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1.
Soc Sci Med ; 305: 115068, 2022 Jul.
Article in English | MEDLINE | ID: mdl-35665689

ABSTRACT

Universal HIV testing is now recommended in generalised HIV epidemic settings. Although home-based HIV counselling and testing (HB-HCT) has been shown to be effective in achieving high levels of HIV status awareness, little is still known about the cost implications of universal and repeated HB-HCT. We estimated the costs of repeated HB-HCT and the scale economies that can be obtained when increasing the population coverage of the intervention. We used primary data from the ANRS 12249 Treatment as Prevention (TasP) trial in rural South Africa (2012-2016), whose testing component included six-monthly repeated HB-HCT. We relied on the dynamic system generalised method of moments (GMM) approach to produce unbiased short- and long-run estimates of economies of scale, using the number of contacts made by HIV counsellors for HB-HCT as the scale variable. We also estimated the mediating effect of the contact quality - measured as the proportion of HIV tests performed among all contacts eligible for an HIV test - on scale economies. The mean cost (standard deviation) of universal and repeated HB-HCT was $24.2 (13.7) per contact, $1694.3 (1527.8) per new HIV diagnosis, and $269.2 (279.0) per appropriate referral to HIV care. The GMM estimations revealed the presence of economies of scale, with a 1% increase in the number of contacts for HB-HCT leading to a 0.27% decrease in the mean cost. Our results also suggested a significant long-run relationship between mean cost and scale, with a 1% increase in the scale leading to a 0.36% decrease in mean cost in the long run. Overall, we showed that significant cost savings can be made from increasing population coverage. Nevertheless, there is a risk that this gain is made at the expense of quality: the higher the quality of HB-HCT activities, the lower the economies of scale.


Subject(s)
Counseling , HIV Infections , Home Care Services , Mass Screening , Clinical Trials as Topic , Counseling/economics , Counseling/methods , HIV Infections/diagnosis , HIV Infections/epidemiology , HIV Infections/prevention & control , Home Care Services/economics , Humans , Mass Screening/economics , Mass Screening/methods , Referral and Consultation , Rural Population , South Africa/epidemiology
2.
PLoS Med ; 19(3): e1003930, 2022 03.
Article in English | MEDLINE | ID: mdl-35235573

ABSTRACT

BACKGROUND: Low syphilis testing uptake is a major public health issue among men who have sex with men (MSM) in many low- and middle-income countries. Syphilis self-testing (SST) may complement and extend facility-based testing. We aimed to evaluate the effectiveness and costs of providing SST on increasing syphilis testing uptake among MSM in China. METHODS AND FINDINGS: An open-label, parallel 3-arm randomized controlled trial (RCT) was conducted between January 7, 2020 and July 17, 2020. Men who were at least 18 years of age, had condomless anal sex with men in the past year, reported not testing for syphilis in the last 6 months, and had a stable residence with mailing addresses were recruited from 124 cities in 26 Chinese provinces. Using block randomization with blocks of size 12, enrolled participants were randomly assigned (1:1:1) into 3 arms: standard of care arm, standard SST arm, and lottery incentivized SST arm (1 in 10 chance to win US$15 if they had a syphilis test). The primary outcome was the proportion of participants who tested for syphilis during the trial period and confirmed with photo verification and between arm comparisons were estimated with risk differences (RDs). Analyses were performed on a modified intention-to-treat basis: Participants were included in the complete case analysis if they had initiated at least 1 follow-up survey. The Syphilis/HIV Duo rapid test kit was used. A total of 451 men were enrolled. In total, 136 (90·7%, 136/150) in the standard of care arm, 142 (94·0%, 142/151) in the standard of SST arm, and 137 (91·3%, 137/150) in the lottery incentivized SST arm were included in the final analysis. The proportion of men who had at least 1 syphilis test during the trial period was 63.4% (95% confidence interval [CI]: 55.5% to 71.3%, p = 0.001) in the standard SST arm, 65.7% (95% CI: 57.7% to 73.6%, p = 0.0002) in the lottery incentivized SST arm, and 14.7% (95% CI: 8.8% to 20.7%, p < 0.001) in the standard of care arm. The estimated RD between the standard SST and standard of care arm was 48.7% (95% CI: 37.8% to 58.4%, p < 0.001). The majority (78.5%, 95% CI: 72.7% to 84.4%, p < 0.001) of syphilis self-testers reported never testing for syphilis. The cost per person tested was US$26.55 for standard SST, US$28.09 for the lottery incentivized SST, and US$66.19 for the standard of care. No study-related adverse events were reported during the study duration. Limitation was that the impact of the Coronavirus Disease 2019 (COVID-19) restrictions may have accentuated demand for decentralized testing. CONCLUSIONS: Compared to standard of care, providing SST significantly increased the proportion of MSM testing for syphilis in China and was cheaper (per person tested). TRIAL REGISTRATION: Chinese Clinical Trial Registry: ChiCTR1900022409.


