The patient impact of point-of-care vs. laboratory placement of Xpert&lt;SUP&gt;®&lt;/SUP&gt; MTB/RIF

Hanrahan, Colleen F.; Clouse, Kate; Bassett, Jean; Mutunga, Lillian; Selibas, Katerina; Stevens, Wendy; Scott, Lesley J.; Sanne, Ian; Rie, Annelies Van

doi:10.5588/ijtld.15.0013

Cited by 32 publications

(20 citation statements)

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“…Although there is a 45% increase in bacteriologically confirmed TB case detection when using Xpert compared to smear microscopy [13] and the turnaround time for TB test results is said to decrease to five days when using laboratory-based Xpert [14], patients are still not initiated on treatment early. Causes of the delays vary from patient factors to health system factors.…”

Section: Introductionmentioning

confidence: 99%

Microbiologically Confirmed Tuberculosis: Factors Associated with Pre-Treatment Loss to Follow-Up, and Time to Treatment Initiation

Mwansa-Kambafwile¹,

Boitumelo²,

Black³

2017

PLoS ONE

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BackgroundThe impact of new diagnostics on pre-treatment loss to follow up (Pre-treatment LTFU) has not been widely investigated. The reported rate of pre-treatment LTFU is however lower in studies where Xpert MTB/Rif (Xpert) has been used onsite as opposed to centrally. The use of the Xpert at point of care (POC) could have a role in reducing the pre-treatment LTFU rate among TB patients. We aimed to determine the pre-treatment LTFU rate and the time to treatment initiation as well as to describe associated factors in patients diagnosed with TB using POC Xpert or smear microscopy.MethodXpert machines were installed at 7 primary healthcare facilities in inner-city Johannesburg. POC Xpert TB testing was the primary diagnostic method for all patients although there were some patients who were tested using only laboratory-based smear microscopy (during power outages or machine operator off-sick). Data on patients’ demographics, TB diagnostic test (Xpert or smear microscopy), test result, and time to treatment initiation were collected. Associations and predictors of pre-treatment LTFU and time to treatment initiation were explored.FindingsA total of 1981 people with presumptive TB were tested (1743 using Xpert and 238 using smear). A bacteriological diagnosis of TB was made in 271 patients (90% Xpert; 10% smear). The median time to treatment initiation in the smear group was 9 days (IQR: 4–20) while those tested using Xpert had a median time of 0 days (IQR: 0–0). Pre-treatment LTFU was 22.5% with no difference between diagnostic groups (p = 0.8).ConclusionThe Pre-treatment LTFU rate of 22.5% found in this study is much higher than the 5% target of the South African National TB Control Program. POC Xpert resulted in a significantly greater proportion of bacteriologically proven TB patients being started on treatment within 30 days of presentation. No risk factors associated with pre-treatment LTFU were identified.

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Section: Introductionmentioning

confidence: 99%

Microbiologically Confirmed Tuberculosis: Factors Associated with Pre-Treatment Loss to Follow-Up, and Time to Treatment Initiation

Mwansa-Kambafwile¹,

Boitumelo²,

Black³

2017

PLoS ONE

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“…7,8,11–13 These earlier modeling studies largely assumed efficiently functioning laboratories that served as initial sites of Xpert scale-up. Over time, however, the focus of Xpert implementation has shifted to district and subdistrict levels, 14–16 where the cost of Xpert may be substantially higher because of lower testing volumes or additional costs associated with transport and installation. 17 Previous work in South Africa has suggested that point-of-treatment placement of Xpert could increase Xpert testing cost by 50% or more; 9 whether that additional cost, as well as the linkage between such additional cost and the potential for Xpert to improve diagnostic outcomes, generalizes to high-burden low-income settings remains uncertain.…”

Section: Introductionmentioning

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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“…Studies at community level were cross-sectional [15][16][17][18][19] and cohort in design (Table 2) [20][21][22]. Studies at primary care level were either diagnostic evaluations [23][24][25][26][27][28][29][30], programme evaluations [31][32][33] or other cross-sectional designs [34][35][36][37]. Studies among hospital inpatients were predominantly diagnostic evaluations [38][39][40][41].…”

Section: Characteristics Of Included Studiesmentioning

confidence: 99%

High HIV and active tuberculosis prevalence and increased mortality risk in adults with symptoms of TB: a systematic review and meta‐analyses

et al. 2018

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Introduction HIV and tuberculosis (TB) remain leading causes of preventable death in low‐ and middle‐income countries (LMICs). The World Health Organization (WHO) recommends HIV testing for all individuals with TB symptoms, but implementation has been suboptimal. We conducted a systematic literature review and meta‐analyses to estimate HIV and TB prevalence, and short‐term (two to six months) mortality, among adults with TB symptoms at community‐ and facility level.MethodsWe searched Embase, Global Health and MEDLINE databases, and reviewed conference abstracts for studies reporting simultaneous HIV and TB screening of adults in LMICs published between January 2003 and December 2017. Meta‐analyses were performed to estimate prevalence of HIV, undiagnosed TB and mortality risk at different health system levels.ResultsSixty‐two studies including 260,792 symptomatic adults were identified, mostly from Africa and Asia. Median HIV prevalence was 19.2% (IQR: 8.3% to 40.4%) at community level, 55.7% (IQR: 20.9% to 71.2%) at primary care level and 80.7% (IQR: 73.8% to 84.6%) at hospital level. Median TB prevalence was 6.9% (IQR: 3.3% to 8.4%) at community, 20.5% (IQR: 11.7% to 46.4%) at primary care and 36.4% (IQR: 22.9% to 40.9%) at hospital level. Median short‐term mortality was 22.6% (IQR: 15.6% to 27.7%) among inpatients, 3.1% (IQR: 1.2% to 4.2%) at primary care and 1.6% (95% CI: 0.45 to 4.13, n = 1 study) at community level.ConclusionsAdults with TB symptoms have extremely high prevalence of HIV infection, even when identified through community surveys. TB prevalence and mortality increased substantially at primary care and inpatient level respectively. Strategies to expand symptom‐based TB screening combined with HIV and TB testing for all symptomatic individuals should be of the highest priority for both disease programmes in LMICs with generalized HIV epidemics. Interventions to reduce short‐term mortality are urgently needed.

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The patient impact of point-of-care vs. laboratory placement of Xpert<SUP>®</SUP> MTB/RIF

Cited by 32 publications

References 10 publications

Microbiologically Confirmed Tuberculosis: Factors Associated with Pre-Treatment Loss to Follow-Up, and Time to Treatment Initiation

Microbiologically Confirmed Tuberculosis: Factors Associated with Pre-Treatment Loss to Follow-Up, and Time to Treatment Initiation

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

High HIV and active tuberculosis prevalence and increased mortality risk in adults with symptoms of TB: a systematic review and meta‐analyses

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