Direct and indirect patient costs of tuberculosis care in India

OBJECTIVE

To synthesise the evidence for estimating the direct and indirect patient costs of drug-sensitive and drug-resistant tuberculosis care in India.

METHOD

PubMed, Embase, Web of Science, IndMED and Google Scholar were searched for studies conducted in India between 2000 and 2018 and published in English. The search terms were "tuberculosis" AND "costs" (cost Analysis, economics, cost of illness, health care costs, health expenditures, direct service costs, catastrophic cost) AND "India". The cost of TB care was from the patient's perspective. Data regarding costs were extracted, indexed to the year 2018 using cumulative inflation rate and converted to US dollars at the exchange rate of 2018.

RESULTS

Thirteen studies were included in this review. The mean (unweighted) total cost incurred by patients being treated for drug-sensitive TB in a public health facility was $ 235.00 (SD- 222.10), and the median of means was $ 170.60 (range - 43.70-718.40). The mean direct cost was 45.5% of the total cost. Only one study, which was conducted in a private facility, reported the mean total cost for drug-resistant TB as $ 7778.04. Catastrophic cost (total cost ≥ 20% of the total annual household income) was experienced by 7% to 32.4% of drug-sensitive TB patients and by 68% of drug-resistant TB patients.

CONCLUSION

Despite free diagnostic and treatment services provided under the Revised National Tuberculosis Control Programme, the patient cost of tuberculosis care is high. Relevant studies vary widely in methodology and cost reporting.

Economic evaluations of onchocerciasis interventions: a systematic review and research needs

OBJECTIVE

To provide a systematic review of economic evaluations that has been conducted for onchocerciasis interventions, to summarise current key knowledge and to identify research gaps.

METHOD

A systematic review of the literature was conducted on the 8th of August 2018 using the PubMed (MEDLINE) and ISI Web of Science electronic databases. No date or language stipulations were applied to the searches.

RESULTS

We identified 14 primary studies reporting the results of economic evaluations of onchocerciasis interventions, seven of which were cost-effectiveness analyses. The studies identified used a variety of different approaches to estimate the costs of the investigated interventions/programmes. Originally, the studies only quantified the benefits associated with preventing blindness. Gradually, methods improved and also captured onchocerciasis-associated skin disease. Studies found that eliminating onchocerciasis would generate billions in economic benefits. The majority of the cost-effectiveness analyses evaluated annual mass drug administration (MDA). The estimated cost per disability-adjusted life year (DALY) averted of annual MDA varies between US$3 and US$30 (cost year variable).

CONCLUSIONS

The cost benefit and cost effectiveness of onchocerciasis interventions have consistently been found to be very favourable. This finding provides strong evidential support for the ongoing efforts to eliminate onchocerciasis from endemic areas. Although these results are very promising, there are several important research gaps that need to be addressed as we move towards the 2020 milestones and beyond.

Reliability of methods to measure energy expenditure during and after resistance exercise

The primary purpose of this study was to assess the reliability of 3 methods estimating energy expenditure (EE) during and in response to resistance exercise. Ten males (aged 29.4 ± 10.2 years) with ≥2 months resistance training (RT) experience performed 3 training sessions incorporating the bench press and back-squat; sessions were separated by 48 to 72 h. Total energy expenditure (TEE) was estimated using a Suunto T6D Heart Rate Monitor and 2 methods (named "Scott" and "Magosso") that used oxygen uptake and blood lactate measurements to determine aerobic and anaerobic energy expenditure (AnEE). For TEE, relative reliability for both the Scott and Magosso methods remained "nearly perfect" across all testing days for the bench press and back-squat; with interclass correlations (ICC) > 0.93 and percentage of the typical error measurement (TEM%) below 5.8%. The heart rate method showed moderate variability between testing days for both exercises; ICCs ranged between 0.66-0.92 with TEM% between 18%-37% during the bench press and 11%-17% during the back-squat. The estimation of AnEE showed that the Scott and Magosso methods had "strong" to "very strong" relative reliability for both exercises; however, a low absolute reliability was observed. Mean EE was significantly higher in the Scott and Magosso methods during the bench press >912 kJ and back-squat >1170 kJ, with the heart rate method estimating 358 kJ and 416 kJ. The Scott and Magosso methods showed a high degree of reliability between testing days when measuring EE. Heart rate methods may significantly underestimate EE during and in response to RT.

Treatment of self-poisoning at a tertiary-level hospital in Bangladesh: cost to patients and government

OBJECTIVES

Approximately 10 000 people die from suicide annually in Bangladesh, many from pesticide poisoning. We aimed to estimate financial costs to patients and health services of treating patients with self-poisoning.

