Rollout strategy for diagnostic test in India may impact TB

Tuberculosis (Credit: © Shutterstock)Main Points:

Xpert MTB/RIF, a recently implemented tuberculosis (TB) test, has the potential to control the TB epidemic in India, but only if the current, narrow, implementation strategy is replaced by a more ambitious one that is better funded, also includes the private sector, and better referral networks are developed between public and private sectors, according to new research published in this week’s PLOS Medicine. The study by David Dowdy, from Johns Hopkins University, United States, and colleagues is a mathematical model that suggests alternative strategies that include engagement with both the public and private sector may have a bigger population level impact on TB than the current implementation strategy of using Xpert for only those at risk of drug-resistance or HIV infection.

Published in:

PLOS Medicine

Study Further:

Xpert MTB/RIF is a new TB diagnostic that is more sensitive than other diagnostics in current widespread use and can detect resistance to certain antibiotics, but its cost is substantial, and the Indian health-care system is fragmented and heavily privatized with the majority of the population seeking private healthcare initially. Currently, due to resource constraints, the Indian Revised National Tuberculosis Control Programme is mainly implementing Xpert MTB/RIF as a rapid drug susceptibility test method among selected patients seeking care in the public sector.

The researchers explored the impact of six different rollout strategies on the incidence of tuberculosis (the number of new cases of tuberculosis in the population per year) by developing a mathematical model of tuberculosis transmission, care-seeking behavior, and diagnostic/treatment practices in India. A scenario that added access to Xpert MTB/RIF for 20% of all individuals with tuberculosis symptoms seeking diagnosis in the public sector and 20% of individuals seeking care from qualified private practitioners to the current national strategy was predicted to reduce the incidence of tuberculosis by 14.1% compared to the current national strategy which is only expected to reduce incidence by 0.2%. However, this scenario required more than 2,200 Xpert machines and reliable treatment referral. Notably, a scenario tested that encouraged informal providers to refer suspected tuberculosis cases to the public sector for diagnosis using currently available tests predicted a greater impact on the incidence of tuberculosis than Xpert scale-up within the public sector alone.

The authors acknowledge that their findings are subject to uncertainties in the assumptions made in their model but note, “Xpert [MTB/RIF] … could substantially reduce the burden of TB disease due to poor diagnosis in India; however, this impact depends not only on the accuracy of the test, but also on the behavior of both patients and providers, their level of access to new tools, and quality TB treatment following diagnosis.”

They conclude, “any Xpert [MTB/RIF] rollout strategy must also consider the complex health-care infrastructure into which the test is being rolled out. To achieve maximum impact of novel diagnostics, India should engage the private sector, improve quality of care across all sectors, and dramatically increase resources.”

Research Article:

Reference:

Salje H, Andrews JR, Deo S, Satyanarayana S, Sun AY, et al. (2014) The Importance of Implementation Strategy in Scaling Up Xpert MTB/RIF for Diagnosis of Tuberculosis in the Indian Health-Care System: A Transmission Model. PLoS Med 11(7): e1001674. doi:10.1371/journal.pmed.1001674, http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001674

Funding:

The project was funded by grants from the Bill & Melinda Gates Foundation (OPP1061487) and Canadian Institutes of Health Research (MOP 123291). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing Interests:

MP serves as a consultant to the Bill & Melinda Gates Foundation (BMGF). MP is also a member of the Editorial Board of PLOS Medicine.

Author Affiliations:

Johns Hopkins Bloomberg School of Public Health, United States

Massachusetts General Hospital, United States

Indian School of Business, India

McGill University, Canada

McGill University Health Centre, Canada

Johns Hopkins School of Medicine, United States

Johns Hopkins University, United States

Contact:

David Dowdy, Johns Hopkins Bloomberg School of Public Health, United States, +1 (410) 614-0902, ddowdy@jhsph.edu

Be the first to comment - What do you think?  Posted by saypeople - July 15, 2014 at 11:00 pm

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Nurses may effectively manage outpatient care of chronic diseases

Nurse and patientMain Point:

Nurse-led protocols are effective for managing outpatient care of chronic illnesses.

Published in:

Annals of Internal Medicine

Study Further:

Chronic diseases cause a substantial burden to the U.S. health care system and account for about 75 percent of every health care dollar spent. There are well-established clinical practice guidelines for the outpatient management of chronic illnesses, but access to quality and appropriate care can be an issue, especially considering the nation’s shortage of primary care physicians. Some groups have suggested that quality care be delivered through a team-based approach, which the American College of Physicians calls the “patient-centered medical home”. One new model of the medical home may involve nurse-managed protocols for routine outpatient care of chronic diseases.

Researchers conducted a systematic review of published evidence to determine whether nurse-managed protocols are effective for outpatient management of adults with diabetes, hypertension, and hyperlipidemia, common chronic illnesses that require ongoing outpatient management. They found that a patient-centered medical home model using nurse-managed protocols helps to improve health outcomes for patients with moderately severe diabetes, hypertension, and hyperlipidemia, and that RNs can successfully titrate medications according to protocols for these conditions. Read more…

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Pill appearance affects how patients take their medications

pills (Credit:  aSIMULAtor/Flickr)Main Point:

Heart patients significantly more likely to stop taking medication after pill changes appearance.

When it comes to taking generic heart medications, appearance matters.

Published in:

Annals of Internal Medicine

Study Further:

Physicians often prescribe generic medications for the treatment of cardiovascular disease because generics are inexpensive for patients and payors and are available in nearly every class of relevant medication – antihypertensive, lipid-lowering, anticoagulant, antiplatelet, and antiarrhythmic agents. While generic drugs are therapeutically interchangeable, pill appearance may vary among manufacturers, or between generic and brand-name versions of a drug. Whether these appearance changes affect patient adherence to medications is an issue because taking medications as prescribed is essential for good outcomes. Read more…

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Having strong social ties protects men from suicide death

Suicide is preventableMain Point:

Social integration, such as being married, attending religious services, and having a large network of friends protects men against suicide.

Published in:

Annals of Internal Medicine

Study Further:

Suicide is one of the top 10 leading causes of death among men in the United States. Prevention efforts usually emphasize the study of psychiatric, psychological, or biological determinants. However, research has shown that a substantial proportion of suicidal behaviors occur in the absence of a formally diagnosed mental disorder, suggesting that a deeper understanding of factors driving suicide is needed. Read more…

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High stress, hostility, depression linked with increased stroke risk

Stress (Credit: marsmet549/flickr)Main Points:

  • Higher levels of stress, hostility and depressive symptoms are associated with significantly increased risk of stroke or transient ischemic attack (TIA) in middle-age and older adults.
  • Significant increased risk was not observed for anger.

Published in:

Stroke

Study Further:

Higher levels of stress, hostility and depressive symptoms are associated with significantly increased risk of stroke or transient ischemic attack (TIA) in middle-age and older adults, according to new research in the American Heart Association journal Stroke.

A TIA is a stroke caused by a temporary blockage of blood flow to the brain. Read more…

Be the first to comment - What do you think?  Posted by saypeople - July 11, 2014 at 1:00 am

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