Purohit Neha, Buttan Sandeep, Gupta Parul Chawla, Choudhury Ranjan Kumar, Soundappan Kathirvel, Kotwal Atul, Prinja Shankar
Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
Sightsavers India, New Delhi, India.
BMJ Open. 2025 Apr 3;15(4):e098113. doi: 10.1136/bmjopen-2024-098113.
Glaucoma is a major cause of irreversible blindness in India; however, if detected early, its progression can be either prevented or stabilised through appropriate medical or surgical treatment. We aim to evaluate the cost-utility of various models for population-based glaucoma screening at primary health centres in India. We also assess the potential impact of the implementation of a population-based screening programme on overall costs of care for glaucoma.
Cost-utility analysis using a mathematical model comprising a decision tree and Markov model was conducted to simulate relevant costs and health outcomes over a lifetime horizon.
Screening services were assumed to be delivered at primary health centres in India.
A hypothetical cohort of different target population groups in terms of age groups and risk of glaucoma (age group 40-75 years, 50-75 years, 40-75 years age group at high risk of glaucoma, 50-75 years age group at high risk of glaucoma) were included in comparative screening strategies.
The exclusive intervention scenarios were 12 screening strategies based on different target population groups (age group 40-75 years, 50-75 years, 40-75 years age group at high risk of glaucoma, 50-75 years age group at high risk of glaucoma), screening methods (face-to-face screening and artificial intelligence-supported face-to-face screening) and screening frequencies for 40-75 years aged population (annual vs once every 5 years screening), in comparison to usual care scenario. The usual care scenario (current practice) implied opportunistic diagnosis by the ophthalmologists at higher levels of care.
The primary outcome was the incremental cost-utility ratio for each of the screening strategies in comparison to usual care. The secondary outcomes were per person lifetime costs, lifetime out-of-pocket expenditures, life years and quality-adjusted life-years (QALYs) in all screening scenarios and usual care.
Depending on the type of screening strategy, the gain in QALY per person ranged from 0.006 to 0.046 relative to usual care. However, the screening strategies, whether adjusted for specific age groups, patient risk profiles, screening methods or frequency, were not found to be cost-effective. Nonetheless, annual face-to-face screening strategies for individuals aged 40-75 years could become cost-effective in a scenario of strengthened public financing and provisioning, such that at least 67% of those seeking care for confirmatory diagnosis and treatment use government-funded facilities, in conjunction with 60% availability of medications at government hospitals.
Enhancing continuity of care following screening through either strengthening of public provisioning or strategic purchasing of care could make glaucoma screening interventions not only cost-effective, but also potentially cost-saving.
青光眼是印度不可逆性失明的主要原因；然而，如果早期发现，通过适当的药物或手术治疗，其进展可以得到预防或稳定。我们旨在评估印度初级卫生中心基于人群的青光眼筛查各种模式的成本效益。我们还评估实施基于人群的筛查计划对青光眼总体护理成本的潜在影响。
使用包含决策树和马尔可夫模型的数学模型进行成本效益分析，以模拟一生中的相关成本和健康结果。
假设筛查服务在印度的初级卫生中心提供。
在比较筛查策略中纳入了不同目标人群组，这些人群在年龄组和青光眼风险方面存在差异（年龄组40 - 75岁、50 - 75岁、40 - 75岁青光眼高风险年龄组、50 - 75岁青光眼高风险年龄组）。
独家干预方案为12种筛查策略，基于不同目标人群组（年龄组40 - 75岁、50 - 75岁、40 - 75岁青光眼高风险年龄组、50 - 75岁青光眼高风险年龄组）、筛查方法（面对面筛查和人工智能支持的面对面筛查）以及40 - 75岁人群的筛查频率（每年筛查与每5年筛查一次），并与常规护理方案进行比较。常规护理方案（当前做法）意味着由更高护理级别的眼科医生进行机会性诊断。
主要结果是每种筛查策略与常规护理相比的增量成本效益比。次要结果是所有筛查方案和常规护理中的人均终身成本、终身自付费用、生命年和质量调整生命年（QALY）。
根据筛查策略的类型，相对于常规护理，每人QALY的增益范围为0.006至0.046。然而，无论是否针对特定年龄组、患者风险状况、筛查方法或频率进行调整，筛查策略均未被发现具有成本效益。尽管如此，在加强公共融资和供应的情况下，针对40 - 75岁个体的年度面对面筛查策略可能会变得具有成本效益，即至少67%寻求确诊诊断和治疗的人使用政府资助的设施，同时政府医院有60%的药物供应。
通过加强公共供应或战略性购买护理来提高筛查后的护理连续性，不仅可以使青光眼筛查干预措施具有成本效益，而且可能节省成本。
