Costs and cost-effectiveness of alternative tuberculosis management strategies in South Africa--implications for policy

OBJECTIVE

To conduct an economic analysis of the Hlabisa community-based directly observed therapy management strategy for tuberculosis and to project costs of three alternative strategies.

SETTING

Hlabisa health district, KwaZulu-Natal, South Africa.

METHODS

An economic analysis comparing the current tuberculosis management strategy in Hlabisa with three alternative strategies (the Hlabisa strategy prior to 1991 based on hospitalisation, the national strategy and sanatorium care) in terms of costs to both health service and patient and of cost-effectiveness.

RESULTS

The current Hlabisa strategy was the most cost-effective (R3799 per patient cured), compared with R98307 for the strategy used prior to 1991, R9940 for the national strategy, and R11145 for sanatorium care. Between 71% and 88% of treatment costs lie with the health service, and hospitalisation (R119 per day) is the most expensive item. Prolonged hospitalisation is extremely expensive, but community care is cheaper (community clinic visit, R28; community health worker visit, R7). The total cost of supervising a patient in the community under the current Hlabisa strategy was R503, equivalent to 4.2 days in hospital. Drug costs (R157) are equivalent to just 1.3 days in hospital.

CONCLUSION

Cost to both health service and patient can be substantially reduced by using community-based directly observed therapy for tuberculosis, a strategy that is cheap and cost-effective in Hlabisa. These findings have important national implications, supporting the goals of the new tuberculosis control programme.

Review of published cost-effectiveness studies on tuberculosis treatment programmes

This article aims to summarise key factors in the published literature associated with cost-effective tuberculosis (TB) treatment programmes and to make recommendations on how techniques for future studies could be improved. There is consistent evidence that fully ambulatory, short course chemotherapy programmes are currently the most cost-effective option, although this may depend on the cost of providing an effective community-based service. Direct supervision may be more cost-effective than self-administration because of the reduced need for monitoring and follow-up; more studies are needed, however, that include real outcome figures and household measures of cost. For studies taking a provider perspective, the methods used for measuring costs will be dependent on sources of information, but centralised accounts are the most preferred source. Effects should be measured in terms of actual outcome, and should preferably not be taken from the literature. Most of the studies reviewed did not consider the difficulties of introducing a theoretically cost-effective change into a health service. More studies are required that document actual changes in programme cost and outcome associated with the introduction of different types of treatment delivery. Future work could consider measuring cost in terms of resources (e.g., staff) rather than only finances, and more work is needed on household perspectives.

Universal directly observed therapy. A treatment strategy for tuberculosis

Patient adherence to prescribed tuberculosis regimens must be assured to prevent relapse, acquired resistance, and transmission. Directly observed therapy (DOT), an outpatient management strategy designed to ensure adherence, is not widely used because it is perceived to be inordinately expensive. The primary focus of this article is on using universal, as opposed to selective, DOT in the treatment of tuberculosis patients. Universal DOT is a policy where it is intended that observed therapy be used for all patients. Selective DOT is a policy where patients are observed taking medications only if certain selection criteria are satisfied. Topics addressed include cost, efficacy, nonadherence, and implementation guidelines.

Effectiveness and cost of rapid and conventional laboratory methods for Mycobacterium tuberculosis screening

OBJECTIVE

Because delay in the diagnosis of tuberculosis (TB) contributes to the spread of disease and the associated mortality risk, the authors examined the effectiveness and cost of recent advances in methods of diagnosing TB and testing for drug susceptibility, comparing these rapid methods to traditional approaches.

METHODS

Decision analysis was used to compare newer rapid and older nonrapid methods for diagnosing TB and testing for drug susceptibility. The average time to diagnosis, average time to treatment, average mortality, and cost of caring for patients evaluated for TB were compared.

RESULTS

Using a combination of solid medium and broth cultures, nucleic acid probes for identification, and radiometric broth drug susceptibility testing would lead to diagnosis on average 15 days faster and to appropriate therapy on average five days sooner than methods currently employed by many U.S. laboratories. The average mortality would drop by five patients per 1000 patients evaluated (31%) and the average cost per patient would drop by $272 (18%).

