1
|
Kaso AW, Hailu A. Costs and cost-effectiveness of Gene Xpert compared to smear microscopy for the diagnosis of pulmonary tuberculosis using real-world data from Arsi zone, Ethiopia. PLoS One 2021; 16:e0259056. [PMID: 34695153 PMCID: PMC8544827 DOI: 10.1371/journal.pone.0259056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 10/11/2021] [Indexed: 12/27/2022] Open
Abstract
Background Early diagnosis and treatment are one of the key strategies of tuberculosis control globally, and there are strong efforts in detecting and treating tuberculosis cases in Ethiopia. Smear microscopy examination has been a routine diagnostic test for pulmonary tuberculosis diagnosis in resource-constrained settings for decades. Recently, many countries, including Ethiopia, are scaling up the use of Gene Xpert without the evaluation of the cost and cost-effectiveness implications of this strategy. Therefore, this study evaluated the cost and cost-effectiveness of Gene Xpert (MTB/RIF) and smear microscopy tests to diagnosis tuberculosis patients in Ethiopia. Methods We compared the costs and cost-effectiveness of tuberculosis diagnosis using smear microscopy and Gene Xpert among 1332 patients per intervention in the Arsi zone. We applied combinations of top-down and bottom-up costing approaches. The costs were estimated from the health providers’ perspective within one year (2017–2018). We employed “cases detected” as an effectiveness measure, and the incremental cost-effectiveness ratio was calculated by dividing the changes in cost and change in effectiveness. All costs and incremental cost-effectiveness ratio were reported in 2018 US$. Results The unit cost per test for Gene Xpert was $12.9 whereas it is $3.1 for AFB smear microscopy testing. The cost per TB case detected was $77.9 for Gene Xpert while it was $55.8 for the smear microscopy method. The cartridge kit cost accounted for 42% of the overall Gene Xpert’s costs and the cost of the reagents and consumables accounted for 41.3% ($1.3) of the unit cost for the smear microscopy method. The ICER for the Gene Xpert strategy was $20.0 per tuberculosis case detected. Conclusion Using Gene Xpert as a routine test instead of standard care (smear microscopy) can be potentially cost-effective. In the cost scenario analysis, the price of the cartridge, the number of tests performed per day, and the life span of the capital equipment were the drivers of the unit cost of the Gene Xpert method. Therefore, Gene Xpert can be a part of the routine TB diagnostic testing strategy in Ethiopia.
Collapse
Affiliation(s)
- Abdene Weya Kaso
- School of Public Health, College of Medicine and Health Science, Dilla University, Dilla, Ethiopia
- * E-mail:
| | - Alemayehu Hailu
- Department of Global Public Health and Primary Care, Bergen Centre for Ethics and Priority Setting, University of Bergen, Bergen, Norway
| |
Collapse
|
2
|
Gomez GB, Mudzengi DL, Bozzani F, Menzies NA, Vassall A. Estimating Cost Functions for Resource Allocation Using Transmission Models: A Case Study of Tuberculosis Case Finding in South Africa. Value Health 2020; 23:1606-1612. [PMID: 33248516 DOI: 10.1016/j.jval.2020.08.2096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 08/22/2020] [Accepted: 08/25/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Cost functions linked to transmission dynamic models are commonly used to estimate the resources required for infectious disease policies. We present a conceptual and empirical approach for estimating these functions, allowing for nonconstant marginal costs. We aim to expand on the current approach which commonly assumes linearity of cost over scale. METHODS We propose a theoretical framework adapted from the field of transport economics. We specify joint functions of production of services within a disease-specific program. We expand these functions to include qualitative insights of program expansion patterns. We present the difference in incremental total costs between an approach assuming constant unit costs and alternative approaches that assume economies of scale, scope and homogeneous or heterogeneous facility recruitment into the programme during scale-up. We illustrate the framework's application in tuberculosis, using secondary data from the literature and routine reporting systems in South Africa. RESULTS Economies of capacity and scope substantially change cost estimates over time. Cost data requirements for the proposed approach included standardized and disaggregated unit costs (for a limited number of outputs) and information on the facilities network available to the program. CONCLUSIONS The defined functional form will determine the magnitude and shape of costs when outputs and coverage are increasing. This in turn will impact resource allocation decisions. Infectious diseases modelers and economists should use transparent and empirically based cost models for analyses that inform resource allocation decisions. This framework describes a general approach for developing these models.
Collapse
Affiliation(s)
- Gabriela B Gomez
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
| | | | - Fiammetta Bozzani
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Nicholas A Menzies
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Center for Health Decision Science, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
3
|
Lu L, Jiang Q, Hong J, Jin X, Gao Q, Bang H, DeRiemer K, Yang C. Catastrophic costs of tuberculosis care in a population with internal migrants in China. BMC Health Serv Res 2020; 20:832. [PMID: 32887605 PMCID: PMC7602335 DOI: 10.1186/s12913-020-05686-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 08/24/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The internal rural-to-urban migration is one of the major challenges for tuberculosis (TB) control in China. Patient costs incurred during TB diagnosis and treatment could cause access and adherence barriers, particularly among migrants. Here, we estimated the prevalence of catastrophic costs of TB patients and its associated factors in an urban population with internal migrants in China. METHODS A cross-sectional survey was conducted to enroll culture-confirmed pulmonary TB patients in Songjiang district, Shanghai, between December 1, 2014, and December 31, 2015. Consenting participants completed a questionnaire, which collected direct and indirect costs before and after the diagnosis of TB. The catastrophic cost was defined as the annual expenses of TB care that exceeds 20% of total household disposable income. We used logistic regression to identify factors associated with catastrophic costs. RESULTS Overall, 248 drug-susceptible TB patients were enrolled, 70% (174/248) of them were from migrants. Migrant patients were significantly younger compared to resident patients. The total costs were 25,824 ($3689) and 13,816 ($1974) Chinese Yuan (RMB) in average for resident and migrant patients, respectively. The direct medical cost comprised about 70% of the total costs among both migrant and resident patients. Overall, 55% (132 of 248) of patients experienced high expenses (>10% of total household income), and 22% (55 of 248) experienced defined catastrophic costs. The reimbursement for TB care only reduced the prevalence of catastrophic costs to 20% (49 of 248). Meanwhile, 52% (90 of 174) of the internal migrants had no available local health insurance. Hospitalizations, no available insurance, and older age (> 45-year-old) contributed significantly to the occurrence of catastrophic costs. CONCLUSIONS The catastrophic cost of TB service cannot be overlooked, despite the free policy. Migrants have difficulties benefiting from health insurance in urban cities. Interventions, including expanded medical financial assistance, are needed to secure universal TB care.
Collapse
Affiliation(s)
- Liping Lu
- Department of Tuberculosis Control, Songjiang District Center for Disease Control and Prevention, Shanghai, China
| | - Qi Jiang
- Key Laboratory of Medical Molecular Virology (MOE/NHC/CAMS), School of Basic Medical Sciences, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jianjun Hong
- Department of Tuberculosis Control, Songjiang District Center for Disease Control and Prevention, Shanghai, China
| | - Xiaoping Jin
- Department of Tuberculosis Control, Songjiang District Center for Disease Control and Prevention, Shanghai, China
| | - Qian Gao
- Key Laboratory of Medical Molecular Virology (MOE/NHC/CAMS), School of Basic Medical Sciences, Shanghai Medical College, Fudan University, Shanghai, China
| | - Heejung Bang
- Department of Public Health Sciences, University of California, Davis, CA, USA
| | - Kathryn DeRiemer
- Department of Public Health Sciences, University of California, Davis, CA, USA
| | - Chongguang Yang
- Key Laboratory of Medical Molecular Virology (MOE/NHC/CAMS), School of Basic Medical Sciences, Shanghai Medical College, Fudan University, Shanghai, China.
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, Yale University, 60 College Street, New Haven, CT, 06510, USA.
| |
Collapse
|
4
|
Khumsri J, Hanvoravongchai P, Hiransuthikul N, Chuchottaworn C. Cost-Effectiveness Analysis of Xpert MTB/RIF for Multi-Outcomes of Patients With Presumptive Pulmonary Tuberculosis in Thailand. Value Health Reg Issues 2020; 21:264-271. [PMID: 32388198 DOI: 10.1016/j.vhri.2019.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 08/22/2019] [Accepted: 09/30/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The cost-effectiveness of screening adult patients for pulmonary tuberculosis is not clear. As such, this study aims to identify the cost-effectiveness between the Xpert MTB/RIF assay and the sputum acid-fast bacilli (AFB) smear. Multi-outcomes were correct diagnosis, time to achieve correct diagnosis, and gain in quality-adjusted life-years (QALYs). METHODS A decision tree model was constructed to reveal a possible clinical pathway of tuberculosis diagnosis. The researchers used a clinical study to establish the probability of all clinical pathways for input into this model. The sample size was calculated following the correct diagnosis. Participants were randomly divided into 2 groups. A structural questionnaire and the Thai version of quality of life (EQ-5D-5L) were used for interviewing. RESULTS The results showed that the time to achieve the correct diagnosis for the group using Xpert MTB/RIF was shorter than that for the group using the sputum AFB smear. Both the correct diagnosis and QALYs of the base case analysis presented the Xpert MTB/RIF method as dominant. A Monte Carlo model, which analyzed the Xpert MTB/RIF method, revealed that the average number of patients who were correctly diagnosed was 673, the QALYs were 945.85 years, and the total cost was $143 110.64. For the sputum AFB smear method, the average number who received a correct diagnosis was 592, the QALYs were 940.40 years, and the total cost was $196 666.84. Probabilistic and one-way sensitivity analysis confirmed that the Xpert MTB/RIF remained dominant. CONCLUSIONS These results provide useful information for the National Strategic Plan to screen all adult patients for pulmonary tuberculosis.
Collapse
Affiliation(s)
- Jiraporn Khumsri
- Department of Medical Services, Nopparat Rajathanee Hospital, Ministry of Public Health, Bangkok, Thailand; Department of Preventive and Social Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Piya Hanvoravongchai
- Department of Preventive and Social Medicine, Chulalongkorn University, Bangkok, Thailand; Thailand Research Center for Health Services System, Chulalongkorn University, Bangkok, Thailand
| | - Narin Hiransuthikul
- Department of Preventive and Social Medicine, Chulalongkorn University, Bangkok, Thailand.
| | - Charoen Chuchottaworn
- Department of Medical Services, Central Chest Institute of Thailand, Ministry of Public Health, Nonthaburi, Thailand
| |
Collapse
|
5
|
Abstract
OBJECTIVES To mitigate the economic burden of tuberculosis (TB), it is important to fully understand the costs of TB treatment from the patient perspective. We therefore sought to quantify the patient-incurred cost of TB treatment in rural Malawi, with specific focus on costs borne by patients requiring inpatient hospitalisation. METHODS We conducted a cross-sectional survey of 197 inpatients and 156 outpatients being treated for TB in rural Malawi. We collected data on out-of-pocket costs and lost wages, including costs to guardians. Costs for inpatient TB treatment were estimated and compared to costs for outpatient TB treatment. We then explored the equity distribution of inpatient TB treatment cost using concentration curves. RESULTS Despite free government services, inpatients were estimated to incur a mean of $137 (standard deviation: $147) per initial TB episode, corresponding to >50% of annual household spending among patients in the lowest expenditure quintile. Non-medical hospitalisation costs accounted for 88% of this total. Patients treated entirely as outpatients incurred estimated costs of $25 (standard deviation: $15) per episode. The concentration curves showed that, among individuals hospitalised for an initial TB episode, poorer patients shouldered a much greater proportion of inpatient TB treatment costs than wealthier ones (concentration index: -0.279). CONCLUSION Patients hospitalised for TB in resource-limited rural Malawi experience devastating costs of TB treatment. Earlier diagnosis and treatment must be prioritised if we are to meet goals of effective TB control, avoidance of catastrophic costs and provision of appropriate patient-centred care in such settings.
Collapse
Affiliation(s)
- Hyejeong Shin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Lucky G. Ngwira
- HIV and TB Group, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Clinical Sciences Department, Liverpool School of Tropical Medicine, UK
| | - Austin Tucker
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Richard E Chaisson
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth L Corbett
- HIV and TB Group, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
6
|
Su Y, Garcia Baena I, Harle AC, Crosby SW, Micah AE, Siroka A, Sahu M, Tsakalos G, Murray CJL, Floyd K, Dieleman JL. Tracking total spending on tuberculosis by source and function in 135 low-income and middle-income countries, 2000-17: a financial modelling study. Lancet Infect Dis 2020; 20:929-942. [PMID: 32334658 PMCID: PMC7649746 DOI: 10.1016/s1473-3099(20)30124-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 01/31/2020] [Accepted: 02/14/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Estimates of government spending and development assistance for tuberculosis exist, but less is known about out-of-pocket and prepaid private spending. We aimed to provide comprehensive estimates of total spending on tuberculosis in low-income and middle-income countries for 2000-17. METHODS We extracted data on tuberculosis spending, unit costs, and health-care use from the WHO global tuberculosis database, Global Fund proposals and reports, National Health Accounts, the WHO-Choosing Interventions that are Cost-Effective project database, and the Institute for Health Metrics and Evaluation Development Assistance for Health Database. We extracted data from at least one of these sources for all 135 low-income and middle-income countries using the World Bank 2019 definitions. We estimated tuberculosis spending by source and function for notified (officially reported) and non-notified tuberculosis cases separately and combined, using spatiotemporal Gaussian process regression to fill in for missing data and estimate uncertainty. We aggregated estimates of government, out-of-pocket, prepaid private, and development assistance spending on tuberculosis to estimate total spending in 2019 US$. FINDINGS Total spending on tuberculosis in 135 low-income and middle-income countries increased annually by 3·9% (95% CI 3·0 to 4·6), from $5·7 billion (5·2 to 6·5) in 2000 to $10·9 billion (10·3 to 11·8) in 2017. Government spending increased annually by 5·1% (4·4 to 5·7) between 2000 and 2017, and reached $6·9 billion (6·5 to 7·5) or 63·5% (59·2 to 66·8) of all tuberculosis spending in 2017. Of government spending, $5·8 billion (5·6 to 6·1) was spent on notified cases. Out-of-pocket spending decreased annually by 0·8% (-2·9 to 1·3), from $2·4 billion (1·9 to 3·1) in 2000 to $2·1 billion (1·6 to 2·7) in 2017. Development assistance for country-specific spending on tuberculosis increased from $54·6 million in 2000 to $1·1 billion in 2017. Administrative costs and development assistance for global projects related to tuberculosis care increased from $85·3 million in 2000 to $576·2 million in 2017. 30 high tuberculosis burden countries of low and middle income accounted for 73·7% (71·8-75·8) of tuberculosis spending in 2017. INTERPRETATION Despite substantial increases since 2000, funding for tuberculosis is still far short of global financing targets and out-of-pocket spending remains high in resource-constrained countries, posing a barrier to patient's access to care and treatment adherence. Of the 30 countries with a high-burden of tuberculosis, just over half were primarily funded by government, while others, especially lower-middle-income and low-income countries, were still primarily dependent on development assistance for tuberculosis or out-of-pocket health spending. FUNDING Bill & Melinda Gates Foundation.
