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SM ISO690:2012 JAMES, Lyndon P., KLAASSEN, Fayette, SWEENEY, Sedona, FURIN, Jennifer Joan, FRANKE, Molly F., YAESOUBI, Reza, CHESOV, Dumitru, CIOBANU, Nelly, CODREANU, Alexandru, KRUDU, V., COHEN, Ted, MENZIES, Nicolas A.. Impact and cost-effectiveness of the 6-month BPaLM regimen for rifampicin-resistant tuberculosis in Moldova: A mathematical modeling analysis. In: PLoS Medicine, 2024, vol. 21, pp. 1-28. ISSN 1549-1277. DOI: https://doi.org/10.1371/journal.pmed.1004401 |
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PLoS Medicine | |
Volumul 21 / 2024 / ISSN 1549-1277 | |
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DOI:https://doi.org/10.1371/journal.pmed.1004401 | |
Pag. 1-28 | |
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Background Emerging evidence suggests that shortened, simplified treatment regimens for rifampicin-resistant tuberculosis (RR-TB) can achieve comparable end-of-treatment (EOT) outcomes to longer regimens. We compared a 6-month regimen containing bedaquiline, pretomanid, linezolid, and moxifloxacin (BPaLM) to a standard of care strategy using a 9- or 18-month regimen depending on whether fluoroquinolone resistance (FQ-R) was detected on drug susceptibility testing (DST). Methods and findings The primary objective was to determine whether 6 months of BPaLM is a cost-effective treatment strategy for RR-TB. We used genomic and demographic data to parameterize a mathematical model estimating long-term health outcomes measured in quality-adjusted life years (QALYs) and lifetime costs in 2022 USD for each treatment strategy for patients 15 years and older diagnosed with pulmonary RR-TB in Moldova, a country with a high burden of TB drug resistance. For each individual, we simulated the natural history of TB and associated treatment outcomes, as well as the process of acquiring resistance to each of 12 anti-TB drugs. Compared to the standard of care, 6 months of BPaLM was cost-effective. This strategy was estimated to reduce lifetime costs by USD3,366 (95% UI: [1,465, 5,742] p < 0.001) per individual, with a nonsignificant change in QALYs (−0.06; 95% UI: [−0.49, 0.032] p = 0.790). For those stopping moxifloxacin under the BPaLM regimen, continuing with BPaL plus clofazimine (BPaLC) provided more QALYs at lower cost than continuing with BPaL alone. Strategies based on 6 months of BPaLM had at least a 93% chance of being cost-effective, so long as BPaLC was continued in the event of stopping moxifloxacin. BPaLM for 6 months also reduced the average time spent with TB resistant to amikacin, bedaquiline, clofazimine, cycloserine, moxifloxacin, and pyrazinamide, while it increased the average time spent with TB resistant to delamanid and pretomanid. Sensitivity analyses showed 6 months of BPaLM to be cost-effective across a broad range of values for the relative effectiveness of BPaLM, and the proportion of the cohort with FQ-R. Compared to the standard of care, 6 months of BPaLM would be expected to save Moldova’s national TB program budget USD7.1 million (95% UI: [1.3 million, 15.4 million] p = 0.002) over the 5-year period from implementation. Our analysis did not account for all possible interactions between specific drugs with regard to treatment outcomes, resistance acquisition, or the consequences of specific types of severe adverse events, nor did we model how the intervention may affect TB transmission dynamics. Conclusions Compared to standard of care, longer regimens, the implementation of the 6-month BPaLM regimen could improve the cost-effectiveness of care for individuals diagnosed with RR-TB, particularly in settings with a high burden of drug-resistant TB. Further research may be warranted to explore the impact and cost-effectiveness of shorter RR-TB regimens across settings with varied drug-resistant TB burdens and national income levels. |
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Cuvinte-cheie article, cohort analysis, cost effectiveness analysis, Drug resistant tuberculosis, drug sensitivity, fluoroquinolone resistance, follow up, health care quality, Hidden Markov Model, human, life expectancy, mathematical model, Monte Carlo method, Mycobacterium tuberculosis, quality adjusted life year, quality of life, rifampicin resistant tuberculosis, rifampicin resistant tuberculosis, sensitivity analysis |
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<?xml version='1.0' encoding='utf-8'?> <resource xmlns:xsi='http://www.w3.org/2001/XMLSchema-instance' xmlns='http://datacite.org/schema/kernel-3' xsi:schemaLocation='http://datacite.org/schema/kernel-3 http://schema.datacite.org/meta/kernel-3/metadata.xsd'> <identifier identifierType='DOI'>10.1371/journal.pmed.1004401</identifier> <creators> <creator> <creatorName>James, L.</creatorName> <affiliation>Howard University, Statele Unite ale Americii</affiliation> </creator> <creator> <creatorName>Klaassen, F.</creatorName> <affiliation>Harvard T H Chan School of Public Health, Boston, Statele Unite ale Americii</affiliation> </creator> <creator> <creatorName>Sweeney, S.</creatorName> <affiliation>London School of Hygiene and Tropical Medicine, Regatul Unit</affiliation> </creator> <creator> <creatorName>Furin, J.</creatorName> <affiliation>Harvard Medical School, Boston, Statele Unite ale Americii</affiliation> </creator> <creator> <creatorName>Franke, M.</creatorName> <affiliation>Harvard Medical School, Boston, Statele Unite ale Americii</affiliation> </creator> <creator> <creatorName>Yaesoubi, R.