Optimizing screening for tuberculosis and hepatitis B prior to starting tumor necrosis factor-α inhibitors in Crohn's disease.
OBJECTIVE
Treatment with tumor necrosis factor-α (TNF-α) inhibitors in patients with Crohn's disease (CD) is associated with potentially serious infections, including tuberculosis (TB) and hepatitis B virus (HBV). We assessed the cost-effectiveness of extensive TB screening and HBV screening prior to initiating TNF-α inhibitors in CD.


METHODS
We constructed two Markov models: (1) comparing tuberculin skin test (TST) combined with chest X-ray (conventional TB screening) versus TST and chest X-ray followed by the interferon-gamma release assay (extensive TB screening) in diagnosing TB; and (2) HBV screening versus no HBV screening. Our base-case included an adult CD patient starting with infliximab treatment. Input parameters were extracted from the literature. Direct medical costs were assessed and discounted following a third-party payer perspective. The main outcome was the incremental cost-effectiveness ratio (ICER). Sensitivity and Monte Carlo analyses were performed over wide ranges of probability and cost estimates.


RESULTS
At base-case, the ICERs of extensive screening and HBV screening were €64,340 and €75,760 respectively to gain one quality-adjusted life year. Sensitivity analyses concluded that extensive TB screening was a cost-effective strategy if the latent TB prevalence is more than 12 % or if the false positivity rate of TST is more than 20 %. HBV screening became cost-effective if HBV reactivation or HBV-related mortality is higher than 37 and 62 %, respectively.


CONCLUSIONS
Extensive TB screening and HBV screening are not cost-effective compared with conventional TB screening and no HBV screening, respectively. However, when targeted at high-risk patient groups, these screening strategies are likely to become cost-effective.
Department of Gastroenterology and Hepatology, University Medical Center Utrecht, PO Box 85500, 3500 GA, Utrecht, The Netherlands, M.vanderhave@umcutrecht.nl.
Mike
M
van der Have
Bas
B
Oldenburg
Herma H
HH
Fidder
Tim D G
TD
Belderbos
Peter D
PD
Siersema
Martijn G H
MG
van Oijen
D000328:Adult; D000911:Antibodies, Monoclonal / Q000009:adverse effects / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D003424:Crohn Disease / Q000150:complications / Q000188:drug therapy* / Q000191:economics / Q000276:immunology; D005060:Europe; D017048:Health Care Costs; D006509:Hepatitis B / Q000150:complications / Q000175:diagnosis* / Q000191:economics / Q000276:immunology; D006801:Humans; D016867:Immunocompromised Host; D007166:Immunosuppressive Agents / Q000009:adverse effects / Q000627:therapeutic use*; D000069285:Infliximab; D059425:Interferon-gamma Release Tests / Q000191:economics; D055985:Latent Tuberculosis / Q000150:complications / Q000175:diagnosis* / Q000191:economics / Q000276:immunology; D008168:Lung / Q000000981:diagnostic imaging; D008390:Markov Chains; D008875:Middle Aged; D018803:Models, Economic; D015233:Models, Statistical; D017063:Outcome Assessment, Health Care; D011859:Radiography; D014374:Tuberculin Test / Q000191:economics
D000911:Antibodies, Monoclonal; D007166:Immunosuppressive Agents; D000069285:Infliximab