Economics of reducing antibiotic usage for clinical mastitis and metritis through genomic selection.

Antibiotics use (ABU) in animal agriculture has been implicated in the emergence of antibiotic resistance, a global public health threat. Economically justifiable antibiotic reduction strategies can motivate farmers to reduce ABU for clinical mastitis (CM) and metritis, the most common reasons for ABU on dairy farms. Our objective was to quantify the reduction in incidence of CM, metritis, and ABU, and the herd performance of a representative US herd that uses genomic selection for Lifetime Net Merit 2018 (NM$) selection index, compared with genetic selection based only on the mastitis (MAST) or metritis resistance (METR) trait or a health trait subindex (HTH$). A stochastic dynamic simulation model of a 1,000-cow herd with multi-trait genetics for 19 correlated traits included in the NM$ affected the performance of animals. The incidence of CM and metritis for each animal was affected by the genetic and environmental components of the MAST or METR, along with a standard phenotypic function that calculated the daily underlying herd probability to contract CM or metritis. Selection decisions were made based on genomic estimated breeding values of the traits of interest. A strategy named AI-NM$ based decisions on the NM$ trait so that the correlated genetic trends in MAST and METR are improved. Three other strategies named AI-MAST, AI-METR, and AI-HTH$ maximized respectively MAST, METR, and HTH$ genetic merit, but with a tradeoff in NM$ genetic merit. The cumulative true breeding values (TBV) of NM$ for 15 yr showed a difference of $4,947 per cow between the AI-NM$ (best strategy for NM$) and AI-METR (worst strategy for NM$). However, the 15-yr cumulative TBV of MAST was 26.50 percentage points (PP) higher in AI-MAST, and 18.5 PP higher for METR in AI-METR, compared with AI-NM$. As a result, the 15-yr cumulative phenotypic CM and metritis incidence was respectively 94.03 PP and 58 PP lower in AI-MAST and AI-METR compared with AI-NM$. Therefore the corresponding 15-yr cumulative ABU decreased by 42% in AI-MAST and by 53% in AI-METR. We found that AI-MAST had the lowest CM incidence across the 15 yr, whereas AI-METR had the lowest incidence of metritis and the smallest total ABU for 15 yr. To achieve the lowest incidence of CM, metritis, and ABU strategies AI-MAST, AI-METR, and AI-HTH$ had to incur 15-yr discounted cumulative losses per cow of $1,486, $1,434, and $1,130, respectively, compared with AI-NM$. Hence, AI-NM$ had the best financial performance, despite having slightly higher incidence of CM, metritis, and ABU.

Chlamydia sequelae cost estimates used in current economic evaluations: does one-size-fit-all?

BACKGROUND: Current evidence suggests that chlamydia screening programmes can be cost-effective, conditional on assumptions within mathematical models. We explored differences in cost estimates used in published economic evaluations of chlamydia screening from seven countries (four papers each from UK and the Netherlands, two each from Sweden and Australia, and one each from Ireland, Canada and Denmark). METHODS: From these studies, we extracted management cost estimates for seven major chlamydia sequelae. In order to compare the influence of different sequelae considered in each paper and their corresponding management costs on the total cost per case of untreated chlamydia, we applied reported unit sequelae management costs considered in each paper to a set of untreated infection to sequela progression probabilities. All costs were adjusted to 2013/2014 Great British Pound (GBP) values. RESULTS: Sequelae management costs ranged from £171 to £3635 (pelvic inflammatory disease); £953 to £3615 (ectopic pregnancy); £546 to £6752 (tubal factor infertility); £159 to £3341 (chronic pelvic pain); £22 to £1008 (epididymitis); £11 to £1459 (neonatal conjunctivitis) and £433 to £3992 (neonatal pneumonia). Total cost of sequelae per case of untreated chlamydia ranged from £37 to £412. CONCLUSIONS: There was substantial variation in cost per case of chlamydia sequelae used in published chlamydia screening economic evaluations, which likely arose from different assumptions about disease management pathways and the country perspectives taken. In light of this, when interpreting these studies, the reader should be satisfied that the cost estimates used sufficiently reflect the perspective taken and current disease management for their respective context.

