Elsevier

Public Health

Volume 148, July 2017, Pages 37-48
Public Health

Original Research
Cost-effectiveness and cost utility of community screening for glaucoma in urban India

https://doi.org/10.1016/j.puhe.2017.02.016Get rights and content

Highlights

  • The introduction of a community screening programme for glaucoma for 40–69 years group in urban India is likely to be cost-effective.

  • In addition, the screening programme could treat additional cases and preserve sight, in comparison with no screening.

  • The results and model are appropriate for funders and government to choose appropriate age groups for screening given their willingness to pay for a quality-adjusted life year (QALY).

Abstract

Objectives

Population-based screening for glaucoma has been demonstrated to be cost-effective if targeted at high-risk groups such as older adults and those with a family history of glaucoma, and through use of a technician for conducting initial assessment rather than a medical specialist. This study attempts to investigate the cost-effectiveness of a hypothetical community screening and subsequent treatment programme for glaucoma in comparison with current practice (i.e. with no screening programme but with some opportunistic case finding) in the urban areas of India.

Study design

A hypothetical screening programme for both primary open-angle glaucoma and angle-closure disease was built for a population aged between 40 and 69 years in the urban areas of India.

Methods

Screening and treatment costs were obtained from an administrator of a tertiary eye hospital in India. The probabilities for the screening pathway were derived from published literature and expert opinion. The glaucoma prevalence rates for urban areas were adapted from the Chennai Glaucoma Study findings. A decision-analytical model using TreeAge Pro 2015 was built to model events, costs and treatment pathways. One-way sensitivity analyses were conducted.

Results

The introduction of a community screening programme for glaucoma is likely to be cost-effective, the estimated incremental cost-effectiveness ratio (ICER) values being

Image 1
10,668.68 when compared with no screening programme and would treat an additional 4443 cases and prevent 1790 person-years of blindness over a 10-year period in the urban areas of India. Sensitivity analyses revealed that glaucoma prevalence rates across various age groups, screening uptake rate, follow-up compliance after screening, treatment costs and utility values of health states associated with medical and surgical treatment of glaucoma had an impact on the ICER values of the screening programme.

Conclusions

In comparison with current practice (i.e. without a screening programme but with some opportunistic case finding), the introduction of a community screening programme for glaucoma for the 40–69 years age group is likely to be relatively cost-effective if implemented in the urban areas of India.

Section snippets

Objectives

Glaucoma contributes to 0.6 million disability-adjusted life years (DALYs) or 1.96% of the overall burden of diseases in India.1 A recent population-based study using modern techniques for detecting glaucoma suggested 11.2 million persons aged 40 years and older are affected due to glaucoma in India; primary open-angle glaucoma (POAG) affecting 6.48 million persons and primary angle-closure glaucoma (PACG) affecting 2.54 million persons.2 Around 27.6 million persons were estimated to have some

Screening programme

A hypothetical screening intervention programme (Fig. 1) was designed for glaucoma detection after discussions with a glaucoma specialist and ophthalmic epidemiologist. The screening protocol has been described in detail elsewhere.21 It is to be noted that, due to the higher proportion of cases in the population, only POAG and angle-closure disease were the focus for the screening programme; secondary and other forms of glaucoma were not to be considered.

Table 1 provides the summary of the

Structure of the decision model

Based on the screening protocol (Fig. 1) and the treatment pathway (Fig. 2), a decision-analytic model (Fig. 3) was developed using TreeAge Pro (version 2015, MA, USA) to model events, costs and treatment pathway of glaucoma with and without screening for the relevant patient group, i.e. population aged between 40 and 69 years. The main outcomes of the model studied were (a) total net cost of each strategy, (b) additional cases treated in the screening arm, (c) cost per quality-adjusted life

Results

The decision-analytic model suggests that, in current practice (i.e. without a screening programme but with some opportunistic case finding), the total cost of glaucoma examination and treatment in one million population of the 40–69 years age group in urban area in India is around

396 million. If an urban community screening programme for diagnosing and treating glaucoma for one million population of 40–69 years age group is implemented, the estimated total costs would be
670

Discussion

Our sensitivity analyses revealed that apart from glaucoma prevalence rates across various age groups, other factors such as screening uptake rates, follow-up compliance after screening, treatment costs and utility values of health states associated with medical and surgical treatment of glaucoma had an impact on the ICER values of the screening programme. Lower values of screening uptake rates showed higher ICER values pointing to the need for improving screening uptake rates for increased

Acknowledgements

The first author acknowledges the support of Dr. Toni Ashton, Professor, School of Population Health, University of Auckland, for critical comments for this manuscript.

Ethical approval

None sought.

Funding

No funding support was received to conduct this study. However, the authors acknowledge the support of NZAID Commonwealth Scholarship provided to the first author for conducting this exercise as part of his dissertation for MPH degree at University of Auckland, New Zealand.

Competing interests

None declared.

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