Cost-effectiveness of expanded latent TB infection testing and treatment: Lynn City, Massachusetts, USA.

BACKGROUND: Between October 2016 and March 2019, Lynn Community Health Center in Massachusetts implemented a targeted latent TB infection testing and treatment (TTT) program, increasing testing from a baseline of 1,200 patients tested to an average of 3,531 patients tested, or 9% of the population per year.METHODS: We compared pre-implementation TTT, represented by the first two quarters of implementation data, to TTT, represented by 12 quarters of data. Time, diagnostic, and laboratory resources were estimated using micro-costing. Other cost and testing data were obtained from the electronic health record, pharmaceutical claims, and published reimbursement rates. A Markov cohort model estimated future health outcomes and cost-effectiveness from a societal perspective in 2020 US dollars. Monte Carlo simulation generated 95% uncertainty intervals.RESULTS: The TTT program exhibited extended dominance over baseline pre-intervention testing and had an incremental cost-effectiveness ratio (ICER) of US$52,603 (US$22,008â-"US$95,360). When compared to baseline pre-TTT testing, the TTT program averted an estimated additional 7.12 TB cases, 3.49 hospitalizations, and 0.16 deaths per lifetime cohort each year.CONCLUSIONS: TTT was more cost-effective than baseline pre-implementation testing. Lynn Community Health Centerâ-™s experience can help inform other clinics considering expanding latent TB infection testing.

Number and cost of hospitalizations with principal and secondary diagnoses of tuberculosis, United States.

OBJECTIVE: To estimate the number and cost of hospitalizations with a diagnosis of active tuberculosis (TB) disease in the United States. METHODS: We analyzed the 2014 National In-Patient Sample using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) codes to identify hospitalizations with a principal (TB-PD) or any secondary discharge (TB-SD) TB diagnosis. We used a generalized linear model with log link and gamma distribution to estimate the cost per TB-PD and TB-SD episode adjusted for patient demographics, insurer, clinical elements, and hospital characteristics. RESULTS: We estimated 4985 TB-PD and 6080 TB-SD hospitalizations nationwide. TB-PD adjusted averaged $16 695 per episode (95%CI $16 168-$17 221). The average for miliary/disseminated TB ($22 498, 95%CI $21 067-$23 929) or TB of the central nervous system ($28 338, 95%CI $25 836-$30 840) was significantly greater than for pulmonary TB ($14 819, 95%CI $14 284-$15 354). The most common principal diagnoses for TB-SD were septicemia (n = 965 hospitalizations), human immunodeficiency virus infection (n = 610), pneumonia (n = 565), and chronic obstructive pulmonary disease and bronchiectasis (COPD-B, n = 150). The adjusted average cost per TB-SD episode was $15 909 (95%CI $15 337-$16 481), varying between $8687 (95%CI $8337-$9036) for COPD-B and $23 335 (95%CI $21 979-$24 690) for septicemia. TB-PD cost the US health care system $123.4 million (95%CI $106.3-$140.5) and TB-SD cost $141.9 million ($128.4-$155.5), of which Medicaid/Medicare covered respectively 67.2% and 69.7%. CONCLUSIONS: TB hospitalizations result in substantial costs within the US health care system.

Tuberculosis hospitalization expenditures per patient from private health insurance claims data, 2010-2014.

OBJECTIVE: To determine hospitalization expenditures for tuberculosis (TB) disease among privately insured patients in the United States. METHODS: We extracted TB hospital admissions data from the 2010-2014 MarketScan® commercial database using International Classification of Diseases version 9 codes for TB (011.0-018.96) as the principal diagnosis. We estimated adjusted average expenditures (in 2014 USD) using regression analyses controlling for patient and claim characteristics. We also estimated the total expenditure paid by enrollee and insurance, and extrapolated it to the entire US employer-based privately insured population. RESULTS: We found 892 TB hospitalizations representing 825 unique enrollees over the 5-year period. The average hospitalization expenditure per person (including multiple hospitalizations) was US$33 085 (95%CI US$31 606- US$34 565). Expenditures for central nervous system TB (US$73 065, 95%CI US$59 572-US$86 558), bone and joint TB (US$56 842, 95%CI US$39 301-US$74 383), and miliary/disseminated TB (US$55 487, 95%CI US$46 101-US$64 873) were significantly higher than those for pulmonary TB (US$28 058, 95%CI US$26 632-US$29 484). The overall total expenditure for hospitalizations for TB disease over the period (2010-2014) was US$38.4 million; it was US$154 million when extrapolated to the entire employer-based privately insured population in the United States. CONCLUSIONS: Hospitalization expenditures for some forms of extra-pulmonary TB were substantially higher than for pulmonary TB.

