Cost analysis of a virtual retina clinic versus fully face-to-face clinics

doi:10.21203/rs.3.rs-3614578/v1

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Cost analysis of a virtual retina clinic versus fully face-to-face clinics

https://doi.org/10.21203/rs.3.rs-3614578/v1

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PURPOSE

To compare the cost of a virtual retina clinic (VRC) with that of fully face-to-face (F2F) clinics in the follow-up of stable retinal diseases.

METHODS

A cost-minimization analysis (CMA) was conducted by measuring resource utilization of patients treated at Donostia University Hospital, for monitoring tests, performed in conventional F2F visits in 2019, and through the VRC in 2020. Our previous study on the VRC effectiveness demonstrated the equivalence of the results of the VRC and F2F approaches, as required for CMA, and a VRC sensitivity of 100% for detecting progression. The unit costs were obtained from the hospital´s accounting system. Furthermore, indirect costs related to labor productivity losses in patients and their companions were analyzed.

RESULTS

No significant differences were found between the total direct direct costs of the VRC and conventional clinics in the follow-up of 481 patients with stable retinal diseases. The differences detected were that VRC staff costs were significantly lower (54.5% vs. 76.8% for F2F clinics) while its equipment costs were higher (32.8% vs. 10%). Overall, including the costs of productivity losses, the VRC is significantly less expensive than in-person care as it more than halves indirect costs.

CONCLUSION

This first study analyzing the costs of a VRC versus fully F2F clinics found that it is not more expensive for the follow-up of stable retinal diseases. Additionally, taking into account indirect costs, the VRC is less expensive, and once the equipment has been acquired, its costs are lower than those of conventional clinics.

VRC

cost-effectiveness

teleophthalmology

This study demonstrates that a virtual retina clinic is not more expensive than face-to-face clinics. Taking into account indirect costs related to loss of labor productivity, the virtual approach is less expensive and once the equipment has been acquired, the costs are lower than those of in-person care.

Telemedicine refers to the use of technology to exchange medical data with the aim of evaluating patients remotely. Technological advances and the ability to visualize and obtain images of the eye directly have made ophthalmology an ideal specialty for applying this approach.¹ The recent widespread interest in teleophthalmology among healthcare providers has been fueled by the development and growing feasibility of this technology, as well as rises in the prevalence of chronic eye diseases and demand for ophthalmic care services in aging populations.¹ Additionally, the number of ophthalmologists has decreased recently in some countries (e.g., the United States).²

The first virtual clinic was implemented in 2011 in Great Britain by orthopedic specialists.^3,4 Within ophthalmology, the glaucoma subspecialty was the first to establish virtual clinics.⁵ Improvements in technology for capturing and disseminating retinal images have allowed virtual retina clinics (VRCs) to become a reality in the last decade and the approach has been expanded to subspecialties such as retinal diseases, cataract and corneal diseases, and pediatric ophthalmology.^6,7 Especially in recent years, in which the coronavirus disease 2019 (COVID-19) pandemic has transformed healthcare provision, use of telehealth has grown markedly.⁸

During the pandemic, the organization of a VRC through our teleretina platform emerged as a natural response in Donostia University Hospital (HUD), in-person consultations being minimized in accordance with American Academy of Ophthalmology recommendations.⁹ Thus, from mid-March 2020 to March 2021, patients with stable retinal diseases were treated through the VRC. This approach involves an optometrist collecting data on patients' symptoms in a standardized manner and performing optometry tests including the acquisition of retinal images and macular optical coherence tomography (OCT), while the ophthalmologist does not see the patient face-to-face (F2F) but rather reports on the case at a later time.

Given the growing demand for telemedicine services, the effectiveness and efficiency of teleophthalmology should be compared to those of traditional forms before wider roll out.¹⁰ There is evidence in the literature that various teleophthalmology platforms are effective in detecting disease progression.^11,12,13 A meta-analysis by Ullah et al. demonstrated that telescreening is moderately sensitive and highly specific for the diagnosis of diabetic retinopathy (DR),¹¹ while that by Kawaguchi et al. suggested that teleophthalmology for DR and age-related macular degeneration (AMD) is as effective as in-person care and increases patient participation.¹² Recently, Juaristi et al. evaluated the effectiveness of this type of platform through a double-control study, demonstrating 100% sensitivity for detecting the progression of a range of retinal diseases, and high levels of patient satisfaction.¹³

