HIM

# Cost-effectiveness and cost-utility of traditional and telemedicine combined population-based age-related macular degeneration and diabetic retinopathy screening in rural and urban China

## Summary

### Background

To assess the cost-effectiveness and cost-utility of a population-level traditional and telemedicine combined age-related macular degeneration (AMD) and diabetic retinopathy (DR) screening program in rural and urban China.

### Methods

Decision-analytic Markov models were conducted to evaluate the costs and benefits of traditional and telemedicine combined AMD and DR screening from a societal perspective. A cohort of all participants aged 50 years old and above was followed through a total of 30 1-year Markov cycles. Separate analyses were performed for rural and urban settings. Relevant parameters such as the prevalence of AMD and DR, transition probability, compliance with screening and treatment, screening sensitivity, specificity, utility, and mortality were collected from published studies specific to China, other Asian counties’ studies, or unpublished data sources such as the National Committee for the Prevention of Blindness. Costs of screening, full examination, and treatment come from the real medical environments and unified pricing of Beijing Municipal Medical Insurance Bureau. Primary outcomes were incremental cost-utility ratios (ICURs) using quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs) using years of blindness avoided. One-way deterministic and simulated probabilistic sensitivity analyses were conducted to reflect uncertainty.

### Findings

Under the status quo, the total expected medical costs for a 50-year-old patient with AMD or DR were $869·59 and$1,514·18 in rural and urban settings, respectively. Both traditional and telemedicine screening were highly cost-effective. In rural settings, ICURs were $191 (95% confidence interval [CI]:$66 to $239) and$199 (95% CI: $-12 to$217), and ICERs were $2,436 (95% CI:$1,089 to $3,254) and$2,441 (95% CI: $1,452 to$3,900) for traditional and telemedicine screening separately. Even more surprising, both screening strategies dominated no screening in urban settings. Our results were insensitive and robust to extensive sensitivity analyses. Among all acceptable screening intervals (from 1 to 5 years), annual screening could not only produce biggest benefits but also keep ICERs less than three times and one time the per capita gross domestic product (GDP) in rural and urban settings separately. When compared with traditional screening, ICERs of telescreening were less than three times the per capita GDP in rural settings ($2,559 to$8,809) and less than one time the per capita GDP in urban settings (less than \$5,564), annual telescreening produced the biggest benefits, it could avert 119 and 270 years of blindness in rural and urban areas separately when 100,000 people were screened.

### Interpretation

We performed decision-analytic Markov models for combined AMD and DR screening in rural and urban China, and the results showed that population-level combined screening for AMD and DR is likely to be highly cost-effective in both rural and urban China for people over 50 years old. Optimal screening may have an interval of every year based on teleophthalmology platforms. In the future, China should pay more attention to chronic eye diseases and the government should establish a sound chronic disease management system and make every patient enjoy equal medical services.

### Funding

National Natural Science Foundation of China, NSFC (82171051); the Major Innovation Platform of Public Health & Disease Control and Prevention, Renmin University of China and Beijing Nova program (Z191100001119072).

## Introduction

Age-related macular degeneration (AMD) and diabetic retinopathy (DR) are the leading causes of vision impairment (VI) and blindness worldwide, with 1·8 and 0·86 million cases of blindness caused by AMD and DR among people aged 50 years and older in 2020.

GBD 2019 Blindness and Vision Impairment Collaborators; Vision Loss Expert Group of the Global Burden of Disease Study
Causes of blindness and vision impairment in 2020 and trends over 30 years, and prevalence of avoidable blindness in relation to VISION 2020: the Right to Sight: an analysis for the global burden of disease study.