Table 2 Summary of the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist for the included studies

Year of publication

2020

2002

2018

2021

2018

1999

2022

2023

2004

2013

Country

Canada

Canada

United States of America

United States of America

Hong Kong

Canada

Spain

USA

United States of America

Canada

Study perspective

Health system perspective

Health care system perspective

Hospital perspective, Third-Party payer perspective, Societal perspective

Health service provider perspective

Health-care system perspective (Societal perspective because in Canada)

Health care system perspective

Intervention

Active testing of groups at increased risk of acquiring Covid-19 (community health care workers and people at long-term care facilities)

Rapid influenza A virus infection diagnostic service

Targeted infection prevention multimodal intervention program for catheter associated urinary tract infections

Two interventions were modeled: an extensively drug-resistant organism registry plus a CRE prevention bundle

3 screening strategies:

TB Xpert screening, TB chest X-ray screening and, LTBI and TB interferon-gamma release assays and chest X-ray screening

Screening with the tuberculin test plus chemoprophylaxis for those at high risk for TB

COVID-19 screening strategy for second wave: serialization of positive serologies for COVID-19 on a quarterly basis in order to avoid performing unnecessary AIDT (PCR or rapid test of antigens), sick leave, and quarantines

Care bundle consisting of 5 components: (1) close monitoring of staff’s

hand hygiene compliance when handling residents; (2) routine

checking of residents’ hydration status; (3) effective residents’ incontinence

and perineal care; (4) in-house UTI treatment and monitor of

antibiotic use; and (5) daily updates regarding the bundle implementation

progress at morning medical staff huddles

Routine glove-use

Three screening strategies for TB on entry to long term care facilities

Comparators

Status quo (= current strategy) defined based on the testing performed between July 8 and 17, 2020, which includes testing of symptomatic people and limited testing of asymptomatic people (e.g., some individuals with exposure or at high risk of exposure).

6 control nursing homes and 6 experimental nursing homes

6 control nursing homes and 6 intervention nursing homes

No intervention scenario

No screening strategy

Intervention screening strategy and current standard of care (case-finding and treatment approach)

Baseline status

Contact-Isolation Precautions Section

No screening

Study design

Cross-sectional study

Randomized clinical trial

Retrospective analysis of randomized clinical trial

Simulation and modelling

A simplified decision analytic process based on Markov model

Modelling

Retrospective observational study

This Quality assurance and performance improvement initiative consisted of 3 stages: a baseline, an intervention and a follow-up

(Crossover design)

Random allocation of two similar sections of the skilled-care unit to one of the infection-control strategies

Modelling

Discount rate

Discounting done, but the rate is not specified.

Discounting done, but the rate is not specified.

The costs and effectiveness outcomes were discounted at an annual rate of 5% and adjusted by half-cycle correction.

5%

3%

Health outcomes

Number of people sampled

For influenza A + residents: illness duration, antibiotic prescription rates (number of times the drug was prescribed, the doses prescribed & duration of the treatment), length of hospital stay

Rate of hospitalization (experimental vs. control)

Attack rate

Mortality rate

QALYs lost related to CAUTI

Number of CRE infections

Number of CRE-attributable deaths

QALYs lost

LYs and QALYs

Incremental costs per case avoided per life-year and per quality-adjusted life-year; Incremental costs per death avoided per life-year and per quality-adjusted life-year; Annualized measurements of health events and the cost impact of screening an annual number of INH related hepatitis and INH-related deaths, an annual number of TB cases, and TB-related deaths, and the annual cost increment per 1000 institutionalized patients)

Number of PCR tests, sick day leaves and quarantines avoided

UTI rates

Acquisition of microbial organisms (MRSA, extended-spectrum β-lactamase (ESBL)-producing Klebsiella pneumoniae (KP), ESBL-producing Escherichia coli (EC), Vancomycin resistant enterococci) measured by positive cultures

Number of cases

Measurement of effectiveness

Cost-benefit

Cost-effectiveness (cost-utility)

Cost- effectiveness (cost-utility & cost-benefit)

Cost- effectiveness

(cost-utility & cost-benefit)

Cost-effectiveness (cost-utility & cost-benefit)

Cost- effectiveness (cost-utility & cost-benefit)

Cost-saving

Cost-saving

Cost-minimization

Cost-effectiveness (cost-utility)

Currency

Canadian dollars

Canadian dollars

United States dollars

United States dollars

United States dollars

Canadian dollars

United States dollars ^a

United States dollars ^a

United States dollars ^a

Canadian dollars

Price date

2020

1999 ^a

2015

2021 ^a

2018 ^a

1992

2020 ^a

2022 ^a

1999 ^a

2010 ^a

Study findings

Active testing strategies can identify a high proportion of people with SARS-CoV-2 infection and minimal or no symptoms.

Our analysis shows that actively testing populations at increased risk of acquiring SARS-CoV-2 in Canada can be feasible. Systematic tracing and testing of 16 contacts per person given a new diagnosis of SARS-CoV-2 infection marginally increases testing costs and could be accomplished with current laboratory capacity.

Our study shows that the new laboratory service provided for the experimental nursing homes significantly diminished the overall duration of outbreaks of influenza A virus infection in nursing homes in the region.

This cost-effectiveness analysis showed that this intervention program was expected to save $34,000 per year and improve health outcomes by 0·2 QALYs.

Targeting these facilities decreased the prevalence of carriage by a relative 17% and 22% regionwide and within Cook County, respectively, regardless of constraints.

Although no screening offered the greatest cost-saving, LTBI/TB screening was the most effective strategy with highest LYs and QALYs gained and more likely to be cost-effective under the willingness to pay threshold of US$50,000 per QALY gained.

Screening improves the health of the average patient in both baseline and sensitivity analysis.

The serological serialization of coronavirus on a quarterly basis, in residents and employees of our nursing home, has proven to be efficient in avoiding unnecessary expenditures during a coronavirus outbreak, as well as avoiding quarantines and sick leave of participants with positive IgG

The implementation of this novel bundle of care was

successful in (1) achieving a strong decline in UTIs among residents without indwelling catheters which met the initiative goal; (2) maintaining UTIs lower than the national rate for more than 2 years which validated the efficacy and sustainability of the bundle; (3) avoiding hospitalizations through in-house treatment of residents; and (4) reducing antibiotic use. The sharp decline in UTIs also generated a net saving of $33,907 per quarter by reducing costs of diagnostic and follow-up tests, use of antibiotics, and extra care expenses related to medical equipment and staff

There was a similar frequency of transmission of antimicrobial-resistant bacteria in the two study sections; there was evidence for resident-to-resident KP transmission in the isolation-precautions section. Routine glove use for healthcare workers, which decreases resident social isolation and healthcare facility costs, may be preferable in many long-term care facilities.

Our study found that screening was costly, with large numbers needed to screen to prevent a case. Our analysis indicated that tuberculin skin test screening is more cost-effective than CXR screening for prevalent disease.

Screening all entrants to long-term care for TB may not be cost-effective in a low-burden setting.