Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Not just 'dynamic': intergenerational outcomes.
- Woody Caan (11 August 2007)
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Cost effectiveness of chlamydia screening
- Ian Simms, Teresa Battison, Jan Clarke, Sarah Randall, Mary Macintosh (6 September 2007)
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Time to think again about chlamydia screening?
- Tracy E Roberts, Suzanne Robinson, Pelham Barton, Stirling Bryan, Anne McCarthy, John Macleod, Matthias Egger, and Nicola Low (21 September 2007)
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Woody Caan, Professor of public health Anglia Ruskin University, Cambridge CB1 1PT, UK.
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The ClaSS team are to be congratulated on their introduction of dynamic modelling to the economics of chlamydia care. [1] However their model will need expansion, if infection with chlamydia has its major economic impact not from adults hospitalised with acute pelvic inflammatory disease but from the lasting sequelae of premature births among offspring. [2],[3] Roberts et al [1] mention unspecified ‘neonatal complications’ but after searching their references (e.g. their 2006 reference 4) these ‘complications’ seem to have had only ‘secondary’ consideration in their economics. The Health Service costs of neonatal intensive care are considerable, but even these pale into insignificance compared to the lifelong costs (to health, social care and the families) from the high proportion of preterm births associated with multiple disabilities. Among a primary care sample of sexually active women aged 16-24 in an economically depressed coastal town (most of whom also combined habitual binge drinking, poor health literacy and low self esteem) we observed much higher rates of infection than the primary care patients used in the ClaSS model. [4] Health inequalities may well become an important factor in addressing the dynamic transmission of chlamydia. Parents who grow up with low social and educational expectations, in deprived communities, may be more prone to early and unrecognised infection, more likely to have the traumatic experience of premature labour, including a disabled child, leading to further impoverishment of the whole family and the social exclusion of the next generation…. [1] Roberts TE, Robinson S, Barton PM, Bryan S, McCarthy A, Macleod J, Egger M, Low N. Cost effectiveness of home based population screening for Chlamydia trachomatis in the UK: economic evaluation of chlamydia screening studies (ClaSS) project. BMJ 2007; 335: 291-294. [2] Caan W. Preterm delivery in primiparous women at low risk. Could epidemic chlamydia contribute to rise in preterm births? BMJ 2006; 332: 1094. [3] Pouta A. Role of chronic Chlamydia trachomatis infection in preterm birth. Rapid Response bmj.com 19 May 2006. [4] McMunn VA, Caan W. Chlamydia infection, alcohol and sexual behaviour in women. British Journal of Midwifery 2007; 15: 221-224 Competing interests: None declared |
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Ian Simms, Epidemiologist National Chlamydia Screening Programme, Health Protection Agency Centre for Infections, NW9 5EQ, Teresa Battison, Jan Clarke, Sarah Randall, Mary Macintosh
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Dear Sir, A recent editorial challenging the approach taken by NICE for assessing cost effectiveness in the NHS [1] concludes that their current QALY threshold has no basis in either theory or evidence. For chlamydia screening, an additional complication in deciding on its value is the variation that currently exists in conclusions arrived at by different dynamic screening models in their predictions of cost effectiveness [2,3,4]. Roberts et al. correctly identify that the incidence of complications following genital chlamydial infection, particularly that of pelvic inflammatory disease (PID), is crucial to evaluating the impact and cost- effectiveness of chlamydial screening programmes [3]. The evidence base surrounding this issue is relatively sparse. In parameterising their model the authors relied on an estimate of progression at the lower end of a spectrum which has previously been debated [4,5]. Adams et al., who also used a stochastic, individual based, dynamic sexual network model, found that offering annual screening opportunistically to men and women under 20 years may be the most cost effective strategy if progression to PID is 10% or higher [4]. These problems undermine the conclusions made by Roberts et al. that "proactive register based screening for chlamydia is not cost-effective" and that the "data are relevant to discussions about the cost effectiveness of the opportunistic model of chlamydia screening