CONCLUSIONS

In this era of cost containment, it is important to incorporate test sensitivity and specificity when evaluating technologies. Tests with higher unit costs may lead to lower medical expenditures when diagnostic accuracy and speed are improved. U.S. laboratories should employ available rapid techniques for the diagnosis of TB.

[Prevalence of tuberculosis in Swiss hospitals in the years 1990 to 1993]

The medical statistics of VESKA (Association of Swiss Hospitals), MSV, comprise and include the spectrum of all diseases in patients admitted to Swiss hospitals which are members of the association. Documentation is carried out in accordance with the WHO ICD code. Tuberculosis is registered under the main figures 010 to 018. The MSV makes an essential contribution in a special area to the recording of tuberculosis in Switzerland. The ICD code classes the disease either in positions 1 to 3 as the category of "all (TB) diagnoses' or as "principal diagnosis' in the first place. The numerical values are either recorded individually for the years 1990 to 1993 or as mean values of these four years. Tuberculosis occupies a small space within the overall statistics. Of a total of 722 868 and 369 840 coded diagnoses (1990 to 1993, averages), 1100 and 627, respectively, fall under tuberculosis in the two categories. This corresponds to a proportion of 0.15% and 0.17%, respectively. Tuberculosis becomes more important because the general average hospital stay of 12.7 days is almost doubled with an average of 24.7 days for tuberculosis patients. If the costs per case generally stand at Sfr. 7353.-, then, for tuberculosis patients, they rise to Sfr. 14 301.-. The overall costs for tuberculosis patients per calendar year total Sfr. 15 731 430.- and Sfr. 8 966 915.-, respectively, in the two categories. Tuberculosis is, therefore, a disease which is still of economic significance even in Switzerland. In the category of types of tuberculosis, pulmonary tuberculosis (011) still today occupies first position compared to previous analyses with current figures of 65.1% and 67.7% respectively. In the case of the extra-pulmonary types, uro-genital tuberculosis (016) stands in second place with 5.7% and 3.5% in the two categories, after the group of tuberculosis of other organs (017) with 5.9% and 6.1%, respectively. There was a constant preponderance of male over female patients (64.3% vs. 35.6%). If decades ago tuberculosis shifted to and was spread over more advanced age groups in Switzerland, the proportion of foreigners now within the whole population has brought about a change. Almost twice as many tuberculosis cases occur within the 20-year to 40-year age group than in the other age groups, in which a certain degree of levelling off is apparent. From comparisons of notifications to authorities in Switzerland and from hospitalization rates, it can be deduced that there is no increased need for hospitalization for any particular age group.

A simple methodology to finance public health initiatives: reimbursement for tuberculosis directly observed therapy services in New York State

New York State (NYS) used Medicaid reimbursement to create incentives for health care providers to offer directly observed therapy (DOT) services for active tuberculosis (TB) disease. This resulted in proliferation of 26 new TB DOT providers and expanded capacity for the New York City (NYC). Department of Health. As a result, over 1,200 individuals now receive DOT in NYC. The reimbursement methodology was also used for other NYS public health initiatives. It is applicable for public health initiatives elsewhere.

Public health campaign funds provide a "safety net" for indigent tuberculosis patients at the Mount Sinai Hospital

This article describes the development of a partnership between a voluntary health care institution and a state agency for a focused public health program providing vital clinical, public health, and social supportive services. In addition to the historical development of this alliance, the article illustrates joint problem-solving processes to address complex issues. Since its inception in 1992, this collaboration has resulted in significant improvements in the health status of a high-risk, difficult-to-serve, indigent population that would otherwise pose a public health threat to the community. Demographics of 17 indigent patients are described. Nine have completed treatment for tuberculosis under directly observed therapy and completion is in sight for six others. None have been lost to follow-up.

Global spread of TB worrying trend for Canadian physicians

Canada has one of the world's lowest rates of tuberculosis infection, but that doesn't mean the disease poses no threat here. TB represents a growing problem in prisons and among Canadians of native and Asian descent. Patients with active TB can be misdiagnosed because few physicians ever see the disease and because the bacillus can infect organs other than the lungs. Frequent screening of at-risk populations and a rigorous course of antibiotics for those who are infected are recommended.

