RESUMO
This study aimed to estimate the cost-effectiveness of four therapeutic approaches available for mucosal leishmaniasis in Brazil: miltefosine, meglumine antimoniate, combined with and without pentoxifylline, and liposomal amphotericin B. The perspective adopted was that of the Brazilian Unified National Health System (SUS). The outcome of interest was "cured patient", which was analyzed using a decision tree model. Estimates of direct costs and effectiveness were obtained from the scientific literature. Meglumine antimoniate alone was the base comparator strategy; liposomal amphotericin B showed an incremental cost-effectiveness ratio (ICER) of USD 7,409.13 per cured patient, and the combination of meglumine antimoniate with pentoxifylline presented an ICER of USD 85.13. Miltefosine was absolutely dominated, with higher cost and similar effectiveness when compared to meglumine antimoniate. Sensitivity analyses, varying the cost by ±25%, did not change the results. However, when the cost of miltefosine was estimated at less than USD 171.23, this strategy was dominant over meglumine antimoniate alone. The results confirm that treatment with liposomal amphotericin B remains the option with the highest ICER among the approaches analyzed. Miltefosine may be cost-effective based on the variation in the acquisition price, which deserves attention because it is the only available oral option. The non-accounting of other aspects prevent the use of these results immediately to support decision-making, but they point out the need to negotiate the prices of drugs available for mucosal leishmaniasis and indicates the need of encouraging technology transfer or other actions aimed at expanding the performance of the Brazilian national industrial complex.
Assuntos
Anfotericina B , Antiprotozoários , Análise Custo-Benefício , Leishmaniose Mucocutânea , Antimoniato de Meglumina , Meglumina , Compostos Organometálicos , Pentoxifilina , Fosforilcolina , Humanos , Fosforilcolina/análogos & derivados , Fosforilcolina/economia , Fosforilcolina/uso terapêutico , Leishmaniose Mucocutânea/tratamento farmacológico , Leishmaniose Mucocutânea/economia , Antiprotozoários/economia , Antiprotozoários/uso terapêutico , Anfotericina B/economia , Anfotericina B/uso terapêutico , Brasil , Meglumina/economia , Meglumina/uso terapêutico , Antimoniato de Meglumina/uso terapêutico , Antimoniato de Meglumina/economia , Compostos Organometálicos/uso terapêutico , Compostos Organometálicos/economia , Pentoxifilina/economia , Pentoxifilina/uso terapêutico , Quimioterapia Combinada/economia , Programas Nacionais de Saúde/economiaRESUMO
INTRODUCTION: Cutaneous leishmaniasis (CL), endemic in Bolivia, mostly affects poor people in rainforest areas. The current first-line treatment consists of systemic pentavalent antimonials (SPA) for 20 days and is paid for by the Ministry of Health (MoH). Long periods of drug shortages and a lack of safe conditions to deliver treatment are challenges to implementation. Intralesional pentavalent antimonials (ILPA) are an alternative to SPA. This study aims to compare the cost of ILPA and SPA, and to estimate the health and economic impacts of changing the first-line treatment for CL in a Bolivian endemic area. METHODS: The cost-per-patient treated was estimated for SPA and ILPA from the perspectives of the MoH and society. The quantity and unit costs of medications, staff time, transportation and loss of production were obtained through a health facility survey (N = 12), official documents and key informants. A one-way sensitivity analysis was conducted on key parameters to evaluate the robustness of the results. The annual number of patients treated and the budget impact of switching to ILPA as the first-line treatment were estimated under different scenarios of increasing treatment utilization. Costs were reported in 2017 international dollars (1 INT$ = 3.10 BOB). RESULTS: Treating CL using ILPA was associated with a cost-saving of $248 per-patient-treated from the MoH perspective, and $688 per-patient-treated from the societal perspective. Switching first-line treatment to ILPA while maintaining the current budget would allow two-and-a-half times the current number of patients to be treated. ILPA remained cost-saving compared to SPA in the sensitivity analysis. CONCLUSIONS: The results of this study support a shift to ILPA as the first-line treatment for CL in Bolivia and possibly in other South American countries.
