Cost-effectiveness analysis of diagnostic options for pneumocystis pneumonia (PCP)

• Published in: PloS one Vol. 6; no. 8; p. e23158
• Main Authors: Harris, Julie R, Marston, Barbara J, Sangrujee, Nalinee, DuPlessis, Desiree, Park, Benjamin
• Format: Journal Article
• Language: English
• Published: United States Public Library of Science 15-08-2011; Public Library of Science (PLoS)
• Subjects: Acquired immune deficiency syndrome; AIDS; AIDS-Related Opportunistic Infections - diagnosis; AIDS-Related Opportunistic Infections - drug therapy; AIDS-Related Opportunistic Infections - epidemiology; Alveoli; Anti-Infective Agents - therapeutic use; Bronchoalveolar Lavage Fluid - microbiology; Bronchus; Chest; Clinical Laboratory Techniques - economics; Clinical Laboratory Techniques - methods; Communicable diseases; Comparative analysis; Cost analysis; Cost benefit analysis; Cost of Illness; Developing countries; Diagnosis; Diagnostic imaging; Diagnostic systems; Economic aspects; Escherichia coli; Health care costs; HIV; Human immunodeficiency virus; Humans; LDCs; Medical diagnosis; Medicine; Mortality; Patients; Pneumocystis carinii; Pneumocystis carinii - drug effects; Pneumocystis carinii - genetics; Pneumocystis carinii - metabolism; Pneumonia; Pneumonia, Pneumocystis - diagnosis; Pneumonia, Pneumocystis - drug therapy; Pneumonia, Pneumocystis - epidemiology; Polymerase chain reaction; Polymerase Chain Reaction - methods; Prevalence; Reproducibility of Results; Salmonella; Sensitivity and Specificity; Social and Behavioral Sciences; South Africa - epidemiology; Sputum; Sputum - microbiology; Staining; Staining and Labeling - methods; Toluidine; Toluidine blue; Trimethoprim, Sulfamethoxazole Drug Combination - therapeutic use; Tuberculosis; Atlanta Georgia; South Africa; Georgia; Kenya; United States > US; Botswana
• ISSN: 1932-6203; 1932-6203
• DOI: 10.1371/journal.pone.0023158

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.
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.
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.