Hyperketonemia in early lactation dairy cattle: a deterministic estimate of component and total cost per case.

The purpose of this study was to develop a deterministic economic model to estimate the costs associated with (1) the component cost per case of hyperketonemia (HYK) and (2) the total cost per case of HYK when accounting for costs related to HYK-attributed diseases. Data from current literature was used to model the incidence and risks of HYK (defined as a blood ß-hydroxybutyrate concentration≥1.2 mmol/L), displaced abomasa (DA), metritis, disease associations, milk production, culling, and reproductive outcomes. The component cost of HYK was estimated based on 1,000 calvings per year; the incidence of HYK in primiparous and multiparous animals; the percent of animals receiving clinical treatment; the direct costs of diagnostics, therapeutics, labor, and death loss; and the indirect costs of future milk production losses, future culling losses, and reproduction losses. Costs attributable to DA and metritis were estimated based on the incidence of each disease in the first 30 DIM; the number of cases of each disease attributable to HYK; the direct costs of diagnostics, therapeutics, discarded milk during treatment and the withdrawal period, veterinary service (DA only), and death loss; and the indirect costs of future milk production losses, future culling losses, and reproduction losses. The component cost per case of HYK was estimated at $134 and $111 for primiparous and multiparous animals, respectively; the average component cost per case of HYK was estimated to be $117. Thirty-four percent of the component cost of HYK was due to future reproductive losses, 26% to death loss, 26% to future milk production losses, 8% to future culling losses, 3% to therapeutics, 2% to labor, and 1% to diagnostics. The total cost per case of HYK was estimated at $375 and $256 for primiparous and multiparous animals, respectively; the average total cost per case of HYK was $289. Forty-one percent of the total cost of HYK was due to the component cost of HYK, 33% to costs attributable to metritis, and 26% to costs attributable to DA. The high total cost of HYK at reported incidences of 40 to 60% highlights the importance of appropriate transition cow nutrition and management to decrease the effect of HYK.

Pelvic inflammatory disease: identifying research gaps--proceedings of a workshop sponsored by Department of Health and Human Services/National Institutes of Health/National Institute of Allergy and Infectious Diseases, November 3-4, 2011.

In November 2011, the National Institutes of Health convened a workshop of basic researchers, epidemiologists, and clinical experts in pelvic inflammatory disease to identify research gaps hindering advances in diagnosis, treatment, and prevention. This article summarizes the presentations, discussions, and conclusions of this group and highlights significant controversies that reveal aspects of pelvic inflammatory disease research that would most greatly benefit from the application of newer molecular, immunologic, and radiologic techniques. Multiple limitations to performing new clinical trials exist; however, emerging data from ongoing clinical trials will add to the current body of knowledge regarding prevention and treatment strategies. In addition, use of established health care databases could serve as a valuable tool for performance of unbiased epidemiologic outcome studies.

Measuring the uptake and impact of Chlamydia screening programs--easier said than done.

The passage of the landmark United States (U.S.) Patient Protection and Affordable Care Act (ACA) of 2010 has placed a new emphasis on prevention services, including increased access, coverage, and improved quality of care. In this legislation, chlamydia screening qualifies along with other preventive services (The Patient Protection and Affordable Care Act, P.H. 111-148, March 2010, §2,713) as an essential health service benefit by virtue of having an "A" rating ("strongly recommended") from the U.S. Preventive Services Task Force. However, along with this important commitment of public health resources comes accountability by demonstrating outcomes and results. It should not come as a surprise that in the current era of unprecedented government budget reductions, there is a compelling need for evidence-based prioritization and impact assessment. Funding agencies increasingly need health program data to show the impact of investment in preventive services, and chlamydia screening is no exception. However, measuring the population-level impact of chlamydia screening expansion in the U.S. since the 1980s has been problematic; conflicting data on screening uptake, chlamydia burden, and adverse reproductive outcomes, including pelvic inflammatory disease (PID) and tubal factor infertility, have all been challenging to interpret, despite compelling epidemiologic evidence supporting intervention.