Assuntos
Antiprotozoários/economia , Orçamentos , Redução de Custos , Leishmaniose Cutânea/tratamento farmacológico , Gluconato de Antimônio e Sódio/economia , Gluconato de Antimônio e Sódio/uso terapêutico , Antiprotozoários/uso terapêutico , Bolívia , Análise Custo-Benefício , Custos de Medicamentos , Custos de Cuidados de Saúde , Humanos , Antimoniato de Meglumina/economia , Antimoniato de Meglumina/uso terapêuticoRESUMO
OBJECTIVE: To estimate the cost-effectiveness of strategies for the treatment of VL in Brazil. METHODS: Cost-effectiveness study comparing three therapeutic options: meglumine antimoniate (MA), liposomal amphotericin B (LAMB) and a combination of LAMB plus MA (LAMB plus MA), from public health system and societal perspectives. An analytical decision-making model was used to compare strategies for the following outcomes: early therapeutic failure avoided at 30 days, days of hospitalisation avoided and VL cure at 180 days. The efficacy and safety parameters of the drugs came from a randomised, open-label trial and the cost data came from a cost-of-illness study, both carried out in Brazil. RESULTS: For all outcomes analysed, the LAMB strategy was more effective. The MA strategy was inferior to the LAMB plus MA strategy for the outcomes early therapeutic failure avoided and cure. When only LAMB and MA were compared from a societal perspective, a cost of US$ 278.56 was estimated for each additional early therapeutic failure avoided, a cost of US$ 26.88 for each additional day of hospitalisation avoided and a cost of US$ 89.88 for each additional case of cured VL, for the LAMB strategy vs. MA. CONCLUSION: In Brazil, the LAMB strategy proved to be cost-effective for treating VL, considering a GDP per capita as the willingness-to-pay threshold, for all of the outcomes analysed in comparison to MA.
OBJECTIF: Estimer la rentabilité des stratégies de traitement de la leishmaniose viscérale (LV) au Brésil. MÉTHODES: Etude coût-efficacité comparant trois options thérapeutiques: l'antimoniate de méglumine (AM), amphotéricine B liposomale (LAMB) et une combinaison de LAMB et MA (LAMB plus AM), du point de vue du système de santé publique et sociétal. Un modèle décisionnel analytique a été utilisé pour comparer les stratégies pour les résultats suivants: échec thérapeutique précoce évité à 30 jours, jours d'hospitalisation évités et guérison de la LV à 180 jours. Les paramètres d'efficacité et de sécurité des médicaments provenaient d'un essai randomisé ouvert et les données relatives aux coûts, d'une étude sur le coût de la maladie, toutes deux menées au Brésil. RÉSULTATS: Pour tous les résultats analysés, la stratégie LAMB était plus efficace. La stratégie AM était inférieure à la stratégie LAMB plus AM pour les résultats: échec thérapeutique précoce évité et guérison. Lorsque seules les stratégies LAMB et AM ont été comparées d'un point de vue sociétal, un coût de 278,56 USD a été estimé pour chaque échec thérapeutique précoce additionnel évité, un coût de 26,88 USD pour chaque jour d'hospitalisation additionnel évité et un coût de 89,88 USD pour chaque cas additionnel de LV guéri, pour la stratégie LAMB par rapport à AM. CONCLUSION: Au Brésil, la stratégie LAMB s'est avérée rentable pour traiter la LV, considérant un PIB par habitant comme seuil de volonté de payer, pour tous les résultats analysés par rapport à l'AM.
Assuntos
Anfotericina B/economia , Anfotericina B/uso terapêutico , Antiprotozoários/uso terapêutico , Leishmaniose Visceral/tratamento farmacológico , Antimoniato de Meglumina/economia , Antimoniato de Meglumina/uso terapêutico , Anfotericina B/administração & dosagem , Antiprotozoários/economia , Brasil , Análise Custo-Benefício , Quimioterapia Combinada , Recursos em Saúde/economia , Recursos em Saúde/estatística & dados numéricos , Serviços de Saúde/economia , Serviços de Saúde/estatística & dados numéricos , Humanos , Antimoniato de Meglumina/administração & dosagem , Modelos EconométricosRESUMO
INTRODUCTION: Visceral leishmaniasis (VL) is fatal if not diagnosed and treated. This study aimed to estimate the cost-effectiveness of diagnostic-therapeutic alternatives for VL in Brazil. METHODS: A decision model estimated the life expectancy and costs of six diagnostic-therapeutic strategies. RESULTS: IT LEISH + liposomal amphotericin B emerged the best option, presenting lower costs and higher effectiveness. DAT-LPC + liposomal amphotericin B showed an incremental cost-effectiveness ratio of US$ 326.31 per life year. CONCLUSIONS: These findings indicate the feasibility of incorporating DAT and designating liposomal amphotericin B as the first-line drug for VL in Brazil.
