Estimation of therapeutic threshold for tuberculosis using adapted nominal group technique and clinical vignettes in clinical and community settings in Southern Africa

IF 2 Q3 INFECTIOUS DISEASES

Journal of Clinical Tuberculosis and Other Mycobacterial Diseases Pub Date : 2025-04-24 DOI:10.1016/j.jctube.2025.100529

Alfred Kipyegon Keter , Alastair Van Heerden , Tom Decroo , Tom Boyles , Shannon Bosman , Thandanani Madonsela , Lindani Innocent Msimango , Lenika Naiken , Carlos Kiyan , Mashaete Kamele , Irene Ayakaka , Klaus Reither , Bart Karl Mario Jacobs , Lutgarde Lynen

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引用次数: 0

Abstract

Background

When confronted with diagnostic uncertainty and a decision on whether to start treatment or not, clinicians consider the potential harm and benefit of offering versus withholding treatment. Treatment can be offered if the probability of tuberculosis (TB) in the patient is above the “therapeutic threshold” (ThT): the probability of disease at which the expected utility of treating and not treating is the same. We estimated ThT for TB in clinical and community settings in Southern Africa using two methods: an adapted nominal group technique (aNGT), and decisions made based on clinical vignettes (CVs).

Methods

We enrolled health professionals involved in the routine management of TB patients in South Africa and Lesotho. The participants elicited, discussed and refined the harms of false positive (FP) and false negative (FN) treatment decisions for stable ambulatory patients in the clinical and community settings. They weighed all harms according to their importance in treatment decisions by distributing 100 points. ThT, calculated as the sum of the weights of the harms of the FP decision divided by the total weight, was estimated using a hierarchical Beta regression model. For the CVs, participants were presented with ten hypothetical TB cases in each setting and asked to indicate whether they would offer TB treatment or not. ThT was estimated using the generalized linear model for binary outcomes.

Results

We enrolled 138 health professionals (aNGT: 123, CVs: 130 and 115 in both). Using aNGT, the overall ThT was 37.7% (95% credible intervals (95% CrI): 35.8–39.8) and 38.2% (95% CrI: 35.9–40.6) in the clinical and community settings, respectively. Compared to aNGT, CVs produced a significantly lower estimate in the clinical setting (27.7%; 95% CrI: 23.8–31.3) but similar in the community setting (37.7%; 95% CrI: 33.1–41.7). We did not find significant differences across the subgroups defined by the measured covariates.

Conclusion

The aNGT produced a reliable estimate of ThT. The difference in the estimates of ThT between the aNGT and CVs may have a limited impact on clinical decisions. Factors influencing ThT and the acceptability of results by healthcare workers will be explored in focus group discussions and in-depth interviews.

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在南部非洲的临床和社区环境中，使用适应的名义小组技术和临床小插曲估计结核病的治疗阈值

当面临诊断的不确定性和是否开始治疗的决定时，临床医生会考虑提供治疗与不提供治疗的潜在危害和益处。如果患者患结核病的概率高于“治疗阈值”（ThT），则可以提供治疗：治疗和不治疗的预期效用相同的疾病概率。我们在南部非洲的临床和社区环境中使用两种方法估计了ThT治疗结核病的效果：一种是经过调整的名义群体技术（aNGT），另一种是基于临床小片段（CVs）做出的决定。方法我们招募了南非和莱索托参与结核病患者常规管理的卫生专业人员。参与者引出，讨论和完善假阳性（FP）和假阴性（FN）治疗决策对临床和社区环境中稳定的门诊患者的危害。他们根据危害在治疗决策中的重要性，分配100分来衡量所有危害。ThT计算为FP决策的危害权重之和除以总权重，使用分层Beta回归模型估计。在这些履历中，参与者在每种情况下都有10个假设的结核病病例，并被要求表明他们是否会提供结核病治疗。使用二元结果的广义线性模型估计ThT。结果共纳入138名卫生专业人员（aNGT: 123， cv: 130和115）。使用aNGT，在临床和社区环境中，总体ThT分别为37.7%（95%可信区间（95% CrI）： 35.8-39.8）和38.2% （95% CrI: 35.9-40.6）。与aNGT相比，CVs在临床环境中产生了明显较低的估计(27.7%；95% CrI: 23.8-31.3)，但在社区环境中相似(37.7%；95% CrI: 33.1-41.7)。我们没有发现测量协变量定义的亚组之间有显著差异。结论aNGT对ThT有可靠的估计。在aNGT和cv之间的ThT估计值的差异可能对临床决策的影响有限。通过焦点小组讨论和深度访谈，探讨影响ThT的因素和医护人员对结果的可接受性。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Journal of Clinical Tuberculosis and Other Mycobacterial Diseases Medicine-Pulmonary and Respiratory Medicine

CiteScore

4.00

自引率

5.00%

发文量

审稿时长

30 weeks

期刊介绍： Journal of Clinical Tuberculosis and Mycobacterial Diseases aims to provide a forum for clinically relevant articles on all aspects of tuberculosis and other mycobacterial infections, including (but not limited to) epidemiology, clinical investigation, transmission, diagnosis, treatment, drug-resistance and public policy, and encourages the submission of clinical studies, thematic reviews and case reports. Journal of Clinical Tuberculosis and Mycobacterial Diseases is an Open Access publication.