title: Cost-effectiveness analysis of diagnostic options for pneumocystis pneumonia (PCP).
abstract: BACKGROUND
  Diagnosis of Pneumocystis jirovecii pneumonia (PCP) is challenging, particularly in developing countries. Highly sensitive diagnostic methods are costly, while less expensive methods often lack sensitivity or specificity. Cost-effectiveness comparisons of the various diagnostic options have not been presented.
  
  
  RESULTS
  We compared cost-effectiveness, as measured by cost per life-years gained and proportion of patients successfully diagnosed and treated, of 33 PCP diagnostic options, involving combinations of specimen collection methods [oral washes, induced and expectorated sputum, and bronchoalveolar lavage (BAL)] and laboratory diagnostic procedures [various staining procedures or polymerase chain reactions (PCR)], or clinical diagnosis with chest x-ray alone. Our analyses were conducted from the perspective of the government payer among ambulatory, HIV-infected patients with symptoms of pneumonia presenting to HIV clinics and hospitals in South Africa. Costing data were obtained from the National Institutes of Communicable Diseases in South Africa. At 50% disease prevalence, diagnostic procedures involving expectorated sputum with any PCR method, or induced sputum with nested or real-time PCR, were all highly cost-effective, successfully treating 77-90% of patients at $26-51 per life-year gained. Procedures using BAL specimens were significantly more expensive without added benefit, successfully treating 68-90% of patients at costs of $189-232 per life-year gained. A relatively cost-effective diagnostic procedure that did not require PCR was Toluidine Blue O staining of induced sputum ($25 per life-year gained, successfully treating 68% of patients). Diagnosis using chest x-rays alone resulted in successful treatment of 77% of patients, though cost-effectiveness was reduced ($109 per life-year gained) compared with several molecular diagnostic options.
  
  
  CONCLUSIONS
  For diagnosis of PCP, use of PCR technologies, when combined with less-invasive patient specimens such as expectorated or induced sputum, represent more cost-effective options than any diagnostic procedure using BAL, or chest x-ray alone.
authors.affiliation: Mycotic Diseases Branch, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America. ggt5@cdc.gov
authors.forename: Julie R
authors.initials: JR
authors.lastname: Harris
authors.forename: Barbara J
authors.initials: BJ
authors.lastname: Marston
authors.forename: Nalinee
authors.initials: N
authors.lastname: Sangrujee
authors.forename: Desiree
authors.initials: D
authors.lastname: DuPlessis
authors.forename: Benjamin
authors.initials: B
authors.lastname: Park
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000175:diagnosis* / Q000188:drug therapy / Q000453:epidemiology; D000890:Anti-Infective Agents / Q000627:therapeutic use; D001992:Bronchoalveolar Lavage Fluid / Q000382:microbiology; D019411:Clinical Laboratory Techniques / Q000191:economics* / Q000379:methods*; D017281:Cost of Illness; D003362:Cost-Benefit Analysis; D006801:Humans; D045363:Pneumocystis carinii / Q000187:drug effects / Q000235:genetics / Q000378:metabolism; D011020:Pneumonia, Pneumocystis / Q000175:diagnosis* / Q000188:drug therapy / Q000453:epidemiology; D016133:Polymerase Chain Reaction / Q000379:methods; D015995:Prevalence; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D013019:South Africa / Q000453:epidemiology; D013183:Sputum / Q000382:microbiology; D013194:Staining and Labeling / Q000379:methods; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000627:therapeutic use
chemical_list: D000890:Anti-Infective Agents; D015662:Trimethoprim, Sulfamethoxazole Drug Combination