Echo-based screening of rheumatic heart disease in children: a cost-effectiveness Markov model

Abstract

Objectives:

To project the cost-effectiveness of population-based echo screening to prevent rheumatic heart disease (RHD) consequences.

Background:

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.

Methods:

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.

Results:

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.

Conclusion:

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.

Keywords::

• Cost-benefit analysis
• Echocardiography
• Pediatrics
• Rheumatic heart disease
• Valves

Transparency

Declaration of funding

This work was supported by a National Heart, Lung, and Blood Institute Career Development Award (K23) HL111335.

Declaration of financial/other relationships

JPZ and MS have disclosed that they have no significant relationships with or financial interests in any commercial companies related to this study or article.

Acknowledgment

The authors acknowledge Dr Rosemary Wyber (Harvard School of Public Health) for her excellent assistance.