Assuntos
Anfotericina B/economia , Antiprotozoários/economia , Análise Custo-Benefício/estatística & dados numéricos , Leishmaniose Visceral/economia , Meglumina/economia , Anfotericina B/administração & dosagem , Antiprotozoários/administração & dosagem , Brasil , Teste de Coombs/economia , Técnica Indireta de Fluorescência para Anticorpo/economia , Humanos , Leishmaniose Visceral/diagnóstico , Leishmaniose Visceral/tratamento farmacológico , Meglumina/administração & dosagem , Sensibilidade e EspecificidadeRESUMO
Abstract INTRODUCTION: Visceral leishmaniasis (VL) is fatal if not diagnosed and treated. This study aimed to estimate the cost-effectiveness of diagnostic-therapeutic alternatives for VL in Brazil. METHODS: A decision model estimated the life expectancy and costs of six diagnostic-therapeutic strategies. RESULTS: IT LEISH + liposomal amphotericin B emerged the best option, presenting lower costs and higher effectiveness. DAT-LPC + liposomal amphotericin B showed an incremental cost-effectiveness ratio of US$ 326.31 per life year. CONCLUSIONS: These findings indicate the feasibility of incorporating DAT and designating liposomal amphotericin B as the first-line drug for VL in Brazil.
Assuntos
Humanos , Anfotericina B/economia , Análise Custo-Benefício/estatística & dados numéricos , Leishmaniose Visceral/economia , Meglumina/economia , Antiprotozoários/economia , Brasil , Teste de Coombs/economia , Anfotericina B/administração & dosagem , Sensibilidade e Especificidade , Técnica Indireta de Fluorescência para Anticorpo/economia , Leishmaniose Visceral/diagnóstico , Leishmaniose Visceral/tratamento farmacológico , Meglumina/administração & dosagem , Antiprotozoários/administração & dosagemRESUMO
BACKGROUND: The World Health Organization's 2020 Goals for Chagas disease include access to antiparasitic treatment and care of all infected/ill patients. Policy makers need to know the economic value of identifying and treating patients earlier. However, the economic value of earlier treatment to cure and prevent the Chagas' spread remains unknown. METHODS: We expanded our existing Chagas disease transmission model to include identification and treatment of Chagas disease patients. We linked this to a clinical and economic model that translated chronic Chagas disease cases into health and economic outcomes. We evaluated the impact and economic outcomes (costs, cost-effectiveness, cost-benefit) of identifying and treating different percentages of patients in the acute and indeterminate disease states in a 2,000-person village in Yucatan, Mexico. RESULTS: In the absence of early treatment, 50 acute and 22 new chronic cases occurred over 50 years. Identifying and treating patients in the acute stage averted 0.5-5.4 acute cases, 0.6-5.5 chronic cases, and 0.6-10.8 disability-adjusted life years (DALYs), saving $694-$7,419 and $6,976-$79,950 from the third-party payer and societal perspectives, respectively. Treating in the indeterminate stage averted 2.2-4.9 acute cases, 6.1-12.8 chronic cases, and 11.7-31.1 DALYs, saving $7,666-$21,938 from the third-party payer perspective and $90,530-$243,068 from the societal perspective. Treating patients in both stages averted ≤9 acute cases and ≤15 chronic cases. Identifying and treating patients early was always economically dominant compared to no treatment. Identifying and treating patients earlier resulted in a cumulative cost-benefit of $7,273-$224,981 at the current cost of identification and treatment. CONCLUSIONS: Even when identifying and treating as little as 5% of cases annually, treating Chagas cases in the acute and indeterminate stages reduces transmission and provides economic and health benefits. This supports the need for improved diagnostics and access to safe and effective treatment.
Assuntos
Antiprotozoários/economia , Doença de Chagas/tratamento farmacológico , Doença de Chagas/economia , Prevenção Secundária/economia , Animais , Antiprotozoários/uso terapêutico , Doença de Chagas/parasitologia , Doença de Chagas/transmissão , Análise Custo-Benefício , Humanos , México , Resultado do Tratamento , Trypanosoma cruzi/efeitos dos fármacos , Trypanosoma cruzi/fisiologiaRESUMO
Bolivian cutaneous leishmaniasis due to Leishmania braziliensis was treated with the combination of miltefosine (150 mg/day for 28 days) plus intralesional pentamidine (120 µg/mm2 lesion area on days 1, 3, and 5). Ninety-two per cent of 50 patients cured. Comparison to historic controls at our site suggests that the efficacy of the two drugs was additive. Adverse effects and cost were also additive. This combination may be attractive when a prime consideration is efficacy (e.g., in rescue therapy), avoidance of parenteral therapy, or the desire to treat locally and also provide systemic protection against parasite dissemination.