Collapse
Affiliation(s)
- Yanfang Su
- Institute for Health Metrics and Evaluation, Seattle, WA, USA
| | | | - Anton C Harle
- Institute for Health Metrics and Evaluation, Seattle, WA, USA
| | - Sawyer W Crosby
- Institute for Health Metrics and Evaluation, Seattle, WA, USA
| | - Angela E Micah
- Institute for Health Metrics and Evaluation, Seattle, WA, USA
| | | | - Maitreyi Sahu
- Institute for Health Metrics and Evaluation, Seattle, WA, USA
| | - Golsum Tsakalos
- Institute for Health Metrics and Evaluation, Seattle, WA, USA
| | | | - Katherine Floyd
- Institute for Health Metrics and Evaluation, Seattle, WA, USA
| | | |
Collapse
|
7
|
Potter JL, Burman M, Tweed CD, Vaghela D, Kunst H, Swinglehurst D, Griffiths CJ. The NHS visitor and migrant cost recovery programme - a threat to health? BMC Public Health 2020; 20:407. [PMID: 32306938 PMCID: PMC7169002 DOI: 10.1186/s12889-020-08524-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 03/13/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND In April 2014 the UK government launched the 'NHS Visitor and Migrant Cost Recovery Programme Implementation Plan' which set out a series of policy changes to recoup costs from 'chargeable' (largely non-UK born) patients. In England, approximately 75% of tuberculosis (TB) cases occur in people born abroad. Delays in TB treatment increase risk of morbidity, mortality and transmission in the community. We investigated whether diagnostic delay has increased since the Cost Recovery Programme (CRP) was introduced. METHODS There were 3342 adult TB cases notified on the London TB Register across Barts Health NHS Trust between 1st January 2011 and 31st December 2016. Cases with missing relevant information were excluded. The median time between symptom onset and treatment initiation before and after the CRP was calculated according to birthplace and compared using the Mann Whitney test. Delayed diagnosis was considered greater or equal to median time to treatment for all patients (79 days). Univariable logistic regression was used to manually select exposure variables for inclusion in a multivariable model to test the association between diagnostic delay and the implementation of the CRP. RESULTS We included 2237 TB cases. Among non-UK born patients, median time-to-treatment increased from 69 days to 89 days following introduction of CRP (p < 0.001). Median time-to-treatment also increased for the UK-born population from 75.5 days to 89.5 days (p = 0.307). The multivariable logistic regression model showed non-UK born patients were more likely to have a delay in diagnosis after the CRP (adjOR 1.37, 95% CI 1.13-1.66, p value 0.001). CONCLUSION Since the introduction of the CRP there has been a significant delay for TB treatment among non-UK born patients. Further research exploring the effect of policies restricting access to healthcare for migrants is urgently needed if we wish to eliminate TB nationally.
Collapse
Affiliation(s)
- J L Potter
- Centre for Primary Care and Public Health, Blizard Institute, Queen Mary University of London, London, England.
| | - M Burman
- Centre for Primary Care and Public Health, Blizard Institute, Queen Mary University of London, London, England
| | - C D Tweed
- MRC Clinical Trials Unit, University College London, London, England
| | - D Vaghela
- Centre for Primary Care and Public Health, Blizard Institute, Queen Mary University of London, London, England
| | - H Kunst
- Centre for Primary Care and Public Health, Blizard Institute, Queen Mary University of London, London, England
| | - D Swinglehurst
- Centre for Primary Care and Public Health, Blizard Institute, Queen Mary University of London, London, England
| | - C J Griffiths
- Centre for Primary Care and Public Health, Blizard Institute, Queen Mary University of London, London, England
| |
Collapse
|
8
|
Gurung SC, Dixit K, Rai B, Caws M, Paudel PR, Dhital R, Acharya S, Budhathoki G, Malla D, Levy JW, van Rest J, Lönnroth K, Viney K, Ramsay A, Wingfield T, Basnyat B, Thapa A, Squire B, Wang D, Mishra G, Shah K, Shrestha A, de Siqueira-Filha NT. The role of active case finding in reducing patient incurred catastrophic costs for tuberculosis in Nepal. Infect Dis Poverty 2019; 8:99. [PMID: 31791412 PMCID: PMC6889665 DOI: 10.1186/s40249-019-0603-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 10/23/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) End TB Strategy has established a milestone to reduce the number of tuberculosis (TB)- affected households facing catastrophic costs to zero by 2020. The role of active case finding (ACF) in reducing patient costs has not been determined globally. This study therefore aimed to compare costs incurred by TB patients diagnosed through ACF and passive case finding (PCF), and to determine the prevalence and intensity of patient-incurred catastrophic costs in Nepal. METHODS The study was conducted in two districts of Nepal: Bardiya and Pyuthan (Province No. 5) between June and August 2018. One hundred patients were included in this study in a 1:1 ratio (PCF: ACF, 25 consecutive ACF and 25 consecutive PCF patients in each district). The WHO TB patient costing tool was applied to collect information from patients or a member of their family regarding indirect and direct medical and non-medical costs. Catastrophic costs were calculated based on the proportion of patients with total costs exceeding 20% of their annual household income. The intensity of catastrophic costs was calculated using the positive overshoot method. The chi-square and Wilcoxon-Mann-Whitney tests were used to compare proportions and costs. Meanwhile, the Mantel Haenszel test was performed to assess the association between catastrophic costs and type of diagnosis. RESULTS Ninety-nine patients were interviewed (50 ACF and 49 PCF). Patients diagnosed through ACF incurred lower costs during the pre-treatment period (direct medical: USD 14 vs USD 32, P = 0.001; direct non-medical: USD 3 vs USD 10, P = 0.004; indirect, time loss: USD 4 vs USD 13, P < 0.001). The cost of the pre-treatment and intensive phases combined was also lower for direct medical (USD 15 vs USD 34, P = 0.002) and non-medical (USD 30 vs USD 54, P = 0.022) costs among ACF patients. The prevalence of catastrophic direct costs was lower for ACF patients for all thresholds. A lower intensity of catastrophic costs was also documented for ACF patients, although the difference was not statistically significant. CONCLUSIONS ACF can reduce patient-incurred costs substantially, contributing to the End TB Strategy target. Other synergistic policies, such as social protection, will also need to be implemented to reduce catastrophic costs to zero among TB-affected households.
Collapse
Affiliation(s)
| | | | - Bhola Rai
- Birat Nepal Medical Trust, Kathmandu, Nepal
| | - Maxine Caws
- Birat Nepal Medical Trust, Kathmandu, Nepal
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | | | | | | | - Jens W. Levy
- KNCV Tuberculosis Foundation, The Hague, Netherlands
| | - Job van Rest
- KNCV Tuberculosis Foundation, The Hague, Netherlands
| | - Knut Lönnroth
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Kerri Viney
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Research School of Population Health, Australian National University, Canberra, Australia
| | | | - Tom Wingfield
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- University of Liverpool, Liverpool, UK
| | - Buddha Basnyat
- Oxford University Clinical Research Unit, Kathmandu, Nepal
| | - Anil Thapa
- National Tuberculosis Centre, Bhaktapur, Nepal
| | - Bertie Squire
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Gokul Mishra
- Birat Nepal Medical Trust, Kathmandu, Nepal
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Noemia Teixeira de Siqueira-Filha
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Institute for Health Technology Assessment, Porto Alegre, Brazil
| |
Collapse
|
9
|
Tchiombiano S, Delfraissy JF, Dabis F. The Global Fund's Sixth Replenishment Conference: a challenge for France, a challenge for global health. Lancet 2019; 394:1214-1215. [PMID: 31591971 DOI: 10.1016/s0140-6736(19)32261-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 09/27/2019] [Indexed: 10/25/2022]
Affiliation(s)
| | | | - François Dabis
- Agence Nationale de Recherches sur le Sida et les Hépatites Virales (ANRS), Paris, France
| |
Collapse
|
10
|
Teo AKJ, Singh SR, Prem K, Hsu LY, Yi S. Delayed diagnosis and treatment of pulmonary tuberculosis in high-burden countries: a systematic review protocol. BMJ Open 2019; 9:e029807. [PMID: 31289094 PMCID: PMC6629411 DOI: 10.1136/bmjopen-2019-029807] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 06/05/2019] [Accepted: 06/12/2019] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Countries identified to bear the highest tuberculosis (TB) incidence account for approximately 85% of the global TB burden. TB is curable, yet nearly 40% of TB cases remained undiagnosed hence delaying treatment and perpetuating transmission. This systematic review aimed to review current evidence on factors associated with delayed diagnosis and treatment of TB in the high TB-burden countries. METHODS AND ANALYSIS This systematic review will incorporate qualitative and observational study designs published between 2008 and 2018. Articles will be retrieved from major databases including PubMed, EMBASE, CINAHL and PsycINFO. Reference lists of key articles, including relevant systematic reviews and meta-analysis, will be screened for additional studies. Two independent reviewers will screen and select studies, extract data and assess the quality and risk of bias of each study. Study-specific estimates will be pooled by meta-analysis, and effect sizes will be presented as OR and their 95% CI. Levels of heterogeneity will be evaluated using chi-square statistic Q and I2. Publication bias will be assessed using forest plots and Egger's tests. Qualitative findings and sample quotes will be extracted. Textual references to the topics of interest will be retrieved and categorised using qualitative thematic analysis. We will triangulate quantitative and qualitative findings for a complete understanding of the reasons for delayed TB diagnosis and treatment. Results will be presented by geographical region. ETHICS AND DISSEMINATION This study will be conducted based on published data. This systematic review may provide insights into the reasons for delayed TB diagnosis in high-burden countries. These findings will also inform future research and key stakeholders in developing interventions to reach these undiagnosed cases effectively. Findings from this review will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42018107237.
Collapse
Affiliation(s)
- Alvin Kuo Jing Teo
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Shweta R Singh
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Kiesha Prem
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Li Yang Hsu
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Siyan Yi
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
- Center for Population Health Research, KHANA, Phnom Penh, Cambodia
| |
Collapse
|
11
|
Tuot S, Teo AKJ, Cazabon D, Sok S, Ung M, Ly S, Choub SC, Yi S. Acceptability of active case finding with a seed-and-recruit model to improve tuberculosis case detection and linkage to treatment in Cambodia: A qualitative study. PLoS One 2019; 14:e0210919. [PMID: 31265458 PMCID: PMC6605634 DOI: 10.1371/journal.pone.0210919] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 06/17/2019] [Indexed: 11/19/2022] Open
Abstract
Background With support of the national tuberculosis (TB) program, KHANA (a local non-governmental organization in Cambodia) has implemented an innovative approach using a seed-and-recruit model to actively find TB cases in the community. The model engaged community members including TB survivors as seed and newly diagnosed people with TB as recruiters to recruit presumptive TB cases in their social network in a snowball approach for screening and linkage to treatment. This study aimed to explore the acceptability of the active case finding with the seed-and-recruit model in detecting new TB cases and determine the characteristics of successful seeds. Methods This qualitative study was conducted in four provinces (Banteay Meanchey, Kampong Chhnang, Siem Reap, and Takeo) in Cambodia in 2017. Fifty-six in-depth interviews and ten focus group discussions (with a total of 64 participants) were conducted with selected beneficiaries and key stakeholders at different levels to gain insights into the acceptability, strengths, and challenges in implementing the model and the characteristics of successful seeds. Transcripts were coded and content analyses were performed. Results The seed-and-recruit active case finding model was generally well-received by the study participants. They saw the benefits of engaging TB survivors and utilizing their social network to find new TB cases in the community. The social embeddedness of the model within the local community was one of the major strengths. The success of the model also hinges on the integration with existing health facilities. Having an extensive social network, being motivated, and having good knowledge about TB were important characteristics of successful seeds. Study participants reported challenges in motivating the presumptive TB cases for screening, logistic capacities, and high workload during the implementation. However, there was a general consensus that the model ought to be expanded. Conclusions These findings indicate that the seed-and-recruit model is well-accepted by the beneficiaries and key stakeholders. Further studies are needed to more comprehensively evaluate the impacts and cost-effectiveness of the model for future expansion in Cambodia as well as in other resource-limited settings.
