Novel health system strategies for tuberculin skin testing at primary care clinics: Performance assessment and health economic evaluation

PLoS One. 2021 Feb 17;16(2):e0246523. doi: 10.1371/journal.pone.0246523. eCollection 2021.

Abstract

Background: Tuberculin skin test (TST) for guiding initiation of tuberculosis preventive therapy poses major challenges in high tuberculosis burden settings.

Methods: At a primary care clinic in Johannesburg, South Africa, 278 HIV-positive adults self-read their TST by reporting if they felt a bump (any induration) at the TST placement site. TST reading (in mm) was fast-tracked to reduce patient wait time and task-shifted to delegate tasks to lower cadre healthcare workers, and result was compared to TST reading by high cadre research staff. TST reading and placement cost to the health system and patients were estimated. Simulations of health system costs were performed for 5 countries (USA, Germany, Brazil, India, Russia) to evaluate generalizability.

Results: Almost all participants (269 of 278, 97%) correctly self-identified the presence or absence of any induration [sensitivity 89% (95% CI 80,95) and specificity 99.5% (95% CI 97,100)]. For detection of a positive TST (induration ≥ 5mm), sensitivity was 90% (95% CI 81,96) and specificity 99% (95% CI 97,100). TST reading agreement between low and high cadre staff was high (kappa 0.97, 95% CI 0.94, 1.00). Total TST cost was 2066 I$ (95% UI 594, 5243) per 100 patients, 87% (95% UI 53, 95) of which were patient costs. Combining fast-track and task-shifting, reduced total costs to 1736 I$ (95% UI 497, 4300) per 100 patients, with 31% (95% UI 15, 42) saving in health system costs. Combining fast-tracking, task-shifting and self-reading, lowered the TST health system costs from 16% (95% UI 8, 26) in Russia to 40% (95% UI 18, 54) in the USA.

Conclusion: A TST strategy where only patients with any self-read induration are asked to return for fast-tracked TST reading by lower cadre healthcare workers is a promising strategy that could be effective and cost-saving, but real-life cost-effectiveness should be further examined.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Economics, Medical
  • Female
  • Humans
  • India
  • Male
  • Mass Screening / methods
  • Middle Aged
  • Primary Health Care
  • Skin Tests / methods*
  • Tuberculin / analysis*
  • Tuberculin Test
  • Tuberculosis / diagnosis*
  • Young Adult

Substances

  • Tuberculin

Grants and funding

This study was funded by the United States Agency for International Development (USAID, https://www.usaid.gov) under award number AID-674-A-12-00033 [EV, JB, CH, LM, AVR], with additional funding from Vlaamse Interuniversitaire Raad (VLIR, https://www.vliruos.be) under award number NDOC2016PR001 [EV]. The content is solely the responsibility of the authors and does not necessarily represent the views of USAID or VLIR. The funders provided salary support [EV, JB, CH, LM, AVR], but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of the authors are articulated in the ‘author contributions’ section.