Strengthening health systems to improve the value of tuberculosis diagnostics in South Africa: A cost and cost-effectiveness analysis.

<h4>Background</h4>In South Africa, replacing smear microscopy with Xpert-MTB/RIF (Xpert) for tuberculosis diagnosis did not reduce mortality and was cost-neutral. The unchanged mortality has been attributed to suboptimal Xpert implementation. We developed a mathematical model to explore...

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Autores principales:	Nicola Foster, Lucy Cunnama, Kerrigan McCarthy, Lebogang Ramma, Mariana Siapka, Edina Sinanovic, Gavin Churchyard, Katherine Fielding, Alison D Grant, Susan Cleary
Formato:	article
Lenguaje:	EN
Publicado:	Public Library of Science (PLoS) 2021
Materias:	Medicine R Science Q
Acceso en línea:	https://doaj.org/article/f0d83dbc885e41678febb32a092c13f2
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spelling	oai:doaj.org-article:f0d83dbc885e41678febb32a092c13f22021-12-02T20:04:02ZStrengthening health systems to improve the value of tuberculosis diagnostics in South Africa: A cost and cost-effectiveness analysis.1932-620310.1371/journal.pone.0251547https://doaj.org/article/f0d83dbc885e41678febb32a092c13f22021-01-01T00:00:00Zhttps://doi.org/10.1371/journal.pone.0251547https://doaj.org/toc/1932-6203<h4>Background</h4>In South Africa, replacing smear microscopy with Xpert-MTB/RIF (Xpert) for tuberculosis diagnosis did not reduce mortality and was cost-neutral. The unchanged mortality has been attributed to suboptimal Xpert implementation. We developed a mathematical model to explore how complementary investments may improve cost-effectiveness of the tuberculosis diagnostic algorithm.<h4>Methods</h4>Complementary investments in the tuberculosis diagnostic pathway were compared to the status quo. Investment scenarios following an initial Xpert test included actions to reduce pre-treatment loss-to-follow-up; supporting same-day clinical diagnosis of tuberculosis after a negative result; and improving access to further tuberculosis diagnostic tests following a negative result. We estimated costs, deaths and disability-adjusted-life-years (DALYs) averted from provider and societal perspectives. Sensitivity analyses explored the mediating influence of behavioural, disease- and organisational characteristics on investment effectiveness.<h4>Findings</h4>Among a cohort of symptomatic patients tested for tuberculosis, with an estimated active tuberculosis prevalence of 13%, reducing pre-treatment loss-to-follow-up from ~20% to ~0% led to a 4% (uncertainty interval [UI] 3; 4%) reduction in mortality compared to the Xpert scenario. Improving access to further tuberculosis diagnostic tests from ~4% to 90% among those with an initial negative Xpert result reduced overall mortality by 28% (UI 27; 28) at $39.70/ DALY averted. Effectiveness of investment scenarios to improve access to further diagnostic tests was dependent on a high return rate for follow-up visits.<h4>Interpretation</h4>Investing in direct and indirect costs to support the TB diagnostic pathway is potentially highly cost-effective.Nicola FosterLucy CunnamaKerrigan McCarthyLebogang RammaMariana SiapkaEdina SinanovicGavin ChurchyardKatherine FieldingAlison D GrantSusan ClearyPublic Library of Science (PLoS)articleMedicineRScienceQENPLoS ONE, Vol 16, Iss 5, p e0251547 (2021)
institution	DOAJ
collection	DOAJ
language	EN
topic	Medicine R Science Q
spellingShingle	Medicine R Science Q Nicola Foster Lucy Cunnama Kerrigan McCarthy Lebogang Ramma Mariana Siapka Edina Sinanovic Gavin Churchyard Katherine Fielding Alison D Grant Susan Cleary Strengthening health systems to improve the value of tuberculosis diagnostics in South Africa: A cost and cost-effectiveness analysis.
description	<h4>Background</h4>In South Africa, replacing smear microscopy with Xpert-MTB/RIF (Xpert) for tuberculosis diagnosis did not reduce mortality and was cost-neutral. The unchanged mortality has been attributed to suboptimal Xpert implementation. We developed a mathematical model to explore how complementary investments may improve cost-effectiveness of the tuberculosis diagnostic algorithm.<h4>Methods</h4>Complementary investments in the tuberculosis diagnostic pathway were compared to the status quo. Investment scenarios following an initial Xpert test included actions to reduce pre-treatment loss-to-follow-up; supporting same-day clinical diagnosis of tuberculosis after a negative result; and improving access to further tuberculosis diagnostic tests following a negative result. We estimated costs, deaths and disability-adjusted-life-years (DALYs) averted from provider and societal perspectives. Sensitivity analyses explored the mediating influence of behavioural, disease- and organisational characteristics on investment effectiveness.<h4>Findings</h4>Among a cohort of symptomatic patients tested for tuberculosis, with an estimated active tuberculosis prevalence of 13%, reducing pre-treatment loss-to-follow-up from ~20% to ~0% led to a 4% (uncertainty interval [UI] 3; 4%) reduction in mortality compared to the Xpert scenario. Improving access to further tuberculosis diagnostic tests from ~4% to 90% among those with an initial negative Xpert result reduced overall mortality by 28% (UI 27; 28) at $39.70/ DALY averted. Effectiveness of investment scenarios to improve access to further diagnostic tests was dependent on a high return rate for follow-up visits.<h4>Interpretation</h4>Investing in direct and indirect costs to support the TB diagnostic pathway is potentially highly cost-effective.
format	article
author	Nicola Foster Lucy Cunnama Kerrigan McCarthy Lebogang Ramma Mariana Siapka Edina Sinanovic Gavin Churchyard Katherine Fielding Alison D Grant Susan Cleary
author_facet	Nicola Foster Lucy Cunnama Kerrigan McCarthy Lebogang Ramma Mariana Siapka Edina Sinanovic Gavin Churchyard Katherine Fielding Alison D Grant Susan Cleary
author_sort	Nicola Foster
title	Strengthening health systems to improve the value of tuberculosis diagnostics in South Africa: A cost and cost-effectiveness analysis.
title_short	Strengthening health systems to improve the value of tuberculosis diagnostics in South Africa: A cost and cost-effectiveness analysis.
title_full	Strengthening health systems to improve the value of tuberculosis diagnostics in South Africa: A cost and cost-effectiveness analysis.
title_fullStr	Strengthening health systems to improve the value of tuberculosis diagnostics in South Africa: A cost and cost-effectiveness analysis.
title_full_unstemmed	Strengthening health systems to improve the value of tuberculosis diagnostics in South Africa: A cost and cost-effectiveness analysis.
title_sort	strengthening health systems to improve the value of tuberculosis diagnostics in south africa: a cost and cost-effectiveness analysis.
publisher	Public Library of Science (PLoS)
publishDate	2021
url	https://doaj.org/article/f0d83dbc885e41678febb32a092c13f2
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Strengthening health systems to improve the value of tuberculosis diagnostics in South Africa: A cost and cost-effectiveness analysis.

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