Collapse
Affiliation(s)
- Sovannary Tuot
- KHANA Center for Population Health Research, Phnom Penh, Cambodia
- Faculty of Social Science and Humanities, Royal University of Phnom Penh, Phnom Penh, Cambodia
| | - Alvin Kuo Jing Teo
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Danielle Cazabon
- McGill International TB Centre, McGill University Health Centre, Montréal, Canada
| | - Say Sok
- KHANA Center for Population Health Research, Phnom Penh, Cambodia
- Faculty of Social Science and Humanities, Royal University of Phnom Penh, Phnom Penh, Cambodia
| | - Mengieng Ung
- Humanities and Social Studies Education Academic Group, National Institute of Education, Nanyang Technology University, Singapore, Singapore
| | - Sangky Ly
- KHANA Center for Population Health Research, Phnom Penh, Cambodia
| | | | - Siyan Yi
- KHANA Center for Population Health Research, Phnom Penh, Cambodia
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
- Center for Global Health Research, Touro University California, Vallejo, the United States of America
- * E-mail:
| |
Collapse
|
12
|
Xu CH, Jeyashree K, Shewade HD, Xia YY, Wang LX, Liu Y, Zhang H, Wang L. Inequity in catastrophic costs among tuberculosis-affected households in China. Infect Dis Poverty 2019; 8:46. [PMID: 31215476 PMCID: PMC6582572 DOI: 10.1186/s40249-019-0564-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/28/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are limited nationally representative studies globally in the post-2015 END tuberculosis (TB) era regarding wealth related inequity in the distribution of catastrophic costs due to TB care. Under the Chinese national tuberculosis programme setting, we aimed to assess extent of equity in distribution of total TB care costs (pre-treatment, treatment and overall) and costs as a proportion of annual household income (AHI), and describe and compare equity in distribution of catastrophic costs (pre-treatment, treatment and overall) across population sub-groups. METHODS Analytical cross-sectional study using data from national TB patient cost survey carried out in 22 counties from six provinces in China in 2017. Drug-susceptible pulmonary TB registered under programme, who had received at least 2 weeks of intensive phase therapy were included. Equity was depicted using concentration curves and concentration indices were compared using dominance test. RESULTS Of 1147 patients, the median cost of pre-treatment, treatment and overall care, were USD 283.5, USD 413.1 and USD 965.5, respectively. Richer quintiles incurred significantly higher pre-treatment and treatment costs compared to poorer quintiles. The distribution of costs as a proportion of AHI and catastrophic costs were significantly pro-poor overall as well as during pre-treatment and treatment phase. All the concentration curves for catastrophic costs (due to pre-treatment, treatment and overall care) stratified by region (east, middle and west), area of residence (urban, rural) and type of insurance (new rural co-operative medical system [NCMS], non-NCMS) also exhibited a pro-poor pattern with statistically significant (P < 0.01) concentration indices. The pro-poor distribution of the catastrophic costs due to TB treatment was significantly more inequitable among rural, compared to urban patients, and NCMS compared to non-NCMS beneficiaries. CONCLUSIONS There is inequity in the distribution of catastrophic costs due to TB care. Universal health coverage, social protection strategies complemented by quality TB care is vital to reduce inequitable distribution of catastrophic costs due to TB care in China.
Collapse
Affiliation(s)
- Cai-Hong Xu
- National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, 100226, China
| | - Kathiresan Jeyashree
- Velammal Medical College Hospital and Research Institute, Madurai, 625009, India
| | - Hemant Deepak Shewade
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, 110016, India
- International Union Against Tuberculosis and Lung Disease (The Union), 75006, Paris, France
- Karuna Trust, Bengaluru, 560041, India
| | - Yin-Yin Xia
- National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, 100226, China
| | - Li-Xia Wang
- National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, 100226, China
| | - Yan Liu
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, 100005, China
| | - Hui Zhang
- National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, 100226, China.
| | - Li Wang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, 100005, China.
| |
Collapse
|
13
|
Reid MJA, Arinaminpathy N, Bloom A, Bloom BR, Boehme C, Chaisson R, Chin DP, Churchyard G, Cox H, Ditiu L, Dybul M, Farrar J, Fauci AS, Fekadu E, Fujiwara PI, Hallett TB, Hanson CL, Harrington M, Herbert N, Hopewell PC, Ikeda C, Jamison DT, Khan AJ, Koek I, Krishnan N, Motsoaledi A, Pai M, Raviglione MC, Sharman A, Small PM, Swaminathan S, Temesgen Z, Vassall A, Venkatesan N, van Weezenbeek K, Yamey G, Agins BD, Alexandru S, Andrews JR, Beyeler N, Bivol S, Brigden G, Cattamanchi A, Cazabon D, Crudu V, Daftary A, Dewan P, Doepel LK, Eisinger RW, Fan V, Fewer S, Furin J, Goldhaber-Fiebert JD, Gomez GB, Graham SM, Gupta D, Kamene M, Khaparde S, Mailu EW, Masini EO, McHugh L, Mitchell E, Moon S, Osberg M, Pande T, Prince L, Rade K, Rao R, Remme M, Seddon JA, Selwyn C, Shete P, Sachdeva KS, Stallworthy G, Vesga JF, Vilc V, Goosby EP. Building a tuberculosis-free world: The Lancet Commission on tuberculosis. Lancet 2019; 393:1331-1384. [PMID: 30904263 DOI: 10.1016/s0140-6736(19)30024-8] [Citation(s) in RCA: 212] [Impact Index Per Article: 42.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 12/20/2018] [Accepted: 12/25/2018] [Indexed: 11/22/2022]
Affiliation(s)
- Michael J A Reid
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA.
| | - Nimalan Arinaminpathy
- School of Public Health, Imperial College London, London, UK; Faculty of Medicine, Imperial College London, London, UK
| | - Amy Bloom
- Tuberculosis Division, United States Agency for International Development, Washington, DC, USA
| | - Barry R Bloom
- Department of Global Health and Population, Harvard University, Cambridge, MA, USA
| | | | - Richard Chaisson
- Departments of Medicine, Epidemiology, and International Health, Johns Hopkins School of Medicine, Baltimore, MA, USA
| | | | | | - Helen Cox
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Mark Dybul
- Department of Medicine, Centre for Global Health and Quality, Georgetown University, Washington, DC, USA
| | | | - Anthony S Fauci
- National Institute of Allergy and Infectious Diseases, US National Institutes of Health, Maryland, MA, USA
| | | | - Paula I Fujiwara
- Department of Tuberculosis and HIV, The International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Timothy B Hallett
- School of Public Health, Imperial College London, London, UK; Faculty of Medicine, Imperial College London, London, UK
| | | | | | - Nick Herbert
- Global TB Caucus, Houses of Parliament, London, UK
| | - Philip C Hopewell
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Chieko Ikeda
- Department of GLobal Health, Ministry of Heath, Labor and Welfare, Tokyo, Japan
| | - Dean T Jamison
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA; Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Aamir J Khan
- Interactive Research & Development, Karachi, Pakistan
| | - Irene Koek
- Global Health Bureau, United States Agency for International Development, Washington, DC, USA
| | - Nalini Krishnan
- Resource Group for Education and Advocacy for Community Health, Chennai, India
| | - Aaron Motsoaledi
- South African National Department of Health, Pretoria, South Africa
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada; McGill International TB Center, McGill University, Montreal, QC, Canada
| | - Mario C Raviglione
- University of Milan, Milan, Italy; Global Studies Institute, University of Geneva, Geneva, Switzerland
| | - Almaz Sharman
- Academy of Preventive Medicine of Kazakhstan, Almaty, Kazakhstan
| | - Peter M Small
- Global Health Institute, School of Medicine, Stony Brook University, Stony Brook, NY, USA
| | | | - Zelalem Temesgen
- Department of Infectious Diseases, Mayo Clinic, Rochester, MI, USA
| | - Anna Vassall
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK; Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, Netherlands
| | | | | | - Gavin Yamey
- Center for Policy Impact in Global Health, Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Bruce D Agins
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Sofia Alexandru
- Institutul de Ftiziopneumologie Chiril Draganiuc, Chisinau, Moldova
| | - Jason R Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Naomi Beyeler
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Stela Bivol
- Center for Health Policies and Studies, Chisinau, Moldova
| | - Grania Brigden
- Department of Tuberculosis and HIV, The International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Adithya Cattamanchi
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Danielle Cazabon
- McGill International TB Center, McGill University, Montreal, QC, Canada
| | - Valeriu Crudu
- Center for Health Policies and Studies, Chisinau, Moldova
| | - Amrita Daftary
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada; McGill International TB Center, McGill University, Montreal, QC, Canada
| | - Puneet Dewan
- Bill & Melinda Gates Foundation, New Delhi, India
| | - Laurie K Doepel
- National Institute of Allergy and Infectious Diseases, US National Institutes of Health, Maryland, MA, USA
| | - Robert W Eisinger
- National Institute of Allergy and Infectious Diseases, US National Institutes of Health, Maryland, MA, USA
| | - Victoria Fan
- T H Chan School of Public Health, Harvard University, Cambridge, MA, USA; Office of Public Health Studies, University of Hawaii, Mānoa, HI, USA
| | - Sara Fewer
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Jennifer Furin
- Division of Infectious Diseases & HIV Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Jeremy D Goldhaber-Fiebert
- Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA
| | - Gabriela B Gomez
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Stephen M Graham
- Department of Tuberculosis and HIV, The International Union Against Tuberculosis and Lung Disease, Paris, France; Department of Paediatrics, Center for International Child Health, University of Melbourne, Melbourne, VIC, Australia; Burnet Institute, Melbourne, VIC, Australia
| | - Devesh Gupta
- Revised National TB Control Program, New Delhi, India
| | - Maureen Kamene
- National Tuberculosis, Leprosy and Lung Disease Program, Ministry of Health, Nairobi, Kenya
| | | | - Eunice W Mailu
- National Tuberculosis, Leprosy and Lung Disease Program, Ministry of Health, Nairobi, Kenya
| | | | - Lorrie McHugh
- Office of the Secretary-General's Special Envoy on Tuberculosis, United Nations, Geneva, Switzerland
| | - Ellen Mitchell
- International Institute of Social Studies, Erasmus University Rotterdam, The Hague, Netherland
| | - Suerie Moon
- Department of Global Health and Population, Harvard University, Cambridge, MA, USA; Global Health Centre, The Graduate Institute Geneva, Geneva, Switzerland
| | | | - Tripti Pande
- McGill International TB Center, McGill University, Montreal, QC, Canada
| | - Lea Prince
- Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA
| | | | - Raghuram Rao
- Ministry of Health and Family Welfare, New Delhi, India
| | - Michelle Remme
- International Institute for Global Health, United Nations University, Kuala Lumpur, Malaysia
| | - James A Seddon
- Department of Medicine, Imperial College London, London, UK; Faculty of Medicine, Imperial College London, London, UK; Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - Casey Selwyn
- Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Priya Shete
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Juan F Vesga
- School of Public Health, Imperial College London, London, UK; Faculty of Medicine, Imperial College London, London, UK
| | | | - Eric P Goosby
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
14
|
Yadav J, John D, Menon G. Out of pocket expenditure on tuberculosis in India: Do households face hardship financing? Indian J Tuberc 2019; 66:448-460. [PMID: 31813431 DOI: 10.1016/j.ijtb.2019.02.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 02/28/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND In 2017, India accounted for 27 percent of the global burden on tuberculosis, and the highest among the top 30 countries with high TB burden. Despite the expansion of DOTS programme many households in India incur high expenditure towards TB treatment. Most of the studies in India have focused on measuring catastrophic health expenditure on TB. Catastrophic health expenditure and its impoverishment effects are difficult to calculate and may misrepresent economic hardship. METHODS This paper uses hardship financing, i.e. when a household sells assets or borrows money on interest to pay for healthcare expenditure, as an indicator of the hardship of the family when it spends on TB treatment using NSSO 71st Round 2014 data. RESULTS Using the NSSO national representative sample, the paper estimated that 26.7% of hospitalized cases and 3.5% percent of patients utilising outpatient care experience hardship financing due to TB in the country. 25.9% of the general population had to sell assets or used borrowings for financing TB hospitalization expenses. Education of head of household, income, type of health facility used, and number of hospitalized days were found to be significant factors influencing hardship financing. CONCLUSION Our study highlights that even with free care for tuberculosis, 21.3% were exposed to hardship financing, suggesting the need to re-look at the subsidy coverage of tuberculosis treatment in the country. The study also suggests the use of hardship financing as an alternative to catastrophic spending method as a index of effectiveness of tuberculosis control programme in the country.
Collapse
Affiliation(s)
- Jeetendra Yadav
- ICMR-National Institute of Medical Statistics (NIMS), Department of Health Research, Ministry of Health & Family Welfare, Govt of India, Medical Enclave Ansari Nagar, New Delhi, 110029, India.
| | - Denny John
- ICMR-National Institute of Medical Statistics (NIMS), Department of Health Research, Ministry of Health & Family Welfare, Govt of India, Medical Enclave Ansari Nagar, New Delhi, 110029, India; Campbell Collaboration, New Delhi, India.
| | - Geetha Menon
- ICMR-National Institute of Medical Statistics (NIMS), Department of Health Research, Ministry of Health & Family Welfare, Govt of India, Medical Enclave Ansari Nagar, New Delhi, 110029, India.
| |
Collapse
|
15
|
Reis-Santos B, Shete P, Bertolde A, Sales CM, Sanchez MN, Arakaki-Sanchez D, Andrade KB, Gomes MGM, Boccia D, Lienhardt C, Maciel EL. Tuberculosis in Brazil and cash transfer programs: A longitudinal database study of the effect of cash transfer on cure rates. PLoS One 2019; 14:e0212617. [PMID: 30794615 PMCID: PMC6386534 DOI: 10.1371/journal.pone.0212617] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 02/06/2019] [Indexed: 01/24/2023] Open
Abstract
Introduction Tuberculosis incidence is disproportionately high among people in poverty. Cash transfer programs have become an important strategy in Brazil fight inequalities as part of comprehensive poverty alleviation policies. This study was aimed at assessing the effect of being a beneficiary of a governmental cash transfer program on tuberculosis (TB) treatment cure rates. Methods We conducted a longitudinal database study including people ≥18 years old with confirmed incident TB in Brazil in 2015. We treated missing data with multiple imputation. Poisson regression models with robust variance were carried out to assess the effect of TB determinants on cure rates. The average effect of being beneficiary of cash transfer was estimated by propensity-score matching. Results In 2015, 25,084 women and men diagnosed as new tuberculosis case, of whom 1,714 (6.8%) were beneficiaries of a national cash transfer. Among the total population with pulmonary tuberculosis several determinants were associated with cure rates. However, among the cash transfer group, this association was vanished in males, blacks, region of residence, and people not deprived of their freedom and who smoke tobacco. The average treatment effect of cash transfers on TB cure rates, based on propensity score matching, found that being beneficiary of cash transfer improved TB cure rates by 8% [Coefficient 0.08 (95% confidence interval 0.06–0.11) in subjects with pulmonary TB]. Conclusion Our study suggests that, in Brazil, the effect of cash transfer on the outcome of TB treatment may be achieved by the indirect effect of other determinants. Also, these results suggest the direct effect of being beneficiary of cash transfer on improving TB cure rates.