What is the cost of pelvic inflammatory disease and how much could be prevented by screening for chlamydia trachomatis? Cost analysis of the Prevention of Pelvic Infection (POPI) trial.

OBJECTIVES: To describe healthcare settings attended by women with clinical pelvic inflammatory disease (PID), to calculate the cost of a PID episode and to estimate how many cases could be prevented in London annually at current chlamydia screening levels. METHODS: An ethnically diverse sample of 2259 16-24 year old, sexually active, female London students were recruited to a chlamydia screening trial in 2004-2006 of whom 94% (2115) were followed up after 12 months for incidence of PID. A cost analysis examined healthcare settings attended by women with PID, the cost of an episode of PID and the number of cases of PID in London due to untreated chlamydia at baseline that could be prevented per year at 2009 annual screening levels. RESULTS: Of 35 PID cases, 17 (47%) first presented in general practice, 15 (42%) at a genitourinary medicine clinic, two elsewhere and one was admitted to hospital. The average number of consultations for a PID episode was 2.0 (range 1-4) and the average cost was £163 (range £29-960). Assuming 414,345 sexually active women aged 16-24 in London, 6% chlamydia prevalence at baseline and a 7.3% difference in PID rates between screened and unscreened chlamydia positives, 391 (95% CI--44 to 882) cases of chlamydia-associated PID costing £63,733 could be prevented each year in London at 21.5% 2009 annual screening levels. CONCLUSIONS: Most women with PID were managed in the community. The number and cost of PID cases prevented by a single annual chlamydia screen is low suggesting that cost effectiveness may depend mainly on the prevention of long-term sequelae.

Estimating the direct costs of pelvic inflammatory disease in adolescents: a within-system analysis.

We used 2008-2009 physician and hospital charges to estimate the direct cost of medical care per case of pelvic inflammatory disease. The estimated average total charge per episode was $3,025 (SD: $4155). The estimated average charge for patients treated in ambulatory (outpatient clinic and emergency department) settings was $7440 lower than for those treated on inpatient units.

Unexpected findings on laparoscopy for suspected acute appendicitis: a pro for laparoscopic appendectomy as the standard procedure for acute appendicitis.

PURPOSE: Evaluation of the feasibility, cost-effectiveness, time of surgery, morbidities, and other/additional findings during laparoscopy for suspected appendicitis. METHODS: Prospective evaluation of 148 laparoscopies for suspected acute appendicitis. RESULTS: Laparoscopic appendectomy was safe and cost-effective. No appendiceal stump leaks or wound infections occurred. Of the patients, 4.7% developed intra-abdominal abscesses. Mean time of all procedures was 47 min: 42 min for simple appendectomies (n = 126), 67 min for perforated appendicitis (n = 15), and 75 min for converted procedures (n = 7). Twenty-one of 148 (14.2%) patients had unexpected findings instead of appendicitis: inflamed epiploic appendices (three times), inflammatory disorders of intestine (five times), intestinal adhesions (two times), ovarian cysts (six times: one time with mesenteric lymphadenitis, one time ruptured), tubo-ovarian abscess (one time), tubal necrosis (one time), adnexitis with mesenteric lymphadenitis (one time), and acute cholecystitis (one time). These diagnoses might have been missed during conventional open appendectomy and were, if necessary, treated during laparoscopy. CONCLUSIONS: Laparoscopic appendectomy should be recommended as standard procedure for acute appendicitis.

Cost and effectiveness of Chlamydia screening among male military recruits: Markov modeling of complications averted through notification of prior female partners.

