[Principles in the treatment and rehabilitation of patients with tuberculosis]

The etiotropic directionality of scientific searches of the introduction of new antibiotics and therapy regimens fails to substantially increase the efficiency of treatment of tuberculosis. The use of the strict multicomponent chemotherapy standards proposed for the treatment of different forms of tuberculosis with Mycobacterium tuberculosis (MBT) being kept in mind does not reduce the number of progressing processes. Etiotropic chemotherapy with the standard regimens of different combinations and intensity, which is aimed at suppressing MBT viability should be always combined with the methods rehabilitating the physiological processes of cell-tissue masses involved into a specific tuberculous process. The basic methods are improvement of the gas-exchange function of respiratory organs; balanced diet; widely use of natural climatic and artificial physical factors. The combined use of etiotropic and rehabilitative therapies accelerates reparative processes and substantially reduces the time of involution of tuberculous inflammation and the patient's recovery. Thus, out of 258 patients with acutely progressive tuberculosis, their use ceased bacillar isolation in 84.2%, by closing decay cavities in 79.8% whereas out of 284 patients receiving the routine chemotherapy regimens, these figures were 57.3 and 40.8%, respectively. The efficient use of general biological principles in the treatment and rehabilitation of patients with active tuberculosis can reduce the time of inpatient treatment by 1.5-2 times and accordingly economic expenses on the cure of a patient.

The cost structure of lung tuberculosis in Germany

Although the total number appears to be decreasing, 7,886 new cases of tuberculosis (TB) were reported in Germany in 2001. Previous American publications reveal considerable differences in the costs caused by the disease. On the basis of the therapy guidelines of the Deutsches Zentralkomitee zur Bekampfung der Tuberkulose (DZK), this study estimates the mean direct outpatient and combined in- and outpatient costs of lung TB, together with the indirect costs of the disease on the basis of the most recent official health statistics. According to this, the mean outpatient costs per case were <euro>1,226 (adults) and <euro>785 (children under 15 years of age). The mean combined inpatient/outpatient costs ranged from <euro>14,301 (adults) to <euro>16,634 (children). These are joined by the mean costs of sick benefit amounting to <euro>2,088. The mean indirect costs per case were <euro>2,461. Consistent implementation of the recommendations of the German DZK is still necessary in order to reduce the significant economic impact of TB disease resulting in high health and socioeconomic costs.

Economic evaluation of the use of PCR assay in diagnosing pulmonary TB in a low-incidence area

To determine whether polymerase chain reaction (PCR) testing in the initial diagnosis of pulmonary tuberculosis (TB) is cost-effective in a low-prevalence population, an economic evaluation was carried out between the smear and culture (NOPCR) and smear, culture and PCR (+PCR) strategies. A decision tree model based on retrospective laboratory data was developed to assess the strategies of testing patients with suspicion of TB. Direct healthcare costs prior to confirmation of TB or nontuberculous mycobacteria by PCR or culture were included. Effectiveness was measured by the probability of correct treatment and isolation decisions. In the baseline situation NOPCR costs Euro 29.50 less than the +PCR strategy per patient tested. According to sensitivity analyses, reducing PCR test price, shortening test performance time or increasing the proportion of smear-positive patients in the tested population would contribute to cost savings with the +PCR strategy. Routine polymerase chain reaction testing of all specimens from suspected tuberculosis patients in a low-prevalence population was not cost-saving. When the polymerase chain reaction assay was applied only to smear-positive sputum specimens, the smear and culture strategy was clearly dominated by it, i.e. the polymerase chain reaction smear-positive sputum strategy was less costly and more effective in producing correct treatment decisions and isolations.

