Inappropriate Tuberculosis Treatment Regimens in Chinese Tuberculosis Hospitals

He, Guo; Hof, Susan van den; Werf, Marieke J. van der; Guo, Hui; Hu, Yuan; Fan, Ji Huan; Zhang, Wei Min; Tostado, Chris P.; Borgdorff, Martien W.

doi:10.1093/cid/cir075

Cited by 26 publications

(22 citation statements)

References 3 publications

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“…Unfortunately, inappropriate treatment of MDR-TB has been a serious problem in China, particularly in hospitals. 24,28 Therefore, treating patients with MDR tuberculosis on the basis of results of drug susceptibility testing should become a mandatory policy.…”

Section: Discussionmentioning

confidence: 99%

Transmission of multidrug-resistant Mycobacterium tuberculosis in Shanghai, China: a retrospective observational study using whole-genome sequencing and epidemiological investigation

Yang

Luò

Shen

et al. 2017

The Lancet Infectious Diseases

217

221

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Summary Background Multidrug-resistant tuberculosis (MDR-TB) is a significant threat to tuberculosis elimination worldwide. Understanding the transmission pattern is crucial for its control. We used a genomic epidemiological approach to assess the recent transmission of MDR-TB and potential risk factors for transmission. Methods In a population-based retrospective study, we performed variable-number-of-tandem-repeat (VNTR) genotyping, followed by whole-genome sequencing (WGS) of isolates from all MDR-TB patients in Shanghai, China, 2009-2012. We measured strain diversity within and between genomically clustered patients. Genomic and epidemiologic data were combined to construct transmission networks. Findings 367 (5%) of 7982 patients with tuberculosis had MDR tuberculosis and 324 (88%) of these had isolates available for genomic analysis. 103 (32%) of the 324 MDR strains were in 38 genomic clusters that differed by 12 or fewer single nucleotide polymorphisms (SNPs), indicating recent transmission of MDR strains. Patients who had delayed diagnosis or were older than 45 years had high risk of recent transmission. 235 (73%) patients with MDR tuberculosis probably had transmission of MDR strains. Transmission network analysis showed that 33 (87%) of the 38 clusters accumulated additional drug-resistance mutations through emergence or fixation of mutations during transmission. 68 (66%) of 103 clustered MDR strains had compensatory mutations of rifampicin resistance. Interpretation Recent transmission of MDR strains, with increasing drug-resistance, helps drive the MDR-TB epidemic in Shanghai, China. WGS provides a measure of the heterogeneity of drug-resistant mutations within and between hosts and enhances our ability to determine the transmission patterns of MDR-TB. Funding National Science and Technology Major Project, National Natural Science Foundation of China, and US National Insitutes of Health.

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Section: Discussionmentioning

confidence: 99%

Transmission of multidrug-resistant Mycobacterium tuberculosis in Shanghai, China: a retrospective observational study using whole-genome sequencing and epidemiological investigation

Yang

Luò

Shen

et al. 2017

The Lancet Infectious Diseases

217

221

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“…However, impacts of the health reform on generally low availability [38], total number of prescriptions [39, 40] or less-than-appropriate use [41] was not clear.…”

Section: Resultsmentioning

confidence: 99%

Comparison of medicines management strategies in insurance schemes in middle-income countries: four case studies

Kaplan

Ashigbie

Brooks

et al. 2017

J of Pharm Policy and Pract

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BackgroundMany middle-income countries are scaling up health insurance schemes to provide financial protection and access to affordable medicines to poor and uninsured populations. Although there is a wealth of evidence on how high income countries with mature insurance schemes manage cost-effective use of medicines, there is limited evidence on the strategies used in middle-income countries. This paper compares the medicines management strategies that four insurance schemes in middle-income countries use to improve access and cost-effective use of medicines among beneficiaries.MethodsWe compare key strategies promoting cost-effective medicines use in the New Rural Cooperative Medical Scheme (NCMS) in China, National Health Insurance Scheme in Ghana, Jamkesmas in Indonesia and Seguro Popular in Mexico. Through the peer-reviewed and grey literature as of late 2013, we identified strategies that met our inclusion criteria as well as any evidence showing if, and/or how, these strategies affected medicines management. Stakeholders involved and affected by medicines coverage policies in these insurance schemes were asked to provide relevant documents describing the medicines related aspects of these insurance programs. We also asked them specifically to identify publications discussing the unintended consequences of the strategies implemented.ResultsUse of formularies, bulk procurement, standard treatment guidelines and separation of prescribing and dispensing were present in all four schemes. Also, increased transparency through publication of tender agreements and procurement prices was introduced in all four. Common strategies shared by three out of four schemes were medicine price negotiation or rebates, generic reference pricing, fixed salaries for prescribers, accredited preferred provider network, disease management programs, and monitoring of medicines purchases. Cost-sharing and payment for performance was rarely used. There was a lack of performance monitoring strategies in all schemes.ConclusionsMost of the strategies used in the insurance schemes focus on containing expenditure growth, including budget caps on pharmaceutical expenditures (Mexico) and ceiling prices on medicines (all four countries). There were few strategies targeting quality improvement as healthcare providers are mostly paid through fixed salaries, irrespective of the quality of their prescribing or the health outcomes actually achieved. Monitoring healthcare system performance has received little attention.

