Systematic review of atropine cost-effectiveness in childhood myopia management

BACKGROUND: Childhood myopia is a global public health concern, with rising prevalence and a significant economic burden due to complications like retinal detachment and macular degeneration. Low-dose atropine (LDA) range 0.01%-0.05% is a clinically effective intervention for slowing myopia progression. However, its economic value remains under-evaluated across diverse settings.

METHODS AND FINDINGS: We conducted a systematic review following PRISMA guidelines and registered in PROSPERO (CRD420251009680) to assess the cost-effectiveness of atropine for myopia management in children. Four model-based economic evaluations met the inclusion criteria, from Hong Kong, New Zealand, Australia/China and France/United Kingdom. Two studies used Markov cohort state-transition models while two employed a cohort decision-analytic model with probabilistic simulation of refractive outcomes. All four economic evaluations adopted a societal perspective; each applied a 3% annual discount rate to costs in their analyses and reported sensitivity analyses around discounting. Time horizons ranged from 5 years for incident myopia to lifetime horizons capturing myopia complications and vision impairment. Across economic models, LDA was consistently found to be cost-effective or cost-saving compared with standard care. Reported incremental cost-effectiveness ratios (ICERs) included approximately NZ$1,590 per quality-adjusted life year (QALY) gained in a New Zealand Markov cost-utility model, and USD 220-275 per diopter spherical equivalent reduction in a 5-year Hong Kong cost-effectiveness analysis. Evidence from high- and middle-income settings indicates that low-dose atropine is a cost-effective strategy, particularly when long-term progression to high myopia and its associated complications is considered. In European settings, low-dose atropine demonstrated a favorable cost profile compared with standard correction in children at higher risk of myopia progression, with consistent findings of cost-neutrality or cost savings when downstream costs of high myopia were included.

CONCLUSION: Studies demonstrate favourable economic value using diverse metrics, including cost per diopter reduction, cost ratios, and cost-utility estimates, rather than uniformly reported ICERs. Greater economic benefits are observed over longer time horizons, largely driven by the avoidance of high myopia-related complications and associated costs.

SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251009680, identifier PROSPERO CRD420251009680.