Health economic aspects of diabetic retinopathy

To ensure that the resources of the health care sector are used effectively, new technologies need to be evaluated before implementation to examine if they generate health outcomes at an acceptable cost. This information can be collected by performing health economic evaluations in which the costs and health outcomes of different technologies are compared. To estimate the effect on health care budgets, there is also a need for information about the prevalence of the specific disease. Health outcomes in health economic evaluations are often measured in quality-adjusted life years (QALYs), which are calculated by multiplying the remaining life years after an intervention by a weight representing the health-related quality of life (HRQoL) during those years. This thesis aims to provide deeper knowledge of the health economic aspects of diabetic retinopathy (DR), an eye complication that affects patients with diabetes and may in the worst case lead to blindness. The focus is on three empirical and two methodological health economic research questions. The empirical research areas cover prevalence, costs, and HRQoL related to patients with DR. The methodological research questions explore the performance of different methods for estimation of QALY weights. This is of interest since it has been argued that the most common methods for estimating QALY weights may not capture all relevant vision-related aspects of quality of life. The analyses comprehend the validity of different methods for estimating QALY weights among patients with DR and if the results of one of the specific methods for estimating QALY weights, the time trade-off (TTO) exercise, are affected by patients’ subjective life expectancy (SLE). The empirical results demonstrate that DR is seen in approximately 40% and 30% of patients with type I and type II diabetes respectively, indicating that the prevalence of DR has decreased in both of these patient groups. Healthcare costs vary considerably between different severity levels of the disease, being estimated at €26, €257, €216, and €433 per patient per year for background retinopathy, proliferative diabetic retinopathy (PDR), diabetic macular oedema (DMO), and PDR combined with DMO respectively. Blindness due to DR is associated with an increased use of transportation services, caregiving services, and assistive technologies as well as productivity losses. This suggests that preventing the progression of DR may lower healthcare costs. Patients with vision impairment due to DR have lowered HRQoL in various dimensions, but the diagnosis of DR in itself has only a limited effect on HRQoL. The results on the methodological research questions show that different methods for estimating QALY weights seem to give different results. In comparison to EQ-5D, the Health Utilities Index Mark 3 (HUI-3) is the most sensitive method for detecting differences in QALY weights due to DR, and if decisions are to be made based on values from the general public, it can be recommended for use in cost-utility analyses of interventions directed at DR. Neither of the direct methods, TTO and the visual analogue scale, seems to be sensitive to differences in visual function, and more research is needed concerning the role of vision in people’s responses to the TTO exercises. In TTO exercises with time frames based on actuarial life expectancy, the patients’ SLE has an effect on their willingness to trade off years for full health. Thus, applying time frames deviating from patients’ SLE may result in biased QALY weights. Such bias may appear stronger within patient populations than within the general public. In conclusion, this thesis offers estimates for prevalence, costs, and QALY weights that can be used in economic evaluations of interventions directed at DR and as benchmarks for future DR research in order to follow up consequences of changes in diabetes care. In addition, it demonstrates that the choice of method for estimating QALY weights may have an impact on whether an intervention is considered cost-effective