Subject(s)
HIV Infections/diagnosis , Homosexuality, Male , Patient Participation/methods , Self-Testing , Syphilis/diagnosis , Adolescent , Adult , COVID-19/epidemiology , China/epidemiology , Follow-Up Studies , HIV Infections/prevention & control , Health Services Accessibility/organization & administration , Homosexuality, Male/statistics & numerical data , Humans , Immunoassay/methods , Male , Mass Screening/economics , Mass Screening/methods , Mass Screening/organization & administration , Middle Aged , Motivation , Pandemics , Reagent Kits, Diagnostic/economics , Reagent Kits, Diagnostic/supply & distribution , SARS-CoV-2 , Sexual and Gender Minorities/statistics & numerical data , Syphilis/epidemiology , Syphilis/prevention & control , Young Adult
3.
PLoS One ; 17(2): e0264206, 2022.
Article in English | MEDLINE | ID: mdl-35192665

ABSTRACT

OBJECTIVES: We sought to evaluate the yield, cost, feasibility, and acceptability of routine tuberculosis (TB) screening of pregnant women in Cotonou, Benin. DESIGN: Mixed-methods, cross-sectional study with a cost assessment. SETTING: Eight participating health facilities in Cotonou, Benin. PARTICIPANTS: Consecutive pregnant women presenting for antenatal care at any participating site who were not in labor or currently being treated for TB from April 2017 to April 2018. INTERVENTIONS: Screening for the presence of TB symptoms by midwives and Xpert MTB/RIF for those with cough for at least two weeks. Semi-structured interviews with 14 midwives and 16 pregnant women about experiences with TB screening. PRIMARY AND SECONDARY OUTCOME MEASURES: Proportion of pregnant women with cough of at least two weeks and/or microbiologically confirmed TB. The cost per pregnant woman screened and per TB case diagnosed in 2019 USD from the health system perspective. RESULTS: Out of 4,070 pregnant women enrolled in the study, 94 (2.3%) had a cough for at least two weeks at the time of screening. The average (standard deviation) age of symptomatic women was 26 ± 5 years and 5 (5.3%) had HIV. Among the 94 symptomatic women, 2 (2.3%) had microbiologically confirmed TB for a TB prevalence of 49 per 100,000 (95% CI: 6 to 177 per 100,000) among pregnant women enrolled in the study. The average cost to screen one pregnant woman for TB was $1.12 USD and the cost per TB case diagnosed was $2271 USD. Thematic analysis suggested knowledge of TB complications in pregnancy was low, but that routine TB screening was acceptable to both midwives and pregnant women. CONCLUSION: Enhanced screening for TB among pregnant women is feasible, acceptable, and inexpensive per woman screened, however in this setting has suboptimal yield even if it can contribute to enhance TB case finding.


Subject(s)
Mass Screening/standards , Pregnancy Complications/epidemiology , Pregnant Women , Tuberculosis, Pulmonary/epidemiology , Adolescent , Adult , Benin , Costs and Cost Analysis , Female , Humans , Mass Screening/economics , Mass Screening/methods , Middle Aged , Pregnancy , Prevalence
4.
Obstet Gynecol ; 139(3): 357-367, 2022 03 01.
Article in English | MEDLINE | ID: mdl-35115449

ABSTRACT

OBJECTIVE: To evaluate the cost effectiveness of universal screening for hepatitis B immunity and vaccination among pregnant women in the United States. METHODS: We designed a decision-analytic model to evaluate the outcomes, costs, and cost effectiveness associated with universal hepatitis B virus (HBV) immunity screening in pregnancy with vaccination of susceptible individuals compared with no screening. A theoretical cohort of 3.6 million women, the approximate number of annual live births in the United States, was used. Outcomes included cases of HBV, hepatocellular carcinoma, decompensated cirrhosis, liver transplant and death, in addition to cost and quality-adjusted life-years (QALYs). Model inputs were derived from the literature, and the willingness-to-pay threshold was $50,000 per QALY. Univariate sensitivity analyses and Monte Carlo simulation models were performed to evaluate the robustness of the results. RESULTS: In a theoretical cohort of 3.6 million women, universal HBV immunity screening and vaccination resulted in 1,702 fewer cases of HBV, seven fewer cases of decompensated cirrhosis, four fewer liver transplants, and 11 fewer deaths over the life expectancy of a woman after pregnancy. Universal screening and vaccination were found to be cost effective, with an incremental cost-effectiveness ratio of $1,890 per QALY. Sensitivity analyses demonstrated the model was robust even when the prevalence of HBV immunity was high and the annual risk of HBV acquisition low. CONCLUSION: Among pregnant women in the United States, universal HBV immunity screening and vaccination of susceptible persons is cost effective compared with not routinely screening and vaccinating.


