Economic evaluation alongside a clinical trial of near-to-patient testing for sexually transmitted infections.

BACKGROUND: Current clinical care for common bacterial STIs (Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Mycoplasma genitalium (MG)) involves empiric antimicrobial therapy when clients are symptomatic, or if asymptomatic, waiting for laboratory testing and recall if indicated. Near-to-patient testing (NPT) can improve pathogen-specific prescribing and reduce unnecessary or inappropriate antibiotic use in treating sexually transmitted infections (STI) by providing same-day delivery of results and treatment. METHODS: We compared the economic cost of NPT to current clinic practice for managing clients with suspected proctitis, non-gonococcal urethritis (NGU), or as an STI contact, from a health provider's perspective. With a microsimulation of 1000 clients, we calculated the cost per client tested and per STI- and pathogen- detected for each testing strategy. Sensitivity analyses were conducted to assess the robustness of the main outcomes. Costs are reported as Australian dollars (2023). RESULTS: In the standard care arm, cost per client tested for proctitis, NGU in men who have sex with men (MSM) and heterosexual men were the highest at $247.96 (95% Prediction Interval (PI): 246.77-249.15), $204.23 (95% PI: 202.70-205.75) and $195.01 (95% PI: 193.81-196.21) respectively. Comparatively, in the NPT arm, it costs $162.36 (95% PI: 161.43-163.28), $158.39 (95% PI: 157.62-159.15) and $149.17 (95% PI: 148.62-149.73), respectively. Using NPT resulted in cost savings of 34.52%, 22.45% and 23.51%, respectively. Among all the testing strategies, substantial difference in cost per client tested between the standard care arm and the NPT arm was observed for contacts of CT or NG, varying from 27.37% to 35.28%. CONCLUSION: We found that NPT is cost-saving compared with standard clinical care for individuals with STI symptoms and sexual contacts of CT, NG, and MG.

Is Accelerated Partner Therapy (APT) a cost-effective alternative to routine patient referral partner notification in the UK? Preliminary cost-consequence analysis of an exploratory trial.

OBJECTIVES: To undertake a cost-consequence analysis to assess two new models of partner notification (PN), known as Accelerated Partner Therapy (APT Hotline and APT Pharmacy), as compared with routine patient referral PN, for sex partners of people with chlamydia, gonorrhoea and non-gonococcal urethritis. METHODS: Comparison of costs and outcomes alongside an exploratory trial involving two genitourinary medicine clinics and six community pharmacies. Index patients selected the PN method (APT Hotline, APT Pharmacy or routine PN) for their partners. Clinics and pharmacies recorded cost and resource use data including duration of consultation and uptake of treatment pack. Cost data were collected prospectively for two out of three interventions, and data were synthesised and compared in terms of effectiveness and costs. RESULTS: Routine PN had the lowest average cost per partner treated (approximately £46) compared with either APT Hotline (approximately £54) or APT Pharmacy (approximately £53) strategies. The cost-consequence analysis revealed that APT strategies were more costly but also more effective at treating partners compared to routine PN. CONCLUSION: The hotline strategy costs more than both the alternative PN strategies. If we accept that strategies which identify and treat partners the fastest are likely to be the most effective in reducing reinfection and onward transmission, then APT Hotline appears an effective PN strategy by treating the highest number of partners in the shortest duration. Whether the additional benefit is worth the additional cost cannot be determined in this preliminary analysis. These data will be useful for informing development of future randomised controlled trials of APT.

The cost-effectiveness of syndromic management for male sexually transmitted disease patients with urethral discharge symptoms and genital ulcer disease in Taiwan.

