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| Cost-utility analysis of pulmonary tuberculosis screening among elderly patients with diabetes mellitus in Nanjing City based on a decision tree-Markov model |
| JIANG Yan1, WANG Rong1, WEN Jiaxin2
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1. Nanjing Center for Disease Control and Prevention, Nanjing, Jiangsu 210003, China;
2. Gusu District Center for Disease Control and Prevention, Suzhou, Jiangsu 215000, China |
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Abstract Objective To evaluate the cost-utility of different pulmonary tuberculosis screening programs using a decision tree-Markov model, so as to provide the theoretical basis for pulmonary tuberculosis prevention and control strategies among elderly patients with diabetes mellitus in Nanjing. Methods The baseline data for this study were obtained from the National Basic Public Health Service Project Management Information Platform. The baseline cohort consisted of patients with diabetes mellitus aged ≥65 years with no history of active tuberculosis and/or currently taking anti-tuberculosis medications. Based on symptoms and chest X-ray findings, three different screening protocols for pulmonary tuberculosis were developed: a passive screening protocol for patients presenting with symptoms, a two-step screening protocol involving X-ray examination following positive symptoms, and a combined screening protocol involving X-ray examination following symptom-based screening; Treeage Pro 2022 software was used to construct a decision tree-Markov model simulating the incidence and progression of pulmonary tuberculosis in elderly patients with diabetes mellitus. The incremental cost-utility ratio (ICUR) of the three screening strategies was calculated and compared in terms of yuan per quality-adjusted life year (QALY), and sensitivity analyses were performed on the model. Results In a simulated screening of 100 000 elderly patients with diabetes mellitus, the number of pulmonary tuberculosis cases detected by passive screening, two-step screening, and combined screening were 3 116, 4 656, and 5 086, with corresponding detection rates of 3.12%, 4.66%, and 5.09%, respectively. The differences were statistically significant (P<0.05). The number of pulmonary tuberculosis-related deaths were 513, 160, and 82, with corresponding mortality of 16.46%, 3.44%, and 1.61%, respectively, and the differences were also statistically significant (P<0.05). Compared with the passive screening strategy, the ICURs for the two-step screening and combined screening strategies were 37 546.89 yuan/quality-adjusted life-year (QALY) and 77 827.52 yuan/QALY, respectively, both of which demonstrated cost utility. Compared with the two-step screening strategy, the ICUR for the combined screening strategy was 197 395.55 yuan/QALY, demonstrating cost utility. Sensitivity analysis indicated that the results were generally robust; when the willingness-to-pay threshold was set at 241 041 yuan/QALY, the combined screening strategy had the highest probability of being cost-utility effective, at 63.70%. Conclusions Theoretically, the combined screening protocol for pulmonary tuberculosis, consisting of symptom screening followed by X-ray examination, is more cost-utility effective among elderly patients with diabetes mellitus in Nanjing City. Therefore, its implementation is recommended for this population.
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Received: 25 February 2026
Revised: 01 June 2026
Published: 22 June 2026
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