Abbott realtime MTB assay for detecting Mycobacterium tuberculosis complex in respiratory specimens: a cost-benefit analysis.

PURPOSE: Molecular screening for Mycobacterium tuberculosis (MTB) can lead to rapid empirical treatment inception and reduce hospitalization time and complementary diagnostic tests. However, in low-prevalence settings, the cost-benefit balance remains controversial due to the high cost. METHODS: We used a Markov model to perform an economic analysis to evaluate the profit after implementing molecular MTB screening (Period B) compared with conventional culture testing (Period A) in respiratory samples from 7,452 consecutive subjects with presumed tuberculosis (TB). RESULTS: The proportion of positivity was comparable between both periods (P > 0.05), with a total of 2.16 and 1.78 samples/patient requested in periods A and B, respectively (P < 0.001). The mean length of hospital stay was 8.66 days (95%CI: 7.63-9.70) in Period B and 11.51 days (95%CI: 10.15-12.87) in Period A (P = 0.001). The healthcare costs associated with diagnosing patients with presumed TB were reduced by €717.95 per patient with PCR screening. The probability of remaining hospitalized and the need for a greater number of outpatient specialty care visits were the variables with the most weight in the model. CONCLUSION: Employing PCR as an MTB screening method in a low-prevalence setting may increase the profits to the system.

Predicting hospitalization costs for pulmonary tuberculosis patients based on machine learning.

BACKGROUND: Pulmonary tuberculosis (PTB) is a prevalent chronic disease associated with a significant economic burden on patients. Using machine learning to predict hospitalization costs can allocate medical resources effectively and optimize the cost structure rationally, so as to control the hospitalization costs of patients better. METHODS: This research analyzed data (2020-2022) from a Kashgar pulmonary hospital's information system, involving 9570 eligible PTB patients. SPSS 26.0 was used for multiple regression analysis, while Python 3.7 was used for random forest regression (RFR) and MLP. The training set included data from 2020 and 2021, while the test set included data from 2022. The models predicted seven various costs related to PTB patients, including diagnostic cost, medical service cost, material cost, treatment cost, drug cost, other cost, and total hospitalization cost. The model's predictive performance was evaluated using R-square (R2), Root Mean Squared Error (RMSE), and Mean Absolute Error (MAE) metrics. RESULTS: Among the 9570 PTB patients included in the study, the median and quartile of total hospitalization cost were 13,150.45 (9891.34, 19,648.48) yuan. Nine factors, including age, marital status, admission condition, length of hospital stay, initial treatment, presence of other diseases, transfer, drug resistance, and admission department, significantly influenced hospitalization costs for PTB patients. Overall, MLP demonstrated superior performance in most cost predictions, outperforming RFR and multiple regression; The performance of RFR is between MLP and multiple regression; The predictive performance of multiple regression is the lowest, but it shows the best results for Other costs. CONCLUSION: The MLP can effectively leverage patient information and accurately predict various hospitalization costs, achieving a rationalized structure of hospitalization costs by adjusting higher-cost inpatient items and balancing different cost categories. The insights of this predictive model also hold relevance for research in other medical conditions.

The economic burden of tuberculosis in Sistan: a high-risk region in Iran.

INTRODUCTION: To estimate the economic burden of tuberculosis treatment in Sistan, the region with the highest number of tuberculosis cases in Iran. METHODS: All patients with smear-positive pulmonary tuberculosis who had contracted tuberculosis in 2018 and successfully completed their treatment were interviewed. RESULTS: Ninety patients with a mean age of 57 ± 18 years were interviewed. Most of them were women (58%), housewives (57%) and resided in rural areas (84%). The mean cost of treatment for tuberculosis was estimated as 6800 USD per patient. Direct costs were 87% of the total cost. Twenty-two patients lost an average income of 530 USD (8514590 rials) during treatment. The results showed the significant correlation of direct and indirect costs with sex, age, place of residence and education (P < 0.05). CONCLUSION: It appears essential to improve social protection and implement interventions to promote knowledge in rural areas.

Patient-incurred cost of inpatient treatment for Tuberculosis in rural Malawi.

