A Cost-Effectiveness Analysis of Timely Otitis Media Treatment through a Community Health Worker Delivered School Screening Program

Abstract

In certain settings, otitis-media related hearing loss forms a large proportion of total hearing loss cases. Delays to timely otitis media diagnosis and appropriate treatment leads to more serious otitis media cases, sometimes chronic suppurative otitis media, which may lead to a permanent hearing loss. A primary driver in the delay to diagnosis and treatment is a lack of easily accessed, trained healthcare workers in the identification and treatment of otitis media. We used an exemplar setting, Zambia, to understand the costs and potential effects of community health worker-delivered screening program for school-age children. The goal of this analysis was to highlight otitis media as a driver of hearing loss and understand the cost-effectiveness of timely diagnosis/treatment to prevent downstream hearing loss. The treatment pathway for otitis media treatment was identified using a cascade of care framework, as well as the effects of increased otitis media treatment access though stakeholder engagement metrics. The treatment for otitis media in this analysis was conservative treatment, aural toileting and topical antibiotics. Additionally, the costs of otitis media and chronic suppurative otitis media and the proportion of both metrics treated in Nigeria were found. Training costs of a program were included in the treatment pathway to adequately model the scale-up strategy. Simulated persons experience yearly age- and sex- specific probabilities of acquiring hearing loss, the prevalence of which is 3.6% in Nigeria. The population of interest was six-year-old children in Nigeria suffering from otitis media across their lifetime. Strategies for comparison to increase appropriate treatment of otitis media included current care and the implementation of a community health worker-delivered screening program. Main measures included lifetime undiscounted and discounted (3%/year) costs and QALYs and incremental cost-effectiveness ratios (ICERs) by Nigerian standard (<3x $2,097.09 was considered cost-effective). Current detection (CD) resulted in 19.22 discounted average person-years of otitis media treatment compared to 19.23 discounted average person-years with implementation of a CHW delivered screening program. Lifetime total per-person undiscounted costs were $64.26 USD for CD and $62.26 USD with the screening program intervention, indicating that the screen is both less costly and more effective than not screening. Results were most sensitive to variations in cost of screen, cost of CSOM, rAOM, pOME resolution from screening, and CI device cost. Limitations included input uncertainty given limited data sources for similar settings. Additionally, we had to use a utility decrement for moderate hearing loss since there is not one in the model that we identified specifically for CSOM. We project that a community health worker delivered screening program is cost-effective by US standards. Further research is needed to determine whether screening at younger ages or different treatments for otitis media is cost-effective.