VALUE IN HEALTH 20 (2017) 1034–1040

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Cost-Utility Analysis of Extending Public Health Insurance

Coverage to Include Diabetic Retinopathy Screening by
Optometrists
Sasha van Katwyk, MSc1, Ya-ping Jin, MD, PhD2,3, Graham E. Trope, MB, PhD, FRCSC3,
Yvonne Buys, MD, FRCSC3, Lisa Masucci, MSc4, Richard Wedge, MD6, John Flanagan, OD, PhD3,7,
Michael H. Brent, MD, FRCSC3, Sherif El-Defrawy, MD, PhD, FRCSC3, Hong Anh Tu, PhD5,
Kednapa Thavorn, MPharm, PhD1,8,9,*
1
Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; 2Dalla Lana
School of Public Health, University of Toronto, Toronto, Ontario, Canada; 3Department of Ophthalmology & Vision Sciences,
University of Toronto, Toronto, Ontario, Canada; 4Institute of Health Policy, Management and Evaluation, University of Toronto,
Ontario, Canada; 5Health Quality Ontario, Toronto, Ontario, Canada; 6Health PEI, Charlottetown, Prince Edwards Island, Canada;
7
School of Optometry and Vision Science Program, University of California Berkeley, California, USA; 8School of Epidemiology, Public
Health and Preventive Medicine, University of Ottawa; Ottawa, Ontario, Canada; 9Institute of Clinical Evaluative Sciences (ICES
UOttawa), Ottawa, Ontario, Canada

AB STR A CT

Background: Diabetic retinopathy (DR) is one of the leading causes of
vision loss and blindness in Canada. Eye examinations play an
important role in early detection. However, DR screening by optom-
etrists is not always universally covered by public or private health
insurance plans. This study assessed whether expanding public
health coverage to include diabetic eye examinations for retinopathy
by optometrists is cost-effective from the perspective of the health
care system. Methods: We conducted a cost-utility analysis of
extended coverage for diabetic eye examinations in Prince Edward
Island to include examinations by optometrists, not currently publicly
covered. We used a Markov chain to simulate disease burden based on
eye examination rates and DR progression over a 30-year time
horizon. Results were presented as an incremental cost per quality-
adjusted life year (QALY) gained. A series of one-way and probabilistic
sensitivity analyses were performed. Results: Extending public health
coverage to eye examinations by optometrists was associated with
higher costs ($9,908,543.32) and improved QALYs (156,862.44), over
30 years, resulting in an incremental cost-effectiveness ratio of
$1668.43/QALY gained. Sensitivity analysis showed that the most
influential determinants of the results were the cost of optometric
screening and selected utility scores. At the commonly used threshold
of $50,000/QALY, the probability that the new policy was cost-effective
was 99.99%. Conclusions: Extending public health coverage to eye
examinations by optometrists is cost-effective based on a commonly
used threshold of $50,000/QALY. Findings from this study can inform
the decision to expand public-insured optometric services for patients
with diabetes.
Keywords: cost-utility analysis, diabetic retinopathy, optometrist,
publicly funded eye examination.
Copyright & 2017, International Society for Pharmacoeconomics and
Outcomes Research (ISPOR). Published by Elsevier Inc.

proliferation of new blood vessels can be managed with a

Introduction
Diabetic retinopathy (DR) is one of the leading causes of vision
loss and blindness [1]. In Canada, approximately 14% of patients
with diabetes (500,000) have some form of DR, and this preva-
lence is expected to rise in conjunction with the increasing
incidence of diabetes [2]. The treatment for DR depends on the
disease state. Background retinopathy, a condition whereby the
eye’s blood vessels are slightly swollen, can be managed with
strict control of blood sugar levels and careful regulation of blood
pressure and renal function, and more severe vision loss from
combination of laser photocoagulation, intravitreal injections of
steroids, antivascular endothelial growth factor therapy, and/or
vitrectomy [3]. Early detection through eye examination allows
for timely treatments, which can significantly prevent or delay
vision loss [4].
Several clinical practice guidelines highlight the role of pri-
mary care physicians in detecting DR and facilitating appropriate
referral to an ophthalmologist [5,6]; however, primary care
physicians often have limited access to specialized instruments
and training to perform the required testing to accurately

