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. 2025 Jul;9(4):627-638.
doi: 10.1007/s41669-025-00572-4. Epub 2025 Apr 10.

Optimizing Diabetic Retinopathy Screening at Primary Health Centres in India: A Cost-Effectiveness Analysis

Neha Purohit  1 , Parul Chawla Gupta  2 , Sandeep Buttan  3 , Akashdeep Singh Chauhan  1   4 , Ranjan Kumar Choudhury  5 , Vishali Gupta  2 , Atul Kotwal  5 , Shankar Prinja  6
Affiliations

Optimizing Diabetic Retinopathy Screening at Primary Health Centres in India: A Cost-Effectiveness Analysis

Neha Purohit et al. Pharmacoecon Open. 2025 Jul.

Abstract

Background: The eye care package under the Ayushman Bharat comprehensive primary healthcare programme includes annual population-based screening for diabetic retinopathy (DR) using non-mydriatic fundus cameras at the primary health centres (PHCs) in India. However, there can be several implementation models for introduction of a systematic screening programme for DR.

Objectives: This study aims to assess the cost effectiveness of screening for DR in comparison with the usual-care scenario without a DR screening programme, and to determine cost-effective approaches for implementation of annual population-based screening for DR by optometrists at PHCs in India in terms of screening modalities (face-to-face vs tele-supported screening [screening followed by transfer and remote grading of images by ophthalmologists] vs artificial intelligence [AI]-supported screening) and target population groups for screening.

Methods: A mathematical model comprising a decision tree and Markov model was developed. An extensive review of published literature was undertaken to obtain model parameters. Primary data collection was done to derive quality-of-life values. We used a lifetime horizon, abridged societal perspective, and discounted future costs and consequences at an annual rate of 3%. The incremental cost-effectiveness ratio (ICER) was computed for alternative screening strategies. A willingness-to-pay equal to gross domestic product per capita equal to ₹171,498 (US$2182) was used to determine the cost-effective choice. Sensitivity analyses were performed to assess the impact of variation in input parameters on the ICER values.

Results: All the annual screening strategies were found to have lower ICERs relative to usual care. Among the screening strategies, annual tele-supported screening in the population with diabetes duration ≥5 years was the most cost-effective strategy with an ICER value of ₹57,408 (US$730) per quality-adjusted life year (QALY) gained. At the national level, this strategy is likely to reduce the annual incidence of vision-threatening DR and blindness by 17.3%, and 38.5%, respectively, and would result in higher benefits in Indian states with higher epidemiological transition. Sensitivity analyses showed that if adequate glycaemic control is achieved in 79% of the diabetic population, annual AI-supported screening in individuals with a diabetes' duration of 10 years or more becomes the most cost-effective strategy.

Conclusion: The results of the study suggest the prioritization of an annual tele-supported DR screening programme in India. They also highlight the importance of the adoption of an integrated approach and functional linkage between eye care and diabetes care, to intensify efforts directed at improving glycaemic control, and to facilitate early DR detection and management.

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Conflict of interest statement

Declarations. Authors’ contributions: All authors contributed to the study conception and design. Data collection, analysis and model development were performed by Neha Purohit, Sandeep Buttan, Parul Gupta Chawla, and Akashdeep Singh Chauhan, and were validated by all the authors. Neha Purohit drafted the manuscript, and all authors provided comments on earlier versions. Shankar Prinja obtained the funding for the study. All authors reviewed and approved the final manuscript. Funding: The work is supported by grant (INV-064844) from the Bill and Melinda Gates Foundation for conducting this study. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Conflict of Interests: Shankar Prinja is an editorial board member of PharmacoEconomics Open. Shankar Prinja was not involved in the selection of peer reviewers for the manuscript nor any of the subsequent editorial decisions. All the other co-authors declare no conflict of interest. Data Availability: All the sources of secondary data used for analysis have been provided in the electronic supplementary material. Primary data related to determination of utility values in patients with diabetic retinopathy can be shared upon written request to the corresponding author, after removal of all personal identifiers to ensure participant privacy. Ethical Approval: The research study was approved by the Institutional Ethics Committee, Post Graduate Institute of Medical Education and Research, Chandigarh, India, vide reference no. PGI/IEC/2024/1599. Consent to Participate: Consent for participation was provided by the patients with diabetic retinopathy who were interviewed for evaluation of quality of life. Consent for Publication: Consent for publication was provided by the patients with diabetic retinopathy who were interviewed for evaluation of quality of life. Code Availability: The Excel model is available as an open access model at the Global Health CEA registry and can be accessed at https://osf.io/ps6br/ .

Figures

Fig. 1
Fig. 1
Effect of change in proportion of population with controlled diabetes on cost effectiveness of dominant strategies. AI artificial intelligence, ICER incremental cost-effectiveness ratio
Fig. 2
Fig. 2
Effect of counselling in early stages of diabetic retinopathy in terms of change in glycaemic control on ICER values of dominant strategies. AI artificial intelligence, ICER incremental cost-effectiveness ratio, WTP willingness-to-pay threshold
See this image and copyright information in PMC

References

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