The natural history of childhood intra-thoracic tuberculosis: a critical review of literature from the pre-chemotherapy era

The pre-chemotherapy literature documented the natural history of tuberculosis in childhood. These disease descriptions remain invaluable for guiding public health policy and research, as the introduction of effective chemotherapy radically changed the history of disease. Specific high-risk groups were identified. Primary infection before 2 years of age frequently progressed to serious disease within the first 12 months without significant prior symptoms. Primary infection between 2 and 10 years of age rarely progressed to serious disease, and such progression was associated with significant clinical symptoms. In children aged >3 years the presence of symptoms represented a window of opportunity in which to establish a clinical diagnosis before serious disease progression. Primary infection after 10 years of age frequently progressed to adult-type disease. Early effective intervention in this group will reduce the burden of cavitating disease and associated disease transmission in the community. Although the pre-chemotherapy literature excluded the influence of human immune deficiency virus (HIV) infection, recent disease descriptions in HIV-infected children indicate that immune-compromised children behave in a similar fashion to immune immature children (less than 2 years of age). An important concept deduced from the natural history of tuberculosis in childhood is that of relevant disease. Deciding which children to treat may be extremely difficult in high-prevalence, low-resource settings. The concept of relevant disease provides guidance for more effective public health intervention.

[Diffculties in medico-social management of tuberculosis in Pneumology Departement of Fann University Teaching Hospital]

This prospective study included all the patients who, during the month of September 1995, were admitted for pulmonary baclliferous tuberculosis to the Pneumology Clinic of the Fann University Hospital, Dakar. The patient's escorts and the health personnel were also included in this study. The aim of the study was to find the different socio-economic and health factors impeding the hospitalization of tuberculosis patients in the Pneumology Clinic of Fann University Hospital. 22 members of the health team, 209 patients aged between 15 and 65 years and 209 escorts were interviewed. Out of the 10% of tuberculosis patients with HIV seropositivity, 80% admitted not to have informed their spouses of their infection. The decision to be admitted was made by the patient himself in 54.4% of cases and by his family in 45.5% of cases. Late admittance with regards to the beginning of symptoms was due to the recourse to traditional medicine in 43.7% of cases, wrong diagnosis in 24%, ignorance in 19.3% and, in 13% of cases, due to inappropiate anti tuberculosis treatment. Despite the fact that anti tuberculosis medicine was free of charge, each patient or his family spent an average sum of 87,500 CFA F (US dollar 175) for a month's admission (the minimal salary (SMIG) in Senegal is 32,000 CFA F (US dollar 64), and 40% of the patients and escorts had difficulties making this payment. 9 patients were judged to be poor by 25.7% of the patients and 8.7% found relations with the health personnel difficult. The escorts deplored the lack of toilets (only 1 out of 4 was functional), the time worn facilities, the overcrowding as well as the irregularity and poor quality of the hospital meals. The entire health team deplored the lack of adequate personnel and 30% of them deplored the lack of hygiene of some patients and escorts. Taking financial charge of tuberculosis patients at the Pneumology Clinic of the Fann University Hospital requires an increased financial effort from the State (rehabilitation of the facilities, recruitment of medical and paramedical personnel, improved meals) harmonisation on a national scale of anti tuberculosis therapeutic protocoles and an Information-Education-Communication (IEC) programme on tuberculosis and hygiene.

A comprehensive comparison of Ziehl-Neelsen and fluorescence microscopy for the diagnosis of tuberculosis in a resource-poor urban setting

SETTING

Nairobi City Council Chest Clinic, Kenya.

OBJECTIVES

To establish the efficiency, costs and cost-effectiveness of six diagnostic strategies using Ziehl-Neelsen (ZN) and fluorescence microscopy (FM).

DESIGN

A cross-sectional study of 1398 TB suspects attending a specialised chest clinic in Nairobi subjected to three sputum examinations by ZN and FM. Lowenstein-Jensen culture was used as the gold standard. Cost analysis included health service and patient costs.

RESULTS

Of 1398 suspects enrolled, 993 (71%) had a complete diagnostic work-up involving three sputum specimens for ZN and FM, culture and chest X-ray (CXR). Irrespective of whether ZN or FM was used on one, two or three smears, the overall diagnostic process detected 92% culture-positive cases. Different strategies affected the ratio of smear-positive to smear-negative TB; however, FM was more sensitive than ZN (P < 0.001). FM performance was not affected by the patient's HIV status. The cost per correctly diagnosed smear-positive case, including savings, was 40.30 US dollars for FM on two specimens compared to 57.70 US dollars for ZN on three specimens.

CONCLUSION

The FM method used on one or two specimens is more cost-effective and shortens the diagnostic process. Consequently, more patients can be put on a regimen for smear-positive TB, contributing to improved treatment and reducing transmission.

