Cost and Cost-Effectiveness of a Digital Adherence Technology for Tuberculosis Treatment Support in Uganda |
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| Institution: | 1. Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA;2. Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda;3. Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA;4. Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA;5. Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA;6. National Tuberculosis and Leprosy Program, Uganda Ministry of Health, Kampala, Uganda;7. Clinical Epidemiology and Biostatistics Unit, Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda;1. Health Economics Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia;2. School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia;3. Centre for Healthcare Transformation, School of Public Health and Social Work and Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, Australia;4. School of Nursing, Queensland University of Technology, Brisbane, Australia;5. School of Public Health, The University of Queensland, Brisbane, Australia;1. Department of Urology, Lenox Hill Hospital, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA;2. Department of Urology, Hospital General Universitario Gregorio Marañón, Madrid, Spain;3. Department of Urology, Ottumwa Regional Health Center, Ottumwa, IA, USA;1. Sanofi, Amsterdam, The Netherlands;2. Erasmus School of health Policy & Management, Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands;1. Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA, USA;2. Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA;3. Department of Surgery, Stanford University, Stanford, CA, USA;4. Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA;5. Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA;6. VA Office of Specialty Care Services, Durham, NC, USA;7. VA National TeleStroke Program and VA Office of Specialty Care Services, Washington, DC, USA;8. Department of Neurology, Baylor College of Medicine, Houston, TX, USA;9. Department of Neurology, University of California San Francisco, San Francisco, CA, USA;10. Department of Emergency Medicine, Stanford University, Stanford, CA, USA;11. VA HSR&D EXTEND QUERI and the Center for Health Information and Communication, Indianapolis VA Medical Center, Indianapolis, IN, USA;12. Department of Neurology, Indiana University, Indianapolis, IN, USA;13. Regenstrief Institute, Inc, Indianapolis, IN, USA;1. Carevive Systems, Inc, Franklin, TN, USA;2. Piedmont Research Strategies, Inc, Greensboro, NC, USA;3. Carevive Systems, Inc, Princeton, NJ, USA;4. Billings Clinic Cancer Center, Billings, MT, USA;1. Department of Surgery, Radboud University Medical Center, Nijmegen, Gelderland, The Netherlands;2. Ouva, San Francisco, CA, USA;3. Faculty of Engineering Technology, University of Twente, Enschede, Overijssel, The Netherlands |
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| Abstract: | ObjectivesDigital adherence technologies like 99DOTS are increasingly considered as an alternative to directly observed therapy for tuberculosis (TB) treatment supervision. We evaluated the cost and cost-effectiveness of 99DOTS in a high-TB-burden setting.MethodsWe assessed the costs of implementing 99DOTS in Uganda through a pragmatic, stepped-wedge randomized trial. We measured costs from the health system perspective at 5 of 18 study facilities. Self-reported service activity time data were used to assess activity-based service costs; other costs were captured from budgets and key informant discussions using standardized forms. We estimated costs and effectiveness considering the 8-month study period (“trial specific”) and using a 5-year time horizon (“extended activities”), the latter including a “marginal clinic” expansion scenario that ignored above-site implementation costs. Cost-effectiveness was assessed as cost per patient successfully completing treatment, using Monte Carlo simulation, cost-effectiveness acceptability curves, and sensitivity analyses to evaluate uncertainty and robustness of results.ResultsThe total cost of implementing 99DOTS in the “trial-specific” scenario was $99 554 across 18 clinics (range $3771-$6238 per clinic). The cost per treatment success in the “trial-specific” scenario was $355 (range $229-$394), falling to $59 (range $50-$70) assuming “extended activities,” and $49 (range $42-$57) in the “marginal clinic” scenario. The incremental cost-effectiveness of 99DOTS in the “extended-activity” scenario was $355 per incremental treatment success.ConclusionsCosts and cost-effectiveness of 99DOTS were influenced by the degree to which infrastructure is scaled over time. If sustained and scaled up, 99DOTS can be a cost-effective option for TB treatment adherence support in high-TB-burden settings like Uganda. |
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| Keywords: | 99DOTS cost analysis cost-effectiveness analysis digital adherence technology tuberculosis |
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