Cost-Effectiveness of Latent Tuberculosis Screening Before Steroid Therapy for Idiopathic Nephrotic Syndrome in Children
Division of Nephrology, The Children's Hospital of Philadelphia, Philadelphia, PA.American Journal of Kidney Diseases (Impact Factor: 5.9). 07/2012; 61(1). DOI: 10.1053/j.ajkd.2012.06.004
BACKGROUND: Guidelines differ on screening recommendations for latent tuberculosis infection (LTBI) prior to immunosuppressive therapy. We aimed to determine the most cost-effective LTBI screening strategy before long-term steroid therapy in a child with new-onset idiopathic nephrotic syndrome. STUDY DESIGN: Markov state-transition model. SETTING & POPULATION: 5-year-old boy with new-onset idiopathic nephrotic syndrome. MODEL, PERSPECTIVE, & TIMEFRAME: The Markov model took a societal perspective over a lifetime horizon. INTERVENTION: 3 strategies were compared: universal tuberculin skin testing (TST), targeted screening using a risk-factor questionnaire, and no screening. A secondary model included the newer interferon γ release assays (IGRAs), requiring only one visit and having greater specificity than TST. OUTCOMES: Marginal cost-effectiveness ratios (2010 US dollars) with effectiveness measured as quality-adjusted life-years (QALYs). RESULTS: At an LTBI prevalence of 1.1% (the average US childhood prevalence in our base case), a no-screening strategy dominated ($2,201; 29.3356 QALYs) targeted screening ($2,218; 29.3356 QALYs) and universal TST ($2,481; 29.3347 QALYs). At a prevalence >10.3%, targeted screening with a risk-factor questionnaire was the most cost-effective option. Higher than a prevalence of 58.5%, universal TST was preferred. In the secondary model, targeted screening with a questionnaire followed by IGRA testing was cost-effective compared with no screening in the base case when the LTBI prevalence was >4.9%. LIMITATIONS: There is no established gold standard for the diagnosis of LTBI. Results of any modeling task are limited by the accuracy of available data. CONCLUSIONS: Prior to starting steroid therapy, only patients in areas with a high prevalence of LTBI will benefit from universal TST. As more evidence becomes available about the use of IGRA testing in children, the assay may become a component of cost-effective screening protocols in populations with a higher burden of LTBI.
- American Journal of Kidney Diseases 01/2013; 61(1):3-5. DOI:10.1053/j.ajkd.2012.10.003 · 5.90 Impact Factor
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ABSTRACT: Bu çalışmada kullanılan hasta verilerinin bir kısmı, 4. Ulusal Viroloji Kongresi (23-26 Haziran 2011, İstanbul)'nde sunulmuştur. ÖZET Primer BK virus (BKV) enfeksiyonları genellikle erken çocukluk döneminde kazanılmakta ve asempto-matik olarak geçirilmektedir. Dünyadaki erişkin popülasyonlarda BKV seroprevalansı %90'a kadar ulaşa-bilir. Primer enfeksiyondan sonra virus ürogenital sistemde latent olarak kalmaktadır. Renal transplant alı-cılarında, BKV'nin neden olduğu primer enfeksiyonlar ve reaktivasyonlar, hastaların %10'unu etkileyebil-mekte ve önlem alınmadığı taktirde bu hastaların yarısından fazlası BKV nefropatisi (BKVN) nedeniyle böbreklerini kaybetmektedir. BKVN'ye bağlı greft kaybını engellemenin tek yolu, transplantasyon sonra-sında BK virus enfeksiyonlarının takibi ve BKVN geliştiren hastaların erken dönemde tanınıp etkin bir bi-çimde tedavi edilmeleridir. Bu çalışmada, pediatrik renal transplant alıcılarında, transplantasyon sonrası dönemde, idrar ve plazma örneklerinden, gerçek zamanlı polimeraz zincir reaksiyonu (rtPCR) ile BKV en-Geliş Tarihi (Received): 25.01.2013 • Kabul Ediliş Tarihi (Accepted): 20.03.2013 Özgün Çalışma/Original Article İletişim (Correspondence): Prof. Dr. Dilek Çolak, Akdeniz Üniversitesi Tıp Fakültesi, Tıbbi Mikrobiyoloji Anabilim Dalı, Viroloji Bilim Dalı, 07070, Arapsuyu, Antalya, Türkiye. Tel (Phone): +90 242 249 6405, E-posta (E-mail): email@example.com Mikrobiyol Bul 2013; 47(3): 461-471Mikrobiyoloji bülteni 01/2013; 47(3):461. · 0.65 Impact Factor
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ABSTRACT: In the United States, more than 10% of national health expenditures are for prescription drugs. Assessing drug costs in US economic evaluation studies is not consistent, as the true acquisition cost of a drug is not known by decision modelers. Current US practice focuses on identifying one reasonable drug cost and imposing some distributional assumption to assess uncertainty. We propose a set of Rules based on current pharmacy practice that account for the heterogeneity of drug product costs. The set of products derived from our Rules, and their associated costs, form an empirical distribution that can be used for more realistic sensitivity analyses and create transparency in drug cost parameter computation. The Rules specify an algorithmic process to select clinically equivalent drug products that reduce pill burden, use an appropriate package size, and assume uniform weighting of substitutable products. Three diverse examples show derived empirical distributions and are compared with previously reported cost estimates. The shapes of the empirical distributions among the 3 drugs differ dramatically, including multiple modes and different variation. Previously published estimates differed from the means of the empirical distributions. Published ranges for sensitivity analyses did not cover the ranges of the empirical distributions. In one example using lisinopril, the empirical mean cost of substitutable products was $444 (range = $23-$953) as compared with a published estimate of $305 (range = $51-$523). Our Rules create a simple and transparent approach to creating cost estimates of drug products and assessing their variability. The approach is easily modified to include a subset of, or different weighting for, substitutable products. The derived empirical distribution is easily incorporated into 1-way or probabilistic sensitivity analyses. © The Author(s) 2014.Medical Decision Making 12/2014; 35(5). DOI:10.1177/0272989X14563987 · 3.24 Impact Factor
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