Improving the economic value of photographic screening for optical coherence tomography-detectable macular oedema

a prospective, multicentre, UK study

J. Olson*, P. Sharp, K. Goatman, G. Prescott, G. Scotland, A. Fleming, S. Philip, C. Santiago, S. Borooah, D. Broadbent, V. Chong, P. Dodson, S. Harding, G. Leese, C. Styles, K. Swa, H. Wharton

*Corresponding author for this work

Research output: Contribution to journalArticle

17 Citations (Scopus)
6 Downloads (Pure)

Abstract

Objectives: To determine the best photographic surrogate markers for detecting sight-threatening macular oedema (MO) in people with diabetes attending UK national screening programmes.

Design: A multicentre, prospective, observational cohort study of 3170 patients with photographic signs of diabetic retinopathy visible within the macular region [exudates within two disc diameters, microaneurysms/dot haemorrhages (M/DHs) and blot haemorrhages (BHs)] who were recruited from seven study centres.

Setting: All patients were recruited and imaged at one of seven study centres in Aberdeen, Birmingham, Dundee, Dunfermline, Edinburgh, Liverpool and Oxford.

Participants: Subjects with features of diabetic retinopathy visible within the macular region attending one of seven diabetic retinal screening programmes.

Interventions: Alternative referral criteria for suspected MO based on photographic surrogate markers; an optical coherence tomographic examination in addition to the standard digital retinal photograph.

Main outcome measures: (1) To determine the best method to detect sight-threatening MO in people with diabetes using photographic surrogate markers. (2) Sensitivity and specificity estimates to assess the costs and consequences of using alternative strategies. (3) Modelled long-term costs and quality-adjusted life-years (QALYs).

Results: Prevalence of MO was strongly related to the presence of lesions and was roughly five times higher in subjects with exudates or BHs or more than two M/DHs within one disc diameter. Having worse visual acuity was associated with about a fivefold higher prevalence of MO. Current manual screening grading schemes that ignore visual acuity or the presence of M/DHs could be improved by taking these into account. Health service costs increase substantially with more sensitive/less specific strategies. A fully automated strategy, using the automated detection of patterns of photographic surrogate markers, is superior to all current manual grading schemes for detecting MO in people with diabetes. The addition of optical coherence tomography (OCT) to each strategy, prior to referral, results in a reduction in costs to the health service with no decrement in the number of MO cases detected.

Conclusions: Compared with all current manual grading schemes, for the same sensitivity, a fully automated strategy, using the automated detection of patterns of photographic surrogate markers, achieves a higher specificity for detecting MO in people with diabetes, especially if visual acuity is included in the automated strategy. Overall, costs to the health service are likely to increase if more sensitive referral strategies are adopted over more specific screening strategies for MO, for only very small gains in QALYs. The addition of OCT to each screening strategy, prior to referral, results in a reduction in costs to the health service with no decrement in the number of MO cases detected.

Original languageEnglish
Pages (from-to)1-141
Number of pages141
JournalHealth Technology Assessment
Volume17
Issue number51
Early online date14 Nov 2013
DOIs
Publication statusPublished - Nov 2013

Keywords

  • treatment diabetic-retinopathy
  • intravitreal triamcinolone acetonide
  • sight-threatening retinopathy
  • retinal thickness
  • visual-acuity
  • laser photocoagulation
  • fundus photography
  • eye disease
  • follow-up
  • cost
  • adult
  • automation
  • biological markers
  • diabetic retinopathy
  • female
  • Great Britain
  • humans
  • macular edema
  • male
  • mass screening
  • photography
  • prospective studies
  • quality improvement
  • sensitivity and specificity
  • tomography, optical coherence

Cite this

Improving the economic value of photographic screening for optical coherence tomography-detectable macular oedema : a prospective, multicentre, UK study. / Olson, J.; Sharp, P.; Goatman, K.; Prescott, G.; Scotland, G.; Fleming, A.; Philip, S.; Santiago, C.; Borooah, S.; Broadbent, D.; Chong, V.; Dodson, P.; Harding, S.; Leese, G.; Styles, C.; Swa, K.; Wharton, H.

In: Health Technology Assessment, Vol. 17, No. 51, 11.2013, p. 1-141.