OBJECTIVES: To mitigate the economic burden of tuberculosis (TB), it is important to fully understand the costs of TB treatment from the patient perspective. We therefore sought to quantify the patient-incurred cost of TB treatment in rural Malawi, with specific focus on costs borne by patients requiring inpatient hospitalisation. METHODS: We conducted a cross-sectional survey of 197 inpatients and 156 outpatients being treated for TB in rural Malawi. We collected data on out-of-pocket costs and lost wages, including costs to guardians. Costs for inpatient TB treatment were estimated and compared to costs for outpatient TB treatment. We then explored the equity distribution of inpatient TB treatment cost using concentration curves. RESULTS: Despite free government services, inpatients were estimated to incur a mean of $137 (standard deviation: $147) per initial TB episode, corresponding to >50% of annual household spending among patients in the lowest expenditure quintile. Non-medical hospitalisation costs accounted for 88% of this total. Patients treated entirely as outpatients incurred estimated costs of $25 (standard deviation: $15) per episode. The concentration curves showed that, among individuals hospitalised for an initial TB episode, poorer patients shouldered a much greater proportion of inpatient TB treatment costs than wealthier ones (concentration index: -0.279). CONCLUSION: Patients hospitalised for TB in resource-limited rural Malawi experience devastating costs of TB treatment. Earlier diagnosis and treatment must be prioritised if we are to meet goals of effective TB control, avoidance of catastrophic costs and provision of appropriate patient-centred care in such settings.

OBJECTIFS: Pour atténuer la charge économique de la tuberculose (TB), il est important de bien comprendre les coûts du traitement de la TB du point de vue du patient. Nous avons donc cherché à quantifier les coûts encourus par les patients pour le traitement de la TB dans les zones rurales du Malawi, en mettant l'accent sur les coûts supportés par les patients nécessitant une hospitalisation. MÉTHODES: Nous avons mené une enquête transversale auprès de 197 patients hospitalisés et 156 patients ambulatoires traités pour la TB dans les régions rurales du Malawi. Nous avons collecté des données sur les dépenses payées directement de la poche et les pertes de salaire, y compris les coûts pour les gardiens des malades. Les coûts du traitement anti-TB des patients hospitaliser ont été estimés et comparés aux ceux des patients ambulatoires. Nous avons ensuite exploré la répartition des équités propres au coût du traitement de la TB des patients hospitalisés en utilisant des courbes de concentration. RÉSULTATS: Malgré les services gratuits du gouvernement, les patients hospitalisés encouraient en moyenne estimée de 137 $ (écart-type: 147 $) par épisode initial de TB, ce qui correspond à >50% des dépenses annuelles des ménages chez les patients du quintile de dépenses le plus bas. Les frais d'hospitalisation non médicaux représentaient 88% de ce total. Les patients traités entièrement en ambulatoire encouraient des coûts estimés à 25 $ (écart type: 15 $) par épisode. Les courbes de concentration ont montré que, parmi les personnes hospitalisées pour un premier épisode de TB, les patients les plus pauvres supportaient une proportion beaucoup plus élevée des coûts de traitement de la TB en hospitalisation que les plus riches (indice de concentration: -0,279). CONCLUSION: Les patients hospitalisés pour la TB dans les régions rurales pauvres du Malawi connaissent des coûts dévastateurs pour le traitement de la TB. Le diagnostic et le traitement précoces doivent être priorisés si nous voulons atteindre des objectifs de contrôle efficace de la TB, d'évitement des coûts catastrophiques et de prestation de soins appropriés centrés sur le patient dans de tels contextes .

Estimating Cost Functions for Resource Allocation Using Transmission Models: A Case Study of Tuberculosis Case Finding in South Africa.

OBJECTIVE: Cost functions linked to transmission dynamic models are commonly used to estimate the resources required for infectious disease policies. We present a conceptual and empirical approach for estimating these functions, allowing for nonconstant marginal costs. We aim to expand on the current approach which commonly assumes linearity of cost over scale. METHODS: We propose a theoretical framework adapted from the field of transport economics. We specify joint functions of production of services within a disease-specific program. We expand these functions to include qualitative insights of program expansion patterns. We present the difference in incremental total costs between an approach assuming constant unit costs and alternative approaches that assume economies of scale, scope and homogeneous or heterogeneous facility recruitment into the programme during scale-up. We illustrate the framework's application in tuberculosis, using secondary data from the literature and routine reporting systems in South Africa. RESULTS: Economies of capacity and scope substantially change cost estimates over time. Cost data requirements for the proposed approach included standardized and disaggregated unit costs (for a limited number of outputs) and information on the facilities network available to the program. CONCLUSIONS: The defined functional form will determine the magnitude and shape of costs when outputs and coverage are increasing. This in turn will impact resource allocation decisions. Infectious diseases modelers and economists should use transparent and empirically based cost models for analyses that inform resource allocation decisions. This framework describes a general approach for developing these models.

