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Original Investigation
November 2, 2020

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

Author Affiliations
  • 1Division of General Internal Medicine and the Center for Clinical Effectiveness, University of Cincinnati Medical Center, Cincinnati, Ohio
  • 2Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
  • 3Department of Pediatrics, The University of Cincinnati College of Medicine, Cincinnati, Ohio
  • 4Department of Pediatrics, Johns Hopkins Medical Center, Baltimore, Maryland
  • 5Department of Pediatrics, Children's National Hospital, The George Washington University, Washington, DC
JAMA Pediatr. 2021;175(1):81-89. doi:10.1001/jamapediatrics.2020.3571
Key Points

Question  What is the most cost-effective way to screen for Chlamydia trachomatis and Neisseria gonorrhoeae in adolescents and young adults seeking acute care at pediatric emergency departments (EDs)?

Findings  In this economic evaluation of a hypothetical population of 10 000 ED visits by individuals aged 15 to 21 years, targeted and universally offered screening strategies were more successful in detection and treatment of sexually transmitted infections than the no screening strategy, but they were more expensive. The incremental cost-effectiveness ratio for targeted screening vs no screening was $6444 and for universally offered screening vs targeted screening was $12 139.

Meaning  Findings from this study suggest that targeted screening and universally offered screening are both cost-effective strategies for identifying chlamydial and gonococcal infections in adolescents and young adults who access acute care at EDs.

Abstract

Importance  Adolescents 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 Participants  This 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.

Interventions  The 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 Measures  Outcome 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 Relevance  This 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.

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