* Address correspondence to: Kednapa Thavorn, Ottawa Hospital Research Institute, The Ottawa Hospital, 501 Smyth Road, PO Box201B,
Ottawa, Ontario, K1H 8L6 Canada.
E-mail: kthavorn@ohri.ca
1098-3015$36.00 – see front matter Copyright & 2017, International Society for Pharmacoeconomics and Outcomes Research (ISPOR).
Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.jval.2017.04.015
 VALUE IN HEALTH 20 (2017) 1034–1040
diagnose DR. Despite this, a large proportion of DR screenings are
performed by primary care physicians [7]. Optometrists have
better training in eye care diagnosis and have the necessary
equipment to diagnose eye-related conditions compared with
primary care physicians. Although lack of government-insured
optometric services for patients with diabetes was found to
negatively impact patients’ access to health care services and
vision health outcomes [8], optometric services are not covered in
some provincial health insurance plans in Canada, including
those of New Brunswick, Prince Edward Island (PEI), and New-
foundland and Labrador.
Health economic evaluation is a systematic approach that can
inform policymakers whether the added benefits of expanding
publicly funded optometric services justify their costs. To date,
no study has assessed the cost-effectiveness of publicly funded
optometric services. Existing studies have shown that a system-
atic DR screening program is cost-effective compared with
opportunistic screening, as in North America and Europe [9]
and that DR screening is a cost-effective addition to a national
diabetes treatment policy [10].
The objective of our study was to assess whether expanding
public health insurance coverage to include eye examinations for
patients with diabetes by optometrists is cost-effective from the
perspective of the health care system.
Methods
Overview
We conducted a cost-utility analysis of a publicly insured optom-
etric service for patients with diabetes in PEI from the perspective
of the health care system. The intervention of interest was a new
optometric policy, whereby eye examinations for DR by optom-
etrists are publicly insured. The comparator was usual care,
whereby eye examinations for patients with diabetes performed
by primary care physicians or referrals to ophthalmologists are
publicly insured. We assumed that patients in the usual care
group were not screened for DR by optometrists at baseline and
that an extended insurance coverage would increase annual DR
screening rates.
The diagnostic accuracy of DR screening modalities and the
effectiveness of treatment alter the likelihood that patients with
diabetes progress through the stages of DR to ultimate vision loss.
This means that changes in the screening rate and screening
accuracy were the main drivers of difference in DR rates between
the usual care (government-insured DR by primary care physi-
cians plus ophthalmologists) and the intervention scenarios
(government-insured DR screening by optometrists and primary
care physicians plus ophthalmologists).
Setting
PEI is an island province in eastern Canada with a total popula-
tion of 146,447 (as of 2015), of whom approximately 70,000 are
over the age of 44 years. In 2015, prevalence of diabetes among
those 444 years of age was just over 11% [11]. Canadian
provincial governments bear the primary cost burden for provid-
ing health care to their residents and are therefore the primary
arbiters for determining what will be publicly covered. Although
physician visits (including eye examinations), as well as oph-
thalmologic DR screening and most treatment, are covered by the
PEI provincial health plan, optometric services are not included in
the plan.
1035
Study Population
The eligible population was PEI residents Z45 years of age who
had diabetes. The 45-year-old cutoff was used because it was the
mean age of patients with diabetes in PEI. Based on PEI’s
Statistics Bureau [11], a cohort with 7958 patients with diabetes
were 444 years of age. Of these 3514 (44.2%) were between 45 and
65 years of age. We used data from the same source to project the
future population in PEI. We categorized our target population to
two age groups (45–64 years and 65þ years) to account for
observed differences in the mortality rates, DR prevalence rates,
and screening rates. Given the projected increase in the older age
cohort in PEI, it was important to model changes in disease
burden and related costs over time. Therefore, each year we
added a new cohort of diabetes cases to the Markov model
representing the newly 45-year-old population of PEI. The newly
added cases were distributed across the stages of DR according to
the prevalence rate at 45 years of age [11].
Decision Analytic Model
We used a probabilistic decision analytic model to simulate the
long-term costs and outcomes for a cohort of PEI residents living
with diabetes. We simulated the natural history of DR among the
population with diabetes according to the most recent prevalence
and transition probability data by using a Markov chain. The
stages of DR used in the Markov chain were as follows: 1) no
diabetic retinopathy (NDR); 2) background diabetic retinopathy
(BDR); 3) pre-proliferative diabetic retinopathy (PPDR); 4) prolifer-
ative diabetic retinopathy (PDR); and 5) end-stage disease—loss of
useful vision [12]. Each year individuals may transit through one
of the five disease states or death [6], according to annual
transition probabilities.
The Markov model estimated the costs and effects over a
period of 30 years, since that was the duration of time for which
we had population projection data that could be reliably trans-
lated into rates of diabetes within our age cohorts. The long
follow-up period also allowed us to capture changes in patients’
demographics and the incidence rates of diabetes over time. Our
patient cohort was expanded to capture new cases of diabetes for
each year. We used PEI Statistics Bureau’s population projection
data to simulate population growth from 2014 to 2044, as the