Nonetheless, there have been few systematic economic reviews of teleophthalmology compared to traditional detection methods. Ullah's meta-analysis confirmed that non-mydriatic retinal telescreening platforms are cost-effective, decrease the workload compared to in-person care, and increase patient compliance when the service is offered free in socially- and economically-deprived areas.¹¹ Further, Sharafeldin et al. reviewed economic studies on teleophthalmology as an alternative to in-person detection in DR, glaucoma, and AMD,¹ finding that it is cost-effective for DR and glaucoma detection and may increase access to disease progression detection in remote populations. According to Sharafeldin, population selection for detection optimizes the cost-effectiveness of teleophthalmology. On the other hand, Juaristi demonstrated that a VRC reduces the demand on ophthalmologists' time by half, in that it can process 12 VRC patients/hour compared to 6 patients/hour through in-person clinics.¹³

The aim of this study was to assess the efficiency of the virtual approach by conducting a cost-minimization analysis (CMA) comparing our VRC with standard fully F2F consultations, to guide decision-making regarding its continuity in the post-pandemic scenario.

Initially, we planned to conduct a randomized clinical trial allocating patients with retinal disease to each arm by the type of service (F2F or VRC). With the arrival of the pandemic, however, it became necessary to organize consultations through our teleretina platform. Therefore, a CMA was conducted comparing the monitoring process for patients assessed through the VRC in 2020 with that for the same patients in 2019, when they had been seen F2F.

CMA assumes that health outcomes are essentially the same with the options examined and measures the difference in associated costs. Consequently, it is expected that the intervention with the lower cost will be adopted.¹⁰ Although it is difficult to identify two forms of ophthalmic care with exactly the same effects, the justification for using CMA is based Juaristi’s study¹³ that documented the effectiveness of the VRC by analyzing the results of the alternative approaches through a double-control study. In this second phase, a CMA study was conducted to evaluate the efficiency of the VRC based on the assumption that the two options have comparable health outcomes.

Patients

We studied all patients seen in the VRC from March 16, 2020, to March 16, 2021, who met the selection criteria (Supplementary material table 1). Data were collected on the following variables: age, sex, underlying conditions, and use of healthcare resources. The same sample of patients was used as a comparison group, analyzing their resource use during conventional F2F consultations a year earlier (in 2019).

The study was conducted in accordance with the principles of the Declaration of Helsinki and maintaining confidentiality of the data collected. It was approved by the HUD’s Ethics Committee. All patients gave written informed consent to participate in the study.

Virtual option

The VRC platform was based in the HUD. Each consultation with the optometrist consisted of gathering clinical data and performing all appropriate tests in a single session: refractometry, VA and non-contact intraocular pressure measurements, macular OCT (3D DRI OCT Triton, Topcon), widefield imaging in macular diseases, ultra-widefield imaging in retinal diseases with peripheral involvement (Clarus ultra-widefield camera, Carl Zeiss Meditec), and a 10-2 visual field test (VFT) (Humphrey 745i analyzer, Zeiss) in patients undergoing HCQ retinopathy screening. These optometry consultations lasted 15 minutes, except in the case of HCQ screening for which 30 minutes were allowed. After these tests, patients left the hospital. The data collected by the optometrist were recorded in a digital form specifically designed for the VRC and stored on the hospital's intranet. Subsequently, a retinal ophthalmologist reported the case asynchronously (by storage and forwarding).

Conventional option

The conventional F2F consultations were conducted at health centers or the hospital. In the health center clinics, consultations lasted 10 minutes and patients were seen by a general ophthalmologist and an assistant nurse or nurse in the same consultation. In the F2F hospital clinic, patients were seen first by an optometrist in a 10-minute consultation for VA measurement and tonometry and then a retinal ophthalmologist in a 10-minute consultation. Any ancillary tests needed (e.g., OCT) were conducted before seeing the ophthalmologist (the same day or a few days earlier). OCT was performed by an optometrist or nurse, VFT by an assistant, and autofluorescence imaging, when needed, by a retinal ophthalmologist helped by a nurse, in 10-, 30- and 5-minute timeframes respectively. Figure 1 describes the connections between the VRC and other HUD retina consultations, namely, the diabetic retinopathy screening service and VRC (both virtual) and health center and hospital clinics (both F2F).

Cost Analysis

On the one hand, we analyzed direct costs, from a healthcare system perspective, and on the other, indirect costs including those associated with labor productivity losses. As direct costs, we considered equipment and ancillary test (retinography, OCT, VFT, and autofluorescence imaging), structural, and staff costs.

Patient costs were obtained multiplying resource use by unit costs measured in euro (€).

The unit costs of equipment for retinography, OCT, autofluorescence imaging, and VFT were calculated considering the value of the equipment, its amortization over 10 years, and the amount of use (hours per year).

