt, appropriate treatment.
ABSTRACT:
The authors used the PROPHET computer model system to project the incidence
and the costs of screening and treatment of eye disease resulting from
diabetes. PROPHET is designed to model the course of a chronic, irreversible
disease. Incidence data for type 2 diabetes were applied to 1990 Medicare,
Social Security Disability Insurance, and Social Security Insurance costs
for screening and treatment; a 5 percent discount rate was used. Costs
of screening were based on complete dilated-eye examinations ($62 each)
at diagnosis and every 2, 3, or 4 years or, for those with retinopathy,
every 6, 12, 18, or 24 months. Treatment (photocoagulation for both eyes)
cost, including fluorescein angiograms, was $1,980. Based on 1988 population
figures for the United States, 576,136 patients yearly develop type 2
diabetes. Blindness in patients with diabetes costs the federal government
$14,296 annually per patient under age 65; per patient aged 65 and over,
federal expenditures are $32 annually (does not include Medicare/Social
Security payments or income tax exemption). Screening and treatment for
eye disease in patients with type 2 diabetes saves 53,986 person-years
of sight at an annual federal budget savings of $247.9 million; these
results assume that 60 percent of type 2 patients receive appropriate
eye care. For patients with type 2 diabetes controlled by insulin, however,
savings would be $1,715 per person, versus $725 for those controlled by
other means. Patients with onset prior to age 45 account for 89.1 percent
of sight savings and 100 percent of cost savings. With recommended eye
care, 112,730 and 94,304 person-years of sight and $624 and $472.1 million
would be saved annually in all patients with diabetes and those with type
2 diabetes, respectively. 4 figures, 2 tables, 52 references.
86
TITLE:
A Relative Cost-Effectiveness Analysis of Different Methods of Screening
for Retinopathy. Sculpher, M.J.; Buxton, M.J.; Ferguson, B.A.; Humphreys,
J.E.; Altman, J.F.; Spiegelhalter, D.J.; Kirby, A.J.; Jacob, J.S.; Bacon,
H.; Dudbridge, S.B.; Stead, J.W.; Feest, T.G.; Cheng, H.; Franklin, S.L.;
Courtney, P.; Talbot, J.F.; Ahmed, R.; Dabbs, T.R. Diabetic Medicine.
8(7): 644650. August/September 1991.
OBJECTIVE:
To determine the relative cost effectiveness of various screening methods
for sight-threatening retinopathy in terms of cost per true-positive case
detected.
CATEGORY:
Tertiary intervention.
Type of
Study: Patient screening.
Methodology: Cost-effectiveness analysis.
Perspective: Health care system.
CONCLUSION:
Cost per true-positive case ranged from £ 633 to £ 1,079 for
general practitioners; it was £ 1,033 for a hospital physician; £
784 for an ophthalmic optician; £ 441 to £ 609 for an ophthalmological
clinical assistant; £ 601 to £ 1,546 for a hospital-based camera;
and £ 497 to £ 747 for a traveling camera. Except for the ophthalmological
clinical assistant (the reference standard), the sensitivity of all screening
methods was low (0.35 to 0.67). Relative Cost-effectiveness changes if
the screening can take place without requiring an additional patient visit
and is strongly related to the relative sensitivity of the screening methods
and to the prior probability (prevalence or incidence) of retinopathy
in the population with diabetes.
RECOMMENDATION:
Approaches to screening, which are discussed in this report, may improve
sensitivity without reducing specificity or increasing cost per true-positive
case substantially.
