Lesson 9: Cost of screening

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Diabetes places a great economic burden on countries due to lost productivity and the costs of treating the disease and managing its complications. The cost of diabetes management to the UK’s National Health Service was estimated at £14 billion pounds in 2012, with about 80% of this being spent on managing its complications, including diabetic retinopathy (DR).

The Diabetes Atlas – 8th Edition highlights the economic impact of diabetes for countries, their health systems, and for individuals with diabetes and their families. It also demonstrates how the mean expenditure per person with diabetes varies widely across different regions. Expenditure is highest in North American settings and lowest in South East Asia and Africa.

A challenge for diabetic eye care services

Nearly 80% of all people with diabetes live in low- and middle-income countries where funding is constrained, there is limited availability of health providers, the provision of the primary healthcare facilities needed to manage diabetes and its complications is inadequate and there are long distances between people with diabetes and the services they need. We need to identify cost-effective strategies and technologies to reach these people, improve their access to eye care and prevent vision loss from DR.

What is cost effective analysis?

The cost-effective analysis is a tool policy-makers can use to assess which health interventions provide the highest “value for money.” Various cost-effectiveness studies for DR services have been undertaken based on available data or using data modelling. Most of these studies have been done in high-income settings but they can provide insights into approaches to DR screening in less well-resourced contexts. Some of the key highlights from these studies are highlighted below:

  • DR screening is more cost-effective than no screening at all. The evidence
  • suggests that strategies aimed at preventing the progression of DR may reduce the economic burden on individuals and society.
  • Systematic screening has been found to be more cost-effective than opportunistic screening.
  • Extending screening intervals to every 2 years, instead of annual screening, can be a cost-effective option.
  • Targeted priority screening of high-risk patients, for example, those with poor glycaemic control or a long duration of diabetes is an option in countries with limited resources.
  • Cost-effective telemedicine programmes improve access to eye care in remote environments and reduce the number of consultations in eye clinics.
  • Charging DR screening fees has been found to lower the uptake and acceptance of eye care services compared to a free screening.
  • Effective non-mydriatic screening technologies have some benefits as mydriasis (dilation of the pupil) has cost implications for the patient, e.g. difficulties in travelling or working.
  • A reliable screening test with high sensitivity and specificity is essential to deliver a cost-effective screening programme. Newer portable technologies should be evaluated in the local setting before being implemented.

In all these cases it remains important to undertake local studies to identify feasibly and cost-effective options for screening models and treatment options. There are many factors that influence the cost of DR screening at the national and local level: distance to the patient, equipment costs, validity and reliability of the screening test, the skills and training for personnel doing the screening and grading; and most importantly the availability of treatment for visually threatening DR (such as laser or anti-VEGF injections) is an essential requirement for every screening programme. Early detection of DR and its management has to be considered in the context of the general and health economic constraints and challenges experienced within your country and local setting.