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Height Screening During the Primary School Years: Evidence Behind Practice?« Back to Volume 23, Issue 3, November 2007 - Table of Contents Height and weight monitoring has long been a fundamental aspect of pediatric care as indicators of both health and possible underlying pathology. Unfortunately, delays in diagnosis and treatment of underlying growth problems are frequently observed. The optimal strategy remains elusive, as the standard cut-offs between normal and abnormal and the recommended growth screening practices vary widely. For example, the Child Health Subcommittee of the UK National Screening Committee recommended a cut-off of 0.4th centile and a single height and weight measurement at or around the time of school entry for screening.1 Fayter et al performed a systematic review of the effectiveness and economic modeling of height screening in primary school aged children to identify height-related conditions (focusing on stature, not obesity). They collected all studies from database inception (1974) to July 2005 that measured child height as part of a population-level assessment of children aged 4 to 11 years in Western Europe, North America, Australia and New Zealand (excluding aboriginal populations). All study designs, except case reports, were accepted. Effectiveness was assessed from the number of cases of all conditions detected. Meta-analysis of diagnostic yield data was precluded by the heterogeneity of child age, reference charts and screening methods used; thus, effectiveness data were limited to descriptive summaries. Twelve studies of height screening programs provided diagnostic yields of new cases and measured 45% to 90% of eligible children. A single measurement at school entry identified new cases of underlying growth conditions at rates of 0.54 to 0.56 per 1000 children screened. Economic modeling was based on pooled raw data from 12 diagnostic yield studies, providing probability distributions for new case detection of each included condition. Lifetime costs and outcomes were modeled, following NICE guidelines, and included screening, referral, and treatment costs reflated to 2006 values. A cost/QALY analysis (a QALY = a year of life, adjusted for its quality or perceived value) compared height screening at school entry (age 5 years) versus no screening (diagnoses found later in clinical practice). QALY estimates, based on the literature and an expert clinical panel, assumed early detection and screening would provide double the QALY gains than later detection from no screening. Using the number of 5-year-old children in England and Wales, the model found an incremental cost-utility of height screening at £9,900 (~$19,800 US) per QALY. Probabilistic sensitivity analysis found that all of the model’s data distributions fell below the UK willingness to pay thresholds of £30,000 per QALY. Thus, the authors concluded that height screening in primary school aged children is diagnostically useful and economically justifiable. Fayter DA, Nixon J, Hartley S, et al. Effectiveness and cost-effectiveness of height screening programmes during the primary school years: a systematic review. Arch Dis Child. 2007 May 2;[Epub ahead of print]. Editor’s CommentIt is striking that such financial analyses are now needed to justify growth screening, a fundamental tenet of pediatric care. However, as highlighted by this paper, many of the considerations remain elusive. What is the optimal height cut-off to identify likely pathology? What is the optimal screening paradigm? Serial height measurements will capture cases of growth deceleration before they become severe enough to cross the single height cut-off for pathology, but how frequent and how many are needed to balance improved sensitivity with increased cost? What is the actual cost of missed or delayed diagnoses and how are QALYs estimated, especially since the impact of short stature on quality of life remains so controversial? And what about the cost of height monitoring itself? Height measurements in the United States are performed as part of routine pediatric well child care,2 and the cost of a stadiometer spread across the patient population is so negligible that it seems virtually free. The only real cost is the time to accurately measure the child and plot the measurements on the appropriate growth chart. With the increasing pressures to expedite patient flow faster and faster, time may be the most expensive aspect of growth screening. Adda Grimberg, MD References - (linked to
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Volume 25 Number 1
June 2009
www.GGHjournal.com
ISSN 1932-9032
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