THE COST-EFFECTIVENESS OF SCREENING ECHOCARDIOGRAMS IN INFANTS WITH CRANIOSYNOSTOSIS UNDERGOING CRANIAL VAULT EXPANSION

Purpose: Craniosynostosis is a congenital malformation caused by premature fusion of cranial sutures. Occurrence of intra-operative venous air emboli during the cranial vault expansion (CVE) surgery used to treat this condition is a common and significant surgical risk and can lead to stroke or death. Infants with an atrial septal defect (ASD) are at increased risk for a stroke due to venous air emboli during CVE.                                        

Despite this well-known risk, no national standards exist regarding the optimal method for identification and treatment of ASDs in infants undergoing CVE. Echocardiogram following a positive physical examination is a common screening practice, but physical exams lack sensitivity and specificity. Echocardiograms for all patients would offer increased sensitivity to detects ASDs, but add cost and patient burden. As part of the development of a standardized clinical pathway for treatment of craniosynostosis, we sought to evaluate the cost-effectiveness of physical examination versus routine echocardiogram evaluations on all infants with craniosynostosis.

Method: We developed a decision analytic model to calculate the costs and health effects (mortality and strokes avoided) in the two screening scenarios: physical exam and echocardiogram. We derived model input parameters estimates from our hospital billing records and the published literature. The analysis was conducted from the payer perspective over a 1-year time horizon. We conducted univariate and multivariate sensitivity analyses on model inputs to test the robustness of the model.

Result: Echocardiogram for all infants with craniosynostosis was more costly and only slightly more effective than physical examination. Use of initial echocardiogram resulted in 1 fewer death and no fewer strokes per 10,000 patients relative to physical examination at a cost of $1,057 per child. The model was most sensitive to the prevalence of ASDs, the sensitivity and specificity of physical examination and echocardiogram, and the cost of echocardiogram.

Conclusion: We found that the use of routine echocardiogram may not be a cost-effective practice for screening for ASDs in infants undergoing CVE surgery. Moreover, we found that the use of decision analytic models can supplement published studies and expert opinion for best clinical practices for clinical pathway development. Our future work will consider additional sources for estimates of cost data, and the prevalence of other atrial level communications that could lead to similar surgical risks.