Higher cost of implementing Xpert&lt;SUP&gt;®&lt;/SUP&gt; MTB/RIF in Ugandan peripheral settings: implications for cost-effectiveness

Hsiang, Esther Y.; Little, Kristen; Haguma, Priscilla; Hanrahan, C. F.; Katamba, Achilles; Cattamanchi, Adithya; Davis, J. Lucian; Vassall, Anna; Dowdy, David W.

doi:10.5588/ijtld.16.0200

Cited by 38 publications

(37 citation statements)

References 26 publications

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“…Our scenario analysis result also revealed that the cost of both diagnostic algorithms was reduced from the base case estimate by increasing the volume of tests per day. This cost estimate is in line with nding from sub-Sahara Africa [29] and Uganda [30] on the cost and cost-effectiveness of the GeneXpert diagnostic test. The cost of the test method was high in health facilities where their testing volume was low.…”

Section: Discussionsupporting

confidence: 82%

Cost-effectiveness of GeneXpert Compared to Smear Microscopy for Diagnosis of Tuberculosis in Ethiopia

Kaso¹,

Hailu²

2020

Preprint

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Background Early diagnosis is one of the pillars of the TB (TB) control, and there are strong efforts to detect and treat cases in Ethiopia. Smear microscopy testing has been a routine test for the diagnosis of pulmonary TB in resource-constrained settings for a long time. Recently, many countries, including Ethiopia, are scaling up the use of GeneXpert without a precise evaluation of the cost and cost-effectiveness of this technology. Therefore, this study aimed to evaluate the cost-effectiveness of GeneXpert compared to smear microscopy tests for the diagnosis of TB patients in Ethiopia. Methods We develop a decision tree model using TreeAge Pro 2020 software. The model accounts for the prevalence and incidence of TB in the study area. The costs were estimated from the health providers' perspective in one year (in 2017/18). We applied an ingredients-based costing approach to identify, measure, and evaluate the smear microscopy cost and GeneXpert. We employed the 'proportion of cases detected' as an outcome measure of effectiveness. The incremental cost-effectiveness ratio (ICER) was calculated by dividing the changes in cost and change effectiveness. One way and probabilistic sensitivity analysis were done by varying different input parameters. All costs and ICER are reported in 2018 US$. Results The unit cost per test for GeneXpert and smear microscopy testing was US$12.9 and $3.1, respectively. The average cost of testing using GeneXpert was $113.0 and $3.3 for smear microscopy. The cost of the cartridge ($10.7) was the primary (83%) parameter influencing the overall cost of GeneXpert, while it was the cost of reagent and consumables $1.28 (41%) for the smear microscopy. The ICER for GeneXpert strategy was $729.8 per new TB cases detected compared to smear microscopy. The sensitivity analysis indicates that TB prevalence was the most influential parameter on the ICER. Conclusion The present study indicates that testing all individuals with suspected TB using GeneXpert is a very cost-effective strategy compared to smear microscopy, and therefore, it can be part of the routine diagnostic testing strategy in Ethiopia.

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Section: Discussionsupporting

confidence: 82%

Cost-effectiveness of GeneXpert Compared to Smear Microscopy for Diagnosis of Tuberculosis in Ethiopia

Kaso¹,

Hailu²

2020

Preprint

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“…Few studies have estimated the economic effect of implementing Xpert at the point of care 22,25,26 and all have used modelling analyses rather than prospectively obtained trial data to assess cost-effectiveness. 19,20,24,25,35 In most of these modelling studies, Xpert was cost-effective either as a full replacement 19,24,25,35 or in conjunction with other diagnostic tests 20,21 compared with the standard of care (smearmicroscopy).…”

Section: Discussionmentioning

confidence: 99%

“…9,17,18 Thus, crucial questions for policy makers, and of prime importance to resource allocation planning, are (1) how does the cost of Xpert performed by a minimally trained nurse at point of care compare with when performed by a trained technician at a centralised laboratory; and (2) is point-ofcare placement of Xpert cost-effective? Although multiple studies 17,[19][20][21][22][23][24][25][26] have examined the economic implications of using Xpert in endemic settings, few have focused on the costs or cost-effectiveness when deployed at point of care, 22,25,26 and no studies have calculated cost-effectiveness using clinical outcome data obtained from a pragmatic real-world prospective study. [19][20][21][22]24,25 To address these questions, we analysed prospectively collected cost and clinical outcome data from a large randomised control parent trial that recruited patients from primary care clinics in four southern African countries (South Africa, Zambia, Zimbabwe, Tanzania).…”

Section: Introductionmentioning

confidence: 99%

Point of care Xpert MTB/RIF versus smear microscopy for tuberculosis diagnosis in southern African primary care clinics: a multicentre economic evaluation