Subject(s)
Cost-Benefit Analysis , Hepatitis B Vaccines/economics , Hepatitis B , Mass Screening/economics , Pregnancy Complications, Infectious , Prenatal Care/economics , Adult , Biomarkers/blood , Cohort Studies , Decision Support Techniques , Female , Hepatitis B/blood , Hepatitis B/diagnosis , Hepatitis B/economics , Hepatitis B/prevention & control , Hepatitis B Antibodies/blood , Humans , Markov Chains , Mass Screening/methods , Models, Economic , Monte Carlo Method , Pregnancy , Pregnancy Complications, Infectious/blood , Pregnancy Complications, Infectious/diagnosis , Pregnancy Complications, Infectious/economics , Pregnancy Complications, Infectious/prevention & control , Prenatal Care/methods , Quality-Adjusted Life Years , United States
6.
Lancet Glob Health ; 10(2): e278-e287, 2022 02.
Article in English | MEDLINE | ID: mdl-35063115

ABSTRACT

BACKGROUND: China has the highest prevalence of hepatitis B virus (HBV) infection worldwide. Universal HBV screening might enable China to reach the WHO 2030 target of 90% diagnostics, 80% treatment, and 65% HBV-related death reduction, and eventually elimination of viral hepatitis. We evaluated the cost-effectiveness of implementing universal HBV screening in China and identified optimal screening strategies. METHODS: We used a Markov cohort model, inputting parameters based on data from previous studies and public databases, to assess the cost-effectiveness of four HBV serological screening strategies in China in different screening scenarios. We simulated universal screening scenarios in 15 adult age groups between 18 and 70 years, with different years of screening implementation (2021, 2026, and 2031) and compared to the status quo (ie, no universal screening); in total, we investigated 180 different screening scenarios. We calculated the incremental cost-effectiveness ratio (ICER) between the different screening strategies and the status quo (current screening strategy). We performed probabilistic and one-way deterministic sensitivity analyses to assess the robustness of our findings. FINDINGS: With a willingness-to-pay level of three times the Chinese gross domestic product (GDP) per capita (US$30 828), all universal screening scenarios in 2021 were cost-effective compared with the status quo. The serum HBsAg/HBsAb/HBeAg/HBeAb/HBcAb (five-test) screening strategy in people aged 18-70 years was the most cost-effective strategy in 2021 (ICER $18 295/quality-adjusted life-years [QALY] gained). This strategy remained the most cost-effective, when the willingness-to-pay threshold was reduced to 2 times GDP per capita. The two-test strategy for people aged 18-70 years became more cost-effective at lower willingness-to-pay levels. The five-test strategy could prevent 3·46 million liver-related deaths in China over the lifetime of the cohort. It remained the most cost-effective strategy when implementation was delayed until 2026 (ICER $20 183/QALY) and 2031 (ICER $23 123/QALY). Screening young people (18-30 years) will no longer be cost-effective in delayed scenarios. INTERPRETATION: The five-test universal screening strategy in people aged 18-70 years, implemented within the next 10 years, is the optimal HBV screening strategy for China. Other screening strategies could be cost-effective alternatives, if budget is limited in rural areas. Delaying strategy implementation reduces overall cost-effectiveness. Early screening initiation will aid global efforts in achieving viral hepatitis elimination. FUNDING: National Natural Science Foundation of China.


Subject(s)
Hepatitis B, Chronic/diagnosis , Mass Screening/organization & administration , Adolescent , Adult , Aged , China/epidemiology , Cost-Benefit Analysis , Humans , Markov Chains , Mass Screening/economics , Middle Aged , Models, Economic , Young Adult
8.
Value Health ; 25(1): 133-146, 2022 01.
Article in English | MEDLINE | ID: mdl-35031092

