A Systematic Review of Studies Evaluating the Cost Utility of Screening High-Risk Populations for Latent Tuberculosis Infection.

BACKGROUND: As tuberculosis screening trends to targeting high-risk populations, knowing the cost effectiveness of such screening is vital to decision makers.
OBJECTIVES: The purpose of this review was to compile cost-utility analyses evaluating latent tuberculosis infection (LTBI) screening in high-risk populations that used quality-adjusted life-years (QALYs) as their measure of effectiveness. DATA SOURCES: A literature search of MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Web of Knowledge, and PubMed was performed from database start to November 2014. INCLUSION CRITERIA: Studies performed in populations at high risk of LTBI and subsequent reactivation that used the QALY as an effectiveness measure were included. STUDY APPRAISAL AND SYNTHESIS: Quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Data extracted included tuberculin skin test (TST) and/or interferon-gamma release assay (IGRA) use, economic, screening, treatment, health state, and epidemiologic parameters. Data were summarized in regard to consistency in model parameters and the incremental cost-effectiveness ratio (ICER), with costs adjusted to 2013 US dollars.
RESULTS: Of 415 studies identified, ultimately eight studies were included in the review. Most took a societal perspective (n = 4), used lifetime time horizons (n = 6), and used Markov models (n = 8). Screening of adult immigrants was found to be cost effective with a TST in one study, but moderately cost effective with an IGRA in another study; screening immigrants arriving more than 5 years prior with an IGRA was moderately cost effective until 44 years of age (n = 1). Screening HIV-positive patients was highly cost effective with a TST (n = 1) and moderately cost effective with an IGRA (n = 1). Screening in those with renal diseases (n = 2) and diabetes (n = 1) was not cost effective. LIMITATIONS: Very few studies used the QALY as their effectiveness measure. Parameter and study design inconsistencies limit the comparability of studies.
CONCLUSIONS: With validity issues in terms of parameters and assumptions, any conclusion should be interpreted with caution. Despite this, some cautionary recommendations emerged: screening HIV patients with a TST is highly cost effective, while screening adult immigrants with an IGRA is moderately cost effective.