Assuntos
Antiprotozoários/uso terapêutico , Leishmania braziliensis/efeitos dos fármacos , Leishmania/efeitos dos fármacos , Leishmaniose Cutânea/tratamento farmacológico , Pentamidina/uso terapêutico , Fosforilcolina/análogos & derivados , Adulto , Antiprotozoários/administração & dosagem , Antiprotozoários/economia , Bolívia , Quimioterapia Combinada/efeitos adversos , Quimioterapia Combinada/economia , Feminino , Humanos , Masculino , Pentamidina/administração & dosagem , Pentamidina/efeitos adversos , Pentamidina/economia , Fosforilcolina/administração & dosagem , Fosforilcolina/efeitos adversos , Fosforilcolina/economia , Fosforilcolina/uso terapêutico , Resultado do TratamentoRESUMO
BACKGROUND: The present health economic evaluation in Afghanistan aims to support public health decision makers and health care managers to allocate resources efficiently to appropriate treatments for cutaneous leishmaniasis (CL) elicited by Leishmania tropica or Leishmania major. METHODS: A decision tree was used to analyse the cost and the effectiveness of two wound care regimens versus intra-lesional antimony in CL patients in Afghanistan. Costs were collected from a societal perspective. Effectiveness was measured in wound free days. The incremental cost-effectiveness ratio (ICER) and incremental net monetary benefit (NMB) were calculated. The model was parameterized with baseline parameters, sensitivity ranges, and parameter distributions. Finally, the model was simulated and results were evaluated with deterministic and probability sensitivity analyses. Final outcomes were the efficiency of the regimens and a budget impact analysis in the context of Afghanistan. RESULTS: Average costs per patients were US$ 11 (SE = 0.016) (Group I: Intra-dermal Sodium Stibogluconate [IL SSG]), US$ 16 (SE = 7.58) (Group II: Electro-thermo-debridement [ETD] + Moist wound treatment [MWT]) and US$ 25 (SE = 0.48) (Group III: MWT) in patients with a single chronic CL ulcer. From a societal perspective the budget impact analysis shows that the regimens' drug costs are lower than indirect disease cost. Average effectiveness in wound free days are 177 (SE = 0.36) in Group II, 147 (SE = 0.33) in Group III, and 129 (SE = 0.27) in Group I. The ICER of Group II versus Group I was US$ 0.09 and Group III versus Group I US$ 0.77, which is very cost-effective with a willingness-to-pay threshold of US$ 2 per wound free day. Within a Monte-Carlo probabilistic sensitivity analysis Group II was cost-effective in 80% of the cases starting at a willingness-to-pay of 80 cent per wound free day. CONCLUSIONS: Group II provided the most cost-effective treatment. The non-treatment alternative is not an option in the management of chronic CL ulcers. MWT of Group III should at least be practiced. The cost-effectiveness of Group III depends on the number of dressings necessary until complete wound closure.
Assuntos
Análise Custo-Benefício , Leishmaniose Cutânea , Modelos Estatísticos , Cicatrização , Afeganistão/epidemiologia , Gluconato de Antimônio e Sódio/economia , Gluconato de Antimônio e Sódio/uso terapêutico , Antiprotozoários/economia , Antiprotozoários/uso terapêutico , Desbridamento/economia , Árvores de Decisões , Humanos , Leishmaniose Cutânea/economia , Leishmaniose Cutânea/epidemiologia , Leishmaniose Cutânea/terapia , Método de Monte Carlo , Ensaios Clínicos Controlados Aleatórios como Assunto , Úlcera/economia , Úlcera/epidemiologia , Úlcera/terapiaRESUMO
Leishmaniasis is a vector-borne infectious disease caused by multiple Leishmania (L.) species with diverse clinical manifestations. There is currently no vaccine against any form of the disease approved in humans, and chemotherapy is the sole approach for treatment. Unfortunately, treatment options are limited to a small number of drugs, partly due to high cost and significant adverse effects. The other obstacle in leishmaniasis treatment is the potential for drug resistance, which has been observed in multiple endemic countries. Immunotherapy maybe another important avenue for controlling leishmaniasis and could help patients control the disease. There are different approaches for immunotherapy in different infectious diseases, generally with low-cost, limited side-effects and no possibility to developing resistance. In this paper, different immunotherapy approaches as alternatives to routine drug treatment will be reviewed against leishmaniasis.
