Decentralized care for multidrug-resistant tuberculosis: a systematic review and meta-analysis

Jennifer Ho, Anthony L Byrne, Nguyen N Linh, Ernesto Jaramillo, Greg J Fox, Jennifer Ho, Anthony L Byrne, Nguyen N Linh, Ernesto Jaramillo, Greg J Fox

Abstract

Objective: To assess the effectiveness of decentralized treatment and care for patients with multidrug-resistant (MDR) tuberculosis, in comparison with centralized approaches.

Methods: We 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.

Findings: Eight 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.

Conclusion: Treatment 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.

Figures

Fig. 1
Fig. 1
Flowchart showing the selection of studies on the centralized and decentralized care of patients with multidrug-resistant tuberculosis
Fig. 2
Fig. 2
Relative risks for treatment success following the decentralized care of multidrug-resistant tuberculosis – compared with centralized care, 1994–2013
Fig. 3
Fig. 3
Relative risks for loss to follow-up during the decentralized care of multidrug-resistant tuberculosis – compared with centralized care, 2003–2013
Fig. 4
Fig. 4
Relative risks for death during the decentralized care of multidrug-resistant tuberculosis – compared with centralized care, 1994–2013
Fig. 5
Fig. 5
Relative risks for treatment failure following the decentralized care of multidrug-resistant tuberculosis – compared with centralized care, 2008–2013

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Source: PubMed

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