Cost effectiveness of antituberculosis interventions

The treatment of tuberculosis (TB) is ranked as the most cost effective of all therapeutic programmes in terms of cost per year of life saved. Nevertheless, TB kills or debilitates more adults aged between 15 and 59 years than any other disease in the world; furthermore, about 2 to 4% of the burden of disease, 7% of all deaths and 26% of all preventable deaths are directly attributable to TB. About one-third of the world's population is infected with the TB bacillus. In the developing world, more women of childbearing age die from TB than from causes directly associated with pregnancy and childbirth. The death of adults in their prime, who are parents, community leaders and producers in most societies, causes a particularly onerous burden besides being a serious public health problem. In the poorest countries, where the magnitude of the TB problem is greatest, those TB control strategies that are economically feasible tend to be less effective. Therefore, in low and middle income countries, cost-effectiveness considerations aimed at prioritising resource allocation in the health sector in general, and in TB control programmes in particular, are of paramount importance. Operationally, the main components of a TB control programme are: (i) detection and treatment of TB; and (ii) prevention of TB through BCG vaccination and chemoprophylaxis. Priority should be given to ensuring that TB patients complete their prescribed course of chemotherapy. Adequate treatment is the most effective way of preventing the spread of TB and the emergence of drug resistance. This article reviews evidence of the effectiveness and cost effectiveness of different approaches to TB care, particularly those that are applicable to low income countries, in both HIV-infected and noninfected patients. Financial implications and ways to implement directly observed therapy for TB in large urban areas are discussed, and the need to address some relevant operational issues is highlighted. The current role of chemoprophylaxis and BCG vaccination is also reviewed.

Evaluation of a tuberculosis screening program for high-risk students in Toronto schools

OBJECTIVE

To evaluate the effectiveness of a tuberculosis (TB) screening program for high-risk students in elementary and secondary schools.

DESIGN

Cross-sectional study of the 1992-93 school screening program conducted by the Department of Public Health of the City of Toronto. Program costs were calculated with the use of 1993 wages, and costs for medical care were based on the 1993 fee schedule of the Ontario Medical Association.

SETTING

Elementary and secondary schools in the City of Toronto.

PARTICIPANTS

Students enrolled for the first time in any grade who were born in a country where TB is endemic or who were aboriginal Canadians were eligible. Of 44,179 students in Toronto schools 1775 met the eligibility criteria.

INTERVENTION

Students were administered a Mantoux skin test, and those with a significant reaction (an induration of 10 mm or more in diameter) were advised to consult a physician for follow-up.

OUTCOME MEASURES

Participation rate, number of participants with a significant reaction, percentage of these who were prescribed isoniazid and who completed chemoprophylaxis, potential number of preventable cases and costs associated with preventing each case.

RESULTS

Of 1775 eligible students 42.9% (761) agreed to participate, and 40.6% (720) were screened. Significant skin-test reactions were detected in 22.5% (162/720) of the participants screened. Of these, 87.7% (142/162) saw a physician; subsequently, 2 cases of TB (1 active and 1 inactive) were detected. Of the remaining 140 students 44.3% (62) were prescribed isoniazid, of whom 9.7% (6/62) refused chemoprophylaxis. Of the remaining 56 students 82.1% (46) completed at least 6 months of chemoprophylaxis and 10.7% (6) were completing treatment at the end of the study. An estimated 3.2 cases were prevented, at a cost of $13,493.15 per case, whereas the undiscounted cost of treatment for an uncomplicated active case of TB in a patient under 19 years of age was $4503.82.

CONCLUSIONS

The effectiveness of this screening program was significantly reduced by poor participation and poor rates of prescription of isoniazid by physicians. Appropriate strategies are needed to reduce barriers to the implementation of these programs.

School-based screening for tuberculous infection. A cost-benefit analysis

OBJECTIVE

To compare tuberculin screening of all kindergartners and high school entrants (screen-all strategy) vs screening limited to high-risk children (targeted screening).

DESIGN

Decision, cost-effectiveness, and cost-benefit analyses.

SETTING AND SUBJECTS

Students in a large urban and rural county.

DEFINITIONS

High risk of tuberculosis infection was defined as birth in a county with a high prevalence of tuberculosis. Low risk was defined as birth in the United States.

OUTCOME MEASURES

Tuberculosis cases prevented for 10, 000 children screened. Net costs, net cost per case prevented, benefit-cost ratio, and incremental cost-effectiveness.

