RESUMO
OBJECTIVE: To estimate the incremental cost-effectiveness of tuberculosis (TB) screening and isoniazid preventive therapy (IPT) among human immunodeficiency virus (HIV) infected adults in Rio de Janeiro, Brazil. DESIGN: We used decision analysis, populated by data from a cluster-randomized trial, to project the costs (in 2010 USD) and effectiveness (in disability-adjusted life years [DALYs] averted) of training health care workers to implement the tuberculin skin test (TST), followed by IPT for TST-positive patients with no evidence of active TB. This intervention was compared to a baseline of usual care. We used time horizons of 1 year for the intervention and 20 years for disease outcomes, with all future DALYs and medical costs discounted at 3% per year. RESULTS: Providing this intervention to 100 people would avert 1.14 discounted DALYs (1.57 undiscounted DALYs). The median estimated incremental cost-effectiveness ratio was $2273 (IQR $1779-$3135) per DALY averted, less than Brazil's 2010 per capita gross domestic product (GDP) of $11,700. Results were most sensitive to the cost of providing the training. CONCLUSION: Training health care workers to screen HIV-infected adults with TST and provide IPT to those with latent tuberculous infection can be considered cost-effective relative to the Brazilian GDP per capita.
Assuntos
Antituberculosos/economia , Antituberculosos/uso terapêutico , Coinfecção , Custos de Medicamentos , Infecções por HIV/economia , Isoniazida/economia , Isoniazida/uso terapêutico , Tuberculose Latente/tratamento farmacológico , Tuberculose Latente/economia , Programas de Rastreamento/economia , Pessoal Técnico de Saúde/economia , Pessoal Técnico de Saúde/educação , Técnicas Bacteriológicas/economia , Brasil/epidemiologia , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Avaliação da Deficiência , Infecções por HIV/diagnóstico , Infecções por HIV/epidemiologia , Humanos , Capacitação em Serviço/economia , Tuberculose Latente/diagnóstico , Tuberculose Latente/epidemiologia , Cadeias de Markov , Programas de Rastreamento/métodos , Modelos Econômicos , Valor Preditivo dos Testes , Avaliação de Programas e Projetos de Saúde , Radiografia Torácica/economia , Fatores de Tempo , Resultado do Tratamento , Teste Tuberculínico/economiaRESUMO
INTRODUCTION: In Latin America, there is a preponderance of prehospital trauma deaths. However, scarce resources mandate that any improvements in prehospital medical care must be cost-effective. This study sought to evaluate the cost-effectiveness of several approaches to improving training for personnel in three ambulance services in Mexico. METHODS: In Monterrey, training was augmented with PreHospital Trauma Life Support (PHTLS) at a cost of [US] dollar 150 per medic trained. In San Pedro, training was augmented with Basic Trauma Life Support (BTLS), Advanced Cardiac Life Support (ACLS), and a locally designed airway management course, at a cost of dollar 400 per medic. Process and outcome of trauma care were assessed before and after the training of these medics and at a control site. RESULTS: The training was effective for both intervention services, with increases in basic airway maneuvers for patients in respiratory distress in Monterrey (16% before versus 39% after) and San Pedro (14% versus 64%). The role of endotrachal intubation for patients with respiratory distress increased only in San Pedro (5% versus 46%), in which the most intensive Advanced Life Support (ALS) training had been provided. However, mortality decreased only in Monterrey, where it had been the highest (8.2% before versus 4.7% after) and where the simplest and lowest cost interventions were implemented. There was no change in process or outcome in the control site. CONCLUSIONS: This study highlights the importance of assuring uniform, basic training for all prehospital providers. This is a more cost-effective approach than is higher-cost ALS training for improving prehospital trauma care in environments such as Latin America.