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Economic evaluation of different methods of screening for amblyopia in kindergarten
Hans-Helmut König1, Jean-Cyriaque Barry
1Department of Health Economics, University of Ulm, Ulm, Germany. hans-helmut.koenig@mathematik.uni-ulm.de
Insights
Monocular visual acuity screening is a cost-effective method for detecting amblyopia in young children. Adding more tests or using refractive screening is less effective and more expensive.
Area of Science:
- Ophthalmology
- Public Health
- Health Economics
Background:
- Amblyopia, or "lazy eye," is a leading cause of vision impairment in children.
- Early detection and treatment of amblyopia are crucial for effective management.
- Cost-effectiveness of different screening strategies remains an important consideration for public health initiatives.
Purpose of the Study:
- To compare the cost-effectiveness of five distinct screening methods for detecting untreated amblyopia in kindergarten-aged children.
- To evaluate these methods from a third-party payer perspective.
Main Methods:
- A decision-analytic model was employed, simulating screening of 3-year-old children in German kindergartens.
- Five screening methods were assessed, varying in visual acuity thresholds, inclusion of cover tests, and use of autorefractive screening.
- Screening test characteristics and costs were derived from a field study of 1180 children.
Main Results:
- Monocular visual acuity screening with rescreening of inconclusive results (Method A-2) demonstrated the lowest cost per detected case (€878).
- Other cost-effective methods included B-2 (€886), D-2 (€908), and D-1 (€965).
- Refractive screening (Method E) proved less effective and had unfavorable cost-effectiveness due to high rates of false results.
Conclusions:
- Monocular visual acuity screening, particularly with a rescreening option for inconclusive results, offers favorable cost-effectiveness for amblyopia detection.
- Incorporating additional tests yielded only marginal improvements in case detection.
- Refractive screening without cycloplegia was found to be less effective and cost-inefficient.
Objective:
To compare the cost-effectiveness of 5 methods of screening for untreated amblyopia in kindergarten from a third-party-payer perspective: A) uncorrected monocular visual acuity testing with pass threshold > or =0.5 (20/40) and < or =1 line difference between eyes; B) same as A, but pass threshold > or =0.6 (20/32); C) same as A, plus cover tests and examination of eye motility and head posture; D) same as C, but pass threshold > or =0.6 (20/32); and E) refractive screening without cycloplegia using the Nikon Retinomax autorefractor.
Methods:
A decision-analytic model was used with a time horizon until diagnostic examination. According to the model, all 3-year-old children were screened in kindergarten with 1 of the screening methods. Children with positive screening results were referred to an ophthalmologist for diagnostic examination. Children with inconclusive screening results were either referred to an ophthalmologist directly (option 1) or rescreened by the same method after 1 year and referred to an ophthalmologist if rescreening was positive or inconclusive (option 2). Screening test characteristics and costs were estimated on the basis of a field study in which 1180 3-year-old children were examined by orthoptists in 121 German kindergartens.
Results:
Compared with methods A option 1 (A-1), B-1, C-1, C-2, E-1, and E-2, there was at least 1 other method that was both less costly and more effective. The average costs per detected case were lowest for method A-2 (878 Euro), followed by methods B-2 (886 Euro), D-2 (908 Euro), and D-1 (965 Euro). When these methods were compared with each other, the additional costs per extra case detected were 1058 Euro (B-2 vs A-2), 1359 Euro (D-2 vs B-2), and 13 448 Euro (D-1 vs D-2).
Conclusions:
Monocular visual acuity screening with rescreening of inconclusive results had a favorable cost-effectiveness. By adding additional test items, few more cases could be detected. Because of a great proportion of false-negative, false-positive, and inconclusive results, refractive screening was less effective with an unfavorable cost-effectiveness.