Estimating tuberculosis cases and their economic costs averted in the United States over the past two decades.

BACKGROUND: Following a concerted public health response to the resurgence of tuberculosis (TB) in the United States in the late 1980s, annual TB incidence decreased substantially. However, no estimates exist of the number and cost savings of TB cases averted. METHODS: TB cases averted in the United States during 1995-2014 were estimated: Scenario 1 used a static 1992 case rate; Scenario 2 applied the 1992 rate to foreign-born cases, and a pre-resurgence 5.1% annual decline to US-born cases; and a statistical model assessed human immunodeficiency virus and TB program indices. We applied the cost of illness to estimate the societal benefits (costs averted) in 2014 dollars. RESULTS: During 1992-2014, 368 184 incident TB cases were reported, and cases decreased by two thirds during that period. In the scenarios and statistical model, TB cases averted during 1995-2014 ranged from approximately 145 000 to 319 000. The societal benefits of averted TB cases ranged from US$3.1 to US$6.7 billion, excluding deaths, and from US$6.7 to US$14.5 billion, including deaths. CONCLUSIONS: Coordinated efforts in TB control and prevention in the United States yielded a remarkable number of TB cases averted and societal economic benefits. We illustrate the value of concerted action and targeted public health funding.

Characteristics and costs of multidrug-resistant tuberculosis in-patient care in the United States, 2005-2007.

OBJECTIVE: A population-based study of 135 multidrug-resistant tuberculosis (MDR-TB) patients reported to the Centers for Disease Control and Prevention (CDC) during 2005-2007 found 73% were hospitalized. We analyzed factors associated with hospitalization. METHODS: We assessed statistically significant multivariable associations with US in-patient TB diagnosis, frequency of hospitalization, length of hospital stay, and in-patient direct costs to the health care system. RESULTS: Of 98 hospitalized patients, 83 (85%) were foreign-born. Blacks, diabetics, or smokers were more likely, and patients with disseminated disease less likely, to receive their TB diagnosis while hospitalized. Patients aged ⩾65 years, those with the acquired immune-deficiency syndrome (AIDS), or with private insurance, were hospitalized more frequently. Excluding deaths, length of stay was greater for patients aged ⩾65 years, those with extensively drug-resistant TB (XDR-TB), those residing in Texas, those with AIDS, those who were unemployed, or those who had TB resistant to all first-line medications vs. others. Average hospitalization cost per XDR-TB patient (US$285 000) was 3.5 times that per MDR-TB patient (US$81 000), in 2010 dollars. Hospitalization episode costs for MDR-TB rank third highest and those for XDR-TB highest among the principal diagnoses. CONCLUSIONS: Hospitalization was common and remains a critical care component for patients who were older, had comorbidities, or required complex management due to XDR-TB. MDR-TB in-patient costs are among the highest for any disease.

Cost-effectiveness of a 12-dose regimen for treating latent tuberculous infection in the United States.

SETTING: A large randomized controlled trial recently showed that for treating latent tuberculous infection (LTBI) in persons at high risk of progression to tuberculosis (TB) disease, a 12-dose regimen of weekly rifapentine plus isoniazid (3HP) administered as directly observed treatment (DOT) can be as effective as 9 months of daily self-administered isoniazid (9H). OBJECTIVES: To assess the cost-effectiveness of 3HP compared to 9H. DESIGN: A computational model was designed to simulate individuals with LTBI treated with 9H or 3HP. Costs and health outcomes were estimated to determine the incremental costs per active TB case prevented and per quality-adjusted life year (QALY) gained by 3HP compared to 9H. RESULTS: Over a 20-year period, treatment of LTBI with 3HP rather than 9H resulted in 5.2 fewer cases of TB and 25 fewer lost QALYs per 1000 individuals treated. From the health system and societal perspectives, 3HP would cost respectively US$21,525 and $4294 more per TB case prevented, and respectively $4565 and $911 more per QALY gained. CONCLUSIONS: 3HP may be a cost-effective alternative to 9H, particularly if the cost of rifapentine decreases, the effectiveness of 3HP can be maintained without DOT, and 3HP treatment is limited to those with a high risk of progression to TB disease.