OBJECTIVE: To assess the cost-effectiveness of syndromic management for the treatment of sexually transmitted diseases (STD) in comparison with the strategies currently used in STD clinics in Taiwan. METHODS: Between July 2004 and June 2005, all male patients with genitourinary symptoms attending two hospitals were included in this study. Current clinical procedures (presumptive treatment and laboratory tests), aetiological diagnosis and syndromic management were compared in terms of diagnostic accuracy, treatment appropriateness, costs and effectiveness. RESULTS: 473 patients met the inclusion criteria and were enrolled in the study. 335 patients (71%) had urethral symptoms (discharge, dysuria or painful urination) and 138 (29%) had genital ulcers, sores and skin rashes. For the current approach, the sensitivity, specificity and positive predictive value (PPV) for the detection of chlamydial, gonococcal and combined forms of infection were 100%, 40.0% and 60.4%, respectively. In contrast, the sensitivity, specificity and PPV for the detection of syphilis were 100%, 86.7% and 70.2%, respectively. For syndromic management, the sensitivity, specificity and PPV detection of chlamydial, gonococcal and combined forms of infection were 85.0%, 40.0% and 56.4%, respectively. In contrast, the sensitivity, specificity and PPV for the detection of syphilis were 78.8%, 18.1% and 23.2%, respectively. The average cost of implementing a correct treatment using the current approach was US$54.27 and US$30.74 for urethritis and syphilis, respectively. For the aetiological approach, the average cost of implementing a correct treatment was US$32.83 and US$21.58 for urethritis and syphilis, respectively. For the syndromic approach, the average cost for a correct treatment was US$3.86 and US$14.30 for urethritis and syphilis, respectively. CONCLUSIONS: In this sample of patients attending STD clinics in Taiwan, syndromic management was found to be a more cost-effective protocol in terms of cost per treated STD patient compared with the current and aetiological protocols for STD.

Management of urethritis in health maintenance organization members receiving care at a multispecialty group practice in Massachusetts.

BACKGROUND: Cost containment has led to a concern that health maintenance organization-insured patients presenting with complaints of urethritis may be treated without being tested. GOAL: To determine the proportion of men presenting with symptoms of urethritis who are tested for Chlamydia trachomatis and Neisseria gonorrhoeae. STUDY DESIGN: Reviews were performed on 196 randomly selected patient records with an outpatient visit and a diagnostic code consistent with urethritis between 1995 and 1997. Data were collected on demographics, diagnostic testing, and treatment. RESULTS: Diagnostic testing for C trachomatis and N gonorrhoeae was performed, respectively, in 92.3% and 83.2% of the men presenting at an initial visit with complaints of urethritis. Altogether, 98.2% of the patients who met the Centers for Disease Control criteria for documenting urethritis were tested for C trachomatis and N gonorrhoeae. CONCLUSION: Diagnostic testing for C trachomatis and N gonorrhoeae is nearly universal in this multispecialty group practice setting, facilitating surveillance and public health efforts.

Cost-effectiveness of management strategies for acute urethritis in the developing world.

OBJECTIVE: To recommend a cost-effective approach for the management of acute male urethritis in the developing world, based on the findings of a theoretical study. METHODS: A model was developed to assess the cost-effectiveness of three urethritis management strategies in a theoretical cohort of 1000 men with urethral syndrome. (1) All patients were treated with cefixime and doxycycline for gonococcal urethritis (GU) and nongonococcal urethritis (NGU), respectively, as recommended by WHO. (2) All patients were treated with doxycycline for NGU; treatment with cefixime was based on the result of direct microscopy of a urethral smear. (3) All patients were treated with cotrimoxazole or kanamycin for GU and doxycycline for NGU. Cefixime was kept for patients not responding to the first GU treatment. Strategy costs included consultations, laboratory diagnosis (where applicable) and drugs. The outcome was the rate of patients cured of urethritis. Cost-effectiveness was measured in terms of cost per cured urethritis. RESULTS: Strategy costs in our model depended largely on drug costs. The first strategy was confirmed as the most effective but also the most expensive approach. Cefixime should cost no more than US$ 1.5 for the strategy to be the most cost-effective. The second strategy saved money and drugs but proved a valuable alternative only when laboratory performance was optimal. The third strategy with cotrimoxazole was the least expensive but a low follow-up visit rate, poor treatment compliance or lower drug efficacy limited effectiveness. Maximizing compliance by replacing cotrimoxazole with single-dose kanamycin had the single greatest impact on the effectiveness of the third strategy. CONCLUSION: Our model suggested that a cost-effective approach would be to treat gonorrhoea with a single-dose antibiotic selected from locally available products that cost no more than US$ 1.5.

Why do men with urethritis in Cameroon prefer to seek care in the informal health sector?

