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

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.