Cost and cost-effectiveness of increased community and primary care facility involvement in tuberculosis care in Lilongwe District, Malawi

SETTING

Lilongwe District, Malawi.

OBJECTIVE

To assess the cost and cost-effectiveness of new treatment strategies for new pulmonary tuberculosis patients, introduced in 1997.

METHODS

For new smear-positive pulmonary patients, two strategies were compared: 1) the strategy used until the end of October 1997, involving 2 months of hospitalisation at the beginning of treatment, and 2) a new decentralised strategy introduced in November 1997, in which patients were given the choice of in- or outpatient care during the first 2 months of treatment. For new smear-negative pulmonary patients, the two strategies compared were 1) the strategy used until the end of October 1997, which did not require any direct observation of treatment (DOT) and 2) a new community-based strategy introduced in November 1997, which required DOT by a community member 'guardian' or a health worker for the first 2 months of treatment. Costs were analysed from the perspective of health services, patients, and the community in 1998 US dollars, using standard methods. Cost-effectiveness was calculated as the cost per patient cured (smear-positive cases) and as the cost per patient completing treatment (new smear-negative cases).

FINDINGS

For new smear-positive patients, the cost per patient treated was dollars 456 with the conventional hospital-based strategy, and dollars 106 with the new decentralised strategy. Costs fell by 54% for health services and 58% for patients. The cost per patient cured was dollars 787 for the conventional hospital-based strategy, and dollars 296 for decentralised treatment. For smear-negative patients, the cost per patient treated was dollars 67 with the conventional unsupervised strategy, and dollars 101 with the community-based DOT strategy. Costs increased for health services, patients and guardians. Cost-effectiveness was similar with both strategies, at around dollars 200 per patient completing treatment. When new smear-positive and new smear-negative patients were considered together, the new strategies were associated with a 50% reduction in total annual costs.

CONCLUSION

There is a strong economic case for expansion of decentralisation and community-based DOT in Malawi. Further investment in training and programme supervision may help to increase effectiveness.

Cost and cost-effectiveness of increased community and primary care facility involvement in tuberculosis care in Machakos District, Kenya

SETTING

Machakos District, Kenya, a rural area 50 km east of Nairobi.

OBJECTIVE

To assess the cost and cost-effectiveness of new treatment strategies for tuberculosis patients, involving decentralisation of care from hospitals to peripheral health units and the community, compared to the conventional approaches to care used until October 1997.

METHODS

Costs were analysed in 1998 US dollars from the perspective of health services, patients, family members and the community, using standard methods. Separate analyses were undertaken for 1) new smear-positive pulmonary patients and 2) new smear-negative and extrapulmonary patients. Cost-effectiveness was calculated as the cost per patient successfully completing treatment (smear-positive cases) and as the cost per patient completing treatment (new smear-negative and extra-pulmonary cases).

FINDINGS

The cost per patient treated for new smear-positive patients was dollars 591 with the conventional hospital-based approach to care, and dollars 209 with decentralised care. Costs fell from all perspectives, and by 65% overall. Cost-effectiveness improved by 66%. The cost per patient treated for new smear-negative/extra-pulmonary patients was dollars 311 with the conventional approach to care, and dollars 197 with decentralised care. Costs fell from all perspectives, and cost-effectiveness improved by 61%.

CONCLUSION

There is a strong economic case for expansion of decentralisation and strengthened community-based care in Kenya. The National Tuberculosis and Leprosy Control Programme will require new funds for start-up training and community mobilisation costs in order to do this.

Cost and cost-effectiveness of community-based care for tuberculosis in Cape Town, South Africa

SETTING

Guguletu and Nyanga areas of Cape Town, South Africa.

OBJECTIVE

To evaluate the affordability and cost-effectiveness of community involvement in tuberculosis (TB) care.

DESIGN

A cost-effectiveness analysis comparing treatment for new smear-positive pulmonary and retreatment TB patients in two similar townships, one providing clinic-based-care with community-based observation options available for its TB patients (Guguletu) and one providing clinic-based care only, with no community-based observation of treatment (Nyanga). Costs were assessed from a societal perspective in 1997 US dollars, and cost-effectiveness was calculated as the cost per patient successfully treated.