Assuntos
Imunoterapia/métodos , Leishmania/imunologia , Leishmaniose/imunologia , Leishmaniose/terapia , Animais , Antiprotozoários/administração & dosagem , Antiprotozoários/efeitos adversos , Antiprotozoários/economia , Antiprotozoários/uso terapêutico , Ensaios Clínicos como Assunto , Citocinas/uso terapêutico , Modelos Animais de Doenças , Resistência a Medicamentos , Humanos , Fatores Imunológicos/uso terapêutico , Imunoterapia/efeitos adversos , Imunoterapia/economia , Leishmania/efeitos dos fármacos , Leishmaniose/tratamento farmacológico , Vacinas contra Leishmaniose/imunologia , CamundongosRESUMO
OBJECTIVE: To compare the cost-effectiveness of L-AmB with that of SbV and AmB-D, for the treatment of mucocutaneous leishmaniasis in a hospital in north-east Brazil. METHODS: We developed an economic model based on retrospective data of 73 hospitalised patients in 2006-2012, from hospital and public health system perspectives. RESULTS: In the economic model, 82.2% of patients who started treatment with L-AmB had completed it after 2 months, vs. 22.0% for the SbV and 19.9% for the AmB-D groups. After 12 months of follow-up, these proportions were 100% in the L-AmB, 77.4% in the AmB-D and 72.2% in the SbV group. Markov chain analyses showed that the group that started therapy with SbV had the lowest mean total cost (US$ 3782.38), followed by AmB-D (US$ 5211.27) and L-AmB (US$ 11 337.44). The incremental cost-effectiveness ratio for L-AmB was US$ 18 816.23 against SbV and US$ 24 504.65 against AmB-D. In the sensitivity analysis, the drug acquisition cost of L-AmB significantly influenced the results. CONCLUSIONS: In the treatment of mucocutaneous leishmaniasis, L-AmB is a cost-effective alternative to SbV and AmB-D owing to its higher effectiveness, safety and shorter course.
Assuntos
Anfotericina B/economia , Antiprotozoários/economia , Análise Custo-Benefício , Custos de Medicamentos , Hospitalização , Leishmania braziliensis , Leishmaniose Mucocutânea/economia , Adulto , Idoso , Anfotericina B/uso terapêutico , Antiprotozoários/uso terapêutico , Brasil , Feminino , Humanos , Leishmaniose Mucocutânea/tratamento farmacológico , Masculino , Pessoa de Meia-Idade , Modelos EconômicosRESUMO
INTRODUCTION:: The drugs available for visceral leishmaniasis (VL) treatment in Brazil have specific characteristics in terms of operability, effectiveness, toxicity, and cost. The aim of this study was to estimate the direct costs of therapies recommended by the Ministry of Health (MH) for VL treatment in Brazil. METHODS:: The analytical perspective used was that adopted by the Brazilian Public Health System. Three drugs and four regimens were included: 1) N-methyl glucamine antimoniate intramuscularly at 20mg per kg per day for 30 days; 2) N-methyl glucamine antimoniate intravenously at 20mg per kg per day for 30 days; 3) amphotericin B deoxycholate at 1mg per kg per day for 21 days; and 4) liposomal amphotericin B at 3mg per kg per day for a 7 days treatment. RESULTS:: The estimated direct costs of treatment for an adult patient using N-methylglucamine antimoniate administered via the intramuscular and intravenous routes were USD 418.52 and USD 669.40, respectively. The estimated cost of treatment with amphotericin B deoxycholate was USD 1,522.70. Finally, the estimated costs of treatment with liposomal amphotericin B were USD 659.79, and USD 11,559.15 using the price adopted by the WHO and the Drug Regulation Board, respectively. CONCLUSIONS:: This analysis indicates the economic feasibility of replacing N-methyl glucamine antimoniate with liposomal amphotericin B, which allows a shorter treatment period with less toxicity compared with other treatments, provided that the purchase value used by the WHO and transferred to the MH is maintained.
