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Chitpim N, Jittikoon J, Udomsinprasert W, Mahasirimongkol S, Chaikledkaew U. Cost-Utility Analysis of Molecular Testing for Tuberculosis Diagnosis in Suspected Pulmonary Tuberculosis in Thailand. CEOR 2022; 14:61-73. [PMID: 35140485 PMCID: PMC8819700 DOI: 10.2147/ceor.s350606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 01/15/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Methods Results Conclusion
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Affiliation(s)
- Natthakan Chitpim
- Social, Economic and Administrative Pharmacy (SEAP) Graduate Program, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Jiraphun Jittikoon
- Department of Biochemistry, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | | | - Surakameth Mahasirimongkol
- Medical Genetics Center, Medical Life Sciences Institute, Department of Medical Sciences, Ministry of Public Health, Bangkok, Thailand
| | - Usa Chaikledkaew
- Social Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
- Correspondence: Usa Chaikledkaew, Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, 447 Sri-Ayudhaya Road, Rajathevi, Bangkok, 10400, Thailand, Tel +66 2-644-8679 ext 5317, Fax +66 2-644-8694, Email
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van der Pol S, Garcia PR, Postma MJ, Villar FA, van Asselt ADI. Economic Analyses of Respiratory Tract Infection Diagnostics: A Systematic Review. Pharmacoeconomics 2021; 39:1411-1427. [PMID: 34263422 PMCID: PMC8279883 DOI: 10.1007/s40273-021-01054-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/02/2021] [Indexed: 05/21/2023]
Abstract
BACKGROUND Diagnostic testing for respiratory tract infections is a tool to manage the current COVID-19 pandemic, as well as the rising incidence of antimicrobial resistance. At the same time, new European regulations for market entry of in vitro diagnostics, in the form of the in vitro diagnostic regulation, may lead to more clinical evidence supporting health-economic analyses. OBJECTIVE The objective of this systematic review was to review the methods used in economic evaluations of applied diagnostic techniques, for all patients seeking care for infectious diseases of the respiratory tract (such as pneumonia, pulmonary tuberculosis, influenza, sinusitis, pharyngitis, sore throats and general respiratory tract infections). METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, articles from three large databases of scientific literature were included (Scopus, Web of Science and PubMed) for the period January 2000 to May 2020. RESULTS A total of 70 economic analyses are included, most of which use decision tree modelling for diagnostic testing for respiratory tract infections in the community-care setting. Many studies do not incorporate a generally comparable clinical outcome in their cost-effectiveness analysis: fewer than half the studies (33/70) used generalisable outcomes such as quality-adjusted life-years. Other papers consider outcomes related to the accuracy of the test or outcomes related to the prescribed treatment. The time horizons of the studies generally are limited. CONCLUSIONS The methods to economically assess diagnostic tests for respiratory tract infections vary and would benefit from clear recommendations from policy makers on the assessed time horizon and outcomes used.
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Affiliation(s)
- Simon van der Pol
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
- UMCG, Sector F, afdeling Gezondheidswetenschappen, Simon van der Pol (FA10), Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
| | - Paula Rojas Garcia
- Department of Economics and Business, University of La Rioja, Rioja, Spain
| | - Maarten J Postma
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Economics, Econometrics and Finance, University of Groningen, Groningen, The Netherlands
| | | | - Antoinette D I van Asselt
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Hao X, Lou H, Bai J, Ding Y, Yang J, Pan W. Cost-effectiveness analysis of Xpert in detecting Mycobacterium tuberculosis: A systematic review. Int J Infect Dis 2020; 95:98-105. [PMID: 32278935 DOI: 10.1016/j.ijid.2020.03.078] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/28/2020] [Accepted: 03/29/2020] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES To report the cost-effectiveness of Xpert in detecting Mycobacterium tuberculosis (MTB) through a comprehensive systematic review. METHODS Specialized bibliographic databases were searched. Study quality was evaluated by commonly-used industry standards. Due to heterogeneity, evidences were synthesized narratively. RESULTS Four studies from intermediate-to-low tuberculosis (TB)-burdern areas and 17 studies from high-TB-burden areas were included. Smear microscopy, clinical diagnosis and chest radiography were mostly used for comparison. Cost elements varied considerably depending on the perspectives. Cost-effectiveness and cost-utility analyses were used by seven and fourteen studies, respectively. All studies were of high quality (CHEERS score of 78.4 and QHES score of 86.9). Average cost per test was 29.8 US$ for Xpert compared with 3.83 US$ for smear microscopy. Cost-effectiveness analyses mostly supported application of Xpert into areas under varying TB burdens. CONCLUSIONS Xpert seems cost-effective under respective willingness-to-pay thresholds in nations with differences in socioeconomy, HIV stress and geographical distribution. Nevertheless, policymakers will benefit from localized studies since regional economic/financial statuses and health-care system should also be considered apart from the reports of cost-effectiveness.
