Directly observed therapy improves tuberculosis care

Actual cases show that directly observed therapy (DOT) works with tuberculosis patients--and while DOT may increase the short-term cost of care, in the long term DOT can deter other costs.

Comparison of sputum induction with fiber-optic bronchoscopy in the diagnosis of tuberculosis

Microbiologic confirmation of pulmonary tuberculosis among patients whose sputum smear is negative is increasingly important because of greater incidence among immunocompromised hosts and emergence of drug-resistant strains. We prospectively compared sputum induction to fiber-optic bronchoscopy in the diagnosis of such patients. Consecutive patients referred for investigation of possible active pulmonary tuberculosis underwent sputum induction with hypertonic saline delivered by an ultrasonic nebulizer between 2 and 48 h before transnasal fiber-optic bronchoscopy. All specimens were examined for acid-fast bacilli with fluorescent microscopy and cultured for mycobacteria. Clinical information was abstracted from patient records, and X-rays were reviewed by two blinded readers. Among 101 participants, sputum induction was well-tolerated without complications and provided adequate samples in 93. Sensitivity of direct acid-fast bacilli smear of specimens from both techniques was low. Sensitivity and negative predictive value of culture from bronchoscopy specimens was 73% and 91% compared with 87% and 96%, respectively, for sputum induction when a specimen was obtained. Direct costs for bronchoscopy totaled Canadian $187.60 compared with Canadian $22.22 for sputum induction. Sputum induction was well-tolerated, low-cost, and provided the same, if not better, diagnostic yield compared with bronchoscopy in the diagnosis of smear-negative pulmonary tuberculosis.

Health-care expenditures for tuberculosis in the United States

BACKGROUND

The resurgence of tuberculosis (TB) and the increase in multidrug-resistant TB prompted this study, which estimates direct expenditures for TB treatment and public health activities in the United States.

METHODS

This retrospective cost of illness study estimated 1991 direct expenditures for TB-related outpatient and inpatient diagnosis and treatment, screening, preventive therapy, contact investigations, surveillance, and outbreak investigations. Existing databases at the Centers for Disease Control and Prevention (Atlanta, Ga) and the Codman Research Group, Lebanon, NH, were supplemented by surveys of state and local TB programs and interviews of organizations that conduct large-scale screening. No estimates of indirect costs were made.

RESULTS

The direct medical expenditures for TB in 1991 were estimated at $703.1 million. This cost includes $423.8 million for inpatient care, $182.3 million for outpatient care, $72.1 million for screening, $3.4 million for contact investigations, $17.9 for preventive therapy, and $3.6 million for surveillance and outbreak investigations. Sensitivity analyses yielded a range of expenditures between $515.7 million and $934.5 million.

CONCLUSIONS

Treatment accounted for more than 86% of all TB-related expenditures; inpatient treatment accounted for 60% of the total. Prevention activities made up only 14% of all costs. Direct medical expenditures may be underestimated because of limitations in the database on hospital expenditures and health department cost-accounting systems and because of the lack of a national database on screening activities. Greater emphasis should be placed on outpatient treatment and prevention in high-risk populations, and improved cost-accounting systems should be developed in state and local health department TB control programs to facilitate economic evaluation and improve the allocation of health dollars.

Tuberculosis surveillance of community hospital employees. A recommended strategy

OBJECTIVE AND METHODS

To suggest a cost-effective strategy with a high degree of surveillance for the transmission of tuberculosis infection to employees in community hospitals. We performed a cost-benefit analysis of tuberculin skin testing over a 4-year period. The setting was a community hospital in Bronx, NY. The subjects consisted of employees of the hospital who were categorized into high-risk employees defined as individuals who worked daily in patient care and low-risk employees defined as those not directly involved in patient care. All cases of tuberculin skin test conversion among employees were reviewed over a 4-year period. The departments involved, total number of employees, chest radiographic findings, and prophylaxis instituted were noted.

RESULTS

The number of employees who were screened over the past 4 years consisted of 897 in 1990, 857 in 1991, 1357 in 1992, and 1316 in 1993. The mean annual conversion rate was 1%, 1.5%, 1.7%, and 1.4% for the 4 years, respectively. Skin test conversions according to job description revealed that of the total number of conversions 42% were from the nursing staff, 6.2% among the physicians and residents, and 52% among the ancillary staff. There was no difference in conversion between medical and nonmedical services such as the gynecology and surgical floors.

CONCLUSION

Since tuberculin conversion rates of high-risk employees and those exposed to infectious tuberculosis cases have been low, we suggested a comprehensive strategy of 6-month tuberculin testing for high-risk employees and yearly testing for low-risk employees and eliminating boosting and repeated testing at 12 weeks in those exposed to infectious cases of tuberculosis.