Assuntos
Antiprotozoários/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Leishmaniose Visceral/tratamento farmacológico , Anfotericina B/economia , Anfotericina B/uso terapêutico , Antiprotozoários/uso terapêutico , Brasil , Protocolos Clínicos , Ácido Desoxicólico/economia , Ácido Desoxicólico/uso terapêutico , Combinação de Medicamentos , Humanos , Leishmaniose Visceral/economia , Meglumina/economia , Meglumina/uso terapêutico , Antimoniato de Meglumina , Compostos Organometálicos/economia , Compostos Organometálicos/uso terapêuticoRESUMO
Abstract INTRODUCTION: The drugs available for visceral leishmaniasis (VL) treatment in Brazil have specific characteristics in terms of operability, effectiveness, toxicity, and cost. The aim of this study was to estimate the direct costs of therapies recommended by the Ministry of Health (MH) for VL treatment in Brazil. METHODS: The analytical perspective used was that adopted by the Brazilian Public Health System. Three drugs and four regimens were included: 1) N-methyl glucamine antimoniate intramuscularly at 20mg per kg per day for 30 days; 2) N-methyl glucamine antimoniate intravenously at 20mg per kg per day for 30 days; 3) amphotericin B deoxycholate at 1mg per kg per day for 21 days; and 4) liposomal amphotericin B at 3mg per kg per day for a 7 days treatment. RESULTS: The estimated direct costs of treatment for an adult patient using N-methylglucamine antimoniate administered via the intramuscular and intravenous routes were USD 418.52 and USD 669.40, respectively. The estimated cost of treatment with amphotericin B deoxycholate was USD 1,522.70. Finally, the estimated costs of treatment with liposomal amphotericin B were USD 659.79, and USD 11,559.15 using the price adopted by the WHO and the Drug Regulation Board, respectively. CONCLUSIONS: This analysis indicates the economic feasibility of replacing N-methyl glucamine antimoniate with liposomal amphotericin B, which allows a shorter treatment period with less toxicity compared with other treatments, provided that the purchase value used by the WHO and transferred to the MH is maintained.
Assuntos
Humanos , Custos de Cuidados de Saúde/estatística & dados numéricos , Leishmaniose Visceral/tratamento farmacológico , Antiprotozoários/economia , Compostos Organometálicos/economia , Compostos Organometálicos/uso terapêutico , Brasil , Anfotericina B/economia , Anfotericina B/uso terapêutico , Protocolos Clínicos , Ácido Desoxicólico/economia , Ácido Desoxicólico/uso terapêutico , Combinação de Medicamentos , Antimoniato de Meglumina , Leishmaniose Visceral/economia , Meglumina/economia , Meglumina/uso terapêutico , Antiprotozoários/uso terapêuticoRESUMO
BACKGROUND: Oral miltefosine has been shown to be non-inferior to first-line, injectable meglumine antimoniate (MA) for the treatment of cutaneous leishmaniasis (CL) in children. Miltefosine may be administered via in-home caregiver Directly Observed Therapy (cDOT), while patients must travel to clinics to receive MA. We performed a cost-effectiveness analysis comparing miltefosine by cDOT versus MA for pediatric CL in southwest Colombia. METHODOLOGY/PRINCIPLE FINDINGS: We developed a Monte Carlo model comparing the cost-per-cure of miltefosine by cDOT compared to MA from patient, government payer, and societal perspectives (societal = sum of patient and government payer perspective costs). Drug effectiveness and adverse events were estimated from clinical trials. Healthcare utilization and costs of travel were obtained from surveys of providers and published sources. The primary outcome was cost-per-cure reported in 2015 USD. Treatment efficacy, costs, and adherence were varied in sensitivity analysis to assess robustness of results. Treatment with miltefosine resulted in substantially lower cost-per-cure from a societal and patient perspective, and slightly higher cost-per-cure from a government payer perspective compared to MA. Mean societal cost-per-cure were $531 (SD±$239) for MA and $188 (SD±$100) for miltefosine, a mean cost-per-cure difference of +$343. Mean cost-per-cure from a patient perspective were $442 (SD ±$233) for MA and $30 (SD±$16) for miltefosine, a mean difference of +$412. Mean cost-per-cure from a government perspective were $89 (SD±$55) for MA and $158 (SD±$98) for miltefosine, with a mean difference of -$69. Results were robust across a variety of assumptions in univariate and multi-way analysis. CONCLUSIONS/SIGNIFICANCE: Treatment of pediatric cutaneous leishmaniasis with miltefosine via cDOT is cost saving from patient and societal perspectives, and moderately more costly from the government payer perspective compared to treatment with MA. Results were robust over a range of sensitivity analyses. Lower drug price for miltefosine could result in cost saving from a government perspective.
