六个结核病高发病率国家儿童结核病诊断去中心化的成本效益和预算影响：一项数学建模研究
Cost-effectiveness and budget impact of decentralising childhood tuberculosis diagnosis in six high tuberculosis incidence countries: a mathematical modelling study.
作者信息
d'Elbée Marc, Harker Martin, Mafirakureva Nyashadzaishe, Nanfuka Mastula, Huyen Ton Nu Nguyet Minh, Taguebue Jean-Voisin, Moh Raoul, Khosa Celso, Mustapha Ayeshatu, Mwanga-Amumpere Juliet, Borand Laurence, Nolna Sylvie Kwedi, Komena Eric, Cumbe Saniata, Mugisha Jacob, Natukunda Naome, Mao Tan Eang, Wittwer Jérôme, Bénard Antoine, Bernard Tanguy, Sohn Hojoon, Bonnet Maryline, Wobudeya Eric, Marcy Olivier, Dodd Peter J
机构信息
University of Bordeaux, National Institute for Health and Medical Research (Inserm) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux, France.
Ceped UMR 196, Université Paris Cité, Research Institute for Sustainable Development (IRD), Inserm, Paris, France.
出版信息
EClinicalMedicine. 2024 Mar 21;70:102528. doi: 10.1016/j.eclinm.2024.102528. eCollection 2024 Apr.
BACKGROUND
The 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.
METHODS
In this mathematical modelling study, we 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). The project was conducted in Cambodia, Cameroon, Côte d'Ivoire, Mozambique, Sierra Leone, and Uganda between August 1st, 2018 and September 30th, 2021. 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 (DALYs) and incremental cost-effectiveness ratios (ICERs). We also calculated the budget impact of nationwide implementation. The TB-Speed Decentralization study is registered with ClinicalTrials.gov, NCT04038632.
FINDINGS
For the DH-focused strategy versus SOC, ICERs ranged between $263 (Cambodia) and $342 (Côte d'Ivoire) per 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 $12.8 M (range 10.8-16.4) (Cambodia) and $50.4 M (36.5-74.4) (Mozambique), and between $13.9 M (12.6-15.6) (Sierra Leone) and $134.6 M (127.1-143.0) (Uganda) for the PHC-focused strategy.
INTERPRETATION
The 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.
FUNDING
Unitaid.
背景
全球儿童结核病负担依然沉重，主要原因是诊断不足。将儿童结核病诊断服务下放到较低层级的卫生系统可提高病例发现率，但关于成本效益或预算影响的实证依据很少。
方法
在这项数学建模研究中，我们评估了与标准治疗（SOC）相比，将儿童结核病综合诊断方案下放到地区医院（以地区医院为重点）或初级卫生中心（以初级卫生中心为重点）的成本效益和预算影响。该项目于2018年8月1日至2021年9月30日在柬埔寨、喀麦隆、科特迪瓦、莫桑比克、塞拉利昂和乌干达开展。开发了一个数学模型，从卫生系统角度评估干预措施的健康和经济结果。估计结果包括结核病病例、死亡人数、伤残调整生命年（DALYs）和增量成本效益比（ICERs）。我们还计算了全国实施的预算影响。结核病快速下放研究已在ClinicalTrials.gov注册，注册号为NCT04038632。
结果
与SOC相比，以地区医院为重点的策略，每避免一个DALY的ICERs在263美元（柬埔寨）至342美元（科特迪瓦）之间。与SOC相比，以初级卫生中心为重点的策略，每避免一个DALY的ICERs在477美元（柬埔寨）至599美元（科特迪瓦）之间。结果对结核病患病率和所用贴现率敏感。实施以地区医院为重点策略的额外成本在1280万美元（范围1080 - 1640万美元）（柬埔寨）至5040万美元（3650 - 7440万美元）（莫桑比克）之间，以初级卫生中心为重点的策略在1390万美元（1260 - 1560万美元）（塞拉利昂）至13460万美元（12710 - 14300万美元）（乌干达）之间。
解读
根据用于决策的成本效益阈值，以地区医院为重点的策略在一些国家可能具有成本效益。任何一种干预措施都需要大量的早期投资。
资金来源
国际药品采购机制。
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