title: Cost-effectiveness of alternative methods for diabetic retinopathy screening.
abstract: OBJECTIVE
  To assess from the perspectives of a government delivery system and patients, the cost-effectiveness of the 45-degrees retinal camera compared to the standard ophthalmologist's exam and an ophthalmic exam by a physician's assistant or nurse practitioner technician, for detecting nonproliferative and proliferative diabetic retinopathy.
  
  
  METHODS
  Comparison of 45-degrees fundus photographs with and without pharmacological pupil dilation taken by technicians and interpreted by experts, direct and indirect ophthalmoscopy by ophthalmologists, and direct ophthalmoscopy by technicians with seven-field stereoscopic fundus photography (reference standard). Costs were estimated from market prices and actual resource use. The study included 352 patients attending outpatient diabetes and general-medicine clinics at VA and DOD facilities.
  
  
  RESULTS
  Medical system costs per true positive were: 45-degrees photos with dilation, $295; 45-degrees photos without dilation, $378; ophthalmologist, $390; and technician, $794. Patient costs per true positive were: 45-degrees photos with dilation, $139; 45-degrees photos without dilation, $171; ophthalmologist, $306; and technician, $1009. Cost-effectiveness is sensitive to program size due to high fixed cost of the camera methods but not to prevalence. Cost-effectiveness of the technician exam is strongly affected by its sensitivity.
  
  
  CONCLUSIONS
  Primary-care screening with retinal photographs through pharmacologically dilated pupils for diabetic retinopathy is an appropriate and cost-effective alternative to screening by an ophthalmologist in this setting. Ophthalmologists are scarce, primary-care physicians are extremely busy, and large clinics allow fixed equipment costs to be spread across many patients.
authors.affiliation: University of Texas Health Science Center, School of Public Health, Houston 77225.
authors.forename: D R
authors.initials: DR
authors.lastname: Lairson
authors.forename: J A
authors.initials: JA
authors.lastname: Pugh
authors.forename: A S
authors.initials: AS
authors.lastname: Kapadia
authors.forename: R J
authors.initials: RJ
authors.lastname: Lorimor
authors.forename: J
authors.initials: J
authors.lastname: Jacobson
authors.forename: R
authors.initials: R
authors.lastname: Velez
mesh_terms: D003362:Cost-Benefit Analysis; D003930:Diabetic Retinopathy / Q000175:diagnosis / Q000191:economics / Q000517:prevention & control*; D005006:Ethnicity; D005451:Fluorescein Angiography / Q000191:economics; D006801:Humans; D008403:Mass Screening / Q000191:economics*; D008875:Middle Aged; D012959:Socioeconomic Factors; D014481:United States