Zachariah Justin P, Samnaliev Mihail
Department of Cardiology, Boston Children's Hospital , Boston, MA , USA and.
J Med Econ. 2015 Jun;18(6):410-9. doi: 10.3111/13696998.2015.1006366. Epub 2015 Feb 9.
To project the cost-effectiveness of population-based echo screening to prevent rheumatic heart disease (RHD) consequences.
RHD is a leading cause of cardiovascular mortality and morbidity during adolescence and young adulthood in low- and middle-per capita income settings. Echocardiography-based screening approaches can dramatically expand the number of children identified at risk of progressive RHD. Cost-effectiveness analysis can inform public health agencies and payers about the net economic benefit of such large-scale population-based screening.
A Markov model was constructed comparing a no-screen to echo screen approach. The echo screen program was modeled as a 2-staged screen of a cohort of 11-year-old children with initial short screening performed by dedicated technicians and follow-up complete echo by cardiologists. Penicillin RHD prophylaxis was modeled to only reduce rheumatic fever recurrence-related exacerbation. Quality-adjusted life years (QALYs) and societal costs (in 2010 Australian dollars) associated with each approach were estimated. One-way, two-way and probabilistic sensitivity analyses were performed on RHD prevalence and transition probabilities; echocardiography test characteristics; and societal level costs including supplies, transportation, and labor.
The incremental costs and QALYs of the screen compared to no screen strategy were -$432 (95% CI = -$1357 to $575) and 0.007 (95% CI = -0.0101 to 0.0237), respectively. The joint probability that the screen was both less costly and more effective exceeded 80%. Sensitivity analyses suggested screen strategy dominance depends mostly on the probability of transitioning out of sub-clinical RHD.
Two-stage echo RHD screening and secondary prophylaxis may achieve modestly improved outcomes at lower cost compared to clinical detection and deserves closer attention from health policy stakeholders.
预测基于人群的超声心动图筛查预防风湿性心脏病（RHD）后果的成本效益。
在中低收入国家，RHD是青少年和青年心血管疾病死亡和发病的主要原因。基于超声心动图的筛查方法可显著增加被识别出有进行性RHD风险的儿童数量。成本效益分析可为公共卫生机构和支付方提供有关此类大规模人群筛查净经济效益的信息。
构建一个马尔可夫模型，比较不筛查和超声心动图筛查两种方法。超声心动图筛查项目被建模为对一组11岁儿童进行两阶段筛查，第一阶段由专业技术人员进行简短筛查，第二阶段由心脏病专家进行完整的超声心动图检查。青霉素预防RHD仅被建模为减少与风湿热复发相关的病情加重。估计了与每种方法相关的质量调整生命年（QALYs）和社会成本（以2010年澳元计）。对RHD患病率和转移概率、超声心动图检查特征以及包括用品、运输和劳动力在内的社会层面成本进行了单向、双向和概率敏感性分析。
与不筛查策略相比，筛查的增量成本和QALYs分别为-$432（95%CI = -$1357至$575）和0.007（95%CI = -0.0101至0.0237）。筛查成本更低且效果更好的联合概率超过80%。敏感性分析表明，筛查策略的优势主要取决于从亚临床RHD转变的概率。
与临床检测相比，两阶段超声心动图RHD筛查和二级预防可能以更低的成本实现适度改善的结果，值得卫生政策利益相关者密切关注。