ABSTRACT

OBJECTIVES: Recent innovations in prostate cancer diagnosis include new biomarkers and more accurate biopsy methods. This study assesses the evidence base on cost-effectiveness of these developments (eg, Prostate Health Index and magnetic resonance imaging [MRI]-guided biopsy) and identifies areas of improvement for future cost-effectiveness models. METHODS: A systematic review using the National Health Service Economic Evaluation Database, MEDLINE, Embase, Health Technology Assessment databases, National Institute for Health and Care Excellence guidelines, and United Kingdom National Screening Committee guidance was performed, between 2009 and 2021. Relevant data were extracted on study type, model inputs, modeling methods and cost-effectiveness conclusions, and results narratively synthesized. RESULTS: A total of 22 model-based economic evaluations were included. A total of 11 compared the cost-effectiveness of new biomarkers to prostate-specific antigen testing alone and all found biomarkers to be cost saving. A total of 8 compared MRI-guided biopsy methods to transrectal ultrasound-guided methods and found MRI-guided methods to be most cost-effective. Newer detection methods showed a reduction in unnecessary biopsies and overtreatment. The most cost-effective follow-up strategy in men with a negative initial biopsy was uncertain. Many studies did not model for stage or grade of cancer, cancer progression, or the entire testing and treatment pathway. Few fully accounted for uncertainty. CONCLUSIONS: This review brings together the cost-effectiveness literature for novel diagnostic methods in prostate cancer, showing that most studies have found new methods to be more cost-effective than standard of care. Several limitations of the models were identified, however, limiting the reliability of the results. Areas for further development include accurately modeling the impact of early diagnostic tests on long-term outcomes of prostate cancer and fully accounting for uncertainty.


Subject(s)
Prostatic Neoplasms/economics , Adult , Aged , Biomarkers , Biopsy/economics , Cost-Benefit Analysis , Humans , Male , Mass Screening/economics , Middle Aged , Prostatic Neoplasms/diagnosis , Quality-Adjusted Life Years
10.
Proc Natl Acad Sci U S A ; 119(2)2022 01 11.
Article in English | MEDLINE | ID: mdl-34983870

ABSTRACT

Pooled testing increases efficiency by grouping individual samples and testing the combined sample, such that many individuals can be cleared with one negative test. This short paper demonstrates that pooled testing is particularly advantageous in the setting of pandemics, given repeated testing, rapid spread, and uncertain risk. Repeated testing mechanically lowers the infection probability at the time of the next test by removing positives from the population. This effect alone means that increasing frequency by x times only increases expected tests by around [Formula: see text] However, this calculation omits a further benefit of frequent testing: Removing infections from the population lowers intragroup transmission, which lowers infection probability and generates further efficiency. For this reason, increasing testing frequency can paradoxically reduce total testing cost. Our calculations are based on the assumption that infection rates are known, but predicting these rates is challenging in a fast-moving pandemic. However, given that frequent testing naturally suppresses the mean and variance of infection rates, we show that our results are very robust to uncertainty and misprediction. Finally, we note that efficiency further increases given natural sampling pools (e.g., workplaces, classrooms) that induce correlated risk via local transmission. We conclude that frequent pooled testing using natural groupings is a cost-effective way to provide consistent testing of a population to suppress infection risk in a pandemic.


Subject(s)
Mass Screening/economics , Mass Screening/methods , COVID-19/diagnosis , COVID-19/epidemiology , COVID-19/prevention & control , COVID-19 Testing , Cost-Benefit Analysis , Humans , Population Surveillance , Prevalence , SARS-CoV-2/isolation & purification , Uncertainty
11.
PLoS One ; 16(12): e0261231, 2021.
Article in English | MEDLINE | ID: mdl-34941883

ABSTRACT

INTRODUCTION: Few economic evaluations have assessed the cost-effectiveness of screening type-2 diabetes mellitus (T2DM) in different healthcare settings. This study aims to evaluate the value for money of various T2DM screening strategies in Vietnam. METHODS: A decision analytical model was constructed to compare costs and quality-adjusted life years (QALYs) of T2DM screening in different health care settings, including (1) screening at commune health station (CHS) and (2) screening at district health center (DHC), with no screening as the current practice. We further explored the costs and QALYs of different initial screening ages and different screening intervals. Cost and utility data were obtained by primary data collection in Vietnam. Incremental cost-effectiveness ratios were calculated from societal and payer perspectives, while uncertainty analysis was performed to explore parameter uncertainties. RESULTS: Annual T2DM screening at either CHS or DHC was cost-effective in Vietnam, from both societal and payer perspectives. Annual screening at CHS was found as the best screening strategy in terms of value for money. From a societal perspective, annual screening at CHS from initial age of 40 years was associated with 0.40 QALYs gained while saving US$ 186.21. Meanwhile, one-off screening was not cost-effective when screening for people younger than 35 years old at both CHS and DHC. CONCLUSIONS: T2DM screening should be included in the Vietnamese health benefits package, and annual screening at either CHS or DHC is recommended.