expected change in annual incidence of diabetes [11].
Each year, probability rate of individuals with diabetes being
screened was equal to the annual screening rates. Recommended
regular screening for DR is once every 2 years. Individuals who
did not receive any screening would transit through the Markov
chain according to the baseline transition probabilities. For our
baseline model, we assumed that the 53% of PEI residents who
received DR screening regularly continued going to primary care
physicians and ophthalmologists over the 2-year period and that
the expanded coverage to optometrists would result in 35%
increase in screening. Of those screened in the usual care group,
we assumed that 80% of DR screening was performed by general
practitioners, who then potentially referred patients to ophthal-
mologists on the basis of test findings. We varied this share of
screenings in a scenario analysis that ranged general practitioner
share of screenings from 50% to 100%. For those who were
screened, their risk of being diagnosed with DR was estimated
according to the incidence of DR and the diagnostic accuracy of
the DR screening by an optometrist or an ophthalmologist. The
sensitivity and specificity of DR screening was based on a
systematic review that included two observational studies in
which the true severity of DR was known and several screening
approaches and practitioners were provided with the same
patient [4]. We assumed that individuals who were diagnosed
with DR (whether true or false positive) received a treatment.
1036 VALUE IN HEALTH 20 (2017) 1034–1040
Fig. 1 – Decision tree model and imbedded Markov chain.
Input Parameters
Transition probabilities
We derived transition probabilities from a study by Liu et al. [13],
which described the probabilities that patients with diabetes
move across the DR pathway from proliferative retinopathy to
blindness. Mortality rates were derived by applying a relative risk
of death resulting from diabetes reported in a 2013 systematic
review [14] to all-cause mortality in the general Canadian pop-
ulation. We used the all-cause annual mortality rates for each age
group (45–64 and 65þ years) reported by Statistics Canada, which
were 0.5% and 8.2%, respectively (sex adjusted) [15]. To properly
account for the effect of age on the incidence of DR, a portion of
the 45–64 years cohort could move into the 65þ years cohort
during every reiteration of the Markov chain. The transition
probabilities between two age groups (45–64 and 65þ years) were
derived by calculating the number of individuals Z65 years of
age obtained from the PEI Statistics Bureau (accounting for
death and migration in the same method as calculated for each
age group).
Eye examination rate
According to Statistics Canada, in 2005, 53% of PEI residents Z45
years of age who were living with diabetes received an eye
examination within the previous 2 years [16]. This percentage
captured all eye examinations and did not differentiate between
public and private payers or consider who administered the eye
examination. Nonetheless, we utilized this as a baseline exami-
nation rate, since it was the best available data for PEI. We
obtained the impact of publicly insured optometric services on
the examination rate from a published Canadian study that had
evaluated the effect of delisting routine eye examinations on
retinopathy screening among patients with diabetes in Ontario
[17]. The Ontario study reported that delisting routine eye
examinations decreased the eye examination rate by 8.7% among
patients 40 to 65 years of age who were living with diabetes,
although this age group was not the intended delisting target.
Based on the results of this Ontario study, the ratio of optomet-
rists to ophthalmologists in PEI (32:6), and the geographic
distribution of optometrists in PEI, we estimated that
government-insured DR screening by optometrists would
increase the screening rate by an additional 35%, resulting in a
screening rate of 88% over 2 years [8]. To test the impact of the
2-year eye examination rate, we performed a scenario analysis
that varied the change in screening rate from 10% (5% per year) to
45% (22.5% per year).
Treatment efficacy and health utility values
Treatment efficacy was based on a 2004 multisite randomized
control trial that evaluated clinical efficacy of minor and
advanced treatments [18]. Patient cohorts were then placed in
the Markov chain according to transition probabilities, test
accuracy, and treatment effectiveness within each respective
outcome branch (Fig. 1). Health utility data were taken from a
2012 utility survey that included two catchment surveys of
patients with diabetes across all age groups and levels of DR.
Using both a health utility index (HUI-3) metric and time trade-off
exercise, the survey calculated the relative utility score for each
level of DR adjusted for all relevant patient factors [19].
Costs
All costs were taken from the PEI Schedule of Benefits (Master
Agreement) [20]. Screening costs for the intervention constituted
a consultation, which included a DR examination by an optom-
etrist. Since there is no standard remuneration for optometrist
consultations, we used the remuneration of a general practitioner
consultation as a base case. We varied the price in our sensitivity
analysis according to the highest (Manitoba: $89.35) and the
lowest (Nova Scotia: $52.00) consultation remuneration found in
all Canadian provinces other than PEI as of 2015. The comparator
(current) screening protocol consisted of a consultation by a
primary care physician followed by referral to an ophthalmolo-
gist and included the fees of a consultation for a DR examination.
Costs of treatment were estimated according to disease severity;
background DR was assumed to receive an intensification of
existing diabetes treatment (e.g., increased insulin schedule), and
more severe DR was treated with laser photocoagulation.
Although multiple treatments are possible for severe DR,
 VALUE IN HEALTH 20 (2017) 1034–1040 1037