Yield and Efficiency of Novel Intensified Tuberculosis Case-Finding Algorithms for People Living with HIV.

RATIONALE: The recommended tuberculosis (TB) intensified case finding (ICF) algorithm for people living with HIV (symptom-based screening followed by Xpert MTB/RIF [Xpert] testing) is insufficiently sensitive and results in unnecessary Xpert testing. OBJECTIVES: To evaluate whether novel ICF algorithms combining C-reactive protein (CRP)-based screening with urine Determine TB-LAM (TB-LAM), sputum Xpert, and/or sputum culture could improve ICF yield and efficiency. METHODS: We compared the yield and efficiency of novel ICF algorithms inclusive of point-of-care CRP-based TB screening and confirmatory testing with urine TB-LAM (if CD4 count ≤100 cells/µl), sputum Xpert, and/or a single sputum culture among consecutive people living with HIV with CD4 counts less than or equal to 350 cells/µl initiating antiretroviral therapy in Uganda. MEASUREMENTS AND MAIN RESULTS: Of 1,245 people living with HIV, 203 (16%) had culture-confirmed TB including 101 (49%) patients with CD4 counts less than or equal to 100 cells/µl. Compared with the current ICF algorithm, point-of-care CRP-based TB screening followed by Xpert testing had similar yield (56% [95% confidence interval, 49-63] vs. 59% [95% confidence interval, 51-65]) but consumed less than half as many Xpert assays per TB case detected (9 vs. 4). Addition of TB-LAM did not significantly increase diagnostic yield relative to the current ICF algorithm but provided same-day diagnosis for 26% of TB patients with advanced HIV. Addition of a single culture to TB-LAM and Xpert substantially improved ICF yield, identifying 78% of all TB cases. CONCLUSIONS: Point-of-care CRP-based screening can improve ICF efficiency among people living with HIV. Addition of TB-LAM and a single culture to Xpert confirmatory testing could enable HIV programs to increase the speed of TB diagnosis and ICF yield.

The NHS visitor and migrant cost recovery programme - a threat to health?

BACKGROUND: In April 2014 the UK government launched the 'NHS Visitor and Migrant Cost Recovery Programme Implementation Plan' which set out a series of policy changes to recoup costs from 'chargeable' (largely non-UK born) patients. In England, approximately 75% of tuberculosis (TB) cases occur in people born abroad. Delays in TB treatment increase risk of morbidity, mortality and transmission in the community. We investigated whether diagnostic delay has increased since the Cost Recovery Programme (CRP) was introduced. METHODS: There were 3342 adult TB cases notified on the London TB Register across Barts Health NHS Trust between 1st January 2011 and 31st December 2016. Cases with missing relevant information were excluded. The median time between symptom onset and treatment initiation before and after the CRP was calculated according to birthplace and compared using the Mann Whitney test. Delayed diagnosis was considered greater or equal to median time to treatment for all patients (79 days). Univariable logistic regression was used to manually select exposure variables for inclusion in a multivariable model to test the association between diagnostic delay and the implementation of the CRP. RESULTS: We included 2237 TB cases. Among non-UK born patients, median time-to-treatment increased from 69 days to 89 days following introduction of CRP (p < 0.001). Median time-to-treatment also increased for the UK-born population from 75.5 days to 89.5 days (p = 0.307). The multivariable logistic regression model showed non-UK born patients were more likely to have a delay in diagnosis after the CRP (adjOR 1.37, 95% CI 1.13-1.66, p value 0.001). CONCLUSION: Since the introduction of the CRP there has been a significant delay for TB treatment among non-UK born patients. Further research exploring the effect of policies restricting access to healthcare for migrants is urgently needed if we wish to eliminate TB nationally.

Catastrophic costs of tuberculosis care in a population with internal migrants in China.