Subject(s)
Diabetes Mellitus, Type 2/diagnosis , Diagnostic Screening Programs/economics , Community Health Centers/economics , Cost-Benefit Analysis , Delivery of Health Care , Diabetes Mellitus, Type 2/economics , Hospitals, District/economics , Humans , Hypoglycemic Agents/economics , Mass Screening/economics , Quality-Adjusted Life Years , Vietnam/epidemiology
12.
Lancet Glob Health ; 10(1): e52-e62, 2022 01.
Article in English | MEDLINE | ID: mdl-34919856

ABSTRACT

BACKGROUND: To address the growing prevalence of hearing loss, WHO has identified a compendium of key evidence-based ear and hearing care interventions to be included within countries' universal health coverage packages. To assess the cost-effectiveness of these interventions and their budgetary effect for countries, we aimed to analyse the investment required to scale up services from baseline to recommended levels, and the return to society for every US$1 invested in the compendium. METHODS: We did a modelling study using the proposed set of WHO interventions (summarised under the acronym HEAR: hearing screening and intervention for newborn babies and infants, pre-school and school-age children, older adults, and adults at higher risk of hearing loss; ear disease prevention and management; access to technologies such as hearing aids, cochlear implants, or hearing assistive technologies; and rehabilitation service provision), which span the life course and include screening and management of hearing loss and related ear diseases, costs and benefits for the national population cohorts of 172 countries. The return on investment was analysed for the period between 2020 and 2030 using three scenarios: a business-as-usual scenario, a progress scenario with a scale-up to 50% of recommended coverage, and an ambitious scenario with scale-up to 90% of recommended coverage. Using data for hearing loss burden from the Global Burden of Disease Study 2019, a transition model with three states (general population, diagnosed, and those who have died) was developed to model the national populations in countries. For the return-on-investment analysis, the monetary value of disability-adjusted life-years (DALYs) averted in addition to productivity gains were compared against the investment required in each scenario. FINDINGS: Scaling up ear and hearing care interventions to 90% requires an overall global investment of US$238·8 billion over 10 years. Over a 10-year period, this investment promises substantial health gains with more than 130 million DALYs averted. These gains translate to a monetary value of more than US$1·3 trillion. In addition, investment in hearing care will result in productivity benefits of more than US$2 trillion at the global level by 2030. Together, these benefits correspond to a return of nearly US$15 for every US$1 invested. INTERPRETATION: This is the first-ever global investment case for integrating ear and hearing care interventions in countries' universal health coverage services. The findings show the economic benefits of investing in this compendium and provide the basis for facilitating the increase of country's health budget for strengthening ear and hearing care services. FUNDING: None.


Subject(s)
Hearing Loss/prevention & control , Hearing Loss/therapy , Universal Health Care , World Health Organization/organization & administration , Cost-Benefit Analysis , Developing Countries , Ear Diseases/economics , Ear Diseases/prevention & control , Ear Diseases/therapy , Health Services Accessibility/economics , Hearing Aids/economics , Hearing Loss/economics , Humans , Mass Screening/economics , Models, Econometric , World Health Organization/economics
13.
Value Health ; 24(12): 1763-1772, 2021 12.
Article in English | MEDLINE | ID: mdl-34838274

ABSTRACT

OBJECTIVE: This study aimed to assess the cost-effectiveness of magnetic resonance imaging (MRI) with combinations of targeted biopsy (TBx) and systematic biopsy (SBx) for early prostate cancer detection in Sweden. METHODS: A cost-utility analysis was conducted from a lifetime societal perspective using a microsimulation model. Five strategies included no screening and quadrennial screening for men aged 55 to 69 years using SBx alone, TBx on positive MRI (MRI + TBx), combined TBx/SBx on positive MRI (MRI + TBx/SBx), and SBx on negative MRI with TBx/SBx on positive MRI (MRI - SBx, MRI + TBx/SBx). Test characteristics were based on a recent Cochrane review. We predicted the number of biopsies, costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios. RESULTS: The screening strategies were classified in Sweden as high costs per QALY gained compared with no screening. Using MRI + TBx and MRI + TBx/SBx reduced the number of biopsy episodes across a lifetime by approximately 40% compared with SBx alone. Both strategies showed strong dominance over SBx alone and MRI - SBx, MRI + TBx. Compared with MRI + TBx, the MRI + TBx/SBx strategy had an incremental cost-effectiveness ratio of more than €200 000 per QALY gained, which was classified in Sweden as a very high cost. These predictions were robust in the probabilistic sensitivity analysis. Limitations included generalizability of the model assumptions and uncertainty regarding the health-state values and study heterogeneity from the Cochrane review. CONCLUSIONS: MRI + TBx and MRI + TBx/SBx showed strong dominance over alternative screening strategies. MRI + TBx resulted in similar or marginally lower gains in QALYs and lower costs than MRI + TBx/SBx. MRI + TBx was considered the optimal choice among the screening strategies.


