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Chung YC, Kao YW, Huang YC, Chen PE, Liao SC, Liu CK, Chen M. Cost-effectiveness of diabetic retinopathy screening for newly diagnosed type 2 diabetic patients: A nationwide population-based propensity score-matched cohort study. Asia Pac J Ophthalmol (Phila) 2024; 13:100071. [PMID: 38768659 DOI: 10.1016/j.apjo.2024.100071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/16/2023] [Accepted: 12/20/2023] [Indexed: 05/22/2024] Open
Abstract
AIMS This study investigated the association between the frequency of screening for diabetic retinopathy (DR) versus the development of DR and corresponding medical expenses among patients newly diagnosed with type 2 diabetes mellitus (T2DM). METHODS This longitudinal, population-based study used the Taiwan National Health Insurance Research Database (2004 to 2020) as a data source. Propensity score matching (PSM) (sex, age, comorbidities and concurrent medication use) was employed in the grouping of T2DM patients according to different frequency of DR screening. Outcome measures included the proportion of patients who developed DR, who received DR treatment, and the associated medical expenses and hospitalizations. RESULTS The 17-year cohort included 337,046 patients. After PSM, three groups each containing 35,739 patients were assembled and analyzed. Compared to low-frequency screening, high-frequency screening was more effective in detecting patients requiring treatment; however, the net cost for treatment was significantly lower. Standard-frequency screening appears to provide the best balance in terms of DR detection, diagnosis interval, the risk of DR-related hospitalization, and DR treatment costs. CONCLUSIONS In this real-world cohort study covering all levels of the healthcare system, infrequent screening was associated with delayed diagnosis and elevated treatment costs, while a fundus screening interval of 1-2 years proved optimal in terms of detection and medical expenditures.
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Affiliation(s)
- Yu-Chien Chung
- Department of Ophthalmology, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan; Graduate Institute of Business Administration, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Yi-Wei Kao
- Artificial Intelligence Development Center, Fu Jen Catholic University, New Taipei City, Taiwan; Department of Applied Statistics and Information Science, Ming Chuan University, Taoyuan City, Taiwan
| | - Yen-Chun Huang
- Department of Artificial Intelligence, Tamkang University, No.151, Yingzhuan Rd., Tamsui Dist., New Taipei City 251301, Taiwan, ROC
| | - Pei-En Chen
- Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan
| | - Shu-Chen Liao
- Graduate Institute of Business Administration, Fu Jen Catholic University, New Taipei City, Taiwan; Department of Orthopaedics, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan
| | - Chih-Kuang Liu
- Graduate Institute of Business Administration, Fu Jen Catholic University, New Taipei City, Taiwan; Camillian St Mary's Hospital Luodong, Yilan, Taiwan
| | - Mingchih Chen
- Graduate Institute of Business Administration, Fu Jen Catholic University, New Taipei City, Taiwan; Artificial Intelligence Development Center, Fu Jen Catholic University, New Taipei City, Taiwan.
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Chung YC, Xu T, Tung TH, Chen M, Chen PE. Early Screening for Diabetic Retinopathy in Newly Diagnosed Type 2 Diabetes and Its Effectiveness in Terms of Morbidity and Clinical Treatment: A Nationwide Population-Based Cohort. Front Public Health 2022; 10:771862. [PMID: 35570930 PMCID: PMC9094682 DOI: 10.3389/fpubh.2022.771862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/21/2022] [Indexed: 11/17/2022] Open
Abstract
Purpose To characterize the association between the frequency of screening for diabetic retinopathy (DR) and the detection of DR in patients with newly diagnosed type 2 diabetes mellitus (T2DM). Methods This nationwide population-based cohort study used data from the National Health Insurance Research Database to identify adult patients who were newly diagnosed with T2DM between 2000 and 2004. Data from their follow-up Diabetic retinopathy (DR) treatments over the next 10 years following diagnosis were also analyzed. Results The 41,522 subjects were respectively assigned to a periodic screening group (n = 3850) and nonperiodic screening group (n = 37,672). Significant differences were observed between the two groups in terms of age, Charlson Comorbidity Index (CCI), sex, DR treatment, and the prevalence of DR. The association between periodic screening and DR treatment, only the elderly, female, and patient with severe CCI status showed the significance in the further stratified analysis. Conclusion Periodic screening (annual or biannual screening in the first 5 years) was more effective than nonperiodic screening in detecting instances of DR in the middle-to-advanced aged group but not among younger patients. Screening pattern did not have a significant effect on the likelihood of DR-related treatment during the 5-year follow-up. It appears that a tight screening schedule for the first 5 years after diagnosis with diabetes is not necessary.
