The TransFORmation of IndiGEnous PrimAry HEAlthcare Delivery (FORGE AHEAD): economic analysis.

BACKGROUND: Indigenous populations have increased risk of developing diabetes and experience poorer treatment outcomes than the general population. The FORGE AHEAD program partnered with First Nations communities across Canada to improve access to resources by developing community-driven primary healthcare models. METHODS: This was an economic assessment of FORGE AHEAD using a payer perspective. Costs of diabetes management and complications during the 18-month intervention were compared to the costs prior to intervention implementation. Cost-effectiveness of the program assessed incremental differences in cost and number of resources utilization events (pre and post). Primary outcome was all-cause hospitalizations. Secondary outcomes were specialist visits, clinic visits and community resource use. Data were obtained from a diabetes registry and published literature. Costs are expressed in 2023 Can$. RESULTS: Study population was ~ 60.5 years old; 57.2% female; median duration of diabetes of 8 years; 87.5% residing in non-isolated communities; 75% residing in communities < 5000 members. Total cost of implementation was $1,221,413.60 and cost/person $27.89. There was increase in the number and cost of hospitalizations visits from 8/$68,765.85 (pre period) to 243/$2,735,612.37. Specialist visits, clinic visits and community resource use followed this trend. CONCLUSION: Considering the low cost of intervention and increased care access, FORGE AHEAD represents a successful community-driven partnership resulting in improved access to resources.

Impact of Intersecting Systems of Oppression on Diabetic Retinopathy Screening Among Those Who Identify as Women of Low Socioeconomic Status: Protocol for a Convergent Mixed Methods Study.

BACKGROUND: By 2025, 5 million Canadians will be diagnosed with diabetes, and women from lower socioeconomic groups will likely account for most new diagnoses. Diabetic retinopathy is a primary vision complication of diabetes and a leading cause of blindness among adults, with 26% prevalence among women. Tele-retina is a branch of telemedicine that delivers eye care remotely. Screening for diabetic retinopathy has great potential to reduce the incidence of blindness, yet there is an adverse association among screening, income, and gender. OBJECTIVE: We aim to explore gender disparity in the provision of tele-retina program services for diabetic retinopathy screening in a cohort of women of low socioeconomic status (SES) receiving services in South Riverdale Community Health Centre (SRCHC) between 2014 and 2019. METHODS: Using a convergent mixed methods design, we want to understand patients', providers', administrators', and decision makers' perceptions of the facilitators and barriers associated with the implementation and adoption of tele-retina. Multivariate logistic regression will be utilized to assess the association among client characteristics, referral source, and diabetic retinopathy screening. Guided by a grounded theory approach, systematic coding of data and thematic analysis will be utilized to identify key facilitators and barriers to the implementation and adoption of tele-retina. RESULTS: For the quantitative component, we anticipate a cohort of 2500 patients, and we expect to collect data on the overall patterns of tele-retina program use, including descriptions of program utilization rates (such as data on received and completed diabetic retinopathy screening referrals) along the landscape of patient populations receiving these services. For the qualitative component, we plan to interview up to 21 patients and 14 providers, administrators, and decision makers, and to conduct up to 14 hours of observations alongside review of relevant documents. The interview guide is being developed in collaboration with our patient partners. Through the use of mixed methods research, the inquiry will be approached from different perspectives. Mixed methods will guide us in combining the rich subjective insights on complex realities from qualitative inquiry with the standard generalizable data that will be generated through quantitative research. The study is under review by the University Health Network Research Ethics Board (19-5628). We expect to begin recruitment in winter 2021. CONCLUSIONS: In Ontario, the screening rate for diabetic retinopathy among low income groups remains below 65%. Understanding the facilitators and barriers to diabetic retinopathy screening may be a prerequisite in the development of a successful screening program. This study is the first Ontario study to focus on diabetic retinopathy screening practices in women of low SES, with the aim to improve their health outcomes and revolutionize access to quality care. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/23492.

Tele-retina screening of diabetic retinopathy among at-risk populations: an economic analysis.

OBJECTIVES: To assess the cost-effectiveness of the pilot Toronto tele-retina screening program in comparison with existing standard of care (SOC) diabetic retinopathy (DR) screening for patients with diabetes mellitus and in a simulated Pan-Ontarian cohort. METHODS: Decision trees were constructed to compare tele-retina to SOC in the pilot and Pan-Ontarian cohort. Cost-effectiveness was assessed as cost per case detected (true-positive) and cost per case correctly diagnosed (true-positive and true-negative results). RESULTS: Pilot program screening costs were $95.77 and $137.56 for tele-retina and SOC, respectively. In the base-case analysis, cost per case correctly detected was $379.06 with tele-retina and $985.56 with SOC, and the cost per case correctly diagnosed was $109.29 and $315.22, respectively. In the sensitivity analysis, cost per case correctly detected was $467.29 with tele-retina and $894.93 with SOC, and the cost per case correctly diagnosed was $136.88 and $250.35, respectively. Pan-Ontarian screening costs were $57.58 and $137.56 for tele-retina and SOC, respectively. The cost per case correctly detected was $281.10 with tele-retina and $982.00 with SOC, and the cost per case correctly diagnosed was $82.21 and $314.14, respectively. For both pilot and Pan-Ontarian sensitivity analyses, tele-retina remained the dominant strategy (ICER <0). CONCLUSIONS: Findings from this study suggest that tele-retina is a more cost-effective means of screening for diabetic retinopathy than the SOC in urban and rural underscreened communities. Subsequent economic studies should focus on evaluations that consider the impact of tele-retina on the prevention of severe vision loss in underscreened urban and rural communities.