Hospital-based evidence on cost-effectiveness of brucellosis diagnostic tests and treatment in Kenyan hospitals.
Hospital-based evidence on cost-effectiveness of brucellosis diagnostic tests and treatment in Kenyan hospitals.
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DOI：
10.1371/journal.pntd.0008977
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发表时间：
2021-01
影响因子：
3.8
通讯作者：
Falzon LC
中科院分区：
文献类型：
--
作者：
Alumasa L;Thomas LF;Amanya F;Njoroge SM;Moriyón I;Makhandia J;Rushton J;Fèvre EM;Falzon LC
肯尼亚的医院继续使用发热抗原布鲁氏菌凝集试验（FBAT）来诊断布鲁氏菌病，尽管有报告显示其不足。与玫瑰孟加拉测试（RBT）相比，这项研究产生了基于医院的关于FBAT性能和成本效益的证据。肯尼亚西部的12家医院储存了使用FBAT检测布鲁氏菌病的患者血清样本，这些样本后来使用RBT重新检测。收集了关于FBAT运行时间和费用以及布鲁氏菌病处方治疗的数据。确定了这两项检测的成本效益（以避免的每个残疾调整生命年（DALY）的美元成本为单位），并进行了基本敏感性分析，以确定最具影响力的参数。在6个月期间，在医院用FBAT检测的180名患者血清样本后来在现场实验室用RBT重新检测。其中FBAT阳性24例（13.3%），RBT阳性3例（1.7%）。FBAT与RBT之间的一致性较弱（Kappa = 0.12）。各医院在FBAT阳性后规定的治疗方法各不相同，只有一家医院规定了标准化的治疗方案。使用FBAT和RBT时避免的平均$/DALY分别为$2,065 （95% CI $481-$6,736）和$304 （95% CI $126-$604）。布鲁氏菌病流行率是影响这两项检测成本效益的最重要参数。外推到国家层面表明，目前每年不必要地花费338,891美元（95%置信区间为47,000美元至1,149,000美元）用于治疗FBAT误检阳性的患者。这些发现强调了使用FBAT进行误诊的可能性。此外，RBT具有成本效益，可被视为这种情况下人类布鲁氏菌病的主要筛选试验。最后，必须协调治疗方案，以确保适当使用抗生素进行治疗。布鲁氏菌病是全球最常见的细菌性人畜共患病，在资源匮乏地区负担更重。在人类中，该病表现为非特异性临床症状，目前的国际指南建议使用两种血清学诊断检测来进行确诊。肯尼亚和一些邻国的许多医院一直在使用发热抗原布鲁氏菌凝集试验（FBAT）进行诊断，尽管有报告显示其性能不佳。在这项研究中，我们比较了FBAT的诊断性能和成本效益与玫瑰孟加拉试验（RBT），一种国际指南推荐的血清学检测。我们的结果表明，与RBT相比，FBAT错误地诊断了许多患者。这是令人关切的，因为它导致不必要的抗生素治疗，增加了疾病的经济负担，加剧了抗生素耐药性的风险。我们还强调了目前各医院开出的布鲁氏菌病治疗方案的差异。最后，我们表明RBT是一种更具成本效益的诊断测试。因此，我们建议在肯尼亚所有医院将RBT视为人布鲁氏菌病的主要诊断检测，并统一治疗指南。
Hospitals in Kenya continue to use the Febrile Antigen Brucella Agglutination Test (FBAT) to diagnose brucellosis, despite reports showing its inadequacy. This study generated hospital-based evidence on the performance and cost-effectiveness of the FBAT, compared to the Rose Bengal Test (RBT).Twelve hospitals in western Kenya stored patient serum samples that were tested for brucellosis using the FBAT, and these were later re-tested using the RBT. Data on the running time and cost of the FBAT, and the treatment prescribed for brucellosis, were collected. The cost-effectiveness of the two tests, defined as the cost in US Dollars ($) per Disability Adjusted Life Year (DALY) averted, was determined, and a basic sensitivity analysis was run to identify the most influential parameters. Over a 6-month period, 180 patient serum samples that were tested with FBAT at the hospitals were later re-tested with RBT at the field laboratory. Of these 24 (13.3%) and 3 (1.7%) tested positive with FBAT and RBT, respectively. The agreement between the FBAT and RBT was slight (Kappa = 0.12). Treatment prescribed following FBAT positivity varied between hospitals, and only one hospital prescribed a standardized therapy regimen. The mean $/DALY averted when using the FBAT and RBT were $2,065 (95% CI $481-$6,736) and $304 (95% CI $126-$604), respectively. Brucellosis prevalence was the most influential parameter in the cost-effectiveness of both tests. Extrapolation to the national level suggested that an estimated $338,891 (95% CI $47,000-$1,149,000) per year is currently spent unnecessarily treating those falsely testing positive by FBAT. These findings highlight the potential for misdiagnosis using the FBAT. Furthermore, the RBT is cost-effective, and could be considered as the mainstay screening test for human brucellosis in this setting. Lastly, the treatment regimens must be harmonized to ensure the appropriate use of antibiotics for treatment. Brucellosis is the most common bacterial zoonosis globally, with a higher burden in low-resource settings. In humans, the disease manifests itself with non-specific clinical signs, and current international guidelines recommend the use of two serological diagnostic tests to make a confirmatory diagnosis. Many hospitals in Kenya and some neighbouring countries have been using the Febrile Antigen Brucella Agglutination Test (FBAT) for diagnosis, despite reports showing its poor performance. In this study we compared the diagnostic performance and cost-effectiveness of the FBAT with that of the Rose Bengal Test (RBT), a serological assay recommended by international guidelines. Our results showed that, compared to the RBT, the FBAT incorrectly diagnosed a number of patients. This is of concern as it leads to unnecessary antibiotic treatments, increasing the economic burden of the disease and exacerbating the risk of antibiotic resistance. We also highlight the discrepancies in brucellosis treatment regimens currently being prescribed by various hospitals. Finally, we showed that the RBT is a more cost-effective diagnostic test. Our recommendation, therefore, is for the RBT to be considered as the mainstay diagnostic test for human brucellosis in all Kenyan hospitals, and for the harmonization of treatment guidelines.
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Neubauer H