Cost-effectiveness of Sexually Transmitted Infection Screening for Adolescents and Young Adults in the Pediatric Emergency Department

Abstract

IMPORTANCEAdolescents and young adults compose almost 50% of all diagnosed sexually transmitted infection (STI) cases annually in the US. Given that these individuals frequently access health care through the emergency department (ED), the ED could be a strategic venue for examining the identification and treatment of STIs.OBJECTIVE To examine the cost-effectiveness of screening strategies for Chlamydia trachomatis and Neisseria gonorrhoeae (chlamydia and gonorrhea) in adolescents and young adults who seek acute care at pediatric EDs. DESIGN, SETTING, AND PARTICIPANTSThis economic evaluation is a component of an ongoing, larger multicenter clinical trial at the Pediatric Emergency Care Applied Research Network. A decision analytic model, created using literature-based estimates for the key parameters, was developed to simulate the events and outcomes associated with 3 strategies for screening and testing chlamydial and gonococcal infections in individuals aged 15 to 21 years who sought acute care at pediatric EDs. Data sources included published (from January 1, 1997, to December 31, 2019) English-language articles indexed in MEDLINE, bibliographies in relevant articles, insurance claims data in the MarketScan database, and reimbursement payments from the Centers for Medicare and Medicaid Services. Because the events and outcomes were simulated, a hypothetical population of 10 000 ED visits by adolescents and young adults was used. INTERVENTIONSThe 3 screening strategies were (1) no screening, (2) targeted screening, and (3) universally offered screening. Targeted screening involved the completion of a sexual health survey, which yielded an estimated STI risk (at risk, high risk, or low risk). MAIN OUTCOMES AND MEASURESOutcome metrics included cost (measured in 2019 US dollars) and the detection and successful treatment of STIs. The incremental cost-effectiveness ratio (ICER) of each strategy was calculated in a base case analysis. The ICER reflects the cost per case detected and successfully treated.RESULTS A 3.6% prevalence of chlamydia and gonorrhea was applied to a hypothetical population of 10 000 ED visits by adolescents and young adults. Targeted screening resulted in the detection and successful treatment of 95 of 360 STI cases (26.4%) at a cost of $313 063, and universally offered screening identified and treated 112 of 360 STI cases (31.1%) at a cost of $515 503. The ICER for targeted screening vs no screening was $6444, and the ICER for universally offered screening vs targeted screening was $12 139. CONCLUSIONS AND RELEVANCEThis economic evaluation found that targeted screening and universally offered screening compared with no screening appeared to be cost-effective strategies for identifying and treating chlamydial and gonococcal infections in adolescents and young adults who used the ED for acute care. Universally offered screening was associated with detecting and successfully treating a higher proportion of STIs in this population.

The Estimated Direct Lifetime Medical Costs of Sexually Transmitted Infections Acquired in the United States in 2018

“…13 Previous estimates of the medical cost burden of STIs have been used in studies of cost-effectiveness and return on investment of a wide range of STI prevention interventions. [47][48][49][50] These previous estimates have also been incorporated in spreadsheet-based tools that allow STI program personnel to estimate the health and economic impact of their program activities. 37,51 Our study, along with the other studies in this Special Issue, can inform updates of these existing tools.…”

CDC Sexually Transmitted Infections Treatment Guidelines, 2021

“…There is an emphasis on antibiotic stewardship around treatment and on optimizing dosing based on pharmacodynamic research. Studies have shown universal STI screening in nontraditional venues, such as emergency departments, is successful in identifying new infections and is likely cost-effective, particularly in high-prevalence communities …”

“…Studies have shown universal STI screening in nontraditional venues, such as emergency departments, is successful in identifying new infections and is likely costeffective, particularly in high-prevalence communities. 6,7 Areas in Need of Future Study or Ongoing Research…”

Youth Involved in the Justice System: Emergency Department Screening and Health Promotion

“…16 Universal screening identified a higher number of STI infections, compared with targeted screening and appears to be a cost-effective strategy for identifying and treating STIs. 17 Screening programs, particularly for justice involved youth, bring their own set of challenges. The sheer number of actionable risk behaviors can be overwhelming for clinicians, particularly in busy settings like EDs.…”