Collapse
Affiliation(s)
- Barbara Reis-Santos
- Laboratory of Epidemiology of Federal University of Espírito Santo, Vitória/ES, Brazil
- * E-mail:
| | - Priya Shete
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA, United States of America
| | - Adelmo Bertolde
- Departamento de Estatística, Universidade Federal do Espírito Santo, Vitória/ES, Brazil
| | - Carolina M. Sales
- Laboratory of Epidemiology of Federal University of Espírito Santo, Vitória/ES, Brazil
| | - Mauro N. Sanchez
- Departamento de Saúde Coletiva, Universidade de Brasília: Asa Norte, Brasília/DF, Brazil
| | | | - Kleydson B. Andrade
- Programa Nacional de Controle da Tuberculose—Ministério da Saúde, Brasília/DF, Brazil
| | - M. Gabriela M. Gomes
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- CIBIO-InBIO, Centro de Investigação em Biodiversidade e Recursos Genéticos, Universidade do Porto, Vairão, Portugal
| | - Delia Boccia
- London School of Hygiene and Tropical Medicine: Keppel St., Bloomsbury, London, United Kingdom
| | - Christian Lienhardt
- Global TB Programme, World Health Organisation, Geneva, Switzerland
- Unité Mixte Internationale TransVIHMI (UMI 233 IRD–U1175 INSERM—Université de Montpellier), Institut de Recherche pour le Développement, Montpellier, France
| | - Ethel L. Maciel
- Laboratory of Epidemiology of Federal University of Espírito Santo, Vitória/ES, Brazil
| |
Collapse
|
16
|
Chen L, Mei JZ, Chen XX, Feng HY, Wang JW, Li HC, Xu GH, Xiao LW, Huang YX, Zhou L. Cost-effectiveness Analysis of Two Therapeutic Regimens for Newly Diagnosed Smear-negative Pulmonary Tuberculosis. Biomed Environ Sci 2018; 31:623-626. [PMID: 30231968 DOI: 10.3967/bes2018.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 07/04/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Liang Chen
- Center for Tuberculosis Control of Guangdong Province, Guangzhou 510430, Guangdong, China
| | - Jin Zhou Mei
- Bao'an Chronic Disease Prevent and Cure Hospital, Shenzheng 518020, Guangdong, China
| | - Xun Xun Chen
- Center for Tuberculosis Control of Guangdong Province, Guangzhou 510430, Guangdong, China
| | - Hui Ying Feng
- Center for Tuberculosis Control of Guangdong Province, Guangzhou 510430, Guangdong, China
| | - Jia Wen Wang
- Center for Tuberculosis Control of Guangdong Province, Guangzhou 510430, Guangdong, China
| | - Hai Cheng Li
- Center for Tuberculosis Control of Guangdong Province, Guangzhou 510430, Guangdong, China
| | - Guang Hui Xu
- Institute for Tuberculosis Control of Jiangmen, Jiangmen 529000, Guangdong, China
| | - Ling Wen Xiao
- Baiyun Center for Chronic Disease Control, Guangzhou 510430, Guangdong, China
| | - Yi Xiang Huang
- School of Public Health, Sun Yet-sen University, Guangzhou 510080, Guangdong, China
| | - Lin Zhou
- Center for Tuberculosis Control of Guangdong Province, Guangzhou 510430, Guangdong, China
| |
Collapse
|
17
|
Richterman A, Steer-Massaro J, Jarolimova J, Luong Nguyen LB, Werdenberg J, Ivers LC. Cash interventions to improve clinical outcomes for pulmonary tuberculosis: systematic review and meta-analysis. Bull World Health Organ 2018; 96:471-483. [PMID: 29962550 PMCID: PMC6022611 DOI: 10.2471/blt.18.208959] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 04/26/2018] [Accepted: 04/30/2018] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To assess cash transfer interventions for improving treatment outcomes of active pulmonary tuberculosis in low- and middle-income countries. METHODS We searched PubMed®, Embase®, Cochrane Library and ClinicalTrials.gov for studies published until 4 August 2017 that reported on cash transfer interventions during the treatment of active pulmonary tuberculosis in low- and middle-income countries. Our primary outcome was a positive clinical outcome, defined as treatment success, treatment completion or microbiologic cure. Using the purchasing power parity conversion factor, we converted the amount of cash received per patient within each study into international dollars (Int$). We calculated odds ratio (OR) for the primary outcome using a random effects meta-analysis. FINDINGS Eight studies met eligibility criteria for review inclusion. Seven studies assessed a tuberculosis-specific intervention, with average amount of cash ranging from Int$ 193-858. One study assessed a tuberculosis-sensitive intervention, with average amount of Int$ 101. Four studies included non-cash co-interventions. All studies showed better primary outcome for the intervention group than the control group. After excluding three studies with high risk of bias, patients receiving tuberculosis-specific cash transfer were more likely to have a positive clinical outcome than patients in the control groups (OR: 1.77; 95% confidence interval: 1.57-2.01). CONCLUSION The evidence available suggests that patients in low- and middle-income countries receiving cash during treatment for active pulmonary tuberculosis are more likely to have a positive clinical outcome. These findings support the incorporation of cash transfer interventions into social protection schemes within tuberculosis treatment programmes.
Collapse
Affiliation(s)
- Aaron Richterman
- Department of Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, United States of America (USA)
| | - Jonathan Steer-Massaro
- Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, USA
| | - Jana Jarolimova
- Department of Medicine, Massachusetts General Hospital, Boston, USA
| | - Liem Binh Luong Nguyen
- Infection, Antimicrobials, Modelling and Evolution, Unité Mixte de Recherche 1137, INSERM, Paris, France
| | | | - Louise C Ivers
- Center for Global Health, Massachusetts General Hospital, Boston, USA
| |
Collapse
|
18
|
Chabala C, Turkova A, Thomason MJ, Wobudeya E, Hissar S, Mave V, van der Zalm M, Palmer M, Kapasa M, Bhavani PK, Balaji S, Raichur PA, Demers AM, Hoddinott G, Owen-Powell E, Kinikar A, Musoke P, Mulenga V, Aarnoutse R, McIlleron H, Hesseling A, Crook AM, Cotton M, Gibb DM. Shorter treatment for minimal tuberculosis (TB) in children (SHINE): a study protocol for a randomised controlled trial. Trials 2018; 19:237. [PMID: 29673395 PMCID: PMC5909210 DOI: 10.1186/s13063-018-2608-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 03/15/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) in children is frequently paucibacillary and non-severe forms of pulmonary TB are common. Evidence for tuberculosis treatment in children is largely extrapolated from adult studies. Trials in adults with smear-negative tuberculosis suggest that treatment can be effectively shortened from 6 to 4 months. New paediatric, fixed-dose combination anti-tuberculosis treatments have recently been introduced in many countries, making the implementation of World Health Organisation (WHO)-revised dosing recommendations feasible. The safety and efficacy of these higher drug doses has not been systematically assessed in large studies in children, and the pharmacokinetics across children representing the range of weights and ages should be confirmed. METHODS/DESIGN SHINE is a multicentre, open-label, parallel-group, non-inferiority, randomised controlled, two-arm trial comparing a 4-month vs the standard 6-month regimen using revised WHO paediatric anti-tuberculosis drug doses. We aim to recruit 1200 African and Indian children aged below 16 years with non-severe TB, with or without HIV infection. The primary efficacy and safety endpoints are TB disease-free survival 72 weeks post randomisation and grade 3 or 4 adverse events. Nested pharmacokinetic studies will evaluate anti-tuberculosis drug concentrations, providing model-based predictions for optimal dosing, and measure antiretroviral exposures in order to describe the drug-drug interactions in a subset of HIV-infected children. Socioeconomic analyses will evaluate the cost-effectiveness of the intervention and social science studies will further explore the acceptability and palatability of these new paediatric drug formulations. DISCUSSION Although recent trials of TB treatment-shortening in adults with sputum-positivity have not been successful, the question has never been addressed in children, who have mainly paucibacillary, non-severe smear-negative disease. SHINE should inform whether treatment-shortening of drug-susceptible TB in children, regardless of HIV status, is efficacious and safe. The trial will also fill existing gaps in knowledge on dosing and acceptability of new anti-tuberculosis formulations and commonly used HIV drugs in settings with a high burden of TB. A positive result from this trial could simplify and shorten treatment, improve adherence and be cost-saving for many children with TB. Recruitment to the SHINE trial begun in July 2016; results are expected in 2020. TRIAL REGISTRATION International Standard Randomised Controlled Trials Number: ISRCTN63579542 , 14 October 2014. Pan African Clinical Trials Registry Number: PACTR201505001141379 , 14 May 2015. Clinical Trial Registry-India, registration number: CTRI/2017/07/009119, 27 July 2017.
Collapse
Affiliation(s)
- Chishala Chabala
- University Teaching Hospital, Children’s Hospital, Private Bag RW IX, Ridgeway, Lusaka, Zambia
| | - Anna Turkova
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, High Holborn, London, WC1V 6LJ UK
| | - Margaret J. Thomason
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, High Holborn, London, WC1V 6LJ UK
| | - Eric Wobudeya
- Makerere University-John Hopkins University Care Ltd, Kampala, Uganda
| | - Syed Hissar
- India Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Vidya Mave
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | | | - Megan Palmer
- Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Monica Kapasa
- University Teaching Hospital, Children’s Hospital, Private Bag RW IX, Ridgeway, Lusaka, Zambia
| | - Perumal K. Bhavani
- India Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Sarath Balaji
- India Institute of Child Health and Hospital for Children, Chennai, India
| | | | - Anne-Marie Demers
- Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Ellen Owen-Powell
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, High Holborn, London, WC1V 6LJ UK
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Philippa Musoke
- Makerere University-John Hopkins University Care Ltd, Kampala, Uganda
| | - Veronica Mulenga
- University Teaching Hospital, Children’s Hospital, Private Bag RW IX, Ridgeway, Lusaka, Zambia
| | - Rob Aarnoutse
- Radbound University Medical Center, Nijmegen, The Netherlands
| | | | - Anneke Hesseling
- Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Angela M. Crook
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, High Holborn, London, WC1V 6LJ UK
| | - Mark Cotton
- Family Infectious Diseases Clinical Research Unit, Stellensbosch University, Cape Town, South Africa
| | - Diana M. Gibb
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, High Holborn, London, WC1V 6LJ UK
| | - on behalf of the SHINE trial team
- University Teaching Hospital, Children’s Hospital, Private Bag RW IX, Ridgeway, Lusaka, Zambia
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, High Holborn, London, WC1V 6LJ UK
- Makerere University-John Hopkins University Care Ltd, Kampala, Uganda
- India Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
- Byramjee Jeejeebhoy Government Medical College, Pune, India
- Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
- India Institute of Child Health and Hospital for Children, Chennai, India
- Radbound University Medical Center, Nijmegen, The Netherlands
- University of Cape Town, Cape Town, South Africa
- Family Infectious Diseases Clinical Research Unit, Stellensbosch University, Cape Town, South Africa
| |
Collapse
|
19
|
Affiliation(s)
- Kee B Park
- Korean American Medical Association, Englewood Cliffs, NJ, USA; Program in Global Surgery and Social Change, Harvard Medical School, Harvard University, Boston, MA 02115, USA.
| | - Uzma Khan
- Interactive Research & Development, Dubai, United Arab Emirates
| | - Kwonjune Seung
- Partners In Health, Boston, MA, USA; Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
20
|
Fuady A, Houweling TA, Mansyur M, Richardus JH. Adaptation of the Tool to Estimate Patient Costs Questionnaire into Indonesian Context for Tuberculosis-affected Households. Acta Med Indones 2018; 50:3-10. [PMID: 29686170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Indonesia is the second-highest country for tuberculosis (TB) incidence worldwide. Hence, it urgently requires improvements and innovations beyond the strategies that are currently being implemented throughout the country. One fundamental step in monitoring its progress is by preparing a validated tool to measure total patient costs and catastrophic total costs. The World Health Organization (WHO) recommends using a version of the generic questionnaire that has been adapted to the local cultural context in order to interpret findings correctly. This study is aimed to adapt the Tool to Estimate Patient Costs questionnaire into the Indonesian context, which measures total costs and catastrophic total costs for tuberculosis-affected households. METHODS the tool was adapted using best-practice guidelines. On the basis of a pre-test performed in a previous study (referred to as Phase 1 Study), we refined the adaptation process by comparing it with the generic tool introduced by the WHO. We also held an expert committee review and performed pre-testing by interviewing 30 TB patients. After pre-testing, the tool was provided with complete explanation sheets for finalization. RESULTS seventy-two major changes were made during the adaptation process including changing the answer choices to match the Indonesian context, refining the flow of questions, deleting questions, changing some words and restoring original questions that had been changed in Phase 1 Study. Participants indicated that most questions were clear and easy to understand. To address recall difficulties by the participants, we made some adaptations to obtain data that might be missing, such as tracking data to medical records, developing a proxy of costs and guiding interviewers to ask for a specific value when participants were uncertain about the estimated market value of property they had sold. CONCLUSION the adapted Tool to Estimate Patient Costs in Bahasa Indonesia is comprehensive and ready for use in future studies on TB-related catastrophic costs and is suitable for monitoring progress to achieve the target of the End TB Strategy.
