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research-article2015

DSTXXX10.1177/1932296815624109Journal of Diabetes Science and TechnologyPasquel et al

Special Section

Cost-effectiveness of Different Diabetic Retinopathy Screening Modalities

Journal of Diabetes Science and Technology 2016, Vol. 10(2) 301­–307 © 2015 Diabetes Technology Society Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1932296815624109 dst.sagepub.com

Francisco J. Pasquel, MD1, Andrew M. Hendrick, MD2, Martha Ryan, MD2, Emily Cason, MPH3, Mohammed K. Ali, MD, MBA3, and K. M. Venkat Narayan, MD, MBA1,3

Abstract Current screening strategies aimed at detection of diabetic retinopathy (DR) historically have poor compliance, but advancements in technology can enable improved access to care. Nearly 80% of all persons with diabetes live in low- and middle-income countries (LMICs), highlighting the importance of a cost effective screening program. Establishing mechanisms to reach populations with geographic and financial barriers to access is essential to prevent visual disability. Teleretinal programs leverage technology to improve access and reduce cost. The quality of currently employed screening modalities depends on many variables including the instrument used, use of pupillary mydriasis, number of photographic fields, and the qualifications of the photographer and image interpreter. Recent telemedicine and newer technological approaches have been introduced, but data for these technologies is yet limited. We present results of a systematic review of studies evaluating cost-effectiveness of DR screening, and discuss potential relevance for LMICs. Keywords diabetic retinopathy, screening, telemedicine, cost, low and middle income countries, smartphones Recent estimates indicate that globally, ~382 million people have diabetes.1 Diabetic retinopathy (DR), the most frequently occurring microvascular complication of diabetes, affects approximately 28% of people with known diabetes and 11% of those newly diagnosed. It can affect nearly all patients with sufficient duration of the disease.2,3 Sight threatening diabetic retinopathy can at least be delayed with good blood pressure and glycemic control.4 However, since the pathophysiological changes in the eye continue in the background and occur asymptomatically, actively screening persons with diabetes on a regular basis becomes necessary. Screening frequency varies by setting and guideline,1,4 and has been reviewed previously.5,6 Despite this knowledge, systematic implementation of diabetic retinopathy screening that reaches every person with diabetes is not common in many countries, especially low- and middle-income countries (LMICs).4,7 Nearly 80% of all persons with diabetes live in LMICs, where primary healthcare facilities for managing diabetes and its complications are inadequate or nonexistent. In these settings, good-quality data on DR prevalence is also lacking.8 Even in upper-middle-income or high-income countries, healthcare disparities exist such that access to care may be limited by geography, race, culture, and/or finances.9 Furthermore, the low access groups have been linked to higher rates of DR.10-12 Given that screening for DR can be expensive and logistically challenging, here we present data

from a systematic review of economic studies of DR screening and discuss potential relevance for LMICs.

Methods We systematically searched the PubMed, Embase, and Web of Science electronic databases for articles published between January 1990 and August 2015 using a combination of terms including “diabetic retinopathy,” “cost-effectiveness” or “cost-utility,” and “screening” as search terms. We excluded studies in languages other than English, narrative reviews, abstracts from scientific meetings not linked to peer reviewed publications, or studies evaluating screening intervals, as this has been evaluated in 2 recent systematic reviews.5,6 Results were merged to identify duplicates. Full texts of relevant articles were assessed. The search yielded a 1

Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA 2 Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA 3 Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA Corresponding Author: Francisco J. Pasquel, MD, Division of Endocrinology, Metabolism & Lipids, Emory University School of Medicine, 49 Jesse Hill Jr Dr SE | FOB Rm 439, Atlanta, GA 30303, USA. Email: [email protected]

302 total of 449 results from PubMed (130), Embase (190), and Web of Science (129). There were 352 results after removal of duplicates. The search was supplemented by reviewing the reference lists of relevant publications. Studies were grouped according to screening approach or teleophthalmology strategies.

