Stage-Stratified Economic Burden, Quality of Life, and Household Financial Coping Strategies in Diabetic Retinopathy in India: A Prospective Study With Exploratory Insurance Projections.

Background Diabetic retinopathy (DR) imposes a substantial economic and psychosocial burden in India, yet stage-specific integrated data remain limited. This study aimed to evaluate the stage-wise economic burden, vision-related quality of life (VRQoL), and household financial coping strategies in patients with DR. Methods This cross-sectional observational study, conducted between November 2024 and March 2025, included 350 patients with type 2 diabetes and DR stratified as mild non-proliferative diabetic retinopathy (NPDR) (n=95), moderate NPDR (n=112), severe NPDR (n=78), and proliferative DR (PDR, n=65). Direct and indirect costs were assessed using structured interviews and verified from medical records where available. VRQoL was evaluated using the IND-VFQ-33. Catastrophic health expenditure (CHE) was defined as healthcare spending exceeding 40% of non-food household expenditure. Between-group comparisons used one-way ANOVA with Bonferroni-corrected post-hoc pairwise testing for normally distributed continuous variables, Kruskal-Wallis tests for non-normally distributed variables, and χ² or Fisher's exact tests for categorical variables. Multiple linear regression, with full assessment of multicollinearity (variance inflation factor, VIF) and inspection of residuals for normality and homoscedasticity, was used to identify independent predictors of VRQoL. Exploratory, stage-weighted insurance projections were derived using a simplified, scenario-based break-even model. Results Patients with PDR were older and had longer duration of diabetes compared with mild NPDR (15.7 ± 4.9 vs. 7.2 ± 3.8 years; p<0.001). Mean total annual cost increased more than six-fold from INR 20,000 ± 3,000 (95% CI 19,396-20,604) in mild NPDR to INR 130,000 ± 13,000 (95% CI 126,840-133,160) in PDR (p<0.001), with all between-stage pairwise differences remaining significant after Bonferroni correction. CHE affected 12% of mild NPDR, 28% of moderate NPDR, 65% of severe NPDR, and 78% of PDR patients (p<0.001). VRQoL worsened markedly from mild NPDR to PDR (30 ± 8 vs. 90 ± 10; p<0.001), with parallel increases in depression and anxiety scores. Coping strategies included borrowing (58%), loans (42%), asset sales (28%), and withdrawal of children from education (15%). Total economic burden was strongly correlated with VRQoL (Spearman's ρ = 0.78, 95% CI 0.73-0.82; p<0.001). Exploratory projections estimated an annual insurance contribution of approximately INR 22,000. Conclusions Diabetic retinopathy in India is associated with a steep, stage-dependent escalation in economic burden, catastrophic expenditure, and deterioration in VRQoL, with significant intergenerational consequences. Exploratory insurance modeling illustrates a potential pathway for mitigating financial burden alongside prevention and early detection.