Cost-effectiveness of different Directly Observed Treatment (DOT) strategies for tuberculosis control programmes in Thailand

Pojjana Hunchangsith (2011). Cost-effectiveness of different Directly Observed Treatment (DOT) strategies for tuberculosis control programmes in Thailand PhD Thesis, School of Population Health, The University of Queensland.

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Author Pojjana Hunchangsith
Thesis Title Cost-effectiveness of different Directly Observed Treatment (DOT) strategies for tuberculosis control programmes in Thailand
School, Centre or Institute School of Population Health
Institution The University of Queensland
Publication date 2011-03
Thesis type PhD Thesis
Supervisor Associate Professor Jan Barendregt
Professor Theo Vos
Dr Melanie Bertram
Total pages 177
Total colour pages 9
Total black and white pages 168
Language eng
Subjects 11 Medical and Health Sciences
Abstract/Summary Governments of developing countries are faced with making decisions on allocations of limited resources for health care services. Similarly for Thailand, the government, as the main third party provider of health services, is facing the rising cost of healthcare due to a growing ageing population, increasing health demands and expensive new technologies for prevention and treatment of diseases. Quantifying burden of disease to provide information on the size of a disease problem is a useful guide for policy makers who face a known set of resource constraints, limited options and limited budget, to develop health policies and decide whether to allocate resources for such a disease. In addition, analysing cost-effectiveness of interventions is helpful information for decision-makers to decide on which intervention is the best value. Among infectious diseases, tuberculosis (TB) remains one of the important causes of morbidity and mortality in Thailand. The country was ranked 18th of the 22 high TB burden countries globally in 2009 by the World Health Organization. Thailand has not yet achieved the global target, which has been set by the World Health Assembly and the Stop TB Partnership as well as within the framework of the Millennium Development Goals, of an 85% rate of successful treatment. Effective cure of TB requires a patient taking anti-TB drugs daily without interruption for 6 months, which is difficult for most patients to maintain. Directly observed treatment (DOT), whereby a trained person observes patients taking their medications, is widely used to improve adherence to treatment. There have been some cost-effectiveness analyses comparing DOT with self-administered treatment (SAT), but none have been done in Thailand. The mobile phone reminder system is another option to enhance compliance to treatment, but it is a relatively new intervention for TB control. To my knowledge, no other studies have evaluated the cost-effectiveness of the mobile phone intervention compared to SAT. This thesis presents national TB burden estimation and cost-effectiveness analysis of five different strategies including DOT by a health worker, DOT by a community member, DOT by a family member, mobile phone reminder system, and SAT for TB control in Thailand. The national TB burden in 2005 was calculated in disability-adjusted life years (DALYs) using the standard global burden of disease methodology. Monte Carlo simulation was used to obtain uncertainty around all outcome measures, and sensitivity of results to key assumptions was conducted. A TB model was developed to evaluate the cost-effectiveness of different TB control strategies compared with SAT, using a decision tree model approach. The model comprised three stages of treatment; initial treatment, re-treatment, and multi-drug resistant TB (MDR-TB) treatment. Costs were calculated based on treatment periods and treatment outcome, reported in international dollars (I$) in 2005. Health outcomes were estimated over the lifetime of smear-positive pulmonary TB patients in DALYs averted based on Thai evidence of DOT, SAT, and mobile phone reminder efficacy. Ninety-five percent uncertainty intervals were determined for all outcome measures using Monte Carlo simulation. The obtained results show TB was responsible for 94,000 (95% uncertainty interval; 74,000-120,000) DALYs in men and 48,000 (38,000-59,000) in women. About two-thirds of the TB burden was attributable to mortality. The most sensitive input variables determining uncertainty around DALY estimates were the number of TB deaths and to a lesser extent, the disability weight. Cost-effectiveness results indicate no preference for any strategy. The uncertainty ranges surrounding the health benefits were wide, including a sizeable probability that SAT could lead to more health gain than DOT strategies. The health gain for family-member DOT was 9,400 DALYs (95% uncertainty interval; -7,200 to 25,000), for community-member DOT was 13,000 DALYs (-21,000 to 37,000) and health-worker DOT was 7,900 DALYs (-50,000 to 43,000). There were cost-savings (from less MDR-TB treatment) associated with family-member DOT (-I$9 million (-I$12 million to -I$5 million)) as the trial treatment failure rate was significantly lower than for SAT. The mobile phone reminder system was not cost-effective, as its mortality rate was much higher than the other treatment strategies. Results from sensitivity of cost-effectiveness to the death rate of mobile phone intervention revealed that if the death rate is similar to that observed under other TB control strategies (between 3-8%), this intervention would have a 100% probability of being cost-effective compared to SAT. In conclusion, the recommended strategy is to implement the DOT programme using family members since it is a cost-saving intervention and is the cheapest to implement. In addition, this intervention is supported by equity in access and acceptability to stakeholders. Mobile phone intervention is potentially a cost-saving intervention and possibly an alternative. However, because the mobile phone intervention is not supported by a randomised controlled trial but only by a small pilot study, a larger study with a control group and representative age distribution is needed to justify the merit of this intervention.
Keyword economic evaluation
self-administered treatment
mobile phone reminder
burden of tuberculosis
Additional Notes colour page: 71, 83, 87, 109, 111, 114, 129, 140, 141 landscape page: 55-62, 89-90, 109, 128, 170-177

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Created: Wed, 22 Feb 2012, 18:19:12 EST by Ms Pojjana Hunchangsith on behalf of Library - Information Access Service