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What is a common limitation of a screening measure?

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Page 2

Authors Country Disease Screening tools (strategies) Comparator Population Time horizon Perspective Discounting Monetary units Effectiveness outcome ICER Conclusion of base case Funding Treatment
Albright et al. [55] USA Group B Streptococci Universal screening with rectovaginal swab No screening Women with a prior cesarean delivery and a current singleton pregnancy planning to undergo a repeat cesarean Lifetime Healthcare 3% 2015 USD Neonatal QALYs Yes Not CE NA Yes
Aronsson et al. [12] Sweden Colorectal cancer (CRC) 1. Fecal immunochemical test (FIT) twice 2. Colonoscopy (once) 3. FIT every 2 years

4. Colonoscopy every 10 years

No Screening 60-year-old Swedish Lifetime Healthcare 3% EUR (no year) QALYs No All strategies were CE vs no screening SCREESCO study Yes
Atkin et al. [18] UK Colorectal cancer 13 different Sttrategies Each other and “no colonoscopy” Individuals with intermediate-grade adenomatous polyps Lifetime NHS 4% 2012–2013 GBP QALYs, ELYs Yes 3-yearly ongoing colonoscopic surveillance without an age cut-off is CE NIHR Yes
Baggaley et al. [75] UK HIV INSTI HIV1/HIV2 rapid antibody test Not clear Hackney Borough 40 years NHS 4% 2012 GBP QALYs Yes Screening is CE NHS, NIHR Yes
Barzi et al. [19] USA Colorectal cancer 13 screening tools: fecal occult blood test, Flex sig, colonoscopy, CT, DNA. No screening US population 35 years Societal 3% USD (no year) Life years gained No Colonoscopy is CE National Cancer Institute Core Yes
Bleijenberg et al. [13] Netherlands Frailty 1. Electronic frailty screening instrument (EFSI)
2. EFSI and nurse-led care program 		Usual care Patients aged 60 or older 1 year Societal 0% 2012 EUR QALYs No EFSI has high probability of being CE. The combination showed less value for money. NA Yes
Cadier et al. [66] France and USA Hepatocellular Carcinoma Biannual ultrasound + MRI + CT + biopsy Real life Patients with diagnosis of compensated cirrhosis 10 years Healthcare 4% 2015 (Unknown) Life years gained Yes Biannual ultrasound (gold standard) screening is CE No funding Yes
Wrenn et al. [79] USA Incidental gallbladder carcinoma Cholecystectomy Not clear Cholecystectomies performed between 06/2009 and 06/2014 NA NA NA NA ELYs No Selective screening based on risk factors of specimen may be a more CE approach. University of Vermont Medical Center Department of Surgery Yes
Campos et al. [20] 50 low- and middle-income countries Cervical cancer 1. Two-dose human papilloma virus (HPV) vaccination
2. One-time screening + treatment when neededz3. Cervical cancer treatment 		Each other 1. 10-year-old girls2. 35-year-old women3. Women with cervical cancer Lifetime Payer 3% 2013 USD DALYs No Both HPV vaccination and screening would be very CE American Cancer Society Yes
Chen et al. [45] China Hearing loss Neonatal hearing screening None Newborns 15 and 82 years NA 3% 2012 RMB 2012 RMB No Newborn hearing screening and intervention program in Shanghai is justified in terms of the resource input National Natural Science Foundation of China Yes
Cheng et al. [76] China Hepatitis E 1. Screening (HEV antibody) and vaccination
2. Universal vaccination 		No vaccination 60-year-old cohort 16 years Societal 3% 2016 USD QALYs Yes Screening and vaccination is the most CE hepatitis E intervention strategy Chinese National Natural Fund Yes
Chevalier et al. [70] France Coronary artery disease Maximal exercise test (ET) None Men aged > 35 years, with more than 2 h a week of training NA NA NA EUR (no year) Cardiovascular disease cases No ET should be targeted at men with at least two cardiovascular risk factors None No
Chowers et al. [21] Israel Human immunodeficiency virus (HIV) Prenatal HIV screening Current policy Newborns 100 years Payer 4% NIS (no year) QALYs No Universal prenatal HIV screening is projected to be cost saving in Israel NA Yes
Coyle et al. [22] Canada Cancer Computed tomography (CT) scan + occult cancer screening Cancer screening alone Patients with unprovoked VTE 12 months Healthcare 0% CAD (no year) QALYs and Missed cancer case No CT scan of the abdomen/pelvis for the screening of occult cancer is not CE Heart and Stroke Foundation of Canada No
Cressman et al. [56] Canada Lung cancer Low-dose computed tomography (LDCT) Chest radiography 60-year-olds 30 years Societal 3% 2015 CAD QALYs Yes High-risk lung cancer screening with LDCT is likely to be considered CE Terry Fox Research Institute Yes
Crowson et al. [23] USA Vestibular schwannomas Non-contrast screening
Magnetic resonance imaging (MRI) 		Full MRI protocol with contrast Patients with asymmetric sensorineural hearing loss NA 3rd-party payer NA USD (no year) Useful results (True positives and true negatives) No A screening MRI protocol is more CE than a full MRI with contrast None No
Devine et al. [24] Thailand-Myanmar Perinatal hepatitis B 1. Hepatitis immunoglobulin (HBIG) after rapid diagnostic tests
2. HBIG after confirmatory test 		Vaccination alone Refugee and migrant population on the Thailand-Myanmar border From first contact to childbirth Healthcare NA USD (no year) Perinatal infection of Hepatitis B Yes HBIG following rapid diagnostic test is CE Wellcome-Trust Major Overseas Programme in SE Asia No
Devine et al. [46] Thailand-Myanmar Plasmodium vivax G6PD testing [1] chloroquine alone
[2] primaquine without screeningz 		Refugee and migrant population on the Thailand-Myanmar border 1 year Healthcare NA 2014 USD DALYs Yes G6PD RDTs to identify patients with G6PD deficiency before supervised primaquine is likely to provide significant health benefits Welcome-Trust Major Overseas Programme in SE Asia Yes
Ditkowsky et al. [25] USA Chlamydia trachomatis Chlamydia screening No Screening Pregnant women aged 15–24 1 year Healthcare NA 2015 USD 2015 USD No Prenatal screening for C. trachomatis resulted in increased expenditure, with a significant reduction in morbidity to woman-infant pairs None Yes
Ethgen et al. [14] France Hepatitis C (HCV) 1. IFN + RBV + PI for F2–F4 2. IFN-based DAAs for F2–F4 3. All-oral, IFN-free DAAs for F2–F4

