Modeled economic evaluation of alternative strategies to reduce sudden cardiac death among children treated for attention deficit/hyperactivity disorder.
BACKGROUND
Stimulants are widely used to treat children with attention deficit/hyperactivity disorder and may increase the risk for sudden cardiac death (SCD). We examined the cost-effectiveness of pretreatment screening with ECG for reducing SCD risk in children diagnosed with attention deficit/hyperactivity disorder who are candidates for stimulant medication. Method and Results- We constructed a state-transition Markov model with 10 annual cycles spanning 7 to 17 years of age. Taking a societal perspective, we compared the cost-effectiveness of 3 screening strategies: (1) performing a history and physical examination with cardiology referral if abnormal (current standard of care); (2) performing a history and physical examination plus ECG after negative history and physical examination, with cardiology referral if either is abnormal; and (3) performing a history and physical examination plus ECG, with cardiology referral only if ECG is abnormal. Children identified with SCD-associated cardiac abnormalities would be restricted from stimulants and from playing competitive sports. The expected incremental cost-effectiveness over strategy 1 was $39,300 and $27,200 per quality-adjusted life-year for strategies 2 and 3, respectively. Monte Carlo simulation found that the chance of incremental cost-effectiveness was 55% for strategy 2 and 71% for strategy 3 (willingness to pay < or =$50,000 per quality-adjusted life-year). Both strategies 2 and 3 would avert 13 SCDs per 400,000 children seeking stimulant treatment for ADHD, for a cost of $1.6 million per life for strategy 2 and $1.2 million per life for strategy 3.


CONCLUSIONS
Relative to current practice, adding ECG screening to history and physical examination pretreatment screening for children with attention deficit/hyperactivity disorder has borderline cost-effectiveness for preventing SCD. Relative cost-effectiveness may be improved by basing cardiology referral on ECG alone. Benefits of ECG screening arise primarily by restricting children identified with SCD risk from competitive sports.
Denchev
Peter
P
Division of Services and Intervention Research, National Institute of Mental Health, 6001 Executive Blvd, Bethesda, MD 20892, USA. denchevp@mail.nih.gov
Kaltman
Jonathan R
JR
Schoenbaum
Michael
M
Vitiello
Benedetto
B
D000293:Adolescent; D001289:Attention Deficit Disorder with Hyperactivity / Q000188:drug therapy*; D002648:Child; D003362:Cost-Benefit Analysis; D016757:Death, Sudden, Cardiac / Q000453:epidemiology / Q000517:prevention & control*; D004562:Electrocardiography; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008390:Markov Chains; D008403:Mass Screening / Q000191:economics* / Q000379:methods*; D008487:Medical History Taking; D015233:Models, Statistical; D010808:Physical Examination; D019057:Quality-Adjusted Life Years; D012307:Risk Factors; D014481:United States / Q000453:epidemiology