Results After excluding studies examining frequency intervals, we identified 18 studies assessing cost-effectiveness of different screening approaches (eg, who performs screening, opportunistic vs systematic screening), different delivery modalities (eg, clinic camera, telemedicine), and factors that influence success (Table 1). Systematically screening patients (through structured screening programs), at the population level is complex, but can outperform opportunistic screening, which usually covers a minority of patients with diabetes in developed countries (Table 1).13,14 In contrast to clinical examination, telemedicine reduces the burden in the eye clinic and improves access in remote environments. Maberley et al10 reported that over 10 years, 67 versus 56 sight years were saved with telemedicine ($3900 vs $9800 per sight year and $15 000 vs $37 000 per QALY) compared to no screening. Photographer medical qualifications influence the specificity but not sensitivity of DR detection.15 The use of trained photographic graders in lieu of physicians, is especially valuable in low or middle income regions where the number of ophthalmologists per capita is often lower compared to developed countries.13,16 Cost-effective telemedicine programs have been reported in a variety of settings, including the United States, Canada, United Kingdom, India, and Norway (Table 1).10,17-21 Telemedicine programs are more cost-effective in people who derive more benefit. For example, populations have more benefit when screened at a younger age, using insulin, higher HbA1c, faster HbA1c change rates, or with high transportation costs.17,18,22,23 In addition, population size and disease burden can determine the cost-effectiveness of a screening program such that screening a low number of individuals is not economically sound.18,20,24 One common target is omission of pupillary mydriasis. This facilitates increased brevity of the screening encounter, comfort for the patient, and overall acceptance. Results from studies evaluating nonmydriatic approaches perform favorably and are cost-effective.10,13,19,21,25,26 Interestingly, the need to pay for care seems to affect usage. Results from a recent randomized trial, evaluating the inverse care law in a DR screening program, showed that paying for the screening (US$8) resulted in a lower uptake of screening than being provided with free screening (OR, 0.59). Paying also resulted in a lower detection rate of DR (OR, 0.73) after adjustment for potential confounding factors. Subjects with higher income or living in better housing

Journal of Diabetes Science and Technology 10(2) were more likely to be screened but less likely to have DR detected, suggesting that those in greatest need might be less able to access care.27 Free systematic DR screening can be a cost-effective option if the health care system is willing to invest US$16 000 per QALY gained.28 The effectiveness of DR screening intervals has been examined in recent systematic reviews.5,6 Echouffo-Tcheugui et al concluded that in patients without DR, screening intervals could safely and effectively be extended to 2 years unless the individuals had poor glycemic control or uncontrolled hypertension.5 A similar systematic review by TaylorPhillips et al found similar results but arrived to a different conclusion, suggesting that current evidence does not support a shift to screening intervals beyond 1 year, given the lack of experimental research design and heterogeneity in definition of those at low risk.6 Current recommendations by the American Diabetes Association suggest that if there is no evidence of DR for 1 or more evaluations, then screening every 2 years may be considered, however if DR is present subsequent examinations should be repeated annually or more frequently by an ophthalmologist or optometrist.29 Advancements in technology could enable improved access to care, but data for recent telemedicine and newer technological approaches is yet limited. Alternative screening innovations such as optical coherence tomography, handheld fundoscopy, and other cell-phone-based techniques have been introduced.30-35 The ubiquity and relative low cost of smartphones with cameras makes for an attractive platform for both image acquisition,21 interpretation,33 and transmission.30 Techniques using a handheld condensing lens paired with a smartphone camera can capture images at a relatively low cost.31,32,35 Recently, Ryan et al reported a prospective comparative study of 3 modalities including: smartphone fundus photography, nonmydriatic fundus photography, and 7-field mydriatic fundus photography. The smartphone is able to detect DR and sight threatening disease, but at a lower sensitivity compared to nonmydriatic fundus photography.36 The economic and clinical feasibility of newer technologies in teleophthalmology need to be further investigated.

Conclusions Establishing mechanisms to reach populations with geographic and financial barriers to access is essential to prevent visual disability globally. Current screening strategies aimed at detection of DR have poor compliance.37-39 Further compounding the challenge is that nearly 80% of all persons with diabetes live in LMICs. Mydriatic 7-field photography or clinical fundus examination are considered to be the gold standard for DR screening.15 Screening modalities can vary according to instrument used (eg, film, Polaroid, scanning laser or digital photography; slit lamp, direct and indirect ophthalmoscope), mydriatic status, number of photographic fields, and qualifications

303

Pasquel et al Table 1.  Economic Studies on Diabetic Retinopathy. Author, year, country

