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Abstract
Purpose: To evaluate the cost–utility of wide-field imaging (WFI) as a complementary technology for retinopathy of prematurity (ROP) screening from the Brazilian Unified Health System's perspective.Introduction: ROP is one of the leading causes of avoidable childhood blindness worldwide, especially in middle-income countries. The current ROP screening involves indirect binocular ophthalmoscopy (IBO) by ROP expert ophthalmologists. However, there is still insufficient ROP screening coverage. An alternative screening strategy is the combination of WFI with IBO.Methods: A cost–utility analysis was performed using a deterministic decision-tree simulation model to estimate incremental cost–utility for ROP care. Two screening strategies were compared: (1) IBO and (2) combination of WFI of all eligible preterm infants and IBO for type 2 ROP or worse and for non-readable images. Eligible population included preterm infants <32 weeks of gestational age or birth weight equal to or <1,500 g. The temporal horizon was lifetime. Visual outcome data was converted to utility, and the health benefits were estimated on quality-adjusted life-years (QALY). Incremental cost per QALY gained was calculated from the health system perspective. Costs were estimated considering equipment, maintenance, consumables, and staff. A micro-costing approach was used for WFI. Two technician nurses were trained for imaging execution and had their time evaluated. Two ROP expert ophthalmologists had their time evaluated for imaging reading. One-way sensitivity analysis and probabilistic sensitivity analysis were performed.Results: Combined screening strategy resulted in a cost-effective program considering 90% ROP screening coverage. Costs per examination: (1) screening with IBO: US dollar (US $) 34.36; (2) screening with combination: US $58.20; (3) laser treatment: US $642.09; (4) long-term follow-up: ranged from US $69.33 to 286.91, based on the infant's visual function. Incremental cost per QALY gained was US $1,746.99/QALY per infant screened with the combination strategy. One-way sensitivity analysis resulted in cost-effectiveness for all parameters. Probabilistic sensitivity analyses yielded a 100% probability of combination being cost-effective in a willingness-to-pay threshold of US $1,800/QALY.Conclusion: The combined strategy for ROP screening was cost-effective. It enhances access for appropriate ROP care in middle-income countries and dminishes opportunity costs for ophthalmologists.
Highlights
Retinopathy of prematurity (ROP) is one of the leading causes of avoidable childhood blindness worldwide, especially in middle-income countries
The eligible population included preterm infants with gestational age (GA)
Nurse technicians’ learning curve to perform anterior and posterior retinography resulted in an efficiency gain of 45%, and to set up and dismantle equipment, of 12%
Summary
ROP is one of the leading causes of avoidable childhood blindness worldwide, especially in middle-income countries. Retinopathy of prematurity (ROP) remains a leading cause of avoidable childhood blindness in middle-income economies, such as Brazil [1, 2]. The combination of [1] high preterm birth rate, [2] improvement of neonatal care quality (leading to better survival rates), and [3] insufficient access to ROP screening and treatment are the main causes of the third ROP epidemic faced in countries such as Brazil [1, 3, 4]. The current screening of infants at risk of ROP, usually determined by gestational age (GA) and birth weight (BW) criteria, requires carefully timed retinal examinations by a skilled ophthalmologist. Only 52% of at-risk preterm infants are estimated to have access to ROP examinations, and probably fewer infants have access to treatment in Brazil [6, 11]
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