BACKGROUND: The internal rural-to-urban migration is one of the major challenges for tuberculosis (TB) control in China. Patient costs incurred during TB diagnosis and treatment could cause access and adherence barriers, particularly among migrants. Here, we estimated the prevalence of catastrophic costs of TB patients and its associated factors in an urban population with internal migrants in China. METHODS: A cross-sectional survey was conducted to enroll culture-confirmed pulmonary TB patients in Songjiang district, Shanghai, between December 1, 2014, and December 31, 2015. Consenting participants completed a questionnaire, which collected direct and indirect costs before and after the diagnosis of TB. The catastrophic cost was defined as the annual expenses of TB care that exceeds 20% of total household disposable income. We used logistic regression to identify factors associated with catastrophic costs. RESULTS: Overall, 248 drug-susceptible TB patients were enrolled, 70% (174/248) of them were from migrants. Migrant patients were significantly younger compared to resident patients. The total costs were 25,824 ($3689) and 13,816 ($1974) Chinese Yuan (RMB) in average for resident and migrant patients, respectively. The direct medical cost comprised about 70% of the total costs among both migrant and resident patients. Overall, 55% (132 of 248) of patients experienced high expenses (>10% of total household income), and 22% (55 of 248) experienced defined catastrophic costs. The reimbursement for TB care only reduced the prevalence of catastrophic costs to 20% (49 of 248). Meanwhile, 52% (90 of 174) of the internal migrants had no available local health insurance. Hospitalizations, no available insurance, and older age (> 45-year-old) contributed significantly to the occurrence of catastrophic costs. CONCLUSIONS: The catastrophic cost of TB service cannot be overlooked, despite the free policy. Migrants have difficulties benefiting from health insurance in urban cities. Interventions, including expanded medical financial assistance, are needed to secure universal TB care.

Should NICE reconsider the 2016 UK guidelines on TB contact tracing? A cost-effectiveness analysis of contact investigations in London.

BACKGROUND: In January 2016, clinical TB guidance in the UK changed to no longer recommend screening contacts of non-pulmonary, non-laryngeal (ETB) index cases. However, no new evidence was cited for this change, and there is evidence that screening these contacts may be worthwhile. The objective of this study was to estimate the cost-effectiveness of screening contacts of adult ETB cases and adult pulmonary or laryngeal TB (PTB) cases in London, UK. METHODS: We carried out a cross-sectional analysis of data collected on TB index cases and contacts in the London TB register and an economic evaluation using a static model describing contact tracing outcomes. Incremental cost-effectiveness ratios (ICERs) were calculated using no screening as the baseline comparator. All adult TB cases (≥15 years old) in London from 2012 to 2015, and their contacts, were eligible (2465/5084 PTB and 2559/6090 ETB index cases were included). RESULTS: Assuming each contact with PTB infects one person/month, the ICER of screening contacts of ETB cases was £78 000/quality-adjusted life-years (QALY) (95% CI 39 000 to 140 000), and screening contacts of PTB cases was £30 000/QALY (95% CI 18 000 to 50 000). The ICER of screening contacts of ETB cases was £30 000/QALY if each contact with PTB infects 3.4 people/month. Limitations of this study include the use of self-reported symptomatic periods and lack of knowledge about onward transmission from PTB contacts. CONCLUSIONS: Screening contacts of ETB cases in London was almost certainly not cost-effective at any conventional willingness-to-pay threshold in England, supporting recent changes to National Institute for Health and Care Excellence national guidelines.

[Incremental cost-effectiveness of the second Xpert MTB/RIF assay for detection of Mycobacterium tuberculosis].

