RESUMO
OBJETIVO: Determinar las razones de la escasa derivación, acceso, y adherencia a programas de ejercicio supervisado (PES) en pacientes con claudicación intermitente (CI) y la costo-efectividad de estos programas a nivel Internacional. MÉTODOS: Se utilizaron las fuentes de datos de PubMed y ScienceDirect. Se incluyeron revisiones con acceso completo, publicados desde el año 2010, que incluían como mínimo 3 artículos de tipo cuantitativo. RESULTADOS: Se incluyeron 5 Revisiones asociadas a los resultados del ejercicio supervisado, su costo-efectividad, la baja derivación y adherencia a PES de los pacientes con CI. En cuanto a la costo-efectividad los resultados indican que los PES fueron rentables con un ICER de £711 a £1.608 por QALY ganado al compararlos con ejercicio no supervisado, y al compararlos con la cirugía de revascularización (CR) no hay diferencia significativa en QALY ganados, sin embargo, el costo por QALY fue 381.694 más alto para la CR. Por otro lado, las principales razones de la subutilización de los PES, es que los pacientes se resisten a asistir, ya que involucra un esfuerzo y responsabilidad, además de tener problemas de reembolso, teniendo baja adherencia. Sumado a esto, el interés personal de los médicos por realizar intervenciones que involucran pago por servicio produce una baja derivación (45% de cirujanos en Europa refieren menos del 50% de sus pacientes). CONCLUSIÓN: Las principales dificultades para adoptar los PES serían una carencia en la destinación de recursos, falta de centros, dificultad de traslado, falta de tiempo, o de interés por parte de los pacientes, además de incentivos financieros a otras alternativas de tratamiento por sobre PES lo que limita su derivación.
OBJECTIVE: To determine the reasons for the limited derivation, access and adherence to supervised exercise programs (SEP) in patients with intermittent claudication (IC) and the cost-effectiveness of these programs internationally. METHODS: PubMed and ScienceDirect databases were searched. Revisions with full access, published since 2010, which included at least 3 quantitative type articles. RESULTS: 5 reviews were included, these were associated with the results of the supervised exercise, its cost-effectiveness, the low referral and adherence to programs of patients with IC. Regarding cost-effectiveness, the results indicated that SEP were more cost-effective with an ICER of £711 to £1.608 per QALY gained when compared with unsupervised exercise, and that when compared with revascularization surgery (RC) there was no significant difference in QALYs, however the cost per QALY was 381.694 higher for the RC. On the other hand, the main reasons for the underutilization of SEP are that patients are reluctant to attend, since it involves effort and responsibility, in addition to having reimbursement problems, therefore having low adherence. Added to this, the personal interest of doctors in performing interventions that involve payment for service produce a low referral (45% of surgeons in Europe refer less than 50% of their patients) CONCLUSION: The main difficulties in adopting the SEP would be a lack in the allocation of resources, lack of centers, difficulty of transportation, lack of time or lack of interest from patients, in addition to financial incentives to other treatment alternatives over SEP, which limits their referral.
Assuntos
Humanos , Terapia Diretamente Observada/economia , Terapia Diretamente Observada/estatística & dados numéricos , Terapia por Exercício/economia , Claudicação Intermitente/terapia , Encaminhamento e Consulta/estatística & dados numéricos , Cooperação do Paciente , Análise Custo-Benefício , Terapia por Exercício/métodos , Terapia por Exercício/estatística & dados numéricos , Cooperação e Adesão ao Tratamento , Mau Uso de Serviços de Saúde , Claudicação Intermitente/reabilitaçãoRESUMO
BACKGROUND: Mexico recently enacted drug policy reform to decriminalize possession of small amounts of illicit drugs and mandated that police refer identified substance users to drug treatment. However, the economic implications of drug treatment expansion are uncertain. We estimated the costs of opioid substitution therapy (OST) provision in Tijuana, Mexico, where opioid use and HIV are major public health concerns. METHODS: We adopted an economic health care provider perspective and applied an ingredients-based micro-costing approach to quantify the average monthly cost of OST (methadone maintenance) provision at two providers (one private and one public) in Tijuana, Mexico. Costs were divided by type of input (capital, recurrent personnel and non-personnel). We defined "delivery cost" as all costs except for the methadone and compared total cost by type of methadone (powdered form or capsule). Cost data were obtained from interviews with senior staff and review of expenditure reports. Service provision data were obtained from activity logs and senior staff interviews. Outcomes were cost per OST contact and cost per person month of OST. We additionally collected information on patient charges for OST provision from published rates. RESULTS: The total cost per OST contact at the private and public sites was $3.12 and $5.90, respectively, corresponding to $95 and $179 per person month of OST. The costs of methadone delivery per OST contact were similar at both sites ($2.78 private and $3.46 public). However, cost of the methadone itself varied substantially ($0.34 per 80 mg dose [powder] at the private site and $2.44 per dose [capsule] at the public site). Patients were charged $1.93-$2.66 per methadone dose. CONCLUSIONS: The cost of OST provision in Mexico is consistent with other upper-middle income settings. However, evidenced-based (OST) drug treatment facilities in Mexico are still unaffordable to most people who inject drugs.
