Cost-effectiveness Analysis of a Personalized, Teleretinal-Inclusive Screening Policy for Diabetic Retinopathy via Markov Modeling

Purpose: Although teleretinal imaging has proved effective in increasing population-level screening for diabetic retinopathy (DR), there is a lack of quantitative understanding of how to incorporate teleretinal imaging into existing screening guidelines. We develop a mathematical model to determine personalized DR screening recommendations that utilize teleretinal imaging and evaluate the cost-effectiveness of the personalized screening policy.Design: A partially observable Markov decision process is employed to determine personalized screening recommendations based on patient compliance, willingness to pay, and A1C level. Deterministic sensitivity analysis was conducted to evaluate the impact of patient-specific factors on personalized screening policy. The cost-effectiveness of identified screening policies was evaluated via hidden-Markov chain Monte Carlo simulation on a data-based hypothetical cohort.Participants: Screening policies were simulated for a hypothetical cohort of 500 000 patients with param-eters based on the literature and electronic medical records of 2457 patients who received teleretinal imaging from 2013 to 2020 from the Harris Health System.Methods: Population-based mathematical modeling study. Interventions included dilated fundus examina-tions referred to as clinical screening, teleretinal imaging, and wait and watch recommendations.Main Outcome Measures: Personalized screening recommendations based on patient-specific factors. Accumulated quality-adjusted life-years (QALYs) and cost (USD) per patient under different screening policies. Incremental cost-effectiveness ratio to compare different policies.Results: For the base cohort, on average, teleretinal imaging was recommended 86.7% of the time over each patient's lifetime. The model-based personalized policy dominated other standardized policies, generating more QALY gains and cost savings for at least 57% of the base cohort. Similar outcomes were observed in sensitivity analyses of the base cohort and the Harris Health-specific cohort and rural population scenario analysis.Conclusions: A mathematical model was developed as a decision support tool to identify a personalized screening policy that incorporates both teleretinal imaging and clinical screening and adapts to patient charac-teristics. Compared with current standardized policies, the model-based policy significantly reduces costs, whereas it is performing comparably, if not better, in terms of QALY gain. A personalized approach to DR screening has significant potential benefits that warrant further exploration.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references. Ophthalmology Retina 2023;7:532-542 & COPY; 2023 by the American Academy of Ophthalmology