Decentralized care for multidrug-resistant tuberculosis: a systematic review and meta-analysis

Abstract

ObjectiveTo assess the effectiveness of decentralized treatment and care for patients with multidrug-resistant (MDR) tuberculosis, in comparison with centralized approaches.MethodsWe searched ClinicalTrials.gov, the Cochrane library, Embase®, Google Scholar, LILACS, PubMed®, Web of Science and the World Health Organization’s portal of clinical trials for studies reporting treatment outcomes for decentralized and centralized care of MDR tuberculosis. The primary outcome was treatment success. When possible, we also evaluated, death, loss to follow-up, treatment adherence and health-system costs. To obtain pooled relative risk (RR) estimates, we performed random-effects meta-analyses.FindingsEight studies met the eligibility criteria for review inclusion. Six cohort studies, with 4026 participants in total, reported on treatment outcomes. The pooled RR estimate for decentralized versus centralized care for treatment success was 1.13 (95% CI: 1.01–1.27). The corresponding estimate for loss to follow-up was RR: 0.66 (95% CI: 0.38–1.13), for death RR: 1.01 (95% CI: 0.67–1.52) and for treatment failure was RR: 1.07 (95% CI: 0.48–2.40). Two of three studies evaluating health-care costs reported lower costs for the decentralized models of care than for the centralized models.ConclusionTreatment success was more likely among patients with MDR tuberculosis treated using a decentralized approach. Further studies are required to explore the effectiveness of decentralized MDR tuberculosis care in a range of different settings.

Successful expansion of community‐based drug‐resistant TB care in rural Eswatini – a retrospective cohort study

“…This study supports existing evidence on the feasibility of ambulatory care models [15]. Overall, treatment success was 71.6% in a predominantly HIV-infected DR-TB treatment cohort and comparable to outcomes reported internationally (65% treatment success in multidrug-resistant and extensively drug-resistant TB) [32].…”

“…These findings indicate the affordability of this community‐based model from the health systems perspective. The costs of our care model were higher than in other RLS, but comparison is limited by differences in context and costing methodology .…”

“…These findings indicate the affordability of this community-based model from the health systems perspective. The costs of our care model were higher than in other RLS, but comparison is limited by differences in context and costing methodology [15]. Lastly, although it was beyond the scope of this analysis to assess temporal trends, we noticed an increase in DR-TB treatment cases during the first years followed by a decline thereafter.…”

“…nurses) or community treatment supporters (CTS) providing care at a venue in the community. Both approaches appear to be feasible in low-and high-HIV prevalence settings [4,[11][12][13][14][15][16][17], and they have the potential to increase case detection, shorten time to treatment initiation and improve survival [14].…”

Who should decide for local health services? A mixed methods study of preferences for decision-making in the decentralized Philippine health system

“…Keywords: Decentralization, Decision making, Health policy, Mixed methods, Philippines, Public health administration Background Decentralization of health services, particularly in the form of devolution of authority to local governments [1], has been implemented in many countries motivated by the expectation that it will empower local decisionmakers to oversee and steer their own health services [2]. Yet beyond a few studies of selected disease-specific programs where decentralization resulted in better health outcomes [3,4], decentralization's effectiveness in improving outcomes related to the broader dimension of health system performance is uncertain based on the limited number of reviews that examined the global evidence [5][6][7]. On the other hand, the fact that local decision-makers are granted the "decision space" [8,9], which provides an idea of the extent of choices available to them, and are able to make decisions for the functions of local health services because of decentralization may already be a desired outcome in itself.…”