title: Cost-effectiveness of improvements in diagnosis and treatment accessibility for tuberculosis control in India.
abstract: METHODS
  Inaccurate diagnosis and inaccessibility of care undercut the effectiveness of high-quality anti-tuberculosis treatment and select for resistance. Rapid diagnostic systems, such as Xpert(®) MTB/RIF for tuberculosis (TB) diagnosis and drug susceptibility testing (DST), and programs that provide high-quality DOTS anti-tuberculosis treatment to patients in the unregulated private sector (public-private mix [PPM]), may help address these challenges, albeit at increased cost.
  
  
  OBJECTIVE
  We extended a microsimulation model of TB in India calibrated to demographic, epidemiologic, and care trends to evaluate 1) replacing DST with Xpert; 2) replacing microscopy and culture with Xpert to diagnose multidrug-resistant TB (MDR-TB) and non-MDR-TB; 3) implementing nationwide PPM; and combinations of (3) with (1) or (2).
  
  
  RESULTS
  PPM (assuming costs of $38/person) and Xpert improved health and increase costs relative to the status quo. PPM alone or with Xpert cost <1 gross domestic product/capita per quality-adjusted life-year gained relative to the next best intervention, and dominated Xpert interventions excluding PPM.
  
  
  CONCLUSIONS
  While both PPM and Xpert are promising tools for combatting TB in India, PPM should be prioritized over Xpert, as private sector engagement is more cost-effective than Xpert alone and, if sufficient resources are available, would substantially increase the value of Xpert if both interventions are implemented together.
authors.affiliation: Department of Management Science and Engineering, Stanford University, Stanford, California, USA.
authors.forename: S-C
authors.initials: SC
authors.lastname: Suen
authors.affiliation: Division of General Medical Disciplines, Department of Medicine, Stanford University, Stanford, California, USA; Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University, Stanford, California, USA.
authors.forename: E
authors.initials: E
authors.lastname: Bendavid
authors.affiliation: Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University, Stanford, California, USA.
authors.forename: J D
authors.initials: JD
authors.lastname: Goldhaber-Fiebert
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D003362:Cost-Benefit Analysis; D003955:Diagnostic Tests, Routine / Q000191:economics*; D005260:Female; D006801:Humans; D007194:India; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D009169:Mycobacterium tuberculosis / Q000235:genetics; D055818:Public-Private Sector Partnerships / Q000191:economics*; D019057:Quality-Adjusted Life Years; D013183:Sputum / Q000382:microbiology*; D018088:Tuberculosis, Multidrug-Resistant / Q000175:diagnosis* / Q000517:prevention & control; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis* / Q000517:prevention & control; D055815:Young Adult