BACKGROUND: Despite rising rates of female screening, a high economic burden remains associated with Chlamydia infection from high rates of undetected asymptomatic disease and its associated sequelae of pelvic inflammatory disease (PID) and chronic pelvic pain (CP). Males comprise the majority of US military recruits and represent an ideal population in which to achieve identification and interruption of sexually transmitted infection among infected partners through mass tandem screening. METHODS: We developed a static decision tree incorporating a calibrated Markov model to predict the differences in healthcare payer direct healthcare costs, cases of PID and CP averted among female partners of male recruits through implementation of either selective (aged 24 and younger) or universal recruit screening policies incorporating partner notification. RESULTS: A policy of selective male screening added $10.30 in direct costs per recruit, whereas universal male screening added an additional $1.60. A policy of selective male screening yielded an incremental cost-effectiveness ratio of $3.7K per case of PID averted, and $7.3K per case of CP averted, whereas universal screening yielded an incremental cost-effectiveness ratio of $8.2K per additional case of PID and $16.4K per additional case of CP averted beyond selective screening. Neither policy was dominant, and results were qualitatively robust to single-variable and probabilistic sensitivity analysis. CONCLUSIONS: In consonance with other studies of mass tandem screening, we found both selective and universal male recruit screening cost-effective as compared with other interventions. Our results argue in favor of universal screening of male recruits for Chlamydia infection, linked to partner notification.

Quality of life utilities for pelvic inflammatory disease health states.

PURPOSE: Quality of life utilities for health states associated with pelvic inflammatory disease (PID) have been estimated but not directly measured. Utilities for PID could have important implications on the cost-effectiveness of interventions to prevent and manage this disease. METHODS: We obtained, in women with versus without a history of PID, visual analogue scale (VAS) and time-tradeoff (TTO) valuations for 5 PID-associated health states: ambulatory PID treatment, hospital PID treatment, ectopic pregnancy, chronic pelvic pain, and infertility. Subjects read brief scenarios describing the medical, functional, and social activity effects typically associated with each state, then gave valuations in the order above. RESULTS: Health state valuations were obtained from 56 women with and 150 women without a PID history. Subjects with a PID history had significantly lower mean valuations (P <0.05) on the VAS for ectopic pregnancy (0.55 vs. 0.63), pelvic pain (0.45 vs. 0.53), and infertility (0.53 vs. 0.66) but not on the TTO; VAS differences remained significant when controlling for demographic and childbearing characteristics. VAS and TTO valuations were similar in women with versus without a history of PID for the ambulatory and hospital PID treatment health states. CONCLUSION: PID has substantial impact on utility. In addition, some PID-related health states are valued less by women who have experienced PID, which could affect cost-effectiveness analyses of PID treatments when examined from the societal versus patient perspective.

Time from sexually transmitted infection acquisition to pelvic inflammatory disease development: influence on the cost-effectiveness of different screening intervals.

OBJECTIVES: To prevent pelvic inflammatory disease (PID), some experts recommend screening for sexually transmitted infection (STI) every 12 months, with more frequent screening suggested in higher-risk women. Nevertheless, the time from STI acquisition to PID development, possibly an important factor to consider in screening interval choice, is unknown and its influence on the effectiveness and cost-effectiveness of screening is unclear. METHODS: Using a Markov model, we estimated PID cases averted and the incremental cost-effectiveness resulting from 6- or 12-month screening strategies for high-risk young women (6%/year infection risk, 2.8%/year PID risk with 12-month screening) while varying PID development time from 1 to 12 months after initial infection. Lower-risk women and alternative parameter values were examined in sensitivity analyses. RESULTS: Relative to 12-month screening, 6-month screening decreases PID cases from 6.0% (1 month development time)to 19.4% (12 months); the incremental cost per quality-adjusted life-year (QALY) gained compared with the other strategies varies from $16,600 (12 months development time) to $31,800 (1 month) for high-risk women. In lower-risk women, every 6-month screening is more economically unfavorable, with greater costs per QALY gained at shorter PID development time. CONCLUSION: From a cost-effectiveness standpoint, uncertainty about PID development time is not a significant factor in choosing a screening interval in high-risk women, but could be important in lower-risk groups. Significant increases in PID cases averted occur with more frequent screening when PID development time is lengthened, which may allow estimation of this interval through the use of more sophisticated modeling techniques.

