Population impact and cost-effectiveness of artificial intelligence-based diabetic retinopathy screening in people living with diabetes in Australia: a cost effectiveness analysis

Background:We aimed to evaluate the cost-effectiveness of an artificial intelligence-(AI) based diabetic retinopathy (DR) screening system in the primary care setting for both non-Indigenous and Indigenous people living with diabetes in Australia. Methods:We performed a cost-effectiveness analysis between January 01, 2022 and August 01, 2023. A decision-analytic Markov model was constructed to simulate DR progression in a population of 1,197,818 non-Indigenous and 65,160 Indigenous Australians living with diabetes aged ≥20 years over 40 years. From a healthcare provider's perspective, we compared current practice to three primary care AI-based screening scenarios-(A) substitution of current manual grading, (B) scaling up to patient acceptance level, and (C) achieving universal screening. Study results were presented as incremental cost-effectiveness ratio (ICER), benefit-cost ratio (BCR), and net monetary benefits (NMB). A Willingness-to-pay (WTP) threshold of AU$50,000 per quality-adjusted life year (QALY) and a discount rate of 3.5% were adopted in this study. Findings:With the status quo, the non-Indigenous diabetic population was projected to develop 96,269 blindness cases, resulting in AU$13,039.6 m spending on DR screening and treatment during 2020-2060. In comparison, all three intervention scenarios were effective and cost-saving. In particular, if a universal screening program was to be implemented (Scenario C), it would prevent 38,347 blindness cases, gain 172,090 QALYs and save AU$595.8 m, leading to a BCR of 3.96 and NMB of AU$9,200 m. Similar findings were also reported in the Indigenous population. With the status quo, 3,396 Indigenous individuals would develop blindness, which would cost the health system AU$796.0 m during 2020-2060. All three intervention scenarios were cost-saving for the Indigenous population. Notably, universal AI-based DR screening (Scenario C) would prevent 1,211 blindness cases and gain 9,800 QALYs in the Indigenous population, leading to a saving of AU$19.2 m with a BCR of 1.62 and NMB of AU$509 m. Interpretation:Our findings suggest that implementing AI-based DR screening in primary care is highly effective and cost-saving in both Indigenous and non-Indigenous populations. Funding:This project received grant funding from the Australian Government: the National Critical Research Infrastructure Initiative, Medical Research Future Fund (MRFAI00035) and the NHMRC Investigator Grant (APP1175405). The contents of the published material are solely the responsibility of the Administering Institution, a participating institution or individual authors and do not reflect the views of the NHMRC. This work was supported by the Global STEM Professorship Scheme (P0046113), the Fundamental Research Funds of the State Key Laboratory of Ophthalmology, Project of Investigation on Health Status of Employees in Financial Industry in Guangzhou, China (Z012014075). The Centre for Eye Research Australia receives Operational Infrastructure Support from the Victorian State Government. W.H. is supported by the Melbourne Research Scholarship established by the University of Melbourne. The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.