Population characteristics

Comparators

Screening modalities/ personnel conducting screening

Screening outcomes

Economic outcomes

Screening approach N = 352 diabetic Lairson et al,43 1992, US patients

Sculpher et al,44 1992, UK

James et al,14 2000, England

Facey et al,13 2002, Scotland

Tu et al,45 2004, England

Khan et al,26 2013, South Africa

Primary care vs 45-degree photographs Cost per true-positive Cost was lower for the ophthalmologist (technician), case detection 45-degree camera direct and indirect with dilation ($295) ophthalmoscopy by vs nondilation ($378), ophthalmologists, standard examination and direct ($390), and direct ophthalmoscopy fundoscopy by a PA or NP by technicians with ($794) for DR screening 7-field stereoscopic fundus photography N = 3423 diabetic Evaluation of GP, optician, hospital Cost of different Cost savings can result patients 13 screening based camera, modalities, with systematic screening options GP-visiting camera, expected cost per during the same combined GP and true positive case appointment as other GP-visiting camera, detected routine health checks, combined optician compared to screening and GP-visiting requiring additional visits camera, selective screening modalities N = 320, and Systematic vs Systematic: 3-field, Sight-threatening eye The CE was £209 and systematic opportunistic nonstereoscopic disease £289 for systematic screening of 1363 screening photography and opportunistic diabetic patients using mydriasis; screening, respectively, opportunistic: direct and incremental CE was ophthalmoscopy by £32 for each additional GP, optometrists, and case; systematic diabetologists screening remained more cost-effective than opportunistic screening N = 2000 iterations Systematic vs Conducted by Cost per QALY for The most cost-effective through Crystal opportunistic optometrists, the move from one modality: combination Ball screening hospitals and GPs at screening program of single staffed hospital any opportunity vs to another units and mobile vans a systematic health using nonmydriatic digital authority program, photography primarily by digital camera (mydriatic and nonmydriatic screening) N = 769 Optometry Topcon nonmydriatic Detection of sightCE for optometry = total optometric vs digital model (professional threatening DR cost/true positives = screen and N photography medical £18 454/22 = £839; cost = 874 digital screening photographer) vs slitper patient screened photography lamp biomicroscopy = £25 599.30/874 (optometrists) = £29.29; CE for digital photography = £25 599/30 = £853; CE was poor in both models N = 14 541, primary Systematic vs Mobile nonmydriatic Cost per blindness Nonmydriatic fundus care, T2D opportunistic digital camera case averted photography is costscreening (photographs taken by effective; the cost of DR a trained technician screening was $22 per with supervision by an person; ICER was $1206 ophthalmic nurse) per blindness case averted (continued)

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Journal of Diabetes Science and Technology 10(2)

Table 1. (continued) Author, year, country

Population characteristics

Lian et al,27 2013, N = 2766 diabetic Hong Kong patients

Prescott et al,34 2014, UK

N = 3170 diabetic patients

Kawasaki et al,46 2014, Japan

N = 50 000 hypothetical cohort

Teleophthalmology N = 250, Bjorvig et al,20 2002, Norway hypothetical cohort of 250 subjects. 42 diabetic patients

Comparators Subjects randomized to free group (N = 1387) vs pay group (N = 1379) Surrogate photographic markers used to screen for ME in England and Scotland, and a hybrid and automated schemes Systematic vs opportunistic screening

Screening modalities/ personnel conducting screening

Screening outcomes

Nonmydriatic fundus Uptake of screening camera (optometrist); and severity of DR subsequently graded detected by optometrist and ophthalmologists

Economic outcomes Lower screening (OR, 0.59; CI, 0.47-0.74) and a lower detection rate of DR (OR, 0.73; CI, 0.600.90) in the pay group

45° macula-centered Years free of The use of OCT in color digital retinal moderate visual conjunction with photograph and OCT loss and QALYs; CE photography within of the alternative screening programs, for grading schemes for patients with surrogate triggering referral markers of ME, is likely to be CE (OCT screening program: £32 vs referral to ophthalmology: £143 Incidental diagnosis, Rate of detecting DR, DR screening program in nonmydriatic 45° preventing blindness, Japan is cost-effective photograph in high and costs of DR compared to the no risk people, annual management systematic screening; fundus examinations; blindness reduction of systematic screening ~16%; incremental cost by ophthalmologists of $64.6, and incremental using dilated fundus effectiveness of 0.0054 examination QALYs per person screened; ICER was $11 857 per QALY

