The Importance of Implementation Strategy in Scaling Up Xpert MTB/RIF for Diagnosis of Tuberculosis in the Indian Health-Care System: A Transmission Model

Salje, Henrik; Andrews, Jason R; Deo, Sarang; Satyanarayana, Srinath; Sun, Amanda; Pai, Madhukar; Dowdy, David W.

doi:10.1371/journal.pmed.1001674

Cited by 44 publications

(36 citation statements)

References 41 publications

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“…Cost-effectiveness of Xpert testing at lower-volume centers could potentially be improved with increased volume of patients referred for testing, such as through facility-based screening and other intensified case-finding initiatives. 27,28 Alternatively, referral networks could be further developed to deliver sputum specimens efficiently to more centralized sites, 29,30 an approach which must consider quality of available transport networks and potential for pre-treatment loss to follow-up while awaiting results. Novel lower-cost platforms for Xpert testing (e.g., Xpert Omni, 31 Alere q 32 ) may also aid in cost-effective decentralization of testing.…”

Section: Discussionmentioning

confidence: 99%

Higher cost of implementing Xpert<SUP>®</SUP> MTB/RIF in Ugandan peripheral settings: implications for cost-effectiveness

Hsiang

Little

Haguma

et al. 2016

int j tuberc lung dis

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SUMMARY Setting Initial cost-effectiveness evaluations of Xpert MTB/RIF (Xpert) for tuberculosis (TB) diagnosis have not fully accounted for realities of implementation in peripheral settings. Objective We evaluated costs and diagnostic outcomes of Xpert testing implemented at various healthcare levels in Uganda. Design We collected empirical cost data from five health centers utilizing Xpert for TB diagnosis, employing an ingredients approach. We reviewed laboratory and patient records to assess outcomes in these sites and ten sites without Xpert. We also estimated incremental cost-effectiveness of Xpert testing; our primary outcome was incremental cost of Xpert testing per newly detected TB case. Results The mean unit cost of an Xpert test was US$21 based on a mean monthly volume of 54 tests per site, though unit cost varied widely (US$16–58) and was primarily determined by testing volume. Total diagnostic costs were 2.4-fold higher in Xpert clinics compared to non-Xpert clinics, though Xpert only increased diagnoses by 12%. Diagnostic costs of Xpert averaged US$119 per newly detected TB case but were as high as US$885 in the lowest-volume center. Conclusion Xpert testing can detect TB cases at reasonable cost but may double diagnostic budgets for relatively small gains, with cost-effectiveness deteriorating with lower testing volumes.

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Section: Discussionmentioning

confidence: 99%

Higher cost of implementing Xpert<SUP>®</SUP> MTB/RIF in Ugandan peripheral settings: implications for cost-effectiveness

Hsiang

Little

Haguma

et al. 2016

int j tuberc lung dis

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“…These dynamic models have linked transmission models to economic models to predict the costeffectiveness of specific intervention strategies. 40,41 One study examined the estimated incidence of new and retreatment cases in countries with a high tuberculosis burden, and concluded that more than 95% of MDR tuberculosis is due to primary transmission of resistant strains. 42 Consistent with the results described above, these findings suggest that a focus on early detection and improved treatment of MDR tuberculosis is needed to curtail future incidence.…”

Section: Modelling Mdr Epidemicsmentioning

confidence: 99%

The epidemiology, pathogenesis, transmission, diagnosis, and management of multidrug-resistant, extensively drug-resistant, and incurable tuberculosis

Dheda

Gumbo

Maartens

et al. 2017

The Lancet Respiratory Medicine

519

474

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“…Worse still, if most transmissions occur in the first 10 months, then even a perfect diagnostic test at the health facility could not avert those events. Thus, the dynamic trajectories of transmission, health-care seeking and diagnostic index of suspicion over the course of TB disease are inextricably linked to the epidemiological impact of novel diagnostic tests 19,[30][31][32][33] -and overly simple depictions of those trajectories may systematically overestimate that impact. Adding complexity to these simple frameworks requires additional data to inform a more nuanced understanding of the impact of diagnostic tests.…”

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confidence: 99%

Understanding the incremental value of novel diagnostic tests for tuberculosis

Arinaminpathy

Dowdy

2015

Nature

109

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Tuberculosis is a major source of global mortality caused by infection, partly because of a tremendous ongoing burden of undiagnosed disease. Improved diagnostic technology may play an increasingly crucial part in global efforts to end tuberculosis, but the ability of diagnostic tests to curb tuberculosis transmission is dependent on multiple factors, including the time taken by a patient to seek health care, the patient's symptoms, and the patterns of transmission before diagnosis. Novel diagnostic assays for tuberculosis have conventionally been evaluated on the basis of characteristics such as sensitivity and specificity, using assumptions that probably overestimate the impact of diagnostic tests on transmission. We argue for a shift in focus to the evaluation of such tests' incremental value, defining outcomes that reflect each test's purpose (for example, transmissions averted) and comparing systems with the test against those without, in terms of those outcomes. Incremental value can also be measured in units of outcome per incremental unit of resource (for example, money or human capacity). Using a novel, simplified model of tuberculosis transmission that addresses some of the limitations of earlier tuberculosis diagnostic models, we demonstrate that the incremental value of any novel test depends not just on its accuracy, but also on elements such as patient behaviour, tuberculosis natural history and health systems. By integrating these factors into a single unified framework, we advance an approach to the evaluation of new diagnostic tests for tuberculosis that considers the incremental value at the population level and demonstrates how additional data could inform more-effective implementation of tuberculosis diagnostic tests under various conditions

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The Importance of Implementation Strategy in Scaling Up Xpert MTB/RIF for Diagnosis of Tuberculosis in the Indian Health-Care System: A Transmission Model

Abstract: Using a modelling approach, David Dowdy and colleagues investigate how different implementation strategies for Xpert MTB/RIF within the complex, fragmented healthcare system of India may affect tuberculosis control. Please see later in the article for the Editors' Summary

Cited by 44 publications

References 41 publications

Higher cost of implementing Xpert<SUP>®</SUP> MTB/RIF in Ugandan peripheral settings: implications for cost-effectiveness

Higher cost of implementing Xpert<SUP>®</SUP> MTB/RIF in Ugandan peripheral settings: implications for cost-effectiveness

The epidemiology, pathogenesis, transmission, diagnosis, and management of multidrug-resistant, extensively drug-resistant, and incurable tuberculosis

Understanding the incremental value of novel diagnostic tests for tuberculosis

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