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Screening Surgeons for HIV Infection: A Cost-effectiveness Analysis

Douglas K. Owens, MD, MSc; Ryan A. Harris, MS; Patricia McJ. Scott, AB; and Robert F. Nease, PhD
[+] Article and Author Information

From the Department of Veterans Affairs Medical Center, Palo Alto, California. Stanford University, Stanford, California. Dartmouth Medical School, Hanover, New Hampshire. Requests for Reprints: Douglas K. Owens, MD, MSc, Section of General Internal Medicine (111A), Department of Veterans Affairs Medical Center, 3801 Miranda Avenue, Palo Alto, CA 94304. Acknowledgments: The authors thank Mark Hlatky, Mark Holodniy, Mary Goldstein, David Shapiro, and Nora Sweeney for comments on the manuscript; John Scott for assistance with the data analysis; and Andrea Sullivan for help with preparation of the manuscript. Grant Support: Dr. Owens is supported by a Career Development Award from the Veterans Affairs Health Services Research and Development Service. Dr. Nease is a Picker/Commonwealth Scholar. In part by grants from the Agency for Health Care Policy and Research (RD3 HSO7232-01) and the Veterans Affairs Health Services Research and Development Field Program, Palo Alto, California.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1995;122(9):641-652. doi:10.7326/0003-4819-122-9-199505010-00001
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Objective: To determine the cost-effectiveness of a policy to screen surgeons for human immunodeficiency virus (HIV) infection to prevent transmission of HIV to patients having invasive procedures.

Design: Cost-effectiveness analysis.

Results: A one-time national screening program would identify approximately 137 surgeons with HIV infection (range, 28 to 423 surgeons) and would prevent approximately 4.3 infections (range, 1.9 to 21.3 infections) in patients treated by infected surgeons and 0.9 infections (range, 0 to 12.9 infections) in sexual partners of infected surgeons at a direct cost of $8.1 million and an induced cost of approximately $44 million. It would result in expenditures of $458 000 per year of life saved (range, $147 000 to $687 000 per year of life saved), whereas an annual screening program would result in expenditures of approximately $1.1 million per year of life saved (range, $338 000 to $1 886 000 per year of life saved). If the prevalence of HIV infection in surgeons is estimated to be three times our base-case estimate (an increase from 0.1% to 0.3%), annual screening would result in expenditures of approximately $741 000 per year of life saved. If the probability of seroconversion after a patient is exposed to a contaminated instrument is increased to 5.0% from our base-case estimate of 0.29%, an annual screening program would still cost more than $228 000 per year of life saved.

Conclusion: Screening surgeons for HIV to prevent transmission of HIV to patients having invasive procedures requires expenditures per year of life saved that are considerably in excess of those of most accepted health interventions. Surveillance studies of patients treated by surgeons infected with HIV should be continued to confirm that transmission of HIV to patients having invasive procedures is rare.

Figures

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Figure 1.
Schematic representation of the decision model.

The square node at left represents the decision to screen. If a physician is screened, the test result is either positive or negative. For each of these results, the decision model calculates the probability of HIV infection by using the sensitivity and specificity of the HIV screening tests and Bayes theorem. The events after screening are modeled in a 23-state Markov model (see Appendix). For persons who are not screened, a 9-state natural history Markov model simulates the natural history for physicians infected with HIV and estimates the age-specific life expectancy of those physicians without HIV infection.

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Figure 2.
Effect of changes in screening frequency on the cost and benefits of screening.

One-time screening results in the most favorable cost-effectiveness ratio; annual screening results in the least favorable cost-effectiveness ratio.

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Figure 3.
Effect of changes in the probability of seroconversion after a patient is exposed to a contaminated instrument on the cost-effectiveness of an annual screening program.

As the probability of seroconversion after exposure increases, the screening program becomes more cost-effective. The curves represent the cost-effectiveness as estimated with both direct and induced costs (top curve) and with direct costs only (bottom curve).

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Figure 4.
Effect of changes in the prevalence of HIV infection among physicians, including all benefits and costs, on the cost-effectiveness of an annual screening program.

The curves represent the cost-effectiveness as estimated with both direct and induced costs (top curve) and with direct costs only (bottom curve).

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