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Ann Intern Med. 2014 May 20;160(10):672-83. doi: 10.7326/M13-2498.

Cost-effectiveness of the children's oncology group long-term follow-up screening guidelines for childhood cancer survivors at risk for treatment-related heart failure.

Abstract

BACKGROUND:

Childhood cancer survivors treated with anthracyclines are at high risk for asymptomatic left ventricular dysfunction (ALVD), subsequent heart failure, and death. The consensus-based Children's Oncology Group (COG) Long-Term Follow-up Guidelines recommend lifetime echocardiographic screening for ALVD.

OBJECTIVE:

To evaluate the efficacy and cost-effectiveness of the COG guidelines and to identify more cost-effective screening strategies.

DESIGN:

Simulation of life histories using Markov health states.

DATA SOURCES:

Childhood Cancer Survivor Study; published literature.

TARGET POPULATION:

Childhood cancer survivors.

TIME HORIZON:

Lifetime.

PERSPECTIVE:

Societal.

INTERVENTION:

Echocardiographic screening followed by angiotensin-converting enzyme (ACE) inhibitor and β-blocker therapies after ALVD diagnosis.

OUTCOME MEASURES:

Quality-adjusted life-years (QALYs), costs, incremental cost-effectiveness ratios (ICERs) in dollars per QALY, and cumulative incidence of heart failure.

RESULTS OF BASE-CASE ANALYSIS:

The COG guidelines versus no screening have an ICER of $61 500, extend life expectancy by 6 months and QALYs by 1.6 months, and reduce the cumulative incidence of heart failure by 18% at 30 years after cancer diagnosis. However, less frequent screenings are more cost-effective than the guidelines and maintain 80% of the health benefits.

RESULTS OF SENSITIVITY ANALYSIS:

The ICER was most sensitive to the magnitude of ALVD treatment efficacy; higher treatment efficacy resulted in lower ICER.

LIMITATION:

Lifetime non-heart failure mortality and the cumulative incidence of heart failure more than 20 years after diagnosis were extrapolated; the efficacy of ACE inhibitor and β-blocker therapy in childhood cancer survivors with ALVD is undetermined (or unknown).

CONCLUSION:

The COG guidelines could reduce the risk for heart failure in survivors at less than $100 000/QALY. Less frequent screening achieves most of the benefits and would be more cost-effective than the COG guidelines.

PMID:
24842414
PMCID:
PMC4073480
DOI:
10.7326/M13-2498
[Indexed for MEDLINE]
Free PMC Article

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