Collapse
Affiliation(s)
- Ahmad Fuady
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, The Netherlands.
| | | | | | | |
Collapse
|
21
|
Noori MY, Ali F, Ali Z, Sharafat S. Comparison Of Ziehl-Neelsen Based Light Microscopy With Led Fluorescent Microscopy For Tuberculosis Diagnosis: An Insight From A Limited Resource-High Burden setting. J Ayub Med Coll Abbottabad 2017; 29:577-579. [PMID: 29330981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Microscopy is the most widely used tool for Tuberculosis screening. Conventionally, Ziehl-Neelsen (ZN) staining has been the widely used for staining Acid-Fast Bacilli (AFB) but with the advent of Fluorescent staining, Auramine O stain is now being adapted as the preferred method for setups with high workload as it has the advantage of being less laborious, since bacteria fluoresce in front of a dark background and are easier to count. This study was performed to compare the efficiency of the two methods in a high-burden, limited resource setting to see the magnitude of diagnostic accuracy between ZN and Fluorescent Microscopy, using culture as the standard.. METHODS Altogether 987 culturally confirmed cases were considered from the period 36 months during January 2011 to December 2013 and data were compiled from the records maintained at the Provincial Tuberculosis Reference Laboratory at Ojha Institute of Chest Diseases, Dow University of Health Sciences, Karachi. The results from 523 cases examined using ZN and 464 cases using Fluorescent staining method were compared for diagnostic accuracy on the basis of Mycobacterial culture results. Smears are prepared from the clinical samples obtained from presumptive tuberculosis patients. RESULTS The results of ZN method showed 94.23% [95% CI 91.32-96.39%] sensitivity and 84.91% [95% CI 78.38-90.08%] specificity. While FM showed a sensitivity of 97.15% [95% CI 94.82-98.63%] and specificity of 83.19% [95% CI 74.99-89.56%].. CONCLUSIONS The results showed that Fluorescent microscopy was slightly more sensitive than ZN light Microscopy, while specificity of both the methods were comparable.
Collapse
Affiliation(s)
- Muhammad Yahya Noori
- Department of Pathology, Dow International Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Faiza Ali
- Department of Pathology, Dow International Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Zaheer Ali
- Department of Pathology, Dow International Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Shaheen Sharafat
- Department of Pathology, Dow International Medical College, Dow University of Health Sciences, Karachi, Pakistan
| |
Collapse
|
22
|
Chan E, Nolan A, Denholm J. How much does tuberculosis cost? An Australian healthcare perspective analysis. Commun Dis Intell (2018) 2017; 41:E191-E194. [PMID: 29720069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Tuberculosis (TB) remains a disease of high morbidity in Australia, with implications for both public health and the individual. Cost analyses is relevant for programmatic evaluation of TB. There is minimal published TB cost data in the Australian setting. Patients with drug sensitive active pulmonary TB (DS-PTB) and latent TB (LTBI) were enrolled in a single tertiary referral centre to evaluate healthcare provider costs. The median cost of treating drug susceptible pulmonary TB in this case series was 11,538 AUD. Approximately 50% of total costs is derived from inpatient hospitalisation bed days. In comparison, the average cost of managing latent TB was 582 AUD per completed course. We find the median provider cost of our DS-PTB treatment group comparable to costs from other regions globally with similar economic profiles. A program designed to detect and treat LTBI to prevent subsequent disease may be cost effective in appropriately selected patients and warrants further study.
Collapse
Affiliation(s)
- Eddie Chan
- Victorian Infectious Diseases Service, Melbourne Health, Parkville, Victoria, Australia
| | - Aine Nolan
- Victorian Tuberculosis Program, Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Justin Denholm
- Victorian Tuberculosis Program, Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| |
Collapse
|
23
|
Affiliation(s)
| | - Anoop Misra
- Fortis CDOC Hopsital for Diabetes and Metabolic Diseases
| |
Collapse
|
24
|
Kimaro GD, Mfinanga S, Simms V, Kivuyo S, Bottomley C, Hawkins N, Harrison TS, Jaffar S, Guinness L. The costs of providing antiretroviral therapy services to HIV-infected individuals presenting with advanced HIV disease at public health centres in Dar es Salaam, Tanzania: Findings from a randomised trial evaluating different health care strategies. PLoS One 2017; 12:e0171917. [PMID: 28234969 PMCID: PMC5325220 DOI: 10.1371/journal.pone.0171917] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 01/28/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Understanding the costs associated with health care delivery strategies is essential for planning. There are few data on health service resources used by patients and their associated costs within antiretroviral (ART) programmes in Africa. MATERIAL AND METHODS The study was nested within a large trial, which evaluated screening for cryptococcal meningitis and tuberculosis and a short initial period of home-based adherence support for patients initiating ART with advanced HIV disease in Tanzania and Zambia. The economic evaluation was done in Tanzania alone. We estimated costs of providing routine ART services from the health service provider's perspective using a micro-costing approach. Incremental costs for the different novel components of service delivery were also estimated. All costs were converted into US dollars (US$) and based on 2012 prices. RESULTS Of 870 individuals enrolled in Tanzania, 434 were enrolled in the intervention arm and 436 in the standard care/control arm. Overall, the median (IQR) age and CD4 cell count at enrolment were 38 [31, 44] years and 52 [20, 89] cells/mm3, respectively. The mean per patient costs over the first three months and over a one year period of follow up following ART initiation in the standard care arm were US$ 107 (95%CI 101-112) and US$ 265 (95%CI 254-275) respectively. ART drugs, clinic visits and hospital admission constituted 50%, 19%, and 19% of the total cost per patient year, while diagnostic tests and non-ART drugs (co-trimoxazole) accounted for 10% and 2% of total per patient year costs. The incremental costs of the intervention to the health service over the first three months was US$ 59 (p<0.001; 95%CI 52-67) and over a one year period was US$ 67(p<0.001; 95%CI 50-83). This is equivalent to an increase of 55% (95%CI 51%-59%) in the mean cost of care over the first three months, and 25% (95%CI 20%-30%) increase over one year of follow up.
Collapse
MESH Headings
- Adult
- Anti-HIV Agents/economics
- Anti-HIV Agents/therapeutic use
- Antiretroviral Therapy, Highly Active/economics
- CD4 Lymphocyte Count
- Delivery of Health Care/economics
- Delivery of Health Care/statistics & numerical data
- Disease Progression
- Female
- HIV Infections/diagnosis
- HIV Infections/drug therapy
- HIV Infections/economics
- HIV Infections/virology
- Health Care Costs/statistics & numerical data
- Health Resources
- Humans
- Male
- Meningitis, Cryptococcal/diagnosis
- Meningitis, Cryptococcal/drug therapy
- Meningitis, Cryptococcal/economics
- Meningitis, Cryptococcal/microbiology
- Public Health Systems Research
- Tanzania
- Trimethoprim, Sulfamethoxazole Drug Combination/economics
- Trimethoprim, Sulfamethoxazole Drug Combination/therapeutic use
- Tuberculosis, Pulmonary/diagnosis
- Tuberculosis, Pulmonary/drug therapy
- Tuberculosis, Pulmonary/economics
- Tuberculosis, Pulmonary/microbiology
- Zambia
Collapse
Affiliation(s)
- Godfather Dickson Kimaro
- Muhimbili Medical Research Centre, National Institute for Medical Research, Dar es Salaam, Tanzania
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sayoki Mfinanga
- Muhimbili Medical Research Centre, National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Victoria Simms
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sokoine Kivuyo
- Muhimbili Medical Research Centre, National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Christian Bottomley
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Neil Hawkins
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Thomas S. Harrison
- Institute for Infection and Immunity, St Georges University of London, London, United Kingdom
| | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Lorna Guinness
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | |
Collapse
|
25
|
Cousins S. Funding shortfalls put target to end TB epidemic by 2035 at risk. BMJ 2016; 355:i5779. [PMID: 27784717 DOI: 10.1136/bmj.i5779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
26
|
Hsairi M, Ben Braham M, Gamara D, Fourati R, Abid F, Tritar F, Charfi MR. Tuberculosis cost in tunisia. Tunis Med 2016; 94:604-611. [PMID: 28685796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Tuberculosis (TB) infects one third of the world population. Its economic impact is important, affecting the global economy in the World. OBJECTIVE To determine the economic costs related to tuberculosis in Tunisia. METHODS Calculations were made for the reference year 2013; we covered all cost components of the disease, which are related to program management, BCG vaccination, health workers training, social mobilization, screening, chemoprophylaxis, and tuberculosis care. With the exception of costs related to care, which were the subject of a specific survey, the costs of other categories were obtained from the National TB Control Program. RESULTS The cost of the different components related to the management, prevention, screening and tuberculosis care in 2013 amounted 504688,000DT. The cost of care represented 80.0% of total costs (6807 808,000DT) ; cost related to program management represented 13.2% (1 121 580,00 DT) and the BCG vaccination 6.0% e (512 300,00DT) The average cost per patient was 1447,360 DTin 2013. CONCLUSION Reducing the cost of tuberculosis, would involve reducing diagnostic delay. It is also recommended to reduce hospitalization recourse, and prevent multidrug resistance which lead to additional expenditures.
Collapse
|
27
|
Hsairi M, Ben Braham M, Gamara D, Fourati R, Abid F, Tritar F, Charfi MR. Tuberculosis cost in tunisia. Tunis Med 2016; 94:604-611. [PMID: 28972252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Tuberculosis (TB) infects one third of the world population. Its economic impact is important, affecting the global economy in the World. OBJECTIVE To determine the economic costs related to tuberculosis in Tunisia. METHODS Calculations were made for the reference year 2013; we covered all cost components of the disease, which are related to program management, BCG vaccination, health workers training, social mobilization, screening, chemoprophylaxis, and tuberculosis care. With the exception of costs related to care, which were the subject of a specific survey, the costs of other categories were obtained from the National TB Control Program. RESULTS The cost of the different components related to the management, prevention, screening and tuberculosis care in 2013 amounted 504688,000DT. The cost of care represented 80.0% of total costs (6807 808,000DT) ; cost related to program management represented 13.2% (1 121 580,00 DT) and the BCG vaccination 6.0% e (512 300,00DT) The average cost per patient was 1447,360 DTin 2013. CONCLUSION Reducing the cost of tuberculosis, would involve reducing diagnostic delay. It is also recommended to reduce hospitalization recourse, and prevent multidrug resistance which lead to additional expenditures.
Collapse
|
28
|
Clarke M, Dick J, Bogg L. Cost-effectiveness analysis of an alternative tuberculosis management strategy for permanent farm dwellers in South Africa amidst health service contraction. Scand J Public Health 2016; 34:83-91. [PMID: 16449048 DOI: 10.1080/14034940510032220] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Aim: To establish the cost-effectiveness of lay health workers (LHWs) in conjunction with the current, local tuberculosis (TB) control programme, amidst health service contraction. Method: A cost-effectiveness analysis, comparing direct time costs of the current TB management strategy among permanent farm dwellers, with an intervention, whereby LHWs are involved in TB control activities on farms. Measure of effectiveness was case finding and cure rates of adult new smear-positive (NSP) TB cases, alongside a randomized control trial (RCT): Results: The observed cost reduction to the Boland Health District was 74% per case detected and cured on the intervention farms relative to the control farms. Intervention farms reached 83% successful treatment completion rate, control farms 65%. Although the successful treatment adherence was significantly different (18% letter). The improved case detection and cure rates were not statistically significant (chisquared test). Direct LHW costs are borne by farmers. Farmers were motivated to bear costs by reduced job absenteeism and other positive side-effects. Even without outcome improvements costs per case cured were 59% lower on the intervention farms. Conclusion: TB control has suffered from budget reductions in South Africa. It is critically important to develop cost-effective strategies to reduce the TB burden. Costs to public budgets can be substantially reduced while maintaining or improving case detection and treatment outcomes, by using farm-based LHWs.
Collapse
Affiliation(s)
- Marina Clarke
- Faculty of Applied Sciences, Cape Peninsula University of Technology, Cape Town, South Africa.
| | | | | |
Collapse
|
29
|
Abstract
This case study examines the ethical dimensions of isolation for patients diagnosed with tuberculosis (TB) in Australia. It seeks to explore the issues of resource allocation, liberty, and public safety for wider consideration and discussion.
Collapse
Affiliation(s)
- Jane Carroll
- Centre for Values Ethics and the Law in Medicine, Level 1, 92-94 Parramatta Rd, Camperdown, NSW, 2050, Australia.
- School of Public Health, University of Sydney, Sydney, NSW, 2006, Australia.
| |
Collapse
|
30
|
Cunnama L, Sinanovic E, Ramma L, Foster N, Berrie L, Stevens W, Molapo S, Marokane P, McCarthy K, Churchyard G, Vassall A. Using Top-down and Bottom-up Costing Approaches in LMICs: The Case for Using Both to Assess the Incremental Costs of New Technologies at Scale. Health Econ 2016; 25 Suppl 1:53-66. [PMID: 26763594 PMCID: PMC5066665 DOI: 10.1002/hec.3295] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 10/27/2015] [Accepted: 11/05/2015] [Indexed: 05/06/2023]
Abstract
PURPOSE Estimating the incremental costs of scaling-up novel technologies in low-income and middle-income countries is a methodologically challenging and substantial empirical undertaking, in the absence of routine cost data collection. We demonstrate a best practice pragmatic approach to estimate the incremental costs of new technologies in low-income and middle-income countries, using the example of costing the scale-up of Xpert Mycobacterium tuberculosis (MTB)/resistance to riframpicin (RIF) in South Africa. MATERIALS AND METHODS We estimate costs, by applying two distinct approaches of bottom-up and top-down costing, together with an assessment of processes and capacity. RESULTS The unit costs measured using the different methods of bottom-up and top-down costing, respectively, are $US16.9 and $US33.5 for Xpert MTB/RIF, and $US6.3 and $US8.5 for microscopy. The incremental cost of Xpert MTB/RIF is estimated to be between $US14.7 and $US17.7. While the average cost of Xpert MTB/RIF was higher than previous studies using standard methods, the incremental cost of Xpert MTB/RIF was found to be lower. CONCLUSION Costs estimates are highly dependent on the method used, so an approach, which clearly identifies resource-use data collected from a bottom-up or top-down perspective, together with capacity measurement, is recommended as a pragmatic approach to capture true incremental cost where routine cost data are scarce.