RESULTS

TB treatment in Guguletu was more cost-effective than TB treatment in Nyanga for both new and retreatment patients (dollars 726 vs. dollars 1201 and dollars 1419 vs. dollars 2058, respectively). This reflected both lower costs (dollars 495 vs. dollars 769 per patient treated for new cases; dollars 823 vs. dollars 1070 per patient treated for retreatment cases) and better treatment outcomes (successful treatment rate 68% vs. 64% and 58% vs. 52% for new and retreatment patients, respectively). Within Guguletu, community-based care was more than twice as cost-effective as clinic-based care (dollars 392 vs. dollars 1302 per patient successfully treated for new patients, and dollars 766 vs. dollars 2008 for retreatment patients), for similar reasons (e.g., for new cases, dollars 314 vs. dollars 703 per patient treated, successful treatment rate 80% vs. 54%).

CONCLUSION

Community involvement in TB care can improve the affordability and cost-effectiveness of TB treatment in urban South Africa. Expansion in the Western Cape and in similar areas of the country is worthy of serious consideration by planners and policy-makers.

Cost and cost-effectiveness of community-based care for tuberculosis patients in rural Uganda

SETTING

Kiboga district, a rural area in Central Uganda.

OBJECTIVE

To assess the cost and cost-effectiveness of community-based care for new smear-positive pulmonary tuberculosis patients compared with conventional hospital-based care.

METHODS

Costs were analysed from the perspective of health services, patients, and community volunteers in 1998 US dollars, using standard methods. Cost-effectiveness was calculated as the cost per patient successfully treated.

FINDINGS

The cost per patient treated for new smear-positive patients was dollars 510 with the conventional hospital-based approach to care (dollars 419 for the health system and dollars 91 for patients), and dollars 289 with community-based care (dollars 227 for health services, dollars 53 for patients and dollars 9 for volunteers). Important new costs associated with community-based care included programme supervision (dollars 18 and dollars 9 per patient at central and district levels, respectively) and training (dollars 18 per patient). The cost per patient successfully treated was dollars 911 with the hospital-based strategy and dollars 391 with community-based care, reflecting both lower costs and higher effectiveness (74% vs. 56% successful treatment rate) with community-based care. Length of hospital stay fell from an average of 60 to 19 days.

CONCLUSION

There is a strong economic case for the implementation of community-based care in Uganda.

Cost-effectiveness of home-based care versus hospital care for chronically ill tuberculosis patients, Francistown, Botswana

SETTING

Francistown, Botswana, 1999.

OBJECTIVE

To determine the affordability and cost-effectiveness of home-based directly observed therapy (DOT) compared to hospital-based DOT for chronically ill tuberculosis (TB) patients, and to describe the characteristics of patients and their caregivers.

DESIGN

Costs for each alternative strategy were analysed from the perspective of the health system and caregivers, in 1998 US dollars. Caregiver costs were assessed using a structured questionnaire administered to a sample of 50 caregivers. Health system costs were assessed using interviews with relevant staff and documentary data such as medical records and expenditure files. These data were used to calculate the average cost of individual components of care, and, for each alternative strategy, the average cost per patient treated. Cost-effectiveness was calculated as the cost per patient compliant with treatment. The characteristics of caregivers and patients were assessed using demographic and socio-economic data collected during interviews, and medical records.

RESULTS

Overall, home-based care reduced the cost per patient treated by 44% compared with hospital-based treatment (dollars 1657 vs. dollars 2970). The cost to the caregiver was reduced by 23% (dollars 551 vs. dollars 720), while the cost to the health system was reduced by 50% (dollars 1106 vs. dollars 2206). The cost per patient complying with treatment was dollars 1726 for home-based care and dollars 2970 for hospitalisation. Caregivers were predominantly female relatives (88%), unemployed (48%), with primary school education or less (82%), and with an income of less than dollars 1000 per annum (71%). Of those patients with an HIV test result, 98% were HIV-positive.

CONCLUSION

Home-based care is more affordable and cost-effective than hospital-based care for chronically ill TB patients, although costs to caregivers remain high in relation to their incomes. Structured home-based DOT should be included as a component of the National Tuberculosis Control Programme in Botswana.