</creatorName> <affiliation>Școala de Sănătate Publică Yale, New Haven, Statele Unite ale Americii</affiliation> </creator> <creator> <creatorName>Chesov, D.I.</creatorName> <affiliation>Universitatea de Stat de Medicină şi Farmacie „Nicolae Testemiţanu“, Moldova, Republica</affiliation> </creator> <creator> <creatorName>Ciobanu, N.</creatorName> <affiliation>IMSP Institutul de Ftiziopneumologie „Chiril Draganiuc“, Moldova, Republica</affiliation> </creator> <creator> <creatorName>Codreanu, A.</creatorName> <affiliation>IMSP Institutul de Ftiziopneumologie „Chiril Draganiuc“, Moldova, Republica</affiliation> </creator> <creator> <creatorName>Crudu, V.N.</creatorName> <affiliation>IMSP Institutul de Ftiziopneumologie „Chiril Draganiuc“, Moldova, Republica</affiliation> </creator> <creator> <creatorName>Cohen, T.</creatorName> <affiliation>Școala de Sănătate Publică Yale, New Haven, Statele Unite ale Americii</affiliation> </creator> <creator> <creatorName>Menzies, N.</creatorName> <affiliation>Harvard T H Chan School of Public Health, Boston, Statele Unite ale Americii</affiliation> </creator> </creators> <titles> <title xml:lang='en'>Impact and cost-effectiveness of the 6-month BPaLM regimen for rifampicin-resistant tuberculosis in Moldova: A mathematical modeling analysis</title> </titles> <publisher>Instrumentul Bibliometric National</publisher> <publicationYear>2024</publicationYear> <relatedIdentifier relatedIdentifierType='ISSN' relationType='IsPartOf'>1549-1277</relatedIdentifier> <subjects> <subject>article</subject> <subject>cohort analysis</subject> <subject>cost effectiveness analysis</subject> <subject>Drug resistant tuberculosis</subject> <subject>drug sensitivity</subject> <subject>fluoroquinolone resistance</subject> <subject>follow up</subject> <subject>health care quality</subject> <subject>Hidden Markov Model</subject> <subject>human</subject> <subject>life expectancy</subject> <subject>mathematical model</subject> <subject>Monte Carlo method</subject> <subject>Mycobacterium tuberculosis</subject> <subject>quality adjusted life year</subject> <subject>quality of life</subject> <subject>rifampicin resistant tuberculosis</subject> <subject>rifampicin resistant tuberculosis</subject> <subject>sensitivity analysis</subject> </subjects> <dates> <date dateType='Issued'>2024-05-01</date> </dates> <resourceType resourceTypeGeneral='Text'>Journal article</resourceType> <descriptions> <description xml:lang='en' descriptionType='Abstract'><p>Background Emerging evidence suggests that shortened, simplified treatment regimens for rifampicin-resistant tuberculosis (RR-TB) can achieve comparable end-of-treatment (EOT) outcomes to longer regimens. We compared a 6-month regimen containing bedaquiline, pretomanid, linezolid, and moxifloxacin (BPaLM) to a standard of care strategy using a 9- or 18-month regimen depending on whether fluoroquinolone resistance (FQ-R) was detected on drug susceptibility testing (DST). Methods and findings The primary objective was to determine whether 6 months of BPaLM is a cost-effective treatment strategy for RR-TB. We used genomic and demographic data to parameterize a mathematical model estimating long-term health outcomes measured in quality-adjusted life years (QALYs) and lifetime costs in 2022 USD for each treatment strategy for patients 15 years and older diagnosed with pulmonary RR-TB in Moldova, a country with a high burden of TB drug resistance. For each individual, we simulated the natural history of TB and associated treatment outcomes, as well as the process of acquiring resistance to each of 12 anti-TB drugs. Compared to the standard of care, 6 months of BPaLM was cost-effective. This strategy was estimated to reduce lifetime costs by USD3,366 (95% UI: [1,465, 5,742] p < 0.001) per individual, with a nonsignificant change in QALYs (−0.06; 95% UI: [−0.49, 0.032] p = 0.790). For those stopping moxifloxacin under the BPaLM regimen, continuing with BPaL plus clofazimine (BPaLC) provided more QALYs at lower cost than continuing with BPaL alone. Strategies based on 6 months of BPaLM had at least a 93% chance of being cost-effective, so long as BPaLC was continued in the event of stopping moxifloxacin. BPaLM for 6 months also reduced the average time spent with TB resistant to amikacin, bedaquiline, clofazimine, cycloserine, moxifloxacin, and pyrazinamide, while it increased the average time spent with TB resistant to delamanid and pretomanid. Sensitivity analyses showed 6 months of BPaLM to be cost-effective across a broad range of values for the relative effectiveness of BPaLM, and the proportion of the cohort with FQ-R. Compared to the standard of care, 6 months of BPaLM would be expected to save Moldova’s national TB program budget USD7.1 million (95% UI: [1.3 million, 15.4 million] p = 0.002) over the 5-year period from implementation. Our analysis did not account for all possible interactions between specific drugs with regard to treatment outcomes, resistance acquisition, or the consequences of specific types of severe adverse events, nor did we model how the intervention may affect TB transmission dynamics. Conclusions Compared to standard of care, longer regimens, the implementation of the 6-month BPaLM regimen could improve the cost-effectiveness of care for individuals diagnosed with RR-TB, particularly in settings with a high burden of drug-resistant TB. Further research may be warranted to explore the impact and cost-effectiveness of shorter RR-TB regimens across settings with varied drug-resistant TB burdens and national income levels. </p><p> </p></description> </descriptions> <formats> <format>application/pdf</format> </formats> </resource>