Division of Applied Health Sciences, School of Medicine & Dentistry, University of Aberdeen, Aberdeen, UK.
College of Life Sciences and Medicine, University of Aberdeen, Aberdeen, UK.
Br J Ophthalmol. 2014 Aug;98(8):1042-9. doi: 10.1136/bjophthalmol-2013-304338. Epub 2014 Mar 28.
BACKGROUND/AIMS: Retinal screening programmes in England and Scotland have similar photographic grading schemes for background (non-proliferative) and proliferative diabetic retinopathy, but diverge over maculopathy. We looked for the most cost-effective method of identifying diabetic macular oedema from retinal photographs including the role of automated grading and optical coherence tomography, a technology that directly visualises oedema.
Patients from seven UK centres were recruited. The following features in at least one eye were required for enrolment: microaneurysms/dot haemorrhages or blot haemorrhages within one disc diameter, or exudates within one or two disc diameters of the centre of the macula. Subjects had optical coherence tomography and digital photography. Manual and automated grading schemes were evaluated. Costs and QALYs were modelled using microsimulation techniques.
3540 patients were recruited, 3170 were analysed. For diabetic macular oedema, England's scheme had a sensitivity of 72.6% and specificity of 66.8%; Scotland's had a sensitivity of 59.5% and specificity of 79.0%. When applying a ceiling ratio of £30,000 per quality adjusted life years (QALY) gained, Scotland's scheme was preferred. Assuming automated grading could be implemented without increasing grading costs, automation produced a greater number of QALYS for a lower cost than England's scheme, but was not cost effective, at the study's operating point, compared with Scotland's. The addition of optical coherence tomography, to each scheme, resulted in cost savings without reducing health benefits.
Retinal screening programmes in the UK should reconsider the screening pathway to make best use of existing and new technologies.
背景/目的：英格兰和苏格兰的视网膜筛查项目都有类似的摄影分级方案，用于背景（非增生性）和增生性糖尿病视网膜病变，但在黄斑病变方面存在分歧。我们从视网膜照片中寻找最具成本效益的方法来识别糖尿病性黄斑水肿，包括自动分级和光学相干断层扫描（一种直接可视化水肿的技术）的作用。
从英国七个中心招募患者。为了入组，至少一只眼睛需要具备以下特征：一个视盘直径内的微动脉瘤/点状出血或斑状出血，或黄斑中心一个或两个视盘直径内的渗出物。受试者接受光学相干断层扫描和数字摄影。评估手动和自动分级方案。使用微模拟技术对成本和 QALYs 进行建模。
共招募 3540 名患者，分析了 3170 名患者。对于糖尿病性黄斑水肿，英格兰的方案敏感性为 72.6%，特异性为 66.8%；苏格兰的方案敏感性为 59.5%，特异性为 79.0%。当应用每获得一个质量调整生命年（QALY）的上限比值为 30000 英镑时，苏格兰的方案更优。假设可以在不增加分级成本的情况下实施自动分级，那么与英格兰的方案相比，自动化可以以更低的成本产生更多的 QALYs，但在研究的运作点，与苏格兰的方案相比，自动化并不具有成本效益。在每个方案中添加光学相干断层扫描，可在不降低健康效益的情况下节省成本。
英国的视网膜筛查项目应重新考虑筛查途径，以充分利用现有和新技术。