METHODS

Data on direct costs to families, sources of funds for treatment and family wealth were collected prospectively over a one-month period in 2016 at the tertiary Chittagong Medical College Hospital, Bangladesh. Aggregate operational costs to the government were calculated using annual budget, bed occupancy and length-of-stay data.

RESULTS

Agrochemicals were the most common substances ingested (58.8%). Median duration of stay and of illness was 2 and 5 days, respectively. Median total cost to patients was conservatively estimated at US$ 98.40, highest in agrochemical poisoning (US$ 179.50), with the greatest cost due to medicines and equipment. Misdiagnosis as organophosphorus poisoning in 17.0% of agrochemical cases resulted in increased cost to patients. Only 51.9% of patients had indicators of wealth; 78.1% borrowed money to cover costs. Conservatively estimated median healthcare costs (US$ 21.30 per patient) were markedly lower than costs to patients.

CONCLUSIONS

Cost to patients of treating a case of agrochemical poisoning was approximately three times the cost of one month's essential items basket. Incorrect diagnosis at admission costs families substantial sums of money and increased length of stay; it costs the national government an estimated US$ 80 428.80 annually. Widespread access to a list of pesticides used in self-poisoning plus greater focus on training doctors to better manage different forms of agrochemical poisoning should reduce the financial burden to patients and healthcare systems.

Costs of diarrhoea and acute respiratory infection attributable to not handwashing: the cases of India and China

OBJECTIVE

To estimate the national costs relating to diarrhoea and acute respiratory infections from not handwashing with soap after contact with excreta and the costs and benefits of handwashing behaviour change programmes in India and China.

METHODS

Data on the reduction in risk of diarrhoea and acute respiratory infection attributable to handwashing with soap were used, together with World Health Organization (WHO) estimates of disability-adjusted life years (DALYs) due to diarrhoea and acute respiratory infection, to estimate DALYs due to not handwashing in India and China. Costs and benefits of behaviour change handwashing programmes and the potential returns to investment are estimated valuing DALYs at per capita GDP for each country.

RESULTS

Annual net costs to India from not handwashing are estimated at US$ 23 billion (16-35) and to China at US$ 12 billion (7-23). Expected net returns to national behaviour change handwashing programmes would be US$ 5.6 billion (3.4-8.6) for India at US$ 23 (16-35) per DALY avoided, which represents a 92-fold return to investment, and US$ 2.64 billion (2.08-5.57) for China at US$ 22 (14-31) per DALY avoided - a 35-fold return on investment.

CONCLUSION

Our results suggest large economic gains relating to decreases in diarrhoea and acute respiratory infection for both India and China from behaviour change programmes to increase handwashing with soap in households.

Incremental cost of implementing residual insecticide treatment with delthametrine on top of intensive routine Aedes aegypti control

OBJECTIVE

Information on the cost of implementing residual insecticide treatment (RIT) for Aedes control is scarce. We evaluated the incremental cost on top of intensive conventional routine activities of the Aedes control programme (ACP) in the city of Santiago de Cuba, Cuba.

METHODS

We conducted the cost analysis study in 2011-2012, from the perspective of the ACP. Data sources were bookkeeping records, activity registers of the Provincial ACP Centre and the accounts of an RIT implementation study in 21 clusters of on average four house blocks comprising 5180 premises.

RESULTS

The annual cost of the routine ACP activities was 19.66 US$ per household. RIT applications in rounds at 4-month intervals covering, on average, 97.2% and using 8.5 g of delthametrine annually per household, cost 3.06 US$ per household per year. Delthametrine comprised 66.5% of this cost; the additional cost for deploying RIT comprised 15.6% of the total ACP routine cost and 27% of the cost related to routine adult stage Aedes control.

CONCLUSIONS

The incremental cost of implementing RIT is high. It should be weighed against the incremental effect on the burden caused by the array of pathogens transmitted by Aedes. The cost could be reduced if the insecticide became cheaper, by limiting the number of yearly applications or by targeting transmission hot spots.

[The extra cost of care-related adverse events in hospitals]

Adverse events bring into question the safety and quality of care for patients, but also represent a significant cost for society. For example, the annual cost of nine adverse events assessed in a study by the French Institute for Research and Documentation in Health Economics (IRDES) was estimated at €682 million in 2007.

Economic burden of underweight and overweight among adults in the Asia-Pacific region: a systematic review

OBJECTIVE

To assess the economic burden of underweight and overweight among adults in the Asia-Pacific region.

METHOD

Systematic review of articles published until March 2015.

RESULTS

Seventeen suitable articles were found, of which 13 assess the economic burden of overweight/obesity and estimate that it accounts for 1.5-9.9% of a country's total healthcare expenditure. Four articles on the economic burden of underweight estimate it at 2.5-3.8% of the country's total GDP. Using hospital data, and compared to normal weight individuals, four articles estimated extra healthcare costs for overweight individuals of 7-9.8% and more, and extra healthcare costs for obese individuals of 17-22.3% and higher.