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Affiliation(s)
- Yu-Chien Chung
- Department of Ophthalmology, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan.,Graduate Institute of Business Administration, Fu Jen Catholic University, New Taipei City, Taiwan.,School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Ting Xu
- Department Endocrinology and Metabolism, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Tao-Hsin Tung
- Evidence-Based Medicine Center, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Mingchih Chen
- Graduate Institute of Business Administration, Fu Jen Catholic University, New Taipei City, Taiwan.,Artificial Intelligence Development Center, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Pei-En Chen
- Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan.,Taiwan Association of Health Industry Management and Development, Taipei, Taiwan
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Abstract
PURPOSE OF REVIEW The purpose of this study is to review the evidence that lower risk groups who could safely be screened less frequently for sight-threatening diabetic retinopathy (DR) than annually. RECENT FINDINGS Data have demonstrated that people with no DR in either eye are at a low risk of progression to sight-threatening DR over a 2-year period (event rate 4.8 per 1000 person years), irrespective of whether the screening method is one-field non-mydriatic or two-field mydriatic digital photography. Low risk has been defined as no retinopathy on two consecutive screening episodes or no retinopathy on one screening episode combined with risk factor data. The risk of an extension to 2 years is less than 5 per 1000 person years in a population with a national screening programme, and the general standard of diabetes care is relatively good, whether low risk is defined as no retinopathy on two consecutive screening episodes or no retinopathy on one screening episode combined with other risk factor data. The definition used in different populations is likely to depend on the availability of data.
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Affiliation(s)
- Peter H Scanlon
- Gloucestershire Retinal Research Group, Gloucestershire Hospitals NHS Foundation Trust, Office above Oakley Ward, Cheltenham General Hospital, Sandford Road, Cheltenham, GL53 7AN, UK.
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, UK.
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Hughes D, Nair S, Harvey JN. Determining diabetic retinopathy screening interval based on time from no retinopathy to laser therapy. J Med Screen 2016; 24:170-175. [PMID: 27810985 DOI: 10.1177/0969141316672687] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives To determine the necessary screening interval for retinopathy in diabetic patients with no retinopathy based on time to laser therapy and to assess long-term visual outcome following screening. Methods In a population-based community screening programme in North Wales, 2917 patients were followed until death or for approximately 12 years. At screening, 2493 had no retinopathy; 424 had mostly minor degrees of non-proliferative retinopathy. Data on timing of first laser therapy and visual outcome following screening were obtained from local hospitals and ophthalmology units. Results Survival analysis showed that very few of the no retinopathy at screening group required laser therapy in the early years compared with the non-proliferative retinopathy group ( p < 0.001). After two years, <0.1% of the no retinopathy at screening group required laser therapy, and at three years 0.2% (cumulative), lower rates of treatment than have been suggested by analyses of sight-threatening retinopathy determined photographically. At follow-up (mean 7.8 ± 4.6 years), mild to moderate visual impairment in one or both eyes due to diabetic retinopathy was more common in those with retinopathy at screening (26% vs. 5%, p < 0.001), but blindness due to diabetes occurred in only 1 in 1000. Conclusions Optimum screening intervals should be determined from time to active treatment. Based on requirement for laser therapy, the screening interval for diabetic patients with no retinopathy can be extended to two to three years. Patients who attend for retinal screening and treatment who have no or non-proliferative retinopathy now have a very low risk of eventual blindness from diabetes.
