Cost-Effectiveness of Latent Tuberculosis Screening Before Steroid Therapy for Idiopathic Nephrotic Syndrome in Children

ArticleinAmerican Journal of Kidney Diseases 61(1) · July 2012with14 Reads
DOI: 10.1053/j.ajkd.2012.06.004 · Source: PubMed
Abstract
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.
    • "This might have been a result of a paucity of information in the literature. Most models [9e16] used published sources to obtain or derive an estimate of the prevalence of LTBI, but some studies [9,11,13,15] have not elaborated on what the prevalence represents (e.g. prevalence of LTBI in contact tracing, prevalence of LTBI based on occasional screening in the population of interest or prevalence of LTBI that would develop to active TB). "
    [Show abstract] [Hide abstract] ABSTRACT: Timely diagnosis and treatment of latent tuberculosis infection (LTBI) through screening remains a key public health priority. Although globally it is recommended to screen people at high risk of developing TB, the economic evidence underpinning these recommendations is limited. This review critically appraised studies that had used a decision-analytical modelling framework to estimate the cost-effectiveness of interferon gamma release assays (IGRAs) compared to tuberculin skin test (TST) for detecting LTBI in high risk populations.
    Full-text · Article · Apr 2016 · American Journal of Kidney Diseases
    • "However, no reference was provided for the basic estimate of 9 % LTBI prevalence as base-case assumption, and, in view of the lower specificity of the TST, it remains unclear why IGRA screening should be used after and not prior to performing a CXR examination. Laskin et al. [43] investigated the cost effectiveness of screening treating 5-year-old children with new-onset idiopathic nephrotic syndrome prior to starting Preventive Treatment for TB in High-Risk Populations "
    [Show abstract] [Hide abstract] ABSTRACT: In view of the goal of eliminating tuberculosis (TB) by 2050, economic evaluations of interventions against the development of TB are increasingly requested. Little research has been published on the incremental cost effectiveness of preventative therapy (PT) in groups at high risk for progression from latent TB infection (LTBI) with Mycobacterium TB (MTB) to active disease. A systematic review of studies with a primary focus on model-driving inputs and methodological differences was conducted. A search of MEDLINE, the Cochrane Library and EMBASE to July 2014 was undertaken, and reference lists of eligible articles and relevant reviews were examined. A total of 876 citations were retrieved, with a total of 24 studies being eligible for inclusion, addressing six high-risk groups other than contact persons. Results varied considerably between studies and countries, and also over time. Although the selected studies generally demonstrated cost effectiveness for PT in HIV-infected subjects and healthcare workers (HCWs), the outcome of these analyses can be questioned in light of recent epidemiologic data. For immigrants from high TB-burden countries, patients with end-stage renal disease, and the immunosuppressed, now defined as further vulnerable groups, no consistent recommendation can be taken from the literature with respect to cost effectiveness of screening and treating LTBI. When the concept of a fixed willingness-to-pay (WTP) threshold as a prerequisite for final categorization was used, the sums ranged between 'no specification' and US$100,000 per quality-adjusted life-year. To date, incremental cost-effectiveness analyses on PT in groups at high risk for TB progression, other than contacts, are surprisingly scarce. The variation found between studies likely reflects variations in the major epidemiologic factors, particularly in the estimates on the accuracy of the tuberculin skin test (TST) and interferon-gamma release assays (IGRA) as screening methods used before considering PT. Further research, including explicit evaluation of local epidemiological conditions, test accuracy, and methodology of WTP thresholds, is needed.
    Full-text · Article · Mar 2015
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