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The cost-effectiveness of HIV testing of physicians and dentists in the United States |
Phillips K A, Lowe R A, Kahn J G, Lurie P, Avins A L, Ciccarone D |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology Human immunodeficiency testing(HIV) testing of physicians and dentists.
Economic study type Cost-effectiveness analysis and cost-benefits analysis.
Study population Hypothetical cohort of physicians and dentists.
Setting Hospital or diagnostic centres. The economic study was carried out in the USA.
Dates to which data relate Effectiveness and resource data were mainly derived from studies published during the period 1989-1993. Price date was 1992.
Source of effectiveness data Data were derived from the literature.
Modelling A decision analysis model was used to assess costs and benefits.
Outcomes assessed in the review Main clinical data related to: percentage of HAWS tested; HIV seroprevalence in HAWs; sensitivity and specificity of the testing sequence; risk of transmission from HAWs to patients.
Study designs and other criteria for inclusion in the review National surveys, reports and other not specified studies.
Sources searched to identify primary studies Criteria used to ensure the validity of primary studies Data quality ranking was derived from the US Preventive Services Task Force.
Methods used to judge relevance and validity, and for extracting data Number of primary studies included A large unspecified number of studies was considered.
Methods of combining primary studies Where it would have been applicable, the method used was not specified.
Investigation of differences between primary studies Results of the review The main baseline effectiveness data used were: 41% of physicians and dentists underwent voluntary testing; HIV seroprevalence in HAWS was 0.4%; test sensitivity and specificity were estimated to be 99% and 99.9% respectively. The estimated risk of the transmission to patients was calculated to be 0.00002 from surgeons, and 0.000002 from dentists.
Measure of benefits used in the economic analysis HIV infections averted and monetary benefits, calculated converting into dollars the value of patient cases averted using a valuation of life approach.
Direct costs A societal perspective was used. Estimates of costs were derived from the literature. Costs included laboratory and counselling costs (test kit, personnel, fringe benefits, overhead); medical care costs averted due to the patients' infections avoided. Costs were reflated to 1992 using the medical consumer price index. A decision analysis model was used to calculate final costs. A 5% discount rate was used.
Indirect Costs HCW's lost productivity due to mandatory practice changes. No other details were given.
Sensitivity analysis A sensitivity analysis was carried out on costs and other relevant model data input. The methods used was not specified, but it seems that the analysis of extremes was applied.
Estimated benefits used in the economic analysis Under a medium seroprevalence and transmission risk scenario for surgeons, the number of patient infections averted would be 9.6, 20.8, 25 and 26.1 for increased voluntary testing, mandatory testing with informed patients, mandatory with restriction of practice, mandatory testing of all physicians with exclusion. For the same options, the results for dentists were 6.6, 13.3, 17.7, 18.4 respectively.
Cost results For surgeons, at baseline conditions, the total costs (in millions) for increased voluntary testing, mandatory testing with informed patients, mandatory with restriction of practice, mandatory testing of all physicians with exclusion were $28.1, $28.4, $27.9 and $27.8 respectively. If the same options were costed for dentists, the results would have been $12.9, $13.8, $13.3 and $13.2 respectively.
Synthesis of costs and benefits At baseline conditions, for surgeons, the cost per infection averted (in parenthesis the incremental cost per infection averted compared with current testing) for increased voluntary testing, mandatory testing with informed patients, mandatory testing with restriction of practice, and mandatory testing of all physicians with exclusion were $2,931,000 ($1,208,000), $1,361,000 ($395,000), $1,115,000 ($291,000), and $1,065,000 ($271,000) respectively. At baseline conditions, if the same options were costed for dentists, the results would have been $1,957,000 ($1,957,000), $1,040,000 ($768,000), $750,000 ($500,000), and $716,000 ($471,000) respectively. The cost-benefit analysis showed that the benefits of mandatory testing of surgeons exceeded the costs when the value of one patient infection averted was greater than $271,000. This threshold increased to $471,000 for dentists. When the lost productivity value due to exclusion of surgeons from practice was considered, the value of one patient averted would have to exceed $43 million for the benefits of testing to exceed the costs. For dentists, this threshold value dropped to $28 million. Results were very sensitive to seroprevalence and transmission risk: the incremental cost-effectiveness ratio ranged from a saving of $81,000 under a scenario of high prevalence and high transmission risk for surgeons, to a maximum of $447,062,000 under a scenario of low prevalence and low transmission risk for dentists. Moreover, sensitivity analysis on various parameters, showed that mandatory testing is more cost-effective if specificity rate is high, the decrease in patient exposures following mandatory restriction is high, the cost of a negative test is low, treatment costs for HIV-positive HAWS are low.
Authors' conclusions The authors stated that on the basis of their analysis, in which there is uncertainty and incomplete data about the main variables of the model, it was not possible to reach any definitive conclusions regarding the cost-effectiveness of mandatory testing policies.
CRD Commentary This is a good and very detailed exercise. As the authors themselves recognise, it represents a good start to informing adebate about the evaluation of policy options for preventing transmission of HIV infections from physicians to patients. The model used in this study was reported in a very clear way and an extensive sensitivity analysis was carried out.
Implications of the study Further research should be conducted for the collection of primary data.
Source of funding National Institute of Mental Health; Agency for Health Care Policy and Research.
Bibliographic details Phillips K A, Lowe R A, Kahn J G, Lurie P, Avins A L, Ciccarone D. The cost-effectiveness of HIV testing of physicians and dentists in the United States. JAMA 1994; 271(11): 851-858 Other publications of related interest Comment in: JAMA 1994;272(6):434-5.
Indexing Status Subject indexing assigned by NLM MeSH AIDS Serodiagnosis /economics /legislation & Cost-Benefit Analysis; Decision Support Techniques; Dentists /standards /statistics & Disclosure; Federal Government; HIV Infections /economics /prevention & HIV Seroprevalence; Health Policy /economics; Humans; Infectious Disease Transmission, Professional-to-Patient /economics /prevention & Physicians /standards /statistics & United States; Voluntary Programs; control; control /transmission; jurisprudence /standards; numerical data; numerical data AccessionNumber 21995005300 Date bibliographic record published 19/07/1996 Date abstract record published 19/07/1996 |
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