Tuberculosis: limitations and strengths of Directly Observed Treatment Short-Course

This study analyzed the limitations and strengths of the Directly Observed Treatment Short-Course (DOTS) for tuberculosis from the perspective of patients and healthcare providers in a Technical Health Supervision unit in the city of S?o Paulo, SP, Brazil. Four patients and 17 healthcare providers from nine Primary Care Units were interviewed from April to June 2006, after signing free and informed consent forms. The reports were decoded according to the speech analysis technique. The Theory of the Social Determination of the Health-Disease Process was adopted as the theoretical framework. The strengths were: establishment of bonds between healthcare providers and patients and the introduction of incentives, which promotes treatment adherence. Limitations included: restricted involvement of DOTS' healthcare providers and reconciling patients' working hours with supervision. Treatment adherence goes beyond the biological sphere and healthcare providers should acknowledge patients' needs that go beyond the supervision of medication taken.     

Costs, health effects and cost-effectiveness of alcohol and tobacco control strategies in Estonia

OBJECTIVE: To assess the population-level costs, effects and cost-effectiveness of different alcohol and tobacco control strategies in Estonia. DESIGN: A WHO cost-effectiveness modelling framework was used to estimate the total costs and effects of interventions. Costs were assessed in Estonian Kroon (EEK) for the year 2000, while effects were expressed in disability-adjusted life years (DALYs) averted. Regional cost-effectiveness estimates for Eastern Europe, were used as baseline and were contextualised by including country-specific input data. RESULTS: Increased excise taxes are the most cost-effective intervention to reduce both hazardous alcohol consumption and smoking: 759 EEK (euro 49) and 218 EEK (euro 14) per DALY averted, respectively. Imposing additional advertising bans would cost 1331 EEK (euro 85) per DALY averted to reduce hazardous alcohol consumption and 304 EEK (euro 19) to reduce smoking. Compared to WHO-CHOICE regional estimates, interventions were less costly and thereby more cost-effective in Estonia. CONCLUSIONS: Interventions in alcohol and tobacco control are cost-effective, and broad implementation of these interventions to upgrade current situation is warranted from the economic point of view. First priority is an increase in taxation, followed by advertising bans and other interventions. The differences between WHO-CHOICE regional cost-effectiveness estimates and contextualised results underline the importance of the country level analysis.     

A Classification and Meta-analysis of Community-based Directly Observed Therapy Programs for Tuberculosis Treatment in Developing Countries

In many developing countries, Directly Observed Therapy (DOT) for tuberculosis has been undertaken mainly in the clinic setting. However, clinic-based DOT may create a high patient load in already overburdened health facilities and increase barriers to care by requiring patients to travel to clinic frequently for therapy. Community-based DOT (CBDOT) may overcome some of these problems. This aims of this review are (a) to describe the main features of CBDOT programs, and (b) to compare features and outcomes of CBDOT programs that do and do not offer financial reward for CBDOT providers. Ten major features define CBDOT program structure and function. Programs that paid their CBDOT providers tended to differ from unpaid programs based on all of these features. CBDOT programs in which providers received financial reward had success rates of 85.7 versus 77.6% in programs without financial reward for providers. This difference was not statistically significant. CBDOT programs fall into two major archetypes, which differ in their structure and possibly in their outcomes.     

Assessing the cost-effectiveness of different measles vaccination strategies for children in the Democratic Republic of Congo

IntroductionOne of the goals of the Global Measles and Rubella Strategic Plan is the reduction in global measles mortality, with high measles vaccination coverage as one of its core components. While measles mortality has been reduced more than 79%, the disease remains a major cause of childhood vaccine preventable disease burden globally. Measles immunization requires a two-dose schedule and only countries with strong, stable immunization programs can rely on routine services to deliver the second dose. In the Democratic Republic of Congo (DRC), weak health infrastructure and lack of provision of the second dose of measles vaccine necessitates the use of supplementary immunization activities (SIAs) to administer the second dose.MethodsWe modeled three vaccination strategies using an age-structured SIR (Susceptible-Infectious-Recovered) model to simulate natural measles dynamics along with the effect of immunization. We compared the cost-effectiveness of two different strategies for the second dose of Measles Containing Vaccine (MCV) to one dose of MCV through routine immunization services over a 15-year time period for a hypothetical birth cohort of 3 million children.ResultsCompared to strategy 1 (MCV1 only), strategy 2 (MCV2 by SIA) would prevent a total of 5,808,750 measles cases, 156,836 measles-related deaths and save U.S. $199 million. Compared to strategy 1, strategy 3 (MCV2 by RI) would prevent a total of 13,232,250 measles cases, 166,475 measles-related deaths and save U.S. $408 million.DiscussionVaccination recommendations should be tailored to each country, offering a framework where countries can adapt to local epidemiological and economical circumstances in the context of other health priorities. Our results reflect the synergistic effect of two doses of MCV and demonstrate that the most cost-effective approach to measles vaccination in DRC is to incorporate the second dose of MCV in the RI schedule provided that high enough coverage can be achieved.     

