MDR-TB patients in KwaZulu-Natal, South Africa: Cost-effectiveness of 5 models of care

Loveday, Marian; Wallengren, Kristina; Reddy, Tarylee; Besada, Donela; Brust, James C.M.; Voce, Anna; Desai, Harsha; Ngozo, Jacqueline; Radebe, Zanele.; Master, Iqbal; Padayatchi, Nesri; Daviaud, Emmanuelle

doi:10.1371/journal.pone.0196003

Cited by 29 publications

(35 citation statements)

References 21 publications

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“…Patient outcomes for decentralized care in our results are similar to those of previous studies on decentralized care, and are also similar to outcomes achieved from hospital based care [8,10]. Our estimates for the cost of successful treatment for MDR-TB through the decentralized programme are, on average, lower than other estimates based on patient data, but higher than the estimate based on treatment guidelines only [8–10]. Costs of RR/MDR-TB treatment were variable in our study, both across resistance profiles as well as within them.…”

Section: Discussionsupporting

confidence: 88%

“…This estimate assumed, however, that all patients were treated precisely according to guidelines, with no variation among patients based on condition, logistical challenges, or other potential variants. Early estimates of the cost to successfully treat RR/MDR-TB through a decentralized, community-based programme were substantially higher than estimates based on guidelines only: $5,531 a 2015 study in Khalyelistsha, near Cape Town [8] and $5,286 from a 2018 study based in KwaZulu Natal [10]. These studies reflect conditions very soon after the guideline changes, though, and may no longer represent true costs incurred.…”

Section: Introductionmentioning

confidence: 99%

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Cost outcome analysis of decentralized care for drug-resistant tuberculosis in Johannesburg, South Africa

et al. 2019

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Background Drug resistant-tuberculosis is a growing burden on the South African health care budget. In response the National Department of Health implemented two important strategies in 2011; universal access to drug-sensitivity testing for rifampicin with Xpert MTB/RIF as the first-line diagnostic test for TB; and decentralization of treatment for RR/MDR-TB to improve access and reduce costs of treatment. Objective Estimate the costs by treatment outcome of decentralized care for rifampicin and multi-drug resistant tuberculosis under routine conditions. The study was set at an outpatient drug resistant-tuberculosis treatment facility at a public academic hospital in Johannesburg, South Africa. During the study period 18–24 month long course treatment was offered for rifampicin-resistant and multi-drug-resistant tuberculosis. Methods Data are from a prospective observational cohort study. Costs of treatment were estimated from the provider perspective using bottom-up micro-costing. Costs were estimated as patient-level resource use multiplied by the unit cost of the resource. Clinic visits, drugs, laboratory tests, and total days hospitalized were collected from patients’ medical records. Staff time was estimated through a time and motion study. A successful treatment outcome was defined as cure or completion of the regimen. Results We enrolled 124 patients with 52% having a successful outcome. The average total cost/patient for all patients was $3,430 and $4,530 for successfully treated patients. The largest contributors to total cost across all outcomes were drugs (43%) and staff (28%). The average cost to achieve a successful outcome including all patients who started treatment (“production cost”) in the cohort is $6,684. Conclusions Decentralized, outpatient RR/MDR-TB care under South Africa’s 2011 strategy costs 74% less per patient than the previous strategy of inpatient care. The treatment cost of RR/MDR-TB is primarily driven by drug and staff costs, which are in turn dependant on treatment length.

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Section: Discussionsupporting

confidence: 88%

Section: Introductionmentioning

confidence: 99%

Cost outcome analysis of decentralized care for drug-resistant tuberculosis in Johannesburg, South Africa

et al. 2019

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“…While this initially involved hospitalization for a period of 20-24 months, it has since evolved to treatment models with reduced hospitalization and currently includes fully-ambulatory models. These initial models of 20-24 months duration ranged in cost from $1,839 to $81,000 per patient treated [4,[6][7][8][9] and had success rates between 52-66% [10][11][12][13][14]. In 2016, the World Health Organization (WHO) recommended the utilization of Shorter Treatment Regimen [15] based on reported success rates of 85% and above [16][17][18][19].…”