Subject(s)
Cost-Benefit Analysis , Magnetic Resonance Imaging/economics , Mass Screening/economics , Prostatic Neoplasms/diagnosis , Aged , Humans , Male , Middle Aged , Prostate-Specific Antigen , Quality-Adjusted Life Years , Sweden
14.
Lancet Public Health ; 7(1): e65-e73, 2022 01.
Article in English | MEDLINE | ID: mdl-34774219

ABSTRACT

BACKGROUND: India faces a high burden of diabetes and hypertension. Currently, there is a dearth of economic evidence about screening programmes, affected age groups, and frequency of screening for these diseases in Indian settings. We assessed the cost effectiveness of population-based screening for diabetes and hypertension compared with current practice in India for different scenarios, according to type of screening test, population age group, and pattern of health-care use. METHODS: We used a hybrid decision model (decision tree and Markov model) to estimate the lifetime costs and consequences from a societal perspective. A meta-analysis was done to assess the effectiveness of population-based screening. Primary data were collected from two Indian states (Haryana and Tamil Nadu) to assess the cost of screening. The data from the National Health System Cost Database and the Costing of Health Services in India study were used to determine the health system cost of diagnostic tests and cost of treating diabetes or hypertension and their complications. A total of 962 patients were recruited to assess out-of-pocket expenditure and quality of life. Parameter uncertainty was evaluated using univariate and multivariable probabilistic sensitivity analyses. Finally, we estimated the incremental cost per quality-adjusted life-year (QALY) gained with alternative scenarios of scaling up primary health care through a health and wellness centre programme for the treatment of diabetes and hypertension. FINDINGS: The incremental cost per QALY gained across various strategies for population-based screening for diabetes and hypertension ranged from US$0·02 million to $0·03 million. At the current pattern of health services use, none of the screening strategies of annual screening, screening every 3 years, and screening every 5 years was cost-effective at a threshold of 1-time per capita gross domestic product in India. In the scenario in which health and wellness centres provided primary care to 20% of patients who were newly diagnosed with uncomplicated diabetes or hypertension, screening the group aged between 30 and 65 years every 5 years or 3 years for either diabetes, hypertension, or a comorbid state (both diabetes and hypertension) became cost-effective. If the share of treatment for patients with newly diagnosed uncomplicated diabetes or hypertension at health and wellness centres increases to 70%, from the existing 4% at subcentres and primary health centres, annual population-based screening becomes a cost saving strategy. INTERPRETATION: Population-based screening for diabetes and hypertension in India could potentially reduce time to diagnosis and treatment and be cost-effective if it is linked to comprehensive primary health care through health and wellness centres for provision of treatment to patients who screen positive. FUNDING: Department of Health Research, Government of India.


Subject(s)
Diabetes Mellitus/diagnosis , Hypertension/diagnosis , Mass Screening/organization & administration , Adult , Age Factors , Aged , Comorbidity , Cost-Benefit Analysis , Decision Trees , Female , Humans , India , Isoindoles , Male , Markov Chains , Mass Screening/economics , Middle Aged , Models, Economic , Patient Acceptance of Health Care/statistics & numerical data , Quality of Life , Quality-Adjusted Life Years , Thiazoles
16.
Med Care ; 60(1): 29-36, 2022 01 01.
Article in English | MEDLINE | ID: mdl-34739415

ABSTRACT

BACKGROUND: Annual lung cancer screening via low-dose computed tomography can reduce lung cancer mortality among high-risk adults by 20%; however, screening take-up remains low. Inadequate insurance coverage or access to care may be a barrier to screening. OBJECTIVE: The objective of this study was to estimate the effect of nearly universal access to Medicare coverage on annual lung cancer screening. RESEARCH DESIGN: A regression discontinuity design was used to estimate the causal effect of nearly universal access to Medicare at age 65. Data come from the 2017 to 2019 Behavioral Risk Factor Surveillance System in 28 states that adopted the optional module on lung cancer screening and lung cancer risk. SUBJECTS: A total of 11,163 individuals at high risk for lung cancer just above and below age 65. MEASURE: Self-reported use of low-dose computed tomography to screen for lung cancer in the past 12 months. RESULTS: A total of 10,951 people at high lung cancer risk (45.7% women, response rate=98.1%) reported lung cancer screening information. Nearly universal access to Medicare increased lung cancer screening by 16.2 percentage points among men (95% confidence interval: 2.4%-30.0%, P=0.02), compared with a baseline screening rate of 11.1% just younger than age 65. Women had a baseline screening rate of 18.2% and experienced no statistically significant change in screening (1.6 percentage point increase, 95% confidence interval: -19.8% to 23.0%, P=0.88). CONCLUSIONS: Gaining Medicare coverage at age 65 increased lung cancer screening take-up among men at high lung cancer risk. Lack of insurance or inadequate access to care hinders screening.