Follow up of an immunocompromised contact group of a case of open pulmonary tuberculosis on a renal unit

BACKGROUND

The organisation, management, outcome and cost of follow up of a large group of mainly immunocompromised patients and healthcare workers who were exposed to a staff member of a London renal unit with smear positive pulmonary tuberculosis are described.

METHODS

Following British Thoracic Society (BTS) guidelines, 576 close contacts were identified and divided into three groups: (1) 303 renal patients including 61 with renal transplants; (2) 90 surgical patients; and (3) 183 staff members. Screened contacts were interviewed, completed a symptoms questionnaire, and were offered a chest radiograph and Heaf or Mantoux test if appropriate with referral to a chest physician if required.

RESULTS

Overall, 524 (85%) living contacts have been screened: 243 (97%) renal (first screening), 63 (70%) surgical, and 135 (74%) staff contacts. Thirty one transplant patients were prescribed isoniazid chemoprophylaxis. Fifty two renal patients had died before screening and 11 deaths occurred after first interview. One case of tuberculosis epidemiologically related to the index case was diagnosed on clinical criteria. A review of the case records and/or death certificates and entries on to tuberculosis registers indicated no further cases. The cost of the investigation was estimated to be approximately franc25 000, or franc44 per contact screened, with staff costs comprising 79% of the total.

CONCLUSIONS

Undiagnosed tuberculosis in healthcare workers working with immunosuppressed patients can lead to large and expensive follow up studies. The applicability of the 1990 and 1994 BTS guidelines to the investigation of tuberculosis in an immunocompromised nosocomial group, and the role of the infection control doctor and the consultant in Communicable Disease Control in overlapping nosocomial and community incidents, are discussed.

Cost-effectiveness of chemotherapy for sputum smear-positive pulmonary tuberculosis in Malawi, Mozambique and Tanzania

The cost-effectiveness of chemotherapy for pulmonary sputum smear-positive tuberculosis was examined in the national tuberculosis control programmes of Malawi, Mozambique and Tanzania. In these three programmes, routine cure rates have exceeded 80 per cent. Average, average incremental and marginal unit costs for standard, short-course and retreatment regimens with and without hospitalization have been measured. The average incremental cost per year of life saved through chemotherapy ranged from US $0.90-3.10. In all conditions, short-course chemotherapy is preferable to standard 12-month chemotherapy. When hospitalization during the intensive phase of chemotherapy increases the cure rate by 10-15 percentage points, it can be relatively cost-effective. Analysing the cost-effectiveness of short-course and standard chemotherapy, where the depth of the margin of benefit is different, illustrates some of the dangers of simplistic use of cost-effectiveness ratios.

Florida's tuberculosis epidemic. Public health response

Florida ranked fourth in the nation with 1,707 tuberculosis cases reported in 1992 for a rate of 12.7 per 100,000 population. Thirteen percent of these patients had AIDS. Recent cases in prisons, shelters, hospitals and schools have stimulated interest and media coverage. Resurgence of strains of multiple-drug resistant tuberculosis is a serious concern. The Florida Department of Health and Rehabilitative Services, in collaboration with allied agencies, has utilized several initiatives in response. The most significant, Tuberculosis Epidemic Containment Plan, details intervention strategies needed to eliminate TB in the state by the year 2010. Successful implementation depends upon local TB prevention and control coalitions that include private and public sector providers.

Pitfalls in the care of patients with tuberculosis. Common errors and their association with the acquisition of drug resistance

OBJECTIVE

To determine, among a group of patients with multidrug-resistant pulmonary tuberculosis, whether there had been management practices that deviated from established guidelines, and whether these decisions were associated with the acquisition of multidrug resistance and adverse medical sequelae.

DESIGN

Case series.

SETTING

Referral center.

PATIENTS

All patients with pulmonary tuberculosis admitted to the National Jewish Center for Immunology and Respiratory Medicine in 1989 through 1990.

INTERVENTIONS

The records of all patients referred to this institution for the treatment of tuberculosis in 1989 through 1990 were reviewed to ascertain the nature of management decisions that might have been associated with the acquisition of drug resistance.

MAIN OUTCOME MEASURES

Standards of practice as defined by the American Thoracic Society, the Centers for Disease Control and Prevention, and the American College of Chest Physicians were compared with these management decisions to determine whether "errors" had been made, resulting in treatment failure and the development of acquired drug resistance.

