ORIGINAL ARTICLE A Cost-Effectiveness Model of Screening Strategies for Amblyopia and Risk Factors and Its Application in a German Setting AFSCHIN GANDJOUR, MD, PhD, STEFANIE SCHLICHTHERLE, MD, ANTJE NEUGEBAUER, MD, WALTER RÜSSMANN, MD, and KARL WILHELM LAUTERBACH, MD, DSs Institute of Health Economics and Clinical Epidemiology, University of Cologne, Cologne, Germany (AG, SS, KWL), Department of Ophthalmology, University of Cologne, Cologne, Germany (AN, WR) ABSTRACT: Purpose. To develop a general setting–independent decision-analytical model that determines the costs, effectiveness, and cost-effectiveness of four screening strategies to detect amblyopia or amblyogenic factors in pre-school children and to apply the model in a German setting. Methods. The general setting–independent decision– analytical model was developed from the perspective of society and the statutory health insurance was developed. Outcomes were the total number of newly detected true positive cases of amblyopia and the costs per newly detected true positive case of amblyopia. Strategies were screening of high-risk children up to the age of 1 year (ophthalmol- ogists), screening of all children up to the age of 1 year (ophthalmologists), screening of all children aged 3 to 4 years (pediatricians or general practitioners), and screening of children aged 3 to 4 years visiting kindergarten (orthoptists). For the application example in a German setting, data from the published medical literature were used. Results. In the base-case analysis of the application example, screening high-risk children by opthalmologists had the lowest average cost per case detected but became dominated (less effective and more costly than an alternative) if a low (5.3%) probability of familial clustering of strabismus was assumed. Considering the various assumptions tested in the sensitivity analysis, screening of all children up to the age of 1 year by opthalmologists was the only strategy not dominated by others. Detection rates, including cases detected before screening, were between 72% and 78% for the strategies that screen for all children. Conclusions. The model suggests that in Germany, both from a cost-effectiveness and a pure effectiveness point of view, screening all children up to the age of 1 year by opthalmologists is the preferred strategy to detect amblyopia or amblyogenic factors. All strategies left a significant portion of children undetected. (Optom Vis Sci 2003;80:259–269) Key Words: amblyopia, children, cost-effectiveness analysis, Germany, screening A mblyopia is defined as a unilateral or bilateral decrease in visual acuity for which no cause can be found through the physical examination of the eye. 1 Risk factors associated with amblyopia are anisometropia, hyperopia, and strabismus. The prevalence rate of amblyopia among children aged 3 to 4 years is between 1% and 5%, depending on the threshold value of visual acuity. 2 The prevalence rates of anisometropia, hyperopia, and strabismus are 3.1%, 3 5.5%, 4 and 5.3%, 5 respectively. Pre-school screening for amblyopia is recommended by a large number of professional societies and experts in the United States, Canada, and Germany. 2, 6 –14 Recent evidence supports the expert recommendations. A controlled trial comparing amblyopia screen- ing and treatment before the age of 37 months with screening and treatment at 37 months demonstrated the superiority of an early approach. 15 Similarly, a prospective cohort study on occlusion therapy for amblyopia showed greater improvement in visual acu- ity among children 5 years of age or younger. 16 Still, the question remains as to whether screening for amblyopia is economically attractive. The high prevalence rate of amblyopia that leads to high costs of detection and treatment makes this question economically relevant. In this regard, it is also important to know whether alternative screening options that are currently not recommended would be more economically attractive. Screening by orthoptists has been shown to be effective in the 1040-5488/03/8003-0259/0 VOL. 80, NO. 3, PP. 259–269 OPTOMETRY AND VISION SCIENCE Copyright © 2003 American Academy of Optometry Optometry and Vision Science, Vol. 80, No. 3, March 2003