Table 1 – Input parameters for the model.

Type / Practitioner Parameter Base Range or 95% Distribution Source
value confidence
interval (CI)

Transition probabilities
Prevalence BDR 10.18% (9.7–10.6) Normal PEI administrative data, 2012
PPDR 1.20% (1.1–1.6) Normal PEI administrative data, 2012
PDR 1.70% (1.4–2.0) Normal PEI administrative data, 2012
Blind 0.25% (0.2–0.3) Normal PEI administrative data, 2012
Probability NDR to BDR 0.09 (0.08–0.11) Beta Liu et al. (2003)
BDR to PPDR 0.12 (0.11–0.13) Beta Liu et al. (2003)
PPDR to PDR 0.60 (0.49–0.72) Beta Liu et al. (2003)
PDR to Blind 0.46 (0.39–0.53) Beta Liu et al. (2003)
Death (45-65) 0.01 (0.008–0.015) Normal Liu et al. (2003)
Death (65þ) 0.16 (0.14–0.25) Normal Liu et al. (2003)
General Practitioner Sensitivity (%) 46 (35–56) Normal Hutchinson et al. (2000)
Specificity (%) 81 (72–91) Normal Hutchinson et al. (2000)
Ophthalmologist Sensitivity (%) 82 (80–84) Normal Hutchinson et al. (2000)
Specificity (%) 95 (94–96) Normal Hutchinson et al. (2000)
Optometrist Sensitivity (%) 74 (67–81) Normal Hutchinson et al. (2000)
Specificity (%) 84 (73–96) Normal Hutchinson et al. (2000)
Costs
General Practitioner Consultation (fee per visit) $62.00 Fixed Health PEI (2015)
Ophthalmologist Consultation (fee per visit) $87.00 Fixed Health PEI (2015)
Ophthalmologist DR Exam $11.50 Fixed Health PEI (2015)
Treatment Photocoagulation $275.20 Fixed Health PEI (2015)
Optometrist Consultation (fee per visit) $62.00 Fixed Health PEI (2015)
Optometrist DR Exam $11.50 Fixed Health PEI (2015)
Utilities NDR 0.88 (0.82–0.95) Beta Heintz et al. (2012)
BR 0.86 (0.79–0.93) Beta Heintz et al. (2012)
PPDR 0.87 (0.78–0.97) Beta Heintz et al. (2012)
PDR 0.83 (0.72–0.93) Beta Heintz et al. (2012)
Blind 0.48 (0.34–0.61) Beta Heintz et al. (2012)
Dead 0 Fixed
BDR, background diabetic retinopathy; PPDR, pre-proliferative diabetic retinopathy; PDR, proliferative diabetic retinopathy; PEI, Prince Edward
Island.

