Cost-Effectiveness of Telemedicine-Based Screening Programs for Retinopathy of Prematurity in Low- and Middle-Income Countries.

OBJECTIVE

Evaluate the cost-effectiveness of telemedicine-based retinopathy of prematurity (ROP) screening strategies compared with binocular indirect ophthalmoscopy (BIO) and the current standard of care (no screening) in Sub-Saharan Africa.

DESIGN

Decision-analytic cost-effectiveness analysis simulating costs and vision outcomes across alternative ROP screening strategies.

SUBJECTS: A simulated cohort of 10 000 qualifying preterm infants (birth weight ≤2000 g or gestational age ≤32 weeks) in neonatal intensive care units across Ghana were modeled for each screening strategy.

METHODS

Three strategies were compared: no screening, BIO, and telemedicine-based screening with nonphysician graders. A hybrid telemedicine approach with 10% of images graded by physicians was also evaluated. The model estimated disease detection, treatment, and vision outcomes, and calculated costs and quality-adjusted life years (QALYs). Sensitivity analyses varied nonphysician grader specificity, ROP incidence, and physician evaluation time for BIO. A willingness-to-pay threshold of $2238 per QALY (1× Ghana's GDP per capita) was applied.

MAIN OUTCOME MEASURES: Incremental cost-effectiveness ratios expressed as cost per QALY gained and dominance relationships among strategies.

RESULTS

Compared with no screening, telemedicine-based screening with nonphysician graders yielded health benefits at a cost of $27 per QALY gained. Incorporating 10% physician grading into the telemedicine platform further improved outcomes at $1331 per QALY gained relative to nonphysician grading alone. Binocular indirect ophthalmoscopy was strongly dominated by the hybrid telemedicine strategy. Sensitivity analyses identified nonphysician grader specificity, disease incidence, and physician evaluation time for BIO as the most influential parameters; overall conclusions were robust across plausible ranges.

CONCLUSIONS

Telemedicine-based ROP screening, particularly a hybrid approach incorporating limited physician grading, appears to be a cost-effective strategy for implementation in Ghana and may be applicable to other countries in Sub-Saharan Africa.

FINANCIAL DISCLOSURES: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.