Echocardiographic Screening for Rheumatic Heart Disease in Indigenous Australian Children: A Cost-Utility Analysis

Abstract

Background: Rheumatic heart disease (RHD) remains a leading cause of cardiovascular morbidity and mortality in children and young adults in disadvantaged populations. The emergence of echocardiographic screening provides the opportunity for early disease detection and intervention. Using our own multistate model of RHD progression derived from Australian RHD register data, we performed a cost-utility analysis of echocardiographic screening in indigenous Australian children, with the dual aims of informing policy decisions in Australia and providing a model that could be adapted in other countries.

Methods and results: We simulated the outcomes of 2 screening strategies, assuming that RHD could be detected 1, 2, or 3 years earlier by screening. Outcomes included reductions in heart failure, surgery, mortality, disability-adjusted life-years, and corresponding costs. Only a strategy of screening all indigenous 5- to 12-year-olds in half of their communities in alternate years was found to be cost-effective (incremental cost-effectiveness ratio less than AU$50 000 per disability-adjusted life-year averted), assuming that RHD can be detected at least 2 years earlier by screening; however, this result was sensitive to a number of assumptions. Additional modeling of improved adherence to secondary prophylaxis alone resulted in dramatic reductions in heart failure, surgery, and death; these outcomes improved even further when combined with screening.

Conclusions: Echocardiographic screening for RHD is cost-effective in our context, assuming that RHD can be detected ≥2 years earlier by screening. Our model can be adapted to any other setting but will require local data or acceptable assumptions for model parameters.

Keywords: cost‐effectiveness; echocardiography; pediatrics; rheumatic heart disease; screening.

Figure 1

Transition probabilities between health states in the first year of rheumatic heart disease (RHD) diagnosis. The 3 shaded circles represent the proportion of children (aged 5–15 years) in each health state when they are first diagnosed with RHD according to current practice. Proportions of children who did not change health states are not shown.

Figure 2

Tornado plot showing the effect of varying individual parameter estimates on the ICER of echocardiographic screening for RHD (Echo B, scenario 2). The solid line in each bar represents the baseline assumption. The dashed line represents an ICER threshold of AU$50 000 per DALY averted. The dotted line represents an ICER threshold of AU$70 000 (which approximates Australia's per capita gross domestic product26) per DALY averted. *At a maximum admission cost of AU$30 200, screening was cost‐saving (ICER less than AU$0 per DALY averted). ARF indicates acute rheumatic fever; DALY, disability‐adjusted life‐year; ICER, incremental cost‐effectiveness ratio; RHD, rheumatic heart disease.

Figure 3

Cost‐effectiveness acceptability curve for Echo B, scenario 2. ICER indicates incremental cost‐effectiveness ratio.