The costs of telemedicine screening for diabetic retinopathy were examined in a trial conducted in northern Norway, involving the University Hospital of Tromsø (UHT) and the primary care centre in Alta, approximately 400 km away. In Alta, specially trained nurses examined 42 diabetic patients using a digital camera to obtain images of the retina. The images were then sent by email to an eye specialist at the UHT. A cost-minimization analysis showed that at low workloads, for example 20 patients per annum, telemedicine was more expensive than conventional examination: NKr8555 versus NKr428 per patient. However, at higher workloads, telemedicine was cheaper. For example, at 200 patients per annum, telemedicine cost NKr971 and conventional examination cost NKr1440 per patient. The break-even point occurred at a patient workload of 110 per annum. Given that there are some 250 diabetic patients in Alta, telemedicine screening is the cheaper service for the public sector.
OBJECTIVE--To assess the cost-effectiveness of identifying asymptomatic carriers of Chlamydia trachomatis among adolescent males. DESIGN--Cost-effectiveness analysis based on cohort analytic studies previously reported and average salaries and costs of medical care in Sweden. SETTING--Adolescent males attending a primary care center for routine health checks. PARTICIPANTS--Estimates of costs and benefits are based on a cohort of 1000 adolescent males and their female contacts. INTERVENTION--Screening with enzyme immunoassay (EIA), either on leukocyte esterase (LE)--positive urine samples (LE-EIA screening) or on all urine samples (EIA screening), was compared with no screening (no treatment or contact tracing). The effects of confirming positive EIA results with a blocking assay and alternative antibiotic regimens on the outcome of the screening strategies were also evaluated. RESULTS--Compared with no screening, the LE-EIA and EIA screening strategies reduced the overall costs when the prevalence of chlamydial infection in males exceeded 2% and 10%, respectively. Enzyme immunoassay screening achieved an overall cure rate that was 12.2% to 12.6% (95% confidence interval) better, but reduced the incremental savings by at least $2144 per cured male, in comparison with LE-EIA screening. Confirmation of positive EIA results reduced the overall cost of the LE-EIA screening strategy when the prevalence of C trachomatis among males was less than 8%. Compared with a 7-day course of doxycycline, a single oral dose of azithromycin administered under supervision in the clinic improved the cure rates of both EIA and LE-EIA screening strategies by 15.1% to 16.3% and 11.2% to 12.0%, respectively, while reducing the corresponding overall costs by 5% and 9%, respectively, regardless of the prevalence of chlamydial infection in males. CONCLUSION--The use of LE-EIA screening combined with treatment of positive cases with azithromycin was the most cost-effective intervention strategy focusing on asymptomatic male carriers of C trachomatis. Positive EIA results should be confirmed when screening low-risk populations.
Comment In: JAMA. 1993 Nov 3;270(17):2097-88411579
Screening for vitamin B12 deficiency and thyroid disease is cheap and enables early diagnosis to be made and treatment to be started while it is still simple and can prevent the development of such serious conditions as dementia, depression, or irreversible tissue damage. In 1995-6, 83% (126/151) of all 75-year-olds in Härryda, a district (population 28,500) to the east of Gothenburg, agreed to undergo a health control designed to detect hypo- or hyper-thyroidism or vitamin B12 deficiency among elderly residents without symptoms (or with atypical symptoms not easily recognised). Of the 126 participants, four (3%) had low plasma cobalamin (vitamin B12) levels (a figure similar to or lower than those reported by others), and were treated with vitamin B12 after further examination; eight (6%) had serum thyroid stimulating hormone (TSH) levels below the lower normal limit, though further examination showed all eight to be euthyroid; and two (1.6%) were diagnosed as being hypothyroid (a lower prevalence than figures reported elsewhere), and were treated with laevothyroxine. The findings suggest that such screening might be useful in primary care. However, the clinical diagnosis of vitamin B12 deficiency, and of hypo- or hyperthyroidism, is often difficult, especially in the elderly; and although a low serum TSH level is also considered to be a reliable marker of hyperthyroidism, like others this study showed that it may occur even in the absence of disease. Thus, serum TSH and plasma B12 levels are useful screening variables, but need to be complemented by other tests before diagnosis is set.
