Cost-effectiveness of Sexually Transmitted Infection Screening for Adolescents and Young Adults in the Pediatric Emergency Department | Adolescent Medicine | JAMA Pediatrics | JAMA Network
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Figure 1.  Decision Tree Model for Individuals Aged 15 to 21 Years Seeking Acute Care at the Pediatric Emergency Department (ED)
Decision Tree Model for Individuals Aged 15 to 21 Years Seeking Acute Care at the Pediatric Emergency Department (ED)

A, The 3 screening strategies shown at the square decision node are usual care (no screening), targeted screening, and universally offered screening. Round nodes represent chance events. Events following testing (represented by the testing diamond) for patients in each of the 3 strategies are shown in the testing subtree (B). Events following no testing (represented by the no testing diamond) are shown in the no testing subtree (C). The rectangular terminal nodes at the far right of the testing subtree represent the outcome metrics of cost and effectiveness for each terminus. NAAT indicates nucleic acid amplification test.

Figure 2.  One-Way Sensitivity Analysis of Probability of Sexually Transmitted Infection (STI)
One-Way Sensitivity Analysis of Probability of Sexually Transmitted Infection (STI)

The 2 screening curves are virtually superimposed above a probability of 5%. Above a probability of approximately 2%, the incremental cost-effectiveness ratio (ICER) is minimally affected by the prevalence of STI among patients presenting to pediatric emergency departments for acute care. Below a probability of 2%, the ICER increases steeply. The base case value is 3.6%.

Figure 3.  Tornado Diagram of the 1-Way Sensitivity Analysis for Universally Offered vs Targeted Screening
Tornado Diagram of the 1-Way Sensitivity Analysis for Universally Offered vs Targeted Screening

The incremental cost-effectiveness ratio (ICER) in $ per sexually transmitted infection (STI) successfully identified and treated ranges from 0 to $50 000. For each parameter, the upper and lower limits of the sensitivity analysis are based on the clinically reasonable range. The base case result is marked by the dotted line at the center of the tornado plot. Parameters at the top of the figure (wide mouth of the tornado) have a larger impact on the ICER within their clinically reasonable range. NAAT indicates nucleic acid amplification test; and PID, pelvic inflammatory disease.