Assuntos
Antiprotozoários/administração & dosagem , Terapia Diretamente Observada/economia , Leishmaniose Cutânea/tratamento farmacológico , Leishmaniose Cutânea/economia , Meglumina/administração & dosagem , Compostos Organometálicos/administração & dosagem , Fosforilcolina/análogos & derivados , Administração Oral , Antiprotozoários/economia , Cuidadores , Criança , Pré-Escolar , Análise Custo-Benefício , Custos de Medicamentos , Feminino , Humanos , Injeções Intramusculares , Leishmania/efeitos dos fármacos , Masculino , Meglumina/economia , Antimoniato de Meglumina , Método de Monte Carlo , Compostos Organometálicos/economia , Fosforilcolina/administração & dosagem , Fosforilcolina/economia , Sensibilidade e Especificidade , Resultado do Tratamento , Estados UnidosRESUMO
BACKGROUND: Chagas disease is currently prevalent in European countries hosting large communities from Latin America. Whether asymptomatic individuals at risk of Chagas disease living in Europe should be screened and treated accordingly is unclear. We performed an economic evaluation of systematic Chagas disease screening of the Latin American population attending primary care centres in Europe. METHODS: We constructed a decision tree model that compared the test option (screening of asymptomatic individuals, treatment, and follow-up of positive cases) with the no-test option (screening, treating, and follow-up of symptomatic individuals). The decision tree included a Markov model with five states, related to the chronic stage of the disease: indeterminate, cardiomyopathy, gastrointestinal, response to treatment, and death. The model started with a target population of 100â000 individuals, of which 4·2% (95% CI 2·2-6·8) were estimated to be infected by Trypanosoma cruzi. The primary outcome was the incremental cost-effectiveness ratio (ICER) between test and no-test options. Deterministic and probabilistic analyses (Monte Carlo simulations) were performed. FINDINGS: In the deterministic analysis, total costs referred to 100â000 individuals in the test and no-test option were 30â903â406 and 6â597â403 respectively, with a difference of 24â306â003. The respective number of quality-adjusted life-years (QALYs) gained in the test and no-test option were 61â820·82 and 57â354·42. The ICER was 5442. In the probabilistic analysis, total costs for the test and no-test option were 32â163â649 (95% CI 31â263â705-33â063â593) and 6â904â764 (6â703â258-7â106â270), respectively. The respective number of QALYs gained was 64â634·35 (95% CI 62â809·6-66â459·1) and 59â875·73 (58â191·18-61â560·28). The difference in QALYs gained between the test and no test options was 4758·62 (95% CI 4618·42-4898·82). The incremental cost-effectiveness ratio (ICER) was 6840·75 (95% CI 2545-2759) per QALY gained for a treatment efficacy of 20% and 4243 per QALY gained for treatment efficacy of 50%. Even with a reduction in Chagas disease prevalence to 0·05% and with large variations in all the parameters, the test option would still be more cost-effective than the no-test option (less than 30000 per QALY). INTERPRETATION: Screening for Chagas disease in asymptomatic Latin American adults living in Europe is a cost-effective strategy. Findings of our model provide an important element to support the implementation of T cruzi screening programmes at primary health centres in European countries hosting Latin American migrants. FUNDING: European Commission 7th Framework Program.
Assuntos
Doença de Chagas/economia , Doença de Chagas/etnologia , Emigrantes e Imigrantes/estatística & dados numéricos , Programas de Rastreamento/economia , Atenção Primária à Saúde/economia , Antiprotozoários/economia , Doença de Chagas/diagnóstico , Análise Custo-Benefício , Europa (Continente)/epidemiologia , Feminino , Humanos , América Latina/etnologia , Masculino , Programas de Rastreamento/estatística & dados numéricos , Atenção Primária à Saúde/organização & administraçãoRESUMO
OBJECTIVE: The treatment of cutaneous leishmaniasis is toxic, has contraindications, and a high cost. The objective of this study was to estimate the cost-effectiveness of thermotherapy versus pentavalent antimonials for the treatment of cutaneous leishmaniasis. METHODS: Effectiveness was the proportion of healing and safety with the adverse effects; these parameters were estimated from a controlled clinical trial and a meta-analysis. A standard costing was conducted. Average and incremental cost-effectiveness ratios were estimated. The uncertainty regarding effectiveness, safety, and costs was determined through sensitivity analyses. RESULTS: The total costs were $66,807 with Glucantime and $14,079 with thermotherapy. The therapeutic effectiveness rates were 64.2% for thermotherapy and 85.1% for Glucantime. The average cost-effectiveness ratios ranged between $721 and $1275 for Glucantime and between $187 and $390 for thermotherapy. Based on the meta-analysis, thermotherapy may be a dominant strategy. CONCLUSION: The excellent cost-effectiveness ratio of thermotherapy shows the relevance of its inclusion in guidelines for the treatment.