Collapse
Affiliation(s)
- Lucy Cunnama
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Edina Sinanovic
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Lebogang Ramma
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nicola Foster
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Leigh Berrie
- National Priority Programmes, National Health Laboratory Services, Johannesburg, South Africa
| | - Wendy Stevens
- National Priority Programmes, National Health Laboratory Services, Johannesburg, South Africa
| | - Sebaka Molapo
- National Priority Programmes, National Health Laboratory Services, Johannesburg, South Africa
| | - Puleng Marokane
- National Priority Programmes, National Health Laboratory Services, Johannesburg, South Africa
| | | | - Gavin Churchyard
- Aurum Institute for Health Research, Johannesburg, South Africa
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anna Vassall
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| |
Collapse
|
31
|
|
32
|
Abimbola S, Ukwaja KN, Onyedum CC, Negin J, Jan S, Martiniuk AL. Transaction costs of access to health care: Implications of the care-seeking pathways of tuberculosis patients for health system governance in Nigeria. Glob Public Health 2015; 10:1060-77. [PMID: 25652349 PMCID: PMC4696418 DOI: 10.1080/17441692.2015.1007470] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 10/17/2014] [Indexed: 11/21/2022]
Abstract
Health care costs incurred prior to the appropriate patient-provider transaction (i.e., transaction costs of access to health care) are potential barriers to accessing health care in low- and middle-income countries. This paper explores these transaction costs and their implications for health system governance through a cross-sectional survey of adult patients who received their first diagnosis of pulmonary tuberculosis (TB) at the three designated secondary health centres for TB care in Ebonyi State, Nigeria. The patients provided information on their care-seeking pathways and the associated costs prior to reaching the appropriate provider. Of the 452 patients, 84% first consulted an inappropriate provider. Only 33% of inappropriate consultations were with qualified providers (QP); the rest were with informal providers such as pharmacy providers (PPs; 57%) and traditional providers (TP; 10%). Notably, 62% of total transaction costs were incurred during the first visit to an inappropriate provider and the mean transaction costs incurred was highest with QPs (US$30.20) compared with PPs (US$14.40) and TPs (US$15.70). These suggest that interventions for reducing transaction costs should include effective decentralisation to integrate TB care with services at the primary health care level, community engagement to address information asymmetry, enforcing regulations to keep informal providers within legal limits and facilitating referral linkages among formal and informal providers to increase early contact with appropriate providers.
Collapse
Affiliation(s)
- Seye Abimbola
- School of Public Health, University of Sydney, Sydney, NSW, Australia
- National Primary Health Care Development Agency, Abuja, Nigeria
- The George Institute for Global Health, Sydney, NSW, Australia
| | | | - Cajetan C. Onyedum
- College of Medicine, University of Nigeria, Enugu Campus, Nsukka, Nigeria
| | - Joel Negin
- School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Stephen Jan
- School of Public Health, University of Sydney, Sydney, NSW, Australia
- The George Institute for Global Health, Sydney, NSW, Australia
| | - Alexandra L.C. Martiniuk
- School of Public Health, University of Sydney, Sydney, NSW, Australia
- The George Institute for Global Health, Sydney, NSW, Australia
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
33
|
Bowerman RJ. The promise of rapid detection of active pulmonary tuberculosis in rural Alaska. Alaska Med 2015; 56:24-28. [PMID: 26554126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND The process by which active pulmonary tuberculosis (TB) is detected can be tediously slow in rural and often roadless Alaska, where several hundred air or boat miles can separate a patient from a chest x-ray and/or sputum collection. Additionally, the only TB reference lab in the state is many hundreds of air miles away, albeit centrally located in Anchorage. Under such conditions, it may take up to a week to process serial sputum AFB smears. This can result in either delayed onset of treatment or unnecessary empiric treatment, all while safety for the community is being considered. This dilemma often results in precautionary hospital isolation of a patient who might otherwise have been able to travel home by air. This article proposes a roadmap for remote health care settings that might bridge our current TB diagnostic ability to a better way in the future. METHODS Current TB diagnostic guidelines in our area (Yukon-Kuskokwim Delta) were reviewed for integration of the Xpert MTB/ RIF assay with the purpose of improving TB health care while emphasizing patient benefits and cost savings. RESULTS A clinical guideline that integrates the rapid TB assay into the current TB diagnostic algorithms for adults and adolescents is proposed. Crude cost savings at our hospital resulting from this guideline are estimated to be $316,000 per year. CONCLUSION The proven utility of a new rapid TB diagnostic, the Xpert MTB/RIF assay, offers the promise of more efficient TB medical care, improved patient human rights and improved hospital and community environmental safety, all with likely huge reduced health care costs in remote Alaska.
Collapse
|
34
|
Wingfield T, Boccia D, Tovar MA, Huff D, Montoya R, Lewis JJ, Gilman RH, Evans CA. Designing and implementing a socioeconomic intervention to enhance TB control: operational evidence from the CRESIPT project in Peru. BMC Public Health 2015; 15:810. [PMID: 26293238 PMCID: PMC4546087 DOI: 10.1186/s12889-015-2128-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 08/07/2015] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Cash transfers are key interventions in the World Health Organisation's post-2015 global TB policy. However, evidence guiding TB-specific cash transfer implementation is limited. We designed, implemented and refined a novel TB-specific socioeconomic intervention that included cash transfers, which aimed to support TB prevention and cure in resource-constrained shantytowns in Lima, Peru for: the Community Randomized Evaluation of a Socioeconomic Intervention to Prevent TB (CRESIPT) project. METHODS Newly-diagnosed TB patients from study-site healthposts were eligible to receive the intervention consisting of economic and social support. Economic support was provided to patient households through cash transfers on meeting the following conditions: screening for TB in household contacts and MDR TB in patients; adhering to TB treatment and chemoprophylaxis; and engaging with CRESIPT social support (household visits and community meetings). To evaluate project acceptability, quantitative and qualitative feedback was collected using a mixed-methods approach during formative activities. Formative activities included consultations, focus group discussions and questionnaires conducted with the project team, project participants, civil society and stakeholders. RESULTS Over 7 months, 135 randomly-selected patients and their 647 household contacts were recruited from 32 impoverished shantytown communities. Of 1299 potential cash transfers, 964 (74 %) were achieved, 259 (19 %) were not achieved, and 76 (7 %) were yet to be achieved. Of those achieved, 885/964 (92 %) were achieved optimally and 79/964 (8 %) sub-optimally. Key project successes were identified during 135 formative activities and included: strong multi-sectorial collaboration; generation of new evidence for TB-specific cash transfer; and the project being perceived as patient-centred and empowering. Challenges included: participant confidence being eroded through cash transfer delays, hidden account-charges and stigma; access to the initial bank-provider being limited; and conditions requiring participation of all TB-affected household members (e.g. community meetings) being hard to achieve. Refinements were made to improve project acceptability and future impact: the initial bank-provider was changed; conditional and unconditional cash transfers were combined; cash transfer sums were increased to a locally-appropriate, evidence-based amount; and cash transfer size varied according to patient household size to maximally reduce mitigation of TB-related costs and be more responsive to household needs. CONCLUSIONS A novel TB-specific socioeconomic intervention including conditional cash transfers has been designed, implemented, refined and is ready for impact assessment, including by the CRESIPT project. The lessons learnt during this research will inform policy-makers and decision-makers for future implementation of related interventions.
Collapse
Affiliation(s)
- Tom Wingfield
- Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Peru.
- Innovation For Health And Development (IFHAD), Infectious Diseases & Immunity, Imperial College London, and Wellcome Trust Imperial College Centre for Global Health Research, London, UK.
- The Monsall Infectious Diseases Unit, North Manchester General Hospital, Manchester, UK.
| | - Delia Boccia
- Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Peru.
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
| | - Marco A Tovar
- Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Peru.
- Innovation For Health And Development (IFHAD), Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru.
| | - Doug Huff
- Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Peru.
- Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA.
| | - Rosario Montoya
- Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Peru.
| | - James J Lewis
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
| | - Robert H Gilman
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Carlton A Evans
- Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Peru.
- Innovation For Health And Development (IFHAD), Infectious Diseases & Immunity, Imperial College London, and Wellcome Trust Imperial College Centre for Global Health Research, London, UK.
- Innovation For Health And Development (IFHAD), Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru.
| |
Collapse
|
35
|
Gama E, Madan J, Banda H, Squire B, Thomson R, Namakhoma I. Economic evaluation of the practical approach to lung health and informal provider interventions for improving the detection of tuberculosis and chronic airways disease at primary care level in Malawi: study protocol for cost-effectiveness analysis. Implement Sci 2015; 10:1. [PMID: 25567289 PMCID: PMC4302070 DOI: 10.1186/s13012-014-0195-8] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 12/16/2014] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Chronic airway diseases pose a big challenge to health systems in most developing countries, particularly in Sub-Saharan Africa. A diagnosis for people with chronic or persistent cough is usually delayed because of individual and health system barriers. However, delayed diagnosis and treatment facilitates further transmission, severity of disease with complications and mortality. The objective of this study is to assess the cost-effectiveness of the practical approach to lung health strategy, a patient-centred approach for diagnosis and treatment of common respiratory illnesses in primary healthcare settings, as a means of strengthening health systems to improve the quality of management of respiratory diseases. METHODS/DESIGN Economic evaluation nested in a cluster randomised controlled trial with three arms will be performed. Measures of effectiveness and costs for all arms of the study will be obtained from the cluster randomised controlled clinical trial. The main outcome measures are a combined rate of major respiratory diseases milestones and process indicators extracted from the practical approach to lung health strategy. For analysis, descriptive as well as regression techniques will be used. A cost-effectiveness analysis will be performed according to intention-to-treat principle and from a societal perspective. Cost-effectiveness ratios will be calculated using bootstrapping techniques. DISCUSSION We hope to demonstrate the cost-effectiveness of the practical approach to lung health and informal healthcare providers, see an improvement in patients' quality of life, achieve a reduction in the duration and occurrence of episodes and the chronicity of respiratory diseases, and are able to report a decrease in the social cost. If the practical approach to lung health and informal healthcare provider's interventions are cost-effective, they could be scaled up to all primary healthcare centres. TRIAL REGISTRATION PACTR: PACTR201411000910192.
Collapse
Affiliation(s)
- Elvis Gama
- Centre for Applied Health Research and Delivery (CAHRD), Liverpool School of Tropical Medicine, Pembroke Place, L3 5QA, Liverpool, UK.
| | - Jason Madan
- Warwick Medical School, University of Warwick, Coventry, UK.
| | | | - Bertie Squire
- Centre for Applied Health Research and Delivery (CAHRD), Liverpool School of Tropical Medicine, Pembroke Place, L3 5QA, Liverpool, UK.
| | - Rachael Thomson
- Centre for Applied Health Research and Delivery (CAHRD), Liverpool School of Tropical Medicine, Pembroke Place, L3 5QA, Liverpool, UK.
| | | |
Collapse
|
36
|
Akrim M, Bennani K, Essolbi A, Sghiar M, Likos A, Benmamoun A, Menzhi OE, Maaroufi A. Determinants of consultation, diagnosis and treatment delays among new smear-positive pulmonary tuberculosis patients in Morocco: a cross-sectional study. East Mediterr Health J 2014; 20:707-716. [PMID: 25601809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 04/04/2014] [Indexed: 06/04/2023]
Abstract
We conducted a cross-sectional survey in 2012 in 12 selected provinces and prefectures in Morocco to determine consultation delay (patient delay), diagnosis delay and treatment delay (health system delays), and factors relating to these delays. The sample included 250 eligible and consenting newly diagnosed smearpositive pulmonary tuberculosis patients who were interviewed at the time of their registration within Diagnosis of Tuberculosis and Respiratory Diseases Reference Centers (CDTMR) or Integrated Health Centers (CSI) using a pretested and structured questionnaire. The median total delay was 46 days [inter-quartile interval (IQI) = 29-84 days]. Patient delay (median = 20; IQI = 8-47 days) was higher than health system delay (median=15; IIQ = 7-35 days). Being illiterate, thinking symptoms will disappear by themselves; having financial constraints and feeling fear of diagnosis or social isolation were associated with patient delay. Consulting first in the private sector or having 3 or more consultations before diagnosis was associated with health system delay.
Collapse
Affiliation(s)
- M Akrim
- Institut National d'Administration Sanitaire, Programme FETP-Maroc, Rabat (Maroc)
| | - K Bennani
- Service des Maladies Respiratoires, Direction de l'Épidémiologie et de Lutte contre les Maladies, Rabat (Maroc)
| | - A Essolbi
- Institut National d'Administration Sanitaire, Programme FETP-Maroc, Rabat (Maroc)
| | - M Sghiar
- Service des Maladies Respiratoires, Direction de l'Épidémiologie et de Lutte contre les Maladies, Rabat (Maroc)
| | - A Likos
- Institut National d'Administration Sanitaire, Programme FETP-Maroc, Rabat (Maroc)
| | - A Benmamoun
- Service des Maladies Respiratoires, Direction de l'Épidémiologie et de Lutte contre les Maladies, Rabat (Maroc)
| | - O El Menzhi
- Service des Maladies Respiratoires, Direction de l'Épidémiologie et de Lutte contre les Maladies, Rabat (Maroc)
| | - A Maaroufi
- Institut National d'Administration Sanitaire, Programme FETP-Maroc, Rabat (Maroc)
| |
Collapse
|
37
|
Affiliation(s)
- David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| |
Collapse
|
38
|
Sanneh AFNS, Al-Shareef AM. Effectiveness and cost effectiveness of screening immigrants schemes for tuberculosis (TB) on arrival from high TB endemic countries to low TB prevalent countries. Afr Health Sci 2014; 14:663-71. [PMID: 25352886 DOI: 10.4314/ahs.v14i3.23] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Immigrants to developed countries are a major source of TB. Therefore amongst strategies adopted for TB control in developed countries include; 1) Screening immigrants at ports of entry referred to as "Port of Arrival Screening" (PoA) and 2) Passive screening (PS) for TB which means screening immigrants through general practices, hospitals, chest-clinics and emergency departments. Evidence of the effectiveness and cost effectiveness of these strategies is not consistent. OBJECTIVE Evaluate efficiency of active PoA TB screening for immigrants from TB endemic-regions compared with Passive Screening of immigrant-populations from TB endemic-regions. METHODS Major electronic-databases and reference lists of relevant studies were searched. Experts of immigrants' TB screening were contacted for additional studies published or unpublished. Systematic search of major databases identified only retrospective cohort-studies. Their qualities were assessed using Scottish Intercollegiate Guidelines Network (SIGN) methodological checklist for comparative cohort-studies. RESULTS Systematic electronic searches identified 1443 citations. Of these 74 studies were retrieved for evaluation against the review's inclusion/exclusion criteria (see study inclusion/exclusion criteria). Four studies met the inclusion criteria (figure 2) which were low in the evidence hierarchy of primary effectiveness studies and had heterogeneities between them. Thus descriptive data-synthesis was performed. Proportionately PoA screening had the lowest percentage of receipt of tuberculin skin test (TST) and the highest percentage of non-attendance for TST reading (table 2). Active PoA screening reduced infectiousness by 34% compared to 30% by passive screening and new entrants screened at PoA were 80% less likely to be hospitalised Odds ratio (OR) = 0.2 (95% confidence interval (CI) 0.1 - 0.2). [Table: see text]. ECONOMIC ANALYSIS One cost effectiveness analysis was found that compared the costs of; active PoA screening, general practice screening and homeless screening groups. The cost of detecting a case of TB were; £1.26, £13.17 and £96.36 for PS, homeless screening and active PoA screening respectively. The cost of preventing a case of TB were; £6.32, £23.00 and £10.00 for PS, homeless screening and PoA screening respectively, showing there is little difference between the different strategies. CONCLUSION Active PoA screening is worth doing with significant benefits including early identification of risk groups with possible timely treatment/chemoprophylaxis intervention, prevention of transmission by significantly reducing infectiousness with subsequent avoidance of hospitalisation in active PoA screening group.