Assuntos
Tratamento de Substituição de Opiáceos/economia , Transtornos Relacionados ao Uso de Opioides/economia , Analgésicos Opioides/economia , Analgésicos Opioides/uso terapêutico , Custos e Análise de Custo , Atenção à Saúde/economia , Terapia Diretamente Observada/economia , Honorários e Preços/estatística & dados numéricos , Redução do Dano , Humanos , Metadona/economia , Metadona/uso terapêutico , México , Transtornos Relacionados ao Uso de Opioides/reabilitação , Setor Privado/economia , Setor Público/economia , Centros de Tratamento de Abuso de Substâncias/economiaRESUMO
BACKGROUND: Non-adherence to tuberculosis (TB) treatment jeopardizes patient health and promotes disease transmission. In July 2011, Ecuador's National Tuberculosis Program (NTP) enacted a monetary incentive program giving adherent drug-resistant TB (DR-TB) patients a US240 bonus each month. OBJECTIVE: To describe patients' experiences with the program qualitatively, and to assess its effects on treatment adherence. METHODS: We interviewed 92 current and five default patients about their treatment experience. NTP data on DR-TB patients receiving treatment were used to compare 12-month default rates among the incentive program group and non-program controls. RESULTS: Our interviews found that patients are financially challenged and use the bonus for a variety of expenses, most commonly food. The most common complaint was that bonus payments were frequently delayed. The 1-year default rate among program patients (9.5%) was significantly lower than the rate among pre-program patients (26.7%). CONCLUSION: Ecuador's monetary incentive program alleviates the economic burden placed by treatment on patients. The bonus does not, however, directly address other treatment barriers, including psychological distress and side effects. The program could benefit from timely delivery of payments. Further research is necessary to assess the program's effect on default rates.
Assuntos
Antituberculosos/uso terapêutico , Farmacorresistência Bacteriana Múltipla , Adesão à Medicação , Motivação , Programas Nacionais de Saúde/economia , Reforço por Recompensa , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , Adulto , Análise Custo-Benefício , Terapia Diretamente Observada/economia , Equador , Feminino , Custos de Cuidados de Saúde , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Renda , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Desenvolvimento de Programas , Avaliação de Programas e Projetos de Saúde , Pesquisa Qualitativa , Fatores Socioeconômicos , Fatores de Tempo , Resultado do Tratamento , Tuberculose Resistente a Múltiplos Medicamentos/diagnóstico , Tuberculose Resistente a Múltiplos Medicamentos/economia , Tuberculose Resistente a Múltiplos Medicamentos/microbiologia , Adulto JovemRESUMO
The objective of this study was to compare the costs and outcomes associated with guardian-supervised directly observed treatment relative to the standard of care Directly Observed Therapy, Short Course (DOTS) provided by community health workers (CHW). New cases of culture-positive pulmonary tuberculosis (TB) treated in Vitória, Espírito Santo State, Brazil, between January 2005 and December 2006 were interviewed and chose their preferred treatment strategy. Costs incurred by providers and patients (and patients' families) were estimated, and cost-effectiveness was assessed by comparing costs per successfully treated patient. 130 patients were included in the study; 84 chose CHW-supervised DOTS and 46 chose guardian-supervised DOTS. 45 of 46 (98%) patients treated with guardian-supervised DOTS were cured or completed treatment compared to 70/84 (83%) of the CHW-supervised patients (p = 0.01). Logistic regression showed only the strategy of supervision to be a significant association with treatment outcome, with guardian-supervised care strongly protective. Cost per patient treated with guardian-supervised DOTS was US$398, compared to US$548 for CHW-supervised DOTS. The guardian-supervised DOTS is an attractive option to complement CHW-supervised DOTS.
