Cost-effectiveness analysis of pediatric cardiac surgery for common lesions in Rwanda

Background: Only 3 % of children in sub-Saharan Africa with congenital heart disease (CHD) have access to life-saving surgery. There is an urgent need to scale up the volume of cardiac procedures. Cost-utility analysis can assess the health economic impacts of performing congenital heart surgery in this region.

Methods: We performed a cost-utility analysis comparing surgical intervention and medical management for a weighted case mix of the four most common CHDs in Rwanda. A Markov model was constructed to simulate the course of each strategy. Probability of peri-operative complications was derived from the local pediatric cardiac surgery program and risks of long-term outcomes from large, published cohort studies. Micro-costing was used to calculate expenses from program cost data. Health benefits were measured in quality-adjusted life years (QALYs). Deterministic and probabilistic sensitivity analysis was performed. Incremental cost-effectiveness ratios (ICER) were compared to a willingness-to-pay threshold three times the GDP per capita of Rwanda (USD$2898·60).

Results: Surgical intervention provided 17·15 additional discounted QALYs compared to medical management for an extra USD$6738·23. The ICER for surgical intervention was USD$269·52/QALY. Increasing the cost of surgery raised the ICER to a maximum of USD$580/QALY. In the probabilistic sensitivity analysis, surgery was cost-effective 100 % of the time including at one-times GDP per capita.

Conclusion: Surgical intervention for common CHD in Rwanda is very cost-effective. The initial cost of surgery is compensated for by decades of additional life years. Increasing case complexity and decreasing the initial cost of surgery can make surgery even more cost-effective.