title: The cost-utility of telemedicine to screen for diabetic retinopathy in India.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  A cost-utility analysis using a Markov model.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
authors.affiliation: Department of Preventive Ophthalmology, Sankara Nethralaya, Vision Research Foundation, Chennai Tamil Nadu, India.
authors.forename: Sudhir
authors.initials: S
authors.lastname: Rachapelle
authors.affiliation: Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom.
authors.forename: Rosa
authors.initials: R
authors.lastname: Legood
authors.affiliation: International Centre for Eye Health, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom.
authors.forename: Yasmene
authors.initials: Y
authors.lastname: Alavi
authors.affiliation: International Centre for Eye Health, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom.
authors.forename: Robert
authors.initials: R
authors.lastname: Lindfield
authors.affiliation: Department of Preventive Ophthalmology, Sankara Nethralaya, Vision Research Foundation, Chennai Tamil Nadu, India.
authors.forename: Tarun
authors.initials: T
authors.lastname: Sharma
authors.affiliation: International Centre for Eye Health, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom; International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, London, United Kingdom. Electronic address: Hannah.Kuper@lshtm.ac.uk.
authors.forename: Hannah
authors.initials: H
authors.lastname: Kuper
authors.affiliation: International Centre for Eye Health, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom; International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, London, United Kingdom.
authors.forename: Sarah
authors.initials: S
authors.lastname: Polack
mesh_terms: D000328:Adult; D003362:Cost-Benefit Analysis; D003930:Diabetic Retinopathy / Q000175:diagnosis / Q000191:economics / Q000517:prevention & control*; D017048:Health Care Costs; D006801:Humans; D007194:India; D017075:Laser Coagulation / Q000191:economics; D008390:Markov Chains; D008403:Mass Screening / Q000191:economics; D019057:Quality-Adjusted Life Years; D015203:Reproducibility of Results; D012424:Rural Population; D012680:Sensitivity and Specificity; D017216:Telemedicine / Q000191:economics*; D015351:Vision Screening / Q000191:economics*; D014792:Visual Acuity