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Affiliation(s)
- Xiaohui Hao
- Department of Medical Microbiology and Parasitology, Navy Medical University (Second Military Medical University), Shanghai, PR China; Department of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, PR China
| | - Hai Lou
- Department of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, PR China
| | - Jie Bai
- Department of Medical Microbiology and Parasitology, Navy Medical University (Second Military Medical University), Shanghai, PR China
| | - Yingying Ding
- Department of Medical Microbiology and Parasitology, Navy Medical University (Second Military Medical University), Shanghai, PR China
| | - Jinghui Yang
- Department of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, PR China
| | - Wei Pan
- Department of Medical Microbiology and Parasitology, Navy Medical University (Second Military Medical University), Shanghai, PR China.
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Wu Z, Rueda ZV, Li T, Zhang Z, Jiang Y, Sha W, Yu F, Chen J, Pan Q, Shen X, Yuan Z. Effect of the Xpert MTB/RIF on the detection of pulmonary tuberculosis cases and rifampicin resistance in Shanghai, China. BMC Infect Dis 2020; 20:153. [PMID: 32070292 DOI: 10.1186/s12879-020-4871-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 02/11/2020] [Indexed: 11/23/2022] Open
Abstract
Background Xpert MTB/RIF (Xpert) is an automated molecular test recommended by World Health Organization (WHO) for diagnosis of tuberculosis (TB). This study evaluated the effect of Xpert implementation on the detection of pulmonary TB (PTB) and rifampicin-resistant TB (RR-TB) cases in Shanghai, China. Methods Xpert was routinely implemented in 2018 for all presumptive PTB patients. All PTB patients above 15 years-old identified within the Provincial TB Control Program during the first half of each of 2017 and 2018, were enrolled to compare the difference in proportions of bacteriological confirmation, patients with drug susceptibility test (DST) results for rifampicin (ie, DST coverage) and RR-TB detection before and after Xpert’s implementation. Results A total of 6047 PTB patients were included in the analysis with 1691 tested by Xpert in 2018. Percentages of bacteriological confirmation, DST coverage and RR-TB detection in 2017 and 2018 were 50% vs. 59%, 36% vs. 49% and 2% vs. 3%, respectively (all p-values < 0.05). Among 1103 PTB patients who completed sputum smear, culture and Xpert testing in 2018, Xpert detected an additional 121 (11%) PTB patients who were negative by smear and culture, but missed 248 (23%) smear and/or culture positive patients. Besides, it accounted for an increase of 9% in DST coverage and 1% in RR-TB detection. The median time from first visit to a TB hospital to RR-TB detection was 62 days (interquartile range -IQR 48–84.2) in 2017 vs. 9 days (IQR 2–45.7) in 2018 (p-value < 0.001). In the multivariate model, using Xpert was associated with decreased time to RR-TB detection (adjusted hazard ratio = 4.62, 95% confidence interval: 3.18–6.71). Conclusions Integrating Xpert with smear, culture and culture-based DST in a routine setting significantly increased bacteriological confirmation, DST coverage and RR-TB detection with a dramatic reduction in the time to RR-TB diagnosis in Shanghai, China. Our findings can be useful for other regions that attempt to integrate Xpert into routine PTB and RR-TB case-finding cascade. Further study should focus on the identification and elimination of operational level challenges to fully utilize the benefit of rapid diagnosis by Xpert.
