The Costs of Diagnosing and Treating Tuberculosis in South Africa - PowerPoint PPT Presentation

The Costs of Diagnosing and Treating Tuberculosis in South Africa Sydney Rosen Center for Global Health and Development Boston University, Boston, MA Health Economics and Epidemiology Research Office (HE 2 RO) Wits University, Johannesburg April 17, 2013

Last Week’s Headline

Overview • Setting the stage: Tuberculosis in South Africa • The cost of treating multidrug resistant TB • Scaling up Xpert MTB/RIF for TB diagnosis • A TB economics research agenda Health Economics and Epidemiology Research Office HE RO 2 Wits Health Consortium University of the Witwatersrand

Tuberculosis in South Africa • Leading cause of death (11.6% of all deaths 2010, v. 2.3% globally) • Very high incidence of drug susceptible TB – 1% or 490,000 new TB cases per year – Third highest number of new cases globally after India and China • High rates TB/HIV co-infection – Adult HIV prevalence 17.3% – ≥ 60% of TB patients co -infected with HIV – TB is the leading cause of death for HIV- infected people • High-burden drug resistant TB country – >10,000 confirmed MDR-TB cases in 2011 – Highest number of XDR-TB cases globally (573 cases reported in 2008) Sources: http://www.unaids.org/en/regionscountries/countries/southafrica/; WHO, Global Tuberculosis Control 2011; WHO, South Africa TB country profile 2012; Statistics South Africa, Mortality and causes of death in South Africa, 2010; Lozano R et al. 2012; WHO, M/XDR-TB: 2010 Global Report on Surveillance and Response; http://www.timeslive.co.za/local/2012/02/02/tb-is-top-killer-of-sa-blacks

South Africa’s TB Epidemic in Context Indicator (2011) South Russian Brazil United Africa Federation States Population 51 million 143 million 192 million 312 million GNI/capita (PPP) $10,710 $20,560 $11,420 $48,820 Adult HIV prevalence 17.3% 1.1% 0.3% 0.6% TB incidence/100,000 993 97 83 4 TB cases/year 389,974 159,479 84,137 10,521 Confirmed MDR-TB 10,085 13,785 556 119 cases/year Sources: http://www.unaids.org/en/regionscountries/countries/; WHO, Global Tuberculosis Control 2012; United Nations, Estimates of mid-year population: 2002 – 2011; World Bank, World Development Indicators, 2012.

TB Diagnosis • Until now, primarily by sputum smear and culture — Xpert MTB/RIF at all centralized laboratories by 2014 — more on that soon • 53% of pulmonary TB cases are smear-negative or unknown and require culture — Smear results 2+ days — Culture results 6 weeks • Case detection rate estimated at 69% • Resistant TB diagnosis by drug- sensitivity testing — After first line treatment failure or previous TB — Takes 42-56 days for results (Loveday et al 2012) Source: WHO, South Africa TB Country Profile 2012

TB Treatment • Treatment of drug-sensitive TB – Treatment lasts 6-8 months – Outpatient care by nurses at primary health clinics with treatment supervisor/direct observation – Treatment success rate 60-75%, varying with smear status, etc. • Treatment of MDR-TB – Treatment lasts 24 months – Guidelines call for ≤ 6 months inpatient care by doctors at specialized hospitals and remainder outpatient – Treatment success rate ≈ 50%; most of the rest die during treatment or default or fail treatment (Brust et al 2010) Source: WHO, South Africa TB Country Profile 2012

The Cost of Inpatient Treatment for MultiDrug Resistant Tuberculosis

Rationale and Objectives • No empirical estimates of the cost of treating MDR-TB in South Africa – Only 4 estimates globally, none in Africa; range $2,791-$16,881/case (Fitzpatrick et al 2012) – 55% of South Africa’s TB control budget reportedly spent on MDR -TB (WHO, South Africa tuberculosis finance profile) – Most high burden countries rely on hospitalization, but outpatient care is recommended by WHO – Difficult to understand or improve treatment delivery or outcomes without better information about costs • Objectives – Estimate the cost per patient of the inpatient phase of MDR-TB treatment – Generate comparison data for evaluating the cost-effectiveness of alternatives to the current inpatient model of care www.phi.org

Approach • Retrospective cohort study • Provincial MDR-TB referral hospital in North West Province • Obtained resource utilization and outcome data from medical records • Data collected up to 12 months from admission or until the earliest of discharge, abscondment, or death • Costs estimated included hospital stay/day, drugs, lab tests, radiography, surgery