Objective: To study the incremental cost-effectiveness of the second Xpert assay in detection of Mycobacterium tuberculosis (Mtb) and rifampicin (RIF) resistance. Methods: We continuously collected 2 896 specimens from suspected tuberculosis patients who had undergone 2 Xpert tests in a week from March 2015 to March 2018, including 2 402 suspected tuberculosis patients with 1 523 males and 879 females, with an average age of 50 years. Among them, 2 144 specimens of sputum and 258 cases of bronchoalveolar lavage fluid were collected. We also enrolled 494 patients with suspected extrapulmonary tuberculosis, 318 males and 176 females, with an average age of 42 years. Among them, 157 pleural effusion specimens, 106 cerebrospinal fluid specimens, 34 urine specimens and 197 pus specimens were collected. All specimens were subjected to two Xpert tests, smear microscopy, liquid rapid culture (BACTEC MGIT 960), and positively cultured bacteria were tested for drug susceptibility. Results: Among the 2 896 specimens from suspected tuberculosis patients, either one of the two Xpert test results was positive (including both tests were positive, the same below) in 1 639 patients, and 1 502 (91.6%) were positive in the first Xpert tests. The additional 137 (8.4%) test results were positive in the second tests. According to the smear test results, all specimens were divided into the smear negative group and the smear positive group. The second Xpert test was significantly higher than the smear-positive group (14.86%, 3.2%, P<0.001), and the extrapulmonary tuberculosis group was higher than the tuberculosis group (11.2%, 8.0%, P=0.12).Of the susceptibility test results, a total of 371 were rifampicin-resistant specimens. The first Xpert detected 91.4% (339/371), and the second Xpert detected the additional 8.1% (30/371).The cost increase of the second test was very significant. Tests were calculated at 650 yuan per time, the tuberculosis group was 1 184 yuan and 13 696 yuan(P<0.001); the extrapulmonary tuberculosis group was 1 755 yuan and 13 961 yuan(P<0.001). In the test of specimens of tuberculosis and extrapulmonary tuberculosis, the smear-negative specimen cost increase of the second Xpert test was lower than that of the smear-positive specimen. Conclusion: The second xpert test showed significant value-added cost-effectiveness in the diagnosis of tuberculosis.

Cash interventions to improve clinical outcomes for pulmonary tuberculosis: systematic review and meta-analysis.

OBJECTIVE: To assess cash transfer interventions for improving treatment outcomes of active pulmonary tuberculosis in low- and middle-income countries. METHODS: We searched PubMed®, Embase®, Cochrane Library and ClinicalTrials.gov for studies published until 4 August 2017 that reported on cash transfer interventions during the treatment of active pulmonary tuberculosis in low- and middle-income countries. Our primary outcome was a positive clinical outcome, defined as treatment success, treatment completion or microbiologic cure. Using the purchasing power parity conversion factor, we converted the amount of cash received per patient within each study into international dollars (Int$). We calculated odds ratio (OR) for the primary outcome using a random effects meta-analysis. FINDINGS: Eight studies met eligibility criteria for review inclusion. Seven studies assessed a tuberculosis-specific intervention, with average amount of cash ranging from Int$ 193-858. One study assessed a tuberculosis-sensitive intervention, with average amount of Int$ 101. Four studies included non-cash co-interventions. All studies showed better primary outcome for the intervention group than the control group. After excluding three studies with high risk of bias, patients receiving tuberculosis-specific cash transfer were more likely to have a positive clinical outcome than patients in the control groups (OR: 1.77; 95% confidence interval: 1.57-2.01). CONCLUSION: The evidence available suggests that patients in low- and middle-income countries receiving cash during treatment for active pulmonary tuberculosis are more likely to have a positive clinical outcome. These findings support the incorporation of cash transfer interventions into social protection schemes within tuberculosis treatment programmes.

How affordable is TB care? Findings from a nationwide TB patient cost survey in Ghana.

OBJECTIVES: Tuberculosis (TB) is known as a disease of the poor. Despite TB diagnosis and care usually being offered for free, TB patients can still face substantial costs, especially in the context of multi-drug resistance (MDR). The End TB Strategy calls for zero TB-affected families incurring 'catastrophic' costs due to TB by 2025. This paper examines, by MDR status, the level and composition of costs incurred by TB-affected households during care seeking and treatment; assesses the affordability of TB care using catastrophic and impoverishment measures; and describes coping strategies used by TB-affected households to pay for TB care. METHODS: A nationally representative survey of TB patients at public health facilities across Ghana. RESULTS: We enrolled 691 patients (66 MDR). The median expenditure for non-MDR TB was US$429.6 during treatment, vs. US$659.0 for MDR patients (P-value = 0.001). Catastrophic costs affected 64.1% of patients. MDR patients were pushed significantly further over the threshold for catastrophic payments than DS patients. Payments for TB care led to a significant increase in the proportion of households in the study sample that live below the poverty line at the time of survey compared to pre-TB diagnosis. Over half of patients undertook coping strategies. CONCLUSION: TB patients in Ghana incur substantial costs, despite free diagnosis and treatment. High rates of catastrophic costs and coping strategies in both non-MDR and MDR patients show that new policies are urgently needed to ensure TB care is actually affordable for TB patients.

Implementing the End TB Strategy in the Western Pacific Region: Translating vision into reality.

