Serological Testing Versus Other Strategies for Diagnosis of Active Tuberculosis in India: A Cost-Effectiveness Analysis
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{"title"=>"Serological testing versus other strategies for diagnosis of active tuberculosis in india: A cost-effectiveness analysis", "type"=>"journal", "authors"=>[{"first_name"=>"David W.", "last_name"=>"Dowdy", "scopus_author_id"=>"6603069678"}, {"first_name"=>"Karen R.", "last_name"=>"Steingart", "scopus_author_id"=>"8438524800"}, {"first_name"=>"Madhukar", "last_name"=>"Pai", "scopus_author_id"=>"14054425400"}], "year"=>2011, "source"=>"PLoS Medicine", "identifiers"=>{"pui"=>"362471707", "sgr"=>"80052331157", "issn"=>"15491277", "pmid"=>"21857810", "scopus"=>"2-s2.0-80052331157", "doi"=>"10.1371/journal.pmed.1001074", "isbn"=>"1549-1277"}, "id"=>"77a87ee2-ae84-3a07-8fee-6e80c6d22957", "abstract"=>"BACKGROUND: Undiagnosed and misdiagnosed tuberculosis (TB) drives the epidemic in India. Serological (antibody detection) TB tests are not recommended by any agency, but widely used in many countries, including the Indian private sector. The cost and impact of using serology compared with other diagnostic techniques is unknown.\\n\\nMETHODS AND FINDINGS: Taking a patient cohort conservatively equal to the annual number of serological tests done in India (1.5 million adults suspected of having active TB), we used decision analysis to estimate costs and effectiveness of sputum smear microscopy (US$3.62 for two smears), microscopy plus automated liquid culture (mycobacterium growth indicator tube [MGIT], US$20/test), and serological testing (anda-tb ELISA, US$20/test). Data on test accuracy and costs were obtained from published literature. We adopted the perspective of the Indian TB control sector and an analysis frame of 1 year. Our primary outcome was the incremental cost per disability-adjusted life year (DALY) averted. We performed one-way sensitivity analysis on all model parameters, with multiway sensitivity analysis on variables to which the model was most sensitive. If used instead of sputum microscopy, serology generated an estimated 14,000 more TB diagnoses, but also 121,000 more false-positive diagnoses, 102,000 fewer DALYs averted, and 32,000 more secondary TB cases than microscopy, at approximately four times the incremental cost (US$47.5 million versus US$11.9 million). When added to high-quality sputum smears, MGIT culture was estimated to avert 130,000 incremental DALYs at an incremental cost of US$213 per DALY averted. Serology was dominated by (i.e., more costly and less effective than) MGIT culture and remained less economically favorable than sputum smear or TB culture in one-way and multiway sensitivity analyses.\\n\\nCONCLUSIONS: In India, sputum smear microscopy remains the most cost-effective diagnostic test available for active TB; efforts to increase access to quality-assured microscopy should take priority. In areas where high-quality microscopy exists and resources are sufficient, MGIT culture is more cost-effective than serology as an additional diagnostic test for TB. These data informed a recently published World Health Organization policy statement against serological tests.", "link"=>"http://www.mendeley.com/research/serological-testing-versus-other-strategies-diagnosis-active-tuberculosis-india-costeffectiveness-an", "reader_count"=>131, "reader_count_by_academic_status"=>{"Unspecified"=>5, "Professor > Associate Professor"=>11, "Librarian"=>3, "Researcher"=>37, "Student > Doctoral Student"=>9, "Student > Ph. D. Student"=>18, "Student > Postgraduate"=>8, "Student > Master"=>18, "Other"=>6, "Student > Bachelor"=>4, "Lecturer > Senior Lecturer"=>6, "Professor"=>6}, "reader_count_by_user_role"=>{"Unspecified"=>5, "Professor > Associate Professor"=>11, "Librarian"=>3, "Researcher"=>37, "Student > Doctoral Student"=>9, "Student > Ph. D. Student"=>18, "Student > Postgraduate"=>8, "Student > Master"=>18, "Other"=>6, "Student > Bachelor"=>4, "Lecturer > Senior Lecturer"=>6, "Professor"=>6}, "reader_count_by_subject_area"=>{"Unspecified"=>14, "Agricultural and