Costs and effectiveness--the impact of economic studies on TB control

This paper assesses the impact of economic studies on TB control during the period 1982-2002, with a focus on cost and cost-effectiveness studies. It begins by identifying broad categories of economic study relevant to TB control, and how economic studies can, theoretically, have an impact on TB control. The impact that economic studies of TB control have had in practice is then analysed through a systematic review of the literature on cost and cost-effectiveness studies related to TB control, and three case studies (one cost study and two cost-effectiveness studies). The results show that in the past 20 years, 66 cost-effectiveness studies and 31 cost studies have been done on a variety of important TB control topics, with a marked increase occurring after 1994. In terms of numbers, these studies have had most potential for impact in industrialized countries, and within industrialized countries are most likely to have had an impact on policy and practice related to screening and preventive therapy. In developing countries with a high burden of tuberculosis, far fewer studies have been undertaken. Here, the main impact of economic studies has been influencing policy and practice on the use of short-course chemotherapy, justifying the implementation of community-based care in Africa, and helping to mobilize funding for TB control based on the argument that short-course treatment for TB is one of the most cost-effective health interventions available. For the future, cost and cost-effectiveness studies will continue to be relevant, as will other types of economic study.

[Ways of enhancing the efficiency of tuberculosis-controlling measures and reducing their cost]

As of now, there are prerequisites for enhancing the efficiency of tuberculosis-controlling measures and for reducing their cost by utilizing material and personnel resources in priority areas. These include: to detect patients with tuberculosis by using current computer technologies, to apply digital X-ray plants, to recruit general practitioners for preventive measures against tuberculosis, to reduce the cost of treatment in patients with tuberculosis by decreasing hospital stay. Introduction of currently available procedures substantially lowers the cost of antituberculous aid and enhances its efficiency.

Trends in the use of antituberculosis drugs in Spain 1993-1998

PURPOSE

To determine and analyse the trends in the use of antituberculosis agents in Spain during 1993-1998.

METHODS

Pharmacoepidemiological study on the use of antituberculosis drugs using the data from prescriptions redeemed by the National Health Service.

RESULTS

The use of antituberculosis drugs over the study period was 6,271,909 defined daily doses (DDDs) in 1993, which fell to 4,433,066 DDDs in 1998. A decreasing trend was thus seen, involving a 29.6% drop between the beginning and the end of the study period. The use of daily doses per 1000 inhabitants was 0.42 in 1993 and 0.30 in the end of the period in 1998. The drug most used during the period of study was Rifinah. In 1993, its percentage of use was 41.2, which then decreased to 34.5 in 1998. After this drug, Rifampicin and Etambutol were those with the highest percentages of use, with values close to 18 and 15, respectively. Regarding estimation of tuberculosis, the prevalence was 25.25 cases per 100,000 inhabitants in 1993 and 16.62 in 1998. A decrease of 23.1% occurred in the cost in pesetas between 1993 and 1998.

CONCLUSIONS

Drug's combinations are the most common therapy for tuberculosis and there were important differences between regions. The highest estimation of this disease is in the northwest region of Spain.

[Pharmacoeconomic model of the use of rifabutin in new cases of pulmonary tuberculosis]

The formalized procedures to commensurate the results and expenditures were used to make a comprehensive evaluation of the clinical efficiency and economical expediency of purposeful application of rifabutin in new cases of disseminated and destructive pulmonary tuberculosis.

Tuberculosis treatment in complex emergencies: are risks outweighing benefits?

Tuberculosis (TB) is a major public health problem in complex emergencies. Humanitarian agencies usually postpone the decision to offer TB treatment and opportunities to treat TB patients are often missed. This paper looks at the problem of tuberculosis treatment in these emergencies and questions whether treatment guidelines could be more flexible than international recommendations. A mathematical model is used to calculate the risks and benefits of different treatment scenarios with increasing default rates. Model outcomes are compared to a situation without treatment. An economic analysis further discusses the findings in a trade-off between the extra costs of treating relapses and failures and the savings in future treatment costs. In complex emergencies, if a TB programme could offer 4-month treatment for 75% of its patients, it could still be considered beneficial in terms of public health. In addition, the proportion of patients following at least 4 months of treatment can be used as an indicator to help evaluate the public health harm and benefit of the TB programme.