It was assumed that structural costs correspond to an additional 15% of the total on both platforms. Structural costs include administrative, maintenance, and cleaning costs.

Staff costs were calculated based on the time spent by each professional multiplied by the costs per minute. The hourly costs, provided by the HUD’s accounting department, were €27.30 for nursing assistants, €39.10 for nurses and optometrists, and €58.60 for ophthalmologists. Table 1 shows the calculation of each type of service provided disaggregated into staff, equipment, and structural costs.

In the VRC, the optometrist performs the tests in 15 minutes (clinical interview, measurement of VA, non-contact intraocular pressure, OCT, and retinography), and the ophthalmologist reports the case in 5 minutes. For HCQ screening through the VRC, VFT is added, and overall, 30 minutes of the optometrist’s and 5 minutes of the ophthalmologist’s time are required. If VRC tests were positive, patients were referred to a hospital F2F clinic.

In 2019, in-person consultations were held at the health centers and hospital with various different cost components. Each patient was assigned the service that had actually been provided. Health center F2F consultations last 10 minutes, and the ophthalmologist is accompanied by a nursing assistant or nurse, and therefore, the unit cost was estimated as the average between that for a nursing assistant and a nurse. On the other hand, hospital F2F consultations consist of a 10-minute consultation with the optometrist and another 10-minute consultation with the specialist physician. For these consultations, if any ancillary tests are needed, test equipment and staff costs must be added: 10 minutes of nurse/optometrist time for macular OCT, 5 minutes of nurse time and 5 minutes of specialist physician time for autofluorescence imaging, and 30 minutes of nursing assistant time for VFT.

In 2019, some visits were first consultations, and hence, they were assigned higher costs according to the staff required and equipment used. Supplementary material Table 2 lists the costs of all consultation and ancillary test combinations.

Furthermore, the indirect costs were analyzed considering labor productivity losses in patients and their companions. Productivity losses were estimated based on responses to a questionnaire administered to patients asking how many working hours had been lost due to attendance at appointments by them and/or their companions. The costs were then calculated through a salary conversion method (the human capital approach), using the cost per hour lost in 2020 (€21.55) obtained from the Basque Statistics Insitute.¹⁵

The indirect costs of patients and their companions were summed if both had requested time off work. The total costs of productivity losses were then estimated by multiplying the unit cost by the lost working hours, and for the F2F clinics, also by the number of hospital visits.

Statistical analysis

All statistical analysis was conducted using the R statistical package (version 3.3.2). Initially, a descriptive analysis of patient characteristics was performed. Differences in categorical variables were evaluated using chi-square tests and means of continuous variables were compared using analysis of variance (ANOVA).

Continuous variables were assessed by t-tests or Mann-Whitney U tests if the data were not normally distributed.

Overall, 481 patients were included in the study. Of these, 54.3% were women and 45.7% were between 66 and 80 years old. The mean age was 67.0 years (range: 18 to 97; standard deviation: 13.9). The most common diseases were DR (30.4%) and AMD (21.8%). Table 2 summarizes patient characteristics.

Analyzing total direct costs, there were no significant differences between the VRC and F2F clinics (Table 3). According to the disaggregated cost analysis, however, staff costs for the virtual approach were significantly lower and equipment costs significantly higher than those for in-person care. Staff costs accounted for 54.5% of the total cost for the VRC and 76.8% for the F2F clinics, while equipment costs accounted for 32.8% of the total cost for the VRC and just 10% for the F2F clinics.

Table 3 also shows the costs per patient for annual follow-up disaggregated by cost component and reason for consultation. In the virtual option, the standard deviations of the costs disaggregated by retinal disease are zero because all patients receive the same service.

Using ANOVA, the costs of retinal diseases were found to be €27.60 in the VRC, including staff costs of €14.70 and equipment costs of €9.40 (except for HCQ screening which cost €40.10). In the F2F clinics, the costs vary depending on the reason for consultation: on average, cases of DR cost €24.20 ± 8.00, AMD €25.10 ± 7.30, epiretinal membrane €26.60 ± 7.30, and HCQ screening €48.80 ± 28.10, while the costs for the other diseases group was €26.40 ± 8.80.

Analyzing indirect costs, there were significant differences between the VRC and F2F clinics (Table 3). For F2F care, patients had to visit the hospital a mean of 1.4 ± 0.5 times, whereas with the VRC, all patients attended only once. The mean estimated cost of labor lost productivity was €9.9 ± 32.4 for the F2F clinics, compared to just €4.1 ± 18.5 for the VRC. Including the productivity lost in the analysis made the virtual approach significantly less expensive than in-person care.

