AUTHOR=Neves Luiza M , Haefeli Lorena M , Zin Andrea A , Steffen Ricardo E , Vasconcelos Zilton F. M , Pinto Márcia 

TITLE=Cost–Utility Analysis of Wide-Field Imaging as an Auxiliary Technology for Retinopathy of Prematurity Care in Brazil

JOURNAL=Frontiers in Pediatrics

VOLUME=Volume 9 - 2021

YEAR=2021

URL=https://www.frontiersin.org/journals/pediatrics/articles/10.3389/fped.2021.757258

DOI=10.3389/fped.2021.757258

ISSN=2296-2360

ABSTRACT=Purpose: To evaluate the cost-utility of wide-field imaging (WFI) as a complementary technology for retinopathy of prematurity (ROP) screening from the Brazilian Unified Health System’s perspective. 
Introduction: ROP is one of the leading causes of avoidable childhood blindness worldwide, especially in middle-income countries. The current ROP screening involves indirect binocular ophthalmoscopy (IBO) by ROP specialist ophthalmologists. However, there is still insufficient ROP screening coverage. An alternative screening strategy is the combination of WFI with IBO.
 Methods: A cost-utility analysis was performed using a deterministic decision-tree simulation model to estimate incremental cost-utility ratio for ROP management. Two screening strategies were compared: 1. IBO; 2. Combination of WFI of all eligible preterm babies and IBO for type 2 ROP or worse and for non-readable images. Eligible population included preterm babies less than 32 weeks of gestational age or birth weight equal to or less than 1,500 grams. The temporal horizon was lifetime. Visual outcome data was converted to utility and the health benefits were estimated on quality-adjusted life years (QALY). Incremental cost per QALY gained was calculated from the health system perspective. Costs were estimated considering equipment, maintenance, consumables, and staff. A micro-costing approach was used for wide-field imaging. Two technician nurses were trained for imaging execution and had their time evaluated. Two ROP expert ophthalmologists had their time evaluated for imaging reading. One-way sensitivity analysis and probabilistic sensitivity analysis were performed. 
Results: Combined screening strategy resulted in a cost-effective program considering 90% ROP screening coverage. Costs per exam: 1. Screening with IBO: United States Dollar (USD) 34.36; 2. Screening with combination: USD 58.20; 3. Laser treatment: USD 642.09; 4. Long term follow-up: ranged from USD 69.33 to 286.91, based on the infant's visual function. Incremental cost per QALY gained was 1,746.99/QALY per infant screened with the combination strategy. One-way sensitivity analysis resulted in cost-effectiveness for all parameters. Probabilistic sensitivity analyses yielded a 100% probability of combination being cost-effective in a willingness-to-pay threshold of 1,800 per QALY.
Conclusion: The combined strategy for ROP screening was cost-effective.  It enhances access for appropriate ROP management in middle-income countries and diminishes opportunity costs for ophthalmologists.