Cost of three models of care for drug-resistant tuberculosis patients in Nigeria

Abstract

BackgroundNigeria accounts for a significant proportion of the global drug-resistant tuberculosis (DR-TB) burden, a large proportion of which goes untreated. Different models for managing DR-TB treatment with varying levels of hospitalization are in use across Nigeria, however costing evidence is required to guide the scale up of DR-TB care. We aimed to estimate and compare the costs of different DR-TB treatment and care models in Nigeria.MethodsWe estimated the costs associated with three models of DR-TB treatment and care: Model (A) patients are hospitalized throughout the 8-month intensive phase, Model (B) patients are partially hospitalized during the intensive phase and Model (C) is entirely ambulatory. Costs of treatment, in-patient and outpatient care and diagnostic and monitoring tests were collected using a standardized data collection sheet from six sites through an ingredient’s approach and cost models were based on the Nigerian National Tuberculosis, Leprosy and Buruli Ulcer Guideline - Sixth Edition (2014) and Guideline for programmatic and clinical management of drug-resistant tuberculosis in Nigeria (2015).ResultsAssuming adherence to the Nigerian DR-TB guidelines, the per patient cost of Model A was $18,528 USD, Model B $15,159 USD and Model C $9425 USD. Major drivers of cost included hospitalization (Models A and B) and costs of out-patient consultations and supervision (Model C).ConclusionUtilizing a decentralized ambulatory model, is a more economically viable approach for the expansion of DR-TB care in Nigeria, given that patient beds for DR-TB treatment and care are limited and costs of hospitalized treatment are considerably more expensive than ambulatory models. Scale-up of less expensive ambulatory care models should be carefully considered in particular, when treatment efficacy is demonstrated to be similar across the different models to allow for patients not requiring hospitalization to be cared for in the least expensive way.

Cost comparison of nine-month treatment regimens with 20-month standardized care for the treatment of rifampicin-resistant/multi-drug resistant tuberculosis in Nigeria

“…There is close patient monitoring with daily home visits by the direct observation of treatment (DOT) officer during the intensive phase for patients on injectable agents which becomes bi-monthly home visits during the continuation phase, interspersed by bi-monthly visits of patients to the DOT clinics for monitoring and drug pick-ups. There are also monthly home visits by the TB and leprosy supervisor overseeing the local government in which the patient lives, monthly home visits by the State DR-TB focal person and quarterly home visits by the State consilium which is a multi-disciplinary Team [ 7 ]. A full description of the nature, frequency and timing of out-patient consultations and supervision including home visits is provided below “ Table 2 ”.…”

“…Diagnostic and monitoring tests. We obtained the costs of TB diagnostic and monitoring tests " Table 3" such as smear microscopy, Xpert MTB/RIF, culture (liquid and solid), line probe assay (LPA) and drug susceptibility testing (DST) from a previous study on Models A, B and C in Nigeria [7]. These costs were obtained in 2014 NGN, inflated to 2019 NGN using the annual inflation of consumer prices in the period 2014-2019 [28] and then expressed in USD using the exchange rate of April 3rd 2020 of 1 USD = 367 NGN [29].…”

“…While this initially involved hospitalization for a period of 20-24 months, it has since evolved to treatment models with reduced hospitalization and currently includes fully-ambulatory models. These initial models of 20-24 months duration ranged in cost from $1,839 to $81,000 per patient treated [4,[6][7][8][9] and had success rates between 52-66% [10][11][12][13][14]. In 2016, the World Health Organization (WHO) recommended the utilization of Shorter Treatment Regimen [15] based on reported success rates of 85% and above [16][17][18][19].…”

“…However, cost data for RR/MDR-TB treatment are limited [ 27 ], specifically costs of models that utilize shorter treatment regimen to manage RR/MDR-TB. Though the costs of Models A, B and C previously used in Nigeria have been published [ 7 ], the costs of Models D, E and F are not known. We therefore conducted a cost-analysis of the shorter treatment regimen in use (Models D and E) as well as one planned to be used to treat RR/MDR-TB in Nigeria (Models F) and compared them to the three models of longer duration previously used in Nigeria though discontinued between 2015 and 2017 (Models A, B and C) “ Table 1 ”.…”

A retrospective analysis of treatment outcomes of drug-susceptible TB in Kazakhstan, 2013–2016

“…[2] Some countries with a high burden of MDR TB in the European region, including Kazakhstan (where 85% of drug-susceptible TB cases are treated as inpatients), [3] provide a significant amount of TB medical care in hospitals, although the outpatient treatment of TB, including MDR TB , has been regarded as an effective and cost-effective approach. [4–6] The need for the development of reliable outpatient TB treatment strategies is of great importance, especially in resource-limited settings, where intensive adherence support strategies, such as Direct Observation of Therapy (DOT), may be unfeasible due to a lack of medical personnel or patient access. [7,8]…”