Screening for refractive error and fitting with spectacles in rural and urban India: Cost-effectiveness

Objectives: To assess the cost-effectiveness of screening for refractive error and fitting with glasses in India. Methods: We populated a decision tree with the costs of screening and spectacles, prevalence of varying levels of presenting and best corrected visual acuity (BCVA) from two studies, and sensitivity and specificity of screening. We calculated dollars spent per disability adjusted life year (DALY) averted separately in urban and rural areas for school-based screening I and primary eye care I programs that fit spectacles to individuals presenting for care. We conducted a series of univariate and probabilistic sensitivity analyses. An intervention was inferred to be highly cost-effective if the incremental cost-effectiveness ratio (ICER) was less than the gross domestic product (GDP) per capita and moderately cost-effective if the ICER was less than three times this level. Results: Compared with no screening, urban SBS was highly cost-effective; rural SBS was moderately cost-effective for ages 5-15 and highly cost-effective for ages 7-15. Both urban and rural PEC were moderately cost-effective in comparison to SBS. Probabilistic sensitivity analysis suggested that SBS is likely the most cost-effective solution for refractive error in India if the 5-15 year old age group is targeted; primary eye care is the best choice if a high value is placed on DALYs and the 7-15 year old age group is targeted. Conclusion: Both SBS and PEC Interventions for refractive error can be considered cost-effective in India. Which is the more cost-effective depends on the choice of targeted age group and area of the intervention.