Assuntos
Serviços de Saúde Comunitária/economia , Agentes Comunitários de Saúde/economia , Terapia Diretamente Observada/economia , Custos de Cuidados de Saúde , Tuberculose Pulmonar/economia , Adulto , Brasil , Análise Custo-Benefício , Feminino , Gastos em Saúde , Disparidades em Assistência à Saúde , Humanos , Masculino , Tuberculose Pulmonar/terapiaRESUMO
BACKGROUND: Costs of tuberculosis diagnosis and treatment may represent a significant burden for the poor and for the health system in resource-poor countries. OBJECTIVES: The aim of this study was to analyze patients' costs of tuberculosis care and to estimate the incremental cost-effectiveness ratio (ICER) of the directly observed treatment (DOT) strategy per completed treatment in Rio de Janeiro, Brazil. METHODS: We interviewed 218 adult patients with bacteriologically confirmed pulmonary tuberculosis. Information on direct (out-of-pocket expenses) and indirect (hours lost) costs, loss in income and costs with extra help were gathered through a questionnaire. Healthcare system additional costs due to supervision of pill-intake were calculated considering staff salaries. Effectiveness was measured by treatment completion rate. The ICER of DOT compared to self-administered therapy (SAT) was calculated. PRINCIPAL FINDINGS: DOT increased costs during the treatment phase, while SAT increased costs in the pre-diagnostic phase, for both the patient and the health system. Treatment completion rates were 71% in SAT facilities and 79% in DOT facilities. Costs per completed treatment were US$ 194 for patients and U$ 189 for the health system in SAT facilities, compared to US$ 336 and US$ 726 in DOT facilities. The ICER was US$ 6,616 per completed DOT treatment compared to SAT. CONCLUSIONS: Costs incurred by TB patients are high in Rio de Janeiro, especially for those under DOT. The DOT strategy doubles patients' costs and increases by fourfold the health system costs per completed treatment. The additional costs for DOT may be one of the contributing factors to the completion rates below the targeted 85% recommended by WHO.
Assuntos
Antituberculosos/uso terapêutico , Serviços de Saúde Comunitária/métodos , Terapia Diretamente Observada/métodos , Tuberculose/tratamento farmacológico , Adulto , Antituberculosos/economia , Brasil , Serviços de Saúde Comunitária/economia , Análise Custo-Benefício , Terapia Diretamente Observada/economia , Feminino , Custos de Cuidados de Saúde , Humanos , Masculino , Inquéritos e Questionários , Resultado do TratamentoRESUMO
BACKGROUND: There is little published information on the costs of multidrug-resistant tuberculosis (MDR-TB) for patients and their families in low- or middle-income countries. METHODS: Between February and July 2007, patients with microbiologically confirmed active TB who had received 2 months of treatment completed an interviewer-administered questionnaire on direct out-of-pocket expenditures and indirect costs from lost wages. Clinical data were abstracted from their medical records. RESULTS: Among 104 non-MDR-TB patients, total TB-related patient costs averaged US$960 per patient, compared to an average total cost of US$6880 for 14 participating MDR-TB patients. This represents respectively 31% and 223% of the average Ecuadorian annual income. The high costs associated with MDR-TB were mainly due to the long duration of illness, which averaged 22 months up to the time of the interview. This resulted in very long periods of unemployment. Most patients experienced a significant drop in income, particularly the MDR-TB patients, all of whom were earning less than US$100/month at the time of the interview. CONCLUSION: Direct and indirect costs borne by patients with active TB and their families are very high in Ecuador, and are highest for patients with MDR-TB. These costs are important barriers to treatment completion.
