Modeled Economic Evaluation of Alternative Strategies to Reduce Sudden Cardiac Death Among Children Treated for Attention Deficit/Hyperactivity Disorder

Abstract

Background-Stimulants are widely used to treat children with attention deficit/hyperactivity disorder and may increase the risk for sudden cardiac death (SCD). We examined the cost-effectiveness of pretreatment screening with ECG for reducing SCD risk in children diagnosed with attention deficit/hyperactivity disorder who are candidates for stimulant medication. Method and Results-We constructed a state-transition Markov model with 10 annual cycles spanning 7 to 17 years of age. Taking a societal perspective, we compared the cost-effectiveness of 3 screening strategies: (1) performing a history and physical examination with cardiology referral if abnormal (current standard of care); (2) performing a history and physical examination plus ECG after negative history and physical examination, with cardiology referral if either is abnormal; and (3) performing a history and physical examination plus ECG, with cardiology referral only if ECG is abnormal. Children identified with SCD-associated cardiac abnormalities would be restricted from stimulants and from playing competitive sports. The expected incremental cost-effectiveness over strategy 1 was $39 300 and $27 200 per quality-adjusted life-year for strategies 2 and 3, respectively. Monte Carlo simulation found that the chance of incremental cost-effectiveness was 55% for strategy 2 and 71% for strategy 3 (willingness to pay Յ$50 000 per quality-adjusted life-year). Both strategies 2 and 3 would avert 13 SCDs per 400 000 children seeking stimulant treatment for ADHD, for a cost of $1.6 million per life for strategy 2 and $1.2 million per life for strategy 3. Conclusions-Relative to current practice, adding ECG screening to history and physical examination pretreatment screening for children with attention deficit/hyperactivity disorder has borderline cost-effectiveness for preventing SCD. Relative cost-effectiveness may be improved by basing cardiology referral on ECG alone. Benefits of ECG screening arise primarily by restricting children identified with SCD risk from competitive sports. (Circulation. 2010;121:1329-1337.)

Adult ADHD Medications and Their Cardiovascular Implications

“…HR and BP should be measured before initiating medications and routinely during treatment. Universal EKG screening has not been shown to be cost effective, as it has not demonstrated any incremental benefit in preventing sudden cardiac death in children with ADHD [34]. EKG screening and cardiologist consultation are recommended for ADHD patients who have positive history of structural cardiac abnormalities [35] and even though baseline EKG before initiating ADHD medications is considered reasonable by ACC/AHA [36], it is not endorsed by American Academy of pediatrics [33].…”

Electrocardiographic Screening Should Not Be Implemented for Children and Adolescents Between Ages 1 and 19 in the United States

“…The incremental cost-effectiveness of ECG screening under the best-case scenario (most favorable outcome for screening) resulted in an incremental cost-effectiveness of between $91 000 and $204 000 per life-year saved. Dencev et al 14 used a model to evaluate alternative strategies (history and physical, history and physical plus ECG if history and physical was abnormal, or history and physical and ECG with referral to a pediatric cardiologist if either the history and physical or the ECG was abnormal). The goal was the reduction in SCD in children treated with stimulant medications for attention deficit disorder.…”

Screening for Sudden Cardiac Death in the Young

“…Assumed incidence rates directly influence cost-effectiveness estimates for prevention programs, with lower incidence rates implying unacceptably low benefits relative to the resources consumed, whereas higher incidence rates imply such programs are cost-effective. 13,17 More precise estimation of SCDY incidence is important for well-informed public health planning for prevention and resource allocation.…”