photocoagulation is the most frequently used and requires fewer
costing assumptions regarding specific clinical patient character-
istics [3].
All key input parameters, including transition probabilities,
treatment efficacy, and health utility values, are shown in Table 1.
Canadian dollars. In accordance with Canadian economic guide-
lines [21], an annual discount rate of 5% was applied for both
costs and outcome. An incremental cost-effectiveness ratio (ICER)
was expressed as an incremental cost per QALY gained Table 2–4.
All analyses were performed in Microsoft Excel version 2012
Table 2–4.

Analysis
We calculated the aggregated costs, the number of screening Sensitivity analysis
tests, and quality-adjusted life years (QALYs) of patients with A series of one-way sensitivity analysis was performed on
diabetes over the 30-year period. Costs were expressed in 2015 the following parameters: 1) cost of optometrist consultation;

Table 2 – Results (167,514 screenings over a 30-year Table 3 – Cost-effectiveness results by

period). discount rate.
Baseline Intervention Incremental Incremental ICER
cost QALY
Expected cost (CAD) $7,677,187.94 $9,908,543.32
Expected QALY 155,525.05 156,862.44 0% $ 4,592,523.41 3,021.96 $1,519.72
Incremental cost (CAD) $2,231,355.39 3% $ 2,905,086.84 1,816.83 $1,598.99
Incremental QALY 1,337.39 5% $ 2,231,355.39 1,337.39 $1,668.43
ICER ($/QALY) $1,668.43 10% $ 1,311,767.45 689.91 $1,901.37
CAD, Canadian dollars; ICER, incremental cost-effectiveness ratio; ICER, incremental cost-effectiveness ratio; QALY, quality-adjusted
QALY, quality-adjusted life year. life year.
1038 VALUE IN HEALTH 20 (2017) 1034–1040

Table 4 – Cost-effectiveness results by time triple from 1% in 2015 to 3% in 2030. PDR would rise from 2% to
horizons. 4% while blindness was expected to be prevalent among 4% of
diabetics. Overall, our model predicted that the DR prevalence
Incremental Incremental ICER among diabetics over the age of 44 would increase from 14% to
cost QALY 30% by 2030.
1 year $ 93,684.30 4.95 $18,927.00
3 years $ 279,262.52 26.87 $10,394.02 Sensitivity Analysis
5 years $ 458,556.27 73.45 $6,242.93
The result of the one-way sensitivity analysis is presented as a
10 years $ 881,462.86 323.74 $2,722.74
tornado plot (Fig. 2). The cost of an optometrist examination,
20 years $ 2,231,355.39 1337.39 $1,668.43
utility values, and the transition probabilities from NDR to BDR
ICER, incremental cost-effectiveness ratio; QALY, quality-adjusted were the top three most influential factors. The probability that
life year. transition of patients with diabetes between NDR and BDR also
had substantial impact on the cost-effectiveness findings.
Figure 3 shows the results of the probabilistic sensitivity
analysis. All iterations fell within the northeast quadrant, indi-
2) screening sensitivity; 3) screening specificity; 4) utility values;
cating that extending government-insured screening for DR by
5) treatment effectiveness; 6) DR prevalence; and [7–10] transition
optometrists was more expensive but also delivered better health
probabilities for each disease state. A probabilistic sensitivity
outcomes compared with PEI’s current coverage policy. Com-
analysis was also performed on all parameters according to the
pared with a common threshold of $50,000/QALY in Canada,
reported 95% confidence interval and reported distributions or, in
extending optometric services for DR screening was considered a
the case of optometrist screening rate, based on an estimated
cost-effective option. Similarly, Figure 4 shows the cost-
range and distribution following a review of the literature. The
effectiveness acceptability curve and suggests that the probabil-
sensitivity analysis was performed by using the Monte Carlo
ity of the new PEI optometrist policy is cost-effective increased
method with 20,000 iterations. The results of the probabilistic
with a greater value of willingness to pay. At the common
sensitivity analysis were used to create a cost-effectiveness
threshold of $50,000/QALY, the probability that the new optom-
acceptability curve, which shows the probability of the interven-
etric policy is cost-effective is 99.99%.
tion being cost-effective over a range of willingness to pay
thresholds.
Scenario Analysis
The ICER results depended on the assumed share of the cost of
Results screenings performed by general practitioners, which ranged
Extending publicly insured eye examination for patients with from $1303.47 at the lower end (50%) to $2023.73 at the upper
diabetes to include examinations by optometrists was associated end (100%). The larger the proportion of screenings performed by
with higher health system cost ($9,908,543.32 vs $7,677,187.94 general practitioners, the smaller was the improvement in
over 30 years) and improve health outcomes (1337.39 QALYs patients’ QALYs. There is also a small inverse relationship
gained over 30 years), resulting in the incremental cost- between the share of the cost of screenings performed by general
effectiveness ratio of $1668.43/QALY gained. Extending publicly practitioner and the total costs in the comparator case. The
insured services to include optometrists was estimated to reason is that with fewer DR cases being identified, there are
increase the number of screenings by 2221 per year. slightly fewer patients who receive treatment.
Over the 30-year period, we found that while patient distri- The cost-effectiveness results also varied according to the
bution across health states remained roughly the same in the expected effect of public reimbursement of optometrist services
first ten years, significant increases in projected diabetes preva- on the annual screening rate. The ICER was $430.45, assuming
lence and an absolute rise in diabetes among those over the age only a 5% increase in screening rates. Although the increased
of 65 led to higher proportions of severe DR in the population. We screening rates raised the costs of treatment, they also improved
projected that the prevalence rate of background DR would nearly
double to 19% of diabetics over the age of 44, while PPDR would

