Five-Year Cost-Effectiveness Modeling of Primary Care-Based, Nonmydriatic Automated Retinal Image Analysis Screening Among Low-Income Patients With Diabetes

Abstract

Background: Artificial intelligence-based technology systems offer an alternative solution for diabetic retinopathy (DR) screening compared with standard, in-office dilated eye examinations. We performed a cost-effectiveness analysis of Automated Retinal Image Analysis System (ARIAS)-based DR screening in a primary care medicine clinic that serves a low-income patient population. Methods: A model-based, cost-effectiveness analysis of two DR screening systems was created utilizing data from a recent study comparing adherence rates to follow-up eye care among adults ages 18 or older with a clinical diagnosis of diabetes. In the study, the patients were prescreened with an ARIAS-based, nonmydriatic (undilated), point-of-care tool in the primary care setting and were compared with patients with diabetes who were referred for dilated retinal screening without prescreening, as is the current standard of care. Using a Markov model with microsimulation resulting in a total of 600 000 simulated patient experiences, we calculated the incremental cost-utility ratio (ICUR) of the two screening approaches, with regard to five-year cost-effectiveness of DR screening and treatment of vision-threatening DR. Results: At five years, ARIAS-based screening showed similar utility as the standard of care screening systems. However, ARIAS reduced costs by 23.3%, with an ICUR of $258 721.81 comparing the current practice to ARIAS. Conclusions: Primary care-based ARIAS DR screening is cost-effective when compared with standard of care screening methods.

Utilization of Remote Diabetic Retinal Screening in a Suburban Healthcare System

“…One such study found a cost-savings of 23.3% for diabetic eye screening conducted by automated widefield nFP provided in the primary care setting as compared with standard dilated retinal examinations. 29 However, our model does not consider the additional costs of acquiring the necessary training and equipment (i.e. fundus camera) for teleophthalmology or its maintenance.…”

“…As a result, they found significantly higher rates of newly-diagnosed DR, compared with the rate in our study. 29,[35][36][37][38][39][40][41] For example, Jani et al 37 found that 20.3% of screened patients had evidence of DR, but those patients lived in rural areas, were mostly non-white, and had not had recent eye examinations. Similarly, Owsley et al 36 found that 21.7% of patients screened positive for DR in a largely uninsured, underserved minority population.…”

“…[18][19][20] Remote retinal screening is typically performed by using non-mydriatic fundus photography (nFP) at the point-of-care, with the images sent to a trained reader, either an ophthalmologist or optometrist, or an automated retinal image analysis system, to look for signs of diabetic eye disease or other ocular pathology. [21][22][23][24][25][26][27][28][29] Because of its high accuracy in monitoring and screening for eye disease, [21][22][23][24] tele-ophthalmology is now considered by the World Health Organization and American Academy of Ophthalmology to be an appropriate tool for population-wide DR screening. 30,31 Tele-ophthalmology also presents a great opportunity for cost-savings when implemented in appropriate patient populations.…”

“…30,31 Tele-ophthalmology also presents a great opportunity for cost-savings when implemented in appropriate patient populations. [27][28][29]32 However, 80-85% of US ophthalmology practices do not currently provide any teleophthalmology services. 33 Previous programs employing remote retinal imaging to screen for DR in the US have primarily focused on its use in underserved populations, and as a result, they have reported substantial rates of newly-diagnosed DR. 29,[34][35][36][37][38][39][40][41] To our knowledge, there is no literature assessing the utilization of a tele-ophthalmology program for remote DR screening in a low-risk, well-insured population.…”

“…[27][28][29]32 However, 80-85% of US ophthalmology practices do not currently provide any teleophthalmology services. 33 Previous programs employing remote retinal imaging to screen for DR in the US have primarily focused on its use in underserved populations, and as a result, they have reported substantial rates of newly-diagnosed DR. 29,[34][35][36][37][38][39][40][41] To our knowledge, there is no literature assessing the utilization of a tele-ophthalmology program for remote DR screening in a low-risk, well-insured population. In this study, patients with diabetes without DR were invited to undergo point-of-care nFP in a suburban primary care setting to screen for DR.…”