Projected cost-effectiveness of statewide universal newborn hearing screening
Projected cost-effectiveness of statewide universal newborn hearing screening
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DOI：
10.1542/peds.110.5.855
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发表时间：
2002-11-01
期刊：
影响因子：
8
通讯作者：
Lieu, TA
中科院分区：
文献类型：
--
作者：
Keren, R;Helfand, M;Lieu, TA
目标。及早识别听力障碍可能会改善聋人的语言结果以及随后的学习和职业表现。目前由32个州授权的普遍新生儿听力筛查(UNHS)可以将确诊听力障碍的中位年龄从12到18个月降低到6个月或更短。然而，由于必须将假阴性测试降至最低，先天性耳聋的患病率很低，而且筛查测试不完善，因此UNHS导致许多假阳性结果，且阳性预测值(PPV)较低。这项研究的目的是从短期和长期利益、危害和财务成本两方面评估UNHS和选择性筛查，并确定筛查过程中可以改进的步骤，以提高成本效益。这项从社会角度进行的成本-效果分析比较了1)无新生儿听力筛查、2)选择性新生儿听力筛查和3)UNHS对80000名婴儿的假设状态出生队列的预测结果。决策模型的概率和成本估计是从已发表的研究、专家意见以及国家和州来源获得的。主要结果是每个6个月后被诊断为耳聋的婴儿的增量成本，其中只包括筛查和诊断评估的成本；以及每个语言正常的聋儿的增量成本，其中还包括医疗保健、教育和辅助设备的成本，以及聋人个体一生中的生产力损失。选择性筛查确定了出生队列中128名聋儿中的62名，转介了所有婴儿的0.18%进行诊断评估，PPV为43%。UNHS确认了128名聋儿中的116名，转介了1.6%的婴儿，PPV为8.8%。我们的模型模拟了真实世界的情况，在这种情况下，一些在筛查中被确认为耳聋的婴儿在6个月前没有收到明确的耳聋诊断；以及一部分耳聋和听力障碍婴儿1)有假阴性筛查结果，2)没有被筛查，或者3)没有通过听力筛查，但没有立即得到诊断评估，但在6个月大的时候仍然得到了诊断。在没有新生儿听力筛查的情况下，大约30名聋儿在6个月大时仅通过被动检测就被识别出来，费用为69000美元。与没有新生儿听力筛查相比，选择性筛查方案导致额外36名婴儿在6个月后被诊断为耳聋，额外成本约为60万美元，每增加一名婴儿在6个月后被诊断为耳聋，成本效益增加约16 000美元。与选择性筛查相比，国民保健制度的方案增加了33名婴儿，他们在6个月大时被诊断为耳聋，额外费用约为150万美元，每增加一个婴儿在6个月大时被诊断为耳聋，增加的成本效益约为44 000美元。将诊断评估的随访率从基本病例估计的77%提高到100%，将联合国保健制度的增量成本降低到每增加一个婴儿的费用为38000美元，这些婴儿在6个月后被诊断为聋。在语言正常和早期干预所产生的终生节约的基本假设下，与选择性筛查和不筛查相比，UNHS使更多的聋儿获得了正常的语言成绩，并从长期来看节省了成本。全民保健制度的短期成本效益与其他新生儿筛查方案的每个确诊病例的成本相当，并可通过提高筛查阳性结果后对诊断评估的随访率来提高。如果早期识别能够提高语言能力，降低教育和职业成本，提高终生生产率，那么与选择性听力筛查和不筛查相比，UNHS具有长期节省成本的潜力。为了了解UNHS的实际长期经济影响，需要更好的证据来证明早期干预对语言结果的影响，以及随后教育成本和终身生产率的变化。
Objectives. Early identification of hearing impairment may improve language outcomes and subsequent school and occupational performance of the deaf. Universal newborn hearing screening (UNHS), currently mandated by 32 states, can reduce the median age of identification of hearing impairment from 12 to 18 months to 6 months or less. However, because false-negative tests must be minimized, the prevalence of congenital deafness is low, and screening tests are imperfect, UNHS results in many false-positive results and has a low positive predictive value (PPV). The objective of this study was to evaluate UNHS and selective screening in terms of both short- and long-term benefits, harms, and financial costs and to identify steps in the screening process that could be improved to increase cost-effectiveness.Methods. The cost-effectiveness analysis, conducted from the societal perspective, compared the projected outcomes of 1) no newborn hearing screening, 2) selective newborn hearing screening, and 3) UNHS for a hypothetical state birth cohort of 80 000 infants. Probability and cost estimates for the decision model were obtained from published studies, expert opinion, and national and state sources. The main outcomes were incremental cost per infant whose deafness was diagnosed by 6 months, which included only the cost of screening and diagnostic evaluation; and incremental cost per deaf child with normal language, which also included the costs of medical care, education and assistive devices, and lost productivity over the lifetime of the deaf individual.Results. Selective screening identified 62 of the 128 deaf infants in the birth cohort, referred 0.18% of all infants for diagnostic evaluation, and had a PPV of 43%. UNHS identified 116 of the 128 deaf infants, referred 1.6% of all infants, and had a PPV of 8.8%. Our model simulated real-world conditions in which some infants whose deafness is identified at screening do not receive a definitive diagnosis of being deaf before 6 months; and a portion of deaf and hard-of-hearing infants who 1) have false- negative screening test results, 2) are not screened, or 3) fail the hearing screen but are not immediately followed up with diagnostic evaluation nonetheless receive a diagnosis by 6 months of age. In the absence of newborn hearing screening, approximately 30 deaf infants were identified by 6 months of age by passive detection alone at a cost of $69 000. The selective screening protocol, when compared with no newborn hearing screening, resulted in an additional 36 infants whose deafness was diagnosed by 6 months at an additional cost of approximately $600 000, yielding an incremental cost-effectiveness of approximately $16 000 per additional infant whose deafness was diagnosed by 6 months. Compared with selective screening, the UNHS protocol resulted in 33 additional infants whose deafness was diagnosed by 6 months of age at an additional cost of approximately $1.5 million, yielding an incremental cost-effectiveness of approximately $44 000 per additional infant whose deafness was diagnosed by 6 months of age. Increasing the rate of follow-up to diagnostic evaluation from the base-case estimate of 77% to 100% decreased the incremental cost of UNHS to $38 000 per additional infant whose deafness was diagnosed by 6 months. Under the base-case assumptions about lifetime savings that result from normal language with early intervention, UNHS resulted in normal language achievement for more deaf children and was cost saving in the long term compared with both selective screening and no screening.Conclusions. The short-term cost-effectiveness of UNHS is comparable to the cost per case diagnosed of other newborn screening programs and could be improved by increasing the rate of follow-up to diagnostic evaluation after positive screening test results. If early identification results in improved language abilities, lower educational and vocational costs, and increased lifetime productivity, then UNHS has the potential for long-term cost savings compared with selective hearing screening and no screening. To understand the actual long-term economic effects of UNHS, better evidence is needed regarding the impact of early intervention on language outcomes and subsequent changes in educational costs and lifetime productivity.