Table 1.  Data Required in the Analysis
Data Required in the Analysis
Table 2.  Results of Base Case Analysis
Results of Base Case Analysis
1.
Centers for Disease Control and Prevention. Sexually transmitted diseases: adolescents and young adults. Last reviewed December 2017. Accessed November 20, 2019. https://www.cdc.gov/std/life-stages-populations/adolescents-youngadults.htm
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Finelli  L, Schillinger  JA, Wasserheit  JN.  Are emergency departments the next frontier for sexually transmitted disease screening?   Sex Transm Dis. 2001;28(1):40-42. doi:10.1097/00007435-200101000-00009 PubMedGoogle ScholarCrossref
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Reed  JL, Punches  BE, Taylor  RG, Macaluso  M, Alessandrini  EA, Kahn  JA.  A qualitative analysis of adolescent and caregiver acceptability of universally offered gonorrhea and chlamydia screening in the pediatric emergency department.   Ann Emerg Med. 2017;70(6):787-796.e2. doi:10.1016/j.annemergmed.2017.04.017PubMedGoogle ScholarCrossref
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Owusu-Edusei  K  Jr, Nguyen  HT, Gift  TL.  Utilization and cost of diagnostic methods for sexually transmitted infection screening among insured American youth, 2008.   Sex Transm Dis. 2013;40(5):354-361. doi:10.1097/OLQ.0b013e318285c58f PubMedGoogle ScholarCrossref
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Jenkins  WD, Zahnd  W, Kovach  R, Kissinger  P.  Chlamydia and gonorrhea screening in United States emergency departments.   J Emerg Med. 2013;44(2):558-567. doi:10.1016/j.jemermed.2012.08.022 PubMedGoogle ScholarCrossref
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Burkins  J, DeMott  JM, Slocum  GW, Gottlieb  M, Peksa  GD.  Factors associated with unsuccessful follow-up in patients undertreated for gonorrhea and chlamydia infections.   Am J Emerg Med. 2020;38(4):715-719. doi:10.1016/j.ajem.2019.06.007 PubMedGoogle ScholarCrossref
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Zakher  B, Cantor  AG, Pappas  M, Daeges  M, Nelson  HD.  Screening for gonorrhea and chlamydia: a systematic review for the U.S. Preventive Services Task Force.   Ann Intern Med. 2014;161(12):884-893. doi:10.7326/M14-1022 PubMedGoogle ScholarCrossref
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Gift  TL, Owens  CJ.  The direct medical cost of epididymitis and orchitis: evidence from a study of insurance claims.   Sex Transm Dis. 2006;33(10)(suppl):S84-S88. doi:10.1097/01.olq.0000235149.41948.fa PubMedGoogle ScholarCrossref
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Centers for Medicare and Medicaid Services. Hospital Outpatient Annual Policy Files. 2019 Hospital outpatient APC payments. Accessed January 16, 2019. https://www.cms.gov/apps/ama/license.asp?file=/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/2019-OPPS-APC-Offset-File.zip
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Bonar  EE, Walton  MA, Caldwell  MT, Whiteside  LK, Barry  KL, Cunningham  RM.  Sexually transmitted infection history among adolescents presenting to the emergency department.   J Emerg Med. 2015;49(5):613-622. doi:10.1016/j.jemermed.2015.02.017 PubMedGoogle ScholarCrossref
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Goyal  MK, Fein  JA, Badolato  GM,  et al.  A computerized sexual health survey improves testing for sexually transmitted infection in a pediatric emergency department.   J Pediatr. 2017;183:147-152.e1. doi:10.1016/j.jpeds.2016.12.045PubMedGoogle ScholarCrossref
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Mehta  SD, Hall  J, Lyss  SB, Skolnik  PR, Pealer  LN, Kharasch  S.  Adult and pediatric emergency department sexually transmitted disease and HIV screening: programmatic overview and outcomes.   Acad Emerg Med. 2007;14(3):250-258. doi:10.1197/j.aem.2006.10.106 PubMedGoogle ScholarCrossref
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Schneider  K, FitzGerald  M, Byczkowski  T, Reed  J.  Screening for asymptomatic gonorrhea and chlamydia in the pediatric emergency department.   Sex Transm Dis. 2016;43(4):209-215. doi:10.1097/OLQ.0000000000000424 PubMedGoogle ScholarCrossref
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Uppal  A, Chou  KJ.  Screening adolescents for sexually transmitted infections in the pediatric emergency department.   Pediatr Emerg Care. 2015;31(1):20-24. doi:10.1097/PEC.0000000000000322 PubMedGoogle ScholarCrossref
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Marrazzo  JM, Celum  CL, Hillis  SD, Fine  D, DeLisle  S, Handsfield  HH.  Performance and cost-effectiveness of selective screening criteria for Chlamydia trachomatis infection in women. Implications for a national chlamydia control strategy.   Sex Transm Dis. 1997;24(3):131-141. doi:10.1097/00007435-199703000-00003 PubMedGoogle ScholarCrossref
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Goyal  MK, Shea  JA, Hayes  KL,  et al.  Development of a sexual health screening tool for adolescent emergency department patients.   Acad Emerg Med. 2016;23(7):809-815. doi:10.1111/acem.12994 PubMedGoogle ScholarCrossref
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Monroe  KW, Weiss  HL, Jones  M, Hook  EW  III.  Acceptability of urine screening for Neisseria gonorrheae and Chlamydia trachomatis in adolescents at an urban emergency department.   Sex Transm Dis. 2003;30(11):850-853. doi:10.1097/01.OLQ.0000086600.71690.14 PubMedGoogle ScholarCrossref
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Papp JR, Schachter J, Gaydos CA, Van Der Pol B. Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae — 2014. MMWR Morb Mortal Wkly Rep. Published March 14, 2014. Accessed December 12, 2019. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6302a1.htm
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US Preventive Services Task Force. Final recommendation statement: chlamydia and gonorrhea. Published September 22, 2014. Accessed December 12, 2019. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/chlamydia-and-gonorrhea-screening
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Aledort  JE, Hook  EW  III, Weinstein  MC, Goldie  SJ.  The cost effectiveness of gonorrhea screening in urban emergency departments.   Sex Transm Dis. 2005;32(7):425-436. doi:10.1097/01.olq.0000154501.22566.fa PubMedGoogle ScholarCrossref
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Howell  MR, Quinn  TC, Gaydos  CA.  Screening for Chlamydia trachomatis in asymptomatic women attending family planning clinics. A cost-effectiveness analysis of three strategies.   Ann Intern Med. 1998;128(4):277-284. doi:10.7326/0003-4819-128-4-199802150-00005 PubMedGoogle ScholarCrossref
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Kraut-Becher  JR, Gift  TL, Haddix  AC, Irwin  KL, Greifinger  RB.  Cost-effectiveness of universal screening for chlamydia and gonorrhea in US jails.   J Urban Health. 2004;81(3):453-471. doi:10.1093/jurban/jth130 PubMedGoogle ScholarCrossref
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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.