Assuntos
Efeitos Psicossociais da Doença , Custos de Cuidados de Saúde , Gastos em Saúde , Salários e Benefícios , Tuberculose Resistente a Múltiplos Medicamentos/economia , Tuberculose/economia , Desemprego , Adolescente , Adulto , Antituberculosos/economia , Antituberculosos/uso terapêutico , Técnicas Bacteriológicas/economia , Custos e Análise de Custo , Testes Diagnósticos de Rotina/economia , Terapia Diretamente Observada/economia , Custos de Medicamentos , Equador , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários , Fatores de Tempo , Tuberculose/diagnóstico , Tuberculose/terapia , Tuberculose Resistente a Múltiplos Medicamentos/diagnóstico , Tuberculose Resistente a Múltiplos Medicamentos/terapia , Adulto JovemRESUMO
BACKGROUND: One of the main problems faced by the Mexican National Tuberculosis Program is the high rate of patients abandoning treatment. This study aimed to determine the magnitude of unaccounted costs of tuberculosis (TB) treatment in Tijuana, Mexico. METHODOLOGY: Subjects were recruited at 21 health centres. Patients had confirmed active pulmonary TB, had been on treatment for more than 12 weeks, and were aged 18 years and older. The questionnaire provided information about demographics, past and current episodes of TB, and various categories of expenses. RESULTS: The study included 180 patients as follows: 48 had been diagnosed with tuberculosis in the past (26.6%) and had either currently relapsed or failed treatment; 160 (88.8%) were under directly observed therapy (DOT); 131 (72.8%) attended a health centre; and the rest received directly observed treatment at home. The daily cost of transportation to the health centre was MXN $25.88 +/- 3.22 (1 USD = 13 MXN). Thirty-two patients (17.8%) had to buy medication at least once, with a monthly medication expense of MXN $440.5 +/- 40.3. Patients receiving DOT at the health centre reported daily food and beverages expenses, spending MXN $56.5 +/- 10.1. Forty-two patients reported laboratory testing expenses, on average MXN $558.8 +/- 85.8 per month. Eighty patients (42.4%) reported expenses on radiographic/ultrasound studies, on average MXN $562.9 +/- 72.1 per six-month regimen. Conclusions TB diagnosis and treatment posed a significant economic burden on patients in terms of both cost and affordability; clinic-based DOT may contribute disproportionately to the costs incurred by patients.
Assuntos
Antituberculosos/economia , Efeitos Psicossociais da Doença , Tuberculose Pulmonar/tratamento farmacológico , Adulto , Antituberculosos/uso terapêutico , Bebidas/economia , Estudos Transversais , Terapia Diretamente Observada/economia , Feminino , Alimentos/economia , Gastos em Saúde , Humanos , Masculino , México , Cooperação do Paciente , Fatores Socioeconômicos , Inquéritos e Questionários , Meios de Transporte/economia , Tuberculose Pulmonar/economia , Tuberculose Pulmonar/psicologiaRESUMO
SETTING: Rio de Janeiro, Brazil, is a middle-income setting with an estimated 1% adult human immunodeficiency virus (HIV) seroprevalence. OBJECTIVE: To examine the cost-effectiveness of DOTS in Rio de Janeiro. DESIGN: Cost-effectiveness analysis based on cost data and an epidemiological model based on programmatic outcomes from the Health Department in Rio de Janeiro, cost data from the retail market sector and epidemiological data from published studies. RESULTS: The 10-year cost of a tuberculosis program treating a population of 262 000 based on self-administered therapy (SAT) was estimated to be $580 271 compared to $1047 886 for DOTS. The largest portion of the DOTS budget was for staff costs and costs incurred by patients, both at 28%. For SAT, the largest percentage of the budget was allocated to medication costs, at 34%. Upgrading from SAT to DOTS averted 1558 cases of tuberculosis (TB, uncertainty range [UR] 1418-1704) and 143 TB deaths (UR 131-155). The incremental cost effectiveness ratio (ICER) for DOTS was $300 per case averted (UR $289-$312) and $3270 per death averted (UR $3123-$3435). In terms of disability adjusted life years (DALYs), DOTS saved 5426 DALYs (UR 4908-5961). The ICER for DOTS was $86 per DALY saved (UR $74-$100). CONCLUSIONS: DOTS is a highly cost-effective intervention in Brazil.
