Author (Country; Year) | Alternatives | Data source | EE Type | Perspective | Model Horizon Discount rate | Cost | Cost description | Differential Costs | ICER | Conclusion |
---|---|---|---|---|---|---|---|---|---|---|
Dasgupta et al. (Canada; 2000) [19] | 1. Screening (medical evaluation, CXR); | Administrative data bases | CEA | Health care payer | Markov 20 years | Direct | CXR, clinic visits, investigations, hospitalization, drugs, physicians’ and pharmacists’ fees, administrative activities. | • TB case detected: CAN$ 31,418; prevented: CAN$ 73,125; | Close-contact investigation was highly cost-effective and resulted in net savings. Immigrant applicant screening and surveillance programs had a significant impact but were much less cost-effective, in large part because of substantial operational problems. Radiographic screening of newly arriving foreign-born populations for TB could be cost-effective and have considerable individual and public health benefits. | |
• CAN$ 55,728; CAN$ 155,729; | ||||||||||
2. Surveillance of inactive TB, including LTBI treatment; | ||||||||||
• CAN$ 10,275; CAN$ 29,668. | ||||||||||
3. Close-contact investigation | ||||||||||
Khan et al. (USA; 2002) [18] | 1. No LTBI screening; | Data bases | CEA, CUA | Societal | Markov Lifetime 3.00% | Health Direct | Transportation, ambulatory care, services of interpreters, laboratory tests, medications, adverse drug reactions, hospitalization, and patients’ time. | Total savings: US$60 to US$90 million, assuming to avert 9–10 thousand TB infections per year. | CEA | Results variable according to country of origin. |
• TST followed by INH: savings or dominated, depending on regions. | ||||||||||
2. TST followed by INH; | Indirect | A strategy of detecting and treating LTBI was cost-saving among immigrants from Mexico, Haiti, sub-Saharan Africa, South Asia, and developing nations in East Asia and the Pacific. | ||||||||
• TST followed RIF: dominant. | ||||||||||
4. TST followed by RIF plus PZM. | • TST followed RIF plus PZM: saving or cost/effective (US$2,551 - US$149,978 per future case averted), depending on regions. | |||||||||
3. TST followed by RIF; | ||||||||||
per QALY | Screening was highly cost-effective among immigrants from other developing nations. RIF-PZM was the preferred treatment for treating LTBI in immigrants from Vietnam, Haiti, and the Philippines. | |||||||||
• TST followed by INH: savings, US$914 - US$5,952, or dominated depending on regions. | ||||||||||
• TST followed by RIF: dominant. | ||||||||||
• TST followed by RIF plus PZM: savings, or US$1,276 - US$53,388, depending on regions. | ||||||||||
Brassard et al. (Canada; 2006) [17] | 1. LTBI school-screening program in newly arrived immigrant children (TST followed by INH); | Clinical trialc | CBA | Health care payer | No | Health Direct | Total material and labor costs associated with the school-screening program and the associate investigations for children and associates. | Total savings: CAN$ 363,923. | The school-based LTBI-screening program was found to be cost-effective. | |
Without associate investigation: CAN$ 268,393. | ||||||||||
Savings were mainly due to hospitalization costs. | ||||||||||
2. Active TB management through passive case finding. | ||||||||||
Porco et al. (USA; 2006) [20] | 1. Follow-up of TB-notification patients, including LTBI treatment for latently infected individuals; | Published literature, administrative data bases | CEA, CUA | Health care payer | Markov 20 years 3.00% | Direct | Diagnostic tests, nursing assessments and doctor visits, drugs, side effects, hospitalizations. | The program yielded 7.7 net QALYs, US$ 25,000 in net savings, and prevented 4 cases of TB. | Treatment of TB4s was cost-saving. | Domestic follow up is highly cost-effective as early detection and treatment reduces the rate of hospitalization. |
Treatment of TB2s was highly cost-effective: US$4,400 per QALY and US$4,700 per case prevented. | ||||||||||
2. No follow-up. | ||||||||||
Oxlade O et al. (Canada;2007) [11] | 1. CXR; | Published literature, administrative data bases | CEA | Societal | Markov | Health Direct | All government and health system costs, patients’ out-of-pocket expenditures, but not TB-related death or disability. | Savings only in high-very high risk populations: | CXR - the least costly ICER per case prevented: CAN$ 875 for immigrants from high-incidence TB up to CAN$ 2.2 million from low incidence. | Screening with CXR would be the most and QFT the least cost-effective. |
2. TST; | 20 years | |||||||||
3. QFT; | 3.00% | |||||||||
4. TST+QTF; | • CXR - CAN$ 44,710; CAN$ 65,490; | Screening for LTBI, with TST or QFT, is cost-effective only if the risk of disease is high. The most cost-effective use of QFT is to test TST-positive persons. | ||||||||
5. No screening. | QFT - the most expensive: CAN$62,643 up to CAN$1,122,200. | |||||||||