    Introduction

    In the United States, although adolescents and young adults represent only 25% of the sexually active population, they compose nearly 50% of all diagnosed sexually transmitted infection (STI) cases.1 Of the 20 million new cases of STIs each year, 10 million cases occur among adolescents and young adults.1 Failure to diagnose and treat STIs in a timely manner can result in reproductive morbidity, including pelvic inflammatory disease (PID), ectopic pregnancy, and infertility, and can facilitate HIV transmission. Adolescents and young adults frequently access health care services through the emergency department (ED). Thus, the ED could be a strategic venue for the diagnosis and treatment of STIs.

    Despite the high rates of STIs among adolescents and young adults who seek health care in the ED,2 ED-based STI screening is not yet routine. Given the hectic and nonprivate nature of the ED, STI screening in this setting can be challenging. Unlike the opt-out HIV screening, which the Centers for Disease Control and Prevention (CDC) recommends for all patients aged 13 years or older in the ED setting,3 no CDC recommendations currently exist for ED-based Chlamydia trachomatis (chlamydia) and Neisseria gonorrhoeae (gonorrhea) screening. Such screening can be offered universally or to all adolescents and young adults using a targeted approach that is based on sexual experience and/or chief complaint.

    In an ongoing multicenter clinical trial at 6 sites within the Pediatric Emergency Care Applied Research Network (PECARN), we are exploring a computerized sexual health survey that is integrated into the electronic health record to provide clinical decision support for chlamydial and gonococcal infection screening in pediatric EDs. One component of this PECARN project is the assessment of the cost-effectiveness of chlamydial and gonococcal screening strategies for adolescents and young adults visiting pediatric EDs for acute care. For this part of the trial, we constructed a decision analytic model using literature-based estimates for the key parameters. After the 4-year clinical trial is completed, we will replace the literature-based estimates with empirical data from the full 6-site study.

    Methods

    This economic evaluation was approved by the University of Utah Institutional Review Board. No informed consent was required because the analysis used literature-based data and did not involve human participation.

    We developed a decision analytic model to simulate the events and outcomes associated with 3 chlamydial and gonococcal screening strategies for individuals aged 15 to 21 years seeking acute care at pediatric EDs. These strategies were (1) no screening (or usual care); (2) targeted screening, which used a sexual health survey to estimate STI risk (at risk, high risk, or low risk); and (3) universally offered screening. The outcome measures were cost (measured in 2019 US dollars) and the detection and successful treatment of STIs.

    Review of Data from the Literature

    We searched MEDLINE for English-language articles published from January 1, 1997, to December 31, 2019. The following keywords were used in the search: emergency service, hospital; screening; sexually transmitted diseases; prevalence; adolescent; young adult; chlamydia infections; Chlamydia trachomatis; gonorrhea; decision trees; decision support techniques; health surveys; decision making, cost-benefit analysis; computer assisted; sexual behavior; and health care costs. Three of us (M.H.E., J.L.R., M.K.G.) conducted the literature search and review. We also reviewed bibliographies in relevant studies.