Subject(s)
Insurance Coverage/economics , Lung Neoplasms/diagnosis , Mass Screening/standards , Aged , Early Detection of Cancer/methods , Early Detection of Cancer/statistics & numerical data , Female , Humans , Insurance Coverage/statistics & numerical data , Lung Neoplasms/epidemiology , Male , Mass Screening/economics , Mass Screening/statistics & numerical data , Middle Aged , United States
17.
CMAJ ; 193(43): E1652-E1659, 2021 11 01.
Article in English | MEDLINE | ID: mdl-34725112

ABSTRACT

BACKGROUND: Active screening for tuberculosis (TB) involves systematic detection of previously undiagnosed TB disease or latent TB infection (LTBI). It may be an important step toward elimination of TB among Inuit in Canada. We aimed to evaluate the cost-effectiveness of community-wide active screening for TB infection and disease in 2 Inuit communities in Nunavik. METHODS: We incorporated screening data from the 2 communities into a decision analysis model. We predicted TB-related health outcomes over a 20-year time frame, beginning in 2019. We assessed the cost-effectiveness of active screening in the presence of varying outbreak frequency and intensity. We also considered scenarios involving variation in timing, impact and uptake of screening programs. RESULTS: Given a single large outbreak in 2019, we estimated that 1 round of active screening reduced TB disease by 13% (95% uncertainty range -3% to 27%) and was cost saving compared with no screening, over 20 years. In the presence of simulated large outbreaks every 3 years thereafter, a single round of active screening was cost saving, as was biennial active screening. Compared with a single round, we also determined that biennial active screening reduced TB disease by 59% (95% uncertainty range 52% to 63%) and was estimated to cost Can$6430 (95% uncertainty range -$29 131 to $13 658 in 2019 Can$) per additional active TB case prevented. With smaller outbreaks or improved rates of treatment initiation and completion for people with LTBI, we determined that biennial active screening remained reasonably cost-effective compared with no active screening. INTERPRETATION: Active screening is a potentially cost-saving approach to reducing disease burden in Inuit communities that have frequent TB outbreaks.


Subject(s)
Cost-Benefit Analysis , Health Care Costs/statistics & numerical data , Health Services, Indigenous/economics , Inuits , Mass Screening/methods , Tuberculosis/diagnosis , Tuberculosis/ethnology , Antitubercular Agents/therapeutic use , Cost of Illness , Decision Trees , Disease Outbreaks , Health Services, Indigenous/organization & administration , Humans , Incidence , Mass Screening/economics , Mass Screening/organization & administration , Quebec/epidemiology , Tuberculosis/economics , Tuberculosis/therapy
18.
Sci Rep ; 11(1): 21382, 2021 11 01.
Article in English | MEDLINE | ID: mdl-34725356

ABSTRACT

The cost of testing can be a substantial contributor to hepatitis C virus (HCV) elimination program costs in many low- and middle-income countries such as Georgia, resulting in the need for innovative and cost-effective strategies for testing. Our objective was to investigate the most cost-effective testing pathways for scaling-up HCV testing in Georgia. We developed a Markov-based model with a lifetime horizon that simulates the natural history of HCV, and the cost of detection and treatment of HCV. We then created an interactive online tool that uses results from the Markov-based model to evaluate the cost-effectiveness of different HCV testing pathways. We compared the current standard-of-care (SoC) testing pathway and four innovative testing pathways for Georgia. The SoC testing was cost-saving compared to no testing, but all four new HCV testing pathways further increased QALYs and decreased costs. The pathway with the highest patient follow-up, due to on-site testing, resulted in the highest discounted QALYs (123 QALY more than the SoC) and lowest costs ($127,052 less than the SoC) per 10,000 persons screened. The current testing algorithm in Georgia can be replaced with a new pathway that is more effective while being cost-saving.


Subject(s)
Hepatitis C/diagnosis , Adult , Antiviral Agents/therapeutic use , Cost-Benefit Analysis , Female , Georgia (Republic)/epidemiology , Hepacivirus/isolation & purification , Hepatitis C/drug therapy , Hepatitis C/economics , Hepatitis C/epidemiology , Humans , Male , Markov Chains , Mass Screening/economics , Microbiological Techniques/economics , Quality-Adjusted Life Years
19.
J Nutr ; 151(12 Suppl 2): 110S-118S, 2021 10 23.
Article in English | MEDLINE | ID: mdl-34689190

