title: The clinical effectiveness and cost-effectiveness of primary stroke prevention in children with sickle cell disease: a systematic review and economic evaluation.
abstract: BACKGROUND
  Sickle cell disease (SCD) is a recessive genetic blood disorder, caused by a mutation in the β-globin gene. For children with SCD, the risk of stroke is estimated to be up to 250 times higher than in the general childhood population. Transcranial Doppler (TCD) ultrasonography is a non-invasive technique which measures local blood velocity in the proximal portions of large intracranial arteries. Screening with TCD ultrasonography identifies individuals with high cerebral blood velocity; these children are at the highest risk of stroke. A number of primary stroke prevention strategies are currently used in clinical practice in the UK including blood transfusion, treatment with hydroxycarbamide and bone marrow transplantation (BMT). No reviews have yet assessed the clinical effectiveness and cost effectiveness of primary stroke prevention strategies in children with SCD identified to be at high risk of stroke using TCD ultrasonography.
  
  
  OBJECTIVE
  To assess the clinical effectiveness and cost-effectiveness of primary stroke prevention treatments for children with SCD who are identified (using TCD ultrasonography) to be at high risk of stroke.
  
  
  METHODS
  Electronic databases were searched from inception up to May 2011, including the Cochrane Database of Systematic Reviews (CDSR), the Cochrane Central Register of Controlled Trials (CENTRAL), the Database of Abstracts of Reviews of Effects (DARE), EMBASE, the Health Technology Assessment (HTA) database, ISI Web of Science Proceedings, ISI Web of Science Citation Index, the NHS Economic Evaluation Database (NHS EED) and MEDLINE.
  
  
  METHODS
  The assessment was conducted according to accepted procedures for conducting and reporting systematic reviews and economic evaluations. A de novo Markov model was developed to determine the cost-effectiveness of TCD ultrasonography and blood transfusion, where clinically appropriate, in patients with SCD.
  
  
  RESULTS
  Two randomised controlled trials met the inclusion criteria involving a study population of 209 participants. One compared blood transfusion with standard care for children who are identified as being at high risk of stroke using TCD ultrasonography. In this trial, one patient in the transfusion group had a stroke (1/63) compared with 11 children in the standard care group (11/67). The other trial assessed the impact of halting chronic transfusion in patients with SCD. Sixteen patients in the transfusion-halted group had an event (16/41) (two patients experienced stroke and 14 reverted to abnormal TCD velocity); there were no events in the continued-transfusion group (0/38). No meta-analyses of these trials were undertaken. No relevant economic evaluations were identified for inclusion in the review. The de novo modelling suggests that blood transfusions plus TCD scans (compared with just TCD scans) for patients with SCD at high risk of stroke, aged ≥ 2 years, may be good value for money. The intervention has an incremental cost-effectiveness ratio of £24,075 per quality-adjusted life-year gained, and helps avoid 68 strokes over the lifetime of a population of 1000 patients. The intervention costs an additional £13,751 per patient and generates 0.6 extra years of life in full health per patient. The data available for the economic analysis are limited. Sensitivity analyses and validation against existing data and expert opinion provide some reassurance that the conclusion of the model is reliable but further research is required to validate these findings.
  
  
  CONCLUSIONS
  The main limitations relate to the availability of published clinical data; no completed randomised controlled trials were identified which evaluated the efficacy of either BMT or hydroxycarbamide for primary stroke prevention. Both the clinical and cost data available for use in the economic analysis are limited. Sensitivity analyses and validation against existing data and expert opinion provide some reassurance that the conclusions of the model are reliable, but further research is required to validate these findings.
  
  
  CONCLUSIONS
  The use of TCD ultrasonography to identify children at high risk of stroke, and treating these children with prophylactic blood transfusions, appears to be both clinically effective and cost-effective compared with TCD ultrasonography only. However, given the limitations in the data available, further research is required to verify this conclusion. Several research recommendations can be proposed from this review. Clinically, more research is needed to assess the effects and optimal duration of long-term blood transfusion and the potential role of hydroxycarbamide in primary stroke prevention. From an economics perspective, further research is required to generate more robust data on which to base estimates of cost-effectiveness or against which model outputs can be calibrated. More data are required to explain how utility weights vary with age, transfusions and strokes. Research is also needed around the cost of paediatric stroke in the UK.
  
  
  BACKGROUND
  PROSPERO CRD42011001496.
  
  
  BACKGROUND
  The National Institute for Health Research Health Technology Assessment programme.
authors.affiliation: Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK.
authors.forename: M G
authors.initials: MG
authors.lastname: Cherry
authors.forename: J
authors.initials: J
authors.lastname: Greenhalgh
authors.forename: L
authors.initials: L
authors.lastname: Osipenko
authors.forename: M
authors.initials: M
authors.lastname: Venkatachalam
authors.forename: A
authors.initials: A
authors.lastname: Boland
authors.forename: Y
authors.initials: Y
authors.lastname: Dundar
authors.forename: K
authors.initials: K
authors.lastname: Marsh
authors.forename: R
authors.initials: R
authors.lastname: Dickson
authors.forename: D C
authors.initials: DC
authors.lastname: Rees
mesh_terms: D000755:Anemia, Sickle Cell / Q000150:complications* / Q000000981:diagnostic imaging / Q000191:economics / Q000473:pathology; D000986:Antisickling Agents / Q000191:economics / Q000627:therapeutic use; D001803:Blood Transfusion / Q000191:economics* / Q000379:methods; D016026:Bone Marrow Transplantation / Q000191:economics / Q000379:methods; D002560:Cerebrovascular Circulation; D002648:Child; D003362:Cost-Benefit Analysis; D006801:Humans; D006918:Hydroxyurea / Q000191:economics / Q000627:therapeutic use; D008390:Markov Chains; D011322:Primary Prevention / Q000191:economics* / Q000379:methods; D019057:Quality-Adjusted Life Years; D016032:Randomized Controlled Trials as Topic; D020521:Stroke / Q000209:etiology* / Q000517:prevention & control*; D017585:Ultrasonography, Doppler, Transcranial
chemical_list: D000986:Antisickling Agents; D006918:Hydroxyurea