Screening and Treatment of Latent Tuberculosis Among Healthcare Workers at Low, Moderate, and High Risk for Tuberculosis Exposure: A Cost-Effectiveness Analysis

Salpeter, Shelley R.; Salpeter, E. E.

doi:10.1086/502343

Cited by 19 publications

(13 citation statements)

References 35 publications

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“…Previous cost-effectiveness methodologies for LTBI screening and treatment have used iterative Markov processes to examine the overall costs to the healthcare system over periods of 15-20 yrs [22][23][24][25][26][27][28], and have included the costs of TB reactivation and drug side-effects, with or without including the costs of loss of quality-of-life and the costs of wider TB transmission. The present authors chose instead to focus only on direct costs over a much shorter time period, for a number of reasons.…”

Section: Discussionmentioning

confidence: 99%

Direct costs of three models for the screening of latent tuberculosis infection

Wrighton-Smith

Jp²

2006

Eur Respir J

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The aim of the present study was to compare the direct costs of three models for detection of latent tuberculosis infection (LTBI) in routine clinical practice in Switzerland.Comparison of the overall costs of screening for LTBI, including medical and radiological examination, and preventive treatment associated with three screening models was carried out. Model 1 relies only on the tuberculin skin test (TST) according to the current national guidelines, model 2 relies on T-SPOT1.TB (Oxford Immunotec, Oxford, UK) only and model 3 relies on TST followed by confirmation of positive results by T-SPOT.TB. Costs were taken directly from the clinic's figures. Clinical assumptions were based on the 267 patients who were referred to the clinic over the study period.Model 3 was found to be the most cost-effective. Using only the skin test (model 1) was the least cost-effective. If only one test for LTBI is to be used, then model 2 (using T-SPOT.TB only) is cheaper than using the TST (model 1).Screening for latent tuberculosis infection by tuberculin skin test followed by confirmation with T-SPOT.TB is less costly than screening with tuberculin skin test alone, as it allows a reduction in the number of people who receive preventive treatment. In groups with a high proportion of negative tuberculin skin tests, screening with T-SPOT.TB test only may be the most cost-effective.

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Section: Discussionmentioning

confidence: 99%

Direct costs of three models for the screening of latent tuberculosis infection

Wrighton-Smith

Jp²

2006

Eur Respir J

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“…cough-inducing procedures, myobacteriology or pathology laboratory work [16]. They were assumed to have a 4.4% annual probability of exposure to contagious TB, corresponding to the ‘moderate-risk’ group described by Salpeter et al in 2004 [17], and reflecting more recent incidence data reported by Lambert et al in 2012 [12]. In the alternate scenario, they were assumed to have a 13.1% annual probability of exposure, corresponding to the ‘high-risk’ group described by Salpeter et al [17, 18].…”

Section: Methodsmentioning

confidence: 99%

“…general patient care, with a 1.3% annual risk of significant exposure, corresponding to Salpeter’s ‘low-risk’ group [12, 17]; in the alternate scenario, the risk of exposure for intermediate-risk workers was increased to 4.4%, corresponding to Salpeter’s ‘moderate-risk’ group [17]. After exposure to a contagious TB patient, workers had a 22.9% probability of becoming infected [18].…”

Section: Methodsmentioning

confidence: 99%

Revisiting annual screening for latent tuberculosis infection in healthcare workers: a cost-effectiveness analysis

Mullie

Schwartzman

Zwerling

et al. 2017

BMC Med

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BackgroundIn North America, tuberculosis incidence is now very low and risk to healthcare workers has fallen. Indeed, recent cohort data question routine annual tuberculosis screening in this context. We compared the cost-effectiveness of three potential strategies for ongoing screening of North American healthcare workers at risk of exposure. The analysis did not evaluate the cost-effectiveness of screening at hiring, and considered only workers with negative baseline tests.MethodsA decision analysis model simulated a hypothetical cohort of 1000 workers following negative baseline tests, considering duties, tuberculosis exposure, testing and treatment. Two tests were modelled, the tuberculin skin test (TST) and QuantiFERON®-TB-Gold In-Tube (QFT). Three screening strategies were compared: (1) annual screening, where workers were tested yearly; (2) targeted screening, where workers with high-risk duties (e.g. respiratory therapy) were tested yearly and other workers only after recognised exposure; and (3) post exposure-only screening, where all workers were tested only after recognised exposure. Workers with high-risk duties had 1% annual risk of infection, while workers with standard patient care duties had 0.3%. In an alternate higher-risk scenario, the corresponding annual risks of infection were 3% and 1%, respectively. We projected costs, morbidity, quality-adjusted survival and mortality over 20 years after hiring. The analysis used the healthcare system perspective and a 3% annual discount rate.ResultsOver 20 years, annual screening with TST yielded an expected 2.68 active tuberculosis cases/1000 workers, versus 2.83 for targeted screening and 3.03 for post-exposure screening only. In all cases, annual screening was associated with poorer quality-adjusted survival, i.e. lost quality-adjusted life years, compared to targeted or post-exposure screening only. The annual TST screening strategy yielded an incremental cost estimate of $1,717,539 per additional case prevented versus targeted TST screening, which in turn cost an incremental $426,678 per additional case prevented versus post-exposure TST screening only. With the alternate “higher-risk” scenario, the annual TST strategy cost an estimated $426,678 per additional case prevented versus the targeted TST strategy, which cost an estimated $52,552 per additional case prevented versus post-exposure TST screening only. In all cases, QFT was more expensive than TST, with no or limited added benefit. Sensitivity analysis suggested that, even with limited exposure recognition, annual screening was poorly cost-effective.ConclusionsFor most North American healthcare workers, annual tuberculosis screening appears poorly cost-effective. Reconsideration of screening practices is warranted.

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“…Yet, TST is the only test for which the risk of developing active TB in persons with a positive result has been well defined [7][8][9]. Recently, interferon gamma release assays (IGRAs) have been increasingly used for LTBI screening.…”

Section: Introductionmentioning

confidence: 99%