Abstract 14702: Determining the Most Cost-Effective Method to Prevent Rheumatic Heart Disease in a Developing World Country

Abstract

Background: Rheumatic heart disease (RHD) secondary to strep throat (GAS) is endemic in the developing world causing morbidity, mortality, lost productivity (affecting country GDP) and significant costs to the patient and the healthcare system. Many patients do not get care. Three strategies were examined (versus standard no prevention) in a cost-effectiveness analysis (CEA) for preventing RHD: primary prophylaxis with benzathine penicillin G (BPG) once monthly to all patients (ages 5-21); secondary prophylaxis with BPG monthly only to those with echocardiographic (echo) evidence of developing RHD (till age 21); and throat swab to detect and subsequently treat GAS as needed.

Methods: A Markov model compared the strategies versus no prevention over the lifetime of an urban living child from age 5 taking a societal perspective. Annual risks for RHD in model (base rates): 0.021 (no prevention), 0.001 (primary prophylaxis), 0.003(secondary prophylaxis) and 0.006 (GAS treatment). Risks incorporate non-compliance and antibiotic resistance. Direct costs of each strategy, including fixed costs (echo machine and labour), and all per person costs included. Indirect costs of lost productivity based on per capita GDP included. Quality adjusted life years (QALY) for RHD with treatment/complications included. Annual age-standardized mortality from all other causes included.

Results: Primary prophylaxis (US$2,499/QALY) is most CE compared to no prevention (generates the most QALYs, though highest expected lifetime cost per person). The incremental CE of primary prophylaxis versus secondary prophylaxis is US$7,185/QALY and US$41,671/QALY versus GAS treatment. Sensitivity analysis shows ranking of strategies depends on various parameters: if probability of developing RHD is greater than 0.01 (10 times base rate) with primary prophylaxis (eg. from non-compliance), then secondary prophylaxis is more CE; if compliance with GAS treatment is greater than 0.75, then GAS treatment is most CE.

Conclusions: Primary prophylaxis with monthly BPG is most CE in our model; however, any strategy is more CE than no prevention when consider lost productivity and decrease GDP in a country that needs to increase economic output.