Pooran

Theron

Zijenah

et al. 2019

The Lancet Global Health

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Background Rapid on-site diagnosis facilitates tuberculosis control. Performing Xpert MTB/RIF (Xpert) at point of care is feasible, even when performed by minimally trained health-care workers, and when compared with point-of-care smear microscopy, reduces time to diagnosis and pretreatment loss to follow-up. However, whether Xpert is cost-effective at point of care remains unclear. Methods We empirically collected cost (US$, 2014) and clinical outcome data from participants presenting to primary health-care facilities in four African countries (South Africa, Zambia, Zimbabwe, and Tanzania) during the TB-NEAT trial. Costs were determined using an bottom-up ingredients approach. Effectiveness measures from the trial included number of cases diagnosed, initiated on treatment, and completing treatment. The primary outcome was the incremental cost-effectiveness of point-of-care Xpert relative to smear microscopy. The study was performed from the perspective of the health-care provider. Findings Using data from 1502 patients, we calculated that the mean Xpert unit cost was lower when performed at a centralised laboratory (Lab Xpert) rather than at point of care ($23•00 [95% CI 22•12-23•88] vs $28•03 [26•19-29•87]). Per 1000 patients screened, and relative to smear microscopy, point-of-care Xpert cost an additional $35 529 (27 054-40 025) and was associated with an additional 24•3 treatment initiations ([-20•0 to 68•5]; $1464 per treatment), 63•4 same-day treatment initiations ([27•3-99•4]; $511 per same-day treatment), and 29•4 treatment completions ([-6•9 to 65•6]; $1211 per completion). Xpert costs were most sensitive to test volume, whereas incremental outcomes were most sensitive to the number of patients initiating and completing treatment. The probability of point-of-care Xpert being cost-effective was 90% at a willingness to pay of $3820 per treatment completion. Interpretation In southern Africa, although point-of-care Xpert unit cost is higher than Lab Xpert, it is likely to offer good value for money relative to smear microscopy. With the current availability of point-of-care nucleic acid amplification platforms (eg, Xpert Edge), these data inform much needed investment and resource allocation strategies in tuberculosis endemic settings. Funding European Union European and Developing Countries Clinical Trials Partnership and the South African Medical Research Council.

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“…Ongoing efforts in scaling up new rapid diagnostics for tuberculosis involves significant investments in the health systems [ 31 – 34 ]. Major threat which may undermine the impact of these investments is sub-optimal uptake and low test volumes have already been reported from several settings globally [ 33 , 35 , 36 ]. These efforts need to be complemented with proactive outreach and education efforts to ensure provider engagement to ensure provider-literacy and awareness, for maximizing impact of this scale-up.…”

Section: Discussionmentioning

confidence: 99%

Catalysing progressive uptake of newer diagnostics by health care providers through outreach and education in four major cities of India

Raizada¹,

Khaparde

Swaminathan

et al. 2018

PLoS ONE

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BackgroundUnlike in adults, diagnosis of TB can be challenging in children, as signs and symptoms of paediatric TB can be very non-specific and similar to other common childhood chest infections, which may lead to under or delayed diagnosis of TB disease. In spite of the increasing availability of rapid high-sensitivity diagnostics in public and private sectors, majority of paediatric TB cases are empirically diagnosed, without laboratory confirmation. To address these diagnostic challenges, World Health Organization (WHO) has recommended upfront Xpert MTB/RIF (Xpert) testing for the diagnosis of TB in paediatric presumptive pulmonary and extra-pulmonary TB (EPTB) cases. However, in spite of the increasing availability of rapid high-sensitivity diagnostics, a significant gap exists in its application with Xpert being rarely used as an upfront diagnostic among patients presumed to have TB. Under an ongoing paediatric project since April 2014, which provided free-of-cost upfront Xpert testing, several low-cost outreach and education interventions were undertaken to increase the diagnostic uptake by different providers catering to the paediatric population, thereby increasing adherence to global guidance.MethodsProviders catering to paediatric population in the project cities were systematically mapped and contacted using different outreach strategies. The focus of outreach efforts was to increase provider literacy and increase their awareness of the availability of free rapid diagnostic services with the goal of changing their diagnostic approaches.ResultsFrom April 2014 to June 2016, more than 5,700 providers/facilities were mapped and 3,670 of them were approached. The number of providers/facilities engaged under the project increased more than 10-fold (43 in April, 2014 to 466 in June, 2016), with significant increase in project uptake, both from public and private sector. Overall 42,238 paediatric presumptive TB cases were enrolled in the project, across the four cities. Over the project period, quarterly diagnostic uptake and paediatric TB cases detection rates increased more than two-fold. TB detection rates were similar in patients from public and private sectors.ConclusionsOngoing efforts in scaling up new rapid diagnostics involves significant investments. These efforts need to be complemented with proactive provider engagement to ensure provider-literacy and awareness, for maximizing impact of this scale-up. The current project demonstrated the usefulness of outreach and education interventions for the effective uptake of newer diagnostics.

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

Cited by 38 publications

References 26 publications

Cost-effectiveness of GeneXpert Compared to Smear Microscopy for Diagnosis of Tuberculosis in Ethiopia

Cost-effectiveness of GeneXpert Compared to Smear Microscopy for Diagnosis of Tuberculosis in Ethiopia

Point of care Xpert MTB/RIF versus smear microscopy for tuberculosis diagnosis in southern African primary care clinics: a multicentre economic evaluation

Catalysing progressive uptake of newer diagnostics by health care providers through outreach and education in four major cities of India

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