Collapse
Affiliation(s)
- A F N S Sanneh
- University of Birmingham, Faculty of Public Health, Biostatistics and Epidemiology
| | - A M Al-Shareef
- University of Birmingham, Faculty of Public Health, Biostatistics and Epidemiology
| |
Collapse
|
39
|
Wingfield T, Boccia D, Tovar M, Gavino A, Zevallos K, Montoya R, Lönnroth K, Evans CA. Defining catastrophic costs and comparing their importance for adverse tuberculosis outcome with multi-drug resistance: a prospective cohort study, Peru. PLoS Med 2014; 11:e1001675. [PMID: 25025331 PMCID: PMC4098993 DOI: 10.1371/journal.pmed.1001675] [Citation(s) in RCA: 168] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 06/05/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Even when tuberculosis (TB) treatment is free, hidden costs incurred by patients and their households (TB-affected households) may worsen poverty and health. Extreme TB-associated costs have been termed "catastrophic" but are poorly defined. We studied TB-affected households' hidden costs and their association with adverse TB outcome to create a clinically relevant definition of catastrophic costs. METHODS AND FINDINGS From 26 October 2002 to 30 November 2009, TB patients (n = 876, 11% with multi-drug-resistant [MDR] TB) and healthy controls (n = 487) were recruited to a prospective cohort study in shantytowns in Lima, Peru. Patients were interviewed prior to and every 2-4 wk throughout treatment, recording direct (household expenses) and indirect (lost income) TB-related costs. Costs were expressed as a proportion of the household's annual income. In poorer households, costs were lower but constituted a higher proportion of the household's annual income: 27% (95% CI = 20%-43%) in the least-poor houses versus 48% (95% CI = 36%-50%) in the poorest. Adverse TB outcome was defined as death, treatment abandonment or treatment failure during therapy, or recurrence within 2 y. 23% (166/725) of patients with a defined treatment outcome had an adverse outcome. Total costs ≥20% of household annual income was defined as catastrophic because this threshold was most strongly associated with adverse TB outcome. Catastrophic costs were incurred by 345 households (39%). Having MDR TB was associated with a higher likelihood of incurring catastrophic costs (54% [95% CI = 43%-61%] versus 38% [95% CI = 34%-41%], p<0.003). Adverse outcome was independently associated with MDR TB (odds ratio [OR] = 8.4 [95% CI = 4.7-15], p<0.001), previous TB (OR = 2.1 [95% CI = 1.3-3.5], p = 0.005), days too unwell to work pre-treatment (OR = 1.01 [95% CI = 1.00-1.01], p = 0.02), and catastrophic costs (OR = 1.7 [95% CI = 1.1-2.6], p = 0.01). The adjusted population attributable fraction of adverse outcomes explained by catastrophic costs was 18% (95% CI = 6.9%-28%), similar to that of MDR TB (20% [95% CI = 14%-25%]). Sensitivity analyses demonstrated that existing catastrophic costs thresholds (≥10% or ≥15% of household annual income) were not associated with adverse outcome in our setting. Study limitations included not measuring certain "dis-saving" variables (including selling household items) and gathering only 6 mo of costs-specific follow-up data for MDR TB patients. CONCLUSIONS Despite free TB care, having TB disease was expensive for impoverished TB patients in Peru. Incurring higher relative costs was associated with adverse TB outcome. The population attributable fraction indicated that catastrophic costs and MDR TB were associated with similar proportions of adverse outcomes. Thus TB is a socioeconomic as well as infectious problem, and TB control interventions should address both the economic and clinical aspects of this disease. Please see later in the article for the Editors' Summary.
Collapse
Affiliation(s)
- Tom Wingfield
- Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Perú
- Innovation For Health And Development (IFHAD), London, United Kingdom
- Infectious Diseases & Immunity, Imperial College London, and Wellcome Trust Imperial College Centre for Global Health Research, London, United Kingdom
- The Monsall Infectious Diseases Unit, North Manchester General Hospital, Manchester, United Kingdom
- * E-mail:
| | - Delia Boccia
- Innovation For Health And Development (IFHAD), London, United Kingdom
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Marco Tovar
- Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Perú
- Innovation For Health And Development (IFHAD), London, United Kingdom
| | - Arquímedes Gavino
- Innovation For Health And Development (IFHAD), London, United Kingdom
| | - Karine Zevallos
- Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Perú
- Innovation For Health And Development (IFHAD), London, United Kingdom
- Laboratorio de Investigación y Desarrollo, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Rosario Montoya
- Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Perú
- Innovation For Health And Development (IFHAD), London, United Kingdom
| | - Knut Lönnroth
- Policy Strategy and Innovations, Stop TB Department, World Health Organization, Geneva, Switzerland
| | - Carlton A. Evans
- Innovation For Health And Development (IFHAD), London, United Kingdom
- Infectious Diseases & Immunity, Imperial College London, and Wellcome Trust Imperial College Centre for Global Health Research, London, United Kingdom
- Laboratorio de Investigación y Desarrollo, Universidad Peruana Cayetano Heredia, Lima, Perú
| |
Collapse
|
40
|
Ndii MK, Kimani NM, Onyambu CK. UTILITY OF ROUTINE CHEST RADIOGRAPHS IN KENYA. East Afr Med J 2014; 91:216-218. [PMID: 26862655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND Many otherwise healthy Kenyans are required to obtain chest radiographs as part of routine medical examination to exclude pulmonary TB, a condition of significant public health concern. Many of these people are required to have these radiographs taken yearly as part of routine check-up. No local data is available to support this practice. Though a quick procedure to perform and readily available throughout the country, chest radiograph exposes the individual to a dose of ionising radiation. Ionising radiation is associated with increased risk of malignancy. The cost is also substantial. OBJECTIVE To determine the prevalence of radiological findings consistent with PTB among routine medical examination chest radiographs. DESIGN A cross-sectional descriptive study. SETTINGS Department of Radiology Kenyatta National Hospital, Department of Imaging and Radiation Medicine, University of Nairobi, Plaza Imaging Solutions, a private radiology practice in Nairobi and Department of Radiology, the Nairobi Hospital. SUBJECTS Four hundred and two chest radiographs of patients presenting for routine medical examinations were analysed. RESULTS Sixty three radiographs had abnormal but clinically insignificant findings (16%). Only one radiograph (0.25%) had radiological features of PTB. The rest were reported as normal (84%). CONCLUSION In this study, the diagnostic yield for the intended purpose (to include/ exclude PTB) was extremely low (0.25%). It is recommended that routine chest radiographs as screening tools for active pulmonary tuberculosis be reconsidered due to poor diagnostic yield. The authors propose a bigger nation wide study before a policy decision can be proposed.
Collapse
|
41
|
Li Y, Ehiri J, Oren E, Hu D, Luo X, Liu Y, Li D, Wang Q. Are we doing enough to stem the tide of acquired MDR-TB in countries with high TB burden? Results of a mixed method study in Chongqing, China. PLoS One 2014; 9:e88330. [PMID: 24505476 PMCID: PMC3914979 DOI: 10.1371/journal.pone.0088330] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2013] [Accepted: 01/06/2014] [Indexed: 11/22/2022] Open
Abstract
Multi-drug resistant tuberculosis (MDR-TB) represents a threat to health and development in countries with high TB burden. China’s MDR-TB prevalence rate of 6.8% is the highest in the world. Interventions to remove barriers against effective TB control, and prevention of MDR-TB are urgently needed in the country. This paper reports a cross-sectional questionnaire survey of 513 pulmonary TB (PTB) patients, and qualitative interviews of 10 healthcare workers (HCWs), and 15 PTB patients. The objective was to assess barriers against effective control of PTB and prevention of MDR-TB by elucidating the perspectives of patients and healthcare providers. Results showed that more than half of the patients experienced patient delay of over 12.5 days. A similar proportion also experienced detection delay of over 30 days, and delay in initiating treatment of over 31 days. Consulting a non-TB health facility ≥3 times before seeking care at TB dispensary was a risk factor for both detection delay [AOR (95% CI): 1.89(1.07, 3.34) and delay in initiating treatment[AOR (95% CI): 1.88 (1.06, 3.36). Results revealed poor implementation of Directly Observed Therapy (DOT), whereby treatment of 34.3% patients was never monitored by HCWs. Only 31.8% patients had ever accessed TB health education before their TB diagnosis. Qualitative data consistently disclosed long patient delay, and indicated that patient’s poor TB knowledge and socioeconomic barriers were primary reasons for patient delay. Seeking care and being treated at a non-TB hospital was an important reason for detection delay. Patient’s long work hours and low income increased risk for treatment non-adherence. Evidence-based measures to improve TB health seeking behavior, reduce patient and detection delays, improve the quality of DOT, address financial and system barriers, and increase access to TB health promotion are urgently needed to address the burgeoning prevalence of MDR-TB in China.
Collapse
Affiliation(s)
- Ying Li
- Department of Social Medicine and Health Service Management, Third Military Medical University, Chongqing, China
- * E-mail:
| | - John Ehiri
- Division of Health Promotion Sciences, Mel & Enid Zuckerman College of Public Health University of Arizona, Tucson, Arizona, United States of America
| | - Eyal Oren
- Division of Epidemiology and Biostatistics, Mel & Enid Zuckerman College of Public Health University of Arizona, Tucson, Arizona, United States of America
| | - Daiyu Hu
- Chongqing Institute of TB Prevention and Treatment, Jiulongpo District, Chongqing, China
| | - Xingneng Luo
- Department of TB control, Center of Disease Control in Shapingba District, Chongqing, China
| | - Ying Liu
- Department of Social Medicine and Health Service Management, Third Military Medical University, Chongqing, China
| | - Daikun Li
- Department of Laboratory Medicine, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Qingya Wang
- Chongqing Institute of TB Prevention and Treatment, Jiulongpo District, Chongqing, China
| |
Collapse
|
42
|
Oztürk AB, Kiliçaslan Z, Işsever H. Effect of smoking and indoor air pollution on the risk of tuberculosis: smoking, indoor air pollution and tuberculosis. Tuberk Toraks 2014; 62:1-6. [PMID: 24814071 DOI: 10.5578/tt.7013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Although epidemiological studies have reported an association between smoking and increases in tuberculosis, the relationship between indoor air pollution and risk of tuberculosis is not fully understood. A limited number of studies have suggested that smoking and indoor air pollution may play a role in the pathogenesis of tuberculosis. In this study, we investigated the effect of smoking and indoor air pollution on the risk of active tuberculosis. MATERIALS AND METHODS It is prospectively recorded age matched case-control study. Three hundred sixty two active tuberculosis cases and 409 healthy controls were included to the study. All participants were interviewed face to face by using a questionnaire including smoking habit, quantity and duration of smoking, number of room/person in the house, monthly income of the family, indoor heating system, and environmental tobacco smoke. RESULTS Patients who smoke had a five fold (95% CI: 3.2-7.5, p< 0.0001) higher odds of having active tuberculosis compared with patients who do not smoke. Similarly, patients using coal or wood for indoor heating had a 1.6 fold (95% CI: 1.179-2.305, p< 0.003) higher odds having tuberculosis. People who have less income (< 200 Euro/month) had 3.2 fold (95% CI: 2.113-5.106, p< 0.0001) higher odds of having tuberculosis compared with people having high income. There was a significant correlation between heavy smoking (≥ 20 packet/year, p< 0.0001) and age onset of smoking (< 16 years of age, p< 0.041). There was no significant association between environmental tobacco smoke and tuberculosis. CONCLUSION Smoking and indoor air pollution may increase the risk of tuberculosis. There is a complex interaction between smoking, socioeconomic conditions, indoor air quality and tuberculosis. Our results suggest that effective indoor air quality control could help to prevent tuberculosis risk.
Collapse
Affiliation(s)
- Ayşe Bilge Oztürk
- Adult Allergy Unit, Medeniyet University, Goztepe Training and Research Hospital, Istanbul, Turkey.
| | | | | |
Collapse
|
43
|
Yitayal M, Aseffa A, Andargie G, Wassie L, Abebe M. Assessment of cost of tuberculosis to patients and their families: a cross-sectional study at Addet Health Center, Yilmana Densa District, Amhara National Regional State. Ethiop Med J 2014; Suppl 1:23-30. [PMID: 24696985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
INTRODUCTION The rising number of tuberculosis cases is putting a considerable strain on health budgets, and threatens to drain resources essential to health and welfare services. OBJECTIVES The objective of this study was to estimate the cost of tuberculosis to outpatients and their families in a rural district health center, Addet Health Center, Yilmana Densa District, Amhara National Regional State in Ethiopia. METHODS Cross-sectional study was conducted to estimate the cost of tuberculosis to outpatients and their families. Data were collected on diagnosis, treatment, transportation, food and other expenses, and also income losses due to tuberculosis before and after the diagnosis of tuberculosis. Data were entered to Epi-Info and transferred to SPSS 13 for analysis. Mean, median, range and standard deviation were used to describe the data. RESULT The mean direct cost and indirect cost of tuberculosis to outpatients and their families were 1078.00 Birr and 2080.43 Birr, respectively, at the time of study. The mean total cost of tuberculosis to outpatients and their families was 3159.23 Birr. CONCLUSION Cost of tuberculosis to patients and their families, especially before the identification of the disease was found to be very high. Therefore, consequences of tuberculosis to patients and their families are particularly serious and potentially devastating.
