Cost-effectiveness of Confirmatory Testing Before Treatment of XXXX .

@entity1 @entity3071 @entity8974 @entity4014 @entity36018 @entity6313
Importance: @entity6313 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 @entity36018 , 10%, topical solution treatment is unknown. Objective: To evaluate the cost and potential harm associated with 3 approaches to @entity6313 evaluation before treatment with oral @entity8974 or @entity36018 , 10%. Design, Setting, and @entity1 : A decision analysis that compared the costs of 3 @entity6313 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 @entity4014 ( @entity3071 ) stain followed by periodic acid-Schiff (PAS) evaluation if @entity3071 testing is negative, and (3) pretreatment testing with PAS. There was no direct @entity1 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: Primary outcomes included direct cost of @entity6313 testing and therapy and cost to avoid harm when treating @entity1 with oral @entity8974 . Results: At a disease prevalence of 75%, per- @entity1 cost savings of empirical @entity8974 therapy without confirmatory testing was  47 compared with the @entity3071 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 @entity8974 at a prevalence of 75% was between  18.2 million and  43.7 million for @entity3071 screening and between  37.6 million and  90.2 million for PAS testing. At a prevalence of 75%, @entity3071 screening and PAS testing before treatment with @entity36018 , 10%, saved  272 and  406 per @entity1 per nail, respectively. Conclusions and Relevance: These results show that empirical treatment with @entity8974 for @entity1 with suspected @entity6313 is more cost-effective than confirmatory testing across all prevalence of disease, with minimal effect on @entity1 safety. In contrast, confirmatory testing before treatment with @entity36018 , 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.