4. All-oral, IFN-free DAAs for F0–F4

No intervention French baby-boomer population (1945–1965 birth cohorts) 20 years Healthcare 4% EUR (no year) QALYs, liver-related deaths No HCV screening and access to all-oral DAAs is CE AbbVie Yes
Ferguson et al. [69] Canada Chronic kidney disease (CKD) CKD screening Usual care Rural Canadian indigenous populations 45 years Healthcare 5% 2013 CAD QALYs Yes Targeted screening and treatment for CKD is CE University of Manitoba, CIHR Yes
Ferrandiz et al. [26] Spain Skin cancer Clinical teleconsultations (CTC) CTC + dermoscopic teleconsultation Patients visiting 5 participating primary care centers because of concern over lesions suggestive of skin cancer NA NA NA EUR (no year) Detected cases No Dermoscopic images improve the results of an internet-based skin cancer screening system Health Council of the Regional Government of Andalusia-Spain No
Goede et al. [27] Canada Colorectal cancer (CRC) Fecal immunochemical testing (FIT) Guaiac fecal occult blood testing and no screening 40-year-old screening participants at average risk of CRC Varied (20 to 45 years) Healthcare 3% 2013 CAD QALYs Yes FIT was the most CE strategy Ontario Ministry of Health and Long-Term Care Yes
Gray et al. [47] UK Breast cancer 1. Risk 1 2. Risk 2 3. Masking

4. Risk 1 + masking

No screening Women eligible for a National Breast Screening Program (NBSP) Lifetime NHS 4% 2014 GBP QALYs Yes Risk stratified NBSPs were relatively CE compared to the UK NBSP FP7-HEALTH-2012-INNOVATION-1 Yes
Gupta et al. [28] USA Cystic lung disease High-resolution computed tomographic (HRCT) imaging no HRCT screening Patients with Spontaneous Pneumothorax NA Societal 3% 2014 USD QALYs Yes HRCT image screening is CE None Yes
Haukaas et al. [44] Norway Tuberculosis (TB) 1. TST + IGRA 2. IGRA