The main contribution of this study is to establish that the costs of a VRC are not significantly higher than those of F2F clinics. The acquisition of more expensive equipment for virtual services is compensated for by reductions in staff costs. The requirement for equivalence of results with the options considered in the CMA was met by the findings of our previous study analyzing effectiveness and patient satisfaction, which showed, on the one hand, a VRC sensitivity of 100%, with no loss of cases that required treatment due to disease progression, and on the other, high rates of patient satisfaction.¹³

By reducing total staff time required by a third, the percentage of staff costs in the total direct costs falls significantly, from 76.8% in the conventional approach to 54.5% in the VRC. Conversely, equipment costs are higher in the VRC: 32.8% of the total direct costs versus just 10% in F2F clinics. This is due to the fact that, in addition to OCT as in most conventional retinal consultations, the VRC uses a widefield imaging system, whose amortization costs must be included.

Apart from direct costs, we have also analyzed indirect costs due to productivity losses. Most patients attend consultations accompanied, for example, because they are elderly or have visual impairment. In some cases, patients and/or companions may need to take work leave to attend.

In relation to this, including productivity losses of our patients and their companions, we demonstrated that the virtual approach is significantly less expensive than fully in-person care in our hospital. Notably, the VRC halves indirect costs because the consultations are a single short event, whereas conventional consultations sometimes require more than one hospital visit.

Regarding cost differences between patient subgroups, HCQ screening uses the most economic resources in F2F and virtual approaches, due to its higher demand for human resources (more time for tests) and equipment. As virtual screening is cheaper than the in-person approach, implementation of a VRC exclusively for HCQ screening could be considered since this is might achieve the greatest cost savings. We believe, however, that all patients requiring retinal monitoring should be evaluated through the same VRC since the teleretina platform is already a specific program within telemedicine for a suitable subset of patients and dedicated virtual HCQ screening would only be justified by it being required by numerous patients, beyond the patient volume at our hospital.

From the economic perspective, the results indicate that with VRCs, staff costs are converted to equipment/technology costs. In relation to this, the emergence of new digital platforms leads us to think that the use of technology will increase, and the role of ophthalmologists may be relegated, as is happening in many areas today. Nevertheless, we believe that ophthalmologists are irreplaceable, that is, that new technology will not fully replace their work since some complex patients will need medical-patient treatment, and will not be suitable candidates for a virtual approach.

Concerning VRCs, Lee et al.¹⁶ note that that instead of investing in VRCs, it would arguably be better to employ more physicians and expand clinical services, but unfortunately, this was not possible in the UK at the time due to a lack of suitably qualified physicians. This suggests that VRCs may additionally help physical clinics cope with future growing demand for care for retinal diseases and potential shortages of ophthalmologists, reducing the workload in physical clinics as well as in the case of epidemics. ^13,16,17

Lastly, a lack of physical space is another problem in many hospitals, making it difficult to schedule additional clinics when demand for consultations increases due to growth in disease prevalence. In this regard, VRCs would be advantageous, as physical clinics require more ophthalmology rooms, whereas for virtual clinics, ophthalmologists only need a computer with a viewer.

Limitations

In economic evaluation studies of teleophthalmology systems, the main limitations tend to be a lack of randomization, quality data and appropriate measures, and small sample sizes¹⁸; our work has the strength of being a double-controlled study with a relatively large sample size. Comparisons with studies analyzing other screening platforms show very heterogeneous results, largely attributable to different organizational models of ophthalmology consultations across countries.^{19, 20, 21, 22, 23} Costs vary greatly depending on the staff time required, ancillary tests performed, and price of equipment on the market at the time. We believe that rather than the absolute total cost, it is relevant to compare the costs of VRCs with those of physical clinics in the same setting. To our knowledge, this is the first study that analyzes the costs of a VRC and compares them with those of F2F clinics within the same hospital, and no significant direct cost differences were observed between the two approaches.

This is the first report on the comparative costs of a VRC, and it demonstrates that it is not more expensive than fully F2F clinics for the follow-up of stable retinal diseases. Moreover, taking into account indirect costs related to labor productivity losses, the virtual approach is less expensive and once the equipment described has been acquired, the costs are lower than those of conventional clinics.

Statements & Declarations

The authors have no conflicts of interest to declare.

Grants: Bottom-up grant from the Department of Health of the Government of the Basque Country

Other funding sources: none

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Table 1. Calculation of unit cost in euro for the most frequently used services in the virtual retinal clinic (VRC) and conventional face-to-face (F2F) clinics.

