SUMMARY
SETTING
Conventional approaches to tuberculosis (TB) diagnosis and resistance
testing are slow. The Xpert® MTB/RIF assay is an emerging molecular
diagnostic assay for rapid TB diagnosis, offering results within 2 hours.
However, the cost-effectiveness of implementing Xpert in settings with low
TB prevalence, such as the United States, is unknown.
OBJECTIVE
We evaluated the cost-effectiveness of incorporating Xpert into TB
diagnostic algorithms in the United States compared to existing
diagnostics.
DESIGN
A decision-analysis model compared current TB diagnostic algorithms
in the United States to algorithms incorporating Xpert. Primary outcomes
were the costs and quality-adjusted life years (QALYs) accrued with each
strategy; cost-effectiveness was represented using incremental
cost-effectiveness ratios (ICER).
RESULTS
Xpert testing of a single sputum sample from TB suspects is expected
to result in lower total health care costs per patient (US$2673) compared to
diagnostic algorithms using only sputum microscopy and culture (US$2728) and
improved health outcomes (6.32 QALYs gained per 1000 TB suspects). Compared
to existing molecular assays, implementation of Xpert in the United States
would be considered highly cost-effective (ICER US$39 992 per QALY
gained).
CONCLUSION
TB diagnostic algorithms incorporating Xpert in the United States are
highly cost-effective.
Tuberculosis (TB) in pregnancy poses a substantial risk of morbidity to both the pregnant woman and the fetus if not diagnosed and treated in a timely manner. Assessing the risk of having Mycobacterium tuberculosis infection is essential to determining when further evaluation should occur. Obstetrician–gynecologists are in a unique position to identify individuals with infection and facilitate further evaluation and follow up as needed. A TB evaluation consists of a TB risk assessment, medical history, physical examination, and a symptom screen; a TB test should be performed if indicated by the TB evaluation. If a pregnant woman has signs or symptoms of TB or if the test result for TB infection is positive, active TB disease must be ruled out before delivery, with a chest radiograph and other diagnostics as indicated. If active TB disease is diagnosed, it should be treated; providers must decide when treatment of latent TB infection is most beneficial. Most women will not require latent TB infection treatment while pregnant, but all require close follow up and monitoring. Treatment should be coordinated with the TB control program within the respective jurisdiction and initiated based on the woman's risk factors including social history, comorbidities (particularly human immunodeficiency virus [HIV] infection), and concomitant medications.
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