Should postnatal oximetry screening be implemented ...

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Article history: Received 21 September 2015 ... Available online 28 October 2015 ... health outcome of postnatal oximetry screening is infant deaths avoided.

International Journal of Cardiology 204 (2016) 45–47

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Should postnatal oximetry screening be implemented nationwide in China? A cost-effectiveness analysis in three regions with different socioeconomic status Ruoyan Gai Tobe a,b,⁎, Gerard R. Martin c, Fuhai Li d, Rintaro Mori a a

Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan School of Public Health, Shandong University, Jinan, China c The George Washington University School of Medicine, the Children's National Medical Center, Washington, DC, USA d Division of Pediatric Cardiology, Qilu Hospital of Shandong University, Jinan, China b

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Article history: Received 21 September 2015 Accepted 27 October 2015 Available online 28 October 2015 Keywords: Pulse oximetry Congenital heart defects Screening Developing countries China Cost-effectiveness

Timely diagnosis and treatment are crucial to reduce the mortality and morbidities of congenital heart defects (CHD). Pulse oximetry is a non-invasive means to measure the oxygen saturation of hemoglobin medical device and has been proved to aid in the detection critical CHD (CCHD). It is low-cost, simple to perform and can be provided by outreach health services [1]. In the developed world, pulse oximetry screening has been widely endorsed for inclusion in routine practice to increase the detection of asymptomatic infants with CCHD before discharge from birth hospitals [2]. In developing countries, where large undetected and underserved population of children with CHD exists, such postnatal screening may potentially be even more beneficial. Moreover, roughly 75% of infants with positive screening results may have other non-cardiac neonatal conditions requiring medical intervention, such as neonatal pneumonia and sepsis [3]. These findings suggest that in developing countries, where the incidence of neonatal pneumonia and sepsis is much higher, pulse oximetry has the potential to additionally detect non-cardiac illness and save life [4]. No economic evaluation of postnatal oximetry screening has yet been implemented in the developing world. Our study aims to assess ⁎ Corresponding author at: Department of Health Policy, National Center for Child Health and Development, Okura 2-10-1, Setagaya-ku, Tokyo 157-8535, Japan. E-mail address: [email protected] (R.G. Tobe). 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.

the cost-effectiveness of introducing pulse oximetry for neonatal CHD screening in three Chinese regions with different socioeconomic status, in order to provide useful information for developing countries. This is a model-based approach to estimate costs and health benefits of postnatal oximetry screening for hypothetical annual birth cohorts in Beijing (metropolitan region), Shandong (developed region), and Gansu (less developed region). We calculated the incremental costs per averted disability-adjusted life years (DALYs) in 2014 US dollars for hypothetical postnatal oximetry screening as routine practice. For cost estimates, we calculated unit costs per screened infant based on the average time of screening [5] and annual salary of medical staff in China, and the additional costs for diagnosis and intervention. Costs were given in 2014 prices in international dollars and discounted at an annual rate of 3%. The screening program would not require additional clinical staff at the hospitals [6]. The sensitivity and specificity of screening derived from a multicenter investigation in China reduced by up to 50% in the sensitivity analysis, depending on the technical capacity of the examining doctors [7]. We assumed that accessibility to timely diagnosis and treatment would vary among the three regions and data would be based on expert estimates due to a lack of information. The primary health outcome of postnatal oximetry screening is infant deaths avoided due to timely diagnosis and treatment. We assumed infant mortality would be similar to that reported in the 1950s, when diagnostic and therapeutic medical care for CCHD were not available [8]. We expected that infant mortality would reduce to approximately 25% if infants received timely diagnosis and treatment [9]. Moreover, we also estimated the number of infants with non-cardiac diseases identified by abnormal screening results. For an intervention to be cost-effective, the World Health Organization recommends an incremental cost-effectiveness ratio (ICER) of less than three times the country's GDP per capita [10]. Due to diversified GDP levels, the willingness-to-pay (WTP) threshold would therefore be different across regions: Int$83,628/DALY in Beijing, Int$50,601/DALY in Shandong and Int$21,939/DALY in Gansu (based on GDP per capita in 2014). Univariate and multivariate sensitivity analyses were performed by TreeAge Pro 2015 to examine the impact of uncertainty of the parameters on the robustness of the model. Our results showed that cost-effectiveness of postnatal oximetry screening compared to no intervention (status quo) varied across the three regions: the intervention was highly cost-effective in Beijing



