Routine echocardiography screening for asymptomatic left ventricular dysfunction in childhood cancer survivors: a model-based estimation of the clinical and economic effects
- PMID: 24842413
- PMCID: PMC4089868
- DOI: 10.7326/M13-2266
Routine echocardiography screening for asymptomatic left ventricular dysfunction in childhood cancer survivors: a model-based estimation of the clinical and economic effects
Abstract
Background: Childhood cancer survivors treated with cardiotoxic therapies are recommended to have routine cardiac assessment every 1 to 5 years, but the long-term benefits are uncertain.
Objective: To estimate the cost-effectiveness of routine cardiac assessment to detect asymptomatic left ventricular dysfunction and of angiotensin-converting enzyme inhibitor and β-blocker treatment to reduce congestive heart failure (CHF) incidence in childhood cancer survivors.
Design: Simulation model.
Data sources: Literature, including data from the Childhood Cancer Survivor Study.
Target population: Childhood cancer survivors.
Time horizon: Lifetime.
Perspective: Societal.
Intervention: Interval-based echocardiography assessment every 1, 2, 5, or 10 years, with subsequent angiotensin-converting enzyme inhibitor or β-blocker treatment for patients with positive test results.
Outcome measures: Lifetime risk for systolic CHF, lifetime costs, quality-adjusted life expectancy, and incremental cost-effectiveness ratios (ICERs).
Results of base-case analysis: The lifetime risk for systolic CHF among 5-year childhood cancer survivors aged 15 years was 18.8% without routine cardiac assessment (average age at onset, 58.8 years). Routine echocardiography reduced lifetime risk for CHF by 2.3% (with assessment every 10 years) to 8.7% (annual assessment). The ICER for assessment every 10 years was $111 600 per quality-adjusted life-year (QALY) compared with no assessment. Assessment every 5 years had an ICER of $117 900 per QALY, and ICERs for more frequent assessment exceeded $165 000 per QALY.
Results of sensitivity analysis: Results were sensitive to treatment effectiveness, absolute excess risk for CHF, and asymptomatic left ventricular dysfunction asymptomatic period. The probability that assessment every 10 or 5 years was preferred at a $100 000-per-QALY threshold was 0.33 for the overall cohort.
Limitation: Treatment effectiveness was based on adult data.
Conclusion: Current recommendations for cardiac assessment may reduce CHF incidence, but less frequent assessment may be preferable.
Figures
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![Appendix Figure 1](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4089868/bin/nihms593609f5.gif)
![Appendix Figure 2](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4089868/bin/nihms593609f6.gif)
Comment in
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Cost-effectiveness of screening for asymptomatic left ventricular dysfunction in childhood cancer survivors.Ann Intern Med. 2014 May 20;160(10):731-2. doi: 10.7326/M14-0823. Ann Intern Med. 2014. PMID: 24842420 No abstract available.
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