Cost-Effectiveness Analysis of Rubella Screening Strategies using Electronic Medical Records

Abstract

Objective The redundancy of routine laboratory tests in medicine has become increasingly more apparent in the age of electronic medical records (EMRs). The purpose of this study was to determine whether targeted screening strategies are more cost-effective than the current standard of universal screening of pregnant women for immunity to rubella.

Study Design A decision analysis model was used to evaluate three strategies: universal screening, screening if a previous titer was not available, and use of an “alert” in the EMR to prompt screening. Cost, probability, and utility values were derived from the literature and institutional data from Lyndon B. Johnson General Hospital. One-way sensitivity analyses were performed on all cost and probability values.

Results The strategy of an EMR alert was most cost-effective, with a cost of $0.27 per quality-adjusted life years (QALY). The model was robust to all costs and probability values over their respective ranges.

Conclusions Although all strategies were cost-effective compared with traditional industry benchmarks of $50,000/QALY, the EMR alert strategy is most cost-effective. Implementing an EMR alert may lead to a more cost-effective approach to prenatal evaluation of rubella immunity.

Keywords

cost-effectiveness - electronic medical record - rubella screening - vaccination - decision analysis

• References

• 1 Infections. In: Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rause DJ, Spong CY, , eds. Williams Obstetrics. 22nd ed. New York, NY: McGraw-Hill Companies Inc; 2005: 1280-1282
• 2 Reef S, Redd S, Abernathy E, Icenogle J. Rubella. In: Manual for the Surveillance of Vaccine-Preventable Diseases. 4th ed. Atlanta, GA: Centers for Disease Control and Prevention; 2008. . Available at: http://www.cdc.gov/vaccines/pubs/surv-manual/chpt14-rubella.html . Accessed October 28, 2011
• 3 Centers for Disease Control and Prevention (CDC). Elimination of rubella and congenital rubella syndrome—United States, 1969–2004. MMWR Morb Mortal Wkly Rep 2005; 54: 279-282
• 4 American Academy of Pediatrics and American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008
• 5 Watson JC, Hadler SC, Dykewicz CA, Reef S, Phillips L. Centers for Disease Control and Prevention. Measles, mumps, and rubella—vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1998; 47 (RR-8) 1-57
• 6 American College of Obstetricians and Gynecologists. Frequently asked questions: FAQ133. Pregnancy. ACOG; 2011. Available at: http://www.acog.org/~/media/For%20Patients/faq133.pdf?dmc=1&ts=20120605T1251142222 . Accessed May 30, 2012
• 7 Stair TO. Reduction of redundant laboratory orders by access to computerized patient records. J Emerg Med 1998; 16: 895-897
• 8 Bates DW, Kuperman GJ, Rittenberg E , et al. A randomized trial of a computer-based intervention to reduce utilization of redundant laboratory tests. Am J Med 1999; 106: 144-150
• 9 United States Department of Labor. CPI inflation calculator. Available at: www.bls.gov/data/inflation_calculator.htm . Accessed August 8, 2012
• 10 Centers for Disease Control. Vaccines and immunizations programs and tools: CDC vaccine price list. Available at: http://www.cdc.gov/vaccines/programs/vfc/awardees/vaccine-management/price-list/index.html . Accessed January 12, 2010
• 11 Orenstein WA, Bart KJ, Hinman AR , et al. The opportunity and obligation to eliminate rubella from the United States. JAMA 1984; 251: 1988-1994
• 12 Lugnér AK, Mollema L, Ruijs WLM, Hahné SJM. A cost-utility analysis of antenatal screening to prevent congenital rubella syndrome. Epidemiol Infect 2010; 138: 1172-1184
• 13 Zimmerman L, Reef SE. Incidence of congenital rubella syndrome at a hospital serving a predominantly Hispanic population, El Paso, Texas. Pediatrics 2001; 107: E40
• 14 Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. 11th ed. Washington, DC: Public Health Foundation; 2009: 257-272
• 15 Centers for Disease Control. Georgia: National vital statistics system birth data: 007; c1999 [updated December 21, 2010; cited November 1, 2009]. Available at: http://www.cdc.gov/nchs/births.htm . Accessed October 28, 2011
• 16 Bonini P, Plebani M, Ceriotti F, Rubboli F. Errors in laboratory medicine. Clin Chem 2002; 48: 691-698
• 17 Centers for Disease Control. Media Release: Death rate 2011. c1999 [updated March 16, 2011]. Available at: http://www.cdc.gov/media/releases/2011/p0316_deathrate.html . Accessed September 11, 2012
• 18 Gilbert WM, Hanson LX, Mosquera M, Moore TR. Cost effectiveness of routine intrapartum rubella screening in a high-risk population. J Matern Fetal Neonatal Med 1995; 4: 262-264
• 19 Robinson JL, Lee BE, Preiksaitis JK, Plitt S, Tipples GA. Prevention of congenital rubella syndrome—what makes sense in 2006?. Epidemiol Rev 2006; 28: 81-87
• 20 Schrag SJ, Fiore AE, Gonik B , et al. Vaccination and perinatal infection prevention practices among obstetrician-gynecologists. Obstet Gynecol 2003; 101: 704-710
• 21 Centers for Disease Control and Prevention (CDC). Rubella and congenital rubella syndrome—United States, 1994–1997. MMWR Morb Mortal Wkly Rep 1997; 46: 350-354
• 22 Osheroff JA, Teich JM, Levick D , et al. Improving Outcomes with Clinical Decision Support: An Implementers Guide. Chicago, IL: Health Information Management Systems Society; 2012
• 23 van Walraven C, Raymond M. Population-based study of repeat laboratory testing. Clin Chem 2003; 49: 1997-2005
• 24 Montana Department of Public Health and Human Services. Serology prices. Available at: www.dphhs.mt.gov/publichealth/lab/documents/Serology.pdf . Accessed August 8, 2012