ABSTRACT:
The authors report on screening for sight-threatening retinopathy of five
patient groups (n = 3,318) in three British centers. Patients' fundi were
assessed by a primary screener (a hospital physician, a general practitioner,
or an ophthalmic optician) using ophthalmoscopy with mydriasis. Additionally,
all patients had their fundi photographed by a nonmydriatic fundus camera,
and they received an ophthalmoscopic examination with mydriasis by an
ophthalmological clinical assistant (the reference standard). The costs
per true-positive case for the primary screeners ranged from £ 633
to £ 1,079 ( £ 1,033 for the hospital physician), for the clinical
assistant from £ 441 to £ 609, and for photography from £
497 for a camera that is taken to general practices in one center to £
1,546 for a hospital-based camera. The cost for true-positive case for
hospital physicians would drop from £ 1,033 to £ 353 if an additional
visit to the hospital were not required. Similarly, if ophthalmoscopy
is part of a general assessment by a general practitioner rather than
requiring an additional visit, the cost per true-positive case would drop
dramatically (to £ 245 to £ 362). Total costs per patient screened
by primary screeners ranged from £ 19.31 for ophthalmic opticians
to £ 37.77 for hospital physicians. The low sensitivities of primary
screeners and of photography (35 to 67 percent) may indicate that none
of these methods would be acceptable in routine clinical practice, despite
their relatively high specificities (86 to 98 percent). Alternatives that
may improve sensitivity (while avoiding a reduction in specificity or
increase in cost per true-positive case detected) include (1) clinical
assistant screening of both hospital and community-based patients; (2)
use of combined screening strategies (e.g., general practitioner, ophthalmoscopy
and fundus photography); and (3) identification of risk factors for retinopathy
that could be used, exclusively or in combination with single or joint
screening methods, as forms of screening in themselves (e.g., patients
with 10+ years of type 1 diabetes could be referred directly to an ophthalmologist
without prior screening). 1 figure, 3 tables, 25 references.
87
TITLE:
Retinopathy in the West of Scotland: Its Detection and Prevalence, and
the Cost-Effectiveness of a Proposed Screening Programme. Foulds, W.S.;
McCuish, A.; Barrie, T.; Green, F.; Scobie, I.N.; Ghafour, I.M.; McClure,
E.; Barber, J.H. Health Bulletin. 41(6): 318-326. November 1983.
OBJECTIVE:
To assess the prevalence of retinopathy as diagnosed by ophthalmoscopy
in the West of Scotland and to evaluate the financial implications of
implementing a screening program for retinopathy in that part of Scotland.
CATEGORY:
Tertiary intervention.
Type of
Study: Patient screening.
Methodology: Cost-effectiveness analysis.
Perspective: Societal.
CONCLUSION:
A projected screening program for retinopathy appeared to be cost savings
in terms of costs of patient identification and screening relative to
savings associated with the prevention of blindness.
RECOMMENDATION:
Universal screening for early detection of serious retinopathy should
be performed.
ABSTRACT:
The authors assessed the prevalence of retinopathy in the West of Scotland.
Based on ophthalmoscopic examination of 1,147 patients with diabetes,
the authors estimated the prevalence of retinopathy to be 26 to 35 percent;
of serious retinopathy, 9.5 to 11 percent. The potential cost-effectiveness
of a proposed screening program involving annual ophthalmoscopic examination
of all patients with diabetes in the West of Scotland (population about
2.5 million) was assessed. Projected annual cost associated with physician/ophthalmologist
examination plus nurse time was £ 51,800. Total annual cost to identify
those patients with serious retinopathy was estimated to be £ 55,300
, or £ 183 per patient with serious retinopathy identified. Total
cost per annum of identifying and treating patients at risk for blindness
was estimated to be £ 387 per patient treated. Costs associated with
identifying and treating a backlog of patients during the first year of
the program were estimated to be £ 86 per patient treated. Projected
savings in blind welfare services and state benefits per case of prevented
blindness were calculated to be £ 3,575. It is estimated that 60
percent of blindness from retinopathy could be prevented by appropriate
laser therapy. Total savings to the state per annum in treating and preventing
blindness in such a percentage of at-risk patients were estimated to be
£ 193,050. One-time savings associated with treating the backlog
of patients with serious retinopathy were estimated to be £ 1.6 million.
Appropriate laser therapy was estimated to result in a net savings of
£ 135,025 annually based on projected treatment costs and savings
for the state associated with blindness prevention. In addition, the 90
patients annually prevented from going blind would be expected to earn
£ 4.67 million. 1 table, 10 references.
88
TITLE:
Retinopathy — Need and Demand for Photocoagulation and Its Cost-Effectiveness:
Evaluation Based on Services in the United Kingdom. Savolainen, E.A.;
Lee, Q.P. Diabetologia. 23(2): 138-140. August 1982.
OBJECTIVE:
To assess both need for photocoagulation and the cost-effectiveness of
using this therapy in patients with retinopathy.
CATEGORY:
Tertiary intervention.
Type of
Study: Patient management.
Methodology: Patient care model.
Perspective: Societal.
CONCLUSION:
The cost of photocoagulation and follow-up is less than the indirect costs
to maintain a blind person for 1 year.
RECOMMENDATION:
Criteria for the need for photocoagulation are urgently needed.