Epidemiological model and cost-effectiveness analysis of tuberculosis treatment programmes in Indonesia

An epidemiological model of tuberculosis, based on the natural history of tuberculosis and the control programmes in Indonesia, was constructed. This model was used for estimating future tuberculosis-prevented cases and costs for three treatment strategies--the 100% standard course, the 100% short course, and the existing strategy (a combination of 65% standard course and 35% short course)--in accordance with the master plan of the Indonesian Government's tuberculosis control programme. A cost-effectiveness analysis of the three strategies confirmed that the short-course strategy was the most cost-effective. Sensitivity analysis, which applied a broad range of parameters, continued to confirm the short-course strategy as the most cost-effective. If the short-course strategy had been applied in 1980 instead of the existing strategy (using the most likely parameters), the short-course strategy would prevent 1.8 million sputum-positive cases and would save 61.0 million dollars by the year 2000.     

Costs of breast cancer and the cost-effectiveness of breast cancer screening.

Breast cancer is the second leading cause of death by cancer among women in the United States. The total cost of illness for breast cancer has been estimated to be $3.8 billion, of which $1.8 billion represents medical care costs. It has been estimated that breast cancer detected early is considerably less expensive than when the tumor is discovered at a later stage. Mass screening using mammography can improve early detection by as much as 15-35%. Cost-effectiveness studies have estimated that the costs of breast cancer screening range between $13,200 and $28,000 per year of life saved. The cost-effectiveness of breast cancer screening in the 40-49-year-old age group is controversial. Mass screening for breast cancer will probably increase total health care costs, but when all economic costs are included, screening appears to be more cost-effective than not screening.     

The cost-effectiveness of different blood-cholesterol-lowering strategies in the prevention of coronary heart disease

Abstract: We aimed to compare the cost-effectiveness of two screening strategies and a population strategy for lowering blood cholesterol to prevent coronary heart disease. Census data, known risk-factor profiles, known coronary heart disease event rates and costs in 1988-89 Australian dollars for all men aged 35 to 64 in the Lower Hunter region of New South Wales (n = 67 651) were used to compare a high-risk strategy identifying and treating men with cholesterol levels above 6.5 mmol/L with diet and drug (cholestyramine), a moderate/high-risk strategy where in addition diet counselling was offered to those with levels 5.5 to 6.5 mmol/L, and a population strategy where the diet of the whole population was changed regardless of blood cholesterol. Costs of implementing strategies, heart disease events saved, discounted and undiscounted cost-effectiveness ratios and savings in initial treatment costs over five years were measured. For the high-risk, moderate/high-risk and population strategies, the costs of implementation were $50.1m, $53.1m and $5.4m respectively; the numbers of events saved were 104, 144, 116 respectively; cost-effectiveness ratios were $482 224, $369 098, $46 667 (per event saved) respectively. Cost savings for each strategy were approximately half a million dollars. The moderate/high-risk strategy was more cost-effective than the high-risk strategy but the population strategy cost one-tenth that of the two screening strategies per event saved. More research is required to design and test strategies that alter the eating habits of the whole population.     

Probabilistic analysis of cost-effectiveness models: choosing between treatment strategies for gastroesophageal reflux disease.

When choosing between mutually exclusive treatment options, it is common to construct a cost-effectiveness frontier on the cost-effectiveness plane that represents efficient points from among the treatment choices. Treatment options internal to the frontier are considered inefficient and are excluded either by strict dominance or by appealing to the principle of extended dominance. However, when uncertainty is considered, options excluded under the baseline analysis may form part of the cost-effectiveness frontier. By adopting a Bayesian approach, where distributions for model parameters are specified, uncertainty in the decision concerning which treatment option should be implemented is addressed directly. The approach is illustrated using an example from a recently published cost-effectiveness analysis of different possible treatment strategies for gastroesophageal reflux disease. It is argued that probabilistic analyses should be encouraged because they have potential to quantify the strength of evidence in favor of particular treatment choices.     

直接督导短程化疗下初治涂阳肺结核治愈影响因素研究

目的探讨直接督导短程化疗(DOTS)下初治涂阳肺结核治愈的有关影响因素,为临床上采取积极的干预措施提供理论依据,从而提高治愈率。方法选取2003年1月～2006年9月确诊为初治涂阳肺结核实施DOTS治疗并完成疗程病例为研究对象,治疗转归为"失败"的病例为病例组,搜集满150例;治疗转归为"治愈"的病例为对照组,搜集满300例,分析比较两组的差异。结果多因素分析结果显示卧室窗户数多、多进食豆类及豆制品、血清白蛋白水平高可显著降低化疗失败的风险;而精神负担重、吸烟时间长、肺部病灶范围广泛、合并糖尿病等是化疗失败的重要因素。血清白蛋白含量≥45 g/L比<35 g/L者化疗失败的风险降低了92.0%(95%CI:79.3%～96.9%);精神负担一般比精神负担较大者失败的风险降低了92.2%(95%CI:85.0%～95.9%)。结论加强健康宣教以减轻病人的精神负担、改善室内通风、增加营养、戒烟等可降低DOTS治疗初治涂阳肺结核失败的风险。     

Randomized controlled trial of directly observed treatment (DOT) for patients with pulmonary tuberculosis in Thailand