The cost effectiveness of opportunistic chlamydia screening in England.

BACKGROUND/AIM: The National Chlamydia Screening Programme (NCSP) is being implemented in England. This study aims to estimate the cost effectiveness of (a) the NCSP strategy (annual screening offer to men and women aged under 25 years) and (b) alternative screening strategies. METHODS: A stochastic, individual based, dynamic sexual network model was combined with a cost effectiveness model to estimate the complications and associated costs of chlamydial infection. The model was constructed and parameterised from the perspective of the National Health Service (NHS) (England), including the direct costs of infection, complications and screening. Unit costs were derived from standard data sources and published studies. The average and incremental cost effectiveness ratio (cost per major outcome averted or quality adjusted life year (QALY) gained) of chlamydia screening strategies targeting women and/or men of different age groups was estimated. Sensitivity analyses were done to explore model uncertainty. RESULTS: All screening strategies modelled are likely to cost the NHS money and improve health. If pelvic inflammatory disease (PID) progression is less than 10% then screening at any level is unlikely to be cost effective. However, if PID progression is 10% or higher the NCSP strategy compared to no screening appears to be cost effective. The incremental cost effectiveness analysis suggests that screening men and women aged under 20 years is the most beneficial strategy that falls below accepted thresholds. There is a high degree of uncertainty in the findings. CONCLUSIONS: Offering an annual screening test to men and women aged under 20 years may be the most cost effective strategy (that is, under accepted thresholds) if PID progression is 10% or higher.

Hospitalization for pelvic inflammatory disease: a cost-effectiveness analysis.

OBJECTIVE: Nulliparous women are frequently hospitalized for treatment of pelvic inflammatory disease (PID). GOAL: The goal of this study was to determine the economic feasibility of hospitalizing adolescents and young women for PID. STUDY DESIGN: The authors conducted a Markov decision model, estimating the cost-effectiveness of hospitalization compared with outpatient therapy for mild to moderate PID for adolescents and young women, calculating costs per quality-adjusted life-year (QALY) gained under various assumptions about hospitalization effects on complications. RESULTS: If hospitalization decreases PID complications by 10%, 20%, or 30%, the cost/QALY gained is 145,000 dollars, 67,400 dollars, or 42,400 dollars, respectively, compared with outpatient therapy. Assumptions about hospitalization effects on the development of chronic pelvic pain heavily weight the analysis; costs/QALY gained by hospitalization increase considerably if chronic pain is unaffected. CONCLUSION: Hospitalization for PID treatment to possibly preserve fertility in nulliparous young women and adolescents is unlikely to be economically reasonable even if substantial improvements in PID complication rates are assumed.

Productivity losses attributable to untreated chlamydial infection and associated pelvic inflammatory disease in reproductive-aged women.

BACKGROUND AND OBJECTIVES: The productivity losses attributable to disease-related morbidity and mortality impose a burden on society in general and on employers in particular. A reliable assessment of the productivity losses associated with untreated infection with Chlamydia trachomatis (Ct) would complement earlier work on direct medical costs and contribute to an estimate of the full cost of chlamydial disease. GOAL: The goal of this study was to estimate the discounted lifetime productivity losses attributable to untreated chlamydial infection in reproductive-aged women. STUDY DESIGN: We developed a cost model using Monte Carlo methods to estimate the lifetime discounted productivity losses attributable to untreated lower genital tract Ct infection among reproductive-aged women. The model considered the impact of disability resulting from acute pelvic inflammatory disease (PID) associated with untreated Ct infection and from the sequelae of acute PID, including chronic pelvic pain, ectopic pregnancy, and infertility. To accommodate disparate Ct infection rates and labor market characteristics across age groups, we matched age-based risk factors for Ct infection with labor market patterns. Data sources included the 2001 National Chlamydia Surveillance Data, the 2001 Current Population Survey, and published literature. RESULTS: Estimates indicate that the mean weighted productivity losses per untreated Ct infection were approximately US dollars 130 (in year 2001 dollars). Mean weighted productivity losses per case of acute PID were estimated at US dollars 649. Estimated productivity losses were highly correlated with age, reflecting age-dependent differences in labor market characteristics. CONCLUSIONS: The productivity losses attributable to untreated infection with Ct and to sequelae of this infection form a substantial portion of the total economic burden of disease. Effective programs to prevent chlamydial infection and effective screening, diagnosis, and treatment of Ct-infected women may reduce productivity losses and substantially lessen the economic burden of disease to employers.