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Affiliation(s)
- Daniel Hughes
- 1 Diabetes Research Group, School of Medical Sciences, Bangor University, Bangor, UK
| | - Sunil Nair
- 2 Department of Diabetes & Endocrinology, Countess of Chester Hospital, Chester, UK
| | - John N Harvey
- 1 Diabetes Research Group, School of Medical Sciences, Bangor University, Bangor, UK
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Results of a diabetic retinopathy screening. Risk markers analysis. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2016; 91:15-9. [PMID: 26614736 DOI: 10.1016/j.oftal.2015.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 08/16/2015] [Accepted: 09/15/2015] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To identify risk markers for retinopathy in patients from our geographic area, and to compare them with those published in other studies. To design a screening interval strategy, taking into account these results, and compare it with intervals suggested in published studies. MATERIAL AND METHODS Cross-sectional observational study on 383 diabetic patients with no previous retinopathy diagnosis, who were screened for diabetic retinopathy. An analysis was made on the possible association between patient factors and presence of retinopathy. RESULTS A greater probability for finding retinopathy in diabetic patients was associated to insulin treatment in our study, with a statistical significance level of 95%. In patients with less than 10year onset of their diabetes, only mild retinopathy without macular oedema was found. CONCLUSIONS Insulin treatment and time of onset of diabetes should be taken into account when designing efficient screening strategies for diabetic retinopathy.
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Soto-Pedre E, Pinies JA, Hernaez-Ortega MC. External validation of a risk assessment model to adjust the frequency of eye-screening visits in patients with diabetes mellitus. J Diabetes Complications 2015; 29:508-11. [PMID: 25725582 DOI: 10.1016/j.jdiacomp.2014.12.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 12/15/2014] [Accepted: 12/29/2014] [Indexed: 11/22/2022]
Abstract
AIMS To validate a sight-threatening diabetic retinopathy (STDR) risk assessment model to adjust the frequency of eye-screening visits in patients with diabetes mellitus. METHODS Retrospective follow-up study of patients with diabetes mellitus attending a diabetes center. Anonimyzed data on gender, type and duration of diabetes, HbA1c, blood pressure and the presence and grade of diabetic retinopathy were gathered to estimate risk for STDR for each individual's worse eye over time by means of a prediction model. Receiver operating characteristics (ROC) analysis was performed to determine the diagnostic ability of the model, and a calibration graph was done to see the model fit. RESULTS 508 screening intervals were analyzed, median diabetes duration was 10years, 87% were type 2 diabetes mellitus, and 3.1% developed STDR before the next screening visit. The area under the ROC curve was 0.74, and the calibration graph showed that model had a good fit. The reduction in screening frequency was 40% compared with fixed annual screening. CONCLUSIONS Current prediction model used to estimate the risk of developing STDR in patients with diabetes performed well. A personalized screening frequency for diabetic retinopathy could be implemented in practice.
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Affiliation(s)
- Enrique Soto-Pedre
- European Innovative Biomedicine Institute (EIBI), C/ Jardines #2, Apt. 1-G, 39700 Castro Urdiales, Cantabria, Spain.