RESULTS

The screen-all strategy would prevent 14.9 cases per 10,000 children screened; targeted screening would prevent 84.9 cases per 10,000 children screened. The screen-all strategy is more costly than no screening; the benefit-cost ratio is 0.58. Targeted screening would result in a net savings; the benefit-cost ratio is 1.2. Screening all children is cost saving only if the reactor rate is 20% or greater. The cost per additional case prevented for screening all children compared with targeted screening (+34 666) is more than twice as high as treatment and contact tracing for a case of tuberculosis (+16 392).

CONCLUSIONS

Targeted screening of schoolchildren is much less costly than mass screening and is more efficient in prevention of tuberculosis.

Community-based tuberculin screening in Montreal: a cost-outcome description

OBJECTIVES

This study describes the costs and outcomes of community-based tuberculin screening programs conducted between 1987 and 1991 in Montreal, Quebec, Canada.

METHODS

Follow-up information was abstracted from hospital records of all reactors detected in tuberculin screening of students in grades 6 and 10, of first-year health professional students, and of workers aged 18 to 25 in a number of workforces. Screening costs were estimated directly from survey records, and follow-up costs were estimated from the annual financial report of the Montreal Chest Hospital for 1989/90.

RESULTS

Of 7669 persons tested, 782 (10.2%) had positive results and 757 (9.9%) were referred to a clinic. Of those, 525 (6.8% of the original 7669) reported, 293 (3.8%) were prescribed therapy, and 154 (2.0%) were compliant. In Canadian dollars, screening cost $5.70 per person tested and $56 per tuberculin reactor detected, but follow-up of reactors accounted for 73% of the total program cost of $13,455 to $18,753 per case of tuberculosis prevented.

CONCLUSIONS

Because of high rates of patient and provider noncompliance, a tuberculin screening program was much less cost-effective than anticipated. Screening costs must be targeted to the highest risk populations, and compliance with recommendations for preventive therapy must be maximized.

An economic evaluation of alternative programme designs for tuberculosis control in rural Uganda

Tuberculosis (TB) and AIDS are infections that are among the most feared of all diseases. Both have been widely discussed by the western media in recent months, for a variety of reasons, but it is the combination of the two diseases in an ever increasing number of patients that is causing concern to health planners and health economists. While AIDS is untreatable and prevention of further infection depends largely on changes in sexual behaviour, TB remains eminently treatable. Preventing the spread of TB depends on the effective treatment of active cases, taking 6-12 months, depending on the drugs used. In order to ensure completion of treatment, a programme of registering and following up patients is required. A number of different programme designs are considered and an analysis of both costs and consequences is attempted in order to find the most cost-effective alternative. Data from western Uganda for 1992 are used for the study and the implications of the findings for both Uganda and other African countries are discussed. It is concluded that a programme based on the ambulatory treatment of patients at their nearest health unit, whilst living at home, is the most cost-effective design, largely because of reduced costs to the patients themselves. Specific recommendations are made regarding the implementation of such a programme.

Preventive chemotherapy for HIV-associated tuberculosis in Uganda: an operational assessment at a voluntary counselling and testing centre

OBJECTIVE

To assess the operational aspects of isoniazid preventive chemotherapy (IPT) for tuberculosis in persons dually infected with HIV and Mycobacterium tuberculosis identified at an independent HIV voluntary counselling and testing centre in Kampala, Uganda.

DESIGN

HIV-infected persons were counselled, had active tuberculosis excluded by medical examination, and were offered purified protein derivative (PPD) skin testing. PPD-positive persons were offered isoniazid 300 mg daily for 6 months. Drugs were supplied, and toxicity and compliance were assessed monthly. Utilization of service, cost, and sustainability were also assessed.

RESULTS

Between 14 June 1991 and 30 September 1992, 9862 persons tested HIV-positive. Of 5594 HIV-infected clients who returned to collect test results, only 1524 (27%) were enrolled. Of those, 1344 were tuberculin-tested (88%); 180 were not tested because of active tuberculosis, serious illnesses, refusal, and other reasons. Of the 1344, 250 (19%) did not return for test reading and 515 were negative (47% of tests read). Of 579 tuberculin-positive persons, 59 (10%) were excluded from preventive chemotherapy because of tuberculosis and other respiratory illnesses. Of 520 persons given isoniazid, 62% collected at least 80% of their drug supplies. No major toxicity was observed. One case of tuberculosis occurred in the first month of treatment. Cost of HIV counselling and testing was US $18.54 per person and cost of follow-up counselling and social support was US $7.89.