    Data from the CDC show marked variations in the incidence and prevalence of STIs by age category (Table 1).4-23 Case rates for both chlamydia and gonorrhea are highest among individuals aged 20 to 24 years, with roughly similar rates of gonorrhea in both female (702.6 per 100 000 population) and male (720.9 per 100 000 population) young adults.3-5 Reported cases of chlamydia are much higher in female (4064.6 per 100 000 population) than male (1784.5 per 100 000 population) young adults.4,5,9 If one assumes that the rate of adolescents and young adults who obtain acute care services from pediatric EDs reflects the rate in the broader population, then the estimated probability of STI among those who do not specifically seek care for STI symptoms is 3.6%. A literature review of screening in US EDs reported the prevalence of chlamydial and gonococcal infection as ranging between 2.0% and 15.0%, suggesting that those seeking acute care in EDs represent an enriched population with respect to STIs.15 However, many studies of the prevalence of chlamydia and gonorrhea in the ED population may be biased given that patients who agreed to be enrolled may be self-selected because of concerns about increased risk.10,11,15,24-28 In a study of universal screening among asymptomatic adolescents and young adults in an urban ED, 7.9% requested testing because of STI symptoms; the probability of STI among these patients was 25.0%.11 If the estimated overall probability of STI is 3.6% among young individuals seeking ED care for acute medical problems and not STI symptoms, and the probability of STI is 25.0% among those requesting testing because of STI symptoms or concerns, then the estimated probability of STI among the remaining asymptomatic ED patients would be 1.8%.

    Although a number of studies have described multivariable STI risk prediction models, surveys, or questionnaires,10,11,24,25,27-29 to our knowledge, only 1 study has formally described test characteristics and area under the receiver operating characteristic curve (AUROC) data for derivation and validation cohorts.6 The AUROC was 0.74 in the derivation set of electronic medical records from 10 437 asymptomatic patients tested for chlamydia and/or gonorrhea between 2000 and 2012 at 2 STI clinics in Vancouver, British Columbia, Canada.6 In the validation set of 14 956 patients, the AUROC was 0.64.6 The STI risk prediction tool had a scoring range of up to 26, based on symptoms and behaviors. With a cutoff or positivity criterion of 11 or more, the tool’s sensitivity was 42.5% and specificity was 75.8%.6 We used the test characteristics of this STI risk prediction tool in our decision analysis, as we do not yet have complete data to calculate an ROC curve for the sexual health survey being used in the ongoing PECARN study.

    Studies have suggested that adolescents and their guardians are supportive of ED-based screening for STIs.2,7,30,31 In a large study of computerized self-interviews for STI screening in ED settings, 800 of the 1337 eligible patients (59.8%) who were approached agreed to complete an STI survey, and the prevalence of STIs was 4.8% (38 of 800).10 This study did not obtain testing data on those who declined to complete the survey (n = 537). When the estimated overall STI prevalence of 3.6% (based on CDC data) was applied, 10 of the 1337 eligible patients were estimated to have an STI. Thus, the estimated prevalence of STIs among the 537 patients who declined to complete the survey was 0.02 (10 of 537). From these estimates, the relative risk of STI in those who completed the survey was 1.32 (0.05 of 0.04), and the relative risk of STI among those who declined to complete the survey was 0.53 (0.02 of 0.04) (Table 1).

    In a study of universal screening for STIs among 553 enrolled patients, 326 (59.0%) agreed to have their urine tested for chlamydia and gonorrhea.11 A review of similar published studies of universal screening in pediatric EDs found that 59.0% to 80.0% of participants agreed to testing.27

    The CDC-recommended method for testing for chlamydial and gonococcal infection is the nucleic acid amplification test (NAAT) of urine specimens.32 Diagnostic accuracy of NAAT is relatively good. Specificity for chlamydia and gonorrhea has been reported to be 97% or higher.17,33 Sensitivity for chlamydia ranges from 86% to 100%, and sensitivity for gonorrhea is between 91% and 100%.17,33

    Precise long-term sequelae of both chlamydial and gonococcal infections are difficult to estimate. An analysis of direct medical costs in the US estimated that PID develops in 15.0% of untreated women with chlamydial or gonococcal infections, whereas epididymitis develops in 1.5% of untreated men with either STI.13 The recommended treatment for chlamydial infection is a single 1-g oral dose of azithromycin or 100 mg of doxycycline twice daily for 7 days.4 Treatment efficacy has been reported to be 97.0%.4 The recommended treatment for uncomplicated gonococcal infections is a single 250-mg dose of ceftriaxone sodium intramuscularly and a 1-g dose of oral azithromycin.5 The reported cure rate of this treatment for uncomplicated urogenital infections is 99.0%.5 However, STI management and ED care follow-up are challenging. Studies have reported a loss to follow-up rate of between 8.0% and 32.0%.15

    Costs

    Major costs for the 3 screening strategies that we considered included the direct costs of testing and treatment for those diagnosed with infection and the costs of sequelae associated with either an untreated infection or an unsuccessful treatment, including PID and epididymitis. Costs of long-term complications from PID and epididymitis, such as infertility, ectopic pregnancy, and chronic pelvic pain, were discounted at 3% per year. We performed the analyses from the health care system perspective and did not include indirect costs, such as those associated with patients’ lost time from work.