TO vs conventional screening

Conventional evaluation Cost comparisons At higher workloads, by ophthalmologist depending on telemedicine led to lower vs digital images volume of screening costs; at 200 patients transmitted via email per year, telemedicine cost $164 per patient and conventional examinations cost $243.5 per patient Specialist visit vs Visits every 6 months Costs per sight-year The camera program was Maberley et al,10 N = 650, isolated 2003, Canada communities screening with a by retina specialists saved and costs per more cost-effective, and digital camera vs photographic QALY had the best cost-perscreening with a QALY ratio, at $15 000; digital camera the camera program would cost less than $5000 per year of vision saved if 65% or more of the population was screened Nonmydriatic QALYs gained and Average CE was $882 Aoki et al,17 2004, N = 10 000 inmates, TO vs US a 40-year-old conventional retinal camera TO costs generated per QALY for TO and AA man as a screening vs conventional $947 for non-TO; in reference case evaluation by eye care the TO strategy, 12.4% provider of patients reached blindness versus 20.5% in non-TO; ARR for blindness: 8.1%, NNS by TO to prevent a blindness case: 12.4% (continued)

305

Pasquel et al Table 1. (continued) Author, year, country

Population characteristics

Comparators

Screening modalities/ personnel conducting screening

Screening outcomes

Whited et al,19 2005, US

Large cohort from Nonmydriatic IHS, VA, and DoD digital TO data compared with conventional screening

Clinic based Number of true ophthalmoscopy with positive cases of pupil dilation vs JVN proliferative DR digital TO system detected (JVN)

Li et al,21 2012, US

N = 611 diabetic patients

Nonmydriatic fundus camera vs conventional retinal examination

TO vs conventional screening

TO vs no Rachapelle et al,24 N = 1000 2013, India hypothetical screening cohort, rural, 40 program years, no previous screen, 25 years follow-up

Kirkizlar et al,18 2013, US

N = 900, T1D and T2D

Phan et al,47 2014, N = 1793 diabetic US patients

Brady et al,48 2014, US

Mobile van, optometrist QALY gained from takes 4 dilated TO vs no screening, stereoscopic CU at different 45-degree fields digital intervals retinal photographs with nonmydriatic camera

TO vs no TO vs regular office screening visits and evaluation program or by ophthalmologist ophthalmologist

TO vs direct eye clinic visit

Prevalence of DR/cost comparison

Topcon digital retinal cameras, nonmydriatic imaging

DR, ME, blindness, and associated QALYs

Cost of teleretinal screening

N = 99 (base case), Decision3-field nonmydriatic Estimation of costs of N = 100 000 trials tree analysis fundus photography; screening for PDR (Monte Carlo compared to no images were simulation) screening transmitted to a remote expert reader

Economic outcomes Number of additional cases and savings with JVN: IHS: 148 cases and $525 690; VA: 96 PDR cases and $2 966 111; DoD: 165 and $129 046; JVN provides better outcomes at lower costs than clinic-based ophthalmoscopy in most scenarios Telemedicine-based DR screening cost less than conventional examinations ($49.95 vs $77.80) Rural TO was costeffective ($1320 per QALY) compared with no screening; screening intervals of up to every 2 years also were costeffective, but annual screening was not ($3183 per QALY) TO is CE in most conditions; telemedicine screening is not CE in patients aged older than 80 years or in populations with more than 3500 patients Teleretinal screening was associated with cost reduction to health plan payers (average cost reduction per screen of $24.38) and a decrease in eye clinic physician workload but failed to match the investment cost (53% gained back by study end) TO screening for PDR resulted in savings of $36 per patient (base case), and a median of $48 in the simulation model

Abbreviations: AA, African American; ARR, absolute risk reduction; CE, cost effectiveness; CI, confidence interval; CU, cost-utility; DoD, Department of Defense; DR, diabetic retinopathy; GP, general practitioner; ICER, incremental cost-effectiveness ratio; IHS, Indian Health Service; JVN, Joslin Vision Network; ME, macular edema; NNS, number needed to screen; NP, nurse practitioner; OCT, optical coherence tomography; OR, odds ratio; PA, physician assistant; PDR, proliferative diabetic retinopathy; QALY, quality-adjusted life-year; T1D, type 1 diabetes; T2D, type 2 diabetes; TO, teleophthalmology; VA, Department of Veterans Affairs.

of the photographer and interpreter. The sensitivity of detecting DR depends on the training of individual. In general, ophthalmic personnel outperform nonophthalmic personnel

at accuracy of screening for DR.13 However, to improve access, teleophthalmology will likely be the cornerstone of most DR screening programs. This strategy has flaws. The

306 need for photography depends on the equipment, which can be cost prohibitive for many systems.14 Skill is required for image acquisition and interpretation,18,40 and action must then be taken to provide the definitive care when deemed necessary with appropriate referral to the ophthalmologist. Mobile programs help solve the geographic access problem,41 but equipment cost remains prohibitive for routine providers and communities that are not supported by governments or foundations.