Section: Introductionmentioning

confidence: 99%

Cost comparison of nine-month treatment regimens with 20-month standardized care for the treatment of rifampicin-resistant/multi-drug resistant tuberculosis in Nigeria

et al. 2020

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Background Globally, drug resistant tuberculosis (DR-TB) continues to be a public health threat. Nigeria, which accounts for a significant proportion of the global burden of rifampicin/multi-drug resistant-TB (RR/MDR-TB) had a funding gap of $168 million dollars for TB treatment in 2018. Since 2010, Nigeria has utilized five different models of care for RR/MDR-TB (Models A-E); Models A, B and C based on a standardized WHO-approved treatment regimen of 20–24 months, were phased out between 2015 and 2019 and replaced by Models D and E. Model D is a fully ambulatory model of 9–12 months during which a shorter treatment regimen including a second-line injectable agent is utilized. Model E is identical to Model D but has patients hospitalized for the first four months of care while Model F which is to be introduced in 2020, is a fully ambulatory, oral bedaquiline-containing shorter treatment regimen of 9–12 months. Treatment models for RR/MDR-TB of 20–24 months duration have had treatment success rates of 52–66% while shorter treatment regimens have reported success rates of 85% and above. In addition, replacing the second-line injectable agent in a shorter treatment regimen with bedaquiline has been found to further improve treatment success in patients with fluoroquinolone-susceptible RR/MDR-TB. Reliable cost data for RR/MDR-TB care are limited, specifically costs of models that utilize shorter treatment regimens and which are vital to guide Nigeria through the provision of RR/MDR-TB care at scale. We therefore conducted a cost analysis of shorter treatment regimens in use and to be used in Nigeria (Models D, E and F) and compared them to three models of longer duration utilized previously in Nigeria (Models A, B and C) to identify any changes in cost from transitioning from Models A-C to Models D-F and opportunities for cost savings. Methods We obtained costs for TB diagnostic and monitoring tests, in-patient and out-patient care from a previous study, inflated these costs to 2019 NGN and then converted to 2020 USD. We obtained other costs from the average of six health facilities and drug costs from the global drug facility. We modeled treatment on strict adherence to two Nigerian National guidelines for programmatic and clinical management of drug-resistant tuberculosis. Results We estimated that the total costs of care from the health sector perspective for Models D, E and F were $4,334, $7,705 and $3,420 respectively. This is significantly lower than the costs of Models A, B and C which were $14,781, $12, 113, $7,572 respectively. Conclusion Replacing Models A–C with Models D and E reduced the costs of RR/MDR-TB care in Nigeria by approximately $5,470 (48%) per patient treated and transitioning from Models D and E to Model F would result in further cost savings of $914 to $4,285 (21 to 56%) for every patient placed on Model F. If the improved outcomes of patients managed using bedaquiline-containing shorter treatment regimens in other countries can be attained in Nigeria, Model F would be the recommended model for the scale up of RR/MDR-TB care in Nigeria.

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“…However, although published estimates of direct healthcare costs associated with each case of a given infectious disease may serve as a proxy for the cost of treatment failure, such estimates are likely highly variable and will need to be tailored based on factors such as the type of strain (e.g., multidrug-resistant versus extensively drug-resistant M . tuberculosis ) and the progression of the disease (e.g., uncomplicated gonorrhea versus progression to pelvic inflammatory disease or epididymitis) [16,17]. It will also be important to determine how to incorporate into this estimate indirect costs such as productivity loss, further transmission, or increased antibiotic resistance due to inappropriate use.…”

Section: Discussionmentioning

confidence: 99%

Surveillance to maintain the sensitivity of genotype-based antibiotic resistance diagnostics

et al. 2019

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The sensitivity of genotype-based diagnostics that predict antimicrobial susceptibility is limited by the extent to which they detect genes and alleles that lead to resistance. As novel resistance variants are expected to emerge, such sensitivity is expected to decline unless the new variants are detected and incorporated into the diagnostic. Here, we present a mathematical framework to define how many diagnostic failures may be expected under varying surveillance regimes and thus quantify the surveillance needed to maintain the sensitivity of genotype-based diagnostics.

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MDR-TB patients in KwaZulu-Natal, South Africa: Cost-effectiveness of 5 models of care

Cited by 29 publications

References 21 publications

Cost outcome analysis of decentralized care for drug-resistant tuberculosis in Johannesburg, South Africa

Cost outcome analysis of decentralized care for drug-resistant tuberculosis in Johannesburg, South Africa

Cost comparison of nine-month treatment regimens with 20-month standardized care for the treatment of rifampicin-resistant/multi-drug resistant tuberculosis in Nigeria

Surveillance to maintain the sensitivity of genotype-based antibiotic resistance diagnostics

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