CONCLUSIONS

Important factors were identified which caused attrition, such as limited motivation by counsellors to discuss tuberculosis issues during HIV pre- and post-test counselling, insufficient availability of medical screening, shifting of sites to collect pills, and frequent tuberculin-negative tests. Active tuberculosis among 6% of persons screened suggests that voluntary counselling and testing sites may be important for tuberculosis case finding and underscores the need to exclude tuberculosis carefully before starting IPT. In developing countries, further studies assessing the feasibility of IPT within tuberculosis and HIV/AIDS programme conditions are needed. Cost-effectiveness of IPT, compared with passive case finding, and its sustainability should be assessed before national policies are established.

The cost of caring for patients with tuberculosis: planning for a disease on the rise

OBJECTIVE

An economic analysis was conducted for all patients with a primary diagnosis of tuberculosis admitted to a university hospital for a 1-year period in 1992.

DESIGN

The economic analysis was conducted by using the hospital billing system to capture resource use for patients with tuberculosis and cost-to-charge ratios to estimate hospital costs.

SETTING

A university teaching hospital.

PATIENTS

Patients with a primary diagnosis of tuberculosis were included in the study.

RESULTS

The average length of stay for patients was 22.7 days on initial admission to the hospital and 13.5 days on readmission. The average cost of care was $27,109 for initial admission, $13,094 for readmission, and $20,222 when all patients were included.

CONCLUSION

Room costs were the most significant contributor to the total cost of care, followed by laboratory costs and ancillary hospital costs. We calculate the average cost for caring for a patient with tuberculosis at approximately $20,000 per year.

Isoniazid prophylactic therapy for tuberculosis in HIV-seropositive patients--a least-cost analysis

The expected upsurge in the number of new cases of tuberculosis resulting from the HIV/AIDS epidemic prompted an examination of the feasibility of prevention strategies to limit the increase in clinical tuberculosis. A computer spreadsheet model was developed to estimate the costs and benefits that would result from isoniazid chemoprophylaxis for tuberculosis in a hypothetical cohort of 100,000 HIV-seropositive people in South Africa over a period of 8 years. At a 50% prevalence of tuberculosis infection among those at high background risk, and 5-10% among those at low risk, there would have been 34,000 cases of active tuberculosis in the cohort and their contacts if no prophylactic therapy had been used. On the other hand, a chemoprophylaxis policy would have meant only 12,200 cases of tuberculosis, if a patient compliance rate of 68.5% had been assumed. Such a policy would have prevented 21,800 cases of active tuberculosis. The estimated total discounted cost of a chemoprophylaxis programme would have been R51.3 million. In the absence of preventive therapy the discounted cost of treating patients with active tuberculosis would have been R91.9 million over the 8-year period. Therefore, if the benefits of chemoprophylaxis were defined in terms of averted health care costs, such a policy would have resulted in net savings of R40.6 million. This study did not estimate losses in production associated with tuberculosis treatment or the value of preventing tuberculosis per se, though such indirect costs would have increased the benefit of the prevention programme.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of HIV infection and tuberculosis on hospitalizations and cost of care for young adults in the United States, 1985 to 1990

OBJECTIVE

To evaluate the effect of human immunodeficiency virus (HIV) infection and tuberculosis on hospitalizations and the cost of care.

DESIGN

National Hospital Discharge Survey, a nationally representative survey of discharges from U.S. nonfederal short-stay hospitals, and statewide billing information.

PATIENTS

Patients 15 to 44 years of age with a listed diagnosis of HIV infection (n = 418,200) or active tuberculosis (n = 77,700) during 1985-1990.