Research output: Contribution to journalArticle

Olson, J. ; Sharp, P. ; Goatman, K. ; Prescott, G. ; Scotland, G. ; Fleming, A. ; Philip, S. ; Santiago, C. ; Borooah, S. ; Broadbent, D. ; Chong, V. ; Dodson, P. ; Harding, S. ; Leese, G. ; Styles, C. ; Swa, K. ; Wharton, H. / Improving the economic value of photographic screening for optical coherence tomography-detectable macular oedema : a prospective, multicentre, UK study. In: Health Technology Assessment. 2013 ; Vol. 17, No. 51. pp. 1-141.
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abstract = "Objectives: To determine the best photographic surrogate markers for detecting sight-threatening macular oedema (MO) in people with diabetes attending UK national screening programmes.Design: A multicentre, prospective, observational cohort study of 3170 patients with photographic signs of diabetic retinopathy visible within the macular region [exudates within two disc diameters, microaneurysms/dot haemorrhages (M/DHs) and blot haemorrhages (BHs)] who were recruited from seven study centres.Setting: All patients were recruited and imaged at one of seven study centres in Aberdeen, Birmingham, Dundee, Dunfermline, Edinburgh, Liverpool and Oxford.Participants: Subjects with features of diabetic retinopathy visible within the macular region attending one of seven diabetic retinal screening programmes.Interventions: Alternative referral criteria for suspected MO based on photographic surrogate markers; an optical coherence tomographic examination in addition to the standard digital retinal photograph.Main outcome measures: (1) To determine the best method to detect sight-threatening MO in people with diabetes using photographic surrogate markers. (2) Sensitivity and specificity estimates to assess the costs and consequences of using alternative strategies. (3) Modelled long-term costs and quality-adjusted life-years (QALYs).Results: Prevalence of MO was strongly related to the presence of lesions and was roughly five times higher in subjects with exudates or BHs or more than two M/DHs within one disc diameter. Having worse visual acuity was associated with about a fivefold higher prevalence of MO. Current manual screening grading schemes that ignore visual acuity or the presence of M/DHs could be improved by taking these into account. Health service costs increase substantially with more sensitive/less specific strategies. A fully automated strategy, using the automated detection of patterns of photographic surrogate markers, is superior to all current manual grading schemes for detecting MO in people with diabetes. The addition of optical coherence tomography (OCT) to each strategy, prior to referral, results in a reduction in costs to the health service with no decrement in the number of MO cases detected.Conclusions: Compared with all current manual grading schemes, for the same sensitivity, a fully automated strategy, using the automated detection of patterns of photographic surrogate markers, achieves a higher specificity for detecting MO in people with diabetes, especially if visual acuity is included in the automated strategy. Overall, costs to the health service are likely to increase if more sensitive referral strategies are adopted over more specific screening strategies for MO, for only very small gains in QALYs. The addition of OCT to each screening strategy, prior to referral, results in a reduction in costs to the health service with no decrement in the number of MO cases detected.",
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author = "J. Olson and P. Sharp and K. Goatman and G. Prescott and G. Scotland and A. Fleming and S. Philip and C. Santiago and S. Borooah and D. Broadbent and V. Chong and P. Dodson and S. Harding and G. Leese and C. Styles and K. Swa and H. Wharton",
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TY - JOUR

T1 - Improving the economic value of photographic screening for optical coherence tomography-detectable macular oedema

T2 - a prospective, multicentre, UK study

AU - Olson, J.

AU - Sharp, P.

AU - Goatman, K.

AU - Prescott, G.

AU - Scotland, G.

AU - Fleming, A.

AU - Philip, S.

AU - Santiago, C.

AU - Borooah, S.

AU - Broadbent, D.

AU - Chong, V.

AU - Dodson, P.

AU - Harding, S.

AU - Leese, G.

AU - Styles, C.

AU - Swa, K.

AU - Wharton, H.