Fig. 2 – Tornado plot representing select results of one-way

sensitivity analysis, incremental cost-effectiveness ratio Fig. 3 – Probabilistic sensitivity analysis, average annual cost
(ICER). and quality-adjusted life year (QALY).
 VALUE IN HEALTH 20 (2017) 1034–1040
Fig. 4 – Cost-effectiveness acceptability curve.
health outcome (QALYs). The proportional change in cost relative
to change in QALY varied over time as the age distribution of
patients changed; however, these ratios were within a $2000/
QALY range. If the effect of expanding public insurance on
screening rates were to reach 100%, the ICER was still lower than
$6000/QALY.
Discussion
Our study shows that extending government-insured eye exami-
nations of patients with diabetes to optometrists is a cost-
effective option from the perspective of the health care system.
Extending public coverage for optometric screening of DR will add
additional cost to the health care system in the expected amount
of $74,378.51 per year over 30 years; however, improving access to
screening by optometrists will significantly delay the progression
of DR, resulting in an average annual gain of 44.58 QALYs for
patients with diabetes over the same period.
An extension of publicly funded services to include optomet-
rists in Canada would ease the pressure on ophthalmologists’
time and resources and lower the incidence of primary care
physicians’ performing incomplete screenings that do not adhere
to established guidelines [22]. In the case of PEI, optometric
services potentially offer better access to care, particularly in
rural areas, as all ophthalmologists in PEI live in one of two urban
centers [23].
Our sensitivity analysis showed that the highest level of
model uncertainty is in the utility value of blindness. The reason
may be that it was estimated from a study with a small sample
size [13]. Also high in variance was the cost of optometric
services, which is to be expected, since the cost of services
account for 23% of total cost of the new policy. Interestingly, we
found that the relative share of screening performed by optom-
etrists and ophthalmologists had only a moderate impact on the
cost-effectiveness results. This finding may be, in part, attributed
to the closely comparable screening accuracy of both practi-
tioners. The probabilistic sensitivity analysis showed that the
probability of the intervention being cost-effective increased with
a greater value of willingness to pay. This probability was 499%
after the willingness to pay value was 4$6000/QALY.
Projecting outcomes for 30 years presents some challenges
when accounting for changes in patient demographics and the
prevalence of diabetes. We utilized basic projections from Sta-
tistics Canada and the PEI Bureau of Statistics with regard to
population trends according to age as well as diabetes prevalence
rates by population group. We also attempted to better represent
the changes in the prevalence of diabetes as it pertains to DR by
calibrating a Markov model to introduce new patients aged 45 at
the start of the annual cycle and transition patients from the 45
1039
cohort to the 65 as they aged, using the expected changes in
population size and the prevalence of diabetes in each age group.
Our projected prevalence and mortality rates for diabetes closely
match those reported by Statistics Canada combined with the
Canadian Diabetes Cost Model prevalence projections [15,24,25]
(Fig. 5). Although we would like to extend our analysis timeframe
to 45 years to represent the lifetime of all patients, Statistic
Canada only provides 30 years’ projection data. We consider this
a small limitation of our study design, especially since it is an
open cohort design, in which new younger individuals are
continuously being added and there is no set lifetime duration
that we could cover.
Most added costs were accrued from additional treatments
performed by ophthalmologists after severe DR was detected.
Although these are added costs to the health care system,
researchers have argued that these costs are likely already