The End TB Strategy aims to end the global tuberculosis (TB) epidemic by 2035 in line with the sustainable development goals targets and has been implemented in the World Health Organization (WHO) Western Pacific Region since 2015. Significant progress has been made in implementing this strategy. However, several challenges still remain. In 2016, an estimated 1.8 million people developed TB in the region, and of these about 20% were missed by national TB programmes. The gap in diagnosis and enrolment as well as treatment completion is greater with drug-resistant TB. Many TB-affected families face catastrophic costs due to the disease. Sustaining financing for TB care is a long-term challenge in many countries. This article emphasizes targeted interventions in high-risk populations, including systematic screening and patient-centred TB care. Several other approaches including improving TB diagnostic tools and algorithm, and engaging all care providers are suggested to find missing TB patients. Drug-resistant TB requires additional resourcing for laboratories, enrolment and patient support. Specific measures are required at different levels to mitigate financial burden due to TB including linking TB to overall social protection schemes. The Moscow Ministerial conference in 2017 and upcoming United Nations (UN) 2018 high-level meeting provide an opportunity to raise TB higher on the global agenda, forge partnerships and move towards universal health coverage.

Adaptation of the Tool to Estimate Patient Costs Questionnaire into Indonesian Context for Tuberculosis-affected Households.

BACKGROUND: Indonesia is the second-highest country for tuberculosis (TB) incidence worldwide. Hence, it urgently requires improvements and innovations beyond the strategies that are currently being implemented throughout the country. One fundamental step in monitoring its progress is by preparing a validated tool to measure total patient costs and catastrophic total costs. The World Health Organization (WHO) recommends using a version of the generic questionnaire that has been adapted to the local cultural context in order to interpret findings correctly. This study is aimed to adapt the Tool to Estimate Patient Costs questionnaire into the Indonesian context, which measures total costs and catastrophic total costs for tuberculosis-affected households. METHODS: the tool was adapted using best-practice guidelines. On the basis of a pre-test performed in a previous study (referred to as Phase 1 Study), we refined the adaptation process by comparing it with the generic tool introduced by the WHO. We also held an expert committee review and performed pre-testing by interviewing 30 TB patients. After pre-testing, the tool was provided with complete explanation sheets for finalization. RESULTS: seventy-two major changes were made during the adaptation process including changing the answer choices to match the Indonesian context, refining the flow of questions, deleting questions, changing some words and restoring original questions that had been changed in Phase 1 Study. Participants indicated that most questions were clear and easy to understand. To address recall difficulties by the participants, we made some adaptations to obtain data that might be missing, such as tracking data to medical records, developing a proxy of costs and guiding interviewers to ask for a specific value when participants were uncertain about the estimated market value of property they had sold. CONCLUSION: the adapted Tool to Estimate Patient Costs in Bahasa Indonesia is comprehensive and ready for use in future studies on TB-related catastrophic costs and is suitable for monitoring progress to achieve the target of the End TB Strategy.

Bringing patient-centered tuberculosis diagnosis into the light of day.

In 2015, the WHO End TB Strategy laid out ambitious goals to dramatically reduce tuberculosis (TB) deaths, incidence, and catastrophic costs through research, bold new strategies, and patient-centered care. In this commentary, recent evidence on sputum collection strategies for smear microscopy is reviewed, and the argument is made that redesigning smear microscopy as a patient-centered service offers the only realistic and widely available strategy to advance TB diagnostic care towards the initial End TB Strategy goals laid out for 2025. Finally, the successful adoption of same-day sputum smear microscopy as a model for patient-centered TB care is suggested to be synergistic with and to form part of the scale-up of new TB diagnostic tools.Please see related article: https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0947-9.

Disease spectrum and management of children admitted with acute respiratory infection in Viet Nam.

