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

J Med Econ. 2015 Jun;18(6):410-9. doi: 10.3111/13696998.2015.1006366. Epub 2015 Feb 9.


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.

Keywords: Cost-benefit analysis; Echocardiography; Pediatrics; Rheumatic heart disease; Valves.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Anti-Bacterial Agents / economics
  • Anti-Bacterial Agents / therapeutic use
  • Antibiotic Prophylaxis / methods
  • Child
  • Cost-Benefit Analysis
  • Echocardiography / economics*
  • Heart Valve Prosthesis / economics
  • Humans
  • Markov Chains*
  • Mass Screening / economics*
  • Models, Econometric*
  • Northern Territory / epidemiology
  • Penicillin G Benzathine / economics
  • Penicillin G Benzathine / therapeutic use
  • Prevalence
  • Quality-Adjusted Life Years
  • Recurrence
  • Rheumatic Fever / prevention & control
  • Rheumatic Heart Disease / diagnosis*
  • Rheumatic Heart Disease / economics


  • Anti-Bacterial Agents
  • Penicillin G Benzathine