Evaluating adolescents in juvenile detention facilities for urogenital chlamydial infection - Costs and effectiveness of alternative interventions

Context: Adolescents in juvenile detention facilities present a unique opportunity to diagnose and treat sexually transmitted diseases. Objective: To evaluate the effectiveness and costs of different strategies for the diagnosis and treatment of chlamydial infection in adolescents in juvenile detention. Design, Setting, and Subjects: For a cohort of adolescents in a juvenile detention facility, sex-specific decision models were developed comparing strategies for diagnosing and treating chlamydial infection. These strategies included not screening, treating everyone, and testing (with leukocyte esterase [LE], ligase chain reaction [LCR], or history and symptoms) followed by treatment for those with positive test results. Two different time horizons were considered: immediate and extended. In the immediate time horizon, we performed a cost-effectiveness analysis looking only at the outcomes associated with treating current infections; in the extended time horizon, we performed a cost-minimization analysis comparing the estimated total costs of diagnosing and treating Chlamydia as well as those associated with complications occurring up to 20 years in the future. Results: In males, the immediate-time-horizon evaluation revealed that treating on the basis of urine LE results produced the lowest incremental cost-effectiveness ratio ($80 per infection treated). In the extended-time-horizon cost-minimization analysis, treating males on the basis of urine LE results was again found to be the least expensive strategy ($10.11 per person). Two other strategies, confirming urine LE results with LCR ($10.96 per person) and screening with urine LCR ($14.04 per person), were found to be less expensive than not screening ($16.66 per person). In females, the immediate-time-horizon evaluation found that treating on the basis of symptoms and history resulted in treating about half the cases of chlamydial infection and produced the lowest incremental cost-effectiveness ratio ($74 per infection treated). More infections were treated when treatment was based on urine LCR results with only a small increase in the incremental cost per case treated ($95 per infection treated). In the extended-time-horizon cost-minimization analysis, treating all females empirically and treating based on results of urine LCR testing were the least expensive strategies ($18.81 and $18.98 per person, respectively). The results were sensitive to several variables, including prevalence of chlamydial infection, in both males and females. Conclusions: For adolescent males in juvenile detention facilities, screening with urine LE minimizes the costs associated with diagnosis, treatment, and sequelae of urogenital chlamydial infection. For adolescent females in juvenile detention, empiric treatment and that based on urine LCR test results are the optimal strategies for managing urogenital chlamydial infection.