    Details of the methods we used to obtain cost data are provided in the eMethods in the Supplement. Briefly, we reviewed insurance claims data in the MarketScan database (Truven Health Analytics, IBM) with Current Procedural Terminology codes for NAATs. Reimbursement payments from the Centers for Medicare and Medicaid Services were used as a proxy for costs. The 2019 cost for each NAAT performed was $39. We consulted the Federal Supply Schedules for the costs of medications, including antibiotic treatments for chlamydial and gonococcal infections.

    Statistical Analysis

    We used Decision Maker, version 3.0 (Lau et al34), to develop a decision analytic model, analyze decision trees, and perform sensitivity analyses.34 Figure 1 and the eMethods in the Supplement provide a detailed description of this decision model.

    We performed a base case analysis to examine the incremental cost-effectiveness ratio (ICER) of strategies as they progressively increased in cost. The ICER reflects the cost per case detected and successfully treated. We conducted both deterministic and probabilistic sensitivity analyses. In the probabilistic sensitivity analyses, second-order Monte Carlo simulations were carried out using distributions for most parameter values in the decision model (eFigure 3 in the Supplement). In the deterministic sensitivity analyses, we examined parameter uncertainty or variation in setting, such as varying prevalence of STI in different geographical locations or settings (eg, urban vs suburban vs rural).

    Results
    Base Case Analysis

    In the base case (Table 2), using an overall STI prevalence of 3.6% for a hypothetical population of 10 000 ED visits by adolescents and young adults, the no screening strategy was the least costly strategy ($190 409), targeted screening was the second most costly ($313 063), and universally offered screening was most costly ($515 503). As each strategy became more expensive, it also became more successful at detection and treatment. No screening resulted in the detection and treatment of 76 STI cases. Targeted screening detected and treated 95 STI cases, whereas universally offered screening detected and treated 112 STI cases. The ICER (cost per case detected and successfully treated) of targeted screening vs no screening was $6444, whereas the ICER of universally offered screening vs targeted screening was $12 139. As discussed, in a population of 10 000 ED visits with a mean overall prevalence of 3.6%, the total number of cases was 360.

    Another way to consider these base case analysis results is by the proportion of patients with STIs who were identified and treated successfully. Thus, the no screening strategy resulted in the detection and successful treatment of 21.1% of STI cases (76 of 360), whereas targeted screening resulted in 26.4% (95 of 360) and universally offered screening resulted in 31.1% (112 of 360) of STI cases. The large proportion of STI cases detected and treated under the no screening strategy was associated with the substantial proportion of ED patients who presented with complaints or concerns about STIs and requested testing.

    Deterministic Sensitivity Analyses

    One of the most important model parameters that might differ from one ED to another was the prevalence of STI among young individuals visiting the ED for acute care. In the base case, we used an overall prevalence of 3.6%. However, this prevalence is known to vary widely according to both patient and geographical factors.15 As shown in Figure 2, the ICERs for both targeted screening vs no screening ($262 621 vs $5712) and for universally offered screening vs targeted screening (ICER: $491 099 vs $10 771; STI probability: 0.001% vs 0.04%) decreased quickly as the prevalence of STI in the population seeking ED care increased. Another critical parameter was the probability that patients diagnosed with an STI sought follow-up visits for appropriate treatment. As shown in eFigure 1 in the Supplement, the ICERs for both targeted screening vs no screening ($572 833 vs $6582) and for universally offered screening vs targeted screening (ICER: $1 051 899 vs $12 392; probability of getting treated: 0.01% vs 0.90%) remained low from the base case value of 0.92 until the probability of getting treated decreased below 0.2, after which it increased sharply.

