Cost-effectiveness and cost-utility of population-based glaucoma screening in China: a decision-analytic Markov model

Abstract

Background: Glaucoma, particularly primary angle closure glaucoma (PACG), is a leading cause of global blindness. Nearly half of all people with PACG are of Chinese descent. Population-level glaucoma screening has generally not been found to be cost-effective in high-income countries; however, this assessment has rarely been done in low-income or middle-income countries. We aimed to assess the cost-effectiveness and cost-utility of population-level glaucoma screening in China.

Methods: We developed decision-analytic Markov models for separate and combined screening for PACG and primary open angle glaucoma (POAG) to evaluate costs and benefits of community-level screening versus opportunistic case finding from a societal perspective. A cohort of individuals was followed in the model from age 50 years through a total of 30 1-year Markov cycles. Analyses were done separately for rural and urban settings. We did a meta-analysis of glaucoma prevalence studies in China to obtain prevalence estimates for PACG and POAG. Screening costs were taken from a Chinese screening programme and treatment costs from a tertiary Chinese eye hospital. Main outcomes were incremental cost-utility ratios (ICURs) using quality-adjusted life-years and incremental cost-effectiveness ratios (ICERs) using years of blindness avoided. We did one-way deterministic and simulated probabilistic sensitivity analyses to reflect uncertainty around ICURs and ICERs.

Findings: Compared with no screening, combined screening of POAG and PACG in rural China is predicted to result in an ICUR of US$569 (95% CI 17 to 4180) and an ICER of $1280 (-58 to 7940), both of which are below the WHO cost-effectiveness threshold of one to three times rural gross domestic product. For the urban China setting, combined screening is predicted to result in fewer net costs and greater gain in health benefits than no screening. Findings were robust in all sensitivity analyses. Over 30 years, a total of 246 (95% CI 63 to 628) and 1325 (510 to 2828) years of blindness are predicted to be avoided for every 100 000 rural and urban residents screened, respectively.

Interpretation: Population screening for glaucoma (POAG and PACG combined) is likely to be cost-effective in both urban and rural China. Future studies should investigate the effectiveness of interventions to improve acceptance of definitive care among people screened.

Funding: Ulverscroft Foundation, Wenzhou Medical University Research Fund, Zhejiang Province Health Innovation Talents Project, and Wenzhou's Ten Major Livelihood Issues 2015.