ABSTRACT

BACKGROUND: The prevalence of type 2 diabetes has increased substantially in India over the past 3 decades. Undiagnosed diabetes presents a public health challenge, especially in rural areas, where access to laboratory testing for diagnosis may not be readily available. OBJECTIVES: The present work explores the use of several machine learning and statistical methods in the development of a predictive tool to screen for prediabetes using survey data from an FFQ to compute the Global Diet Quality Score (GDQS). METHODS: The outcome variable prediabetes status (yes/no) used throughout this study was determined based upon a fasting blood glucose measurement ≥100 mg/dL. The algorithms utilized included the generalized linear model (GLM), random forest, least absolute shrinkage and selection operator (LASSO), elastic net (EN), and generalized linear mixed model (GLMM) with family unit as a (cluster) random (intercept) effect to account for intrafamily correlation. Model performance was assessed on held-out test data, and comparisons made with respect to area under the receiver operating characteristic curve (AUC), sensitivity, and specificity. RESULTS: The GLMM, GLM, LASSO, and random forest modeling techniques each performed quite well (AUCs >0.70) and included the GDQS food groups and age, among other predictors. The fully adjusted GLMM, which included a random intercept for family unit, achieved slightly superior results (AUC of 0.72) in classifying the prediabetes outcome in these cluster-correlated data. CONCLUSIONS: The models presented in the current work show promise in identifying individuals at risk of developing diabetes, although further studies are necessary to assess other potentially impactful predictors, as well as the consistency and generalizability of model performance. In addition, future studies to examine the utility of the GDQS in screening for other noncommunicable diseases are recommended.


Subject(s)
Diet, Healthy , Diet , Machine Learning , Models, Statistical , Prediabetic State/diagnosis , Adolescent , Adult , Aged , Aged, 80 and over , Algorithms , Blood Glucose/analysis , Cross-Sectional Studies , Diabetes Mellitus, Type 2/diagnosis , Diabetes Mellitus, Type 2/epidemiology , Fasting , Female , Humans , India/epidemiology , Male , Mass Screening/economics , Middle Aged , Rural Population , Young Adult
20.
Microbiol Spectr ; 9(2): e0108921, 2021 10 31.
Article in English | MEDLINE | ID: mdl-34643445

ABSTRACT

Routine testing for SARS-CoV-2 is rare for institutes of higher education due to prohibitive costs and supply chain delays. During spring 2021, we routinely tested all residential students 1 to 2 times per week using pooled, RNA-extraction-free, reverse transcription quantitative PCR (RT-qPCR) testing of saliva at a cost of $0.43/sample with same-day results. The limit of detection was 500 copies/ml on individual samples, and analysis indicates 1,000 and 2,500 copies/ml in pools of 5 and 10, respectively, which is orders of magnitude more sensitive than rapid antigen tests. Importantly, saliva testing flagged 83% of semester positives (43,884 tests administered) and was 95.6% concordant with nasopharyngeal diagnostic results (69.0% concordant on the first test when the nucleocapsid gene (N1) cycle threshold (CT) value was >30). Moreover, testing reduced weekly cases by 59.9% in the spring despite far looser restrictions, allowing for more normalcy while eliminating outbreaks. We also coupled our testing with a survey to clarify symptoms and transmissibility among college-age students. While only 8.5% remained asymptomatic throughout, symptoms were disparate and often cold-like (e.g., only 37.3% developed a fever), highlighting the difficulty with relying on symptom monitoring among this demographic. Based on reported symptom progression, we estimate that we removed 348 days of infectious individuals by routine testing. Interestingly, viral load (CT value) at the time of testing did not affect transmissibility (R2 = 0.0085), though those experiencing noticeable symptoms at the time of testing were more likely to spread the virus to close contacts (31.6% versus 14.3%). Together, our findings support routine testing for reducing the spread of SARS-CoV-2. Implementation of cost- and resource-efficient approaches should receive strong consideration in communities that lack herd immunity. IMPORTANCE This study highlights the utility of routine testing for SARS-CoV-2 using pooled saliva while maintaining high sensitivity of detection (under 2,500 copies/ml) and rapid turnaround of high volume (up to 930 samples in 8 h by two technicians and one quantitative PCR [qPCR] machine). This pooled approach allowed us to test all residential students 1 to 2 times per week on our college campus during the spring of 2021 and flagged 83% of our semester positives. Most students were asymptomatic or presented with symptoms mirroring common colds at the time of testing, allowing for removal of infectious individuals before they otherwise would have sought testing. To our knowledge, the total per-sample consumable cost of $0.43 is the lowest to date. With many communities still lagging in vaccination rates, routine testing that is cost-efficient highlights the capacity of the laboratory's role in controlling the spread of SARS-CoV-2.


Subject(s)
COVID-19 Nucleic Acid Testing/economics , COVID-19/diagnosis , Cost-Benefit Analysis , Mass Screening/economics , Reverse Transcriptase Polymerase Chain Reaction/economics , Saliva/virology , COVID-19/prevention & control , Coronavirus Nucleocapsid Proteins/genetics , Humans , Illinois , Limit of Detection , Mass Screening/methods , Nasopharynx/virology , Phosphoproteins/genetics , SARS-CoV-2/isolation & purification , Universities , Viral Load/methods
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