2. Improving the Value of Screening For Macular Oedema using Surrogate Photographic Markers Dr John Olson NHS Grampian

3. Improving The Economic Value Of Photographic Screening For Optical Coherence Tomography Detectable Macular Oedema – A Prospective Multicentre, United Kingdom Study Olson J, Sharp P, Goatman K, Prescott G, Scotland G, Fleming A, Philip S, Santiago C, Borooah S, Broadbent D, Chong V, Dodson P, Harding S, Leese G, Styles C, Swa K, Wharton H Health Technol Assess, Vol 17,, May- June 2013, In Press

4. A Success Story? Systematic screening programme for diabetic retinopathy

5. Missing the target? The health-economic case is based on the detection of people with, or at risk of –proliferative diabetic retinopathy –before they develop complications Vitreous haemorrhage Traction retinal detachment But 90% of referrals are for ? diabetic macular oedema

6. Why? Retinal photographs are not discriminatory for proliferative retinopathy or its precursors Other things may be present –e.g. diabetic “maculopathy” –We have to manage these findings

7. How did we get there? Retinopathy grades based on ETDRS Maculopathy grades basedon …(GOBSAT)

8. Different management New VesselsOedema Definitive treatmentIndefinite treatment Management independent of visual acuity Management depended on visual acuity 2 D red structure3 D transparent elevation Few false +vesMany false +ves 

9. What did ISMO question? Can we do it better? What will it cost? What will it mean?

10. The Answers In Short- Can Grading Schemes do it better ? Computer says nah

11. The Answers In Short- Can OCT do it better ? Yes Increases the specificity of referrals With no loss of sensitivity

12. The Answers- What will it cost? Less If you use OCT Whatever grading strategy you use Saves you money

13. The Answers- What will it mean?

14. Study Highlights © 2008 Google-Imagery © 2008 TerraMetrics Aberdeen Dundee Edinburgh Liverpool Birmingham Oxford Study centres Aberdeen Birmingham Dundee Edinburgh Glasgow Liverpool Oxford Glasgow

15. Every day practice Aberdeen Dundee Edinburgh Liverpool Birmingham Oxford Glasgow

16. 3450 Subjects Photographic signs of diabetic retinopathy –exudates ≤ 2DDr –blot haemorrhages ≤ 1DDr –dot haemorrhages/microaneurysms ≤ 1DDr Each subject had photography and optical coherence tomography on both eyes, where possible.

17. Patient Characteristics Median age 60 60.7% male 85.4% Caucasian 77.4% type 2 diabetes

18. 370 Excluded (10.5%) 6 years older Female Asian/ Black Zeiss Stratus Topcon OCT 1000

19. Lesion Distribution Expected %Recruited % Ma/dot only69.840.3 Blot no exudate8.68.4 Exudate21.620.4 No Ma/dot/blot/ exudate ≤ 1DDr 28.1

20. Definition of Macular Oedema Central ETDRS region thickness > 250µm OR any of 5 inner regions > 300µm AND visible intraretinal cyst/ area of subretinal fluid

22. Prevalence of oedema 7.7% of study population Prevalence differed greatly by centre –3.7% to 12.2% Prevalence differed greatly by scanner –4.5% to 11.8%

23. Relationship to Centre Aberdeen 12.0% Birmingham 3.7% Dundee 12.2% Edinburgh 6.4% Liverpool 2.9% Dunfermline 4.4% Oxford 7.7%

24. All scanners are equal, but some scanners are more equal than others Zeiss Stratus –4.5% Topcon OCT1000 –6.5% Heidelberg Spectralis –8.7% Zeiss Cirrus –11.8%

25. Relationship to patient features Older age –68yrs cf 60 Caucasian –8.4% cf 3-4% Type 2 diabetes –8.7% cf 3.9% Poorer vision –5x more likely –If VA ≤ 6/9 BUT NOT –Sex, glitazone, amblyopia

26. Relationship to Lesions R Eye %L Eye % No lesions 0.80.6 Ma/dot only 2.22.3 Blot no Exudate 10.211.2 Exudate12.511.2 Other1.1

28. Can we do any better? Three Grading Strategies Examined –Manual grading Presence/ absence of features SDRGS 2007 –Computer-assisted manual annotation All individual lesions ≤ 2DDr –Fully automated annotation grading Three versions –Automated image analysis –+VA –+VA + Age+ Type DM + Sex

29. Manual Grading (features)

30. Scotland –59.5% sensitivity –79.0% specificity England –72.6% sensitivity –66.8% specificity England plus –73.3% sensitivity –70.9% specificity

31. Computer Assisted, Manual Annotation, Grading Best for sensitivity & specificity Time-consuming procedure Unlikely to be considered for routine screening practice

34. In Years To Come

35. Marvin the Manically Depressed Autograder "I think you ought to know…. I'm feeling very depressed......nobody likes me"

36. DRS in Scotland 2012

37. What will it cost? Cost per screen £33.13 Cost per OCT screen £31.96 Total cost for ?oedema£65.09 Cost of attending ophthalmology £90.00 (Cost of Slit lamp within DRS £27.29)

38. TABLE 30 Screening and referral cost per true case of macular oedema detected for 3,170 patients; Adjusted for expected frequency of different patient categories and based on Scottish screening and referral costs * Reference strategy; a figures in table based on assumption that fully automated grading can be implemented at zero net increase in grading costs;++ Represents a cost saving per case missed relative to the reference strategy; d strategy more costly and less effective than an alternative strategy (dominated)

39. What does it mean? At present we spend £13,750,000 a year –250,000 people @ £55 –Screening + 1 st visit to ophthalmology –£2,337,500 on ? M2 If we do nothing, other than introduce OCT into the screening pathway we save money

40. Should we grade differently? Current Scottish Criteria + OCT is the most cost effective of all strategies

41. What if we do nothing? 20 year “M2” Markov Model Only 5.6% of M2 at risk of visual loss Repetitive nature of screening –12% of non-referred MO modelled to progress at 12 months cf 5% of referred (laser Rx) More sensitive strategies –More OCTs, more referrals Bilateral incidence 12% –QALY determined by VA in better seeing eye Additional cost per QALY going to strategy 16 –£882,307 at 5 years –£353,927 at 20 years –(£20-30,00 UK threshold for “cost-effectiveness)

42. What should we do? Cost-effectiveness acceptability curves for the alternative strategies based on a 20 year time horizon and using quality adjusted life years as the measure of effect

43. How should we manage M2s? Is this the answer? Photos graded as M2 Check VA Do an OCT if VA 6/12 or worse? Otherwise rescreen in 6 months?

44. Thank You

45. Modelled visual acuity changes for “CSMO”