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Cost-effectiveness of screening strategies for gonorrhea among females in private sector care |
Bernstein K T, Mehta S D, Rompalo A M, Erbelding E J |
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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. CRD summary This study investigated the most cost-effective strategy for gonorrhoea infection screening using urine nucleic acid amplification testing among females 15 to 35 years old in private sector care. The most cost-effective screening strategy was that for women under 25 years old, with specific risk factors, but this was cost-saving only at a prevalence of 4.75% or greater. The study was generally well conducted although the sources of data were not extensively described. The authors’ conclusions appear to be valid. Type of economic evaluation Cost-effectiveness analysis Study objective The objective was to determine the most cost-effective strategy for gonorrhoea infection screening with urine nucleic acid amplification testing (NAATS) among asymptomatic females aged 15 to 35 years in the private sector care. Interventions Six screening strategies for gonorrhoea were examined.
Strategy one was to screen women under 25 years old. Strategy two was to screen women under 30 years old. Strategy three was to screen women under 25 years old, who also reported a risk factor such as pregnancy, drug use, or new sexual partner in the last 30 days. Strategy four was to screen women under 30 years old, who also reported any risk. Strategy five was to screen women under 25 years old, or those who reported any risk. Strategy six was to screen women under 30 years old, or those who reported any risk.
These screening strategies were compared with a background no-screening option. Location/setting USA/private medical clinic. Methods Analytical approach:This economic evaluation was based on a decision analytic model which compared the six screening strategies with no screening. The time horizon was 10 years and the authors did not report their perspective.
Effectiveness data:The clinical data were derived from a selection of known, relevant studies. The characteristics of the eligible population, the prevalence of gonorrhoea and the accuracy of screening were obtained from a retrospective cohort of women attending the Baltimore City Sexually Transmitted Disease Clinics between 1999 and 2002 (more than 20,000 cases). The data on the risk of consequences of untreated gonorrhoea (e.g. pelvic inflammatory disease) came from published studies, the details of which were not given.
Monetary benefit and utility valuations:None.
Measure of benefit:The summary benefit measure was the number of cases treated.
Cost data:The analysis of costs included the following items: screening, drugs for gonorrhoea treatment (including the management of treatment-related adverse events), and health services associated with untreated infections (pelvic inflammatory disease, chronic pelvic pain, tubal infertility, and ectopic pregnancy for women, and acute urethritis and epididymitis for their male partners). The costs and quantities were derived from published sources, the details of which were not given, or Medicare reimbursement rates. All costs were in US dollars ($) and the price year was 2003. Future costs associated with disease-related sequelae were discounted at an annual rate of 3%.
Analysis of uncertainty:A deterministic univariate sensitivity analysis was carried out using minimum and maximum values for the costs. Threshold analyses were also performed to identify for certain parameters, the values at which the cost-effectiveness results might change. Results At a gonorrhoea prevalence of 3% in a cohort of 10,000 women, the total costs were $254,304 with no screening, $391,962 with strategy one, $448,740 with strategy two, $302,490 with strategy three, $325,348 with strategy four, $442,396 with strategy five, and $476,235 with strategy six.
The incremental number of cases treated, over the next most effective strategy, were 90 with strategy three over no screening, 15 with strategy four over strategy three, 67 for strategy one over strategy four, 29 for strategy five over strategy one, 4 for strategy two over strategy five, and 13 for strategy six over strategy two.
The incremental cost per treated case was $535.40 with strategy three over no screening, $1,523.87 with strategy four over strategy three, $994.24 with strategy one over strategy four, $1,739.10 with strategy five over strategy one, $1,586 with strategy two over strategy five, and $2,114 with strategy six over strategy two. Thus, strategy three was associated with the lowest incremental cost per case treated.
Variations in the costs suggested that, only increasing the cost of sequelae, made strategy three cost-saving over no screening. The threshold analysis indicated that that strategy three became cost-saving when the prevalence of gonorrhoea in the population exceeded 4.75% or when the cost of NAATS was less than $26.50 ($42.90 in the base-case analysis). Authors' conclusions The authors concluded that the most cost-effective gonorrhoea infection screening strategy was that of screening women under 25 years old, with specific risk factors. However, only with a gonorrhoea prevalence of 4.75% or greater was this strategy cost-saving. CRD commentary Interventions:The selection of the comparators (no screening compared with alternative screening options) was appropriate as it covered a range of possible screening strategies.
Effectiveness/benefits:The approach used to identify the sources of evidence was not described, and the primary studies may have been selected rather than identified through a systematic literature review. The data on test accuracy were obtained from a very large retrospective study, performed in private medical clinics, which represented this setting. This study was also used for the prevalence data, which may not have represented the prevalence of gonorrhoea in US women enrolled in other settings. The authors did not provide information regarding the design and other features of the other primary sources of data, which makes it difficult to judge the validity of the clinical evidence. The benefit measure is specific to this disease and is not comparable with the benefits of other health care interventions.
Costs:The economic viewpoint was not explicitly stated, but only health care costs appear to have been included. The costs were presented as macro-categories, which were not broken down into individual items. The unit costs and resource quantities were not presented separately, although some unit costs were reported. The sources of economic data were reported but not described, except for Medicaid. The price year and the use of discounting were reported.
Analysis and results:The costs and benefits were appropriately combined using an incremental analysis. The issue of uncertainty was well addressed by means of a deterministic analysis, which focused on both individual and multiple model inputs. The results of both the base-case and the sensitivity analyses were clearly presented. The authors compared their results with those of other studies and provided possible explanations for differences in the findings. However, as a disease-specific measure was used and no commonly accepted threshold is available, it is hard to draw a conclusion regarding the optimal screening strategy.
Concluding remarks:The study was generally well conducted although the sources of data were not extensively described. The authors’ conclusions appear to be valid. Bibliographic details Bernstein K T, Mehta S D, Rompalo A M, Erbelding E J. Cost-effectiveness of screening strategies for gonorrhea among females in private sector care. Obstetrics and Gynecology 2006; 107(4): 813-821 Other publications of related interest Mehta SD, Bishai D, Howell MR, et al. Cost-effectiveness of five strategies for gonorrhea and chlamydia control among female and male emergency department patients. Sex Transm Dis 2002;29:83-91.
Kraut-Becher JR, Gift TL, Haddix AC, et al. Cost-effectiveness of universal screening for chlamydia and gonorrhea in US jails. J Urban Health 2004;81:453-71.
Howell MR, Kassler WJ, Haddix A. Partner notification to prevent pelvic inflammatory disease in women: cost-effectiveness of two strategies. Sex Transm Dis 1997;24:287-92. Indexing Status Subject indexing assigned by NLM MeSH Adolescent; Adult; Age Distribution; Analysis of Variance; Case-Control Studies; Cost-Benefit Analysis; Female; Gonorrhea /diagnosis /economics /epidemiology; Health Care Costs; Humans; Mass Screening /economics /methods; Prevalence; Private Practice /economics; Private Sector /economics; Probability; Risk Assessment; Sensitivity and Specificity; Severity of Illness Index; Sexually Transmitted Diseases /epidemiology /prevention & control AccessionNumber 22006001271 Date bibliographic record published 11/07/2006 Date abstract record published 29/04/2009 |
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