The cost-effectiveness of a screening for celiac disease

INTRODUCTION:  Celiac disease is a chronic disease characterized by intolerance to gluten. A gluten-free diet is the only available treatment. The majority of individuals with celiac disease remain undiagnosed, and the delay from first symptoms related to the disease to the diagnosis is long. The only option to identify most cases is a screening of the general population. The cost-effectiveness criterion then needs to be fulfilled. No economic evaluation this far is sufficiently comprehensive.

Our objective was to perform a comprehensive health economic evaluation of a celiac disease mass screening at 12-years of age, taking a life course perspective on future benefits and drawbacks into account, and considering both changes in resource use and health related quality of life as outcomes.

METHODS:  We used a Markov model with six states; three states corresponding to undiagnosed disease, two to diagnosed disease and one to death. We evaluated a hypothetical screening at age 12. Cost and health utilities were estimated for each year until death. Health was measured with EuroQol 5 dimensions and translated to quality-adjusted life year (QALY) scores. The following cost items were used: i) the screening, ii) health care visits, iii) hospitalization, iv) sick leave, and v) the gluten-free diet. We based most our estimates, including transition probabilities, on our own previous studies; one among children and one among adults. The cost-effectiveness was presented as cost per QALY gained.

RESULTS: The cost per QALY gained for a screening was €110,000. This is above the commonly recommended threshold value €50,000 per QALY gained.

CONCLUSIONS: A screening for celiac disease at 12-years of age may not be cost-effective. Interventions aiming at an improved knowledge about the disease might be preferable. However, some assumptions in the model are difficult to verify. We intend to further look into these.