Effectiveness and cost-effectiveness of a pharmacy-based screening programme for Chlamydia trachomatis in a high-risk health centre population in Amsterdam using mailed home-collected urine samples.

In order to increase case-detection of Chlamydia trachomatis (CT) in a multicultural, low-income and high-CT-prevalence neighbourhood, a novel approach was piloted in collaboration with the pharmacy of the health centre. During a two-year period, women aged 15-29 years who collected their contraceptives at the pharmacy were offered CT-test materials. Home-collected urine could be mailed to the laboratory and the general practitioner received the results. Nine percent of respondents were CT-positive (14% among 15-24 year-olds). There was a strong association with Surinamese/Antillean background. Uptake of the programme was low (27%). Net cost per pelvic inflammatory disease prevented ranged from cost-saving up to 3872 Euros in a low complication rate/high testing cost scenario. Faced with higher risk, but low participation rates, active case-detection of CT-infections in 'high-prevalence-areas' needs a concerted approach by different providers and community organizations, both in secondary and primary prevention. Pharmacists can contribute if proper liaison is made with primary care providers and/or public health services for (partner-)treatment, counselling and comprehensive sexual health care.

Costo hospitalario de la enfermedad inflamatoria pélvica aguda / Hospital cost for acute inflamatory pelvic disease

Se realiza un estudio prospectivo descriptivo lineal en el período comprendido de junio de 1997 a mayo de 1998, en una muestra constituída por 103 pacientes ingresadas con el diagnóstico en Enfermedad Inflamatoria Pélvica Aguda (E.I.P.A), en el hospital docente Ginecobstétrico de Matanzas. En cada paciente se evaluaran los costos directo e indirecto, el 8,7 por ciento de las pacientes requirió tratamiento quirúrgico. El costo total de la E.I.P.A en este período fue de $ 76 841,44 que representó el 6,29 por ciento del presupuesto de la institución para otros gastos. El costo de las investigaciones fue de $ 912,16, en unidad quirúrgica y laparascopia $ 13 293,20 y en medicamentos $ 19 071. El antibiótico más utilizado fue la penicilina cristalina siendo el de mejores resultados por su costo - beneficio. Teniendo en cuenta la morbilidad y el costo de la E.I.P.A se recomienda continuar laborando en los aspectos preventivos de la enfermedad...

Costo hospitalario de la enfermedad inflamatoria pélvica aguda / Hospital cost for acute inflamatory pelvic disease

Se realiza un estudio prospectivo descriptivo lineal en el período comprendido de junio de 1997 a mayo de 1998, en una muestra constituída por 103 pacientes ingresadas con el diagnóstico en Enfermedad Inflamatoria Pélvica Aguda (E.I.P.A), en el hospital docente Ginecobstétrico de Matanzas. En cada paciente se evaluaran los costos directo e indirecto, el 8,7 por ciento de las pacientes requirió tratamiento quirúrgico. El costo total de la E.I.P.A en este período fue de $ 76 841,44 que representó el 6,29 por ciento del presupuesto de la institución para otros gastos. El costo de las investigaciones fue de $ 912,16, en unidad quirúrgica y laparascopia $ 13 293,20 y en medicamentos $ 19 071. El antibiótico más utilizado fue la penicilina cristalina siendo el de mejores resultados por su costo - beneficio. Teniendo en cuenta la morbilidad y el costo de la E.I.P.A se recomienda continuar laborando en los aspectos preventivos de la enfermedad...(AU)