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Breheny K, Sutton AJ, Deeks JJ. Model-based economic evaluations of diagnostic point of care tests were rarely fit for purpose. J Clin Epidemiol 2019; 109:1-11. [PMID: 30423377 DOI: 10.1016/j.jclinepi.2018.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/09/2018] [Accepted: 11/05/2018] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Linked evidence models are recommended to predict health benefits and cost-effectiveness of diagnostic tests. We considered how published models accounted for changes in patient pathways that occur with point of care tests (POCTs) and their impact on patient health and costs. STUDY DESIGN AND SETTING Model-based evaluations of diagnostic POCTs published from 2004 to 2017 were identified from searching six databases. For each model, we assessed the outcomes considered, and whether reduced time to diagnosis and increased access to testing affected patient health and costs. RESULTS Seventy-four model-based evaluations were included: 95% incorporated evidence on test accuracy, but 34% only assessed intermediate outcomes such as rates of correct diagnosis. Of 54 models where POCTs reduced testing time, 39% addressed the economic and 37% addressed the health benefits of faster diagnosis. No model considered differences in access to tests. CONCLUSION Many models fail to capture the effects of POCTs in increasing access, advancing speed of diagnosis and treatment, and reducing anxiety and the associated costs. Many only consider the impact of testing from changes in accuracy. Ensuring models incorporate changes in patient pathways from faster and more accessible testing will lead to economic evaluations that better reflect the impact of POCTs.
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Sagili KD, Muniyandi M, Nilgiriwala KS, Shringarpure KS, Satyanarayana S, Kirubakaran R, Chadha SS, Tharyan P. Cost-effectiveness of GeneXpert and LED-FM for diagnosis of pulmonary tuberculosis: A systematic review. PLoS One 2018; 13:e0205233. [PMID: 30372436 PMCID: PMC6205591 DOI: 10.1371/journal.pone.0205233] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 09/23/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Early and accurate diagnosis of tuberculosis is a priority for TB programs globally to initiate treatment early and improve treatment outcomes. Currently, Ziehl-Neelsen (ZN) stain-based microscopy, GeneXpert and Light Emitting Diode-Fluorescence Microscopy (LED-FM) are used for diagnosing pulmonary drug sensitive tuberculosis. Published evidence synthesising the cost-effectiveness of these diagnostic tools is scarce. METHODOLOGY PubMed, EMBASE and Cost-effectiveness analysis registry were searched for studies that reported on the cost-effectiveness of GeneXpert and LED-FM, compared to ZN microscopy for diagnosing pulmonary TB. Risk of bias was assessed independently by four authors using the Consensus Health Economic Criteria (CHEC) extended checklist. The data variables included the study settings, population, type of intervention, type of comparator, year of study, duration of study, type of study design, costs for the test and the comparator and effectiveness indicators. Incremental cost-effectiveness ratio (ICER) was used for assessing the relative cost-effectiveness in this review. RESULTS Of the 496 studies identified by the search, thirteen studies were included after removing duplicates and studies that did not fulfil inclusion criteria. Four studies compared LED-FM with ZN and nine studies compared GeneXpert with ZN. Three studies used patient cohorts and eight were modelling studies with hypothetical cohorts used to evaluate cost-effectiveness. All these studies were conducted from a health system perspective, with four studies utilising cost utility analysis. There were considerable variations in costing parameters and effectiveness indicators that precluded meta-analysis. The key findings from the included studies suggest that LED-FM and GeneXpert may be cost effective for pulmonary TB diagnosis from a health system perspective. CONCLUSION Our review identifies a consistent trend of the cost effectiveness of LED-FM and GeneXpert for pulmonary TB diagnosis in different countries with diverse context of socio-economic condition, HIV burden and geographical distribution. However, all the studies used different parameters to estimate the impact of these tools and this underscores the need for improving the methodological issues related to the conduct and reporting of cost-effectiveness studies.