OBJECTIVE: To study the impact of cost of treatment for sexually transmitted diseases (STDs) on the preference of men with urethritis to seek care in the informal sector. SUBJECTS AND METHODS: A random sample of young men from the general population of Yaoundé and Douala, Cameroon, and of employees of a Yaoundé factory underwent a structured interview on the occurrence of STD-related complaints and health seeking behaviour. Men who consulted in the formal sector were compared with men consulting in the informal sector, with regards to cost of medication and level of education. RESULTS: Sixteen percent of men in the general population and 20% of factory employees reported a history of urethritis in the 12 months preceding the interview. Of the men in the general population 53% had sought care in the formal sector; among the factory employees this proportion was 56%. Men who did not consult in the formal sector spent significantly less on drugs than men who did consult in the formal sector: median cost $14.4 versus $24.0 (p = 0.02) for drugs purchased in pharmacies; median cost $8 versus $32 for drugs purchased in small stores or from acquaintances. Preference for formal health services was associated with higher educational attainment. CONCLUSION: In large towns in Cameroon the utilisation of formal health services for STD related complaints is low and the high cost of treatment in the formal sector may play an important role in the choice of care option.

Efficiency and cost-effectiveness of field follow-up for patients with Chlamydia trachomatis infection in a sexually transmitted diseases clinic.

Unlike contact-tracing procedures for syphilis and gonorrhea, field follow-up to locate and treat patients with Chlamydia trachomatis infections has not been extensively applied in the United States. We implemented two studies to assess the efficiency and cost-effectiveness of using field follow-up for contact of two groups: patients with chlamydial infection detected as part of a screening program and women who were sexual partners of men with nongonococcal urethritis (NGU). Of the 142 patients with chlamydial infection who had not been treated empirically, 112 (79%) returned for treatment when a reminder system was used, as compared with a return rate of 97% (259/266) achieved by field follow-up (P less than 0.0001). Among the 678 men with NGU enrolled in a randomized trial of field follow-up vs. two self-referral methods, field follow-up yielded over three times as many partners returning to the clinic for treatment as did either of the other two methods (P less than 0.001). Analyses using the estimated costs of the intervention strategies and the medical costs associated with an untreated chlamydial infection showed that field follow-up by trained investigators proved to be not only the most efficient method for locating patients with chlamydial infection and/or patients who were at risk for it, but also the most cost-effective in terms of total health-care dollars spent.

Chlamydia trachomatis infections in the United States. What are they costing us?

Chlamydia trachomatis has emerged as the most common sexually transmitted bacterial pathogen in the United States and is now recognized to cause substantial morbidity. To determine the economic consequences of chlamydial infections in the United States, we analyzed data from local, state, and national sources. We estimate that C trachomatis infections cost Americans over $1.4 billion per year in direct and indirect costs. Chlamydial infections in women account for 79% of this cost, although men and infants are also affected. Three fourths of the total cost is due to sequelae of untreated, uncomplicated infections. If the current rate of chlamydial infection persists, the projected annual costs will exceed $2.18 billion by 1990. Reducing the incidence of personal suffering and heavy economic burden imposed by C trachomatis infections requires establishment and maintenance of effective prevention/control programs.

Urethritis in men: benefits, risks, and costs of alternative strategies of management.

Four alternative strategies for the management of men with acute urethritis were analyzed: treating patients with tetracycline, with or without a urethral culture, without basing the initial treatment decision on the results of a gram-stained smear; treating patients with penicillin, without basing initial treatment on the results of a gram-stained smear; basing initial treatment with tetracycline or penicillin on the results of a gram-stained smear; and basing treatment on the results of both a gram-stained smear and a culture. The tetracycline strategy resulted in fewer days of morbidity, a lower probability of premature death, lower dollar costs, and a much lower rate of uncured nongonococcal urethritis, but in slightly higher rates of uncured gonorrhea and syphilis than more traditional strategies. Use of culture with the tetracycline strategy (1A) permitted tracing of gonorrhea contacts, achieved the same low morbidity, and added little cost. The conclusions were true regardless of the probability of gonorrhea and for reasonable estimates of probable compliance with oral medication regimens. Test-of-cure cultures for patients who were asymptomatic after treatment for gonorrhea required the expenditure of from $4,900 to $109,800 for each case of asymptomatic persistent gonorrhea discovered and cured, depending on the strategy used.