Cost-utility Analysis of Opportunistic and Systematic Diabetic Retinopathy Screening Strategies from the Perspective of the Brazilian Public Healthcare System.

OBJECTIVE: To perform a cost-utility analysis of diabetic retinopathy (DR) screening strategies from the perspective of the Brazilian Public Healthcare System. METHODS: A model-based economic evaluation was performed to estimate the incremental costs per quality-adjusted life-year (QALY) gained between three DR screening strategies: (1) the opportunistic ophthalmology referral-based (usual practice), (2) the systematic ophthalmology referral-based, and (3) the systematic teleophthalmology-based. The target population included individuals with type 2 diabetes (T2D) aged 40 years, without retinopathy, followed over a 40-year time horizon. A Markov model was developed with five health states and a 1-year cycle. Model parameters were based on literature and country databases. One-way and probabilistic sensitivity analyses were performed to assess model parameters' uncertainty. WHO willingness-to-pay (WHO-WTP) thresholds were used as reference (i.e. one and three times the Brazilian per capita Gross Domestic Product of R$32747 in 2018). RESULTS: Compared to usual practice, the systematic teleophthalmology-based screening was associated with an incremental cost of R$21445/QALY gained ($9792/QALY gained). The systematic ophthalmology referral-based screening was more expensive (incremental costs = R$4) and less effective (incremental QALY = -0.012) compared to the systematic teleophthalmology-based screening. The probability of systematic teleophthalmology-based screening being cost-effective compared to usual practice was 0.46 and 0.67 at the minimum and the maximum WHO-WTP thresholds, respectively. CONCLUSION: Systematic teleophthalmology-based DR screening for the Brazilian population with T2D would be considered very cost effective compared to the opportunistic ophthalmology referral-based screening according to the WHO-WTP threshold. However, there is still a considerable amount of uncertainty around the results.

Diagnostic performance of retinal digital photography for diabetic retinopathy screening in primary care.

Introduction: We must study alternatives to structure an effective diabetic retinopathy screening program for Brazilian public health system. Objectives: Evaluate the diagnostic performance of retinal digital photography for diabetic retinopathy screening in primary care, accuracy of the family physician in diabetic retinopathy identification compared to the ophthalmologist, and the need for dilation. Methodology: In a primary care service were performed retinal photographs with non-mydriatic Retinal Camera in 219 type 2 diabetic patients with and without medication mydriasis. We evaluated the performance of the diagnostic of the photos graded by three family physicians with training compared to two ophthalmologists (gold standard), and explore related factors with the need for mydriasis pharmacologically. Results: The prevalence of diabetic retinopathy and proliferative diabetic retinopathy was 19.2% and 1.5%, respectively. The sensitivity of family physicians to evaluate diabetic retinopathy averaged 82.9% (66.7-94.8%); specificity, 92% (90.2-93.3%); the accuracy, 90.3% (88.2-93%) and positive predictive value, 71.2% (68-75.5%). The agreement calculated using the kappa adjusted coefficient was from 0.74 to 0.8 for retinopathy and 0.88 to 0.92 for macular edema. Without drug mydriasis the photos were unreadable by 14.8%, when using mydriatic collyrium this number decreased to 8.7% (McNemar test, P < 0.005). Patients with more than 65 years old has more readability after drug mydriasis (McNemar test, P = 0.011). Conclusion: Trained family physician reached a good performance for evaluation of retinography for diabetic retinopathy. There was improvement in readability with pupil dilation in older patients.

Risk factors for mortality in traumatic cervical spinal cord injury: Brazilian data.

BACKGROUND: Predictive factors for mortality are different among countries; knowledge of risk factors is important for planning strategies to reduce mortality in trauma. The objective of this study was to identify predictors of death in traumatic cervical spinal cord injury (TSCI) in Brazil. METHODS: From 2001 to 2005, 84 patients with clinically detectable TSCI were identified in this retrospective study. For each patient, neurologic and associated injuries, physiologic variables, complications, treatment, and hospital mortality were recorded. Bivariate and multivariate logistic regression analyses were done to identify predictors of mortality. RESULTS: Twenty-two (26.2%) patients died in hospital. Car crash (39%) and falls (37.85) were the most frequent causes of trauma. The causes of death were as follows: neurologic, 8 (36.4%); respiratory, 4 (18.2%); septic complications, 2 (9.1%); venous thrombosis and embolism, 2 (9.1%); and undetermined, 4 (18.2%). Bivariate analysis identified absent neurologic function (risk ratios [RR] = 4.5; 95% confidence intervals [CI], 1.6-12.7), high injury severity score (p = 0.001) and low revised trauma score (p = 0.001); Glasgow Coma Scale (GCS) score <9 (RR = 47.4; 95% CI, 5.4-413.2); shock at admission (RR = 2.5; 95% CI, 0.8-7.9); vasopressor use (RR = 25.8; 95% CI, 6.1-109.6); mechanical ventilation (RR = 31.9; 95% CI, 6.6-154.0); acute renal insufficiency (RR = 10.0; 95% CI, 0.98-102.1) as associated with mortality. The mainly independents predictors for mortality were GCS score <9 and vasopressor use. Lowest mortality rate (5.2%) was observed for patients with TSCI alone. CONCLUSIONS: GCS score <9, mechanical ventilation, and vasopressor use were predictors of mortality with TCSI, and if these risk factors were absent, we observed low mortality rate.