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Affiliation(s)
- Karuna D. Sagili
- International Union against Tuberculosis and Lung Disease, South East Asia Regional office, New Delhi, India
| | | | | | | | - Srinath Satyanarayana
- International Union against Tuberculosis and Lung Disease, South East Asia Regional office, New Delhi, India
| | - Richard Kirubakaran
- Prof BV Moses Centre for Evidence- Informed Health Care, Christian Medical College, Vellore, India
| | - Sarabjit S. Chadha
- International Union against Tuberculosis and Lung Disease, South East Asia Regional office, New Delhi, India
| | - Prathap Tharyan
- Prof BV Moses Centre for Evidence- Informed Health Care, Christian Medical College, Vellore, India
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Reviono R, Setianingsih W, Damayanti KE, Ekasari R. The dynamic of tuberculosis case finding in the era of the public-private mix strategy for tuberculosis control in Central Java, Indonesia. Glob Health Action 2018; 10:1353777. [PMID: 28766465 PMCID: PMC5964974 DOI: 10.1080/16549716.2017.1353777] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: The public–private mix (PPM) strategy has strengthened tuberculosis care and control in many countries. Indonesia, a country with a high tuberculosis burden, has a low tuberculosis case detection rate (CDR), despite PPM implementation in 2003. The PPM in Indonesia involves primary healthcare centers, hospitals, and specialized chest clinics. The long-term impact of the strategy is unknown. Objective: We aimed to explore the case detection achievements of the tuberculosis program since PPM implementation in Central Java in 2003. Methods: This retrospective cohort study covered the period 1 January 2000 to 31 December 2014. The data from tuberculosis patients treated in all health facilities in Central Java implementing directly observed treatment short-course, recorded via a standardized form, were analyzed after being validated by the Office of Health of Central Java Province. We evaluated the CDR, case notification rate, and total number of cases, using linear regression to analyze the temporal trends of those indicators in the phases of PPM implementation. Results: The CDR increased during the initial phase (2000–2005), decreased during the mid-phase (2006–2009), and increased slightly during the late phase (2010–2014), ranging from 13 to 61.72. These trends were observed despite a steady increase in the number of participating healthcare facilities. The regression analysis showed that the CDR of referral institutions contributed the most to the total CDR of Central Java Province. Many of the smear-negative tuberculosis cases recorded at primary healthcare centers may have been smear positive; this probable misclassification could have been partially avoided if more specific and sensitive diagnostic tools were available. Conclusions: The CDR remains below the national target (70%). Early awareness of a negative trend in certain program indicators is important to ensure program sustainability. Careful observation of the indicator pattern will secure the long-term success of the program.
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Affiliation(s)
- Reviono Reviono
- a Faculty of Medicine , Universitas Sebelas Maret , Surakarta , Indonesia.,b Dr Moewardi Hospital, Surakarta , Central Java , Indonesia
| | - Wahyu Setianingsih
- c Office of Health of Central Java Province, Semarang , Central Java , Indonesia
| | | | - Ratna Ekasari
- d KNCV (Koninklijke Nederlandse Centrale Vereniging tot Bestrijding der Tuberculose) Central Java , Indonesia
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Padmasawitri TIA, Frederix GW, Alisjahbana B, Klungel O, Hövels AM. Disparities in model-based cost-effectiveness analyses of tuberculosis diagnosis: A systematic review. PLoS One 2018; 13:e0193293. [PMID: 29742106 PMCID: PMC5942841 DOI: 10.1371/journal.pone.0193293] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 01/30/2018] [Indexed: 01/17/2023] Open
Abstract
Background Structural approach disparities were minimally addressed in past systematic reviews of model-based cost-effectiveness analyses addressing Tuberculosis management strategies. This review aimed to identify the structural approach disparities in model-based cost-effectiveness analysis studies addressing Tuberculosis diagnosis and describe potential hazards caused by those disparities. Methods A systematic search to identify studies published before October 2015 was performed in five electronic databases. After removal of duplication, studies’ titles and abstracts were screened based on predetermined criteria. The full texts of potentially relevant studies were subsequently screened and excluded when they did not address active pulmonary Tuberculosis diagnosis. Quality of the studies was assessed using the “Philips’ checklist.” Various data regarding general information, cost-effectiveness results, and disease modeling were extracted using standardized data extraction forms. Data pertaining to models’ structural approaches were compared and analyzed qualitatively for their applicability in various study settings, as well as their potential influence on main outcomes and cost-effectiveness conclusion. Results A total of 27 studies were included in the review. Most studies utilized a static model, which could underestimate the cost-effectiveness of the diagnostic tools strategies, due to the omission of indirect diagnosis effects, i.e. transmission reduction. A few structural assumption disparities were found in the dynamic models. Extensive disparities were found in the static models, consisting of varying structural assumptions regarding treatment outcomes, clinical diagnosis and empirical treatment, inpatient discharge decision, and re-diagnosis of false negative patients. Conclusion In cost-effectiveness analysis studies addressing active pulmonary Tuberculosis diagnosis, models showed numerous disparities in their structural approaches. Several structural approaches could be inapplicable in certain settings. Furthermore, they could contribute to under- or overestimation of the cost-effectiveness of the diagnosis tools or strategies. They could thus lead to ambiguities and difficulties when interpreting a study result. A set of recommendations is proposed to manage issues related to these structural disparities.