CONCLUSION

Despite methodological diversity across the studies, there is a consensus that both underweight and overweight impose a substantial financial burden on healthcare systems in the Asia-Pacific region.

Cost per patient of treatment for rifampicin-resistant tuberculosis in a community-based programme in Khayelitsha, South Africa

Objectives

The high cost of rifampicin‐resistant tuberculosis (RR‐TB) treatment hinders treatment access. South Africa has a high RR‐TB burden, and national policy outlines decentralisation to improve access and reduce costs. We analysed health system costs associated with RR‐TB treatment by drug resistance profile and treatment outcome in a decentralised programme.

Methods

Retrospective, routinely collected patient‐level data were combined with unit cost data to determine costs for each patient in a cohort treated between January 2009 and December 2011. Drug costs were based on recommended regimens according to drug resistance and treatment duration. Hospitalisation costs were estimated based on admission/discharge dates, while clinic visit and diagnostic/monitoring costs were estimated according to recommendations and treatment duration. Missing data were imputed.

Results

Among 467 patients (72% HIV infected), 49% were successfully treated. Treatment was initiated in primary care for 62%, with the remainder as inpatients. The mean cost per patient treated was $7916 (range 260–87 140), ranging from $5369 among patients who did not complete treatment to $23 006 for treatment failure. Mean cost for successful treatment was $8359 (2585–32 506). Second‐line drug resistance was associated with a mean cost of $15 567 vs. $6852 for only first‐line resistance, with the major cost difference due to hospitalisation. Costs are reported in 2013 USD.

Conclusions

RR‐TB treatment cost was high and varied according to treatment outcome. Despite decentralisation, hospitalisation remained a significant cost, particularly among those with more extensive resistance and those with treatment failure. These cost estimates can be used to model the impact of new interventions to improve patient outcomes.

Cost of neurocysticercosis patients treated in two referral hospitals in Mexico City, Mexico

OBJECTIVES

To estimate annual costs related to the diagnosis, treatment and productivity losses among patients with neurocysticercosis (NCC) receiving treatment at two referral hospitals, the Instituto Nacional de Neurologia y Neurocirugia (INNN) and the Hospital de Especialidades of the Instituto Mexicano del Seguro Social (HE-IMSS), in Mexico City from July 2007 to August 2008.

METHODS

Information on presenting clinical manifestations, diagnostic tests, hospitalisations, surgical procedures and other treatments received by NCC outpatients was collected from medical charts, and supplemented by an individual questionnaire regarding productivity losses and out-of-pocket expenses related to NCC.

RESULTS

The annual average per-patient direct costs were US$ 503 (95% CI: 414-592) and US$ 438 (95% CI: 322-571) for patients without a history of hospitalisation and/or surgery seen at the INNN and the HE-IMSS, respectively. These costs increased to US$ 2506 (95% CI: 1797-3215) and US$ 2170 (95% CI: 1303-3037), respectively, for patients with a history of hospitalisation and/or surgery. The average annual per-patient indirect costs were US$ 246 (95% CI: 165-324) and US$ 114 (95% CI: 51-178), respectively, using minimum salary wages for individuals not officially employed.

CONCLUSIONS

The total annual cost for patients who had and had not been hospitalised and/or undergone a surgical procedure for the diagnosis or treatment of NCC corresponded to 212% and 41% of an annual minimum wage salary, respectively. The disease tends to affect rural socioeconomically disadvantaged populations and creates health disparities and significant economic losses in Mexico.

The health system burden of chronic disease care: an estimation of provider costs of selected chronic diseases in Uganda

Objective

To explore the chronic disease services in Uganda: their level of utilisation, the total service costs and unit costs per visit.

Methods

Full financial and economic cost data were collected from 12 facilities in two districts, from the provider's perspective. A combination of ingredients‐based and step‐down allocation costing approaches was used. The diseases under study were diabetes, hypertension, chronic obstructive pulmonary disease (COPD), epilepsy and HIV infection. Data were collected through a review of facility records, direct observation and structured interviews with health workers.

Results

Provision of chronic care services was concentrated at higher‐level facilities. Excluding drugs, the total costs for NCD care fell below 2% of total facility costs. Unit costs per visit varied widely, both across different levels of the health system, and between facilities of the same level. This variability was driven by differences in clinical and drug prescribing practices.

Conclusion

Most patients reported directly to higher‐level facilities, bypassing nearby peripheral facilities. NCD services in Uganda are underfunded particularly at peripheral facilities. There is a need to estimate the budget impact of improving NCD care and to standardise treatment guidelines.