ABSTRACT:
The authors used published literature from 1962 to 1978 to estimate the
number of patients with diabetes needing photocoagulation for retinopathy
in two regional Health Authorities in England. They also reviewed case
notes (only 141 of 272 sampled were available) from 9 of 10 photocoagulation
centers in the region. Interviews were conducted with consultants at the
centers, and information on manpower, equipment, and practices with different
patient groups was obtained to develop a model for estimating consultant
hours and treatments needed per year. It was estimated that 10,608 eyes
were in need of photocoagulation, which would require 21,417 consultant
hours per year and 14,496 treatments. The estimated number of actual treatments
for 1979 was only 3,080. The annual outpatient cost for photocoagulation
and follow-up was £ 100 per patient ( £ 170 in 1981 to 1982
prices). The cost of maintaining one blind person for 1 year (considering
lost earnings and Social Security payments) was estimated to be £
1,751 ( £ 2,871 at the end of 1981). As two of the nine centers in
the sample accept patients from outside the regions, these data indicate
that fewer than 20 percent of the patient need for photocoagulation was
met. Patients may be undiagnosed or diagnosed too late for treatment to
be effective. Criteria are needed to guide early detection, adequate treatment,
and follow-up of retinopathy in patients with diabetes. Interested physicians,
and possibly paramedical staff, will require training in photocoagulation
to meet the need for this service. 1 figure, 1 table, 10 references.
89
TITLE:
Screening for Retinopathy in a Clinical Setting: A Comparison of Direct
Ophthalmoscopy by Primary Care Physicians with Fundus Photography. Griffith,
S.P.; Freeman, W.L.; Shaw, C.J.; Mitchell, W.H.; Olden, C.R.; Figgs, L.D.;
Kinyoun, J.L.; Underwood, D.L.; Will, J.C. Journal of Family Practice.
37(1): 49-56. July 1993.
OBJECTIVE:
To compare the accuracy and cost-effectiveness of two approaches to screening
for retinopathy in a clinical setting: (1) ophthalmoscopy by trained primary
care physicians followed by referral to ophthalmologists as indicated,
and (2) seven-view nonstereoscopic, mydriatic fundal photographs read
by general ophthalmologists and retinal specialists.
CATEGORY:
Tertiary intervention.
Type of
Study: Patient screening.
Methodology: Cost-effectiveness analysis.
Perspective: Health care system.
CONCLUSION:
Dilated ophthalmoscopic screening by primary care physicians followed
by referral to an ophthalmologist if indicated was at least as accurate
as and more cost effective than nonstereoscopic mydriatic fundus photographs
read by ophthalmologists in screening for retinopathy.
RECOMMENDATION:
Future studies should measure the absolute sensitivity, specificity, and
predictive value of referral decisions for various diabetic retinal screening
strategies and should estimate their costs. Similar trials should be conducted
in other clinical settings to assess physicians' referral decisions.
ABSTRACT:
The two screening strategies were implemented at a rural clinic in Toppenish,
Washington, that served more than 400 Native Americans with diabetes.
During the 2.5-year study period, 243 clinic visits were recorded; 93
referrals were made, of which 83 were completed. The primary care physicians
were first given a 2-hour update about retinopathy and their role as screeners;
they were told to refer every patient with marked retinopathy to an ophthalmologist.
The "primary physician method" referred all 17 patients ultimately
diagnosed with significant retinopathy. Estimated maximum sensitivity
in diagnosing retinopathy was 100 percent for primary physicians; for
the general ophthalmologists and retinal specialists reading photographs,
it was 94 and 100 percent, respectively. Estimated maximum specificity
was 93 percent for the primary physician, 82 percent for the general ophthalmologists,
and 64 percent for the retinal specialists. Projected costs, including
personnel and material costs plus examination charges (according to the
American Academy of Ophthalmology), for screening and diagnosing 100 patients
by these methods were $3,132 for ophthalmoscopic screening by primary
providers, $4,942 to $5,734 for screening by retinal photography, and
$8,800 for referring all patients for full annual examination by an ophthalmologist.
Transportation, training, equipment, and other direct or indirect costs
were not included. 3 tables, 34 references.
90
TITLE:
Screening for Retinopathy in South Africa with 60° Retinal Colour Photography.
Joannou, J.; Kalk, W.J.; Mahomed, I.; Ntsepo, S.; Berzin, M.; Joffe, B.I.;
Raal, F.J.; Sachs, E.; Van Der Merwe, M.T.; Wing, J.R. Journal of Internal
Medicine. 239(1): 4347. January 1996.