being introduced in England". These conclusions are unwarranted, and misleading in the development of chlamydia screening within England. As recently pointed out in the BMJ, there is a distinct difference between ‘proactive’ and ‘opportunistic’ methodologies [6]. The latter approach within the National Chlamydia Screening Programme incorporates a much wider vision of integrated opportunities to the delivery of screening in general practice and other healthcare and non-health care settings. The paper distracts us from asking how many cases of chlamydial infection go on to develop PID and, subsequently, infertility? These questions remain unanswered, and inevitably preclude at this stage meaningful or accurate predictions of cost effectiveness. References 1 Appleby J, Devlin N, Parkin D. NICE's cost effectiveness threshold. BMJ 2007;335:358-359. 2 Kretzschmar M. Evaluation of chlamydia screening: can individual based modelling provide answers? Seattle, USA: 17th Biennial meeting of the International Society for Sexually Transmitted Disease Research (ISSTDR), 2007. 3 Roberts TE, Robinson S, Barton PM, Bryan S, McCarthy A, Macleod J, Egger M, Low N. Cost effectiveness of home based population screening for Chlamydia trachomatis in the UK: economic evaluation of chlamydia screening studies (ClaSS) project. BMJ 2007;335(7614):291. 4 Adams EJ, Turner KM, Edmunds WJ. The cost-effectiveness of opportunistic chlamydia screening in England. Sex Transm Infect 2007;83:267-75. 5 Simms I, Macintosh M, Horner P, Emmett L, Clarke J on behalf of the National Chlamydia Screening Programme. Estimates of complications associated with Chlamydia trachomatis need to be refined http://sti.bmj.com/cgi/eletters/82/3/212 (accessed 21 August 2007). 6 Low N. Screening programmes for chlamydial infection: when will we ever learn? BMJ 2007;334(7596):725-8. Competing interests: None declared |
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Tracy E Roberts, Senior Lecturer in Health Economics Department of Health Economics, University of Birmingham, B15 2 RT, Suzanne Robinson, Pelham Barton, Stirling Bryan, Anne McCarthy, John Macleod, Matthias Egger, and Nicola Low
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Ian Simms and colleagues at the National Chlamydia Screening Programme (NCSP) argue that the cost-effectiveness of chlamydia screening cannot be estimated meaningfully. We presume therefore that they agree that a screening programme is premature,1 because two key requirements of the UK National Screening Committee have not been fulfilled: the natural history of the condition is not adequately understood; and the cost-effectiveness of the programme has not been established. At least £80 million (http://www.dh.gov.uk; gateway ref: 5135) has, however, been spent rolling out opportunistic chlamydia screening across England.
We maintain that studies using proactive screening are relevant to the NCSP. For a screening programme to be effective in the long term, a sufficiently high proportion of the target population needs to be screened at the defined screening interval.1 Opportunistic screening does not achieve this, by definition. Estimating the cost-effectiveness of measures to ensure regular follow up is therefore important. Contrary to popular belief, the cost of using GP registers to organise regular invitations was similar to the infrastructure costs required for the NCSP opportunistic approach.2 3 We share Simms and colleagues’ concerns about QALY thresholds, the state of individual-based modelling of chlamydia transmission, and uncertainties about the complication rates of untreated chlamydia and of the cost-effectiveness of chlamydia screening programmes. Taken together with the lack of randomised controlled trial evidence of the effectiveness of an opportunistic chlamydia screening programme,4 perhaps it is time to (re)evaluate the evidence about the appropriateness of a chlamydia screening programme? References 1. Low N. Screening programmes for chlamydial infection: when will we ever learn? BMJ 2007;334:725-28. 2. Robinson SM, Roberts TE, Barton PM, Bryan S, Macleod JA, McCarthy A et al. The health care and patient costs of an proactive chlamydia screening programme: the Chlamydia Screening Studies (ClaSS) project. Sex Transm Infect 2007;doi 10.1136/sti.2006.023374. 3. Adams EJ, LaMontagne DS, Johnston AR, Pimenta JM, Fenton KA, Edmunds WJ. Modelling the healthcare costs of an opportunistic chlamydia screening programme. Sex Transm Infect 2004;80:363-70. 4. Low N, Bender N, Nartey L, Redmond S, Shang A, Stephenson JM. Revised rapid review of effectiveness - chlamydia screening. http://guidance.nice.org.uk/page.aspx?o=371768, 2006. Competing interests: None declared |
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