Recommendations Cost-effective strategies and technology to provide wide coverage are necessary. This is particularly important for regions where the ratio of providers and distance to reach them is most prohibitive, and large gaps exist. To improve the status quo, several options can be considered: (1) economic viability may be improved by decreased screening frequency in low risk individuals;5,29,42 (2) to improve geographic access, governments and health care payers may consider teleretinopathy screening programs; (3) modern nonmydriatic cameras should be considered when economically feasible; (4) to improve economic viability, more portable and less expensive equipment to detect diabetic retinopathy can be considered, recognizing the trade off in performance,30,32,33,35 and supporting the acceleration of this research may have important economic and social benefits. The ideal screening technology must be portable, noninvasive, reliable, and easy to use by relatively unskilled persons. Testing must be deployed in areas with sufficient volume of patients that resources spent on travel cover the cost reduction in preventing blinding disease.18,20 The objective of screening programs is to identify individuals who will benefit from sight saving laser therapy. As such, the final obstacle to overcome for successful implementation of these screening programs is to partner with an ophthalmologist who can deliver timely laser treatment when indicated. Abbreviations ARR, absolute risk reduction; CE, cost effectiveness; CU, costutility; DoD, Department of Defense; DR, diabetic retinopathy; GP, general practitioner; ICER, incremental cost-effectiveness ratio; IHS, Indian Health Service; JVN, Joslin Vision Network; LMIC, low- and middle-income countries; ME, macular edema; NNS, number needed to screen; OR, odds ratio; PDR, proliferative diabetic retinopathy; QALY, quality-adjusted life-year; TO, teleophthalmology; VA, Department of Veterans Affairs.

Author Contributions FJP, MKA, and KMVN designed the study. FJP acquired the information and drafted the manuscript. AMH, MR, EC, MKA, and KMVN critically reviewed and edited the manuscript.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Journal of Diabetes Science and Technology 10(2) Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

References 1. International Diabetes Federation. Diabetes Atlas. 6th ed. Brussels: International Diabetes Federation, 2013. Available at: http://www.idf.org/sites/default/files/EN_6E_Atlas_Full. pdf. Accessed November 18, 2013. 2. Klein R, Klein BE, Moss SE, Davis MD, DeMets DL. The Wisconsin Epidemiologic Study of Diabetic Retinopathy. IX. Four-year incidence and progression of diabetic retinopathy when age at diagnosis is less than 30 years. Arch Ophthalmol. 1989;107(2):237-243. 3. Klein R, Klein BE, Moss SE, Davis MD, DeMets DL. The Wisconsin Epidemiologic Study of Diabetic Retinopathy. X. Four-year incidence and progression of diabetic retinopathy when age at diagnosis is 30 years or more. Arch Ophthalmol. 1989;107(2):244-249. 4. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl 1):S14-S80. 5. Echouffo-Tcheugui JB, Ali MK, Roglic G, Hayward RA, Narayan KM. Screening intervals for diabetic retinopathy and incidence of visual loss: a systematic review. Diabetic Med. 2013;30(11):1272-1292. 6. Taylor-Phillips S, Mistry H, Leslie R, et al. Extending the diabetic retinopathy screening interval beyond 1 year: systematic review. Brit J Ophthalmol. 2015;bjophthalmol-2014-305938. 7. Hall M, Felton AM. The St Vincent Declaration 20 years on—defeating diabetes in the 21st century. Diabetes Voice. 2009;54(2):42-44. 8. Ruta LM, Magliano DJ, Lemesurier R, Taylor HR, Zimmet PZ, Shaw JE. Prevalence of diabetic retinopathy in type 2 diabetes in developing and developed countries. Diabetic Med. 2013;30(4):387-398. 9. Peek ME, Cargill A, Huang ES. Diabetes health disparities: a systematic review of health care interventions. Med Care Res Rev. 2007;64(5 suppl):101S-156S. 10. Maberley D, Walker H, Koushik A, Cruess A. Screening for diabetic retinopathy in James Bay, Ontario: a cost-effectiveness analysis. CMAJ. 2003;168(2):160-164. 11. Haffner SM, Fong D, Stern MP, et al. Diabetic retinopathy in Mexican Americans and non-Hispanic whites. Diabetes. 1988;37(7):878-884. 12. Harris MI, Klein R, Cowie CC, Rowland M, Byrd-Holt DD. Is the risk of diabetic retinopathy greater in non-Hispanic blacks and Mexican Americans than in non-Hispanic whites with type 2 diabetes? A U.S. population study. Diabetes Care. 1998;21(8):1230-1235. 13. Facey K, Cummins E, Macpherson K, Morris A, Reay L, Slattery J. Health Technology Assessment Report 1: Organisations of Services for Diabetic Retinopathy Screening. Glasgow, Scotland: Health Technology Board for Scotland; 2002. 14. James M, Turner DA, Broadbent DM, Vora J, Harding SP. Cost effectiveness analysis of screening for sight threatening diabetic eye disease. BMJ. 2000;320(7250):1627-1631. 15. Bragge P, Gruen RL, Chau M, Forbes A, Taylor HR. Screening for presence or absence of diabetic retinopathy: a meta-analysis. Arch Ophthalmol. 2011;129(4):435-444.

