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

Details

• Alternative Title:
  JAMA Intern Med
• Personal Author:
  Tasillo, Abriana ; Salomon, Joshua A. ; Trikalinos, Thomas A. ; Horsburgh, C. Robert ; Marks, Suzanne M. ; Linas, Benjamin P.
• Description:
  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.
  
  
• Keywords:
  Antitubercular Agents Bayes Theorem Comorbidity Cost-Benefit Analysis Decision Trees Emigrants And Immigrants Female Humans Isoniazid Latent Tuberculosis Male Markov Chains Quality-Adjusted Life Years Rifampin Tuberculin Test United States

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• Source:
  JAMA Intern Med. 177(12):1755-1764
• Pubmed ID:
  29049814
• Pubmed Central ID:
  PMC5808933
• Document Type:
  Journal Article
• Funding:
  CC999999/ImCDC/Intramural CDC HHSUnited States/ ; P30 AI042853/AI/NIAID NIH HHSUnited States/ ; U38 PS004644/PS/NCHHSTP CDC HHSUnited States/
• Volume:
  177
• Issue:
  12
• Collection(s):
  CDC Public Access
• Main Document Checksum:
  urn:sha256:f38fdf410c80b9dc59c37dadf02714e341942e964c8f8451aba301e13c890bbc
• Download URL:
  https://stacks.cdc.gov/view/cdc/51683/cdc_51683_DS1.pdf
• File Type:
  [PDF - 347.16 KB ]