Sculpher M J, Buxton M J, Ferguson B A, Spiegelhalter D J, Kirby A J
Health Economics Research Group, Brunel University, Uxbridge, Middlesex, UK.
Health Econ. 1992 Apr;1(1):39-51. doi: 10.1002/hec.4730010107.
Diabetic retinopathy is the most common cause of blindness among adults of working age in the UK. If the disease is detected early effective treatment can be provided and this has resulted in calls for a systematic national screening programme. Using data on the screening of 3423 diabetics collected as part of an experimental programme in three UK centres, the relative cost-effectiveness of various screening options is assessed. The paper utilises direct evidence on a number of single modality screening options, including ophthalmoscopy undertaken by general practitioners or ophthalmic opticians, and non-mydriatic photography. With the objective of increasing the sensitivity of screening and using data collected in the study, options based on two further potential screening strategies are modelled and evaluated: combined screening using both ophthalmoscopy and non-mydriatic photography; and selective screening where high-risk diabetics are directly referred to an ophthalmologist and low-risk cases are either left unscreened or are screened by one of the single or combined modality screening options. Given the objective of early detection, effectiveness is assessed in terms of the sensitivity and specificity of the referral decisions of screening options. Both health service and private resource costs of the various screening options are estimated, the latter in terms of travel and the opportunity cost of time. Cost effectiveness is evaluated in terms of the expected cost per true positive case of diabetic retinopathy referred by the screening options. To narrow the choice between the options, those subject to three-way domination with respect to the three choice variables of sensitivity, specificity and expected cost per true positive are excluded. Amongst the remaining options, the choice is dependent on the trade-off between the higher specifics of unselective single modality screening options and the higher sensitivities and lower expected costs per true positive case detected of combined modality and selective screening options.
糖尿病视网膜病变是英国工作年龄成年人失明的最常见原因。如果能早期发现该疾病，就能提供有效的治疗，这促使人们呼吁开展全国性系统筛查计划。利用作为英国三个中心的一项实验计划的一部分收集的3423名糖尿病患者的筛查数据，评估了各种筛查方案的相对成本效益。本文利用了关于多种单模态筛查方案的直接证据，包括全科医生或眼科验光师进行的检眼镜检查以及非散瞳摄影。为了提高筛查的敏感性并利用研究中收集的数据，对基于另外两种潜在筛查策略的方案进行了建模和评估：检眼镜检查和非散瞳摄影联合筛查；以及选择性筛查，即高危糖尿病患者直接转诊至眼科医生，低危患者要么不进行筛查，要么通过单模态或联合模态筛查方案之一进行筛查。鉴于早期检测的目标，从筛查方案转诊决策的敏感性和特异性方面评估有效性。估计了各种筛查方案的医疗服务和私人资源成本，后者包括交通费用和时间机会成本。根据筛查方案转诊的糖尿病视网膜病变每例真阳性病例的预期成本评估成本效益。为了缩小方案之间的选择范围，排除了在敏感性、特异性和每例真阳性预期成本这三个选择变量方面受到三向支配的方案。在其余方案中，选择取决于非选择性单模态筛查方案较高特异性与联合模态和选择性筛查方案较高敏感性以及每例检测到的真阳性病例较低预期成本之间的权衡。
