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ANNUAL RETINAL EXAMS FOR DIABETIC PATIENTS PROVIDE FEW BENEFITS
ANN ARBOR, Mich.-- U.S. Department of Veterans Affairs (VA) researchers reporting in the February 16 issue of the Journal of the American Medical Association, find that individually tailored vision screenings for diabetic patients could produce significant savings without substantially reducing health benefits.
Current practice generally calls for yearly retinal exams for patients with Type 2 (adult-onset) diabetes to detect early-stage, reversible blindness such as diabetic retinopathy (an eye disease affecting blood vessels in the retina) and macular edema (liquid accumulation in the part of the eye involved in focusing). However, the VA study showed only marginal benefit from annual screening, compared to screening less frequently, unless patients were at high risk for blindness.
"Our findings suggest that the quality standards currently employed in health care are not appropriate," said staff physician and lead author Sandeep Vijan, M.D., of the VA Ann Arbor Health Care System. "Individualized screening could lead to substantial savings, both in terms of health care resources and patient time and energy."
Using survey results from a nationally representative sample of the U.S. population, researchers examined data on diabetics over age 40 and grouped them according to initial levels of eye disease. They then applied screening information, derived from epidemiological studies, to this population to find out the costs and benefits of screening intervals ranging from one to five years. Quality adjusted life years (QALYs), which account for blindness in extended life expectancy, were used as the standardized measure of outcome.
The VA scientists used the model for predicting global warming in their calculations to determine the cost effectiveness of the annual retinal screenings. "The way we predicted the cost and benefit of annual screening is similar to the way scientists predict global warming. Individualized studies of the various components are synthesized to determine the overall effect, and results from random regions are extrapolated to the population as a whole," Dr. Vijan explained.
The two factors used to categorize risk of blindness were age and blood sugar control, measured by the level of hemoglobin A1c (blood protein combined with glucose) in the blood. The prototypical high-risk patient is 45 years old and has a hemoglobin A1c of 11 percent, his low-risk counterpart is 65 years old and has a hemoglobin A1c of 7 percent. With no retinal screening, the younger person would be expected to spend an average of 358 days blind in his lifetime, while the 65 year old would be expected to spend 20 days blind.
Vijan's team concluded that benefits of increasing screening frequency were marginal. For example, with screening every three years, the 65 year old would reduce his days of blindness from 20 to 12, while screening annually further reduces time blind to nine days, but at more than the twice the cost. However, as the risk of blindness increases, the researchers recommend increasing screening frequency as well.
In the U.S., researchers estimate that annual screening costs $107, 510 per QALY gained, while screening every other year costs $49,760 per QALY. They suggest changing current practice guidelines to prescribe screening every two to three years for most people with type 2 diabetes, with more frequent visits for higher risk populations.
Vijan and colleagues plan further research to evaluate the effectiveness of new cameras specifically designed to photograph the eye and detect abnormalities, replacing the need for ophthalmologists in regions of the country where specialists are scarce. Investigators shall weigh the convenience and accuracy of this technology.
Diabetes is the leading cause of new blindness in adults age 20 to 74. An estimated 10.3 million people have been diagnosed with diabetes in the United States, with an additional 5.4 million undiagnosed. Type 2 diabetes is the most common form of the disease, usually appearing after age 40.
VA co-authors of this paper include Timothy P. Hofer, M.D., M.S. and Rodney A. Hayward, M.D. VA's Quality Enhancement Research Initiative and the Michigan Diabetes Research and Training Center, University of Michigan, supported this study.
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Source: U.S. Department of Veterans Affairs
http://www.va.gov
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