提高活动性肺结核的级联结局：结核病干预措施的全球系统评价和荟萃分析。

BACKGROUND: To inform policy and implementation that can enhance prevention and improve tuberculosis (TB) care cascade outcomes, this review aimed to summarize the impact of various interventions on care cascade outcomes for active TB. METHODS AND FINDINGS: In this systematic review and meta-analysis, we retrieved English articles with comparator arms (like randomized controlled trials (RCTs) and before and after intervention studies) that evaluated TB interventions published from January 1970 to September 30, 2022, from Embase, CINAHL, PubMed, and the Cochrane library. Commentaries, qualitative studies, conference abstracts, studies without standard of care comparator arms, and studies that did not report quantitative results for TB care cascade outcomes were excluded. Data from studies with similar comparator arms were pooled in a random effects model, and outcomes were reported as odds ratio (OR) with 95% confidence interval (CI) and number of studies (k). The quality of evidence was appraised using GRADE, and the study was registered on PROSPERO (CRD42018103331). Of 21,548 deduplicated studies, 144 eligible studies were included. Of 144 studies, 128 were from low/middle-income countries, 84 were RCTs, and 25 integrated TB and HIV care. Counselling and education was significantly associated with testing (OR = 8.82, 95% CI:1.71 to 45.43; I2 = 99.9%, k = 7), diagnosis (OR = 1.44, 95% CI:1.08 to 1.92; I2 = 97.6%, k = 9), linkage to care (OR = 3.10, 95% CI = 1.97 to 4.86; I2 = 0%, k = 1), cure (OR = 2.08, 95% CI:1.11 to 3.88; I2 = 76.7%, k = 4), treatment completion (OR = 1.48, 95% CI: 1.07 to 2.03; I2 = 73.1%, k = 8), and treatment success (OR = 3.24, 95% CI: 1.88 to 5.55; I2 = 75.9%, k = 5) outcomes compared to standard-of-care. Incentives, multisector collaborations, and community-based interventions were associated with at least three TB care cascade outcomes; digital interventions and mixed interventions were associated with an increased likelihood of two cascade outcomes each. These findings remained salient when studies were limited to RCTs only. Also, our study does not cover the entire care cascade as we did not measure gaps in pre-testing, pretreatment, and post-treatment outcomes (like loss to follow-up and TB recurrence). CONCLUSIONS: Among TB interventions, education and counseling, incentives, community-based interventions, and mixed interventions were associated with multiple active TB care cascade outcomes. However, cost-effectiveness and local-setting contexts should be considered when choosing such strategies due to their high heterogeneity.

背景：为了为能够加强预防和改善结核病（TB）护理级联结局的政策和实施提供信息，本综述旨在总结各种干预措施对活动性 TB 护理级联结局的影响。

方法和发现：在这项系统评价和荟萃分析中，我们从 Embase、CINAHL、PubMed 和 Cochrane 图书馆检索了 1970 年 1 月至 2022 年 9 月 30 日发表的具有对照臂（如随机对照试验（RCT）和干预前后研究）的评估 TB 干预措施的英文文章。排除评论、定性研究、会议摘要、没有标准护理对照臂的研究以及没有报告 TB 护理级联结局的定量结果的研究。具有相似对照臂的研究的数据被合并到一个随机效应模型中，结果以比值比（OR）和 95%置信区间（CI）以及研究数量（k）报告。使用 GRADE 评估证据质量，并在 PROSPERO（CRD42018103331）上进行了注册。在 21548 篇去重的研究中，有 144 篇符合条件的研究被纳入。在 144 项研究中，128 项来自中低收入国家，84 项为 RCT，25 项为结核病和艾滋病综合护理。咨询和教育与检测（OR = 8.82，95%CI：1.71 至 45.43；I2 = 99.9%，k = 7）、诊断（OR = 1.44，95%CI：1.08 至 1.92；I2 = 97.6%，k = 9）、与护理的关联（OR = 3.10，95%CI = 1.97 至 4.86；I2 = 0%，k = 1）、治愈（OR = 2.08，95%CI：1.11 至 3.88；I2 = 76.7%，k = 4）、治疗完成（OR = 1.48，95%CI：1.07 至 2.03；I2 = 73.1%，k = 8）和治疗成功（OR = 3.24，95%CI：1.88 至 5.55；I2 = 75.9%，k = 5）结局与标准护理相比具有显著相关性。激励措施、多部门合作和基于社区的干预措施与至少三个 TB 护理级联结局相关；数字干预措施和混合干预措施与每个级联结局的增加几率相关。当研究仅限于 RCT 时，这些发现仍然存在。此外，由于存在高度异质性，我们的研究并未涵盖整个护理级联，因为我们没有测量检测前、治疗前和治疗后（如失访和 TB 复发）的差距。

结论：在结核病干预措施中，教育和咨询、激励措施、基于社区的干预措施和混合干预措施与多个活动性结核病护理级联结局相关。然而，由于其高度异质性，在选择这些策略时应考虑成本效益和当地环境背景。