Biological Sciences"=>24, "Business, Management and Accounting"=>2, "Veterinary Science and Veterinary Medicine"=>3, "Chemistry"=>2, "Computer Science"=>2, "Economics, Econometrics and Finance"=>5, "Engineering"=>1, "Biochemistry, Genetics and Molecular Biology"=>3, "Mathematics"=>1, "Medicine and Dentistry"=>59, "Psychology"=>1, "Social Sciences"=>10, "Immunology and Microbiology"=>4}, "reader_count_by_subdiscipline"=>{"Medicine and Dentistry"=>{"Medicine and Dentistry"=>59}, "Social Sciences"=>{"Social Sciences"=>10}, "Psychology"=>{"Psychology"=>1}, "Mathematics"=>{"Mathematics"=>1}, "Unspecified"=>{"Unspecified"=>14}, "Engineering"=>{"Engineering"=>1}, "Chemistry"=>{"Chemistry"=>2}, "Economics, Econometrics and Finance"=>{"Economics, Econometrics and Finance"=>5}, "Immunology and Microbiology"=>{"Immunology and Microbiology"=>4}, "Agricultural and Biological Sciences"=>{"Agricultural and Biological Sciences"=>24}, "Computer Science"=>{"Computer Science"=>2}, "Business, Management and Accounting"=>{"Business, Management and Accounting"=>2}, "Biochemistry, Genetics and Molecular Biology"=>{"Biochemistry, Genetics and Molecular Biology"=>3}, "Veterinary Science and Veterinary Medicine"=>{"Veterinary Science and Veterinary Medicine"=>3}}, "reader_count_by_country"=>{"Netherlands"=>1, "Argentina"=>1, "United States"=>3, "Japan"=>1, "Denmark"=>1, "Brazil"=>3, "United Kingdom"=>2, "South Africa"=>2, "India"=>5}, "group_count"=>8}

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Figshare

  • {"files"=>["https://ndownloader.figshare.com/files/747352"], "description"=>"<p>Specificity and sensitivity (for smear-positive and smear-negative TB) would be required to achieve values above the primary line for serology to be more effective than sputum smear microscopy alone. The vertical and horizontal lines denote the 95% credible intervals of estimated accuracy from published studies of anda-TB <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001074#pmed.1001074-Steingart2\" target=\"_blank\">[14]</a>, the most widely used serological test in India. (A) compares serology alone against sputum smear microscopy alone in a setting where 53% of TB patients are smear-positive (base case scenario), while (B) considers a scenario in which only 40% of TB patients are smear-positive.</p>", "links"=>[], "tags"=>["specificity", "serology"], "article_id"=>417723, "categories"=>["Biotechnology", "Infectious Diseases"], "users"=>["David W. Dowdy", "Karen R. Steingart", "Madhukar Pai"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1001074.g002", "stats"=>{"downloads"=>3, "page_views"=>17, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Three_way_sensitivity_analysis_sensitivity_and_specificity_of_serology_for_active_TB_/417723", "title"=>"Three-way sensitivity analysis: sensitivity and specificity of serology for active TB.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2013-02-20 15:51:24"}
  • {"files"=>["https://ndownloader.figshare.com/files/747554"], "description"=>"a<p>Parameter values for HIV-positive patients are excluded from this table owing to low HIV prevalence but were incorporated into the model and can be found in reference <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001074#pmed.1001074-Dowdy1\" target=\"_blank\">[17]</a>.</p>b<p>In the absence of any TB-specific microbiological test.</p>c<p>Excludes studies not performed in developing countries.</p><p>ART, antiretroviral therapy.</p>", "links"=>[], "tags"=>["estimates"], "article_id"=>417923, "categories"=>["Biotechnology", "Infectious Diseases"], "users"=>["David W. Dowdy", "Karen R. Steingart", "Madhukar Pai"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1001074.t002", "stats"=>{"downloads"=>0, "page_views"=>4, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Parameter_estimates_used_in_the_model_/417923", "title"=>"Parameter estimates used in the model.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2013-02-20 15:52:31"}