RESULTS

During 1985-1990, hospitalizations related to HIV infection increased sixfold, from 18 to 102 per 100,000 persons; during 1988-1990, hospitalizations related to tuberculosis increased twofold, from 8 to 16 per 100,000 persons. The prevalence of tuberculosis among HIV-infected patients increased from 2.4% in 1985-1988 to 5.1% in 1989-1990 (P = 0.003). The prevalence of HIV infection among patients with tuberculosis increased from 11% in 1985-1988 to 28% in 1989 to 39% in 1990 (P < 0.001). Infection with HIV was more prevalent among patients with extrapulmonary tuberculosis (31%) than among those with pulmonary tuberculosis (18%) (P = 0.01). An increase in the duration of hospital stay was associated with both tuberculosis and HIV infection. From 1985 to 1990, inpatient care costs increased 7.7-fold and 3.2-fold for HIV and tuberculosis hospitalizations, respectively. During this period, HIV and tuberculosis hospitalizations resulted in 5,793,000 and 1,107,900 days of care, respectively, with an estimated direct cost of $5.7 to $7.4 billion and $0.89 to $1.07 billion, respectively. Estimated national costs of inpatient care for HIV infection or tuberculosis or both totaled $6.4 to $8.1 billion, 5% of which was for patients with both HIV infection and tuberculosis.

CONCLUSIONS

This is the first study to use a nationally representative sample of hospitals, combined with cost data, to estimate hospitalizations and their costs for HIV and tuberculosis care. Our findings suggest that the convergence of the HIV and tuberculosis epidemics has had an increasing effect on morbidity and the cost of care among young adults in the United States. The increasing prevalence of comorbidity of HIV infection and tuberculosis in inpatients underscores the need for strict infection control of tuberculosis on the part of hospitals, increased attention to prevention, and early identification and treatment of HIV infection, and tuberculosis to reduce morbidity, hospitalizations, and the cost of care.

The 20th Kellersberger Memorial Lecture, 1994. Leprosy and tuberculosis combined programmes: an uneasy partnership?

One of the purposes of this memorial lecture is to relate progress and difficulties in the field of leprosy to work in other fields. Tuberculosis is a disease closely related to leprosy and in 1982 the Kellersberger lecture was given by Dr. Styblo, someone whose name is synonymous with the development of effective Tuberculosis Control Programme in Africa. His title was "Tuberculosis and its control: lessons to be learned from past experience, and implications for leprosy control programme" (1). Many countries in Africa, including Ethiopia, have adopted the strategy of a combined leprosy and TB control programme. In this lecture then, I will examine more closely the strategy of combining the two programmes. I want to look at some of the problems that may arise and then draw out the ways in which each side of the partnership can contribute to the other, so that the combination can be more effective than either programme could hope to be on its own. This lecture will focus mainly on management issues, which are currently the most important barriers to effective control of both diseases, but the socio-economic aspects of disease, so much a part of Dr. Kellersberger's working life, will also be prominent.

The use of high-efficiency particulate air-filter respirators to protect hospital workers from tuberculosis. A cost-effectiveness analysis

BACKGROUND

After outbreaks of multidrug-resistant tuberculosis, the Centers for Disease Control and Prevention proposed the use of respirators with high-efficiency particulate air filters (HEPA respirators) as part of isolation precautions against tuberculosis, along with a respiratory-protection program for health care workers that includes medical evaluation, training, and tests of the fit of the respirators. Each HEPA respirator costs between $7.51 and $9.08, about 10 times the cost of respirators currently used.

METHODS

We conducted a cost-effectiveness analysis using data from the University of Virginia Hospital on exposure to patients with tuberculosis and rates at which the purified-protein-derivative (PPD) skin test became positive in hospital workers. The costs of a respiratory-protection program were based on those of an existing program for workers dealing with hazardous substances.

RESULTS

During 1992, 11 patients with documented tuberculosis were admitted to our hospital. Eight of 3852 workers (0.2 percent) had PPD tests that became positive. Five of these conversions were believed to be due to the booster phenomenon; one followed unprotected exposure to a patient not yet in isolation; the other two occurred in workers who had never entered a tuberculosis isolation room. These data suggest that it will take more than one year for the use of HEPA respirators to prevent a single conversion of the PPD test. Assuming that one conversion is prevented per year, however, it would take 41 years at out hospital to prevent one case of occupationally acquired tuberculosis, at a cost of $1.3 million to $18.5 million.

CONCLUSIONS

Given the effectiveness of currently recommended measures to prevent nosocomial transmission of tuberculosis, the addition of HEPA respirators would offer negligible protective efficacy at great cost.