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Affiliation(s)
- T. I. Armina Padmasawitri
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- Pharmacology and Clinical Pharmacy Research Group, School of Pharmacy, Institut Teknologi Bandung, Bandung, Indonesia
| | - Gerardus W. Frederix
- Julius Centre for Health Sciences and Primary Care, University Medical Centre, Utrecht, The Netherlands
| | - Bachti Alisjahbana
- TB-HIV Research Centre, Medical Faculty, Padjadjaran University, Hasan Sadikin Hospital, Bandung, Indonesia
| | - Olaf Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Anke M. Hövels
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- * E-mail:
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Wang G, Wang S, Jiang G, Fu Y, Shang Y, Huang H. Incremental cost-effectiveness of the second Xpert MTB/RIF assay to detect Mycobacterium tuberculosis. J Thorac Dis 2018; 10:1689-1695. [PMID: 29707322 DOI: 10.21037/jtd.2018.02.60] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Due to the non-homogeneity of specimens collected from tuberculosis (TB) suspects, repeated Xpert MTB/RIF (Xpert) may have potential clinical benefits. Incremental cost-effectiveness was analyzed for the second Xpert assay to detect Mycobacterium tuberculosis (Mtb) and rifampicin (RIF) resistance. Methods Specimens were collected from 1,063 pulmonary TB (PTB) and 398 extrapulmonary TB (EPTB) suspects, who had two Xpert tests sequentially within one week. The specimens were subjected to smear, culture, Xpert and drug susceptibility testing. Incremental cost-effectiveness of the serial Xpert assays was evaluated. Results Among 813 Xpert-positive TB patients, 755 (92.87%) were identified by the first assay whereas the additional 58 (7.13%) were identified by the second assay. The second Xpert assay had higher incremental yield for smear-negative than for smear-positive specimens (12.07% vs. 1.84%, P<0.001), and higher incremental yield for EPTB than for PTB (10.71% vs. 4.65%, P=0.003). About 94.48% (137/145) of the RIF-resistant patients were identified by the first Xpert assay and 5.52% (8/145) were identified by the second Xpert assay. After the first assay, the incremental cost of performing a second Xpert was huge: US$22.82 vs. US$467.72 (P<0.001) and US$35.02 vs. US$291.87 (P<0.001) for PTB and EPTB, respectively. The incremental cost of performing a second Xpert is lower in smear-negative than in smear-positive group in both PTB and EPTB. Conclusions One Xpert assay is sufficient for smear-positive cases, and a second Xpert assay is beneficial not only for Mtb detection but also for RIF-resistant diagnosis for smear-negative TB suspects, whereas the incremental cost for the second Xpert is huge.