Assuntos
Antiprotozoários/economia , Hipertermia Induzida/economia , Leishmaniose Cutânea/terapia , Antiprotozoários/efeitos adversos , Antiprotozoários/uso terapêutico , Análise Custo-Benefício , Custos de Medicamentos , Humanos , Hipertermia Induzida/efeitos adversos , IncertezaRESUMO
Visceral leishmaniasis (VL) is a deadly neglected tropical disease that poses a serious problem in various countries all over the world. Implementation of various intervention strategies fail in controlling the spread of this disease due to issues of parasite drug resistance and resistance of sandfly vectors to insecticide sprays. Due to this, policy makers need to develop novel strategies or resort to a combination of multiple intervention strategies to control the spread of the disease. To address this issue, we propose an extensive SIR-type model for anthroponotic visceral leishmaniasis transmission with seasonal fluctuations modeled in the form of periodic sandfly biting rate. Fitting the model for real data reported in South Sudan, we estimate the model parameters and compare the model predictions with known VL cases. Using optimal control theory, we study the effects of popular control strategies namely, drug-based treatment of symptomatic and PKDL-infected individuals, insecticide treated bednets and spray of insecticides on the dynamics of infected human and vector populations. We propose that the strategies remain ineffective in curbing the disease individually, as opposed to the use of optimal combinations of the mentioned strategies. Testing the model for different optimal combinations while considering periodic seasonal fluctuations, we find that the optimal combination of treatment of individuals and insecticide sprays perform well in controlling the disease for the time period of intervention introduced. Performing a cost-effective analysis we identify that the same strategy also proves to be efficacious and cost-effective. Finally, we suggest that our model would be helpful for policy makers to predict the best intervention strategies for specific time periods and their appropriate implementation for elimination of visceral leishmaniasis.
Assuntos
Simulação por Computador , Controle de Insetos/métodos , Insetos Vetores/parasitologia , Leishmania , Leishmaniose Visceral/prevenção & controle , Modelos Teóricos , Psychodidae/parasitologia , Animais , Antiprotozoários/economia , Antiprotozoários/uso terapêutico , Análise Custo-Benefício , Reservatórios de Doenças , Custos de Medicamentos , Humanos , Índia/epidemiologia , Mordeduras e Picadas de Insetos/epidemiologia , Mordeduras e Picadas de Insetos/parasitologia , Controle de Insetos/economia , Mosquiteiros Tratados com Inseticida/economia , Inseticidas/economia , Leishmaniose Cutânea/tratamento farmacológico , Leishmaniose Cutânea/epidemiologia , Leishmaniose Visceral/economia , Leishmaniose Visceral/epidemiologia , Leishmaniose Visceral/transmissão , Estações do AnoRESUMO
BACKGROUND: Visceral leishmaniasis (VL) is a neglected parasitic disease that is fatal if left untreated. VL is endemic in Morocco and other countries in North Africa were it mainly affects children from rural areas. In Morocco, the direct observation of Leishmania parasites in bone marrow aspirates and serological tests are used to diagnose VL. Glucantime is the first line of treatment. The objective of this study was to report the costs associated to standard clinical management of pediatric VL from the provider perspective in Morocco. As a secondary objective we described the current clinical practices and the epidemiological characteristics of pediatric VL patients. METHODS: From March to June 2014 we conducted a survey in eight hospitals treating pediatric VL patients in Morocco. A pro-forma was used to collect demographic, clinical and management data from medical records. We specifically collected data on VL diagnosis and treatment. We also estimated the days of hospitalization and the time to start VL treatment. Costs were estimated by multiplying the use of resources in terms of number of days in hospital, tests performed and drugs provided by the official prices. For patients receiving part of their treatment at Primary Health Centers (PHC) we estimated the cost of administering the Glucantime as outpatient. We calculated the median cost per VL patient. We also estimated the cost of managing a VL case when different treatment strategies were applied: inpatient and outpatient. RESULTS: We obtained data from 127 VL patients. The median total cost per pediatric VL case in Morocco is 520 US$. The cost in hospitals applying an outpatient strategy is significantly lower (307 US$) than hospitals keeping the patients for the whole treatment (636 US$). However the outpatient strategy is not yet recommended as VL treatment for children in the Moroccan guidelines. VL diagnosis and treatment regimens should be standardized following the current guidelines in Morocco.