    Figure 3 features a tornado diagram, which summarizes the results of a series of 1-way sensitivity analyses that we performed. As shown, the parameters with the greatest association with results are at the top of the diagram, whereas those with the least association are at the bottom. Parameters with the greatest association with results within their clinical plausible ranges included the probability of getting tested for symptoms or worries about STI (0.08%; range, 0.05%-0.14%), the probability of STI (0.04%; range, 0.03%-0.14%), and the probability of STI among symptomatic or worried patients (0.25%; range, 0.21%-0.32%) (Table 1).

    In addition, we explored moving the operating point of the STI survey along its ROC curve by performing a sensitivity analysis on the score cutoff for the 26-point scale. As shown in eFigure 2 in the Supplement, the ICER for targeted screening vs no screening decreased (ICER: $8941 vs $496) as the cutoff for high risk of STI increased (cutoff: 1 vs 25). This finding corresponds to a higher specificity of the tool at the cost of decreasing sensitivity. Thus, the ICER was lowest in the absence of false-positive results. However, at a specificity of 100%, the sensitivity was only 0.6%, resulting in the lowest rate of success in detection and treatment for the targeted screening strategy: 76 cases were detected and successfully treated (the same number as with the no screening strategy) in a hypothetical population of 10 000 ED visits by adolescents and young adults (eTable 1 in the Supplement). The cost and successful detection and treatment of the universally offered screening strategy were not associated with the test characteristics of the sexual health survey used in the targeted screening strategy. However, the ICER of universally offered screening compared with targeted screening varied as the cost and successful detection and treatment of targeted screening changed.

    We also examined a scenario in which an STI survey with much better performance characteristics was used. If the sensitivity and specificity of the survey tool were 99%, targeted screening would be less costly but more successful in detection and treatment than no screening (eTable 2 in the Supplement). The ICER for universally offered screening vs targeted screening would now be considerably higher at $32 584 per case identified and successfully treated.

    Discussion

    We found that targeted screening and universally offered screening had a reasonable cost per case detected and successfully treated, with $6444 for target screening and $12 139 for universal screening. Both strategies were associated with the detection and treatment of STI cases in a larger proportion of patients visiting the ED than the no screening strategies, with 26.4% of cases detected and treated owing to target screening and 31.1% of cases with universal screening vs 21.1% with no screening. In a hypothetical cohort of 10 000 ED visits by young individuals, assuming a 3.6% prevalence of chlamydial or gonococcal infection, targeted screening resulted in the detection and treatment of STI in 95 of 360 cases, whereas universally offered screening resulted in the detection and treatment of STI in 112 of 360 cases.

    Substantial factors that limited the success in STI detection and treatment under both targeted and universal strategies were the proportion of patients who agreed to complete the sexual history survey used to estimate STI risk in the targeted screening strategy and the proportion of patients who agreed to undergo testing either after being identified as high risk by the survey or under the universally offered screening strategy. In addition, clinicians needed to order testing of urine specimens after agreement from patients, and patients needed to either return to the ED for treatment of gonorrhea or obtain an oral prescription for the treatment of chlamydia.

    Details of the screening strategies in the present decision model mirror the protocol of the ongoing PECARN multicenter clinical trial. Thus, testing for chlamydia and gonorrhea was performed with urine NAAT assays rather than with point-of-care tests. The test characteristics of NAATs and the ease of obtaining specimens and specimen transport are better than any other testing modality available for the diagnosis of chlamydia and gonorrhea and are recommended by the CDC.32 However, this modality obviates the ability to treat on site during the ED visit and introduces the added complication of follow-up and adherence with treatment. We assumed that 92% of patients who were diagnosed with an STI would get appropriate treatment according to a systematic review of EDs between 1995 and 2010.15 However, as the probability of receiving treatment decreased to less than 20%, the cost per case detected and successfully treated for either screening strategy increased steeply.