expressed in PEI’s health system through other care costs linked
to vision loss [26]. For instance, although this intervention will
bring about higher rates of laser photocoagulation, intravitreal
injections and vitrectomy procedures in the short term, a sig-
nificant share of such procedures would have eventually
occurred at a later point in the patient’s lifetime when the patient
experiences vision loss at a more severe stage.
This health economic evaluation utilized a decision analytic
model to synthesize data from various sources, leading to some
limitations that merit discussion. First, our study population was
Z45 years of age—that is, we could have missed the small
portion of DR cases in younger patients and therefore could have
underestimated the cost of screening. This matters, since most
clinical guidelines recommend that regular screening start 3 to 5
years after diagnosis of type I DM, which is the most prevalent
type of diabetes among those o45 years of age. Second, we
assumed that the costs of intensified blood glucose and blood
pressure treatments were comparable in the intervention and
usual care groups and therefore did not include them in our
analysis. Given the limited variation in the study results because
of the changes in costs shown in our sensitivity analyses, the
inclusion of these drug costs could have had a negligible impact
on our findings. Third, health utility values were based on a
single US study providing utility values that matched our cate-
gorization of DR stages. It should be noted that the sociodemo-
graphic and clinical characteristics of the participants in our
study might have been different from those of our target
population. Although the structural uncertainty introduced by
our reliance on a single source would be best characterized by
using health utility values from alternative sources, such evi-
dence is currently unavailable. Further studies should measure
Fig. 5 – Diabetes prevalence among Prince Edward Island
(PEI) residents with diabetes 45 years of age or older,
projected national average compared to our projected
prevalence in PEI.
1040 VALUE IN HEALTH 20 (2017) 1034–1040
the health utilities of Canadian patients with DR by disease
stages. Finally, our transition probabilities were derived from a
Taiwanese study, which had different patient characteristics and
a different health care system affecting disease progression.
However, this Taiwanese study was the most recent study and
based on the same type of disease stage progression as that in
our study. Moreover, our sensitivity analyses showed that these
transition probabilities had minimal impact on the study find-
ings. Future studies should take advantage of the availability of
routinely collected administrative databases and derive long-
term progression of DR among patients with diabetes in devel-
oped countries.
Conclusions
Our study suggests that extending public health coverage to
include DR screening by optometrists would be cost-effective
from the perspective of the health care system. Our study lends a
strong economic case to support the extension of publicly
insured optometric services to patients with diabetes.
Acknowledgments
Authors JP, GET, RW, JF, SED, and KT contributed to the conception
of the study question and design and obtained the funding. SK and
KT developed the health economic model, performed the data
analysis, interpreted the results and drafted the initial version of
the manuscript. JP, GET, YB, RW, JF, SED, and MB contributed to
framing the details of the clinical questions and provided clinical
expertise for the development of the manuscript. LM provided
methodologic support and helped with a model validation. HAT
helped with literature review. All authors reviewed and approved
the final manuscript and can take responsibility for the integrity of
the data and the accuracy of the data analysis.
The authors have no conflicts of interest to disclose.
This study was supported by the Canadian Institutes of Health
Research (CIHR).
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