• TST - CAN$ 136260; CAN$ 476320; | ||||||||||
TST - better than QFT with saving up to CAN$35,000 compared to QFT, but in populations BCG-vaccinated after infancy, where TST more expensive because of low specificity. | ||||||||||
Three scenarios: | • QFT - CAN$ 100,490; CAN$ 440,550. | |||||||||
Screening with TST or QFT was much more cost-effective in contacts than entering immigrants. | ||||||||||
a) immigration entry screening; | ||||||||||
However, the selection of screening strategy is less important than program performance. Programs considering these new ex vivo tests for LTBI should thus first ensure that a high proportion of those with positive tests will be medically evaluated, prescribed and complete therapy. | ||||||||||
b) close or | ||||||||||
c) casual contacts. | ||||||||||
Hardy et al. (UK; 2010) [21] | 1. NICE guidance 2006; | Clinical trialc | CEA | Health care payer | No | Health Direct | Cost per case LTBI identified | Cost per case identified: | QFT-first protocol can be carried out more cheaply than a CXR-first protocol, with a cost-saving of about 35% (£67.65) compared to NICE protocol. This saving is due to the reduced number of CXRs required. | |
• NICE protocol: £160.81; | ||||||||||
• Leed protocol: £93.16. | ||||||||||
2. Leeds protocol: QTF first in immigrants from countries with TB incidence >200/105 followed by CXR (all ages, but mean age was 30.8 year). | ||||||||||
Linas et al. (USA; 2011) [23] | 1. TST; | Published literature | CEA, CUA | Health care payer | Markov Lifetime 3.00% | Health Direct | Nursing and physician visits, diagnostic tests, medications, hospitalizations, contact tracing, and directly observed therapy. | • Individuals at highest risk of TB reactivation (close contacts and HIV-infected) - ICER of IGRA compared to TST was <$100,000/QALY gained. | In foreign-born subjects IGRA was cost-saving compared to TST and cost-effective compared to no screening. | |
2. IGRA; | ||||||||||
3. No LTBI screening. | ||||||||||
Risk-groupsa | ||||||||||
• The foreign-born - IGRA was cost-saving compared to TST and cost-effective compared to no screening (ICER <$100,000/ QALY gained). | ||||||||||
• Vulnerable populations (homeless, drug user, former prisoner) - ICER of TST screening was approximately $100,000-$150,000/QALY gained, but IGRA was not cost-effective. | ||||||||||
• Medical co-morbidities (diabetes and others) - ICER of screening with TST or IGRA was >$100,000/QALY. | ||||||||||
Pareek et al. (UK; 2011) [15] | 1. QFT; | Clinical trialc | CEA | Government health care payer | Markov 20 years 3.50% | Direct | UK NICE TB guidelines | Screening of immigrants from any countries irrespective of tuberculosis incidence would cost: | • Screen immigrants aged 16–35 years from countries with incidences/105 | Screening for latent infection can be implemented cost-effectively at a level of incidence that identifies most immigrants with latent tuberculosis, thereby preventing substantial numbers of future cases of active tuberculosis. |
2. NICE guidance 2006b. | ||||||||||
• QFT more than £1.5 million and prevent 44.5 cases of tuberculosis; | ≥250/105: £ 17,956 per case averted; ≥ 150/105: £ 20,819; ≥40/105: £ 29,403. | |||||||||
Screen immigrants aged ≤35 years irrespective of TB incidence: £ 101,938. | ||||||||||
• NICE guidance ≈£850,000 and prevent 13.2 cases. | ||||||||||
Pareek et al. (UK; 2012) [16] | 1. TST+ in <35y old immigrants; | Clinical trialc | CEA | Government health care payer | Markov 20 years | Direct | Current UK national guidance associated with additional costs of between £594,957 and £1,530,303 over 20 years. | • QFN (single): £21,565 - £34,754 per TB case averted. | Mandatory CXR on arrival could be safely eliminated in order to improve screening cost-effectiveness with single-step QTF at incidence threshold >250/105 per year. | |
• CXR plus single QFN: £59,489. | ||||||||||
2. QTF+ in <35y old immigrants; | • CXR plus single T.SPOT.TB: £402,422. | |||||||||
3. T-SPOT+ in <35y old immigrants. | ||||||||||
All with or without CXR port of entry. | ||||||||||
Iqbal et al. (USA, 2014) [22] | 1. QFT; | Administrative data base (2007) | CEA | Government health care payer | Decision model | Health Direct | Screening, CXR, Treatments, lab tests and diagnostics, physicians’ and staff time. | Total screening cost: TST US$38; QFT-G US$74 | Differential costs for screening and follow-up for subjects who were estimated to be test positive on 1,000 latent TB infections | QFT is cost-effective especially for high-risk populations such as foreign-born individuals. |
2. TST. | ||||||||||
Key assumption. | ||||||||||
False positive rates: | • U.S. born | |||||||||
• U.S. born | QFT: +US$25,037 vs. TST. | |||||||||
TST 66%; QFT 40% | • Foreign born | |||||||||
Treatment duration: 9 months | QFT: −US$135,946. | |||||||||
• Foreign born | ||||||||||
TST 69%; QFT 18% | ||||||||||
Treatment duration: 9 months |