Elsevier

Ophthalmology

Volume 120, Issue 3, March 2013, Pages 566-573
Ophthalmology

Original article
The Cost–Utility of Telemedicine to Screen for Diabetic Retinopathy in India

https://doi.org/10.1016/j.ophtha.2012.09.002Get rights and content

Purpose

To assess the cost-effectiveness of a telemedicine diabetic retinopathy (DR) screening program in rural Southern India that conducts 1-off screening camps (i.e., screening offered once) in villages and to assess the incremental cost-effectiveness ratios of different screening intervals.

Design

A cost–utility analysis using a Markov model.

Participants

A hypothetical cohort of 1000 rural diabetic patients aged 40 years who had not been previously screened for DR and who were followed over a 25-year period in Chennai, India.

Methods

We interviewed 249 people with diabetes using the time trade-off method to estimate utility values associated with DR. Patient and provider costs of telemedicine screening and hospital-based DR treatment were estimated through interviews with 100 diabetic patients, sampled when attending screening in rural camps (n = 50) or treatment at the base hospital in Chennai (n = 50), and with program and hospital managers. The sensitivity and specificity of the DR screening test were assessed in comparison with diagnosis using a gold standard method for 346 diabetic patients. Other model parameters were derived from the literature. A Markov model was developed in TreeAge Pro 2009 (TreeAge Software Inc, Williamstown, MA) using these data.

Main Outcome Measures

Cost per quality-adjusted life-year (QALY) gained from the current teleophthalmology program of 1-off screening in comparison with no screening program and the cost–utility of this program at different screening intervals.

Results

By using the World Health Organization threshold of cost-effectiveness, the current rural teleophthalmology program was cost-effective ($1320 per QALY) compared with no screening from a health provider perspective. Screening intervals of up to a frequency of screening every 2 years also were cost-effective, but annual screening was not (>$3183 per QALY). From a societal perspective, telescreening up to a frequency of once every 5 years was cost-effective, but not more frequently.

Conclusions

From a health provider perspective, a 1-off DR telescreening program is cost-effective compared with no screening in this rural Indian setting. Increasing the frequency of screening up to 2 years also is cost-effective. The results are dependent on the administrative costs of establishing and maintaining screening at regular intervals and on achieving sufficient coverage.

Financial Disclosure(s)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Section snippets

Study Setting and Program Description

The study was undertaken in rural Tamil Nadu, Southern India. A recent survey in rural Tamil Nadu estimated the diabetes prevalence at 7.8% among people aged ≥20 years.16

The Sankara Nethralaya Medical Research Foundation teleophthalmology program conducts DR screening camps in villages in the rural districts neighboring Chennai. In the current program, 1-off screening (i.e., screening offered once) is conducted in each village rather than diabetic persons being invited for screening repeatedly

Model Parameters

Table 1 shows the per-person costs of telescreening, hospital retinal examinations, and laser photocoagulation treatment from the health provider and societal perspective. The health provider costs of telescreening were $7.36 per person screened, and the societal costs (i.e., including direct and indirect household costs) were $9.38. Costs for retinal examination and a single laser photocoagulation treatment at the hospital were $5.84 and $7.51 per person, respectively, from the health provider

Discussion

Our cost–utility model suggests that from a health provider perspective, the current Sankara Nethralaya rural teleophthalmology screening program is cost-effective compared with no DR screening for rural diabetic patients if the World Health Organization–suggested threshold (1–3 times the Indian GDP) is used to define cost-effectiveness.18, 19 Increasing the screening frequency to provide screening at regular intervals would increase the costs of the program; however, the increased QALYs gained

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    Manuscript no. 2012-634.

    Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

    This study was funded by a grant from Sightsavers. The funding organization had no role in the design or conduct of this research.

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