Patients' Costs and Cost-Effectiveness of Tuberculosis Treatment in DOTS and Non-DOTS Facilities in Rio de Janeiro, Brazil

Abstract

BackgroundCosts of tuberculosis diagnosis and treatment may represent a significant burden for the poor and for the health system in resource-poor countries.ObjectivesThe aim of this study was to analyze patients' costs of tuberculosis care and to estimate the incremental cost-effectiveness ratio (ICER) of the directly observed treatment (DOT) strategy per completed treatment in Rio de Janeiro, Brazil.MethodsWe interviewed 218 adult patients with bacteriologically confirmed pulmonary tuberculosis. Information on direct (out-of-pocket expenses) and indirect (hours lost) costs, loss in income and costs with extra help were gathered through a questionnaire. Healthcare system additional costs due to supervision of pill-intake were calculated considering staff salaries. Effectiveness was measured by treatment completion rate. The ICER of DOT compared to self-administered therapy (SAT) was calculated.Principal FindingsDOT increased costs during the treatment phase, while SAT increased costs in the pre-diagnostic phase, for both the patient and the health system. Treatment completion rates were 71% in SAT facilities and 79% in DOT facilities. Costs per completed treatment were US$ 194 for patients and U$ 189 for the health system in SAT facilities, compared to US$ 336 and US$ 726 in DOT facilities. The ICER was US$ 6,616 per completed DOT treatment compared to SAT.ConclusionsCosts incurred by TB patients are high in Rio de Janeiro, especially for those under DOT. The DOT strategy doubles patients' costs and increases by fourfold the health system costs per completed treatment. The additional costs for DOT may be one of the contributing factors to the completion rates below the targeted 85% recommended by WHO.

Is the directly observed therapy short course (DOTS) an effective strategy for tuberculosis control in a developing country?

“…This review showed that treatment completion rates were most likely to exceed 90% when treatment was based on a patient-centred approach using DOT. Similar benefits of DOT were also reported by Steffen and colleagues who compared treatment completion rates of persons using self-administered treatment (SAT) facilities in Rio de Janeiro, Brazil [14] . Treatment completion rates were 71% in SAT facilities and 79% in DOT facilities.…”

“…In SAT facilities, the costs per completed treatment were US$ 194 for patients and US$ 189 for the health system, compared to US$ 336 and US$ 726 in DOT facilities. The ICER was US$ 6 616 per completed DOT treatment compared to SAT [14] .…”

Preditores dos desfechos do tratamento da tuberculose

“…These factors might be related to knowledge or understanding of the disease, its treatment, and the importance of treatment adherence, as well as to the costs of treatment for patients and their families. (21) The present study has some limitations. The reduced number of some exposures and some outcomes did not allow the evaluation of factors independently predictive of outcomes.…”

“…Diabetes mellitus, in addition to increasing mortality, has been described as being related to delayed sputum conversion, increased chances of recurrence, and increased chances of developing multidrug-resistant tuberculosis. (21) Socioeconomic factors also increased the probability of unfavorable outcomes. Among the patients with a lower income and a lower level of education, the rate of treatment abandonment was higher, as was the rate of treatment failure, which might be associated with poor treatment adherence even without abandonment.…”

Costos de bolsillo de pacientes con diagnóstico de Tuberculosis en Colombia

“…El gasto de bolsillo más elevado para los pacientes que reciben tratamiento bajo la terapia DOTS en la investigación realizada por Ukwaja y col. (11) en una población nigeriana, fue el correspondiente al transporte, por un valor de 83 200 COP, similar a lo observado en el presente estudio en las ciudades de Medellín y Quibdó. Algo parecido se pudo observar en el estudio realizado por Steffen y col. (12) , en Brasil, donde los costos directos más altos fueron el trasporte y la medicación no TB, con 33 054 COP y 32 153 COP, respectivamente.…”