3. IGRA for risk

No screening Immigrants under 35 years of age from countries with a high incidence of TB 10 years Healthcare 4% 2013 EUR Avoided TB cases Yes IGRA is the optimal algorithm at a threshold above €28,400 None No
Heidari et al. [29] Iran Hearing loss 1. AABR
2. OAE 		Each other Newborns 1 year Healthcare NA IRR (no year) Detected cases No AABR is the CE alternative compared to OAE I.R. Iran’s National Institute of Health Research No
Horn et al. [30] USA Substance abuse 1. Minimal screening 2. Screening, assessment and referral

3. 2 + brief intervention and follow-up

Each other Patients from emergency departments of 6 clinical sites across the US 1 year NA NA 2013 USD 2013 USD No Resources could be better utilized supporting other health interventions. NA Yes
Htet et al. [71] Myanmar Pulmonary tuberculosis Interventional model Conventional model Household contacts 5 months NA NA USD (no year) Detected cases Yes The interventional model was more CE than the modified conventional model. NA No
Hunter et al. [31] USA Breast cancer Digital breast tomosynthesis Full-field digital mammography Patients undergoing screening mammography 1 year NA NA 2014 USD Cancer detected No DBT is a cost-equivalent or potentially CE alternative to FFDM NA No
John et al. [48] India Glaucoma Community screening No screening people aged 40–69 years in urban areas in India 10 years Healthcare 3% 2015 INR Additional treated cases, QALYs Yes A community screening program is likely to be CE NZAID Commonwealth Scholarship Yes
Keller et al. [68] Australia Prostate cancer Serum prostate specific antigen (PSA) test every 2 years Opportunistic screening Australian male cohort aged between 50 and 69 years. 20 years Healthcare 5% 2015 AUD QALYs Yes PSA-based screening is not CE University of Queensland Yes
Kievit et al. [32] Netherlands Cardiovascular (CV) disease CV risk profiling No screening Patients with rheumatoid arthritis (RA) 10 years Medical 4% for costs and 1.5% for outcomes EUR (no year) QALYs No Screening for CV events in RA patients was estimated to be CE NA Yes
Kim et al. [49] South Korea Hepatitis C One-time screening No screening People aged 40–70 5 years Healthcare 5% USD (no year) QALYs Yes HCV screening and treatment is likely to be highly CE Bristol-Myers Squibb Pharmaceuticals Yes
Kim et al. [63] USA Human Papillomavirus 1. Cytology 2. HPV test

3. Co-test

Each other US women 10–44 years Societal 3% USD (no year) QALYs No Screening can be modified to start at later ages and at lower frequencies National Cancer Institute of the National Institutes of Health No
Lapointe-Shaw et al. [72] USA Carbapenemase-producing Enterobacteriaceae Rectal swab screening No screening 65-year-old patients admitted to a general medical inpatient service. 19.2 years US Hospital 3% 2016 USD QALYs Yes Screening inpatients for CPE carriage is likely CE None No
Lew et al. [58] Australia Colorectal cancer Projected iFOBT screening No screening People aged 50–74 24 years Health services 5% 2015 AUD Life years gained No The program is highly CE Cancer Institute NSW and Cancer Council NSW Yes
Liow et al. [77] USA Bone malignancies Routine femoral head histopathology None Patients that underwent primary total hip arthroplasty 4 years NA NA 2016 USD QALYs Yes Routine femoral head histopathology may be CE NA Yes
Mo et al. [15] China Cervical cancer 1. Liquid-based cytology test + HPV DNA test 2. Pap smear cytology test + HPV DNA test

3. Visual inspection with acetic acid

No intervention Adolescent girls (Above 12 years old) Lifetime Societal 3% 2015 USD QALYs Yes The HPV4/9 vaccine with current screening strategies was highly CE Japan Society for the Promotion of Sciences Yes
Morton et al. [50] UK Breast cancer Mammography No screening Females over 45 years old 20 years NHS 4% 2016 GBP QALYs Yes Calculations suggested that breast cancer screening is CE NA Yes
Mullie et al. [51] Canada and USA Latent tuberculosis 1. Tuberculin skin test
2. QuantiFERON®-TB-Gold In-Tube 		Each other Healthcare workers 20 years Healthcare 3% 2015 CAD QALYs Yes Annual tuberculosis screening appears poorly CE McGill University, CIHR Yes
Petry et al. [16] Germany Human papillomavirus 1. HPV test followed by Pap cytology 2. HPV test followed by cytology 3. HPV test followed by colposcopy

