Cost-utility Analysis of Opportunistic and Systematic Diabetic Retinopathy Screening Strategies from the Perspective of the Brazilian Public Healthcare System

Abstract

Objective To perform a cost-utility analysis of diabetic retinopathy (DR) screening strategies from the perspective of the Brazilian Public Healthcare System. Methods A model-based economic evaluation was performed to estimate the incremental costs per quality-adjusted life-year (QALY) gained between three DR screening strategies: (1) the opportunistic ophthalmology referral-based (usual practice), (2) the systematic ophthalmology referral-based, and (3) the systematic teleophthalmology-based. The target population included individuals with type 2 diabetes (T2D) aged 40 years, without retinopathy, followed over a 40-year time horizon. A Markov model was developed with five health states and a 1-year cycle. Model parameters were based on literature and country databases. One-way and probabilistic sensitivity analyses were performed to assess model parameters' uncertainty. WHO willingness-to-pay (WHO-WTP) thresholds were used as reference (i.e. one and three times the Brazilian per capita Gross Domestic Product of R$32747 in 2018). Results Compared to usual practice, the systematic teleophthalmology-based screening was associated with an incremental cost of R$21445/QALY gained ($9792/QALY gained). The systematic ophthalmology referral-based screening was more expensive (incremental costs = R$4) and less effective (incremental QALY = −0.012) compared to the systematic teleophthalmology-based screening. The probability of systematic teleophthalmology-based screening being cost-effective compared to usual practice was 0.46 and 0.67 at the minimum and the maximum WHO-WTP thresholds, respectively. Conclusion Systematic teleophthalmology-based DR screening for the Brazilian population with T2D would be considered very cost effective compared to the opportunistic ophthalmology referral-based screening according to the WHO-WTP threshold. However, there is still a considerable amount of uncertainty around the results.

Cost-effectiveness of diabetic retinopathy screening programs using telemedicine: a systematic review

“…Ben et al [26] performed a model-based economic evaluation to compare three DR screening practices in Brazil. The population included were patients with type 2 DM aged 40 years and without known DR.…”

“…Kanjee et al [25] demonstrated a lower cost to the telemedicine program compared to the conventional in-clinic screening in a Canadian cohort. Ben et al [26] presented that systematic teleophthalmology based screening is cost-effective compared to opportunistic ophthalmology-referral based screening in Brazil. Stanimirovic et al [27] found that teleophthalmology screening dominated the standard of care in a Canadian pilot study (ICER < 0).…”

Diabetic retinopathy screening in urban primary care setting with a handheld smartphone-based retinal camera

“…The sustainability and cost-effectiveness of screening programs are also fundamental for its implementation and success; to the best of our knowledge, ours is the first report on the performance of low-cost, portable handheld devices for DR screening in an urban setting in Brazil, a continent-sized country with very heterogeneous socioeconomic realities and an uneven distribution of ophthalmologists [17], home to the fifth biggest diabetic population in the world [18] and also to the largest public free and chronically underfinanced healthcare system [19]. Multiple socioeconomic barriers prevent access to eye examination in the poor regions of Brazil [3]. Recently, several authors have proposed teleophthalmology to increase access in Brazil and elsewhere, with favorable cost-effectiveness results and a reduced burden to specialized services [3,16,17], in both geographically isolated [15] and highly urbanized areas [20].…”

“…Diabetic retinopathy (DR) is a leading cause of severe visual loss which affects approximately 30 million individuals worldwide and can be prevented with timely screening, detection and treatment; however, even in high-income countries, access to yearly eye examinations is limited to only one-third to one-half of adults with diabetes, leaving a substantial number of patients at risk [1]. In the USA, only about 60% of people with diabetes have recommended yearly screenings for diabetic retinopathy; in some community-based studies, that rate is even lower [2]; in middle-to low-income countries, where access to ophthalmic care is generally limited, the rate of individuals with diabetes who have access to eye examinations is remarkably low [3]. In Brazil, primary health care is developed through forms of teamwork composed of a physician, a nurse, nursing assistants and community agents of health, aiming to assist populations defined by basic health units ("Unidade Básica de Saúde"-UBSs).…”

Diabetic Retinopathy Screening in Urban Primary Care Setting with a Handheld Smartphone-based Retinal Camera.

“…Multiple socioeconomic barriers prevent access to eye examination in the poor regions of Brazil [2]. Recently, several authors have proposed teleophthalmology to increase access, with favorable cost-effectiveness results and a reduced burden to specialized services [13,16].…”