OBJECTIVE: To assess the acute respiratory infection (ARI) disease spectrum, duration of hospitalisation and outcome in children hospitalised with an ARI in Viet Nam. METHODS: We conducted a retrospective descriptive study of ARI admissions to primary (Hoa Vang District Hospital), secondary (Da Nang Hospital for Women and Children) and tertiary (National Hospital of Paediatrics in Ha Noi) level hospitals in Viet Nam over 12 months (01/09/2015 to 31/08/2016). RESULTS: Acute respiratory infections accounted for 27.9% (37 436/134 061) of all paediatric admissions; nearly half (47.6%) of all children admitted to Hoa Vang District Hospital. Most (64.6%) of children hospitalised with an ARI were <2 years of age. Influenza/pneumonia accounted for 69.4% of admissions; tuberculosis for only 0.3%. Overall 284 (0.8%) children died; most deaths (269/284; 94.7%) occurred at the tertiary referral hospital. The average duration of hospitalisation was 7.6 days (median 7 days). The average direct hospitalisation cost per ARI admission was 157.5 USD in Da Nang Provincial Hospital. In total, 62.6% of admissions were covered by health insurance. CONCLUSION: Acute respiratory infection is a major cause of paediatric hospitalisation in Viet Nam, characterised by prolonged hospitalisation for relatively mild disease. There is huge potential to reduce unnecessary hospital admission and cost.

Tuberculosis active case finding in Cambodia: a pragmatic, cost-effectiveness comparison of three implementation models.

BACKGROUND: Globally, almost 40% of tuberculosis (TB) patients remain undiagnosed, and those that are diagnosed often experience prolonged delays before initiating correct treatment, leading to ongoing transmission. While there is a push for active case finding (ACF) to improve early detection and treatment of TB, there is extremely limited evidence about the relative cost-effectiveness of different ACF implementation models. Cambodia presents a unique opportunity for addressing this gap in evidence as ACF has been implemented using different models, but no comparisons have been conducted. The objective of our study is to contribute to knowledge and methodology on comparing cost-effectiveness of alternative ACF implementation models from the health service perspective, using programmatic data, in order to inform national policy and practice. METHODS: We retrospectively compared three distinct ACF implementation models - door to door symptom screening in urban slums, checking contacts of TB patients, and door to door symptom screening focusing on rural populations aged above 55 - in terms of the number of new bacteriologically-positive pulmonary TB cases diagnosed and the cost of implementation assuming activities are conducted by the national TB program of Cambodia. We calculated the cost per additional case detected using the alternative ACF models. RESULTS: Our analysis, which is the first of its kind for TB, revealed that the ACF model based on door to door screening in poor urban areas of Phnom Penh was the most cost-effective (249 USD per case detected, 737 cases diagnosed), followed by the model based on testing contacts of TB patients (308 USD per case detected, 807 cases diagnosed), and symptomatic screening of older rural populations (316 USD per case detected, 397 cases diagnosed). CONCLUSIONS: Our study provides new evidence on the relative effectiveness and economics of three implementation models for enhanced TB case finding, in line with calls for data from 'routine conditions' to be included in disease control program strategic planning. Such cost-effectiveness comparisons are essential to inform resource allocation decisions of national policy makers in resource constraint settings. We applied a novel, pragmatic methodological approach, which was designed to provide results that are directly relevant to policy makers, costing the interventions from Cambodia's national TB program's perspective and using case finding data from implementation activities, rather than experimental settings.

Delay in diagnosis of pulmonary tuberculosis in low-and middle-income settings: systematic review and meta-analysis.

BACKGROUND: Assessment of delays in seeking care and diagnosis of tuberculosis is essential to evaluate effectiveness of tuberculosis control programs, and identify programmatic impediments. Thus, this review of studies aimed to examine the extent of patient, health system, and total delays in diagnosis of pulmonary tuberculosis in low- and middle- income countries. METHODS: It was done following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Electronic databases were searched to retrieve studies published from 2007 to 2015 including Pubmed central, Springer link, Hinari and Google scholar. Searching terms were pulmonary tuberculosis, health care seeking, health care seeking behavior, patient delay, diagnostic delay, health system delay, provider delay, and doctor delay. Retrieved studies were systematically reviewed and summarized using Comprehensive Meta-analysis software. RESULTS: Forty studies involving 18,975 patients qualified for systematic review, and 14 of them qualified for meta-analysis. The median diagnostic delay ranged from 30 to 366.5 days [IQR = 44-77.8], with a 4-199 days [IQR = 15-50] and 2-128.5 days [IQR = 12-34] due to patient and health system delays, respectively. The meta-analysis showed 42% of pulmonary tuberculosis patients delayed seeking care by a month or more; uneducated patients [pooled OR = 1.5, 95%CI = 1.1-1.9] and those who sought initial care from informal providers [pooled OR = 3, 95%CI = 2.3-3.9] had higher odds of patient delay. CONCLUSION: Delay in diagnosis is still a major challenge of tuberculosis control and prevention programs in low- and middle- income settings. Efforts to develop new strategies for better case-finding using the existing systems and improving patients' care seeking behavior need to be intensified.

