Clinical Impact, Costs, and Cost-Effectiveness of Expanded SARS-CoV-2 Testing in Massachusetts

Neilan, Anne M; Losina, Elena; Bangs, Audrey C; Flanagan, Clare; Panella, Christopher; Eskibozkurt, G Ege; Mohareb, Amir; Hyle, Emily P; Scott, Justine A; Weinstein, Milton C; Siedner, Mark J; Reddy, Krishna P; Harling, Guy; Freedberg, Kenneth A; Shebl, Fatma M; Kazemian, Pooyan; Ciaranello, Andrea L

BACKGROUND: We projected the clinical and economic impact of alternative testing strategies on COVID-19 incidence and mortality in Massachusetts using a microsimulation model. METHODS: We compared four testing strategies: 1) Hospitalized: PCR testing only patients with severe/critical symptoms warranting hospitalization; 2) Symptomatic: PCR for any COVID-19-consistent symptoms, with self-isolation if positive; 3) Symptomatic+asymptomatic-once: Symptomatic and one-time PCR for the entire population; and, 4) Symptomatic+asymptomatic-monthly: Symptomatic with monthly re-testing for the entire population. We examined effective reproduction numbers (R(e), 0.9-2.0) at which policy conclusions would change. We assumed homogeneous mixing among the Massachusetts population (excluding those residing in long-term care facilities). We used published data on disease progression and mortality, transmission, PCR sensitivity/specificity (70/100%) and costs. Model-projected outcomes included infections, deaths, tests performed, hospital-days, and costs over 180-days, as well as incremental cost-effectiveness ratios (ICER, $/quality-adjusted life-year [QALY]). RESULTS: At R(e) 0.9, Symptomatic+asymptomatic-monthly vs. Hospitalized resulted in a 64% reduction in infections and a 46% reduction in deaths, but required >66-fold more tests/day with 5-fold higher costs. Symptomatic+asymptomatic-monthly had an ICER <$100,000/QALY only when R(e) ≥1.6; when test cost was ≤$3, every 14-day testing was cost-effective at all R(e) examined. CONCLUSIONS: Testing people with any COVID-19-consistent symptoms would be cost-saving compared to testing only those whose symptoms warrant hospital care. Expanding PCR testing to asymptomatic people would decrease infections, deaths, and hospitalizations. Despite modest sensitivity, low-cost, repeat screening of the entire population could be cost-effective in all epidemic settings.