Knowledge, attitudes and risk perceptions about tuberculosis: US National Health Interview Survey.

BACKGROUND: Tuberculosis (TB) disproportionately affects the human immunodeficiency virus (HIV) infected, foreign-born, Black, Hispanic, American Indian/Alaska Native, Asian, homeless, incarcerated, alcoholic, diabetic or cancer patients, male, those aged >44 years, smokers and poor persons. METHODS: We present TB knowledge, attitudes and risk perceptions overall and for those experiencing TB disparities from the 2000-2005 US National Health Interview Survey (NHIS). RESULTS: A total of 32% of respondents said TB is curable; 44% correctly recognized that TB is transmitted by air. Persons with less knowledge about TB transmission were aged 18-24 years, alcohol abusers, educated <12 years, Hispanics or males. Persons less likely to say TB is curable were aged 18-44 years, smokers, HIV-tested, uninsured, alcohol abusers or homeless/incarcerated. Only 28% of foreign-born persons from Mexico/Central America/the Caribbean said TB was curable. CONCLUSIONS: Knowledge about TB transmission and curability was low among a representative US population. Renewed TB educational efforts are needed for all populations, but should be targeted to populations disproportionately affected, especially those who are HIV-infected, homeless/incarcerated, Black, alcohol abusers, uninsured or born in Mexico/Central America/the Caribbean.

Costs of patients hospitalized for multidrug-resistant tuberculosis.

SETTING: From 1993 through 1998, 1846 cases of multidrug-resistant tuberculosis (MDR-TB) were reported in the United States. Costs associated with MDR-TB are likely to be much higher than for drug-susceptible tuberculosis due to longer hospitalization, longer treatment with more expensive and toxic medications, greater productivity losses, and higher mortality. OBJECTIVE: To measure the societal costs of patients hospitalized for MDR-TB. DESIGN: We detailed in-patient costs for 13 multidrug-resistant patients enrolled in a national study. We estimated costs for physician care, out-patient treatment, and productivity losses for survivors and for deceased patients. RESULTS: In-patient costs averaged US$25,853 per person and $1036 per person-day of hospitalization. Outpatient costs per person ranged from $5744 to $41,821 (average $19028, or $44 a day). Direct medical costs averaged $44,881; indirect costs for those who survived averaged $32,964, and indirect costs for those who died averaged $686,381 per person. Total costs per person ranged from $28,217 to $181492 (average $89,594) for those who survived, and from $509490 to $1278066 (average $717555) for those who died. CONCLUSION: The societal costs of MDR-TB varied, mostly because of length of therapy (including in-patient), and deaths during treatment.

Causes and costs of hospitalization of tuberculosis patients in the United States.

OBJECTIVE: To examine the costs, lengths of stay and patient characteristics associated with tuberculosis (TB) hospitalizations. METHODS: A prospective cohort study of 1493 TB patients followed from diagnosis to completion of therapy at 10 public health programs and area hospitals in the US. The main outcome measures were the following: 1) occurrence, 2) cost, and 3) length of stay of TB-related hospitalizations. RESULTS: There were 821 TB-related hospitalizations among the study participants; 678 (83%) were initial hospitalizations and 143 (17%) were hospitalizations during the treatment of TB. Patients infected with human immunodeficiency virus (HIV) (OR 1.8, 95% CI 1.2-2.6), and homeless patients (OR, 1.7 95% CI 1.1-2.8) were at increased risk of being hospitalized at diagnosis. Homeless patients (RR 2.5, 95%CI 1.5-4.3), patients who used alcohol excessively (RR 1.9, 95% CI 1.2-3.0), and patients with multidrug-resistant TB (RR 5.7, 95% CI 2.7-11.8) were at increased risk of hospitalization during treatment. The median length of stay varied from 9 to 17 days, and median costs per hospitalization varied from $6441 to $12968 among the sites. CONCLUSION: Important social factors, HIV infection, and local hospitalization practice patterns contribute significantly to the high cost of TB-related hospitalizations. Efforts to address these specific factors are needed to reduce the cost of preventable hospitalizations.

Hospitalization of homeless persons with tuberculosis in the United States.