Medicaid policies for HIV-related drug therapies: perspectives of the state affiliates of the American Pharmaceutical Association

OBJECTIVES

To determine how Medicaid prescription drug policies differ by state, and to assess how these policies affect pharmacies and the drug therapies available to Medicaid patients with HIV infection or tuberculosis. EVALUATION PROCESS: The state affiliates of the American Pharmaceutical Association (APhA) were surveyed to learn how state Medicaid policies impact the provision of prescription drugs to Medicaid patients within their state. The survey focused on Medicaid payment level incentives, Medicaid payments compared with private payments, Medicaid utilization policies, and incentives and disincentives in each state's Medicaid payment system.

RESULTS

Approximately two-thirds of the APhA affiliates reported that the Medicaid payment levels in their states for drugs used to treat HIV-related illnesses were at least moderately below private payment levels; in 11 states these Medicaid payments were substantially below those of private payers. Many APhA affiliates responding to the survey stated that the Medicaid program in their state limited the number of reimbursed drugs that Medicaid patients can receive. Eight APhA affiliates reporting that these utilization limits created restrictions on the ability of Medicaid patients with AIDS and HIV-related infections to receive needed medications.

CONCLUSIONS

With Medicaid programs becoming the major payers of AIDS-related healthcare, federal policies should standardize Medicaid coverage, payment, and utilization policies for prescription drugs needed by Medicaid recipients with HIV-related conditions. This would enable Medicaid patients to receive necessary and adequate drug therapies regardless of their state of residence. These federally mandated policies also would require an increased federal role in financing this expanded Medicaid drug coverage.

[Decision regarding chemoprophylaxis with isoniazid in patients using parenteral drugs and infected with HIV]

OBJECTIVES

Analyze the decision to enact or to refrain from chemoprophylaxis (CP) with isoniazide (INH) in patients who are intravenous drug users (IVDU) in Spain infected by the human immunodeficiency virus (HIV), either classified or not with hypersensitive skin tests.

METHODS

With the bibliographic information available and the help of decision tree, an analysis of the effectiveness and of the consequences of drug costs of CP with INH in those patients is performed.

RESULTS

Overall, the HIV+ IVDU benefit from CP is an increase in survival of 80 days, with a savings of 7,252 pesetas per patient. The intradermal reaction with PPD and the retarded hypersensitivity tests (HCR) allow us to classify them in three subgroups: a) PPD+ where CP is universally admitted and thus corroborates our study; b) PPD-/HCR- where CP increases survival 201 days and saves 20,616 pesetas per patient; and c) PPD-/HCR+ where survival is increased 33 days and the pharmacological costs increase 1,536 pesetas per patient under CP.

CONCLUSIONS

For the present situation in Spain, CP with INH is effective in HIV+ IVDU patients, independent of the results of the intradermal reaction skin tests.

Cutaneous reactions to thiacetazone in Zambia--implications for tuberculosis treatment strategies

Tuberculosis in patients infected with human immunodeficiency virus (HIV) is a growing threat to public health in Africa. Thiacetazone, one of the continent's most widely used antituberculous agents, may lead to severe cutaneous reactions in the HIV infected individual. We describe the impact of this reaction on the tuberculosis (TB) control programme of a district hospital in Zambia in 1990, and examine the cost implications of changing the standard treatment regime. We carried out a retrospective survey of records of all patients beginning TB treatment in 1990, together with HIV test results and the cost of all treatments given. From this we derived estimates of costs of different regimes which are and could be used in TB control in Zambia. Severe reactions occurred in 18.7% of all HIV seropositive patients receiving thiacetazone, fatally so in 1.2% (odds ratio 16.6). The greatest part of the cost of the current regime is that attributable to the inpatient stay; we estimated that 29.4% of patients would be unable to receive drugs as out-patients but, even allowing for this, rifampicin-based regimes given to outpatients where possible would not cost more than the current strategy. We conclude that ethical and economic considerations support a change to rifampicin-based regimes in areas of Africa where HIV seroprevalence is high.

