Economic Evaluation of Molecular Testing for Pulmonary Tuberculosis Diagnosis: A Systematic Review

Natthakan Chitpim,1 Panida Yoopetch,2 Jiraphun Jittikoon,3 Wanvisa Udomsinprasert,3 Kornkanok Bunwong,4,5 Surakameth Mahasirimongkol,6 Usa Chaikledkaew2,7 1Social, Economic and Administrative Pharmacy (SEAP) Graduate Program, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand; 2Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand; 3Department of Biochemistry, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand; 4Department of Mathematics, Faculty of Science, Mahidol University, Bangkok, Thailand; 5Centre of Excellence in Mathematics, MHESI, Bangkok, Thailand; 6Office of Permanent Secretary, Ministry of Public Health, Nonthaburi, Thailand; 7Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, ThailandCorrespondence: Usa Chaikledkaew, Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, 447 Sri-Ayudhaya Road, Ratchathewi, Bangkok, 10400, Thailand, Email [email protected]: Rapid molecular assays such as Xpert MTB/RIF and TB-LAMP accelerate pulmonary tuberculosis (TB) diagnosis but are more expensive than smear microscopy. This study provided an updated economic synthesis for presumptive adult pulmonary TB in high-burden settings, broadening the evidence from Xpert MTB/RIF to other WHO endorsed tests compared to conventional strategies.Methods: Medline, Embase and Scopus were searched through March 2025. The strategy combined search terms related to molecular diagnostic tests, pulmonary tuberculosis, and economic evaluation study designs. Full economic evaluations comparing molecular tests with smear microscopy, culture or passive case-finding were eligible. Two reviewers independently screened articles, extracted data, and adjusted costs to 2025 US dollars (USD) using average exchange rates. Reporting quality was appraised using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 checklist. Due to heterogeneity in evaluation criteria, model structures, time horizons, and outcome measures, meta-analysis were not feasible. Therefore, results were synthesized narratively, and incremental cost-effectiveness ratios (ICERs) were contextualized against country-specific cost-effectiveness thresholds to enable meaningful cross-study interpretation.Results: Eight studies conducted in low- and middle-income countries with high TB burdens were included. All evaluated Xpert MTB/RIF and the Thai studies also examined TB-LAMP. Five studies reported cost per disability-adjusted life years (DALYs) averted or quality-adjusted life years (QALYs) gained, while three used TB cases detected or years of life saved (YLS). CHEERS reporting quality was high (median is 23/28 items). Reported ICERs for molecular testing were either cost-saving or highly cost-effective compared with country-specific thresholds. Probabilistic sensitivity analyses (five studies) indicated ≥ 90% probability of cost-effectiveness in four studies and 6% in one.Conclusion: Recent evidence supports the cost-effectiveness and cost-saving of Xpert MTB/RIF and TB-LAMP for diagnosing adult pulmonary TB. Policymakers should prioritize reducing cartridge costs and implementing models that capture patient-level benefits to maximize economic benefits.Keywords: Xpert MTB/RIF, cost-effectiveness, molecular testing, systematic review