Gaeddert Mary, Jaganath Devan, Civan Abdulkadir, Nguyen Hoa, Bonnet Maryline, Wobudeya Eric, Marcy Olivier, De Allegri Manuela, Denkinger Claudia M
Department of Infectious Diseases and Tropical Medicine, University Hospital Heidelberg, Heidelberg, Germany.
Division of Pediatric Infectious Diseases, University of California San Francisco, San Francisco, USA.
medRxiv. 2025 Jun 20:2025.06.20.25329945. doi: 10.1101/2025.06.20.25329945.
To improve childhood tuberculosis (TB) diagnosis, treatment-decision algorithms (TDAs) with and without chest X-ray (CXR) were developed for children under age 10. We aimed to model diagnostic performance and costs of implementing TDAs in primary healthcare (PHC) and district hospital (DH) settings in Uganda.
We developed decision-tree models following the TDA pathway from evaluation to treatment-decision. We compared six scenarios with combinations of diagnostic testing (stool and respiratory Xpert, urine lipoarabinomannan, and/or CXR) at PHCs and DHs. Outcomes were diagnostic accuracy and cost per correct treatment-decision for a cohort of 10,000 children with presumptive TB using a Monte Carlo simulation from a health system perspective. Costs were reported in 2024 International dollars.
In all scenarios, TDA's had high sensitivity (80.8-91.9%) but low specificity (51.2-60.9%). Total diagnostic and treatment costs for the cohort were I$1,768,958-2,458,790; largely driven by overtreatment of false-positive cases. Diagnostic costs were mostly offset by reducing overtreatment. The cost per treatment-decision was lowest using mobile CXR at PHC (I$287.40) and highest with DH referral (I$445.84).
The TDAs have high sensitivity and can be implemented at PHCs with lower costs than DHs. Improving specificity and reducing treatment costs would enable affordable, large-scale implementation.
为改善儿童结核病（TB）诊断，针对10岁以下儿童开发了有和没有胸部X线检查（CXR）的治疗决策算法（TDA）。我们旨在模拟在乌干达初级卫生保健（PHC）和地区医院（DH）环境中实施TDA的诊断性能和成本。
我们按照从评估到治疗决策的TDA路径开发了决策树模型。我们比较了在初级卫生保健机构和地区医院进行诊断测试（粪便和呼吸道Xpert、尿液脂阿拉伯甘露聚糖和/或胸部X线检查）组合的六种情况。从卫生系统角度使用蒙特卡罗模拟，对10,000名疑似结核病儿童队列的结果是诊断准确性和每个正确治疗决策的成本。成本以2024年国际美元报告。
在所有情况下，TDA具有高敏感性（80.8 - 91.9%）但低特异性（51.2 - 60.9%）。该队列的总诊断和治疗成本为1,768,958 - 2,458,790国际美元；主要由假阳性病例的过度治疗驱动。诊断成本大多因减少过度治疗而抵消。在初级卫生保健机构使用移动胸部X线检查时每个治疗决策的成本最低（287.40国际美元），而转诊到地区医院时最高（445.84国际美元）。
TDA具有高敏感性，并且可以在初级卫生保健机构以低于地区医院的成本实施。提高特异性和降低治疗成本将实现可负担的大规模实施。
