Diabetic Retinopathy Screening Intervals: Balancing Safety Against the Cost of Annual Recall
DOI:
https://doi.org/10.5281/zenodo.22260598Keywords:
Diabetic retinopathy, Screening interval, Risk stratification, Cost-effectiveness, Health equityAbstract
Annual screening for diabetic retinopathy has been standard for two decades, and the interval was set by expert opinion rather
than by evidence. Extending it for people at low risk has since been recommended and, in England, implemented for those with no
detectable retinopathy at two consecutive visits. The economic case is not uniform. A Welsh cost-utility analysis of 26,812 people
with type 2 diabetes and 1,232 with type 1 reported that moving to biennial screening saved the health service £71,243 per
quality-adjusted life year forgone in type 2 diabetes but only £23,446 in type 1, and at a lower discount rate the type 1 figure fell to
£14,221, below the threshold at which the trade is considered acceptable. A randomised equivalence trial has tested intervals of 6,
12 and 24 months by individual risk. The unresolved question is equity: the safety evidence derives largely from populations of
white ethnicity, and analysis of 105,083 people has raised the possibility that extending intervals delays detection in some groups.
References
Scanlon PH. "The English National Screening Programme for diabetic retinopathy 2003-2016". Acta Diabetol 54(2017):515-525.
Taylor-Phillips S, Mistry H, Leslie R, Todkill D, Tsertsvadze A, Connock M, et al. "Extending the diabetic retinopathy screening interval beyond 1 year: systematic review". Br J Ophthalmol 100(2016):105-114.
Kristinsson JK, Stefansson E, Jonasson F, Gislason I, Bjornsson S. "Screening for eye disease in type 2 diabetes mellitus". Acta Ophthalmol 72(1994):341-346.
Aspelund T, Thornorisdottir O, Olafsdottir E, Gudmundsdottir A, Einarsdottir AB, Mehlsen J, et al. "Individual risk assessment and information technology to optimise screening frequency for diabetic retinopathy". Diabetologia 54(2011):2525-2532.
North East London investigators. "A simple score-based strategy to improve equity of the UK biennial diabetic eye screening protocol among people deemed as low risk". Diabetologia (2025).
Scanlon PH, Aldington SJ, Leal J, Luengo-Fernandez R, Oke J, Sivaprasad S, et al. "Development of a cost-effectiveness model for optimisation of the screening interval in diabetic retinopathy screening". Health Technol Assess 19(2015):1-116.
Scotland cost-effectiveness investigators. "Modelling the cost-effectiveness of adopting risk-stratified approaches to extended screening intervals in the national diabetic retinopathy screening programme in Scotland". Diabet Med 33(2016):886-895.
Stratton IM, Aldington SJ, Taylor DJ, Adler AI, Scanlon PH. "A simple risk stratification for time to development of sight-threatening diabetic retinopathy". Diabetes Care 36(2013):580-585.
Broadbent DM, Wang A, Cheyne CP, James M, Lathe J, Stratton IM, et al. "Safety and cost-effectiveness of individualised screening for diabetic retinopathy: the ISDR open-label, equivalence RCT". Diabetologia 64(2021):56-69.
Welsh cost-utility investigators. "Cost-effectiveness of biennial screening for diabetes related retinopathy in people with type 1 and type 2 diabetes compared to annual screening". Eur J Health Econ 21(2020):1035-1044.
McGhee S, Harding S, Broadbent D. "Screening intervals in diabetic retinopathy: applicability and potential pitfalls of individualised risk algorithms". Diabetologia 55(2012):1-3.
Systematic review authors. "Screening interval for diabetic retinopathy: insufficient evidence to extend beyond one year". Br J Ophthalmol 100(2016):105-114.
Leese GP, Stratton IM, Land M, Bachmann MO, Thomson H, Nangia V, et al. "Progression of diabetes retinal status within community screening programmes and potential implications for screening intervals". Diabetes Care 38(2015):488-494.
