Mafirakureva Nyashadzaishe, Denoeud-Ndam Lise, Tchounga Boris Kevin, Otieno-Masaba Rose, Herrera Nicole, Mukherjee Sushant, Casenghi Martina, Tiam Appolinaire, Dodd Peter J
Division of Population Health, The University of Sheffield, Sheffield, UK
Elizabeth Glaser Pediatric AIDS Foundation, Geneva, Switzerland.
BMJ Glob Health. 2024 Dec 18;9(12):e016416. doi: 10.1136/bmjgh-2024-016416.
In 2021, over one million children developed tuberculosis, resulting in 214 000 deaths, largely due to inadequate diagnosis and treatment. The diagnosis and treatment of tuberculosis is limited in most high-burden countries because services are highly centralised at secondary/tertiary levels and are managed in a vertical, non-integrated way. To improve case detection and treatment among children, the World Health Organisation (WHO) recommends decentralised and integrated tuberculosis care models. The Integrating Paediatric TB Services Into Child Healthcare Services in Africa (INPUT) stepped-wedge cluster-randomised trial evaluated the impact of integrating tuberculosis services into healthcare for children under five in Cameroon and Kenya, compared with usual care, finding a 10-fold increase in tuberculosis case detection in Cameroon but no effect in Kenya.
We estimated intervention impact on healthcare outcomes, resource use, health system costs and cost-effectiveness relative to the standard of care (SoC) using a decision tree analytical approach and data from the INPUT trial. INPUT trial data on cascades, resource use and intervention diagnostic rate ratios were used to parametrise the decision tree model. Health outcomes following tuberculosis treatment were modelled in terms of mortality and disability-adjusted life-years (DALYs).
For every 100 children starting antituberculosis treatment under SoC, an additional 876 (95% uncertainty interval (UI) -76 to 5518) in Cameroon and -6 (95% UI -61 to 96) in Kenya would start treatment under the intervention. Treatment success would increase by 5% in Cameroon and 9% in Kenya under the intervention compared with SoC. An estimated 350 (95% UI -31 to 2204) and 3 (95% UI -22 to 48) deaths would be prevented in Cameroon and Kenya, respectively. The incremental cost-effectiveness ratio for the intervention compared with SoC was US$506 and US$1299 per DALY averted in Cameroon and Kenya, respectively.
Although likely to be effective, the cost-effectiveness of integrating tuberculosis services into child healthcare services depends on baseline service coverage, tuberculosis detection and treatment outcomes.
2021年，超过100万儿童患上结核病，导致21.4万人死亡，这主要是由于诊断和治疗不足所致。在大多数高负担国家，结核病的诊断和治疗受到限制，因为服务高度集中在二级/三级医疗机构，且以垂直、非整合的方式进行管理。为了提高儿童病例的发现率和治疗率，世界卫生组织（WHO）推荐采用分散式和整合式结核病护理模式。“将儿科结核病服务纳入非洲儿童医疗服务”（INPUT）阶梯楔形整群随机试验评估了在喀麦隆和肯尼亚将结核病服务纳入五岁以下儿童医疗保健的影响，并与常规护理进行了比较，结果发现喀麦隆的结核病病例发现率提高了10倍，但在肯尼亚没有效果。
我们使用决策树分析方法和INPUT试验的数据，估计了相对于标准治疗（SoC），干预措施对医疗保健结果、资源使用、卫生系统成本和成本效益的影响。INPUT试验中关于疾病传播、资源使用和干预诊断率比的数据被用于参数化决策树模型。结核病治疗后的健康结果以死亡率和伤残调整生命年（DALYs）来建模。
在SoC下每100名开始抗结核治疗的儿童中，在喀麦隆，干预措施下将有额外876名（95%不确定区间（UI）-76至5518）儿童开始治疗，在肯尼亚则为-6名（95%UI-61至96）。与SoC相比，干预措施下喀麦隆的治疗成功率将提高5%，肯尼亚将提高9%。估计喀麦隆和肯尼亚分别可预防350例（95%UI-31至2204）和3例（95%UI-22至48）死亡。与SoC相比，干预措施的增量成本效益比在喀麦隆和肯尼亚分别为每避免一个DALY506美元和1299美元。
虽然将结核病服务纳入儿童医疗保健服务可能有效，但其成本效益取决于基线服务覆盖率、结核病检测和治疗结果。