RESULTS

Among the 35 study patients, errors were detected in the management decisions in 28; there was an average of 3.93 errors per patient. The most common errors were the addition of a single drug to a failing regimen, failure to identify preexisting or acquired drug resistance, initiation of an inadequate primary regimen, failure to identify and address noncompliance, and inappropriate isoniazid preventive therapy. The multidrug resistance acquired through the errors resulted in prolonged hospitalizations, treatment with more toxic drugs, and high-risk resectional surgery. The costs for this "salvage therapy" were extraordinary, averaging $180,000 per patient.

CONCLUSIONS

Aggressive professional education, tighter control on the provisions of care for tuberculosis patients, and the committing of additional resources to tuberculosis control programs are vital in improving the care of tuberculosis patients and limiting the development of acquired drug resistance.

Cost-effectiveness analysis of three short-course anti-tuberculosis programmes compared with a standard regimen in Thailand

The present study was undertaken to compare the efficacy, effectiveness and cost-effectiveness of three short-course regimens with a standard programme for treatment of new tuberculosis (TB) cases. The study was conducted by reviewing the results of TB treatment in 1642 newly diagnosed, sputum positive pulmonary TB patients with four drug regimens carried out in five zonal TB centres throughout Thailand in 1987-1989. Analysis showed that the three-short-course regimens were more cost-effective than the standard regimen from the perspective of both providers and patients. Among the three short-course programmes, isoniazid, rifampicin and pyrazinamide for 2 months, followed by isoniazid and rifampicin twice a week for 4 months was the most cost-effective (US$70.24/effectiveness from providers' perspective and US$103.31/effective from patients' perspective). The result of this study throws some light on the development of new policy options, with scarce health resources, in the treatment of tuberculosis by the National Tuberculosis Programme in Thailand.

Use of BCG vaccine in shelters for the homeless. A decision analysis

As a result of many interacting variables, including crowded shelters and limited access to health care, homeless persons are at high risk for tuberculosis. Using traditional approaches, control of tuberculosis in this population has been difficult. Decision analysis was used to investigate the cost-effectiveness of BCG (bacillus Calmette-Guérin) vaccination in persons attending homeless shelters. This vaccination was cost-effective over a wide range of assumptions. Using conservative assumptions, a vaccine that was at least 40 percent effective would result in a net cost savings. If the efficacy of the vaccine were 50 percent, $4,000 would be saved, 12 life-years gained, and 23 cases of active tuberculosis prevented for every 1,000 persons vaccinated. Further study of the BCG vaccine in homeless persons and other populations at risk is warranted.

Improving the quality of healthcare delivery to homeless tuberculosis patients: a new approach

"Doing things the same old way" can lead to complacency and eventually to a breakdown in the healthcare system. Such is the case with the deadly disease tuberculosis (TB). While TB was thought to be a disease of the past, the United States is experiencing an alarming rise in the incidence of the disease, especially among those least likely to get help or to stick with a treatment program. This article explores a more creative approach for reaching out to treat homeless people who have TB.

[Hospitalization of tuberculosis patients in Swiss hospitals in 1990]

Despite a wide spectrum of efficient chemotherapies, tuberculosis patients even today are often given inpatient treatment. This fact is shown by the MSV, the Medical Statistics of VESKA (Association of Swiss Hospitals), which is coded according to the ICD key and numbers tuberculosis forms from 010 to 018. The MSV figures for the year 1990 in its associated clinics are: total diagnoses 685,204, principal diagnoses 346,671, number of nursing days 4,613,737 and average stay 13.3 days. At the same time, the following data were registered: total of 1009 hospitalizations with a tuberculosis diagnosis, including 555 patients with a principal diagnosis of tuberculosis. Hospitalizations due to tuberculosis as the principal diagnosis account for 13,995 nursing days, which corresponds to 0.3% of the total. The average hospital stay lasts 25.2 days. In both diagnosis groups, first place is occupied by pulmonary tuberculosis (011) with 67.0% and 70.5% respectively, and among the extrathoracic forms 013-018, urogenital tuberculosis (016) with 6.3% principal diagnosis. The cases with the principal diagnosis of tuberculosis generate (partly calculated, partly estimated) hospital costs of approximately Sfr. 4.9 million and a paid wage total of some Sfr. 1.5 million. In the case of secondary tuberculoses of the 2nd and 3rd position in the statistics, analogous sums of an estimated total of Sfr. 2.4 million are added. It is therefore safe to say that tuberculosis is still not without financial significance in Switzerland.(ABSTRACT TRUNCATED AT 250 WORDS)

