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

Abstract

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 MEASURESNumber 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

US Tuberculosis Rates among Persons Born Outside the United States Compared with Rates in Their Countries of Birth, 2012–20161

“…However, available resources for TB prevention programs remain limited, which highlights the need to ensure that TB testing programs are as cost-effective as possible. Tasillo et al demonstrated the cost-effectiveness of testing and treating LTBI among non-US-born persons (31). Our analysis emphasizes the value of focusing on country of birth and length of time in the United States to guide how to best expand LTBI testing and treatment.…”

Latent tuberculosis infection: Opportunities and challenges

“…Expanded treatment of LTBI will be required to reduce the TB incidence further. The use of IGRA for diagnosis and rifamycin‐based regimens for treatment of LTBI appears to be a cost‐effective community intervention for immigrants in the US, both with and without medical risks for progression . In Japan, mandatory reporting of LTBI may facilitate the evaluation of country‐level strategies that could help inform strategies in the US and elsewhere …”

“…The use of IGRA for diagnosis and rifamycin-based regimens for treatment of LTBI appears to be a cost-effective community intervention for immigrants in the US, both with and without medical risks for progression. 70 In Japan, mandatory reporting of LTBI may facilitate the evaluation of country-level strategies 71 that could help inform strategies in the US and elsewhere. 67,71 For countries with an intermediate or higher TB incidence, implementing effective LTBI treatment programmes represents both a challenge and opportunity.…”

Decision Science at Work: The Case of Latent Tuberculosis Screening

“…As noted by the authors, the assumptions of this study differ from previous studies, [4][5][6] including our own, which reported that LTBI screening and treatment for immigrant patients with CKD would be cost prohibitive, with associated incremental cost-effectiveness ratios in the hundreds of thousands of dollars. These discrepancies underscore the importance of health care system context when making decisions.…”