Pasquel et al 16. Resnikoff S, Pascolini D, Etya’ale D, et al. Global data on visual impairment in the year 2002. Bull World Health Org. 2004;82(11):844-851. 17. Aoki N, Dunn K, Fukui T, Beck JR, Schull WJ, Li HK. Cost-effectiveness analysis of telemedicine to evaluate diabetic retinopathy in a prison population. Diabetes Care. 2004;27(5):1095-1101. 18. Kirkizlar E, Serban N, Sisson JA, Swann JL, Barnes CS, Williams MD. Evaluation of telemedicine for screening of diabetic retinopathy in the veterans health administration. Ophthalmology. 2013;120(12):2604-2610. 19. Whited JD, Datta SK, Aiello LM, et al. A modeled economic analysis of a digital tele-ophthalmology system as used by three federal health care agencies for detecting proliferative diabetic retinopathy. Telemed J e-health. 2005;11(6):641-651. 20. Bjorvig S, Johansen MA, Fossen K. An economic analysis of screening for diabetic retinopathy. J Telemed Telecare. 2002;8(1):32-35. 21. Li Z, Wu C, Olayiwola JN, Hilaire DS, Huang JJ. Telemedicinebased digital retinal imaging vs standard ophthalmologic evaluation for the assessment of diabetic retinopathy. Connecticut Med. 2012;76(2):85-90. 22. Dasbach EJ, Fryback DG, Newcomb PA, Klein R, Klein BE. Cost-effectiveness of strategies for detecting diabetic retinopathy. Med Care. 1991;29(1):20-39. 23. Rein DB, Wittenborn JS, Zhang X, et al. The cost-effectiveness of three screening alternatives for people with diabetes with no or early diabetic retinopathy. Health Serv Res. 2011;46(5):1534-1561. 24. Rachapelle S, Legood R, Alavi Y, et al. The cost-utility of telemedicine to screen for diabetic retinopathy in India. Ophthalmology. 2013;120(3):566-573. 25. Askew DA, Crossland L, Ware RS, et al. Diabetic retinopathy screening and monitoring of early stage disease in general practice: design and methods. Contemp Clin Trials. 2012;33(5):969-975. 26. Khan T, Bertram MY, Jina R, Mash B, Levitt N, Hofman K. Preventing diabetes blindness: cost effectiveness of a screening programme using digital non-mydriatic fundus photography for diabetic retinopathy in a primary health care setting in South Africa. Diabetes Res Clin Pract. 2013;101(2): 170-176. 27. Lian JX, McGhee SM, Gangwani RA, et al. Screening for diabetic retinopathy with or without a copayment in a randomized controlled trial: influence of the inverse care law. Ophthalmology. 2013;120(6):1247-1253. 28. Gangwani R, Wong D, Lai W, Wong I, McGhee S. Abu Dhabi World Ophthalmology Congress (WOC) 2012: Abstract FP-EPI-SA 221, February 16-20, 2012. 29. American Diabetes Association. Microvascular complications and foot care. Diabetes Care. 2015;38(suppl 1):S58-S66. 30. Blanckenberg M, Worst C, Scheffer C. Development of a mobile phone based ophthalmoscope for telemedicine. In: Conference Proceedings: Annual International Conference of the IEEE Engineering in Medicine and Biology Society. 2011:5236-5239. 31. Bursell SE, Brazionis L, Jenkins A. Telemedicine and ocular health in diabetes mellitus. Clin Exper Optometry. 2012;95(3):311-327.