Collapse
|
44
|
Ukwaja KN, Alobu I, lgwenyi C, Hopewell PC. The high cost of free tuberculosis services: patient and household costs associated with tuberculosis care in Ebonyi State, Nigeria. PLoS One 2013; 8:e73134. [PMID: 24015293 PMCID: PMC3754914 DOI: 10.1371/journal.pone.0073134] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Accepted: 07/23/2013] [Indexed: 12/14/2022] Open
Abstract
Objective Poverty is both a cause and consequence of tuberculosis. The objective of this study is to quantify patient/household costs for an episode of tuberculosis (TB), its relationships with household impoverishment, and the strategies used to cope with the costs by TB patients in a resource-limited high TB/HIV setting. Methods A cross-sectional study was conducted in three rural hospitals in southeast Nigeria. Consecutive adults with newly diagnosed pulmonary TB were interviewed to determine the costs each incurred in their care-seeking pathway using a standardised questionnaire. We defined direct costs as out-of-pocket payments, and indirect costs as lost income. Results Of 452 patients enrolled, majority were male 55% (249), and rural residents 79% (356), with a mean age of 34 (±11.6) years. Median direct pre-diagnosis/diagnosis cost was $49 per patient. Median direct treatment cost was $36 per patient. Indirect pre-diagnostic and treatment costs were $416, or 79% of total patient costs, $528. The median total cost of TB care per household was $592; corresponding to 37% of median annual household income pre-TB. Most patients reported having to borrow money 212(47%), sell assets 42(9%), or both 144(32%) to cope with the cost of care. Following an episode of TB, household income reduced increasing the proportion of households classified as poor from 54% to 79%. Before TB illness, independent predictors of household poverty were; rural residence (adjusted odds ratio [aOR] 2.8), HIV-positive status (aOR 4.8), and care-seeking at a private facility (aOR 5.1). After TB care, independent determinants of household poverty were; younger age (≤35 years; aOR 2.4), male gender (aOR 2.1), and HIV-positive status (aOR 2.5). Conclusion Patient and household costs for TB care are potentially catastrophic even where services are provided free-of-charge. There is an urgent need to implement strategies for TB care that are affordable for the poor.
Collapse
Affiliation(s)
- Kingsley N. Ukwaja
- Department of Internal Medicine, Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
- * E-mail:
| | - Isaac Alobu
- National Tuberculosis and Leprosy Control Programme, Ministry of Health, Ebonyi State, Nigeria
| | - Chika lgwenyi
- Department of Internal Medicine, Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
| | - Philip C. Hopewell
- Francis J. Curry International Tuberculosis Center, Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California, San Francisco, California, United States of America
| |
Collapse
|
45
|
Mancuso JD, Aronson NE, Keep LW. Can the active component U.S. military achieve tuberculosis elimination? MSMR 2013; 20:2-3. [PMID: 23731006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
|
46
|
Chaidir L, Parwati I, Annisa J, Muhsinin S, Meilana I, Alisjahbana B, van Crevel R. Implementation of LED fluorescence microscopy for diagnosis of pulmonary and HIV-associated tuberculosis in a hospital setting in Indonesia. PLoS One 2013; 8:e61727. [PMID: 23620787 PMCID: PMC3631225 DOI: 10.1371/journal.pone.0061727] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Accepted: 03/11/2013] [Indexed: 11/18/2022] Open
Abstract
Background Fluorescence microscopy (FM) has not been implemented widely in TB endemic settings and little evaluation has been done in HIV-infected patients. We evaluated diagnostic performance, time and costs of FM with light-emitting diodes technology (LED-FM), compared with conventional (Zieh-Neelsen) microscopy in a hospital in Indonesia which acts as referral centre for HIV-infected patients. Method We included pulmonary tuberculosis suspects from the outpatient and HIV clinic. Direct and concentrated sputum smears were examined using LED-FM and ZN microscopy by two technicians who were blinded for the HIV-status and the result of the comparative test. Mean reading time per slide was recorded and cost of each slide was calculated. Mycobacteria culture served as the reference standard. Results Among 404 tuberculosis suspects from the outpatient clinic and 256 from the HIV clinic, mycobacteria culture was positive in 12.6% and 27%, respectively. The optimal sensitivity of LED-FM was achieved by using a threshold of ≥2 AFB/length. LED-FM had a higher sensitivity (75.5% vs. 54.9%, P<0.01) but lower specificity (90.0% vs 96.6%, P<0.01) compared to ZN microscopy. HIV was associated with a lower sensitivity but similar specificity. The average reading time using LED-FM was significantly shorter (2.23±0.78 vs 5.82±1.60 minutes, P<0.01), while costs per slide were similar. Conclusion High sensitivity of LED-FM combined with shorter reading time of sputum smear slides make this method a potential alternative to ZN microscopy. Additional data on specificity are needed for effective implementation of this technique in high burden TB laboratories.
Collapse
Affiliation(s)
- Lidya Chaidir
- Health Research Unit, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin Hospital, Bandung, Indonesia
- * E-mail:
| | - Ida Parwati
- Department of Clinical Pathology, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin Hospital, Bandung, Indonesia
| | - Jessi Annisa
- Health Research Unit, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin Hospital, Bandung, Indonesia
| | - Soni Muhsinin
- Health Research Unit, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin Hospital, Bandung, Indonesia
| | - Intan Meilana
- Health Research Unit, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin Hospital, Bandung, Indonesia
| | - Bachti Alisjahbana
- Health Research Unit, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin Hospital, Bandung, Indonesia
| | - Reinout van Crevel
- Department of Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| |
Collapse
|
47
|
Laokri S, Weil O, Drabo KM, Dembelé SM, Kafando B, Dujardin B. Removal of user fees no guarantee of universal health coverage: observations from Burkina Faso. Bull World Health Organ 2013; 91:277-82. [PMID: 23599551 PMCID: PMC3629451 DOI: 10.2471/blt.12.110015] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Revised: 10/22/2012] [Accepted: 11/16/2012] [Indexed: 12/30/2022] Open
Abstract
In theory, the removal of user fees puts health services within reach of everyone, including the very poor. When Burkina Faso adopted the DOTS strategy for the control of tuberculosis, the intention was to provide free tuberculosis care. In 2007-2008, interviews were used to collect information from 242 smear-positive patients with pulmonary tuberculosis who were enrolled in the national tuberculosis control programme in six rural districts. The median direct costs associated with tuberculosis were estimated at 101 United States dollars (US$) per patient. These costs represented 23% of the mean annual income of a patient's household. During the course of their care, three quarters of the interviewed patients apparently faced "catastrophic" health expenditure. Inadequacies in the health system and policies appeared to be responsible for nearly half of the direct costs (US$ 45 per patient). Although the households of patients developed coping strategies, these had far-reaching, adverse effects on the quality of lives of the households' members and the socioeconomic stability of the households. Each tuberculosis patient lost a median of 45 days of work as a result of the illness. For a population living on or below the poverty line, every failure in health-care delivery increases the risk of "catastrophic" health expenditure, exacerbates socioeconomic inequalities, and reduces the probability of adequate treatment and cure. In Burkina Faso, a policy of "free" care for tuberculosis patients has not met with complete success. These observations should help define post-2015 global strategies for tuberculosis care, prevention and control.
Collapse
Affiliation(s)
- Samia Laokri
- School of Public Health, Université Libre de Bruxelles, Route de Lennik 808, CP 594, B-1070 Brussels, Belgium.
| | | | | | | | | | | |
Collapse
|
48
|
Maimakov T, Sadykova L, Kalmataeva Z, Kurakpaev K, Šmigelskas K. Treatment of tuberculosis in South Kazakhstan: clinical and economical aspects. Medicina (Kaunas) 2013; 49:335-340. [PMID: 24375246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND AND OBJECTIVE Since 1990, the tuberculosis incidence rate in Eastern Europe and post-Soviet republics has been increasing in many countries including Kazakhstan. This problem is particularly important in Kazakhstan regions with limited financial resources, among them - in South Kazakhstan province. The aim of this study was to investigate the main clinical and antibiotic-related economic aspects of tuberculosis treatment in South Kazakhstan province. MATERIAL AND METHODS In total, 502 patients participated in the study. They were hospitalized to the tuberculosis dispensary of Sayram district (South Kazakhstan province) in 2007-2013. Statistical analysis included logistic regression for better treatment outcomes and analysis of antibiotic treatment costs. RESULTS Two-thirds of patients had infiltrative tuberculosis (67%). Positive treatment outcomes were determined in 85% of cases. The patients were mostly treated with cycloserine, protionamide, capreomycin, and ofloxacin. The majority of antibiotic costs were related to the treatment with capreomycin. In case of the positive results of the test for Mycobacterium tuberculosis, antibiotic expenses were almost 3 times greater than in case of negative test results (P<0.001). CONCLUSIONS The majority of patients had extensively drug-resistant tuberculosis. The negative results of the test for Mycobacterium tuberculosis at discharge were not related to pretreatment factors. Antibiotic-related costs were significantly higher in case of the positive results of the test of Mycobacterium tuberculosis, but were not associated with gender, residence place, hospitalization recurrence, or main blood test results before treatment.
Collapse
Affiliation(s)
| | | | | | | | - Kastytis Šmigelskas
- Department of Health Psychology, Medical Academy, Lithuanian University of Health Sciences, A. Mickevičiaus 9, 44307 Kaunas, Lithuania.
| |
Collapse
|
49
|
Falodun OI, Adesokan HK, Cadmus SIB. Recovery rates of Mycobacterium tuberculosis using five decontamination methods. Afr J Med Med Sci 2012; 41 Suppl:181-185. [PMID: 23678654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Tuberculosis (TB) caused by Mycobacterium tuberculosis remains one of the leading infectious diseases in resource limited countries of the world, including Nigeria. For optimal care of patients with pulmonary TB, effective decontamination methods are required for isolation and identification of M. tuberculosis from other fast growing organisms found in sputum samples of infected patients. Five methods of sputum decontamination including the Petroff, oxalic, bleach, simplified concentration and Kudoh methods were assessed prior to mycobacterial culture. In all, thirty human sputum samples were processed and results analysed after eight weeks of incubation. Overall, there was a significant difference in the growth yield using the different methods (Friedman test statistic, Q(K) = 36.3; P < 0.05). Again, a significant difference (Friedman test statistic, Q(K) = 48.0; P < 0.05) was observed between the valuable and non-valuable yield of mycobacteria. Furthermore, the simplified concentration method had the best performance in terms of pure culture growth/minimal media contamination coupled with a cost benefit ratio of 0.10; the bleach method being the least. Given these findings, coupled with laboratory challenges in developing countries as well as ease of use on the field/cost effectiveness; we propose the simplified concentration as an optimal decontamination method for use in resource limited settings where TB remains an endemic problem.
Collapse
Affiliation(s)
- O I Falodun
- Department of Botany and Microbiology, University of Ibadan, Ibadan, Nigeria
| | | | | |
Collapse
|
50
|
Menzies NA, Cohen T, Lin HH, Murray M, Salomon JA. Population health impact and cost-effectiveness of tuberculosis diagnosis with Xpert MTB/RIF: a dynamic simulation and economic evaluation. PLoS Med 2012; 9:e1001347. [PMID: 23185139 PMCID: PMC3502465 DOI: 10.1371/journal.pmed.1001347] [Citation(s) in RCA: 153] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Accepted: 10/12/2012] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The Xpert MTB/RIF test enables rapid detection of tuberculosis (TB) and rifampicin resistance. The World Health Organization recommends Xpert for initial diagnosis in individuals suspected of having multidrug-resistant TB (MDR-TB) or HIV-associated TB, and many countries are moving quickly toward adopting Xpert. As roll-out proceeds, it is essential to understand the potential health impact and cost-effectiveness of diagnostic strategies based on Xpert. METHODS AND FINDINGS We evaluated potential health and economic consequences of implementing Xpert in five southern African countries--Botswana, Lesotho, Namibia, South Africa, and Swaziland--where drug resistance and TB-HIV coinfection are prevalent. Using a calibrated, dynamic mathematical model, we compared the status quo diagnostic algorithm, emphasizing sputum smear, against an algorithm incorporating Xpert for initial diagnosis. Results were projected over 10- and 20-y time periods starting from 2012. Compared to status quo, implementation of Xpert would avert 132,000 (95% CI: 55,000-284,000) TB cases and 182,000 (97,000-302,000) TB deaths in southern Africa over the 10 y following introduction, and would reduce prevalence by 28% (14%-40%) by 2022, with more modest reductions in incidence. Health system costs are projected to increase substantially with Xpert, by US$460 million (294-699 million) over 10 y. Antiretroviral therapy for HIV represents a substantial fraction of these additional costs, because of improved survival in TB/HIV-infected populations through better TB case-finding and treatment. Costs for treating MDR-TB are also expected to rise significantly with Xpert scale-up. Relative to status quo, Xpert has an estimated cost-effectiveness of US$959 (633-1,485) per disability-adjusted life-year averted over 10 y. Across countries, cost-effectiveness ratios ranged from US$792 (482-1,785) in Swaziland to US$1,257 (767-2,276) in Botswana. Assessing outcomes over a 10-y period focuses on the near-term consequences of Xpert adoption, but the cost-effectiveness results are conservative, with cost-effectiveness ratios assessed over a 20-y time horizon approximately 20% lower than the 10-y values. CONCLUSIONS Introduction of Xpert could substantially change TB morbidity and mortality through improved case-finding and treatment, with more limited impact on long-term transmission dynamics. Despite extant uncertainty about TB natural history and intervention impact in southern Africa, adoption of Xpert evidently offers reasonable value for its cost, based on conventional benchmarks for cost-effectiveness. However, the additional financial burden would be substantial, including significant increases in costs for treating HIV and MDR-TB. Given the fundamental influence of HIV on TB dynamics and intervention costs, care should be taken when interpreting the results of this analysis outside of settings with high HIV prevalence.
Collapse
Affiliation(s)
- Nicolas A Menzies
- Center for Health Decision Sciences, Harvard School of Public Health, Boston, Massachusetts, United States of America.
| | | | | | | | | |
Collapse
|