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Cost-effective analysis of screening for biliary atresia with the stool color card
Douglas Mogul1, Mo Zhou, Paul Intihar
1*Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Johns Hopkins University School of Medicine †Department of Health Policy and Management, Johns Hopkins University School of Public Health ‡Department of Financial Analysis, Johns Hopkins Hospital §Johns Hopkins Carey Business School, Baltimore, MD.
Insights
Screening for biliary atresia (BA) using a stool color card is a cost-saving strategy. This method improves outcomes by reducing deaths and liver transplants, making it economically feasible for the United States.
Area of Science:
- Pediatric Gastroenterology and Hepatology
- Health Economics and Outcomes Research
- Public Health Screening
Background:
- Biliary atresia (BA) is a primary cause of pediatric end-stage liver disease and liver transplantation in the US.
- Delayed diagnosis of BA leads to poorer outcomes, including increased mortality and need for transplantation.
- Early detection is crucial for improving patient prognosis and reducing healthcare burdens.
Purpose of the Study:
- To evaluate the cost-effectiveness of nationwide screening for biliary atresia (BA) using a stool color card in the United States.
- To compare the outcomes and costs of BA screening versus no screening over a 20-year period.
- To determine if stool color card screening is a dominant strategy in managing BA.
Main Methods:
- A 20-year Markov model simulated the natural history and transplant outcomes of BA patients in the US.
- Data on health states, transplant rates, and mortality were sourced from published literature.
- Costs were estimated using literature data and the Johns Hopkins database; screening strategy B utilized a Taiwan-developed stool color card.
Main Results:
- Nationwide screening (Strategy B) was projected to cost $133.9 million over 20 years, compared to $142.5 million for no screening (Strategy A).
- Screening is associated with improved outcomes: 3731.7 life-years gained, 71 deaths, and 147 liver transplants, versus 3702 life-years, 74 deaths, and 158 transplants without screening.
- There is a >97% probability that stool color card screening is cost-saving and increases life-years gained, with specificity being the key parameter.
Conclusions:
- Screening for biliary atresia (BA) using a stool color card is a dominant strategy, offering lower costs and better patient outcomes compared to no screening.
- This approach represents an economically feasible method to improve BA management and outcomes in the US.
- The findings support the implementation of stool color card screening as a vital public health initiative for pediatric liver disease.
Background:
Biliary atresia (BA) is the leading cause of pediatric end-stage liver disease and liver transplantation in the United States. Early diagnosis leads to improved outcomes, but diagnosis is often delayed, leading to increased rates of transplantation and mortality.
Methods:
A Markov model was developed to simulate the natural history and transplant-related outcomes of patients with BA in a US cohort studied for 20 years. Data regarding proportions of individuals in different health states, including transplant and death, were obtained from published literature. Costs were derived from the literature and the Johns Hopkins database of charges using the cost-to-charge ratio. Strategy A represented the status quo and assumed no screening. Strategy B used nationwide screening with the stool color card developed by the Taiwan Health Bureau. The cost associated with both strategies was compared with the number of life-years gained, deaths, and the number of transplants for a 20-year interval. A dominant strategy was one that was associated with lower cost alongside improved outcomes, including increases in life-years gained, reductions in number of deaths, and reductions in number of transplants. One-way and probabilistic sensitivity analyses were performed.
Results:
In strategy A, the 20-year cost was $142,479,725 with 3702 life-years, 74 deaths and 158 liver transplants. For strategy B, the cost was $133,893,563 with 3731.7 life-years, 71 deaths and 147 liver transplants. There was a >97% probability that screening with the stool color card would be cost saving and associated with an increase in life-years gained. Among all parameters, only stool color card specificity was associated with the potential for screening to no longer be cost saving.
Conclusions:
Compared with no screening, screening with the stool color card is a dominant strategy associated with lower costs and better outcomes. These findings suggest that screening with the stool color card could be an important, economically feasible strategy for improving outcomes in BA in the United States.
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