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

Abstract

SummaryObjectivesThe high cost of rifampicin‐resistant tuberculosis (RR‐TB) treatment hinders treatment access. South Africa has a high RR‐TB burden, and national policy outlines decentralisation to improve access and reduce costs. We analysed health system costs associated with RR‐TB treatment by drug resistance profile and treatment outcome in a decentralised programme.MethodsRetrospective, routinely collected patient‐level data were combined with unit cost data to determine costs for each patient in a cohort treated between January 2009 and December 2011. Drug costs were based on recommended regimens according to drug resistance and treatment duration. Hospitalisation costs were estimated based on admission/discharge dates, while clinic visit and diagnostic/monitoring costs were estimated according to recommendations and treatment duration. Missing data were imputed.ResultsAmong 467 patients (72% HIV infected), 49% were successfully treated. Treatment was initiated in primary care for 62%, with the remainder as inpatients. The mean cost per patient treated was $7916 (range 260–87 140), ranging from $5369 among patients who did not complete treatment to $23 006 for treatment failure. Mean cost for successful treatment was $8359 (2585–32 506). Second‐line drug resistance was associated with a mean cost of $15 567 vs. $6852 for only first‐line resistance, with the major cost difference due to hospitalisation. Costs are reported in 2013 USD.Conclusions RR‐TB treatment cost was high and varied according to treatment outcome. Despite decentralisation, hospitalisation remained a significant cost, particularly among those with more extensive resistance and those with treatment failure. These cost estimates can be used to model the impact of new interventions to improve patient outcomes.

Drug resistant TB: UK multicentre study (DRUMS): Treatment, management and outcomes in London and West Midlands 2008–2014

“…Shorter treatment duration through the use of new drugs, delaminid and bedaquiline [8,29] with higher efficacy, is likely to improve completion rates, speed up culture conversion and reduce duration of long hospitalisation in the future [10,[30][31][32]. A 12 month regimen has recently become a WHO recommended option for selected patients who are supported to achieve full adherence and have no additional resistance (eg: pyrazinamide) [33,34].…”

Infection Control for Drug-Resistant Tuberculosis: Early Diagnosis and Treatment Is the Key: Table 1.

“…These need to be context-specific, easy to implement, and sustainable within already stressed health systems. While cost and lack of resources are commonly cited as barriers to TBIC, these costs need to be seen in the light of the high cost of treating a single MDR tuberculosis patient, recently estimated at a mean of approximately US$8000 in South Africa [50].…”

Cost of managing severe cutaneous adverse drug reactions to first‐line tuberculosis therapy in South Africa

“…For the proposed comparator population, patients would be hospitalised for the stabilisation period, followed by an outpatient‐initiated anti‐TB drug regimen to which they had never been exposed. Follow‐up and monitoring would be performed as per the South African National TB Programme (NTP) protocols . In South Africa, the management of TB is guided by the NTP, which has been instrumental in optimising TB diagnosis, rollout of antiretroviral therapy (ART) along with TB drugs contributing to the improved management of TB in South Africa .…”

“…However, rifabutin, bedaquiline and delamanid have improved safety profiles with equivalent efficacy . They provide an all‐oral alternative to first‐line drugs following CADR that can be implemented in an outpatient setting eliminating the need for rechallenge. Their higher costs and the risk of development of drug resistance limit their widespread use to treat drug‐sensitive TB (DS‐TB) .…”