A MODELED ECONOMIC EVALUATION OF ALTERNATIVE STRATEGIES TO REDUCE SUDDEN CARDIAC DEATH AMONG CHILDREN TREATED FOR ATTENTION DEFICIT AND HYPERACTIVITY DISORDER

Purpose: To estimate the cost-effectiveness of performing screening electrocardiograms (ECG) prior to initiation of stimulant medication for 7 year old children diagnosed with Attention Deficit/Hyperactivity Disorder (ADHD) in order to reduce Sudden Cardiac Death (SCD), as recently recommended by an American Heart Association Scientific Statement.

Method: A state-transition Markov model was constructed. The model covers a period of 10 years (from ages 7 to 17), divided in 10 Markov cycles – one year each. The analysis is done from the societal perspective. We compare the cost-effectiveness of three main screening approaches: performing a history and physical examination (H&P) with positive results being referred to a pediatric cardiologist for a conclusive opinion (Strategy 1). Strategy 1 is the current standard of care, and serves as the reference point to estimate the cost-effectiveness of the other two strategies: performing a H&P plus ECG, with abnormalities in either test being referred to a pediatric cardiologist for a conclusive opinion (Strategy 2); and performing a H&P plus ECG, with only abnormalities on ECG being referred to a pediatric cardiologist for a conclusive opinion (Strategy 3). The model assumes that stimulants increase the risk of SCD 10% over the baseline rate. The model takes into account spontaneous remission of ADHD with age, and possible discontinuation of the medication due to other reasons. Patients who are diagnosed with heart disease associated with a risk of SCD by the pediatric cardiologist are restricted from receiving stimulant medication and playing competitive sports.

Result: The expected incremental cost-effectiveness is $41,000/QALY for Strategy 2 and $27,000/QALY for Strategy 3, both relative to Strategy 1. Monte Carlo microsimulation of 1,000 trials with 400,000 patients each demonstrates that the probability of cost-effectiveness (willingness-to-pay = $50,000/QALY) is 55% for Strategy 2 and 71% for Strategy 3. In terms of lives saved (vs. QALYs), Strategies 2 and 3 both save 33 lives per million children screened (vs. Strategy 1), corresponding to a cost per saved life of $1.6 million for Strategy 2 and $1.16 million for Strategy 3.

Conclusion: Addition of the ECG to routine screening prior to initiation of stimulant medications for ADHD has borderline cost-effectiveness.  A novel approach, using the ECG without routine H&P, may be more cost-effective.