Incidence and economics of tuberculosis in swine slaughtered from 1976 to 1988

The Swine Tuberculosis Regulations, revised in 1972, stipulated that all swine carcasses with mycobacterial lesions in more than 2 primary sites should be passed for cooking (PFC). Economic loss from a condemned carcass is 100%, whereas loss from a PFC carcass is 66%. Increased condemned and PFC swine carcass rates in 1972, 1973, and 1974, and the economic losses from them were attributed to changes in the regulations. An industrial organization estimated increased economic losses from swine tuberculosis, but detected decreased rates of condemned and PFC swine carcasses in 1975 and 1986. The federal meat inspection data for 1976 to 1988 indicated that the yearly condemned carcass rate remained < 8.0/100,000 swine slaughtered, whereas the PFC carcass rate decreased by 74.1%, from 52.4 to 13.6/100,000 swine slaughtered. The incidence (condemned + PFC) per 100,000 swine slaughtered decreased by 67.7%, from 58.03 in 1976 to 18.72 in 1988. The Agricultural Statistics indicated that a yearly loss from tuberculosis of $2.3 million in 1976 decreased by 73% to $0.97 million in 1988. A yearly loss of $41,580/$100 million of animal value decreased by 70% to $12,880/$100 million in 1988. The decreased incidence of swine tuberculosis and the economic losses with this disease indicate that the swine industry in the United States was not adversely affected by the change in the Swine Tuberculosis Regulations.

The impact of HIV on resource utilization by patients with tuberculosis in a tertiary referral hospital, Nairobi, Kenya

By using routinely collected data and results from research studies at the Infectious Diseases Hospital (IDH), Nairobi, we have begun to determine the scale of the increase in resource utilisation and treatment costs for tuberculosis control services caused by the HIV epidemic. New cases of tuberculosis registered annually at the IDH rose 61%, from 447 in 1985 to 720 in 1990. HIV seroprevalence among patients with tuberculosis rose from 7.5% in 1986 to 42% in 1990. The inpatient mortality rate rose from 8.4% in 1985 to 16.8% in 1989, but fell to 13.5% in 1990. HIV-positive patients were admitted to hospital on 2 or more occasions more often than HIV-negative patients (Relative risk (RR) = 2.46, 95% confidence intervals (CI), 1.1-5.7), but average duration of admission was similar for the 2 groups. Significantly more HIV-positive patients were prescribed antibiotics, antifungal agents, antidiarrhoeal agents, analgesics and corticosteroids than HIV-negative patients. Microbiological investigations, apart from those for tuberculosis, were performed more commonly among HIV-positive patients (RR = 2.0, 95% CI 1.0-4.2). Using this data, the average cost of ideal drug therapy, including antituberculosis drugs and treatment for intercurrent infections and other complications, was estimated using 1992 prices (ECHO, Coulsdon Surrey, UK). The costs were US$16.62 and US$32.94 for HIV-negative patients using 'standard' therapy (2STH/10TH) and short course therapy (2SHRZ/6TH) respectively, and US$41.18 for HIV-positive patients using a short-course regimen without thiacetazone (2EHRZ/6EH). The HIV epidemic is causing both an increase in the numbers of patients requiring treatment and an increase in the average cost of treatment per patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Analysis and efficiency-evaluation of case-finding among symptomatic suspects in rural area by smear microscopy]

216,307 suspects were discovered within the period from Oct. 1st, 1987 to Spt. 30th, 1988 in rural area of 26 counties. The suspect rate was demonstrated to be 2.2%; 182,917 persons accepted smear microscopy among suspects and the smear microscopy rate was 84.6%; 7,046 smear positive cases were detected and the smear positive rate was confirmed to be 3.95% among smear-accepted suspects. Smear microscopy among symptomatic suspects in rural area for infectious case-finding is recommended, because this method costs low, and is more effective and practical.

The economic impact of tuberculosis in hospitals in New York City: a preliminary analysis

There is a nationwide resurgence of tuberculosis (TB) in the country’s urban centers; New York City stands at the forefront of this resurgence. The root causes are increased homelessness, drug addiction and poverty, all symbols of deteriorating social and economic conditions in the city. The inadequate level of public health resources devoted to TB has also contributed to its spread. Still, even with these factors, it is questionable whether the escalating number of TB cases in this country would have occurred without the reservoir of immunosuppressed persons, who are less resistant to the disease, created by the AIDS epidemic. The fear and urgency of this public health crisis, which has been emerging since the beginning of the last decade, are fueled by the rise of TB strains resistant to the first-line drugs and by the disease’s contagiousness.