Drones and digital adherence monitoring for community-based tuberculosis control in remote Madagascar: A cost-effectiveness analysis

Abstract

Background Continuing tuberculosis control with current approaches is unlikely to reach the World Health Organization’s objective to eliminate TB by 2035. Innovative interventions such as unmanned aerial vehicles (or drones) and digital adherence monitoring technologies have the potential to enhance patient-centric quality tuberculosis care and help challenged National Tuberculosis Programs leapfrog over the impediments of conventional Directly Observed Therapy (DOTS) implementation. A bundle of innovative interventions referred to for its delivery technology as the Drone Observed Therapy System (DrOTS) was implemented in remote Madagascar. Given the potentially increased cost these interventions represent for health systems, a cost-effectiveness analysis was indicated. Methods A decision analysis model was created to calculate the incremental cost-effectiveness of the DrOTS strategy compared to DOTS, the standard of care, in a study population of 200,000 inhabitants in rural Madagascar with tuberculosis disease prevalence of 250/100,000. A mixed top-down and bottom-up costing approach was used to identify costs associated with both models, and net costs were calculated accounting for resulting TB treatment costs. Net cost per disability-adjusted life years averted was calculated. Sensitivity analyses were performed for key input variables to identify main drivers of health and cost outcomes, and cost-effectiveness. Findings Net cost per TB patient identified within DOTS and DrOTS were, respectively, $282 and $1,172. The incremental cost per additional TB patient diagnosed in DrOTS was $2,631 and the incremental cost-effectiveness ratio of DrOTS compared to DOTS was $177 per DALY averted. Analyses suggest that integrating drones with interventions ensuring highly sensitive laboratory testing and high treatment adherence optimizes cost-effectiveness. Conclusion Innovative technology packages including drones, digital adherence monitoring technologies, and molecular diagnostics for TB case finding and retention within the cascade of care can be cost effective. Their integration with other interventions within health systems may further lower costs and support access to universal health coverage.

The cost-effectiveness of digital health interventions: A systematic review of the literature

“…- Good, if at least 80% of the items were satisfied: 24 studies (69%) reported ( 8 , 11 , 12 , 15 , 17 – 19 , 21 – 31 , 33 , 34 , 37 – 40 ).…”

“…Modeling techniques are generally used to predict the effect and the potential cost (or savings) of a determined technology where it is not feasible to wait for lifetime data to validate the cost-effectiveness ( 42 ). In our review, several studies used modeling techniques to predict the intervention effect and cost over a long period, or even a lifetime ( 14 , 15 , 17 , 18 , 21 , 22 , 24 , 25 , 31 , 36 , 40 , 41 ). In these cases, it became fundamental to clearly express the uncertainty of the analysis described.…”

“…Of the remaining articles, 12 studies (12/35, 34.3%) found digital health interventions gained QALYs with a higher cost at an acceptable ICER when compared with a relative national benchmark (six studies in videoconferencing systems, four studies in text messaging, two studies in telephone support) ( 8 , 10 , 11 , 19 – 21 , 23 , 24 , 26 , 33 , 34 , 36 ). Finally, a total of 20 out of the 35 studies (20/35, 57.1%) found the digital health interventions gained higher QALYs with cost-savings (nine studies in videoconferencing systems, one study in text messaging, five studies in web platforms and digital health portals, three studies in mobile phone-based systems and applications, two studies in digital health technologies and innovations) ( 7 , 9 , 12 , 13 , 15 – 18 , 22 , 25 , 27 , 29 – 32 , 35 , 38 – 41 ).…”

“…Two out of the three studies in this section found the digital health interventions to be highly cost-effective, resulting in higher QALYs with cost-savings ( 15 , 25 ), while one study reported to be cost-effective but with higher costs ( 14 ).…”

Technologies for Medication Adherence Monitoring and Technology Assessment Criteria: Narrative Review

“…The size and storage capacity vary among the different types of available electronic pill boxes or bags. Most of the identified electronic pill boxes or bags possessed the ability to transmit patient medication adherence data in real time via existing cellular networks [ 1 , 9 , 26 - 28 , 38 - 43 , 100 ], wireless Bluetooth [ 1 , 44 , 45 ], or general packet radio service [ 27 , 46 , 101 , 102 ]. One device required manual uploading of patient adherence data during clinic visits [ 47 ].…”