| | - Jose A Pinies
- Pinies Diabetes Centre (PDC), C/ Gran Via 40 Bis, 2°, 48009 Bilbao, Vizcaya, Spain
| | - Maria C Hernaez-Ortega
- European Innovative Biomedicine Institute (EIBI), C/ Jardines #2, Apt. 1-G, 39700 Castro Urdiales, Cantabria, Spain
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Soto-Pedre E, Navea A, Millan S, Hernaez-Ortega MC, Morales J, Desco MC, Pérez P. Evaluation of automated image analysis software for the detection of diabetic retinopathy to reduce the ophthalmologists' workload. Acta Ophthalmol 2015; 93:e52-6. [PMID: 24975456 DOI: 10.1111/aos.12481] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 05/17/2014] [Indexed: 11/30/2022]
Abstract
AIMS To assess the safety and workload reduction of an automated 'disease/no disease' grading system for diabetic retinopathy (DR) within a systematic screening programme. METHODS Single 45° macular field image per eye was obtained from consecutive patients attending a regional primary care based DR screening programme in Valencia (Spain). The sensitivity and specificity of automated system operating as 'one or more than one microaneurysm detection for disease presence' grader were determined relative to a manual grading as gold standard. Data on age, gender and diabetes mellitus were also recorded. RESULTS A total of 5278 patients with diabetes were screened. The median age and duration of diabetes was 69 years and 6.9 years, respectively. Estimated prevalence of DR was 15.6%. The software classified 43.9% of the patients as having no DR and 26.1% as having ungradable images. Detection of DR was achieved with 94.5% sensitivity (95% CI 92.6- 96.5) and 68.8% specificity (95%CI 67.2-70.4). The overall accuracy of the automated system was 72.5% (95%CI 71.1-73.9). CONCLUSIONS The present retinal image processing algorithm that can act as prefilter to flag out images with pathological lesions can be implemented in practice. Our results suggest that it could be considered when implementing DR screening programmes.
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Affiliation(s)
| | - Amparo Navea
- Fundación Oftalmológica del Mediterráneo (FOM); Valencia Spain
| | - Saray Millan
- Fundación Oftalmológica del Mediterráneo (FOM); Valencia Spain
| | | | - Jesús Morales
- Fundación Oftalmológica del Mediterráneo (FOM); Valencia Spain
| | - Maria C. Desco
- Fundación Oftalmológica del Mediterráneo (FOM); Valencia Spain
| | - Pablo Pérez
- Fundación Oftalmológica del Mediterráneo (FOM); Valencia Spain
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Taylor-Phillips S, Mistry H, Leslie R, Todkill D, Tsertsvadze A, Connock M, Clarke A. Extending the diabetic retinopathy screening interval beyond 1 year: systematic review. Br J Ophthalmol 2015; 100:105-14. [PMID: 25586713 PMCID: PMC4717369 DOI: 10.1136/bjophthalmol-2014-305938] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Accepted: 12/14/2014] [Indexed: 01/09/2023]
Abstract
To determine whether the recommended screening interval for diabetic retinopathy (DR) in the UK can safely be extended beyond 1 year. Systematic review of clinical and cost-effectiveness studies. Nine databases were searched with no date restrictions. Randomised controlled trials (RCTs), cohort studies, prognostic or economic modelling studies which described the incidence and progression of DR in populations with type 1 diabetes mellitus or type 2 diabetes mellitus of either sex and of any age reporting incidence and progression of DR in relation to screening interval (vs annual screening interval) and/or prognostic factors were included. Narrative synthesis was undertaken. 14 013 papers were identified, of which 11 observational studies, 5 risk stratification modelling studies and 9 economic studies were included. Data were available for 262 541 patients of whom at least 228 649 (87%) had type 2 diabetes. There were no RCTs. Studies concluded that there is little difference between clinical outcomes from screening 1 yearly or 2 yearly in low-risk patients. However there was high loss to follow-up (13–31%), heterogeneity in definitions of low risk and variation in screening and grading protocols for prior retinopathy results. Observational and economic modelling studies in low-risk patients show little difference in clinical outcomes between 1-year and 2-year screening intervals. The lack of experimental research designs and heterogeneity in definition of low risk considerably limits the reliability and validity of this conclusion. Cost-effectiveness findings were mixed. There is insufficient evidence to recommend a move to extend the screening interval beyond 1 year.