4. Co-testing with HPV and Pap

Pap cytology Women aged 30–65 10 years NA 3% EUR (no year) Avoided deaths No The greatest clinical impact was achieved with primary HPV screening (with genotyping) followed by colposcopy Hoffmann-La Roche Yes
Phisalprapa et al. [33] Thailand Nonalcoholic fatty liver disease Ultrasonography screening No screening 50-year-old metabolic syndrome patients Lifetime Societal 3% 2014 USD QALYs Yes Ultrasonography screening for NAFLD with intensive weight reduction program is CE NA Yes
Pil et al. [59] Belgium Skin Cancer Total body skin examination (TBSE) Lesion-directed screening Belgian population over 18 years of age 50 years Societal Outcomes at 1.5% and costs at 3% EUR (no year) QALYs Yes 1-time TBSE is the most CE strategy The LEO Foundation and the Belgian Federation Against Cancer Yes
Prusa et al. [80] Austria Toxoplasmosis Prenatal screening No screening Birth cohorts from 1992 to 2008 and 20 years Societal 3% 2012 Euro Life and productivity loss No Cost savings of prenatal screening for toxoplasmosis and treatment are outstanding None Yes
Requena-Mendez et al. [34] All Europe Chagas disease T. cruzi serological screening No screening Latin American adults living in Europe Lifetime Healthcare 3% EUR (no year) QALYs YES Screening for Chagas disease in asymptomatic Latin American adults living in Europe is a CE strategy. European Commission 7th Framework Program Yes
Roberts et al. [60] Australia Rheumatic heart disease Echocardiographic screening Screening every other year and no screening Indigenous Australian Children 40 years Healthcare 5% 2013 AUD DALYs, heart failure, surgery Yes Echocardiographic screening is CE assuming that RHD can be detected ≥ 2 years earlier by screening University of Western Australia Yes
Rodriguez-Perez et al. [64] Spain Type 2 diabetes DIABSCORE HbA1c or blood glucose Adult primary care patients in Spain NA NA NA EUR (no year) Cases detected No DIABSCORE is a CE and valid method for opportunistic screening of type 2 diabetes Carlos III Health Institute No
Saito et al. [35] Japan Gastric cancer ABC method: HPA and measuring serum PG concentrations Annual endoscopic screening 50-year-old Japanese individuals who have high gastric cancer incidence and mortality who had not undergone H. pylori eradication 30 years Healthcare 2% 2014 USD Lives saved and QALYs Yes ABC method cost less and saved more lives Niigata University of Health and Welfare Yes
Schiller-Fruehwirth et al. [36] Austria Breast cancer 1. Organized screening
2. Opportunistic screening 		No screening 40-year-old asymptomatic women Lifetime Healthcare 3% 2012 EUR Life years gained Yes The decision to adopt organized screening is likely an efficient use of limited health care resources in Austria Main Association of Social Security Institutions Yes
Selvapatt et al. [65] UK Hepatitis C HCV testing No screening All persons attending a London DTU Lifetime Healthcare 4% 2013 GBP ELYs, QALYs Yes Concludes cost effectiveness of outreach testing and treatment of hepatitis Biomedical Research Council to Imperial College Department of Hepatology Yes
Sharma et al. [61] Lebanon Cervical cancer 1. Cytology
2. HPV DNA screen 		No screening Women aged 25–65 years NA Societal 3% I$ (no year) Years of life saved Yes Increasing coverage to 50% with extended screening intervals provides greater health benefits None Yes
Smit et al. [73] Belgium Tuberculosis X-ray screening No screening Risk groups: prisoners, youth in detention centers, undocumented migrants 1 year Flemish Agency for Care and Health 0% 2013–14 EUR Detected cases No Tuberculosis screening is relatively expensive Flemish Agency for Care and Health No
Ten Haaf et al. [52] Canada Lung cancer Computer tomography No screening Persons born between 1940 and 1969 Lifetime Healthcare 3% 2015 CAD Life years gained, false positive screen Yes Lung cancer screening with stringent smoking eligibility criteria can be CE Clinical Evaluative Sciences Yes
Teng et al. [62] New Zealand Helicobacter pylori infection, gastric cancer 1. Fecal antigen
2. Serology 		Current practice Total population and targeted Māori (25–69 years old) Lifetime Healthcare 3% 2011 USD QALYs Yes Screening was likely to be CE particularly for indigenous populations Health Research Council of New Zealand Yes
Tjalma et al. [37] Belgium Cervical cancer Dual stain cytology Cytology Women between 25 and 65 years of age 60 years Healthcare NA EUR (no year) QALYs Yes Diagnostic cytology benefits all stakeholders involved in cervical cancer screening NA Yes
Tufail et al. [38] UK Diabetic retinopathy Automated diabetic retinopathy image assessment systems (ARIAS) Human graders Patients with a diagnosis of diabetes mellitus who attended their annual visit at the diabetes eye-screening program NA NHS 4% 2013–2014 GBP Appropriate screening outcome No ARIAS have the potential to reduce costs and to aid delivery of DR screening Novartis No
Meulen et al. [39] Netherlands Colorectal cancer (CRC) 1. Fecal immunology test 2. gFOBT