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Affiliation(s)
- Guirong Wang
- National Clinical Laboratory for Tuberculosis, Beijing Key laboratory for Drug-resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing 101149, China
| | - Shuqi Wang
- National Clinical Laboratory for Tuberculosis, Beijing Key laboratory for Drug-resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing 101149, China
| | - Guanglu Jiang
- National Clinical Laboratory for Tuberculosis, Beijing Key laboratory for Drug-resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing 101149, China
| | - Yuhong Fu
- National Clinical Laboratory for Tuberculosis, Beijing Key laboratory for Drug-resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing 101149, China
| | - Yuanyuan Shang
- National Clinical Laboratory for Tuberculosis, Beijing Key laboratory for Drug-resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing 101149, China
| | - Hairong Huang
- National Clinical Laboratory for Tuberculosis, Beijing Key laboratory for Drug-resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing 101149, China
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Li J, Yip BHK, Leung C, Chung W, Kwok KO, Chan EYY, Yeoh E, Chung P. Screening for latent and active tuberculosis infection in the elderly at admission to residential care homes: A cost-effectiveness analysis in an intermediate disease burden area. PLoS One 2018; 13:e0189531. [PMID: 29293514 PMCID: PMC5749681 DOI: 10.1371/journal.pone.0189531] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 11/27/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) in the elderly remains a challenge in intermediate disease burden areas like Hong Kong. Given a higher TB burden in the elderly and limited impact of current case-finding strategy by patient-initiated pathway, proactive screening approaches for the high-risk group could be optimal and increasingly need targeted economic evaluations. In this study, we examined whether and under what circumstance the screening strategies are cost-effective compared with no screening strategy for the elderly at admission to residential care homes. METHODS A decision analytic process based on Markov model was adopted to evaluate the cost-effectiveness of four strategies: (i) no screening, (ii) TB screening (CXR) and (iii) TB screening (Xpert) represent screening for TB in symptomatic elderly by chest X-ray and Xpert® MTB/RIF respectively, and (iv) LTBI/TB screening represents screening for latent and active TB infection by QuantiFERON®-TB Gold In-Tube and chest X-ray. The target population was a hypothetical cohort of 65-year-old people, using a health service provider perspective and a time horizon of 20 years. The outcomes were direct medical costs, life-years and quality-adjusted life-years (QALYs) measured by incremental cost-effectiveness ratio (ICER). RESULTS In the base-case analysis, no screening was the most cost-saving; TB screening (CXR) was dominated by TB screening (Xpert); LTBI/TB screening resulted in more life-years and QALYs accrued. The ICERs of LTBI/TB screening were US$19,712 and US$29,951 per QALY gained compared with no screening and TB screening (Xpert), respectively. At the willingness-to-pay threshold of US$50,000 per QALY gained, LTBI/TB screening was the most cost-effective when the probability of annual LTBI reactivation was greater than 0.155% and acceptability of LTBI/TB screening was greater than 38%. In 1,000 iterations of Monte Carlo simulation, the probabilities of no screening, TB screening (CXR), TB screening (Xpert), and LTBI/TB screening to be cost-effective were 0, 1.3%, 20.1%, and 78.6% respectively. CONCLUSIONS Screening for latent and active TB infection in Hong Kong elderly people at admission to residential care homes appears to be highly effective and cost-effective. The key findings may be the next key factor to bring down TB endemic in the elderly population among intermediate TB burden areas.
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Affiliation(s)
- Jun Li
- Jockey School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Benjamin H. K. Yip
- Jockey School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Chichiu Leung
- Tuberculosis and Chest Service, Department of Health, Hong Kong, China
| | - Wankyo Chung
- Department of Public Health Science, Graduate School of Public Health, Seoul National University, Seoul, South Korea
| | - Kin On Kwok
- Jockey School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Emily Y. Y. Chan
- Jockey School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Engkiong Yeoh
- Jockey School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Puihong Chung
- Jockey School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
- * E-mail:
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Suen SC, Brandeau ML, Goldhaber-Fiebert JD. Optimal timing of drug sensitivity testing for patients on first-line tuberculosis treatment. Health Care Manag Sci 2017; 21:632-646. [PMID: 28861650 DOI: 10.1007/s10729-017-9416-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 08/11/2017] [Indexed: 10/19/2022]
Abstract
Effective treatment for tuberculosis (TB) patients on first-line treatment involves triaging those with drug-resistant (DR) TB to appropriate treatment alternatives. Patients likely to have DR TB are identified using results from repeated inexpensive sputum-smear (SS) tests and expensive but definitive drug sensitivity tests (DST). Early DST may lead to high costs and unnecessary testing; late DST may lead to poor health outcomes and disease transmission. We use a partially observable Markov decision process (POMDP) framework to determine optimal DST timing. We develop policy-relevant structural properties of the POMDP model. We apply our model to TB in India to identify the patterns of SS test results that should prompt DST if transmission costs remain at status-quo levels. Unlike previous analyses of personalized treatment policies, we take a societal perspective and consider the effects of disease transmission. The inclusion of such effects can significantly alter the optimal policy. We find that an optimal DST policy could save India approximately $1.9 billion annually.
