Abstract
ObjectiveTo assess the effectiveness of decentralized treatment and care for patients with multidrug-resistant (MDR) tuberculosis, in comparison with centralized approaches.MethodsWe searched ClinicalTrials.gov, the Cochrane library, Embase®, Google Scholar, LILACS, PubMed®, Web of Science and the World Health Organization’s portal of clinical trials for studies reporting treatment outcomes for decentralized and centralized care of MDR tuberculosis. The primary outcome was treatment success. When possible, we also evaluated, death, loss to follow-up, treatment adherence and health-system costs. To obtain pooled relative risk (RR) estimates, we performed random-effects meta-analyses.FindingsEight studies met the eligibility criteria for review inclusion. Six cohort studies, with 4026 participants in total, reported on treatment outcomes. The pooled RR estimate for decentralized versus centralized care for treatment success was 1.13 (95% CI: 1.01–1.27). The corresponding estimate for loss to follow-up was RR: 0.66 (95% CI: 0.38–1.13), for death RR: 1.01 (95% CI: 0.67–1.52) and for treatment failure was RR: 1.07 (95% CI: 0.48–2.40). Two of three studies evaluating health-care costs reported lower costs for the decentralized models of care than for the centralized models.ConclusionTreatment success was more likely among patients with MDR tuberculosis treated using a decentralized approach. Further studies are required to explore the effectiveness of decentralized MDR tuberculosis care in a range of different settings.
Highlights
Mycobacterium tuberculosis resistant to both isoniazid and rifampicin, so-called multidrug resistance, poses a major threat to the control of tuberculosis worldwide
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]
Of the six studies that reported on treatment outcomes, five evaluated treatment success (B Kerschberger, unpublished data),[19,20,22,24] four evaluated loss to follow-up (B Kerschberger, unpublished data),[20,21,22] four evaluated death (B Kerschberger, unpublished data),[20,22,24] and three evaluated treatment failure(B Kerschberger, unpublished data).[20,22]
Summary
Mycobacterium tuberculosis resistant to both isoniazid and rifampicin, so-called multidrug resistance, poses a major threat to the control of tuberculosis worldwide. 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.[7,8,9] 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, based on the results of a small number of uncontrolled studies.[2] In the treatment of drug-susceptible tuberculosis, decentralized care is well established and appears as effective as hospital-based approaches.[7,8,9] 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, based on the results of a small number of uncontrolled studies.[2]
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