While directly observed treatment (DOT) has been recommended as the standard approach to tuberculosis control, empirical data on its feasibility and efficiency are still scarce. We conducted a controlled trial of DOT at 15 health care facilities at various levels of the government health care system in Thailand. A total of 836 patients diagnosed between August 1996 and October 1997 were randomly assigned to be treated either under DOT or self-supervised using monthly drug supplies (SS). Options for treatment supervisors were health staff, community members or members of the patients' families. Treatment outcomes were compared on the basis of cure, treatment-completion, default and death rates. In both study arms, treatment outcomes were improved compared to pre-study conditions. Cure and treatment-completion rates were significantly higher in the DOT cohort (76% and 84%) than in the SS group (67% and 76%). The benefits of DOT were more pronounced at district and provincial hospitals (DOT cure rate 81% vs. 69% in the SS group), while differences for patients treated at referral centres were non-significant (DOT cure rate 72% vs. 66% in the SS group). No significant differences in outcomes could be observed between patient groups receiving DOT under the various options for treatment supervisors. DOT appears especially suited for treatment at decentralized facilities. While a general focus on programme performance can improve outcomes, DOT provides significant additional benefits. If basic conditions are met, a DOT strategy can be tailored to country-specific conditions by exploring multiple observation options, without decreasing its effectiveness.     

Cost,affordability and cost-effectiveness of strategies to control tuberculosis in countries with high HIV prevalence

Background  

The HIV epidemic has caused a dramatic increase in tuberculosis (TB) in East and southern Africa. Several strategies have the potential to reduce the burden of TB in high HIV prevalence settings, and cost and cost-effectiveness analyses can help to prioritize them when budget constraints exist. However, published cost and cost-effectiveness studies are limited.     

Missed opportunity for standardized diagnosis and treatment among adult Tuberculosis patients in hospitals involved in Public-Private Mix for Directly Observed Treatment Short-Course strategy in Indonesia: a cross-sectional study

Background  

The engagement of hospitals in Public-Private Mix (PPM) for Directly Observed Treatment Short-Course (DOTS) strategy has increased rapidly internationally - including in Indonesia. In view of the rapid global scaling-up of hospital engagement, we aimed to estimate the proportion of outpatient adult Tuberculosis patients who received standardized diagnosis and treatment at outpatients units of hospitals involved in the PPM-DOTS strategy.     

长沙市天心区2005-2009年实施DOTS策略防治结核病的成本效益分析

目的对2005-2009年长沙市天心区实施结核病控制项目的成本-效益进行分析,为该区下一步制定结核病防控策略提供理论依据。方法对2005-2009年天心区结核病防治中投入的经费、病人发现、治疗等情况进行分析。结果 5年间共投入经费70.28万元;发现肺结核病人1 214例,其中初治涂阳病人364人,复治涂阳病人43人,初治涂阴病人807人,节约治疗费用152.67万元;可减少3 230～4 845人受结核菌的感染,减少161.5～242.25人成为活动性肺结核病人;治愈病人,可减少误工损失28.75万元,减少成为新活动性肺结核病人可减少的误工费14.38万～21.56万元;治愈病人可挽回QALYs 3 404.1年,挽回GDP6 876.28万元;减少成为新活动性肺结核病人,可挽回QALYs1 702.0～2 553.1年,挽回GDP3 438.04万～5 157.26万元。结论 2005-2009年间天心区结核病防治工作实现了低成本、高效益,符合疾病控制与卫生经济学成本-效益原则。     

Costs of home care for advanced breast and cervical cancer in relation to cost-effectiveness of screening.

The costs of home care in the Netherlands are estimated for women with advanced breast and cervical cancer. We observe a growing role of intensive home care for the terminally ill patients. The average costs of home care are dfl 8,500 per patient for breast cancer patients and dfl 7,200 for cervical cancer patients. More than half of these costs are incurred in the last month before death. The level of home care in the preceding months is quite modest (dfl 120 per month for both diseases), not taking into account informal care. The costs of home care for patients with advanced cancer are only slightly related to the site of the primary tumor from which the metastases originate. Total average costs per patient during advanced disease, including hospital and nursing home care, amount to dfl 42,700 for breast cancer and dfl 29,000 for cervical cancer. This difference in costs is largely attributable to the longer duration of advanced disease for breast cancer, which substantially affects hospital costs. The high costs of care to patients with advanced cancer contribute to a favourable cost-effectiveness ratio of those screening programmes which reduce mortality and consequently the costs of care to advanced cancer patients.     

A model for evaluating the cost-effectiveness of cholesterol-lowering treatment.

We describe and illustrate the use of a generalizable model for evaluating the cost-effectiveness of alternative cholesterol-lowering treatments. We combine standard incidence-based techniques for measuring the cost of illness with logistic risk functions from the Framingham Heart Study to project, for persons with known coronary risk characteristics, the likelihood of developing coronary heart disease (CHD) over a lifetime as well as a number of related outcomes, including the expected loss of years of life due to CHD, the expected lifetime direct and indirect costs of CHD, and the changes in these outcomes that would result from cholesterol-lowering treatment.