Stanimirovic Aleksandra, Francis Troy, Meerai Sonia, Mathew Suja, Ibrahim Sarah, Bowen James M, PIkula Aleksandra, Rac Valeria
Toronto General Hospital Research Institute, Ted Rogers Centre for Heart Research at Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.
Institute of Health Policy, Management and Evaluation, University of Toronto, Dalla Lana School of Public Health, Toronto, ON, Canada.
JMIR Res Protoc. 2025 Apr 30;14:e60488. doi: 10.2196/60488.
Diabetic retinopathy (DR) remains the primary vision complication of diabetes and the leading cause of blindness among adults, with up to 30% prevalence among low-income populations. Tele-retina is a cost-effective screening alternative to vision loss prevention, yet there is an adverse association between screening and income. Intersectionality theory notes that barriers to achieving health equity result from the intersection of personal and social characteristics. Experiences at this intersection are influenced by interpersonal and structural systems of oppression. Studies have found that tele-retina is the preferred strategy over standard of care screening for at-risk populations. No study has assessed the economic equity impact of DR screening using a theoretical foundation.
This study aims to address shortcomings related to the utilization of intersectionality theory in the economic evaluation of DR screening. We propose conducting a distributional cost-effectiveness analysis (DCEA) of the tele-retina program.
The study will be undertaken using a deductive theoretical drive sequential multimethod approach, consisting of two studies: (1) a modified Delphi study and (2) DCEA. The Delphi panel (patient partners, field experts, and decision makers; N=35-50) will select the social constructs (eg, age, gender) for at-risk populations and potential trade-offs between health maximization and equity. The research will be guided by a social theory framework (intersectionality theory) to understand the impact of social constructs on economic outcomes. Social constructs that are selected by the Delphi panel will be integrated into the validated tele-retina cost-effectiveness analysis model, which will serve as a case study for DCEA.
We have submitted the research ethics board application to the University Health Network Research Ethics Board and are expecting to begin recruitment for the Delphi study in Spring 2025. We anticipate beginning work on the model in the summer of 2025 and completing it by early 2026.
The Delphi study will provide an understanding of which social factors are deemed necessary by the stakeholders for guiding the inequity in care access. Study results will offer information related to the net health benefit of the intervention and the health equity impact of the tele-retina program, hence providing a more comprehensive valuation of the tele-retina program, which is informative to policy makers and governments whose goal is to mitigate the drivers of health inequities. We anticipate that each of these drivers will raise important questions regarding the implications for decision-making that may have not yet been addressed by Canadian health technology assessment bodies, such as the Canada Drug Agency. This is the first Canadian study to (1) have social constructs for DCEA selected by the Delphi panel, (2) mainstream how health equity framework and social constructs are used in economic assessment, (3) improve DR screening programs by using health equity lens, and (4) scale and adopt "de-novo" integration of social constructs in economic models for program evaluation.
INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/60488.
糖尿病视网膜病变（DR）仍然是糖尿病的主要视力并发症，也是成年人失明的主要原因，在低收入人群中的患病率高达30%。远程视网膜筛查是一种具有成本效益的预防视力丧失的筛查方法，但筛查与收入之间存在不利关联。交叉性理论指出，实现健康公平的障碍源于个人和社会特征的交叉。在这个交叉点上的经历受到人际和结构性压迫系统的影响。研究发现，对于高危人群而言，远程视网膜筛查是比标准护理筛查更可取的策略。尚无研究基于理论基础评估DR筛查的经济公平性影响。
本研究旨在解决在DR筛查的经济评估中运用交叉性理论方面的不足。我们提议对远程视网膜项目进行分布成本效益分析（DCEA）。
本研究将采用演绎理论驱动的序贯多方法，包括两项研究：（1）一项改良德尔菲研究和（2）DCEA。德尔菲小组（患者伙伴、领域专家和决策者；N = 35 - 50）将为高危人群选择社会结构因素（如年龄、性别）以及健康最大化与公平之间的潜在权衡。该研究将以社会理论框架（交叉性理论）为指导，以理解社会结构因素对经济结果的影响。德尔菲小组选择的社会结构因素将被纳入经过验证的远程视网膜成本效益分析模型，该模型将作为DCEA的案例研究。
我们已向大学健康网络研究伦理委员会提交了研究伦理委员会申请，预计2025年春季开始德尔菲研究的招募工作。我们预计2025年夏季开始模型工作，并在2026年初完成。
德尔菲研究将有助于了解利益相关者认为哪些社会因素对于指导医疗服务获取方面的不公平是必要的。研究结果将提供与干预措施的净健康效益以及远程视网膜项目的健康公平性影响相关的信息，从而对远程视网膜项目进行更全面的评估，这对于旨在减轻健康不公平驱动因素的政策制定者和政府来说具有参考价值。我们预计这些驱动因素中的每一个都将引发关于决策影响的重要问题，而加拿大卫生技术评估机构（如加拿大药品管理局）可能尚未解决这些问题。这是加拿大第一项（1）由德尔菲小组选择用于DCEA的社会结构因素的研究，（2）将健康公平框架和社会结构因素在经济评估中的应用主流化的研究，（3）通过运用健康公平视角改进DR筛查项目的研究，以及（4）在项目评估的经济模型中对社会结构因素进行“从头开始”的整合并加以扩展和采用的研究。
国际注册报告识别码（IRRID）：PRR1 - 10.2196/60488