3. Sigmoidoscopy

Each other Screening-naive subjects ages 50 to 74 years, living in the southwest of the Netherlands Lifetime Healthcare 3% 2012 EUR Positivity rates, detection of adenoma and CRC, QALYs Yes Screening stratified by gender is not more CE than uniform FIT screening NA Yes
van Katwyk et al. [53] Canada Diabetic retinopathy Extended coverage of diabetic eye examination Usual care Prince Edward Island residents over 45 years of age who had diabetes 30 years Healthcare 5% 2015 CAD QALYs Yes Extending public health coverage to eye examinations by optometrists is CE CIHR Yes
van Luijt et al. [67] Norway Breast cancer Mammography No screening Norway female population Lifetime Societal 4% 2014 NOK QALYs No The NBCSP is a highly CE measure to reduce breast cancer specific mortality Research Council Norway Yes
Wang et al. [17] China Chronic kidney disease 1. Day 1 2. Random 3. Day 1 + random

4. Day 1+ random + day 2

Each other Outpatients admitted to Peking University First Hospital from January 2013 to January 2014 30 years Societal 5% CNY (no year) QALYs Yes Combining two first morning urine samples and one randomized spot urine sample is CE National Key Technology R&D Program of the Ministry of Science and Technology Yes
Welton et al. [40] England and Wales Atrial fibrillation 1. Single systematic population screen
2. Single systematic opportunistic screen 		No screening General population in England and Wales Lifetime NHS 4% 2015 GBP QALYs Yes Population-based screening is likely to be CE NIHR Yes
Whittington et al. [74] USA Staphylococcus aureus infection 1. Universal decolonization 2. Targeted decolonization

3. Screening and isolation

Each other Hypothetical cohort of adults admitted to the Intensive care unit. 1 year Hospital NA 2015 USD QALYs Yes This study supports updating the standard practice to a decolonization approach. NA No
Williams et al. [41] USA Prosthetic joint infection 1. 4 swabs decolonization 2. 2 swabs

3. Nasal swab alone

No screening and decolonization Hip and knee replacement patients NA Societal NA 2016 USD Cases of prosthetic joint infections No The 2-swab and universal-decolonization strategy were most CE None Yes
Yang et al. [54] Taiwan Lung cancer 1. Computed tomography (CT)
2. Radiography 		No screening Smokers between 55 and 75 years of age Lifetime Healthcare 3% 2013 USD QALYs Yes Low-dose CT screening for lung cancer among high-risk smokers would be CE in Taiwan Ministry of Science and Technology, and the National Cheng Kung University Hospital Yes
Yarnoff et al. [42] USA Chronic kidney disease (CKD) CKD risk scores No screening US population Lifetime Healthcare 3% 2010 USD QALYs Yes CKD risk scores may allow clinicians to cost-effectively identify a broader population for CKD screening Centers for Disease Control and Prevention Yes
Yoshimura et al. [78] Japan Osteoporosis Screening and alendronate therapy No screening and no therapy Postmenopausal women over 60 years 5 years Healthcare 3% USD (no year) QALYs Yes Screening and treatment would be CE for Japanese women over 60 years. Ministry of Education, Culture, Sports, Science and Technology Yes
Zimmermann et al. [43] Kenya Cervical cancer 1. Visual inspection with acetic acid (VIA) 2. Papanicolaou smear

3. Testing for human papillomavirus (HPV)

Cryotherapy without screening Hypothetical cohort of 38-year-old women Lifetime Societal 3% 2014 USD ELYs No VIA was most CE unless HPV could be reduced to a single visit NA Yes

  1. QALYs quality-adjusted life years, ELYs expected life years, RMB Renminbi, USD United States dollar, CAD Canadian dollar, AUD Australian dollar, EUR euro; GBP British pound, NIS Israeli new shekel, IRR Iranian rial, CNY Chinese yuan, INR Indian rupee, NOK Norwegian krone, CE cost-effective, NA not applicable

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