Improving the cost-effectiveness of photographic screening for diabetic macular oedema: a prospective, multi-centre, UK study

Gordon Prescott, Peter Sharp, Keith Goatman, Graham Scotland, Alan Fleming, Sam Philip, Roger Staff, Cynthia Santiago, Shyamanga Borooah, Deborah Broadbent, Victor Chong, Paul Dodson, Simon Harding, Graham Leese, Roly Megaw, Caroline Styles, Ken Swa, Helen Wharton, John Olson*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

43 Citations (Scopus)
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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.

Methods 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.

Results 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.

Conclusions Retinal screening programmes in the UK should reconsider the screening pathway to make best use of existing and new technologies.

Original languageEnglish
Pages (from-to)1042-1049
Number of pages8
JournalBritish Journal of Ophthalmology
Issue number8
Early online date28 Mar 2014
Publication statusPublished - Aug 2014


  • retinopathy
  • photocoagulation
  • program
  • adult
  • aged
  • automation
  • cost-benefit-analysis
  • diabetic retinopathy
  • female
  • Great Britain
  • humans
  • macular edema
  • male
  • mass screening
  • middle aged
  • photography
  • prospective studies
  • quality improvement
  • quality-adjusted life years
  • sensitivity and specificity
  • tomography, optical coherence


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