# Seizing the silent vision loss: cost–utility analysis of population-based glaucoma screening in India

## TL;DR

This study evaluates the cost-effectiveness of glaucoma screening in India and finds that improved public healthcare access could make screening cost-effective.

## Contribution

The study introduces a novel cost–utility analysis of population-based glaucoma screening strategies in India, identifying conditions under which such interventions could become cost-effective.

## Key findings

- Screening strategies gained 0.006 to 0.046 QALYs per person compared to usual care.
- Annual face-to-face screening for 40–75-year-olds could be cost-effective with improved public healthcare access.
- Strategic strengthening of public care could make glaucoma screening cost-saving.

## Abstract

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.