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Cost-effectiveness of Testing and Treatment for Latent Tuberculosis Infection in Residents Born Outside the United States With and Without Medical Comorbidities in a Simulation Model.
JAMA Intern Med. 2017 12 01; 177(12):1755-1764.JIM

Abstract

Importance

Testing for and treating latent tuberculosis infection (LTBI) is among the main strategies to achieve TB elimination in the United States. The best approach to testing among non-US born residents, particularly those with comorbid conditions, is uncertain.

Objective

To estimate health outcomes, costs, and cost-effectiveness of LTBI testing and treatment among non-US born residents with and without medical comorbidities.

Design, Setting, and Participants

Decision analytic tree and Markov cohort simulation model among non-US born residents with no comorbidities, with diabetes, with HIV infection, or with end-stage renal disease (ESRD) using a health care sector perspective with 3% annual discounting. Strategies compared included no testing, tuberculin skin test (TST), interferon gamma release assay (IGRA), confirm positive (initial TST, IGRA only for TST-positive results; both tests positive indicates LTBI), and confirm negative (initial IGRA, then TST for IGRA-negative; any test positive indicates LTBI). All strategies were coupled to treatment with 3 months of self-administered rifapentine and isoniazid.

Main Outcomes and Measures

Number needed to test and treat to prevent 1 case of TB reactivation, discounted quality-adjusted life-years (QALYs), discounted lifetime medical costs, and incremental cost-effectiveness ratios (ICERs).

Results

Improving health outcomes increased costs, with choice of test dependent on willingness to pay. Strategies ranked by ascending costs and benefits: no testing, confirm positive, TST, IGRA, and confirm negative. The ICERs varied by non-US born patient risk group: patients with no comorbidities, IGRA was likely cost-effective at $83 000/QALY; patients with diabetes, both confirm positive ($53 000/QALY) and IGRA ($120 000/QALY) were likely cost-effective; patients with HIV, confirm negative was clearly preferred ($63 000/QALY); and patients with ESRD, no testing was cost-effective. Increased LTBI prevalence and reduced return for TST reading improved IGRA's relative performance. In 10 000 probabilistic simulations among non-US born patients with no comorbidities, with diabetes, and with HIV, some form of testing was virtually always cost-effective. These simulations highlight the uncertainty of test choice for non-US born patients with no comorbidities and non-US born patients with diabetes, but strategies including IGRA were preferred in over 60% of simulations for all non-US born populations except those with ESRD.

Conclusions and Relevance

Testing for and treating LTBI among non-US born residents with and without selected comorbidities is likely cost-effective except among those with ESRD in whom competing risks of death limit benefits. Strategies including IGRA fell below a $100 000/QALY willingness-to-pay threshold for non-US born patients with no comorbidities, patients with diabetes, and patients with HIV.

Authors+Show Affiliations

HIV Epidemiology & Outcomes Unit, Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts.Harvard T. H. Chan School of Public Health, Boston, Massachusetts.Center for Evidence-Based Medicine, Brown University, Providence, Rhode Island.Boston University School of Public Health, Boston, Massachusetts.Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia.HIV Epidemiology & Outcomes Unit, Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts. Boston University School of Public Health, Boston, Massachusetts.

Pub Type(s)

Journal Article
Meta-Analysis
Research Support, U.S. Gov't, P.H.S.

