Cost-effectiveness of alternative methods for diabetic retinopathy screening.
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.
Lairson
D R
DR
University of Texas Health Science Center, School of Public Health, Houston 77225.
Pugh
J A
JA
Kapadia
A S
AS
Lorimor
R J
RJ
Jacobson
J
J
Velez
R
R
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