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
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
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DOI：
10.1001/jamainternmed.2017.3941
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发表时间：
2017-12-01
影响因子：
39
通讯作者：
Linas, Benjamin P.
中科院分区：
文献类型：
--
作者：
Tasillo, Abriana;Salomon, Joshua A.;Linas, Benjamin P.
检测和治疗潜伏性结核感染（LTBI）是美国实现结核病消除的主要策略之一。在非美国出生的居民中进行检测的最佳方法，特别是那些有合并症的居民，是不确定的。或终末期肾病（ESRD），使用医疗保健部门的观点，每年折扣3%。比较的策略包括不检测、结核菌素皮肤试验（TST）、干扰素γ释放试验（IGRA）、确认阳性（初始TST，IGRA仅用于TST阳性结果;两种试验均阳性表示LTBI）和确认阴性（初始IGRA，然后TST用于IGRA阴性;任何试验阳性表示LTBI）。所有的策略都加上治疗与3个月的自我管理利福喷丁和isoniazid.Main结果和措施的数量需要测试和治疗，以防止1例结核病再激活，折扣质量调整生命年（QERS），折扣终身医疗费用，和增量成本效益比（ICERs）。按成本和收益递增排列的策略：不检测、确认阳性、TST、IGRA和确认阴性。ICER因非美国出生的患者风险组而异：无合并症的患者，IGRA可能具有成本效益，为83 000美元/QALY;糖尿病患者，均证实为阳性（53 000美元/质量调整生命年）和IGRA（120 000美元/QALY）可能具有成本效益;确认为阴性的HIV患者显然是首选（63 000美元/QALY）;和ESRD患者，没有测试是成本效益。LTBI患病率增加和TST阅读回报减少改善了IGRA的相对表现。在10000例非美国出生的无合并症、糖尿病和HIV患者的概率模拟中，某种形式的检测几乎总是具有成本效益的。这些模拟强调了非美国出生的无合并症患者和非美国出生的糖尿病患者的测试选择的不确定性，但包括IGRA在内的策略在超过60%的模拟中对所有非美国出生的人群（ESRD人群除外）是首选的。结论和相关性在有和无选定合并症的非美国出生的居民中检测和治疗LTBI可能花费-有效，但终末期肾病患者除外，这些患者的死亡风险限制了获益。对于无合并症的非美国出生患者、糖尿病患者和HIV患者，包括IGRA在内的策略低于10万美元/QALY的支付意愿阈值。
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.