Hospital costs of high-burden diseases: malaria and pulmonary tuberculosis in a high HIV prevalence context in Zimbabwe

This paper explores the measurement of hospital costs and efficiency in a context where data is scarce, incomplete or of poor quality. It argues that there is scope for using tracers to examine and compare hospital cost structures and relative efficiency in such contexts. Two high-burden diseases, malaria and pulmonary tuberculosis, are used as tracers to calculate the average costs of inpatient care at selected tertiary hospitals. This study shows that it is feasible to prospectively collect cost data for specific diseases and explore in detail both patient cost distribution and susceptible areas for efficiency improvement. The present study found that the critical source of efficiency variation in public hospitals in Zimbabwe lies in the way hospital beds are used.

Tuberculose em internamento: avaliação de custos

OBJECTIVE

To calculate the costs of in hospital tuberculosis treatment and to compare the estimated charges of multidrug-resistant tuberculosis (MDR-TB) and drug susceptible tuberculosis patients (TB).

DESIGN

Descriptive study.

SETTING

Tuberculosis Unit (Pulido Valente Hospital), Lisbon, Portugal.

METHODS

The records of all TB patients discharged between January and December 2000 were reviewed. The cost analysis was conducted by using the hospital cost accounting system data and the charges approved by the national public health system. The main outcome measures were the following costs: 1) laboratory and ancillary services, 2) medication and 3) other direct and indirect components.

RESULTS

The 116 study patients were divided into 3 groups: HIV/TB-48 (41.4%), TB 62 (53.4%) and MDR-TB-6 (5.2%). The estimated cost of treatment for all patients was PTE 213,732.769, but only 42% was covered by diagnosis-related groups financing system. In the MDR-TB group, the median cost per day (PTE 7,531) and the median cost per episode (PTE 316,593) were significantly higher comparing with the TB group, regarding laboratory services and medication items.

CONCLUSIONS

The hospital care budget based on the diagnosis-related groups financing system, accounted for less than half the estimated costs of tuberculosis in-patients. Also, in regarding tuberculosis the diagnosis-related groups system does not account for a major confounder like MDR-TB, which has an huge impact on the length of hospital stay and increasing laboratory and medication costs.

[On grouping the contingents of tuberculosis dispensaries]

The contingents followed up at the dispensaries in the Ukraine are analyzed. These include as high as 15.42% of patients with tuberculosis, 5.03% with questionable tuberculosis, 67.13% with inactive tuberculosis or infections, and 12.42% of persons contacting with patients. A total of 4.84% of the appropriations are used to follow up the contingents. A new procedure for grouping TB dispensary contingents is proposed.

[The cost of treatment in new case and multidrug resistant case in pulmonary tuberculosis]

The treatment of multidrug-resistant pulmonary tuberculosis (MDR-Tbc) is quite difficult, and the disease has high morbidity and mortality rates. This study was designed to compare the costs of treatment in new tuberculosis (new-Tbc) cases and MDR-Tbc cases. Data base of the study was composed of the data from therapy principles of new-Tbc cases and MDR-Tbc, and official directives and price lists of Turkish Pharmacology Society in 2001 fiscal year regulating treatment costs. For new-Tbc cases, the treatment cost included expanses for 20 days of hospitalisation, one month work loss and six months drug supply and laboratory costs; for MDR-Tbc cases, it was comprised by expenses for seven months hospitalisation in average, 12 months work loss, 24 months drug supply and laboratory costs, and probable surgical interventions and post-operative intensive care. The service of hospital stuff and medical equipment provided was disregarded. The cost analyses was calculated as charge price of American dollars ($) dated 14.09.2001. It was found that the cost of therapy for new-Tbc cases and MDR-Tbc cases were 1134.89 $ and 17529.15 $, respectively. In MDR-Tbc cases, the costs of hospitalisation, work loss, drug therapy and laboratory procedures were 10.5, 12, 98.7 and 5.3 times higher respectively, when compared with those of new-Tbc. The cost of thoracotomy for one patient including the cost for 10 days period of post-operative care in intensive care unit was 391.93 $. The treatment of MDR-Tbc has a high cost, and 16 new-Tbc cases can be treated with the same cost in our country. In conclusion, we think that successful treatment strategies for both new-Tbc cases and MDR-Tbc cases will lower the cost of tuberculosis treatment.