الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Diabetic Macular Edema (DME) is the leading cause of vision loss which affects approximately 6.8% of the diabetic population. (1-3) It is typically confirmed by slit-lamp examination with the aid of optical coherence tomography (OCT). (4) Anti-VEGF intravitreal injections are now used in management of DME based on the treatment and retreatment schedule where patients receive three initial consecutive monthly intravitreal injections of anti-VEGF followed by further treatment according to defined retreatment criteria. Meanwhile, follow up visits with visual acuity measurement and OCT should be continued to at least 12 months. (6)
Adherence of DME patients to intravitreal injections and follow up visits is crucial for treatment of DME and improvement of vision and their quality of life. (7-8) It was shown that factors that determine adherence fall in these dimensions: social- economic factors, therapy-related factors, health-system and clinician factors, patient factors, and patient-doctor relationship factors. (13)Barriers that hinder patients from adequately adhering to their regimens are geographic, organizational, financial, and psychological barriers, with interactions among them all. (14) Untreated DME can cause medical costs that are 29% higher than diabetic patients without DME. (15)
Cost-effectiveness analysis helps to identify neglected opportunities by highlighting interventions that are relatively inexpensive, and have the potential to reduce the disease burden. (16)while, Markov model is a simulation model to simulate costs and changes in visual acuity in DME patients that occur over time. (17)
Aim of the study
To measure the cost-effectiveness of adherence to DME therapeutic regimen among patients attending ophthalmology out-patient clinics in Alexandria Main University Hospital, Egypt.
Target population and study sample
A Cross-sectional study design was conducted on all DME patients registered in ophthalmology out-patient clinic’s medical records in the year 2015, about 320 patients and their medical records according to clinics’ registry in Alexandria Main University Hospital after exclusion of patients diagnosed with other diseases.
Data Collection methods and tools
1. Data abstraction sheet (Appendix I) was used to collect data from the medical records about patients’ adherence to their monthly therapeutic regimen of DME and the patients were categorized as being (adherent, partially-adherent and non-adherent)using scaled scoring system based on RESTORE study. (6)
2. A structured pre-designed interview Questionnaire (Appendix II) was used for data collection from DME patients about some determinants and barriers to patients’ adherence to DME theraputic regimen. Patients were telephoned and invited to the clinic to be interviewed.
3. Cost effectiveness analysis was estimated by calculating the incremental cost-effectiveness ratio (ICER) for patients with DME undergoing therapeutic regimen in ophthalmology department in Alexandria Main University Hospital
4. Markov model was constructed to simulate costs and changes in visionwhere costs and benefits were discounted at 3% annually over a 15 years horizon. (121)
The results of the present study revealed the followings:
• Adherent patients to DME therapeutic regimen in ophthalmology out-patient clinics in Alexandria Main University Hospital were only about quarter of patients.
• All patients knew that DM disease is the direct cause of diabetic macular edema and that DME can readily affect their vision.
• Three quarters of patients agreed that they have been introduced to the same treating ophthalmologist.
• The majority of patients’ opinion was that the distance of residence and transportation time were the main barriers of adherence to DME therapeutic regimen.
• Only quarter of the patients thought that the adherence to DME therapeutic regimen in ophthalmology out-patient retina clinicwere important.
• Most of patients were neutral towards their regimen while about third of patients were satisfied about doctors’ and nurses’ way of treatment during follow up visits.
• Adherence to DME theraputic regimen tends to be more in younger patients, male patients, who live in urban areas, married patients, employees or workers, who were graduated at college and whose monthly income cover their living costs
• Adherent patients to DME therapeutic regimen tend to incur more costs than non-adherent and partly-adherent patients but gained more visual improvement at the end of the study.
• Adherence is the optimal strategy for patients undergoing DME therapeutic regimen in ophthalmology out-patient retina clinic being cost-effective strategy with an (ICER= 31105 L.E/QALY).
• After applying Markov model over a 15-year horizon in patients who are adherent to DME therapeutic regimen, the adherence to anti-VEGF intravitreal injections was still cost-effective strategy with an ICER at the end of model to be (3899 L.E/QALY).
The following recommendations were suggested:
1) Training of the staff of ophthalmologists and nursesthe ways of good communication to patients, acknowledge them by details of their therapeutic regimen and remove any barriers to improve their adherence to their therapeutic regimens.
2) Increase of the staff from ophthalmologists to decrease the rate of frequent turn-over in clinics and increase the days of the retina clinic in ophthalmology department to cover the larger number of patients.
3) Implementation of health education programs to increase awarenessand knowledge of patients about importance of adherence to their theraputic regimens.
4) Improvement of medical records in clinics of Alexandria Main University Hospital to allow complete and valid data for researchers.
5) Provision more fund to important therapeutic regimens such as DME therapeutic regimen to overcome financial barriers of the adherence totheraputic regimens.
6) Conductionof more studies around Egypt to assess adherence of patients to DME therapeutic regimen to be able to generalize the findings of the present study and implementation of cost-effectivenessanalysis studies about adherence of patients in wider perspective such as hospital, health system or societal perspective