(Int$7833/DALY); cost-effective in Shandong (Int$27,780/DALY), and not cost-effective in Gansu (Int$167,407) (Table 1). In Beijing and Shandong, postnatal oximetry screening will improve health outcomes, including early detection of CHD and non-cardiac neonatal conditions, prevention of infant deaths, and averting DALYs. At each WTP threshold, the probability that pulse oximetry plus clinical assessment dominates clinical assessment is 100% in Beijing, 58% in Shandong, and 0% in Gansu (Fig. 1). Sensitivity analysis showed that the proportion of timely diagnosis and treatment among infants with CCHD contributed to such a huge gap in cost-effectiveness across the different regions, and the ICER gradually reduced with improvement of the proportion. Our study revealed that pulse oximetry plus clinical assessment was cost-effective only in developed regions of China with a higher GDP per capita and better accessibility to pediatric cardiac medical care, which reflects similar findings of the cost-effectiveness of screening in developed countries [11–14]. In a global context, the success of pulse oximetry screening in the developing world depends on the availability and affordability of pediatric cardiac medical care. Our results suggest that in terms of cost-effectiveness and feasibility, the application of postnatal oximetry screening should first be implemented in developed metropolitan regions to maximize the benefits of neonatal CHD screening within the country. On the other hand, the relevantly high disease and economic burden of CHD in less developed regions should not be neglected. Although the exact incidence of CHD in different regions of China is unknown, some poor and remote areas of less developed regions may have a higher incidence of CHD due to a deficient intake of folic acid among pregnant women [15]. Although pediatric cardiac medical care is available in China, it is highly concentrated in urban tertiary hospitals and the associated medical costs are catastrophic for most families of infants with CHD [16]. Improvement in the coverage and reimbursement rate of the current medical insurance scheme is an urgent task, particularly for those living in unprivileged regions.

Table 1 Health benefits and cost-effectiveness of the screening program in different Chinese regions.

GDP per capita (international dollars = Int$) Annual live births Proportion of timely diagnosis and treatment Detection of CCHD No intervention Clinical assessment Clinical assessment plus pulse oximetry Detection of CHD No intervention Clinical assessment Clinical assessment plus pulse oximetry Detection of non-cardiac conditions No intervention Clinical assessment Clinical assessment plus pulse oximetry Infant deaths averted No intervention Clinical assessment Clinical assessment plus pulse oximetry DALYs due to infant deaths averted No intervention Clinical assessment Clinical assessment plus pulse oximetry ACER (Int$/DALY averted) No intervention Clinical assessment Clinical assessment plus pulse oximetry ICER (Int$/DALY averted) No intervention Clinical assessment Clinical assessment plus pulse oximetry




27,876 188,870 50%

16,867 1,110,535 25%

7313 313,971 10%

0 351 422

0 2063 2484

0 583 702

0 1330 2044

0 7823 12,020

0 2212 3398

0 44 47

0 256 275

0 72 78

0 79 95

0 232 279

0 26 32

0 1701 2048

0 5001 6022

0 566 681

0 6239 7833

0 22,487 27,780

0 136,224 167,407

(−) 6239 15,020

(−) 22,487 51,636

(−) 136,224 307,952

Fig. 1. Acceptability curve.

Despite several limitations in the currently available data, postnatal oximetry screening showed different feasibility across regions with diversified socioeconomic status in China. In light of such geographical diversity, the first step in realistic practice would be to implement postnatal oximetry screening in developed regions. What cannot be assessed with this model is the value of parents knowing that something is wrong with their child in less developed regions. Accessibility to pediatric cardiac medical care is crucial before the screening program can be implemented nationwide.

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