Cost-effectiveness of adding novel or group 5 interventions to a background regimen for the treatment of multidrug-resistant tuberculosis in Germany.

BACKGROUND: Treatment of multidrug-resistant tuberculosis (MDR-TB) is complex, lengthy, and involves a minimum of four drugs termed a background regimen (BR), that have not previously been prescribed or that have proven susceptible to patient sputum culture isolates. In recent years, promising new treatment options have emerged as add-on therapies to a BR. The aim of this study was to evaluate the long-term costs and effectiveness of adding the novel or group 5 interventions bedaquiline, delamanid, and linezolid to a background regimen (BR) of drugs for the treatment of adult patients with pulmonary multidrug-resistant tuberculosis (MDR-TB), within their marketing authorisations, from a German healthcare cost-effectiveness perspective. METHODS: A cohort-based Markov model was developed to simulate the incremental cost-effectiveness ratio of bedaquiline plus BR, delamanid plus BR, or linezolid plus BR versus BR alone in the treatment of MDR-TB, over a 10-year time horizon. Effectiveness of treatment was evaluated in Quality-Adjusted Life-Years (QALYs) and Life-Years Gained (LYG), using inputs from clinical trials for bedaquiline and delamanid and from a German observational study for linezolid. Cost data were obtained from German Drug Directory costs (€/2015), published literature, and expert opinion. A 3% yearly discount rate was applied. Probabilistic and deterministic sensitivity analyses were conducted. RESULTS: The total discounted costs per-patient were €85,575 for bedaquiline plus BR, €81,079 for delamanid plus BR, and €80,460 for linezolid plus BR, compared with a cost of €60,962 for BR alone. The total discounted QALYs per-patient were 5.95 for bedaquiline plus BR, 5.36 for delamanid plus BR, and 3.91 for linezolid plus BR, compared with 3.68 for BR alone. All interventions were therefore associated with higher QALYs and higher costs than BR alone, with incremental costs per QALY gained of €22,238 for bedaquiline, €38,703 for delamanid, and €87,484 for linezolid, versus BR alone. In a fully incremental analysis, bedaquiline plus BR was the most cost-effective treatment option at thresholds greater than €22,000 per QALY gained. In probabilistic analyses, the probability that bedaquiline plus BR was the most cost-effective treatment strategy at a willingness-to-pay threshold of €30,000 was 54.5%, compared with 22.9% for BR alone, 18.2% for delamanid plus BR, and 4.4% for linezolid. CONCLUSIONS: In Germany, the addition of bedaquiline, delamanid, or linezolid to a BR would result in QALY gains over BR alone. Based on this analysis, bedaquiline is likely to be the most cost-effective intervention for the treatment of MDR-TB, when added to a BR regimen at thresholds greater than €22,000 per QALY.

Infectious disease screening in asylum seekers: range, coverage and economic evaluation in Germany, 2015.

Screening asylum seekers for infectious diseases is widely performed, but economic evaluations of such are scarce. We performed a policy analysis and economic evaluation of such screening in Germany, and analysed the effect of screening policies on cost differences between federal states. Of the 16 states, screening was compulsory for tuberculosis (TB) in asylum seekers ≥ 16 years of age in all states as well as in children < 16 years of age and pregnant women in six states, hepatitis B and enteropathogens in three, syphilis in two and human immunodeficiency virus (HIV) in one state. Of 441,899 asylum seekers, 88.0% were screened for TB, 22.9% for enteropathogens, 16.9% for hepatitis B, 13.1% for syphilis and 11.3% for HIV. The total costs for compulsory screening in 2015 were 10.3 million euros (EUR). Costs per case were highest for infections with Shigella spp. (80,200 EUR), Salmonella spp. (8,000 EUR), TB in those ≥ 16 years of age (5,300 EUR) and syphilis (1,150 EUR). States with extended screening had per capita costs 2.84 times those of states that exclusively screened for TB in asylum seekers ≥ 16 years of age (p < 0.0001, 95% confidence interval (CI): 1.96-4.10). Screening practices in Germany entailed high costs; evidence-based approaches to infectious disease screening are needed.