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 interferongamma 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.