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Optimising the management of vaginal discharge syndrome in Bulgaria: cost-effectiveness of four clinical algorithms with risk-assessment
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Edité par CCSD ; BMJ Publishing Group -
International audience. Objectives: To evaluate the performance and cost-effectiveness of the WHO recommendations of incorporating risk-assessment scores and population prevalence of Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) into vaginal discharge syndrome (VDS) algorithms. Methods: Non-pregnant women presenting with VDS were recruited at a non-governmental sexual health clinic in Sofia, Bulgaria. NG/CT was diagnosed by PCR and vaginal infections by microscopy. Risk factors for NG/CT were identified in multivariable analysis. Four algorithms based on different combinations of behavioural factors, clinical findings and vaginal microscopy were developed. Performance of each algorithm was evaluated for detecting vaginal and cervical infections separately. Cost-effectiveness was based on cost-per-patient-treated and cost-per-case-correctly-treated. Sensitivity analysis explored the influence of NG/CT prevalence on cost-effectiveness. Results: 60% (252/420) of women had genital infections, with 9.5% (40/423) having NG/CT. Factors associated with NG/CT included new and multiple sexual partners in the last 3 months, symptomatic partner, childlessness, and >10 polymorphonuclear cells-per-field on vaginal microscopy. For NG/CT detection, the algorithm that relied solely on behavioural risk-factors was less sensitive but more specific than those that included speculum exam or microscopy but had higher correct-treatment rate and lower over-treatment rates. The cost-per-true-case-treated using a combination of risk factors, speculum exam and microscopy was 24.08. A halving and tripling of NG/CT prevalence would have approximately the inverse impact on the cost-effectiveness estimates. Conclusions: Management of NG/CT in Bulgaria was improved by the use of syndromic approach that included risk-scores. Approaches that did not rely on microscopy lost sensitivity but were more cost-effective.
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