Table 2

Effectiveness of service models and organisational structures interventions to improve TB identification and TB management

PopulationIntervention (I)Comparator (C)Studies (first author, year, country)No. of participantsComparisonOutcomeRisk of bias
IC
Homeless peopleHealth/TB education and promotion of screening by street teams, drug users support centres, shelters and CHWs.Beginning of the intervention when CHWs were just introduced.Goetsch,20 2012, Germany.465125Retrospective comparison over intervention period.Improved annual TB screening uptake among homeless people and drug users (from 10.0% to 15.0% at the peak).20 The percentage of all drug users with active TB identified by screening increased from 13.4% to 61.0% (OR 10.1 (95%CI 4.44 to 23.0)).11 High*
Drug usersNo active screening policy.Duarte,11 2011, Portugal.Retrospective before–after comparison.High†
Homeless peopleTB education and promotion of screening by peers and shelter staff.TB education and promotion of screening by shelter staff only.Aldridge,19 2015, UK.11501192Comparing randomised intervention cluster with comparator cluster.No difference in screening uptake (I=40% (IQR 25–61) versus C=45% (IQR 33–55), aRR=0.98 (95% CI 0.80 to 1.20)).Medium‡
MigrantsPremigration screeningPostmigration screening at POA.Mor,27 2008, cited in the NICE review, Israel.162105Retrospective Intervention versus comparator comparison.Reduced the risk of developing TB in the new country and was cost-effective (0.28% of the premigration versus 0.32% of the postmigration screening migrants developed TB; RR 0.82, p<0.01). The detection period was shorter as well (193 days vs 487 days between entry and diagnosis; OR=0.72 (95% CI 0.59 to 0.89) p=0.002).High§
Prisoners and homeless peopleTB screening in a prison.TB screening at a homeless centre.Miller,26 2006, cited in the NICE review, USA.22 920822Retrospective comparison of two cohorts.No difference in screening uptake (94.7% in prison vs 95% in homeless centre p=0.179) but higher proportion of active TB cases were identified at the homeless centre (1.2% vs 0.03% at a prison setting, p<0.001).Medium¶
Homeless people and migrantsActive case finding by symptom-based questionnaire at homeless centres.Active case finding by symptom-based questionnaire at POA.Bothamley,25 2002, cited in the NICE review, UK.262199Cost analysis.Active case finding at POA was most cost-effective (costs per person screened for every case prevented at POA £10.00, at homeless centre £23.00).High**
MigrantsActive case finding at a specialised TB clinic using two visits.Active case finding at a general primary care clinic, with referral for CXR, using three visits.El-Hamad,24 2001, cited in the NICE review, Italy.749483Prospective intervention versus comparator comparison.Improved screening completion among migrants (85.6% in TB clinic vs 71.4% at primary care clinic, p=not reported; OR=2.57 (95% CI 1.92 to 3.42)).Medium††
Drug usersContact tracing by peers or CHWs from the same migrant community.Peers versus other healthcare workers.Ricks,23 2008, cited in the NICE review, USA.4846RCTImproved contact tracing among drug users (75% by peers vs 47% by healthcare workers, p=0.03)23 and migrants (from 55.4% without CHWs to 66.2% with CHWs; aOR 1.8 (95% CI 1.3 to 2.5) p<0.001).21 Low
MigrantsNormal practice before introducing CHWs.Ospina, 21 2012,
Spain.
388572Before–after comparison.Medium‡‡
Drug users and homeless peopleMobile TB screening and treatment service at convenient location in the community.Passive case detection and management at a TB clinic.Jit,22 2011, UK.48252Prospective intervention versus comparator comparison plus economic evaluation.Improved TB identification among homeless people and drug users; particularly in asymptomatic patients (35.4% extra identified) and those who delay seeking healthcare (22.2% extra identified). Higher treatment completion rate (67.1% vs 56.8%) and lower lost to follow-up rate (2.1% vs 17.2%). Both parts of the service are cost-effective (screening= £18 000/QALY gained, treatment is £4100/QALY gained).Medium§§
Drug usersEnhanced case management by peers.Limited case management by regular healthcare workers.Ricks,23 2008, cited in the NICE review, USA.4846RCTImproved treatment completion in drug users (85% by peers vs 61% by healthcare workers, RR=2.68 (95% CI 1.24 to 5.82) p=0.01).Low
Drug usersDOT and active follow-up of non-compliant patients by ‘key partners’.Non-compulsory TB treatment and education about TB disease and treatment to improve compliance.Duarte,11 2011, Portugal.465125Retrospective before–after comparison.Reduced treatment default rates (from 35.4% to 10.2%; OR 0.21 (95% CI 0.08 to 0.54)).High**
Migrants, drug users, homeless people and prisonersDOT at a convenient location in the community.DOT at a health clinic.Dèruaz,28 2004, cited in the NICE review, Switzerland.3618Retrospective before–after comparison.No significant difference in successful treatment outcome, treatment completion and cure rate (85.2% at convenient location vs 92.6% at health clinic, p=0.67).High¶¶
  • Footnotes risk of bias:

  • *Not adjusted for important confounding factors (intervention and comparator group were recruited over different time periods). Denominator not given therefore unable to calculate screening coverage.

  • †Risk of selection bias as participation was voluntary. Not adjusted for important confounding factors (intervention and comparator group were recruited over different time periods). No statistical test used to show statistical significance of the findings; an estimated number was used for the denominator.

  • ‡Most comparator sites were not naïve for peer intervention, no individual information of the participants was collected and the characteristics between the two groups might have been significantly different.

  • §Not adjusted for important confounding factors (intervention and comparator group were recruited over different time periods), premigration group had a shorter follow-up period than postmigration group what may have influenced the detection of number of TB cases in the premigration group.

  • ¶Unclear if the differences in outcome was caused by the setting or by the different methods or to differences in TB prevalence in the different populations.

  • **TB prevalence might be different in the different populations as the costs are calculated per active case detected this is a major issue, there were only three active TB cases detected, all in the POA group. The economic perspective used was not reported, and the costs of identification were not discounted.

  • ††Not adjusted for difference in baseline characteristics.

  • ‡‡Not adjusted for important confounding factors (intervention and comparator group were recruited over different time periods). Contact tracing of only one contact was enough to be called contact tracing, and the ultimate aim of contact tracing (increase cased detection and reduce transmission) was not analysed in this study.

  • §§Study was designed to evaluate the cost-effectiveness, no statistical test used to evaluate statistical significant findings. The ‘Find and Treat’ service identifies extremely hard-to-reach populations that would never self-present, and the findings would underestimate the benefit of the service. The economical evaluation is based on a compartmental model that does not take secondary transmission and drug resistance into account.

  • ¶¶Risk of bias due to difference in collecting treatment adherence outcome at the health clinic a nurse recorded treatment adherence at time of visit, in the social outreach group a healthcare worker was interviewed up to 6 months after treatment completion and was asked about the treatment adherence, risk of recall bias. Not recorded how many people per setting received 6 months of DOT (full DOT) and how many received 2 months of DOT and 4 months of self-treatment (partial DOT), what was another intervention in this study. Allocation to setting was based on needs of participants what might have caused bias.

  • aOR, adjusted ORs; aRR, adjusted risk ratio; CHWs, community health workers; CXR, chest X-ray; DOT, directly observed treatment; POA, port of arrival; QALYs, quality-adjusted life years; RCT, randomised controlled trial; TB, tuberculosis.