title: Primary prevention of acute rheumatic fever and rheumatic heart disease with penicillin in South African children with pharyngitis: a cost-effectiveness analysis.
abstract: BACKGROUND
  Acute rheumatic fever and subsequent rheumatic heart disease remain significant in developing countries. We describe a cost-effective analysis of 7 strategies for the primary prevention of acute rheumatic fever and rheumatic heart disease in children presenting with pharyngitis in urban primary care clinics in South Africa.
  
  
  RESULTS
  We used a Markov model to assess the cost-effectiveness of treatment with intramuscular penicillin using each of the following strategies: (1) empirical (treat all); (2) positive throat culture (culture all); (3) clinical decision rule (CDR) score ≥2 (CDR 2+); (4) CDR score ≥3 (CDR 3+); (5) treating those with a CDR score ≥2 plus those with CDR score <2 and positive cultures (CDR 2+, culture CDR negatives); (6) treating those with a CDR score ≥3 plus those with CDR score <3 and positive cultures (CDR 3+, culture CDR negatives); and (7) treat none. The strategies ranked in order from lowest cost were treat all ($11.19 per child), CDR 2+ ($11.20); the CDR 3+ ($13.00); CDR 2+, culture CDR negatives ($16.42); CDR 3+, culture CDR negatives ($23.89); and culture all ($27.21). The CDR 2+ is the preferred strategy at less than $150/quality-adjusted life year compared with the treat all strategy. A strategy of culturing all children compared with the CDR 2+ strategy costs more than $125 000/quality-adjusted life year gained.
  
  
  CONCLUSIONS
  Treating all children presenting with pharyngitis in urban primary care clinics in South Africa with intramuscular penicillin is the least costly. A strategy of using a clinical decision rule without culturing is overall the preferred strategy. A strategy of culturing all children may be prohibitively expensive.
authors: Primary Health Care Directorate, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
authors: James
authors: J
authors: Irlam
authors: Bongani M
authors: BM
authors: Mayosi
authors: Mark
authors: M
authors: Engel
authors: Thomas A
authors: TA
authors: Gaziano
mesh_terms: D000293:Adolescent; D000900:Anti-Bacterial Agents / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D003362:Cost-Benefit Analysis; D003695:Delivery of Health Care / Q000191:economics; D003906:Developing Countries / Q000191:economics*; D016527:Drug Costs; D006801:Humans; D008390:Markov Chains; D018803:Models, Economic; D010406:Penicillins / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use*; D010612:Pharyngitis / Q000175:diagnosis / Q000188:drug therapy* / Q000191:economics* / Q000453:epidemiology / Q000382:microbiology; D015995:Prevalence; D011322:Primary Prevention / Q000191:economics*; D019057:Quality-Adjusted Life Years; D012213:Rheumatic Fever / Q000175:diagnosis / Q000191:economics* / Q000453:epidemiology / Q000382:microbiology / Q000517:prevention & control*; D012214:Rheumatic Heart Disease / Q000175:diagnosis / Q000191:economics* / Q000453:epidemiology / Q000382:microbiology / Q000517:prevention & control*; D013019:South Africa / Q000453:epidemiology; D016896:Treatment Outcome; D019037:Urban Health Services / Q000191:economics
chemical_list: D000900:Anti-Bacterial Agents; D010406:Penicillins
keywords: cost-benefit analysis; prevention; rheumatic heart disease