Cost-Effectiveness Analysis of Medical Intervention in Patients with Early Detection of Diabetic Retinopathy in a Tertiary Care Hospital in Bangladesh

Background and aims: The economic burden resulting from diabetic retinopathy (DR) consumes a major portion of resources
allocated for health-care services. Cost-effectiveness of various interventions on DR and its complications has relatively been well
explored in developed countries, but these are almost absent in developing countries. The present study was undertaken to assess the
cost-effectiveness of medical intervention in patients with DR.
Materials and methods: Two hundred patients with DR, at least 1 year of follow-up, were purposively selected from Out-Patient
Department of BIRDEM (tertiary diabetes care hospital), Bangladesh. Of them 100 were late in detection of DR (LDR) & 100 were
detected early (EDR). The degree & extent of complications like cardiopathy, peripheral neuropathy, nephropathy & peripheral
vascular disease, treatment outcome, clinical effectiveness of interventions and direct, indirect & incremental cost of complications
were calculated. Comparison was made between the groups. Cost included drugs, hospitalizations, diagnostics & visits.
Results: A total of 200 patients were considered for an average of 365 days, amounting to 656 person-years of observation in total. In
LDR group, 42.4% had mild nonproliferative DR (NPDR), 31.4% had moderate, 15.1% had severe NPDR & 11.1% had proliferative
DR (PDR). In EDR group, 58.4% had mild and 41.6% had moderate NPDR. The mean±SD fasting serum glucose of the groups (LDR
& EDR respectively) was 9.36±0.40 & 4.78±0.38 mmol/l, total cholesterol was 206.50±42.60 & 104.20±35.50 mg/dl, HbA1c was
9.80±0.50% & 5.70±0.38%, TG was 163.76±99.46 & 155.67±94.84 mg/dl, SBP was 172.5±20.9 & 109.5±11.9 mmHg and DBP was
97.7±10.0 & 70.7±9.3 mmHg. About 17% patients in LDR & 34% in EDR were free of diabetic complications other than DR. In LDR
& EDR, 18% & 46% had one complication, 27% & 8% had two and 30% & 4% had more than two complications respectively. The
most frequent complication was cardiopathy, which affected 31% patients in LDR & 25% in EDR, followed by peripheral neuropathy
19% & 16%, nephropathy 15% & 11%, and peripheral vascular disease 8 % & 4% respectively. The average annual cost of care was
US$ 27954 (direct US$ 16983 & indirect US$ 10971), with an average US$ 140 per patient. Among the average annual cost LDR
consumed US$ 19737 (US$ 197 per patient) & EDR US$ 8217 (US$ 82 per patient). US$ 13473 (48%) of costs was attributable to
drugs for both groups of which US$ 10817 (80%) was for LDR & US$ 2656 (20%) for EDR, US$ 8739 (31%) to hospitalizations of
which US$ 5211 (60%) for LDR & 3528 (40%) for EDR. In case of diagnostics & visits the corresponding values were US$ 2136
(60%) & 1419 (40%) and US$ 1673 (76%) & 514 (24%) for LDR & EDR respectively. The annual medical costs increased with the
increased number of complications from US$ 1322 to 2298 & to 3991 in LDR with one, two & more than two complications (other
than DR) which is increasing at a rapid rate and US$ 917 to 1556 & to 2372 in EDR respectively, increasing at a diminishing marginal
rate. The regression equation showed that medical cost is significantly related to complications tested in both univariate (P<0.0001) &
multiple linear regression analyses (R2=0.53; F=82.3, P<0.0001).
Conclusion: Proper management with regular screening substantially reduces the expenditure related to care of patients with diabetic
retinopathy & related complications even in a developing country. Strategies aimed at preventing DR & early detection of the onset of
retinopathy complication will reduce medical costs in a substantial way.