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Improving the cost-effectiveness of photographic screening for diabetic macular oedema: a prospective, multi-centre, UK study
  1. Gordon Prescott1,
  2. Peter Sharp2,
  3. Keith Goatman2,
  4. Graham Scotland1,
  5. Alan Fleming2,
  6. Sam Philip3,
  7. Roger Staff4,
  8. Cynthia Santiago5,
  9. Shyamanga Borooah6,
  10. Deborah Broadbent7,8,
  11. Victor Chong9,
  12. Paul Dodson10,
  13. Simon Harding7,8,
  14. Graham Leese11,
  15. Roly Megaw6,
  16. Caroline Styles12,
  17. Ken Swa13,
  18. Helen Wharton14,
  19. John Olson15
  1. 1Division of Applied Health Sciences, School of Medicine & Dentistry, University of Aberdeen, Aberdeen, UK
  2. 2College of Life Sciences and Medicine, University of Aberdeen, Aberdeen, UK
  3. 3Grampian Diabetes Research Unit, Diabetes Centre, Aberdeen Royal Infirmary, Aberdeen, UK
  4. 4Medical Physics, NHS Grampian, Aberdeen, UK
  5. 5Eye Out-patient Department, Aberdeen Royal Infirmary, Aberdeen, UK
  6. 6Princess Alexandra Eye Pavilion, Edinburgh, UK
  7. 7Liverpool Diabetes Eye Centre, St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
  8. 8Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
  9. 9Department of Ophthalmology, Oxford Eye Hospital, Oxford, UK
  10. 10Heartlands Hospital & Aston University, Birmingham, UK
  11. 11Ninewells Hospital, Dundee, UK
  12. 12Queen Margaret Hospital, Dunfermline, UK
  13. 13National Services Division, NHS National Services, Edinburgh, UK
  14. 14Birmingham and Black Country Diabetic Eye Screening Programme, Diabetes and Endocrinology Unit, Heartlands Hospital, Birmingham, UK
  15. 15Grampian Retinal Screening Programme, Aberdeen, UK
  1. Correspondence to Dr John Olson, Grampian Retinal Screening Programme, David Anderson Building, Foresterhill Road, Aberdeen, AB25 2ZP, UK; john.olson{at}


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.

  • Retina
  • Macula
  • Diagnostic tests/Investigation

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