Cost Utility of Mobile Telescreening
of Diabetic Retinopathy in rural south India
Dr R.R.Sudhir1 DO. DNB. MPH (Johns Hopkins USA)
Head of Dept of Preventive Ophthalmology
Senior Consultant Cornea Services
Consultant In-charge of EMR
Co-investigators :
Sarah Polack2, Rosa Legod2, Yasmene Alavi2, Robert
Lindfield2, Tarun Sharma1, Hannah Kuper1
1Sankara
Nethralaya
Medical and Vision Research Foundation
Chennai, India
&
2International Center For Eye Health
(London School of Hygiene & Tropical Medicine)
Introduction
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Diabetic retinopathy (DR) can cause blindness, but this can be
prevented through early detection and treatment.
Diabetic populations in rural communities in India typically
have limited access to ophthalmic care.
Ensuring regular diabetic ophthalmic examinations for rural
populations therefore poses a considerable challenge.
Rural Mobile telescreening for DR provides examination
services for population who may not otherwise have access to
them.
Evidence regarding the cost-effectiveness of screening for DR
in low income settings is lacking.
Cost Utility of Mobile Telescreening of Diabetic Retinopathy in rural south India Dr R R Sudhir
AIM

To assess the cost-effectiveness of a telescreening of Diabetic
Retinopathy program in rural Southern India and to assess the
incremental cost effectiveness ratios associated with different
screening intervals.
Cost Utility of Mobile Telescreening of Diabetic Retinopathy in rural south India Dr R R Sudhir
Methods
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We used a Markov model to estimate the cost-utility of
 a) the current teleophthalmology program which involves one-off
screening in comparison to no screening programme, and
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b)the cost-utility of this program at different screening intervals.
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Six different screening interval strategies were compared: no screening,
once in a life time screening (current approach) and twice in a life time
screening, screening every 5 years, 3 years, 2 years and annual
screening.
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The model was based on a hypothetical cohort of 1000 rural diabetes
patients aged 40yrs who had not been previously screened for DR.
Cost Utility of Mobile Telescreening of Diabetic Retinopathy in rural south India Dr R R Sudhir
Methods
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To estimate utility values associated with DR, 249 people with
diabetes were interviewed using the time-trade off method.
Patient and provider costs of screening and treating DR were
estimated through interviews with 100 diabetic patients as well
as program and hospital managers.
The sensitivity and specificity of the DR screening was
assessed by comparing it to diagnosis using a gold standard
method for 346 diabetes patients.
Other model parameters were derived from literature.
Incremental cost-utility ratios were calculated from health
provider and societal perspective each successive strategy
comparing the most to the next least costly (e.g. comparing
annual screening to screening every 2years)..
Cost Utility of Mobile Telescreening of Diabetic Retinopathy in rural south India Dr R R Sudhir
Markov model parameter estimates assumptions
Parameter
Utility values
No Diabetic Retinopathy
Mild/moderate NPDR
Sight threatening DR
Bilateral blindness (VA<6/60)
Baseline Case Sensitivity analysis range
0.87
0.79
0.70
0.55
0.78-0.97*
0.72-0.86*
0.64-0.77*
0.46-0.64*
Annual transition probabilities (4,5,6,7)
No DR to mild/moderate NPDR
0.06
0.01-0.10¥
Mild/moderate NPDR to STDR
0.06
0.01-0.11¥
MO to blind without laser
MO to blind with laser
PDR to blind without laser
PDR to blind with laser
0.05
0.03
0.09
0.02
0.03-0.07
0.01-0.05
0.05-0.11
0.002-0.03
0.89
0.11
0.004
0.84-0.93*
0.06-0.16*
0.0-0.016*
Prevalence of DR among diabetics
No DR
Mild/moderate NPDR
STDR
8
Cost Utility of Mobile Telescreening of Diabetic Retinopathy in rural south India Dr R R Sudhir
Incremental cost-effectiveness of different tele-screening intervalscomparisons made to next most intensive strategy
Strategy
Cost $
Incremental
cost
QALY
Incremental
QALY
ICER*
Health provider perspective
No screening
0.0
-
12.6722
-
-
Once in a life time
6.5
6.5
12.6771
0.0049
1,320
Twice in a life time
11.7
5.3
12.6810
0.0039
1,343
Every 5 yrs
31.4
19.6
12.6907
0.0097
2,027
Every 3 yrs
48.8
17.4
12.6992
0.0084
2,034
Every 2 yrs
67.2
18.4
12.7067
0.0075
2,435
Annual
118.5
51.4
12.7195
0.0127
4,029
Societal perspective
No screening
0.0
Once in a life time
13.2
13.2
12.6771
0.0049
2,692
Twice in a life time
22.9
9.7
12.6810
0.0039
2,475
Every 5 yrs
53.2
30.3
12.6907
0.0097
3,134
Every 3 yrs
81.7
28.4
12.6992
0.0084
3,365
Every 2 yrs
109.4
27.7
12.7067
0.0075
3,669
Annual
181.7
72.4
12.7195
0.0127
5,677
12.6722
WHO suggested cost effective range,1-3 times the Indian GDP ($1061-3183).
Cost Utility of Mobile Telescreening of Diabetic Retinopathy in rural south India Dr R R Sudhir
Discussion
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The Strength of our study :
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Utility value (0.55) derived from a sample of diabetic patients from the
program area.
Primary data on costs, effectiveness and diagnostic tool accuracy
were collected from the program setting rather than relying on
published studies undertaken in other countries.
Data on baseline DR prevalence was estimated from a recent
population based study conducted in Chennai.
Limitation : Our model assumed 100% attendance of the
initial cohort at each subsequent DR screening. Although
there is evidence that DR screening in rural communities may
increase compliance compared to hospital based screening,
complete attendance may not be realistic.
Cost Utility of Mobile Telescreening of Diabetic Retinopathy in rural south India Dr R R Sudhir
Conclusion
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Our analysis suggests that a one-off telescreening program
for DR is cost-effective compared to no screening in this rural
Indian setting from a health provider perspective.
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Increasing the frequency of screening up to 2 years is also
cost-effective, although this is dependent on the
administrative costs of establishing and maintaining
screening at regular intervals and on achieving sufficient
coverage
Cost Utility of Mobile Telescreening of Diabetic Retinopathy in rural south India Dr R R Sudhir
Thank you
Acknowledgements
Study Grant : Sight Savers International
Cost Utility of Mobile Telescreening of Diabetic Retinopathy in rural south India Dr R R Sudhir