OBJECTIVE:
To assess the use of a 60° mydriatic fundal camera to screen for retinopathy.
CATEGORY:
Tertiary intervention.
Type of
Study: Patient screening.
Methodology: Cost analysis.
Perspective: Health care system.
CONCLUSION:
Mydriatic retinal photography with a 60° field was more sensitive and
diagnostically more accurate than funduscopy by clinic doctors and compared
well with screening by an ophthalmologist. Screening for treatable retinopathy
by 60° mydriatic retinal photography is likely to be cost effective.
RECOMMENDATION:
Both retinae should be screened.
ABSTRACT:
Patients attending a diabetes clinic in South Africa were screened for
retinopathy by mydriatic fundal photography with a 60° camera. Selected
eyes were evaluated by an ophthalmologist. Randomized photographs were
assessed through single or two overlapping 45° fields (by masking the
slides) and at 60°. The authors found that 92 percent to 94 percent of
photographs were diagnostically useful (80 percent were excellent quality),
which compares well with nonmydriatic cameras. Compared with an ophthalmologist's
assessment, retinal photography had a sensitivity of 93 percent and a
specificity of 89 percent for any retinopathy, and 100 percent and 75
percent, respectively, for severe retinopathy. Funduscopy missed 28 percent
of affected eyes, compared with only 5.5 percent missed by photography.
A single 45° field missed 31 percent and two overlapping 45° fields missed
11 percent of retinopathy as compared with that detected by a 60° field
camera. For the 122 eyes assessed at the three field areas, the mean scores
increased significantly as the field area increased (p < 0.0001 for
each comparison). The costs of screening were calculated from the price
of film and processing (but not the camera) and from related staff salaries
for the first 663 patients screened. The basic expenditure (in U.S. dollars)
was determined to be $5.85 per patient screened, $13.55 per patient with
retinopathy (n = 286), and $37.03 for each patient referred for formal
ophthalmological assessment (n = 103, 15.5 percent). 2 figures, 1 table,
30 references.
91
TITLE:
Use of Mobile Screening Unit for Retinopathy in Rural and Urban Areas.
Leese, G.P.; Ahmed, S.; Newton, R.W.; Jung, R.T.; Ellingford, A.; Baines,
P.; Roxburgh, S.; Coleiro, J. British Medical Journal. 306(6871):
187-189. January 16, 1993.
OBJECTIVE:
To compare the rate of retinopathy detected by a mobile screening unit
equipped with a nonmydriatic Polaroid between rural and urban areas; to
identify the cost associated with the service.
CATEGORY:
Tertiary intervention.
Type of
Study: Patient screening.
Methodology: Cost analysis.
Perspective: Health care system.
CONCLUSION:
Mobile eye-screening units seem to be particularly effective at identifying
previously unrecognized advanced retinopathy in rural patients with diabetes;
these patients were more likely than urban patients to need urgent laser
photocoagulation. The cost per patient with mobile eye screening units
was relatively low.
RECOMMENDATION:
Patients with diabetes living in rural areas are less likely to seek help
at hospital clinics and would benefit from an expanded mobile-eye-screening
program to detect and treat retinopathy.
ABSTRACT:
Researchers compared the effective-ness of screening for retinopathy using
mobile eye-screening units in rural versus urban patients with diabetes
during 2 years in the Tayside region of Scotland. They estimated that
64 to 77 percent of the population with diabetes was screened: 1,225 urban
and 961 rural patients were photographed with a nonmydriatic fundal camera.
Rural patients were less likely to attend a hospital clinic than urban
patients (46 percent versus 86 percent, p < 0.001) and were less likely
to be receiving insulin (27 percent versus 34 percent, p < 0.001).
Advanced retinopathy was greater among rural than urban patients (13 percent
versus 7 percent, p < 0.001), and more rural patients required urgent
laser photocoagulation (1.4 percent versus 0.5 percent, p < 0.02).
Direct and indirect costs, estimated for screening 1,800 patients a year,
included the salary of the ophthalmic photographer; the purchasing and
processing of film; and the servicing, running, and depreciation costs
of the van and camera. The cost of the screening program per patient was
£ 10, which is cheaper than all alternatives. This cost is equivalent
to £ 350 per patient with previously unrecognized disease and £
1,000 per patient receiving laser treatment. These costs are low compared
with alternatives and could be further reduced by screening more patients
per unit. 5 tables, 23 references.
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