Elsevier

Ophthalmology

Volume 123, Issue 12, December 2016, Pages 2571-2580
Ophthalmology

Original article
Cost-effectiveness of a National Telemedicine Diabetic Retinopathy Screening Program in Singapore

https://doi.org/10.1016/j.ophtha.2016.08.021Get rights and content

Purpose

To determine the incremental cost-effectiveness of a new telemedicine technician-based assessment relative to an existing model of family physician (FP)–based assessment of diabetic retinopathy (DR) in Singapore from the health system and societal perspectives.

Design

Model-based, cost-effectiveness analysis of the Singapore Integrated Diabetic Retinopathy Program (SiDRP).

Participants

A hypothetical cohort of patients aged 55 years with type 2 diabetes previously not screened for DR.

Methods

The SiDRP is a new telemedicine-based DR screening program using trained technicians to assess retinal photographs. We compared the cost-effectiveness of SiDRP with the existing model in which FPs assess photographs. We developed a hybrid decision tree/Markov model to simulate the costs, effectiveness, and incremental cost-effectiveness ratio (ICER) of SiDRP relative to FP-based DR screening over a lifetime horizon. We estimated the costs from the health system and societal perspectives. Effectiveness was measured in terms of quality-adjusted life-years (QALYs). Result robustness was calculated using deterministic and probabilistic sensitivity analyses.

Main Outcome Measures

The ICER.

Results

From the societal perspective that takes into account all costs and effects, the telemedicine-based DR screening model had significantly lower costs (total cost savings of S$173 per person) while generating similar QALYs compared with the physician-based model (i.e., 13.1 QALYs). From the health system perspective that includes only direct medical costs, the cost savings are S$144 per person. By extrapolating these data to approximately 170 000 patients with diabetes currently being screened yearly for DR in Singapore's primary care polyclinics, the present value of future cost savings associated with the telemedicine-based model is estimated to be S$29.4 million over a lifetime horizon.

Conclusions

While generating similar health outcomes, the telemedicine-based DR screening using technicians in the primary care setting saves costs for Singapore compared with the FP model. Our data provide a strong economic rationale to expand the telemedicine-based DR screening program in Singapore and elsewhere.

Section snippets

Singapore Integrated Diabetic Retinopathy Program

The SiDRP program provides “real-time” assessment of DR photographs by a centralized team of trained and accredited graders supported by a tele-ophthalmology information technology infrastructure. Under the SiDRP system, retinal images are captured in primary care settings and subsequently transmitted to an ocular imaging center via a secured, web-based tele-ophthalmology platform. The trained graders assess the severity of DR in these images and send the results back to the FPs in the primary

Results

Panel 1 of Table 2 shows the total costs, total effectiveness, and ICER of the SiDRP compared with the FP model from the societal perspective. Over a lifetime, a patient with diabetes incurs a total cost of S$2802 and S$2629 under the FP and SiDRP models, respectively. In other words, SiDRP generates a cost savings of S$173 per patient.

The total QALY gain from the SiDRP is almost the same as the FP model (i.e., 13.1129 vs. 13.1123 QALYs). The similar health benefits between the SiDRP and FP

Discussion

This study estimated the cost-effectiveness of a telemedicine technician-based DR screening program (SiDRP) compared with the existing model (assessment by FP) in primary care in Singapore. Base-case results indicated that SiDRP generates a cost savings of $173 per patient ($144 from the health system perspective) relative to the FP model while generating equal QALYs. Our results were robust to variations in a number of key parameters. Extrapolating these results to the current volume of

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    Supplemental material is available at www.aaojournal.org.

    Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

    The authors received funding from the Singapore Ministry of Health, Grant Reference AIC/RPDD/SIDRP/SERI/FY2013/0018 and AIC/HPD/FY2016/0912.

    Author Contributions:

    Conception and design: Nguyen, Wong, Lamoureux

    Data collection: Wei, Wong, Lamoureux

    Analysis and interpretation: Nguyen, Wei, Tapp, Mital, Ting, Wong, Tan, Laude, Tai, Tan, Finkelstein, Wong, Lamoureux

    Obtained funding: Not applicable

    Overall responsibility: Nguyen, Wei, Tapp, Mital, Ting, Wong, Tan, Laude, Tai, Tan, Finkelstein, Wong, Lamoureux

    Both authors T.Y.W. and E.L.L. contributed equally.

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