Looker HC, Nyangoma SO, Cromie DT, Olson JA, Leese GP, Philip S, et al. "Predicted impact of extending the screening interval for diabetic retinopathy: the Scottish Diabetic Retinopathy Screening programme". Diabetologia 56(2013):1716-1725.
Soto-Pedre E, Navea A, Millan S, Hernaez-Ortega MC, Morales J. "Evaluation of automated image analysis software for the detection of diabetic retinopathy to reduce the ophthalmologists workload". Acta Ophthalmol 93(2015):e52-e56.
Ting DSW, Cheung CY, Lim G, Tan GSW, Quang ND, Gan A, et al. "Development and validation of a deep learning system for diabetic retinopathy and related eye diseases using retinal images from multiethnic populations with diabetes". JAMA 318(2017):2211-2223.
Wong TY, Sun J, Kawasaki R, Ruamviboonsuk P, Gupta N, Lansingh VC, et al. "Guidelines on diabetic eye care: the International Council of Ophthalmology recommendations for screening, follow-up, referral, and treatment based on resource settings". Ophthalmology 125(2018):1608-1622.
Solomon SD, Chew E, Duh EJ, Sobrin L, Sun JK, VanderBeek BL, et al. "Diabetic retinopathy: a position statement by the American Diabetes Association". Diabetes Care 40(2017):412-418.
Yau JWY, Rogers SL, Kawasaki R, Lamoureux EL, Kowalski JW, Bek T, et al. "Global prevalence and major risk factors of diabetic retinopathy". Diabetes Care 35(2012):556-564.
Liew G, Michaelides M, Bunce C. "A comparison of the causes of blindness certifications in England and Wales in working age adults (16-64 years), 1999-2000 with 2009-2010". BMJ Open 4(2014):e004015.
Scanlon PH. "Update on screening for sight-threatening diabetic retinopathy". Ophthalmic Res 62(2019):218-224.
Olson J, Sharp P, Goatman K, Prescott G, Scotland G, Fleming A, et al. "Improving the economic value of photographic screening for optical coherence tomography-detectable macular oedema: a prospective, multicentre, UK study". Health Technol Assess 17(2013):1-142.
Chalk D, Pitt M, Vaidya B, Stein K. "Can the retinal screening interval be safely increased to 2 years for type 2 diabetic patients without retinopathy?". Diabetes Care 35(2012):1663-1668.
Echouffo-Tcheugui JB, Ali MK, Roglic G, Hayward RA, Narayan KM. "Screening intervals for diabetic retinopathy and incidence of visual loss: a systematic review". Diabet Med 30(2013):1272-1292.
Thomas RL, Dunstan FD, Luzio SD, Chowdhury SR, North RV, Hale SL, et al. "Prevalence of diabetic retinopathy within a national diabetic retinopathy screening service". Br J Ophthalmol 99(2015):64-68.
Scanlon PH, Aldington SJ, Stratton IM. "Delay in diabetic retinopathy screening increases the rate of detection of referable diabetic retinopathy". Diabet Med 31(2014):439-442.
Lund SH, Aspelund T, Kirby P, Russell G, Einarsson S, Palsson O, et al. "Individualised risk assessment for diabetic retinopathy and optimisation of screening intervals: a scientific approach to reducing healthcare costs". Br J Ophthalmol 100(2016):683-687.
Garvican L, Scanlon PH. "A pilot quality assurance scheme for diabetic retinopathy risk reduction programmes". Diabet Med 21(2004):1066-1074.
Gulliford MC, Dodhia H, Chamley M, McCormick K, Mohamed M, Naithani S, et al. "Socio-economic and ethnic inequalities in diabetes retinal screening". Diabet Med 27(2010):282-288.
Millett C, Dodhia H. "Diabetes retinopathy screening: audit of equity in participation and selected outcomes in south east London". J Med Screen 13(2006):152-155.
Sivaprasad S, Gupta B, Gulliford MC, Dodhia H, Mohamed M, Nagi D, et al. "Ethnic variations in the prevalence of diabetic retinopathy in people with diabetes attending screening in the United Kingdom (DRIVE UK)". PLoS One 7(2012):e32182.
