The cost-utility of telemedicine to screen for diabetic retinopathy in India

Ophthalmology. 2013 Mar;120(3):566-573. doi: 10.1016/j.ophtha.2012.09.002. Epub 2012 Dec 1.


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.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Cost-Benefit Analysis
  • Diabetic Retinopathy / diagnosis
  • Diabetic Retinopathy / economics
  • Diabetic Retinopathy / prevention & control*
  • Health Care Costs*
  • Humans
  • India
  • Laser Coagulation / economics
  • Markov Chains
  • Mass Screening / economics
  • Quality-Adjusted Life Years
  • Reproducibility of Results
  • Rural Population
  • Sensitivity and Specificity
  • Telemedicine / economics*
  • Vision Screening / economics*
  • Visual Acuity