    Prevalence of chlamydia and gonorrhea is a major factor in detection and successful treatment and in the cost-effectiveness associated with screening. We used a conservative estimate of 3.6% STI prevalence, based on surveillance data from the CDC for adolescents aged 15 to 21 years. We assumed that the prevalence of chlamydia and gonorrhea among young individuals who used the ED for a variety of acute care issues would reflect the overall population prevalence in the US for this age group. Sensitivity analyses showed that the cost per case detected and successfully treated decreased as the prevalence of STIs increased among those who sought ED care. Other cost-effectiveness analyses have assumed chlamydia and gonorrhea prevalence as high as 13.6% for an ED population.8 In the present analysis, the ICERs would decrease to $1061 for targeted screening and to $2078 for universally offered screening if a prevalence of 13.6% were applied. Although almost all of the pediatric EDs in the 6-site PECARN study treat patients up to age 21 years, the STI prevalence may be lower in EDs that treat patients up to age 18 years only, given that the highest prevalence subgroup is between the ages of 20 and 24 years. It is possible that EDs with lower age limits or those in other geographical regions may have a lower STI prevalence. Thus, the decisions about optimal screening strategies could be nuanced, to account for the prevalence at individual centers. If the prevalence at a particular center were known to be less than 1%, then targeted screening would become the more cost-effective option. If prevalence were less than 0.5%, then even targeted screening would no longer be highly cost-effective. A caveat about these specific thresholds is that they are defined as highly cost-effective on the basis of a societal willingness-to-pay threshold of $50 000 per quality-adjusted life-year. No willingness-to-pay thresholds were established for our utility metric of cost per case identified and successfully treated.

    The proportion of patients who come to the ED for acute care who get tested for chlamydia and gonorrhea because of symptoms or worries has implications for the cost-effectiveness of screening strategies. We used a base case estimate of 7.9% from a previous study in an urban ED setting.11 The larger this number, the less successful were any screening strategies, because greater proportions of possible cases were detected outside of the screening programs.

    The multicenter clinical trial on which we modeled the present analysis differs from other published cost-effectiveness analyses in several ways. This study examined screening of both female and male adolescents and young adults, whereas previous studies generally have focused on young women.35,36 Some analyses have focused on the diagnosis and treatment of gonorrhea alone,35 but the present study included both chlamydia and gonorrhea. The ED setting of this work is also different from the setting in other studies, such as jails and family planning clinics, which have reported higher STI prevalence.36,37

    Limitations

    This study has limitations. The major limitation is the use of literature-based estimates for base case parameter values and for the test characteristics of an STI risk prediction survey until the completion of the 6-site PECARN clinical trial. We tried to address the uncertainty in parameter estimates by conducting exhaustive deterministic and probabilistic sensitivity analyses. After the completion of the 4-year pragmatic trial, we will replace the literature-based parameter estimates with empirical data from the study and reanalyze the results.

    Conclusions

    Adolescents and young adults frequently access health care through ED visits. In this economic evaluation, the pediatric ED served as a strategic venue for examining the diagnosis and treatment of STI cases in this patient population. A decision analytic model was developed to simulate the events and outcomes associated with 3 screening strategies for chlamydial and gonococcal infection and to assess the cost-effectiveness of each strategy. Targeted screening and universally offered screening compared with no screening appeared to be cost-effective strategies for detecting and treating STIs in this population, and universally offered screening appeared to identify and successfully treat a higher proportion of STI cases.

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    Article Information

    Accepted for Publication: June 24, 2020.

    Published Online: November 2, 2020. doi:10.1001/jamapediatrics.2020.3571

    Corresponding Author: Mark H. Eckman, MD, MS, Division of General Internal Medicine and the Center for Clinical Effectiveness, University of Cincinnati Medical Center, PO Box 670535, Cincinnati, OH 45267-0535 (mark.eckman@uc.edu).

    Author Contributions: Dr Eckman had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: All authors.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: All authors.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Eckman.

    Obtained funding: Reed, Goyal.

    Administrative, technical, or material support: Trent.

    Conflict of Interest Disclosures: Dr Eckman reported receiving grants from the National Institutes of Health National Institute of Child Health and Human Development (NICHD), the National Center for Advancing Translational Sciences, and Bristol-Myers Squibb during the conduct of the study. Dr Reed reported receiving grants from the NICHD during the conduct of the study. Dr Trent reported receiving grants from the NICHD during the conduct of the study, grants and nonfinancial support from Hologic Inc, nonfinancial support from SpeeDx LLC, and personal fees from Church & Dwight Inc (Trojan Sexual Health Advisory Council) outside the submitted work. Dr Goyal reported receiving grants from the NICHD during the conduct of the study. No other conflicts were reported.

    Funding/Support: This study was funded in part by grant R01HD094213 from the NICHD (all authors), grant UL1TR001425 from the National Center for Advancing Translational Sciences (Dr Eckman), and grant CV 185-764 from Bristol-Myers Squibb (Dr Eckman).

    Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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