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“…The TB component of the infectious and endemic disease control (IEDC-TB) project in the People’ Republic of China indicated that new smear-positive cases should be treated with 2HRZS/4HR regimen [11, 19]. Patients treated in non-CTDs had a lower possibility to obtain the standardized chemotherapy regimens than those treated in CTD and a previous study by Chinese National Center for TB Control and Prevention showed similar results that only a small proportion of TB cases in hospitals (non- CTDs) were treated with appropriate NTP/WHO treatment regimens [20]. As improper therapeutic strategy could result in an extra burden not only to the patients but also to the community by increasing chances of drug resistance development, non-CTDs were proved to be less efficient in TB control in this respect.…”

Section: Discussionmentioning

confidence: 97%

Better care provided to patients with tuberculosis at county designated TB hospitals (CTD) compared to non-CTDs in rural China

Zhang²,

Zhou

et al. 2017

BMC Infect Dis

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BackgroundThe primary unit of tuberculosis (TB) medical care in China is the county TB dispensary or county designated hospital (CTD), where patients can receive free diagnosis and treatment. However, a substantial number of patients seek their anti-TB treatment from general health facilities (Non-CTDs). This study aimed to investigate the first anti-TB treatment experience and choice of health facilities of retreated TB patients and their determinants.MethodsA cross-sectional study was conducted in Jiangsu, Shandong and Sichuan provinces. All registered re-treated TB patients were investigated using a structured questionnaire covering information on demographics, socio-economic characteristics, and previous anti-TB treatment experiences.ResultsTotally, 75.3% of 544 patients visited CTD directly for initial treatment. Patients who were female (OR:1.71, 95% CI: 1.01-2.87), over 40 years of age (OR:2.80, 95% CI: 1.24-6.33), from Jiangsu (OR:3.07, 95% CI: 1.57-6.01) and Sichuan (OR:4.47, 95% CI: 2.29-8.73) and those diagnosed before 2005 (OR:6.87, 95% CI: 4.24-11.13) had a significant higher risk receiving their initial treatment at a non-CTD. Patients were more likely to have standardized diagnosis and treatment regimens in CTD (89.8%) than in non-CTDs (65.9%). Patients treated in non-CTDs versus in CTD had a lower possibility to complete their treatment course during first TB episode (χ 2 = 3.926, P = 0.048), but there was no significant difference in the cure rate between different facilities (CTD 60.8%, Non-CTDs 59.1%). Patients in non-CTDs incurred higher costs (1,360 CNY) than those treated in CTD (920CNY).ConclusionCTD play a key role in the National Tuberculosis Control Program. Patients should be guided to seek health care in county designated hospital, where they are more likely to receive appropriate examinations, treatment regimens and rigorous supervision, and to bear a lighter economic burden.

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Inappropriate Tuberculosis Treatment Regimens in Chinese Tuberculosis Hospitals

Cited by 26 publications

References 3 publications

Transmission of multidrug-resistant Mycobacterium tuberculosis in Shanghai, China: a retrospective observational study using whole-genome sequencing and epidemiological investigation

Transmission of multidrug-resistant Mycobacterium tuberculosis in Shanghai, China: a retrospective observational study using whole-genome sequencing and epidemiological investigation

Comparison of medicines management strategies in insurance schemes in middle-income countries: four case studies

Better care provided to patients with tuberculosis at county designated TB hospitals (CTD) compared to non-CTDs in rural China

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