OBJECTIVES: This study assessed whether homeless patients are hospitalized for tuberculosis (TB) more frequently and longer than other patients and possible reasons for this. METHODS: We prospectively studied hospitalizations of a cohort of TB patients. RESULTS: HIV-infected homeless patients were hospitalized more frequently than other patients, while homeless patients who had no insurance or whose insurance status was unknown were hospitalized longer. Hospitalization cost $2000 more per homeless patient than for other patients. The public sector paid nearly all costs. CONCLUSIONS: Homeless people may be hospitalized less if given access to medical care that provides early detection and treatment of TB infection and disease and HIV infection. Providing housing and social services may also reduce hospital utilization and increase therapy completion rates.

Identification and assessment of velopharyngeal inadequacy.

PURPOSE: To review current literature with respect to the diagnosis and assessment of velopharyngeal inadequacy (VPI), including present knowledge about the most common causes of VPI. METHODS: Data sources include published reports over the past 20 years derived from computerized databases and bibliographies of pertinent articles and books. Indexing terms used were "velopharyngeal incompetence," "velopharyngeal inadequacy." "velopharyngeal insufficiency." CONCLUSION: VPI is most commonly associated with cleft palate, submucous cleft palate, and following adenoidectomy. The otolaryngologist can prevent the latter by preoperative identification of physical stigmata associated with VPI. Perceptual assessment is the criterion standard for diagnosis of VPI. Multiview videofluorography and flexible nasal endoscopy provide the best direct assessments to help plan and direct the optimal treatment of VPI.

Dissemination of clinical results. Mastectomy versus lumpectomy and radiation therapy.

OBJECTIVES: This study is an assessment of the extent to which clinical findings concerning mastectomy versus lumpectomy with radiation treatment have been disseminated in practice over time. METHODS: The authors examined the use of breast-conserving surgery followed by radiation therapy as an alternative treatment to mastectomy for early-stage breast cancer by analyzing 5 years (1986-1990) of inpatient and outpatient claims data from four insurers: Medicare, Medicaid, Blue Cross of Western Pennsylvania, and Pennsylvania Blue Shield. The 9,288 women who were eligible for either a lumpectomy or mastectomy during the study period represented approximately 90% of south western Pennsylvania's adult female population. Given the efficacy of both procedures, the authors expected a trend toward more BCS. RESULTS: By 1990, the use of lumpectomy increased significantly to 42.4% from 35.2%. The choice of lumpectomy was associated with younger women, private health insurance, absence of axillary node metastases, and treatment in urban hospitals. The authors also found, however, that only 45.3% of women with Medicaid coverage who had a lumpectomy during the study period received the requisite follow-up radiation therapy, compared with 77.5% of private insurance subscribers and 88.1% of Medicare beneficiaries. This finding is troubling even though there was substantially more compliance in the later years of the study, with 60.0% of eligible Medicaid beneficiaries receiving follow-up radiation therapy in 1990. CONCLUSIONS: This research illustrates the usefulness of administrative claims data in describing trends and practice patterns as well as the need for a different type of research to discover the reasons for the lack of compliance with treatment protocols by women or physicians.

Comparing prenatal and neonatal diagnosis of hemoglobinopathies.

OBJECTIVES: To compare the results of prenatal and neonatal hemoglobinopathy screening, a pilot program was developed at the Northern California Kaiser Permanente Health Care Program, a prepaid health maintenance program serving 2.5 million members. METHODS: In this program, 54,700 pregnant women were screened for hemoglobinopathies. RESULTS: Of the 54,700 women screened, 1019 (1.9%) had a hemoglobinopathy trait, and 81 women with at-risk fetuses were identified. Half the women with fetuses at risk for thalassemia accepted prenatal diagnosis; of those whose fetuses were at risk for sickle-cell disease or other hemoglobinopathies, 30% accepted prenatal diagnosis. Of the 81 at-risk couples, 53 refused amniocentesis for definitive fetal diagnosis; only 28 (35%) accepted; all 4 women who were carrying a fetus with thalassemia major elected to terminate the pregnancy. Only 7 of the 21 cases of hemoglobinopathies were diagnosed prenatally; 14 were discovered neonatally. CONCLUSIONS: Prenatal screening was not found to be an ideal method of identifying hemoglobinopathies of the newborn in this large population. With cost-effectiveness a high priority in health care delivery, we believe that testing of newborns for hemoglobinopathies will continue to be the preferred screening method. A combined prenatal and neonatal program would offer the maximum benefit to patients by adding prenatal counseling, parental options, education, and early complete diagnosis to neonatal screening.