Anti-tuberculosis programs in Thailand: a cost analysis

The standard regimen, a combination of isoniazid and thiacetazone, which has been used for treatment of tuberculosis (TB) in Thailand for the past 20 years is inexpensive, but possesses a high degree of toxicity and requires 18-24 months of continuous treatment, resulting in poor compliance and a low success rate of treatment. The more efficacious short-course chemotherapy introduced into the National Tuberculosis Program in 1985 is limited by the high costs of drugs. However, the cost of providing care is not limited only to drug costs but also includes other services costs. The present study was undertaken to compare the total provider costs of 3 short-course regimens with that of the standard program in the treatment of newly diagnosed pulmonary TB. Data were collected at 4 zonal TB centers through out Thailand in 1987-1988. Analysis showed that the 3 short-course regimens had lower costs than the standard regimen from the provider perspective. Among these 3 regimens that of isoniazid, rifampicin and pyrazinamide for 2 months, followed by isoniazid and rifampicin twice a week for 4 months had the lowest costs (Baht 1,499). Despite the lowest drug cost (B 431) of the standard regimen, the total provider costs were the highest (B 2,541) due to the highest routine service cost of B 2,066. Thus to determine the cost of a disease requires consideration of both drug costs and also other cost components.

[The hospital costs for patients with human immunodeficiency virus infection]

BACKGROUND

The economic issues derived from the care of HIV patients are increasingly more important and they affect to different levels of sanitary assistance. In Spain these costs are not always evaluated and there is no information about the efficiency of inverted resources.

METHODS

The cost of mean hospital stay due to HIV (+) patients has been estimated and compared with two infectious diseases: respiratory tuberculosis (TBC) and viral hepatitis (VH), and we have analyzed their evolution in the period studied. The study was conducted between July 1st 1987 and December 31st 1989 at the Infectious Unit for the three mentioned diseases.

RESULTS

The 227 included patients originated 292 hospitalizations. The total cost derived from hospital stays was 169,466,323 ptas. The mean cost for HIV(+) patients was 576,184 ptas, for TBC patients 1,111,115 ptas, and for VH 443,219 ptas. The number of HIV(+) stays has increased each year.

CONCLUSIONS

The observed results suggest that it could be interesting to think about new systems of inpatient care.

Cost effectiveness of chemotherapy for pulmonary tuberculosis in three sub-Saharan African countries

The value of programmes to control pulmonary tuberculosis in developing countries remains the subject of debate. We have examined the cost-effectiveness of chemotherapy programmes for the control of pulmonary sputum-smear-positive tuberculosis in Malawi, Mozambique, and Tanzania. Effective cure rates of 86-90% were achieved with short-course chemotherapy and of 60-66% with standard chemotherapy. The average incremental costs per year of life saved were US $1.7-2.1 for short-course chemotherapy with hospital admission, $2.4-3.4 for standard chemotherapy with hospital admission, $0.9-1.1 for ambulatory short-course chemotherapy, and $0.9-1.3 for ambulatory standard chemotherapy. Chemotherapy for smear-positive tuberculosis is thus cheaper than other cost-effective health interventions such as immunisation against measles and oral rehydration therapy. Because the greatest benefit of chemotherapy is reduced transmission of the bacillus, treating HIV-seropositive, tuberculosis smear-positive patients would be only slightly less cost-effective than treating HIV-seronegative, tuberculosis-smear-positive patients.

[The cost of pulmonary tuberculosis treatment in the Congo]

The author assesses the cost of treating pulmonary tuberculosis. This is extremely high because there is no standard treatment. The 15 months--course used in the Congo is 2.5 times more expensive than the standardized regimen using WHO drug prices. The author recommends the institution of a better system of treatment of tuberculosis in order to economise and to assure a regular supply of medicines.

A cost-effectiveness analysis of the routine use of isoniazid prophylaxis in patients with a positive Mantoux skin test

The role of isoniazid prophylaxis in low-risk patients with positive Mantoux skin tests has recently been questioned. In general, recent research has focused on the risk/benefit ratio. We, therefore, decided to extend these data and apply a cost-effectiveness analysis of the routine use of isoniazid prophylaxis from a societal perspective. Costs per case prevented were calculated for a 20-, 50-, and 70-yr-old low-risk patient who had a positive Mantoux test with base, high, and low costings. Rates were also calculated based on the use of direct costs alone and direct and indirect costs combined. Costs varied from Canadian $8,586.00 in a 20-yr-old patient to $40,102.00 in a 70-yr-old patient per case prevented based on direct costs with costs ranging from $3,236.00 to $11,320.00 with both direct and indirect costs included. These costs could be considered reasonable from a societal perspective but do not address the issue of any increased life expectancy resulting from chemoprophylaxis.

