Cost-effectiveness and cost-utility of traditional and telemedicine combined population-based age-related macular degeneration and diabetic retinopathy screening in rural and urban China

Background To assess the cost-effectiveness and cost-utility of a population-level traditional and telemedicine combined age-related macular degeneration (AMD) and diabetic retinopathy (DR) screening program in rural and urban China. Methods Decision-analytic Markov models were conducted to evaluate the costs and benefits of traditional and telemedicine combined AMD and DR screening from a societal perspective. A cohort of all participants aged 50 years old and above was followed through a total of 30 1-year Markov cycles. Separate analyses were performed for rural and urban settings. Relevant parameters such as the prevalence of AMD and DR, transition probability, compliance with screening and treatment, screening sensitivity, specificity, utility, and mortality were collected from published studies specific to China, other Asian counties' studies, or unpublished data sources such as the National Committee for the Prevention of Blindness. Costs of screening, full examination, and treatment come from the real medical environments and unified pricing of Beijing Municipal Medical Insurance Bureau. Primary outcomes were incremental cost-utility ratios (ICURs) using quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs) using years of blindness avoided. One-way deterministic and simulated probabilistic sensitivity analyses were conducted to reflect uncertainty. Findings Under the status quo, the total expected medical costs for a 50-year-old patient with AMD or DR were $869.59 and $1,514.18 in rural and urban settings, respectively. Both traditional and telemedicine screening were highly cost-effective. In rural settings, ICURs were $191 (95% confidence interval [CI]: $66 to $239) and $199 (95% CI: $-12 to $217), and ICERs were $2,436 (95% CI: $1,089 to $3,254) and $2,441 (95% CI: $1,452 to $3,900) for traditional and telemedicine screening separately. Even more surprising, both screening strategies dominated no screening in urban settings. Our results were insensitive and robust to extensive sensitivity analyses. Among all acceptable screening intervals (from 1 to 5 years), annual screening could not only produce biggest benefits but also keep ICERs less than three times and one time the per capita gross domestic product (GDP) in rural and urban settings separately. When compared with traditional screening, ICERs of telescreening were less than three times the per capita GDP in rural settings ($2,559 to $8,809) and less than one time the per capita GDP in urban settings (less than $5,564), annual telescreening produced the biggest benefits, it could avert 119 and 270 years of blindness in rural and urban areas separately when 100,000 people were screened. Interpretation We performed decision-analytic Markov models for combined AMD and DR screening in rural and urban China, and the results showed that population-level combined screening for AMD and DR is likely to be highly cost-effective in both rural and urban China for people over 50 years old. Optimal screening may have an interval of every year based on teleophthalmology platforms. In the future, China should pay more attention to chronic eye diseases and the government should establish a sound chronic disease management system and make every patient enjoy equal medical services. Copyright (C) 2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Automated summary

This study assessed the cost-effectiveness of an AMD and DR screening program in rural and urban China. The results showed that screening for AMD and DR in individuals aged 50 and above is highly cost-effective in both rural and urban settings. Annual telemedicine screening produced the greatest benefits and could help prevent blindness. Therefore, China should prioritize chronic eye diseases and establish a comprehensive chronic disease management system to ensure equal access to medical services for all patients.