The Cost Effectiveness of Gonorrhea Screening in Urban Emergency Departments

In Brief Background: The prevalence of gonorrhea (GC) among adolescent and young women attending some urban emergency departments (EDs) ranges from 1% to 7%, but historically screening has not been logistically practical. Goal: The primary goal of the study was to assess the cost effectiveness of GC screening in women ages 15 to 29, seeking care in urban EDs, using noninvasive or rapid point-of-care tests. Study: We developed a state-transition Markov model to compare the net lifetime health consequences, costs, and cost effectiveness of routine ED care (no screening for women without genitourinary symptoms) to GC screening using 1 of 5 detection methods: Gram-stained smears of endocervical swab specimens, urine-based nucleic acid amplification tests (NAATs), NAATs performed on endocervical swabs, rapid immunochromotographic strip test (RIS) performed on clinician-collected vaginal swabs, and RIS on patient-collected vaginal swabs. Results: Screening women between 15 and 29 years of age using urine-based NAATs prevented 1247 cases of pelvic inflammatory disease (PID) and saved $177 per patient compared with no screening. Compared with urine-based NAAT, screening with RIS using clinician-obtained vaginal swabs prevented an additional 220 cases of PID and had an incremental cost effectiveness ratio of $6490 per quality-adjusted life year (QALY). Results were sensitive to assumptions about loss to follow-up, gonorrhea prevalence, and test costs. Conclusion: Screening females aged 15 to 29 for gonorrhea in some urban EDs will prevent substantial reproductive morbidity. Screening with rapid, point-of-care tests is cost effective compared with other well-accepted preventive interventions. The promise of a noninvasive rapid test that permits immediate treatment for gonorrhea, and the results of our analysis, lend support to the emerging consensus that further declines in gonorrhea rates in the United States may require public health investments in new, high-prevalence settings (such as EDs) as the next critical frontier for STD screening. We found that screening women aged 15 to 29 for gonorrhea with urine-based NAAT in an urban EDs provided cost savings to society compared to no screening and prevented substantial morbidity. Screening with rapid, point-of-care tests was found to be cost-effective compared to other well-accepted preventive interventions.