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Affiliation(s)
- Sze-Chuan Suen
- Daniel J. Epstein Department of Industrial and Systems Engineering, University of Southern California, CA, USA.
| | - Margaret L Brandeau
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
| | - Jeremy D Goldhaber-Fiebert
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA
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Wikman-Jorgensen PE, Llenas-García J, Pérez-Porcuna TM, Hobbins M, Ehmer J, Mussa MA, Ascaso C. Microscopic observation drug-susceptibility assay vs. Xpert ® MTB/RIF for the diagnosis of tuberculosis in a rural African setting: a cost-utility analysis. Trop Med Int Health 2017; 22:734-743. [PMID: 28380276 DOI: 10.1111/tmi.12879] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare the cost-utility of microscopic observation drug-susceptibility assay (MODS) and Xpert® MTB/RIF implementation for tuberculosis (TB) diagnosis in rural northern Mozambique. METHODS Stochastic transmission compartmental TB model from the healthcare provider perspective with parameter input from direct measurements, systematic literature reviews and expert opinion. MODS and Xpert® MTB/RIF were evaluated as replacement test of smear microscopy (SM) or as an add-on test after a negative SM. Costs were calculated in 2013 USD, effects in disability-adjusted life years (DALY). Willingness to pay threshold (WPT) was established at once the per capita Gross National Income of Mozambique. RESULTS MODS as an add-on test to negative SM produced an incremental cost-effectiveness ratio (ICER) of 5647.89USD/DALY averted. MODS as a substitute for SM yielded an ICER of 5374.58USD/DALY averted. Xpert® MTB/RIF as an add-on test to negative SM yielded ICER of 345.71USD/DALY averted. Xpert® MTB/RIF as a substitute for SM obtained an ICER of 122.13USD/DALY averted. TB prevalence and risk of infection were the main factors impacting MODS and Xpert® MTB/RIF ICER in the one-way sensitivity analysis. In the probabilistic sensitivity analysis, Xpert® MTB/RIF was most likely to have an ICER below the WPT, whereas MODS was not. CONCLUSION Our cost-utility analysis favours the implementation of Xpert® MTB/RIF as a replacement of SM for all TB suspects in this rural high TB/HIV prevalence African setting.
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Affiliation(s)
- Philip E Wikman-Jorgensen
- Department of Public Health, University of Barcelona, Barcelona, Spain.,SolidarMed Mozambique, Ancuabe, Mozambique
| | - Jara Llenas-García
- SolidarMed Mozambique, Ancuabe, Mozambique.,Infectious Diseases Unit, Hospital General Universitario de Elche, Alicante, Spain
| | - Tomàs M Pérez-Porcuna
- Department of Public Health, University of Barcelona, Barcelona, Spain.,Research Unit, Paediatrics Department, CAP Valldoreix, Mutua Terrassa Foundation, Mutua Terrassa University Hospital, Terrassa, Catalunya, Spain
| | | | | | - Manuel A Mussa
- Provincial Health Directorate, Operational Research Nucleus of Pemba, Pemba, Mozambique
| | - Carlos Ascaso
- Department of Public Health, University of Barcelona, Barcelona, Spain
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Affiliation(s)
- David S Hui
- 1 Department of Medicine and Therapeutics.,2 Stanley Ho Center for Emerging Infectious Diseases, and
| | - Nelson Lee
- 1 Department of Medicine and Therapeutics.,2 Stanley Ho Center for Emerging Infectious Diseases, and
| | - Paul K S Chan
- 2 Stanley Ho Center for Emerging Infectious Diseases, and.,3 Department of Microbiology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
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