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Affiliation(s)
| | - Hema Mistry
- Warwick Medical School, The University of Warwick, Coventry, UK
| | - Rachael Leslie
- Warwick Medical School, The University of Warwick, Coventry, UK
| | - Dan Todkill
- Warwick Medical School, The University of Warwick, Coventry, UK
| | | | - Martin Connock
- Warwick Medical School, The University of Warwick, Coventry, UK
| | - Aileen Clarke
- Warwick Medical School, The University of Warwick, Coventry, UK
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Ribeiro L, Oliveira CM, Neves C, Ramos JD, Ferreira H, Cunha-Vaz J. Screening for Diabetic Retinopathy in the Central Region of Portugal. Added Value of Automated 'Disease/No Disease' Grading. Ophthalmologica 2014; 233:000368426. [PMID: 25427567 DOI: 10.1159/000368426] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 09/05/2014] [Indexed: 11/19/2022]
Abstract
Purpose: To describe the procedures of a nonmydriatic diabetic retinopathy (DR) screening program in the Central Region of Portugal and the added value of the introduction of an automated disease/no disease analysis. Methods: The images from the DR screening program are analyzed in a central reading center using first an automated disease/no disease analysis followed by human grading of the disease cases. The grading scale used is as follows: R0 - no retinopathy, RL - nonproliferative DR, M - maculopathy, RP - proliferative DR and NC - not classifiable. Results: Since the introduction of automated analysis in July 2011, a total of 89,626 eyes (45,148 patients) were screened with the following distribution: R0 - 71.5%, RL - 22.7%, M - 2.2%, RP - 0.1% and NC - 3.5%. The implemented automated system showed the potential for human grading burden reduction of 48.42%. Conclusions: Screening for DR using automated analysis allied to a simplified grading scale identifies DR vision-threatening complications well while decreasing human burden. © 2014 S. Karger AG, Basel.
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Affiliation(s)
- Luisa Ribeiro
- AIBILI, CORC - Association for Innovation and Biomedial Research on Light and Image, Coimbra Ophthalmology Reading Center, Coimbra, Portugal
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Echouffo-Tcheugui JB, Ali MK, Roglic G, Hayward RA, Narayan KM. Screening intervals for diabetic retinopathy and incidence of visual loss: a systematic review. Diabet Med 2013; 30:1272-92. [PMID: 23819487 DOI: 10.1111/dme.12274] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2013] [Indexed: 12/18/2022]
Abstract
Screening for diabetic retinopathy can help to prevent this complication, but evidence regarding frequency of screening is uncertain. This paper systematically reviews the published literature on the relationship between screening intervals for diabetic retinopathy and the incidence of visual loss. The PubMed and EMBASE databases were searched until December 2012. Twenty five studies fulfilled the inclusion criteria, as these assessed the incidence/prevalence of sight-threatening diabetic retinopathy in relation to screening frequency. The included studies comprised 15 evaluations of real-world screening programmes, three studies modelling the natural history of diabetic retinopathy and seven cost-effectiveness studies. In evaluations of diabetic retinopathy screening programmes, the appropriate screening interval ranged from one to four years, in people with no retinopathy at baseline. Despite study heterogeneity, the overall tendency observed in these programmes was that 2-year screening intervals among people with no diabetic retinopathy at diagnosis were not associated with high incidence of sight-threatening diabetic retinopathy. The modelling studies (non-economic and economic) assessed a range of screening intervals (1-5 years). The aggregated evidence from both the natural history and cost-effectiveness models favors a screening interval >1 year, but ≤2 years. Such an interval would be appropriate, safe and cost-effective for people with no diabetic retinopathy at diagnosis, while screening intervals ≤1 year would be preferable for people with pre-existing diabetic retinopathy. A 2-year screening interval for people with no sight threatening diabetic retinopathy at diagnosis may be safely adopted. For patients with pre-existing diabetic retinopathy, a shorter interval ≤1 year is warranted.
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Affiliation(s)
- J B Echouffo-Tcheugui
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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