Cost-Utility Analysis of Orthoptic Screening in Kindergarten: A Markov Model Based on Data From Germany

Abstract

Objective. To estimate the long-term cost-effectiveness of a hypothetical screening program for untreated amblyopia in 3-year-old children conducted by orthoptists in all German kindergartens in the year 2000. Methods. A cost-utility analysis was performed for which a decision tree was combined with a Markov model. Incremental costs and effects during the children’s remaining lifetime were estimated. The model took into account the probability of treatment without screening, age-specific treatment success rates, costs of screening and treatment, as well as effects of unilateral and bilateral visual impairment caused by amblyopia and other eye diseases coming along later in life on quality of life (utility). Model parameter values were obtained from a field study of orthoptic screening in kindergarten, from the literature, and from expert interviews. Costs were estimated from a third-party payer perspective. Uncertainty was assessed by univariate and probabilistic sensitivity analysis (Monte Carlo simulation). Results. The incremental cost-effectiveness ratio (ICER) of orthoptic screening was 7397 Euro (€) per quality-adjusted life year (QALY) when costs and effects were discounted at 5%. In univariate sensitivity analysis, the ICER was sensitive to the uncertainty regarding the utility of unilateral visual impairment and to the discount rate for effects; besides uncertainty regarding the prevalence of untreated amblyopia, the odds ratio of success of treatment when started late, and the probability of treatment without screening had a noticeable but much smaller effect. Monte Carlo simulation yielded a 90% uncertainty interval for the ICER of 3452 €/QALY to 72 637 €/QALY; the probability of an ICER <25 000 €/QALY was 84%. Conclusions. The ICER of orthoptic screening seems to fall within a range that warrants careful consideration by decision-makers. Much of the uncertainty in results comes from the uncertainty regarding the effect of amblyopia on quality of life. To reduce this uncertainty, the impact of amblyopia on utility should be investigated.