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

Anil Pooran, Grant Theron, Lynn Zijenah, Duncan Chanda, Petra Clowes, Lawrence Mwenge, Farirai Mutenherwa, Paul Lecesse, John Metcalfe, Hojoon Sohn, Michael Hoelscher, Alex Pym, Jonny Peter, David Wesley Dowdy, Keertan Dheda

Research output: Contribution to journalArticle

Abstract

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.

Original languageEnglish (US)
Pages (from-to)e798-e807
JournalThe Lancet Global Health
Volume7
Issue number6
DOIs
StatePublished - Jun 1 2019

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Point-of-Care Systems
Cost-Benefit Analysis
Microscopy
Primary Health Care
Tuberculosis
Costs and Cost Analysis
Therapeutics
Zambia
Southern Africa
Zimbabwe
Tanzania
Resource Allocation
Health Facilities
European Union
South Africa
Health Personnel
Nucleic Acids
Developing Countries
Clinical Trials

ASJC Scopus subject areas

  • Medicine(all)

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Point of care Xpert MTB/RIF versus smear microscopy for tuberculosis diagnosis in southern African primary care clinics : a multicentre economic evaluation. / Pooran, Anil; Theron, Grant; Zijenah, Lynn; Chanda, Duncan; Clowes, Petra; Mwenge, Lawrence; Mutenherwa, Farirai; Lecesse, Paul; Metcalfe, John; Sohn, Hojoon; Hoelscher, Michael; Pym, Alex; Peter, Jonny; Dowdy, David Wesley; Dheda, Keertan.

In: The Lancet Global Health, Vol. 7, No. 6, 01.06.2019, p. e798-e807.

Research output: Contribution to journalArticle

Pooran, A, Theron, G, Zijenah, L, Chanda, D, Clowes, P, Mwenge, L, Mutenherwa, F, Lecesse, P, Metcalfe, J, Sohn, H, Hoelscher, M, Pym, A, Peter, J, Dowdy, DW & Dheda, K 2019, 'Point of care Xpert MTB/RIF versus smear microscopy for tuberculosis diagnosis in southern African primary care clinics: a multicentre economic evaluation', The Lancet Global Health, vol. 7, no. 6, pp. e798-e807. https://doi.org/10.1016/S2214-109X(19)30164-0
Pooran, Anil ; Theron, Grant ; Zijenah, Lynn ; Chanda, Duncan ; Clowes, Petra ; Mwenge, Lawrence ; Mutenherwa, Farirai ; Lecesse, Paul ; Metcalfe, John ; Sohn, Hojoon ; Hoelscher, Michael ; Pym, Alex ; Peter, Jonny ; Dowdy, David Wesley ; Dheda, Keertan. / Point of care Xpert MTB/RIF versus smear microscopy for tuberculosis diagnosis in southern African primary care clinics : a multicentre economic evaluation. In: The Lancet Global Health. 2019 ; Vol. 7, No. 6. pp. e798-e807.
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AU - Theron, Grant

AU - Zijenah, Lynn

AU - Chanda, Duncan

AU - Clowes, Petra

AU - Mwenge, Lawrence

AU - Mutenherwa, Farirai

AU - Lecesse, Paul

AU - Metcalfe, John

AU - Sohn, Hojoon

AU - Hoelscher, Michael

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N2 - 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.

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