Abstract | IMPORTANCE:
Onychomycosis is the most common disease of the nail in adults. International guidelines urge health care professionals to perform confirmatory diagnostic testing before initiating systemic therapy. This approach was determined to be cost-effective in studies from the late 1990s but has not been evaluated more recently. The effect of testing on the costs of efinaconazole, 10%, topical solution treatment is unknown. OBJECTIVE: DESIGN, SETTING, AND PARTICIPANTS: A decision analysis that compared the costs of 3 onychomycosis management algorithms based on recently published data of test statistics, disease prevalence, and relevant costs: (1) empirical therapy without confirmatory testing, (2) pretreatment confirmatory testing with potassium hydroxide (KOH) stain followed by periodic acid-Schiff (PAS) evaluation if KOH testing is negative, and (3) pretreatment testing with PAS. There was no direct patient evaluation. Selection of included studies was based on outcome variables and the quality of study design. The study was conducted from April 1, 2014, to September 1, 2015. MAIN OUTCOMES AND MEASURES: RESULTS: At a disease prevalence of 75%, per-patient cost savings of empirical terbinafine therapy without confirmatory testing was $47 compared with the KOH screening model and $135 compared with PAS testing. The cost of testing necessary to prevent a single case of clinically relevant liver toxic effects related to terbinafine at a prevalence of 75% was between $18.2 million and $43.7 million for KOH screening and between $37.6 million and $90.2 million for PAS testing. At a prevalence of 75%, KOH screening and PAS testing before treatment with efinaconazole, 10%, saved $272 and $406 per patient per nail, respectively. CONCLUSIONS AND RELEVANCE: These results show that empirical treatment with terbinafine for patients with suspected onychomycosis is more cost-effective than confirmatory testing across all prevalence of disease, with minimal effect on patient safety. In contrast, confirmatory testing before treatment with efinaconazole, 10%, is associated with reduced costs. Blanket recommendations for confirmatory testing before systemic therapy should be reconsidered and replaced with recommendations tailored to specific therapies.
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Authors | Anar Mikailov, Jeffrey Cohen, Cara Joyce, Arash Mostaghimi |
Journal | JAMA dermatology
(JAMA Dermatol)
Vol. 152
Issue 3
Pg. 276-81
(Mar 2016)
ISSN: 2168-6084 [Electronic] United States |
PMID | 26716567
(Publication Type: Comparative Study, Journal Article, Pragmatic Clinical Trial)
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Chemical References |
- Hydroxides
- Naphthalenes
- Potassium Compounds
- Triazoles
- Terbinafine
- efinaconazole
- potassium hydroxide
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Topics |
- Administration, Oral
- Administration, Topical
- Algorithms
- Cost Savings
(economics)
- Cost-Benefit Analysis
(statistics & numerical data)
- Decision Support Techniques
- Decision Trees
- Health Care Costs
(statistics & numerical data)
- Humans
- Hydroxides
(economics)
- Naphthalenes
(adverse effects, economics, therapeutic use)
- Onychomycosis
(diagnosis, drug therapy, economics)
- Periodic Acid-Schiff Reaction
- Potassium Compounds
(economics)
- Potentially Inappropriate Medication List
(economics)
- Terbinafine
- Triazoles
(adverse effects, economics, therapeutic use)
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