  • {"files"=>["https://ndownloader.figshare.com/files/747251"], "description"=>"<p>Depicted is a simplified version of the analytic framework for this decision analysis. The square represents a decision node, circles chance nodes, and triangles terminal nodes. The branch of the decision node (sputum smear + serology) is compared to similar branches corresponding to scenarios of no TB-specific diagnosis, sputum smear only, and sputum smear plus TB culture (commercial liquid media), as described in the text. Probabilities, costs, and DALYs are calculated at each terminal node according to the parameters described in <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001074#pmed-1001074-t002\" target=\"_blank\">Table 2</a>. ARV, antiretroviral therapy; +, positive; −, negative.</p>", "links"=>[], "tags"=>["Infectious diseases", "public health and epidemiology"], "article_id"=>417620, "categories"=>["Biotechnology", "Infectious Diseases"], "users"=>["David W. Dowdy", "Karen R. Steingart", "Madhukar Pai"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1001074.g001", "stats"=>{"downloads"=>2, "page_views"=>10, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Study_decision_tree_/417620", "title"=>"Study decision tree.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2013-02-20 15:50:52"}
  • {"files"=>["https://ndownloader.figshare.com/files/747571"], "description"=>"a<p>Rapid chromatographic immunoassay.</p>", "links"=>[], "tags"=>["assays", "tuberculosis", "indian"], "article_id"=>417949, "categories"=>["Biotechnology", "Infectious Diseases"], "users"=>["David W. Dowdy", "Karen R. Steingart", "Madhukar Pai"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1001074.t001", "stats"=>{"downloads"=>9, "page_views"=>6, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Serological_assays_for_tuberculosis_on_the_Indian_market_/417949", "title"=>"Serological assays for tuberculosis on the Indian market.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2013-02-20 15:52:40"}
  • {"files"=>["https://ndownloader.figshare.com/files/747403"], "description"=>"<p>For the incremental cost-effectiveness ratio (ICER) to be more favorable for serology than for TB culture using commercial liquid media (MGIT) in the base-case scenario (73% sensitivity and 99% specificity), the sensitivity and specificity of serology for smear-negative TB must achieve values above the primary line. The estimated sensitivity and specificity of serology in the base case are 59% and 87%, respectively <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001074#pmed.1001074-Steingart2\" target=\"_blank\">[14]</a>.</p>", "links"=>[], "tags"=>["serology", "drug-sensitive"], "article_id"=>417779, "categories"=>["Biotechnology", "Infectious Diseases"], "users"=>["David W. Dowdy", "Karen R. Steingart", "Madhukar Pai"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1001074.g003", "stats"=>{"downloads"=>2, "page_views"=>7, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Two_way_sensitivity_analysis_serology_versus_culture_for_diagnosis_of_drug_sensitive_TB_/417779", "title"=>"Two-way sensitivity analysis: serology versus culture for diagnosis of drug-sensitive TB.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2013-02-20 15:51:45"}
  • {"files"=>["https://ndownloader.figshare.com/files/747516"], "description"=>"<p>Cost-effectiveness of diagnostic strategies for 1.5 million persons with suspected active TB in India.</p>", "links"=>[], "tags"=>["diagnostic", "strategies", "persons", "suspected", "tb"], "article_id"=>417892, "categories"=>["Biotechnology", "Infectious Diseases"], "users"=>["David W. Dowdy", "Karen R. Steingart", "Madhukar Pai"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1001074.t003", "stats"=>{"downloads"=>0, "page_views"=>4, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Cost_effectiveness_of_diagnostic_strategies_for_1_5_million_persons_with_suspected_active_TB_in_India_/417892", "title"=>"Cost-effectiveness of diagnostic strategies for 1.5 million persons with suspected active TB in India.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2013-02-20 15:52:20"}

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Relative Metric

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