Study Sample • Enrolled all admitted Recorded in hospital register Mar 2009-Feb 2010 patients with confirmed 277 MDR-TB Non-MDR TB diagnosis Initiated or completed - March 2009-February 2010 83 MDR-TB treatment at - Excluded transfers in or out another site Not eligible (other • N=128 (121 for costs) 49 criteria) • Median age 39; 45% 12 female; 64% unemployed Enrolled in study 133 • 50% smear-, 50% smear+ Smear-status known at admission 128 Complete resource utilization records • 83% previous TB 121 • 64% HIV infected

Treatment Outcomes at 12 Months 3%� 3%� 8%� Culture� converted,� discharged� Absconded� Died� in� hospital� Cured or S ll� admi ed� at� 12� 86%� 21% completed months� Failed 46% Died 23% Defaulted 10% Source: Farley et al 2011

Resource Utilization and Costs $236; 2% $223; 1% $380; 2% All Smear Smear Cost patients positive negative (n=121) (n=55) (n=61) Number of months in 3.5 [1.7] 4.2 [1.9] 3.2 [1.2] hospital [SD] $16.325; 95% Average cost/patient $17,164 $20,440 $15,450 Hospital stay (personnel, infrastructure) MDR-TB drugs TB laboratory monitoring Other costs

Limitations • Single site in one province, small sample • Cost of MDR-TB inpatient phase only, omits 18-21 months outpatient care – Drugs and laboratory monitoring will comprise a larger share of total costs if full continuation phase of treatment included • Results conditional on being admitted at all – Hospital admission took a mean of 111 days after sample collected for DST – Study in another province found that 40% of MDR-TB patients with HIV die within 30 days of testing (Gandhi et al 2010)

Conclusions • Average 12-month cost of inpatient treatment for MDR-TB = $17,164 – 67 x the full cost of treating drug-sensitive TB (Pooran et al. 2013) – 25 x the annual cost of first-line ART (Long et al 2011) • MDR-TB treatment capacity is severely limited – In 2011, only 56% of diagnosed MDR- and XDR-TB patients started on treatment due to shortage of hospital beds in specialized wards (WHO 2012) – Patients in our sample waited ≈ 1 month even after MDR -TB diagnosis – Advent of Xpert MTB/RIF expected to increase the MDR-TB case load ≤ 70% (Meyer -Rath et al 2012)

What Can Be Done About This? • Most important: improve drug-sensitive TB treatment to prevent drug resistance – First line cure rate 64-73% (WHO, South Africa TB Country Profile 2012) – 83% of patients in study sample had a history of previous TB • New guidelines (2011) allow some MDR-TB patients to be initiated and treated as outpatients only and shorten admission for others (until smear conversion rather than culture conversion) • Cost reduction could be substantial, but… – Only about half of patients (or fewer) thought eligible for outpatient initiation — must be smear- negative and in “good or fair condition” – Implementation of new guidelines has barely started – Substantial additional funding needed to implement new strategy (improved infrastructure, more outreach staff, better drugs)

A Little Back-of-the-Envelope Cost Comparison Inpatient model Outpatient model (old guidelines) (new guidelines) *Costs for inpatient care and clinic visits to down-referral TB 124 days inpatient care for 42 days inpatient care for wards and smear +; 95 days for smear - smear +; 0 days for smear - primary health clinics only; drugs and lab tests and 57 outpatient visits for 115 outpatient visits for fixed costs of smear +; 78 outpatient smear +; 132 outpatient facilities assumed visits for smear - visits for smear - to be the same for both strategies Average cost/patient Average cost/patient $17,333* $4,061* Sources: Schnippel et al 2012; Pooran et al 2013; NDOH Policy Framework 2011

But, As Usual, the Devil Is In the Details • Very unclear how many patients can be initiated as outpatients • Recent publication (Pooran et al 2013) assumed 90% (no evidence provided) • Our data suggest 35% (smear negative and BMI ≥ 18) • What difference would it make? Value (costs exclude drugs and laboratory Our back-of-the-envelope tests) analysis Cost/inpatient initiate $7,210 Cost/outpatient initiate $911 Average cost/patient if 35% eligible $5,005 Average cost/patient if 90% eligible $1,541 Difference if 10,000 patients treated $35 million Sources: Schnippel et al 2012; Pooran et al 2013

The Cost and Impact of Scaling Up Xpert MTB/RIF South African M edical J ournal 2013; 103: 101-06