Cost-effectiveness of nucleic acid amplification testing to guide treatment for vaginitis: a decision-modeling analysis.

We evaluated the cost-effectiveness of test-and-treat scenarios for vaginitis, scenarios based on clinical and microscopic examination (CME), nucleic acid amplification testing (NAAT), or nonamplified nucleic acid probe (probe) testing. The symptom resolution outcome and the payer cost of diagnosis and treatment were estimated in decision analytical models in a hypothetical patient population. Compared with probe testing, NAAT resulted in symptom resolution in more patients (615 versus 475 per 1000 tested) at a cost of $210 per incremental symptom resolution, a cost lower than the willingness to pay for symptom resolution ($871) implied by payer coverage for probe testing. Following a negative CME, the NAAT scenario resulted in symptom resolution in more patients (650 per 1000 patients tested) than did either CME (525) or the CME probe testing-based scenario (602) at incremental cost-effectiveness ratios lower than the willingness to pay implied by coverage for CME. Therefore, NAAT is likely to cost-effectively improve health outcomes for patients with vaginitis.

"Shotgun" versus sequential testing. Cost-effectiveness of diagnostic strategies for vaginitis.

BACKGROUND: Although vaginitis is a common outpatient problem, only 60% of patients can be diagnosed at the initial office visit of a primary care provider using the office procedures of pH testing, whiff tests, normal saline, and potassium hydroxide preps. OBJECTIVE: To determine the most cost-effective diagnostic and treatment approach for the medical management of vaginitis. DESIGN: Decision and cost-effectiveness analyses. PARTICIPANTS: Healthy women with symptoms of vaginitis undiagnosed after an initial pelvic exam, wet mount preparations, pH, and the four criteria to diagnose bacterial vaginosis. SETTING: General office practice. METHODS: We evaluated 28 diagnostic strategies comprised of combinations of pH testing, vaginal cultures for yeast and Trichomonas vaginalis, Gram's stain for bacterial vaginosis, and DNA probes for Neisseria gonorrhoeae and Chlamydia. Data sources for the study were confined to English language literature. MEASUREMENT: The outcome measures were symptom-days and costs. RESULTS: The least expensive strategy was to perform yeast culture, gonorrhoeae and Chlamydia probes at the initial visit, and Gram's stain and Trichomonas culture only when the vaginal pH exceeded 4.9 (330 dollars, 7.30 symptom days). Other strategies cost 8 dollars to 76 dollars more and increased duration of symptoms by up to 1.3 days. In probabilistic sensitivity analysis, this strategy was always the most effective strategy and was also least expensive 58% of the time. CONCLUSIONS: For patients with vaginitis symptoms undiagnosed by pelvic examination, wet mount preparations and related office tests, a comprehensive, pH-guided testing strategy at the initial office visit is less expensive and more effective than ordering tests sequentially.

Diagnostic testing and return visits for acute problems in prepaid, case-managed Medicaid plans compared with fee-for-service.

Enrollment of Medicaid recipients into capitated, case-managed systems of health care has been advocated as a means to control costs. We studied the effect of such systems on care for urinary tract infection (UTI), pelvic inflammatory disease, and vaginitis among women enrolled in Aid to Families with Dependent Children in capitated demonstration programs in Santa Barbara County, California, and Jackson County, Missouri (prepaid), compared with similar but fee-for-service (FFS) counties in Ventura County, California, and St Louis, Mo. Structured abstracts were performed on 2382 outpatient charts with one of the three conditions in 1985. The proportion of cases with UTI in which a urine culture was obtained was similar in Santa Barbara (prepaid) and Ventura (FFS), 47% vs 46%, but greater in Jackson County (prepaid) than St Louis (FFS), 58% vs 32%. The proportion of cases with return visits for a UTI was: Santa Barbara (prepaid), 40%; Ventura (FFS), 33%; Jackson (prepaid), 72%; and St Louis (FFS), 53%. The proportion of patients with pelvic inflammatory disease with cervical cultures for gonorrhea as Santa Barbara (prepaid), 81%; Ventura (FFS), 52%; Jackson (prepaid), 86%; and St Louis (FFS), 61%. The proportion of women returning for follow-up after pelvic inflammatory disease was similar across all counties at 40% and 50%. The number of office diagnostic tests performed for vaginitis was greater in both demonstration counties. These data do not demonstrate any diminution in either diagnostic testing or follow-up visits for three common ambulatory problems in a Medicaid population enrolled in a capitated, case-managed system, with some trends for more care in the demonstration sites.

Medication costs in different provider settings.

Comparison was made of the cost of medications between Shared Health Facilities (SHFs) or Medicaid Mills and a Neighborhood Health Center (NHC) for nine conditions in fields of adult medicine, pediatrics, and gynecology. A total of 10 cases from SHF reviews were matched by diagnosis, age, and length of time under care with those in the NHC. For otitis media and pharyngitis in children and questionable urinary tract infection and vaginitis in adult women, the average costs were significantly higher in the SHFs. Average costs for family planning services and vaginal bleeding were higher in the SHFs but not significantly so. Medication costs for children with asthma and adults with bronchitis and hypertension were approximately the same in both settings. The reasons for higher costs included greater use of more expensive antibiotics, concurrent use of decongestants and antihistamines for infectious conditions of childhood, and dispensing of medications on "shot-gun" basis without adequate diagnostic studies. The most striking difference was the additional average cost of $798 for hospitalization of the SHF patients with vaginal bleeding when D & C and surgery were performed. The NHC women had no hospitalizations as the recommended procedure of endocervical biopsy in the office was Center policy. Other quality inferences noted in the NHC, but not in SHFs, were routine performance of throat cultures for pharyngitis, wet smears for vaginitis, and deferral of treatment until cultures were received for urinary tract infection. The small number of cases for each condition and the large intersample variability were limiting factors in this study, but the findings do suggest that higher standards of care contribute to lower therapy costs.

Strategies for diagnosing vaginitis.

Detailed history, physical examination, laboratory, and follow-up data were obtained from 821 patients presenting to a primary care clinic over an 18-month period with the symptoms of vaginal infection or urinary tract infection (UTI). Information useful in deciding when to perform a vaginal examination, when to obtain various types of cultures, and when to perform microscopic examination of a saline suspension or Gram stain is presented. Of particular interest were the findings that patients with dysuria more commonly have vaginitis than UTI, the superiority of a saline examination to other means of diagnosing yeast vaginitis, and the rarity of a positive trichomonas preparation when the vaginal discharge had a curd-like appearance.