Informing decision-making for universal access to quality tuberculosis diagnosis in India

An economic-epidemiological model

Hojoon Sohn, Parastu Kasaie, Emily Kendall, Gabriela B. Gomez, Anna Vassall, Madhukar Pai, David Wesley Dowdy

Research output: Contribution to journalArticle

Abstract

Background: India and many other high-burden countries have committed to providing universal access to high-quality diagnosis and drug susceptibility testing (DST) for tuberculosis (TB), but the most cost-effective approach to achieve this goal remains uncertain. Centralized testing at district-level hub facilities with a supporting sample transport network can generate economies of scale, but decentralization to the peripheral level may provide faster diagnosis and reduce losses to follow-up (LTFU). Methods: We generated functions to evaluate the costs of centralized and decentralized molecular testing for tuberculosis with Xpert MTB/RIF (Xpert), a WHO-endorsed test which can be performed at centralized and decentralized levels. We merged the cost estimates with an agent-based simulation of TB transmission in a hypothetical representative region in India to assess the impact and cost-effectiveness of each strategy. Results: Compared against centralized Xpert testing, decentralization was most favorable when testing volume at decentralized facilities and pre-treatment LTFU were high, and specimen transport network was exclusively established for TB. Assuming equal quality of centralized and decentralized testing, decentralization was cost-saving, saving a median 338,000 (interquartile simulation range [IQR] - 222,000; 889,000) per 20 million people over 10 years, in the most cost-favorable scenario. In the most cost-unfavorable scenario, decentralized testing would cost a median 3161 [IQR 2412; 4731] per disability-adjusted life year averted relative to centralized testing. Conclusions: Decentralization of Xpert testing is likely to be cost-saving or cost-effective in most settings to which these simulation results might generalize. More decentralized testing is more cost-effective in settings with moderate-to-high peripheral testing volumes, high existing clinical LTFU, inability to share specimen transport costs with other disease entities, and ability to ensure high-quality peripheral Xpert testing. Decision-makers should assess these factors when deciding whether to decentralize molecular testing for tuberculosis.

Original languageEnglish (US)
Article number155
JournalBMC medicine
Volume17
Issue number1
DOIs
StatePublished - Aug 6 2019

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Economic Models
India
Decision Making
Tuberculosis
Costs and Cost Analysis
Politics
Quality-Adjusted Life Years
Cost-Benefit Analysis

Keywords

  • Cost-benefit analysis
  • Diagnostic techniques and procedures
  • Systems analysis
  • Tuberculosis

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Informing decision-making for universal access to quality tuberculosis diagnosis in India : An economic-epidemiological model. / Sohn, Hojoon; Kasaie, Parastu; Kendall, Emily; Gomez, Gabriela B.; Vassall, Anna; Pai, Madhukar; Dowdy, David Wesley.

In: BMC medicine, Vol. 17, No. 1, 155, 06.08.2019.

Research output: Contribution to journalArticle

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