Academic journal article Bulletin of the World Health Organization

Decentralized Care for Multidrug-Resistant Tuberculosis: A Systematic Review and Meta-analysis/Prise En Charge Decentralisee De la Tuberculose Multiresistante: Revue Systematique et Meta-analyse/Atencion Descentralizada Para la Tuberculosis Multirresistente: Una Revision Sistematica Y Un Metaanalisis

Academic journal article Bulletin of the World Health Organization

Decentralized Care for Multidrug-Resistant Tuberculosis: A Systematic Review and Meta-analysis/Prise En Charge Decentralisee De la Tuberculose Multiresistante: Revue Systematique et Meta-analyse/Atencion Descentralizada Para la Tuberculosis Multirresistente: Una Revision Sistematica Y Un Metaanalisis

Article excerpt

Introduction

Mycobacterium tuberculosis resistant to both isoniazid and rifampicin, so-called multidrug resistance, poses a major threat to the control of tuberculosis worldwide. In 2015, there were an estimated 480000 new cases of multidrug-resistant (MDR) tuberculosis, an additional 100000 cases with rifampicin resistance that also required treatment with second-line medicines, and approximately 250 000 deaths from MDR tuberculosis. (1) An estimated 9.5% of people with MDR tuberculosis have extensively drug-resistant (XDR) tuberculosis --i.e. MDR tuberculosis that is also resistant to a second-line injectable drug and a fluoroquinolone. It has been estimated that, of all the cases of MDR tuberculosis that commenced treatment in 2013, only 52% achieved treatment success and the rest died (17%), were lost to follow-up or otherwise not evaluated (22%) or were identified as treatment failures (9%). (1) The recommended therapy for MDR tuberculosis requires a combination of second-line drugs that are, in general, more costly, less efficacious, more toxic and must be taken for much longer than the first-line drugs used against tuberculosis. (2)

Historically, treatment for MDR tuberculosis has been provided through specialized, centralized programmes and typically involved prolonged inpatient care. (3) This approach is based on the view that treatment adherence, the management of adverse events and infection control may be better in hospital settings than in the community. (4,5) However, in many centralized facilities, insufficient resources preclude the prolonged inpatient care of cases of MDR tuberculosis. Reliance on centralized treatment, especially in facilities that lack effective infection control and where treatment may be delayed until inpatient beds become available, may inadvertently increase the risk of transmission of MDR M. tuberculosis. In addition, in comparison with decentralized interventions, centralized approaches have been associated with poorer rates of retention in care. (6) In the treatment of drug-susceptible tuberculosis, decentralized care is well established and appears as effective as hospital-based approaches. (7-9) Since 2011, the World Health Organization (WHO) has recommended that "patients with multidrug-resistant tuberculosis should be treated using mainly ambulatory care". (2) This recommendation was, however, based on the results of a small number of uncontrolled studies. (2)

We recently performed a systematic review and metaanalysis to try to determine if--compared with treatment and care provided solely by specialized centres for the treatment of MDR tuberculosis--decentralized treatment and care for MDR tuberculosis patients was more or less likely to lead to improved treatment outcomes, treatment adherence, adverse events, acquired drug resistance, lower patient costs and lower health-system costs. Our results have already contributed to forthcoming, revised WHO guidelines for the treatment of tuberculosis.

Methods

Our systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Metaanalyses guidelines. (10)

Study eligibility

Studies were eligible if they included both patients receiving decentralized care and patients receiving centralized care--as defined below. Studies were excluded if they lacked a comparator group or enrolled fewer than 10 participants in the intervention arm. This approach enabled a direct comparison to be performed between individuals receiving either model of care in the same setting. Included studies needed to report on at least one clinical outcome--i.e. treatment adherence, the standard WHO-defined tuberculosis treatment outcomes of cure, completion, death, failure or relapse (11) and/or adverse reactions. Studies reporting costs, to patients and/or health systems, were also included. We included case-control studies that each included at least 10 patients, modelling studies, prospective cohorts, randomized controlled trials and retrospective cohorts. …

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