307 32. Haddock LJ, Kim DY, Mukai S. Simple, inexpensive technique for high-quality smartphone fundus photography in human and animal eyes. J Ophthalmol. 2013;2013:518479. 33. Kumar S, Wang EH, Pokabla MJ, Noecker RJ. Teleophthalmology assessment of diabetic retinopathy fundus images: smartphone versus standard office computer workstation. Telemed J e-health. 2012;18(2):158-162. 34. Prescott G, Sharp P, Goatman K, et al. Improving the costeffectiveness of photographic screening for diabetic macular oedema: a prospective, multi-centre, UK study. Brit J Ophthalmol. 2014. 35. Suto S, Hiraoka T, Okamoto Y, Okamoto F, Oshika T. [Photography of anterior eye segment and fundus with smartphone]. Nippon Ganka Gakkai zasshi. 2014;118(1):7-14. 36. Ryan ME, Rajalakshmi R, Prathiba V, et al. Comparison Among Methods of Retinopathy Assessment (CAMRA) study: smartphone, nonmydriatic, and mydriatic photography. Ophthalmology. 2015;122:2038-2043. 37. Klein R, Klein BE, Moss SE, Davis MD, DeMets DL. The Wisconsin Epidemiologic Study of Diabetic Retinopathy. VI. Retinal photocoagulation. Ophthalmology. 1987;94(7):747-753. 38. Witkin SR, Klein R. Ophthalmologic care for persons with diabetes. JAMA. 1984;251(19):2534-2537. 39. Bressler NM, Varma R, Doan QV, et al. Underuse of the health care system by persons with diabetes mellitus and diabetic macular edema in the United States. JAMA Ophthalmol. 2014;132(2):168-173. 40. Murgatroyd H, Ellingford A, Cox A, et al. Effect of mydriasis and different field strategies on digital image screening of diabetic eye disease. Brit J Ophthalmol. 2004;88(7):920-924. 41. Murthy KR, Murthy PR, Rao S, Murthy GJ, Kapur A, Lefebvre P. A novel model to deliver advanced eye care for people with diabetes living in resource-poor settings: results of care provided to date. Diabetes Care. 2012;35(4):e31. 42. Vijan S, Hofer TP, Hayward RA. Cost-utility analysis of screening intervals for diabetic retinopathy in patients with type 2 diabetes mellitus. JAMA. 2000;283(7):889-896. 43. Lairson DR, Pugh JA, Kapadia AS, Lorimor RJ, Jacobson J, Velez R. Cost-effectiveness of alternative methods for diabetic retinopathy screening. Diabetes Care. 1992;15(10):1369-1377. 44. Sculpher MJ, Buxton MJ, Ferguson BA, Spiegelhalter DJ, Kirby AJ. Screening for diabetic retinopathy: a relative costeffectiveness analysis of alternative modalities and strategies. Health Econ. 1992;1(1):39-51. 45. Tu KL, Palimar P, Sen S, Mathew P, Khaleeli A. Comparison of optometry vs digital photography screening for diabetic retinopathy in a single district. Eye (Lond). 2004;18(1):3-8. 46. Kawasaki R, Akune Y, Hiratsuka Y, Fukuhara S, Yamada M. Cost-utility analysis of screening for diabetic retinopathy in Japan: a probabilistic Markov modeling study. Ophthalmic Epidemiol. 2014;22(1):4-12. 47. Phan A-DT, Koczman JJ, Yung C-W, Pernic AA, Doerr ED, Kaehr MM. Cost analysis of teleretinal screening for diabetic retinopathy in a county hospital population. Diabetes Care. 2014;37(12):e252-e253. 48. Brady CJ, Villanti AC, Gupta OP, Graham MG, Sergott RC. Tele-ophthalmology screening for proliferative diabetic retinopathy in urban primary care offices: an economic analysis. Ophthalmic Surg Lasers Imaging Retina. 2014;45(6):556.

Cost-effectiveness of Different Diabetic Retinopathy Screening Modalities.

Current screening strategies aimed at detection of diabetic retinopathy (DR) historically have poor compliance, but advancements in technology can ena...
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