139 / 232
mimic
the
rate
nationwide
for
children
under
age
three.
It
also
assumes
that
the
one
publicly
funded
patient
who
pursues
antiviral
therapy
will mitigate
hearing
loss
to
an
extent
that
s/
he
will
only
require
hearing
aids
rather
than
bilateral
cochlear
implants.
The model
shows
a
large
net
benefit.
The
next
two
models
that
appear
in
Table
1
illustrate
the
difference
if,
under
the
same
set
of
assumptions,
no
cochlear
implants
are
avoided
or
only
a
single
implant
(unilateral)
is
avoided.
In
the case where no cochlear
implants are avoided,
there
is a net cost
to
the government, and
in
the case of a
single cochlear
implant
avoided,
the
costs
and
benefits
essentially
cancel
each
other
out.
The final model considers how costs and benefits might differ
if
the
number
of
publicly
insured
infants
increases
as
individuals
take
advantage
of
their
public
insurance
eligibility
to
avoid
tax
penalties
for
the uninsured or as
increased numbers of
individuals
are eligible
for public
insurance under
currently debated Medicaid
expansion
in Utah.
This model
considers
the
extreme
scenario
of
80%
of
infants
on
public
insurance
(using
the
high
end
of
the
Department
of
Health
data
on
current
eligibility).
All
other
assumptions
follow
the
base
model.
While
this
increases
dramatically
the
public
dollars
paid
for
CMV
screenings,
it
only
increases
the
number
of
CMV-positive
children
that
take VGC
on
public
insurance
from
one
to
two
children
per
year.
At most
it
might mean
that
two
children
avoid
cochlear
implantation
each
year
rather
than one. The model above calculates
the benefit
if one
of
those
two
children would
have
had
a
single
CI
and
the
other
would
have
been
bilateral
and
both
are
able
to
avoid
cochlear
implantation.
Overall,
this
model
illustrates
that
the
effect
of
increased
public
insurance
is
not
as
significant
a
factor
in
the
calculation
as
the
potential
cost–savings
if VGC
treatment
proves
effective.
In
sum,
we
found
the
implementation
of
Utah’s
hearing-
targeted
CMV
screening
program
to
have
a
net
public
benefit
in
three
of
the
four
cost–benefit
scenarios we
investigated. Only
in
the
instance where
no
cochlear
implant
is
avoided
in
a
year
does
the
program
show
a
net
public
cost,
albeit
a modest
one.
4. Discussion
The
enormous
societal
costs
of
congenital
CMV
must
be
balanced against
the
costs
incurred
from any early CMV
screening
program.
A
targeted
hearing
early
CMV
testing
approach was
a
compromise
to
identify
infants
at
greatest
risk
to
develop
progressive
SNHL.
A
targeted
approach
requires
CMV
testing
of
a
small
number
of
infants
per
year
as
compared
to
testing
thousands
of
infants
if
a
universal
program was
implemented.
Williams
et
al.,
estimated
the
cost of
a
targeted CMV
screening
program within
the United Kingdom
[12]
. They utilized data
from
the
national
hearing
screening
program
in
England
and
from
a
recently
completed
study
using
saliva
swabs.
The
costs
of
screening
time,
PCR
testing,
and
treatment were
calculated.
They
estimated
that
the
cost
for
this
approach would
be
$10,693
per
child
and
concluded
this
amount would be
favorable
compared
to
other
screening
programs.
The
costs
per
child
determined
from
our
analysis
would
be
much
less
than
that
from
the Williams
et
al.,
study
although
a
direct
comparison
is
difficult
given
the
different
health
care
systems. Much
of
the
cost
from
screening
and
treatment
of
the
congenitally
infected
hearing
impaired
infants
will
come
from
antiviral
therapy
and
from
cochlear
implantation.
Eighteen
months
since
implementation
of
this
approach,
eight
of
fourteen
infants
diagnosed
with
CMV
have
undergone
antiviral
therapy.
Kimberlin
et
al.,
reported
one
child who
underwent
6 months
of
VGC
therapy
requiring
cochlear
implantation
compared
to
three
children
who
underwent
6
week
VGC
therapy
requiring
this
surgical procedure at
the 12 month
follow up period
[10]
. At
the 24
month
follow up period,
four children undergoing 6 months of VGC
therapy
required
cochlear
implantation
compared
to
six
children
requiring
the
same procedure undergoing 6 weeks of VGC
therapy.
It may be
that our cost–benefit estimates are overly generous as
only
a
minority
of
children
who
would
qualify
for
cochlear
implants
in
the
United
States
actually
receive
them
[10]
.
This
potential over-estimation however,
is
likely offset by
the
fact
that
we
did
not
include
the
familial
and
educational
benefits
of
early
intervention
that will
be
attributable
to
the Utah
law. Nor
did we
account
for
the
benefits
of
the
preventive
educational
program-
ming mandated
by
the
legislation.
Both
of
these
omissions make
our
analyses
conservative.
5. Conclusion
Our
results
support
a
possible
societal
savings
from
early
identification
and
treatment
of
CMV.
This
analysis
considers
only
the
impact
of
the
screening
portion
of
the
program.
Overall,
the
results
suggest
that
there
is
reason
for
optimism
about
the
return
on
investment
to
the
government
associated with
the Utah
law.
Table
1
Cost–benefit
figures
of mandatory
CMV
testing
for
infants who
fail
two
newborn
hearing
screenings
using
different model
assumptions.
Baseline model
a
No
cochlear
implants
avoided
One
cochlear
implant
avoided
80%
of
newborns
on
public
insurance
2014
2015
2014
2015
2014
2015
2014
2015
Costs
Program
setup
$4,000
$4000
$4000
$4,000
Fixed
administrative
$30,800
$30,800
$30,800
$30,800
$30,800
$30,800
$30,800
$30,800
Screenings
$7,260
$7,260
$7260
$7260
$7260
$7,260
$7,260
$7,260
Antiviral
treatment
and monitoring
tests
$4,839
$4,839
$4839
$4839
$4839
$4,839
$9,678
$9,678
Total
costs
$46,899
$42,899
$46,899
$42,899
$46,899
$42,899
$57,348
$53,348
Benefits
Treatment
savings
$93,600
$93,600
$0
$0
$46,800
$46,800
$140,400
$140,400
Benefits–costs
$46,691
$50,701
($46,899)
($42,899)
($99)
$3,901
$83,052
$87,052
a
The
base model
chooses
values
near
the middle
of
the
ranges
provided
for
the
costs/benefits
for which we
have
ranges
and
uses
precise
estimates where
available.
Program setup & fixed administrative costs are
those outlined
in
the fiscal note
incurred directly by
the Department of Health, screening costs are
the costs
to
the government
through Medicaid/CHIP
for
the proportion of screening costs expected
to be publicly
funded, and antiviral
treatment and monitoring
tests are
likewise
those
incurred only by
the
patients who
are
publicly
funded
and
elect
to
undergo
those
procedures.
This model
assumes
one
child
covered
by Medicaid/CHIP
and
diagnosed with
CMV-related
sensorineural
hearing
loss
each
year,
that
child
takes
antivirals,
and
s/he would
have
needed
cochlear
implants without
the
intervention.
A.
Bergevin
et al.
/
International
Journal
of
Pediatric Otorhinolaryngology
79
(2015)
2090–2093
117