Language

eng

PubMed ID

29049814

Citation

Tasillo, Abriana, et al. "Cost-effectiveness of Testing and Treatment for Latent Tuberculosis Infection in Residents Born Outside the United States With and Without Medical Comorbidities in a Simulation Model." JAMA Internal Medicine, vol. 177, no. 12, 2017, pp. 1755-1764.
Tasillo A, Salomon JA, Trikalinos TA, et al. Cost-effectiveness of Testing and Treatment for Latent Tuberculosis Infection in Residents Born Outside the United States With and Without Medical Comorbidities in a Simulation Model. JAMA Intern Med. 2017;177(12):1755-1764.
Tasillo, A., Salomon, J. A., Trikalinos, T. A., Horsburgh, C. R., Marks, S. M., & Linas, B. P. (2017). Cost-effectiveness of Testing and Treatment for Latent Tuberculosis Infection in Residents Born Outside the United States With and Without Medical Comorbidities in a Simulation Model. JAMA Internal Medicine, 177(12), 1755-1764. https://doi.org/10.1001/jamainternmed.2017.3941
Tasillo A, et al. Cost-effectiveness of Testing and Treatment for Latent Tuberculosis Infection in Residents Born Outside the United States With and Without Medical Comorbidities in a Simulation Model. JAMA Intern Med. 2017 12 1;177(12):1755-1764. PubMed PMID: 29049814.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Cost-effectiveness of Testing and Treatment for Latent Tuberculosis Infection in Residents Born Outside the United States With and Without Medical Comorbidities in a Simulation Model. AU - Tasillo,Abriana, AU - Salomon,Joshua A, AU - Trikalinos,Thomas A, AU - Horsburgh,C Robert,Jr AU - Marks,Suzanne M, AU - Linas,Benjamin P, PY - 2017/10/20/pubmed PY - 2017/12/9/medline PY - 2017/10/20/entrez SP - 1755 EP - 1764 JF - JAMA internal medicine JO - JAMA Intern Med VL - 177 IS - 12 N2 - Importance: Testing for and treating latent tuberculosis infection (LTBI) is among the main strategies to achieve TB elimination in the United States. The best approach to testing among non-US born residents, particularly those with comorbid conditions, is uncertain. Objective: To estimate health outcomes, costs, and cost-effectiveness of LTBI testing and treatment among non-US born residents with and without medical comorbidities. Design, Setting, and Participants: Decision analytic tree and Markov cohort simulation model among non-US born residents with no comorbidities, with diabetes, with HIV infection, or with end-stage renal disease (ESRD) using a health care sector perspective with 3% annual discounting. Strategies compared included no testing, tuberculin skin test (TST), interferon gamma release assay (IGRA), confirm positive (initial TST, IGRA only for TST-positive results; both tests positive indicates LTBI), and confirm negative (initial IGRA, then TST for IGRA-negative; any test positive indicates LTBI). All strategies were coupled to treatment with 3 months of self-administered rifapentine and isoniazid. Main Outcomes and Measures: Number needed to test and treat to prevent 1 case of TB reactivation, discounted quality-adjusted life-years (QALYs), discounted lifetime medical costs, and incremental cost-effectiveness ratios (ICERs). Results: Improving health outcomes increased costs, with choice of test dependent on willingness to pay. Strategies ranked by ascending costs and benefits: no testing, confirm positive, TST, IGRA, and confirm negative. The ICERs varied by non-US born patient risk group: patients with no comorbidities, IGRA was likely cost-effective at $83 000/QALY; patients with diabetes, both confirm positive ($53 000/QALY) and IGRA ($120 000/QALY) were likely cost-effective; patients with HIV, confirm negative was clearly preferred ($63 000/QALY); and patients with ESRD, no testing was cost-effective. Increased LTBI prevalence and reduced return for TST reading improved IGRA's relative performance. In 10 000 probabilistic simulations among non-US born patients with no comorbidities, with diabetes, and with HIV, some form of testing was virtually always cost-effective. These simulations highlight the uncertainty of test choice for non-US born patients with no comorbidities and non-US born patients with diabetes, but strategies including IGRA were preferred in over 60% of simulations for all non-US born populations except those with ESRD. Conclusions and Relevance: Testing for and treating LTBI among non-US born residents with and without selected comorbidities is likely cost-effective except among those with ESRD in whom competing risks of death limit benefits. Strategies including IGRA fell below a $100 000/QALY willingness-to-pay threshold for non-US born patients with no comorbidities, patients with diabetes, and patients with HIV. SN - 2168-6114 UR - https://www.unboundmedicine.com/medline/citation/29049814/Cost_effectiveness_of_Testing_and_Treatment_for_Latent_Tuberculosis_Infection_in_Residents_Born_Outside_the_United_States_With_and_Without_Medical_Comorbidities_in_a_Simulation_Model_ L2 - https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/10.1001/jamainternmed.2017.3941 DB - PRIME DP - Unbound Medicine ER -