	Nursing assistants	Nurses and optometrists	Ophthalmologists	Total staff cost	Equipment costs	Structural costs	Total cost
Costs in €/hour	27.30	39.10	58.60
Virtual option 2020
VRC 2020		9.80	4.90	14.70	9.40	3.60	27.70
VRC-HCQ		19.50	4.90	24.40	10.50	5.20	40.10
Conventional option 2019
F2F: Health center clinic + OCT	2.30	9.80	9.80	21.90	3.70	3.80	29.40
F2F: HUD + OCT		13.00	9.80	22.80	3.70	4.00	30.50
F2F: HUD + OCT + VFT + Autofluorescence	13.60	16.30	14.60	44.50	13.00	8.60	66.20
First F2F consultation in 2019: HUD + OCT		26.00	19.50	45.50	7.40	8.00	60.90
First F2F consultation -HCQ in 2019: HUD + OCT + VFT + Autofluorescence	27.30	32.50	29.30	89.10	26.10	17.30	132.50

Abbreviations: VRC, virtual retina clinic. HCQ, hydroxychloroquine. F2F, face-to-face. OCT, optical coherence tomography. HUD, Donostia University Hospital. VFT, visual field test.

Table 2. Patient characteristics.

Sex	Frequency	Percentage
Male	220	45.7
Female	261	54.3
Total	481	100.0
Consultation in 2019	Frequency	Percentage
Held at a health center	278	57.8
Held at the hospital	192	39.9
First consultation	11	2.3
Total	481	100.0
Age group, years	Frequency	Percentage
≤50	65	13.5
51-65	125	26.0
66-80	216	44.9
≥81	75	15.6
Total	481	100.0
Reason for consultation	Frequency	Percentage
Dry age-related macular degeneration	105	21.8
Hydroxychloroquine retinopathy screening	54	11.2
Epiretinal membrane	58	12.1
Diabetic retinopathy	146	30.4
Others	118	24.5
Total	481	100.0

Table 3. Patient-specific costs in euro for the annual check-up for reason for consultation, disaggregated by cost component and year.

			2020			2019
		Mean		Standard deviation	Mean		Standard deviation
Diabetic retinopathy	Staff***	14.70		0.00	19.20		5.10
	Equipment ***	9.40		0.00	1.90		2.00
	Structural costs	3.60		0.00	3.20		1.00
	Total direct costs***	27.60		0.00	24.20		8.00
	Indirect costs***	3.00		10.60	7.70		23.60
	Total costs	30.60		10.60	32.00		25.30
Age-related macular degeneration	Staff ***	14.70		0.00	19.70		4.60
	Equipment ***	9.40		0.00	2.10		1.90
	Structural costs	3.60		0.00	3.30		1.00
	Total direct costs***	27.60		0.00	25.10		7.30
	Indirect costs	3.30		11.60	6.60		19.00
	Total costs	30.90		11.60	31.70		20.00
Epiretinal membrane	Staff ***	14.70		0.00	20.50		4.60
	Equipment ***	9.40		0.00	2.60		1.90
	Structural costs	3.60		0.00	3.50		0.90
	Total direct costs	27.60		0.00	26.60		7.30
	Indirect costs	0.20		1.40	2.20		12.60
	Total costs	27.80		1.40	28.80		15.10
Hydroxychloroquine screening	Staff ***	24.40		0.00	35.10		17.90
	Equipment ***	10.50		0.00	7.30		6.90
	Structural costs	5.20		0.00	6.40		3.70
	Total direct costs**	40.10		0.00	48.80		28.10
	Indirect costs*	14.80		44.10	32.30		44.10
	Total costs*	54.90		44.10	81.10		44.10
Other conditions	Staff ***	14.70		0.00	20.30		5.40
	Equipment ***	9.40		0.00	2.60		2.70
	Structural costs	3.60		0.00	3.40		1.20
	Total direct costs*	27.60		0.00	26.40		8.80
	Indirect costs*	3.20		14.50	8.90		24.20
	Total costs	30.80		14.50	35.20		25.80
Total	Staff ***	15.80		3.10	21.50		9.00
	Equipment ***	9.50		0.30	2.80		3.50
	Structural costs	3.80		0.50	3.70		1.80
	Total direct costs	29.00		3.90	28.00		14.10
	Indirect costs***	4.10		18.50	9.90		32.40
	Total costs**	33.10		19.70	37.80		37.00

* Statistically significant: p>0.05;** 0.05 > p > 0.01; *** p < 0.01.

No competing interests reported.

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Cost analysis of a virtual retina clinic versus fully face-to-face clinics

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