Saldarriaga Enrique M, Pollock Emily D, Jackson David A, Gift Thomas L, Barbee Lindley A, Bachmann Laura H, Spicknall Ian H
National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention, and the Center for Forecasting and Outbreak Analytics, Centers for Disease Control and Prevention, Atlanta, Georgia.
Obstet Gynecol. 2025 Aug 7. doi: 10.1097/AOG.0000000000006019.
The traditional syphilis screening algorithm, which involves a nontreponemal assay followed by confirmatory treponemal testing, has been challenged by an alternative approach known as the reverse sequence algorithm. The latter reverses the order of the tests and incorporates a second treponemal test for discordant results. Although the reverse sequence may offer operational advantages, there is a need for formal cost-effectiveness analyses to compare these two syphilis screening alternatives.
We conducted cost-effectiveness analyses from the health care sector perspective to compare the reverse sequence with the traditional algorithm. We employed a decision tree for pregnant women in prenatal care that included the possibility of congenital syphilis outcomes. A simulated a cohort of 10,000 people was screened over 1 year to estimate total costs and quality-adjusted life-years (QALYs) under each algorithm. We estimated incremental cost-effectiveness ratios (ICERs). Sensitivity analyses were performed to identify influential parameters affecting the ICERs and to conduct scenario analyses.
During prenatal care, the reverse sequence detected four more cases, overtreated 185 more individuals, and prevented 0.42 more congenital syphilis cases (ICER $463,735/QALY gained), when compared with the traditional algorithm. Sensitivity analyses revealed that syphilis prevalence had the greatest effect on the ICER. To achieve ICERs below $50,000/QALY gained, syphilis prevalence would need to exceed 6% during prenatal care.
Our analysis indicates that, under likely parameter values, the reverse sequence algorithm is equally effective but more costly than the traditional algorithm and therefore not cost effective. Although treponemal test automation may offer potential savings in laboratory costs, these are outweighed by overtreatment costs.
传统的梅毒筛查算法是先进行非梅毒螺旋体检测，然后进行确证性梅毒螺旋体检测，这种算法受到了另一种称为反向序列算法的挑战。后者颠倒了检测顺序，并对结果不一致的情况采用第二次梅毒螺旋体检测。尽管反向序列可能具有操作上的优势，但仍需要进行正式的成本效益分析来比较这两种梅毒筛查方法。
我们从医疗保健部门的角度进行成本效益分析，以比较反向序列算法与传统算法。我们为产前护理中的孕妇使用了决策树，其中包括先天性梅毒结果的可能性。模拟了一组10000人在1年内进行筛查，以估计每种算法下的总成本和质量调整生命年（QALY）。我们估计了增量成本效益比（ICER）。进行敏感性分析以确定影响ICER的有影响力的参数并进行情景分析。
在产前护理期间，与传统算法相比，反向序列算法多检测出4例病例，多过度治疗了185人，并多预防了0.42例先天性梅毒病例（获得每QALY的ICER为463735美元）。敏感性分析表明，梅毒患病率对ICER影响最大。要使获得每QALY的ICER低于50000美元，产前护理期间梅毒患病率需超过6%。
我们的分析表明，在可能的参数值下，反向序列算法与传统算法同样有效，但成本更高，因此不具有成本效益。尽管梅毒螺旋体检测自动化可能会节省实验室成本，但这些节省被过度治疗成本所抵消。