A 62-dose, 6-month therapy for pulmonary and extrapulmonary tuberculosis. A twice-weekly, directly observed, and cost-effective regimen

STUDY OBJECTIVE

To evaluate the efficacy and toxicity of a 62-dose, four-drug, 6-month, and directly observed regimen for treatment of pulmonary and extrapulmonary tuberculosis.

DESIGN

An open, nonblinded clinical trial, with intended follow-up of patients for 36 months after the completion of therapy.

SETTING

A metropolitan tuberculosis clinic in a public health department.

PATIENTS

From March 1981 through April 1989, we enrolled 160 patients with suspected or known tuberculosis; 35 of these patients were excluded from the analysis.

INTERVENTIONS

Isoniazid, rifampin, pyrazinamide, and streptomycin were administered daily for 2 weeks; these drugs were then given in higher doses twice weekly for 6 weeks, followed by isoniazid and rifampin twice weekly for 6 weeks, followed by isoniazid and rifampin twice weekly for 18 weeks. A total of 62 doses were administered, and all therapy was directly observed by a nurse or an outreach worker.

MEASUREMENTS AND MAIN RESULTS

Of the 125 evaluable patients, 101 (81%) had pulmonary tuberculosis, 7 (6%) had both pulmonary and extrapulmonary involvement, and 17 (13%) had extrapulmonary disease only. Seventy-one (57%) patients had a history of recent alcoholism. There were two relapses (1.6% +/- 2.2%), occurring 6 and 56 months after the completion of therapy. The time at which sputum samples became culture negative in pulmonary patients ranged from 1 to 19 weeks (median, 4.6 weeks); 40% +/- 9.6% of patients were culture-negative after 4 weeks of therapy, 75% +/- 8.5% after 8 weeks, 94% +/- 4.7% after 12 weeks, 97% +/- 3.3% after 16 weeks, and 100% after 20 weeks. Adverse drug reactions included hyperuricemia (greater than 178 mumol/L [3 mg/dL] above normal) secondary to pyrazinamide in 80 patients (64%), twofold or greater elevations of aspartate aminotransferase in 21 patients (17%), 1.5-fold or greater elevations of alkaline phosphatase in 33 patients (27%), cutaneous abnormalities in 8 patients (6%), nausea in five patients (4%), and dizziness in 1 patient (1%).

CONCLUSIONS

This 62-dose, largely twice-weekly tuberculosis treatment regimen is efficacious and relatively nontoxic and is especially useful for patients in whom directly observed therapy is indicated.

[The anti-tuberculosis campaign throughout the world: strategies and actions in the field]

Tuberculosis will remain one of the main health concerns in the world for the next ten years. Economic crises in the Third World and AIDS epidemics in Africa have contributed to maintain a high level prevalence of tuberculosis in the poorest countries. Failures of tuberculosis control measures are due more often to mistakes in health planning and in health manpower training than to the lack of technologies. Short-course chemotherapy is an important technological achievement for the treatment of tuberculosis, but case holding and case finding are not efficient in several high-prevalence countries. BCG vaccination and chemoprophylaxis, especially in immunodeficient children or adults, need more evaluation studies.

Comparison of daily and twice-weekly regimens to treat pulmonary tuberculosis

A randomised controlled trial compared the effectiveness and toxicity in pulmonary tuberculosis of two drug regimens containing rifampicin and isoniazid given daily or twice-weekly for 4 months after a 2-month period of intensive treatment with daily isoniazid, rifampicin, and pyrazinamide. 667 patients with newly diagnosed pulmonary tuberculosis were randomly allocated to continue daily treatment with isoniazid (400 mg) and rifampicin (600 mg) or to twice-weekly treatment with isoniazid (900 mg) and rifampicin (600 mg). 544 of the 667 patients (81%) completed the 6-month course (287 of 337 [85%] treated daily and 257 of 330 [79%] treated twice-weekly). Drug toxicity was not a great problem; the treatment was permanently discontinued in only 2% of patients. There was no significant difference at the end of months 5 and/or 6 of chemotherapy between the groups treated daily and twice-weekly in the proportions with bacteriological failure (at least one positive sputum culture with more than 20 colonies) or who had died from tuberculosis (17 [6%] vs 10 [3%]). Nor was there a significant difference in the relapse rate (17 [7%] treated daily vs 10 [4%] treated twice-weekly) during follow-up of 12 months. Thus, the twice-weekly regimen was at least as effective as the daily regimen for treatment of pulmonary tuberculosis.