Breast cancer remains a major health problem among Canadian women. Efforts directed at primary prevention of the disease are limited. Secondary prevention through screening appears to be the most promising intervention available in controlling the disease. In recent years, there have been ongoing debates over the effectiveness of available breast screening modalities (breast self-examination [BSE], clinical breast examination [CBE], and screening mammography). In this article I provide an overview of evidence related to each of the three breast screening modalities. The evidence shows that screening mammography and proper examination of breasts can be useful in reducing breast cancer mortality.
BACKGROUND: Carotid surgery in asymptomatic subjects with carotid stenosis is effective to prevent ischemic stroke. There is, however, uncertainty how to find such persons at risk, because mass screening with carotid artery ultrasonography (US) is not cost-effective. Signs of carotid bruits corresponding to the carotid arteries may serve as a tool to select subjects for further investigation. This study is thus aimed at determining the usefulness of carotid bruits in the screening of carotid stenoses. METHODS: 1555 consecutive carotid ultrasonography investigations from 1486 cases done between January 2004 and March 2006 at Norrlands University Hospital, Sweden, were examined. 356 subjects, medium age 69 (27-88) years, had a significant (> or = 50%) US-verified carotid stenosis uni- or bilaterally, 291 had been examined for signs of carotid bruits. The likelihood ratios for carotid bruits to predict US-verified carotid stenoses were calculated and expressed as likelihood percentages. RESULTS: Thirty-one out of 100 persons (31%) with carotid bruit as an indication to perform carotid US had a significant (> or = 50%) carotid stenosis. 281 of the 356 (79%) cases with significant carotid stenoses were found among patients with cerebrovascular disease (CVD). 145 of 226 (64%) CVD patients with a significant carotid stenosis had a carotid bruit. In patients with 50-99% carotid stenoses carotid bruits had an accuracy of 75% (436/582), a sensitivity of 71% (236/334), a specificity of 81% (200/248), a positive likelihood ratio at 3.65 and a negative likelihood at 0.36. Patients with 70-99% stenoses had the highest sensitivity at 77% (183/238). In patients with 100% carotid stenoses, carotid bruits had a sensitivity of 26% (15/57) and a specificity of 49% (256/525). CONCLUSION: Although carotid bruits are not accurate to confirm or to exclude significant carotid stenoses, these signs are appropriate for directed screening for further investigation with carotid US if the patient lacks contraindications for surgery. Lack of carotid bruits in CVD patients does not exclude a carotid stenosis.
Although tuberculosis (TB) screening of immigrants has been conducted for over 50 yr in many industrialized countries, its cost- effectiveness has never been evaluated. We prospectively compared the yield and cost-effectiveness of two immigrant TB screening programs, using close-contact investigation and passive case detection. Study subjects included all immigration applicants undergoing radiographic screening, already arrived immigrants requiring surveillance for inactive TB, and close contacts of active cases resident in Montreal, Quebec, Canada, who were referred from June 1996 to June 1997 to the Montreal Chest Institute (MCI), a referral center specializing in respiratory diseases. For all subjects seen, demographic data, investigations, diagnoses, and therapy were abstracted from administrative data bases and medical charts. Estimated costs of detecting and treating each prevalent active case and preventing future active cases, based on federal and provincial health reimbursement schedules, were compared with the costs for passively diagnosed cases of active TB. Over a period of 1 yr, the three programs detected 27 cases of prevalent active TB and prevented 14 future cases. As compared with passive case detection, close-contact investigation resulted in net savings of $815 for each prevalent active case detected and treated and of $2,186 for each future active case prevented. The incremental cost to treat each case of prevalent active TB was $39,409 for applicant screening and $24,225 for surveillance, and the cost of preventing each case was $33,275 for applicants and $65,126 for surveillance. Close-contact investigation was highly cost effective and resulted in net savings. Immigrant applicant screening and surveillance programs had a significant impact but were much less cost effective, in large part because of substantial operational problems.
Comment In: Am J Respir Crit Care Med. 2001 Jan;163(1):1-211208612