Open Access

A store-and-forward telemedicine for retinopathy of prematurity screen: is it cost-effective in Thailand?


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Figure 1

The decision tree for the screening of ROP in high-risk infants using telemedicine compared with the current practice.
The decision tree for the screening of ROP in high-risk infants using telemedicine compared with the current practice.

Figure 2

Cost-effectiveness acceptability curve.
Cost-effectiveness acceptability curve.

Figure 3

One-way sensitivity analysis of repair and maintenance cost of the RetCam ROP = retinopathy of prematurity, IO = indirect ophthalmoscopy.
One-way sensitivity analysis of repair and maintenance cost of the RetCam ROP = retinopathy of prematurity, IO = indirect ophthalmoscopy.

Figure 4

One-way sensitivity analysis of the number of infants who require ROP screening per yearROP = retinopathy of prematurity, IO = indirect ophthalmoscopy, ICER = incremental cost-effectiveness ratio, QALY = quality-adjusted life years.
One-way sensitivity analysis of the number of infants who require ROP screening per yearROP = retinopathy of prematurity, IO = indirect ophthalmoscopy, ICER = incremental cost-effectiveness ratio, QALY = quality-adjusted life years.

Comparing direct medical costs of telemedicine with the current practice

Costs

Current practice

Telemedicine

Capital costs (per year)

 Indirect ophthalmoscope

9,972

 Lens 20/28 diopters

997

 Scleral depressor

712

 Lid speculum

142

142

 RetCam Shuttle

498,597

 Vehicle

142,456

 Training (start-up)

2,500

Repair and maintenance costs (per year)

997

49,860

Labor (per infant screen)

 Nurse

87

9

 General ophthalmologist

19

 Technician/photographer

12

 Expert ophthalmologist

10

Materials

 Medicines

4

20

 Gas

650

 Total fix cost (per year)

12,820

693,555

 Number of infants screened

400

400

 Unit cost per case screen

142

2,434

Values and distributions and sources of parameters used in the decision analytic model

Parameters

Mean (SE)

Parameter distribution

Sources

Baseline events

 Prevalence of ROP in high-risk infants

9.0% (2.9%)

Beta

Trial

 Proportion of ROP in both eyes

88.9% (9.9%)

Beta

Trial

 Yearly probability of dying in general population

Age-dependent

[11]

Performance

 Proportion of referrals from IO by general

14.0% (3.5%)

Beta

Trial

 ophthalmologists

 Proportion of referrals from RetCam

11.2% (3.2%)

Beta

Trial

 Sensitivity of IO by general ophthalmologists

88.9% (95% CI: 57%-98%)

Beta

Trial

 Specificity of IO by general ophthalmologists

93.4% (95% CI: 86%-97%)

Beta

Trial

 Sensitivity of RetCam by expert ophthalmologists

100.0% (95% CI: 70%-100%)

Beta

Trial

 Specificity of RetCam by expert ophthalmologists

97.8% (95% CI: 92%-99%)

Beta

Trial

 Proportion of non-interpretable photo

2.0% (1.4%)

Beta

Trial

 Proportion of ROP in non-interpretable photo

50.0% (28.9%)

Beta

Trial

Costs (2013, THB)

Direct medical costs

 General ophthalmologist monthly salary

20,000 (6,000)

Gamma

Trial

 Nurse monthly salary

15,000 (4,500)

Gamma

Trial

 Photographer monthly salary

8,000 (2,400)

Gamma

Trial

 Expert ophthalmologist monthly salary

20,000 (6,000)

Gamma

Trial

 Training costs

2,500 (750)

Gamma

Trial

Follow-up and treatment costs

 Cost of follow-up per visit

291 (87)

Gamma

 Cost of retinal detachment

5,754 (1,726)

Gamma

 Cost of laser treatment

1,053 (316)

Gamma

Resource used

 Time use for providing telemedicine (minutes)

 General ophthalmologist

10 (3)

 Nurse

60 (18)

Gamma

Trial

 Expert ophthalmologist (after screening)

60 (18)

 Time use for providing telemedicine (minutes)

 Photographer

15 (5)

 Nurse

6 (2)

Gamma

Trial

 Expert ophthalmologist

5 (2)

 Number of follow-ups

Assumption

 For retinal detachment

6

 For laser treatment

3

 For low risk of ROP

5

Referral costs

 Fuel

2,149 (285)

Gamma

Trial

 Staff

1,791 (276)

Gamma

Trial

Direct nonmedical costs

 Parental income loss per visit

965(144)

Gamma

Trial

 Travelling cost

1,794 (2,056)

Gamma

Trial

 Food cost

343 (318)

Gamma

Trial

 Accommodation cost

1,156 (159)

Gamma

Trial

 Government subsidy per year

5,000

Health outcomes and utility estimates

Probability of unfavorable outcome (blind/low vision) 9.82% (1.62%)

Beta

[4]

 from laser treatment

 Hazard ratio of death for some VI versus no VI

1.23 (95% CI: 1.16-1 . 3 1 )

Log normal

[12]

 Hazard ratio of death for severe VI versus no VI

1.54 (95% CI: 1.28-1 . 8 6 )

Log normal

[12]

 Utility for unilateral blindness

0.89 (0.0079)

Beta

[13]

 Utility for bilateral blindness

0.81 (0.0098)

Beta

[13]

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Medicine, Assistive Professions, Nursing, Basic Medical Science, other, Clinical Medicine