PY - 2013/11

Y1 - 2013/11

N2 - Objectives: To determine the best photographic surrogate markers for detecting sight-threatening macular oedema (MO) in people with diabetes attending UK national screening programmes.Design: A multicentre, prospective, observational cohort study of 3170 patients with photographic signs of diabetic retinopathy visible within the macular region [exudates within two disc diameters, microaneurysms/dot haemorrhages (M/DHs) and blot haemorrhages (BHs)] who were recruited from seven study centres.Setting: All patients were recruited and imaged at one of seven study centres in Aberdeen, Birmingham, Dundee, Dunfermline, Edinburgh, Liverpool and Oxford.Participants: Subjects with features of diabetic retinopathy visible within the macular region attending one of seven diabetic retinal screening programmes.Interventions: Alternative referral criteria for suspected MO based on photographic surrogate markers; an optical coherence tomographic examination in addition to the standard digital retinal photograph.Main outcome measures: (1) To determine the best method to detect sight-threatening MO in people with diabetes using photographic surrogate markers. (2) Sensitivity and specificity estimates to assess the costs and consequences of using alternative strategies. (3) Modelled long-term costs and quality-adjusted life-years (QALYs).Results: Prevalence of MO was strongly related to the presence of lesions and was roughly five times higher in subjects with exudates or BHs or more than two M/DHs within one disc diameter. Having worse visual acuity was associated with about a fivefold higher prevalence of MO. Current manual screening grading schemes that ignore visual acuity or the presence of M/DHs could be improved by taking these into account. Health service costs increase substantially with more sensitive/less specific strategies. A fully automated strategy, using the automated detection of patterns of photographic surrogate markers, is superior to all current manual grading schemes for detecting MO in people with diabetes. The addition of optical coherence tomography (OCT) to each strategy, prior to referral, results in a reduction in costs to the health service with no decrement in the number of MO cases detected.Conclusions: Compared with all current manual grading schemes, for the same sensitivity, a fully automated strategy, using the automated detection of patterns of photographic surrogate markers, achieves a higher specificity for detecting MO in people with diabetes, especially if visual acuity is included in the automated strategy. Overall, costs to the health service are likely to increase if more sensitive referral strategies are adopted over more specific screening strategies for MO, for only very small gains in QALYs. The addition of OCT to each screening strategy, prior to referral, results in a reduction in costs to the health service with no decrement in the number of MO cases detected.

AB - Objectives: To determine the best photographic surrogate markers for detecting sight-threatening macular oedema (MO) in people with diabetes attending UK national screening programmes.Design: A multicentre, prospective, observational cohort study of 3170 patients with photographic signs of diabetic retinopathy visible within the macular region [exudates within two disc diameters, microaneurysms/dot haemorrhages (M/DHs) and blot haemorrhages (BHs)] who were recruited from seven study centres.Setting: All patients were recruited and imaged at one of seven study centres in Aberdeen, Birmingham, Dundee, Dunfermline, Edinburgh, Liverpool and Oxford.Participants: Subjects with features of diabetic retinopathy visible within the macular region attending one of seven diabetic retinal screening programmes.Interventions: Alternative referral criteria for suspected MO based on photographic surrogate markers; an optical coherence tomographic examination in addition to the standard digital retinal photograph.Main outcome measures: (1) To determine the best method to detect sight-threatening MO in people with diabetes using photographic surrogate markers. (2) Sensitivity and specificity estimates to assess the costs and consequences of using alternative strategies. (3) Modelled long-term costs and quality-adjusted life-years (QALYs).Results: Prevalence of MO was strongly related to the presence of lesions and was roughly five times higher in subjects with exudates or BHs or more than two M/DHs within one disc diameter. Having worse visual acuity was associated with about a fivefold higher prevalence of MO. Current manual screening grading schemes that ignore visual acuity or the presence of M/DHs could be improved by taking these into account. Health service costs increase substantially with more sensitive/less specific strategies. A fully automated strategy, using the automated detection of patterns of photographic surrogate markers, is superior to all current manual grading schemes for detecting MO in people with diabetes. The addition of optical coherence tomography (OCT) to each strategy, prior to referral, results in a reduction in costs to the health service with no decrement in the number of MO cases detected.Conclusions: Compared with all current manual grading schemes, for the same sensitivity, a fully automated strategy, using the automated detection of patterns of photographic surrogate markers, achieves a higher specificity for detecting MO in people with diabetes, especially if visual acuity is included in the automated strategy. Overall, costs to the health service are likely to increase if more sensitive referral strategies are adopted over more specific screening strategies for MO, for only very small gains in QALYs. The addition of OCT to each screening strategy, prior to referral, results in a reduction in costs to the health service with no decrement in the number of MO cases detected.

KW - treatment diabetic-retinopathy

KW - intravitreal triamcinolone acetonide

KW - sight-threatening retinopathy

KW - retinal thickness

KW - visual-acuity

KW - laser photocoagulation

KW - fundus photography

KW - eye disease

KW - follow-up

KW - cost

KW - adult

KW - automation

KW - biological markers

KW - diabetic retinopathy

KW - female

KW - Great Britain

KW - humans

KW - macular edema

KW - male

KW - mass screening

KW - photography

KW - prospective studies

KW - quality improvement

KW - sensitivity and specificity

KW - tomography, optical coherence

U2 - 10.3310/hta17510

DO - 10.3310/hta17510

M3 - Article

VL - 17

SP - 1

EP - 141

JO - Health Technology Assessment

JF - Health Technology Assessment

SN - 1366-5278

IS - 51

ER -