Multicomponent strategy with decentralised molecular testing for tuberculosis in Uganda: a cost and cost-effectiveness analysis

Thompson, Ryan R.; Nalugwa, Talemwa; Oyuku, Denis; Tucker, Austin; Nantale, Mariam; Nakaweesa, Annet; Musinguzi, Johnson; Reza, Tania F.; Zimmer, A.; Ferguson, Olivia; Turyahabwe, Stavia; Joloba, Moses; Cattamanchi, Adithya; Katamba, Achilles; Dowdy, David W.; Sohn, Hojoon

doi:10.1016/s2214-109x(22)00509-5

Cited by 16 publications

(8 citation statements)

References 21 publications

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“…39 The transition from smear-based diagnosis to testing through cartridge-based PCR has been supported by the World Health Organization, 40 and strategies to optimize delivery through decentralization have been trialed and modeled in several settings. [41][42][43] At an onsite test cost of about $35 per test and assuming 13% loss to follow-up, Sohn et al estimated in India that decentralized testing would range between $2,300 and $3,200 per DALY averted-near the cost-effectiveness threshold in our model ($2,328). This aligns with our results (middle panel of Figure 5), in which the probability of onsite testing cost-effectiveness in this parameter space ($35 onsite testing cost and 13% utility lost due to send-out delays) was estimated to be 87%.…”

Section: Tuberculosis Modelmentioning

confidence: 62%

A Generalizable Decision-Making Framework for Selecting Onsite versus Send-out Clinical Laboratory Testing

Schroeder,

Rebman,

Kasaie

et al. 2024

Med Decis Making

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Background Laboratory networks provide services through onsite testing or through specimen transport to higher-tier laboratories. This decision is based on the interplay of testing characteristics, treatment characteristics, and epidemiological characteristics. Objectives Our objective was to develop a generalizable model using the threshold approach to medical decision making to inform test placement decisions. Methods We developed a decision model to compare the incremental utility of onsite versus send-out testing for clinical purposes. We then performed Monte Carlo simulations to identify the settings under which each strategy would be preferred. Tuberculosis was modeled as an exemplar. Results The most important determinants of the decision to test onsite versus send-out were the clinical utility lost due to send-out testing delays and the accuracy decrement with onsite testing. When the sensitivity decrements of onsite testing were minimal, onsite testing tended to be preferred when send-out delays reduced clinical utility by >20%. By contrast, when onsite testing incurred large reductions in sensitivity, onsite testing tended to be preferred when utility lost due to delays was >50%. The relative cost of onsite versus send-out testing affected these thresholds, particularly when testing costs were >10% of treatment costs. Conclusions Decision makers can select onsite versus send-out testing in an evidence-based fashion using estimates of the percentage of clinical utility lost due to send-out delays and the relative accuracy of onsite versus send-out testing. This model is designed to be generalizable to a wide variety of use cases. Highlights The design of laboratory networks, including the decision to place diagnostic instruments at the point-of-care or at higher tiers as accessed through specimen transport, can be informed using the threshold approach to medical decision making. The most important determinants of the decision to test onsite versus send-out were the clinical utility lost due to send-out testing delays and the accuracy decrement with onsite testing. The threshold approach to medical decision making can be used to compare point-of-care testing accuracy decrements with the lost utility of treatment due to send-out testing delays. The relative cost of onsite versus send-out testing affected these thresholds, particularly when testing costs were >10% of treatment costs.

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Section: Tuberculosis Modelmentioning

confidence: 62%

A Generalizable Decision-Making Framework for Selecting Onsite versus Send-out Clinical Laboratory Testing

Schroeder,

Rebman,

Kasaie

et al. 2024

Med Decis Making

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“…Thompson and colleagues estimated the cost-effectiveness of an adult tuberculosis diagnostic strategy decentralised in community health centres in Uganda. 28 The authors recommended decentralised testing services with ICERs ranging US$687 per additional treatment initiation in 14 days and US$1332 per additional tuberculosis diagnosis. Cost-effectiveness notably increased with high testing volumes and lower equipment costs.…”

Section: Discussionmentioning

confidence: 99%

Cost-effectiveness and budget impact of decentralising childhood tuberculosis diagnosis in six high tuberculosis incidence countries: a mathematical modelling study

d’Elbée,

Harker,

Mafirakureva

et al. 2024

eClinicalMedicine

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“…Thompson and colleagues estimated the cost-effectiveness of an adult tuberculosis diagnostic strategy decentralised in community health centres in Uganda. 26 The authors recommended decentralised testing services with ICERs ranging US$687 per additional treatment initiation in 14 days and US$1,332 per additional tuberculosis diagnosis. Cost- effectiveness notably increased with high testing volumes and lower equipment costs.…”

Section: Discussionmentioning

confidence: 99%

Cost-effectiveness and budget impact of decentralising childhood tuberculosis diagnosis: a mathematical modelling study in six high tuberculosis incidence countries

d’Elbée,

Harker,

Mafirakureva

et al. 2023

Preprint

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BackgroundThe burden of childhood tuberculosis remains high globally, largely due to under-diagnosis. Decentralising childhood tuberculosis diagnosis services to lower health system levels could improve case detection, but there is little empirically based evidence on cost-effectiveness or budget impact.MethodsWe assessed the cost-effectiveness and budget impact of decentralising a comprehensive diagnosis package for childhood tuberculosis to district hospitals (DH-focused) or primary health centres (PHC-focused) compared to standard of care (SOC) in Cambodia, Cameroon, Côte d’Ivoire, Mozambique, Sierra Leone, and Uganda (NCT04038632). A mathematical model was developed to assess the health and economic outcomes of the intervention from a health system perspective. Estimated outcomes were tuberculosis cases, deaths, disability- adjusted life years and incremental cost-effectiveness ratios (ICERs). We also calculated the budget impact of nationwide implementation.FindingsFor the DH-focused strategy versus SOC, ICERs ranged between $263 (Cambodia) and $342 (Côte d’Ivoire) per disability-adjusted life-year (DALY) averted. For the PHC-focused strategy versus SOC, ICERs ranged between $477 (Cambodia) and $599 (Côte d’Ivoire) per DALY averted. Results were sensitive to TB prevalence and the discount rate used. The additional costs of implementing the DH-focused strategy ranged between $13M (Cambodia) and $50M (Mozambique), and between $14M (Sierra Leone) and $135M (Uganda) for the PHC-focused strategy.InterpretationThe DH-focused strategy may be cost-effective in some countries, depending on the cost- effectiveness threshold used for policy making. Either intervention would require substantial early investment.FundingUnitaid

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Multicomponent strategy with decentralised molecular testing for tuberculosis in Uganda: a cost and cost-effectiveness analysis

Cited by 16 publications

References 21 publications

A Generalizable Decision-Making Framework for Selecting Onsite versus Send-out Clinical Laboratory Testing

A Generalizable Decision-Making Framework for Selecting Onsite versus Send-out Clinical Laboratory Testing

Cost-effectiveness and budget impact of decentralising childhood tuberculosis diagnosis in six high tuberculosis incidence countries: a mathematical modelling study

Cost-effectiveness and budget impact of decentralising childhood tuberculosis diagnosis: a mathematical modelling study in six high tuberculosis incidence countries

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