Assuntos
Antituberculosos/uso terapêutico , Terapia Diretamente Observada/economia , Tuberculose/tratamento farmacológico , Brasil/epidemiologia , Análise Custo-Benefício , Feminino , Soropositividade para HIV/epidemiologia , Humanos , Masculino , Prevalência , Tuberculose/epidemiologia , População UrbanaRESUMO
BACKGROUND: Implementation of the World Health Organization's DOTS strategy (Directly Observed Treatment Short-course therapy) can result in significant reduction in tuberculosis incidence. We estimated potential costs and benefits of DOTS expansion in Haiti from the government, and societal perspectives. METHODS: Using decision analysis incorporating multiple Markov processes (Markov modelling), we compared expected tuberculosis morbidity, mortality and costs in Haiti with DOTS expansion to reach all of the country, and achieve WHO benchmarks, or if the current situation did not change. Probabilities of tuberculosis related outcomes were derived from the published literature. Government health expenditures, patient and family costs were measured in direct surveys in Haiti and expressed in 2003 US$. RESULTS: Starting in 2003, DOTS expansion in Haiti is anticipated to cost $4.2 million and result in 63,080 fewer tuberculosis cases, 53,120 fewer tuberculosis deaths, and net societal savings of $131 million, over 20 years. Current government spending for tuberculosis is high, relative to the per capita income, and would be only slightly lower with DOTS. Societal savings would begin within 4 years, and would be substantial in all scenarios considered, including higher HIV seroprevalence or drug resistance, unchanged incidence following DOTS expansion, or doubling of initial and ongoing costs for DOTS expansion. CONCLUSION: A modest investment for DOTS expansion in Haiti would provide considerable humanitarian benefit by reducing tuberculosis-related morbidity, mortality and costs for patients and their families. These benefits, together with projected minimal Haitian government savings, argue strongly for donor support for DOTS expansion.
Assuntos
Antituberculosos/administração & dosagem , Efeitos Psicossociais da Doença , Terapia Diretamente Observada/economia , Custos de Cuidados de Saúde , Tuberculose Pulmonar/tratamento farmacológico , Tuberculose Pulmonar/economia , Antituberculosos/economia , Quimioterapia Combinada , Etambutol/administração & dosagem , Etambutol/economia , Haiti/epidemiologia , Humanos , Isoniazida/administração & dosagem , Isoniazida/economia , Avaliação de Programas e Projetos de Saúde , Pirazinamida/administração & dosagem , Pirazinamida/economia , Rifampina/administração & dosagem , Rifampina/economia , Resultado do Tratamento , Tuberculose Pulmonar/epidemiologia , Organização Mundial da SaúdeRESUMO
BACKGROUND: Despite the existence of effective drug treatments, tuberculosis (TB) causes 2 million deaths annually worldwide. Effective treatment is complicated by multidrug-resistant TB (MDR TB) strains that respond only to second-line drugs. We projected the health benefits and cost-effectiveness of using drug susceptibility testing and second-line drugs in a lower-middle-income setting with high levels of MDR TB. METHODS AND FINDINGS: We developed a dynamic state-transition model of TB. In a base case analysis, the model was calibrated to approximate the TB epidemic in Peru, a setting with a smear-positive TB incidence of 120 per 100,000 and 4.5% MDR TB among prevalent cases. Secondary analyses considered other settings. The following strategies were evaluated: first-line drugs administered under directly observed therapy (DOTS), locally standardized second-line drugs for previously treated cases (STR1), locally standardized second-line drugs for previously treated cases with test-confirmed MDR TB (STR2), comprehensive drug susceptibility testing and individualized treatment for previously treated cases (ITR1), and comprehensive drug susceptibility testing and individualized treatment for all cases (ITR2). Outcomes were costs per TB death averted and costs per quality-adjusted life year (QALY) gained. We found that strategies incorporating the use of second-line drug regimens following first-line treatment failure were highly cost-effective compared to strategies using first-line drugs only. In our base case, standardized second-line treatment for confirmed MDR TB cases (STR2) had an incremental cost-effectiveness ratio of 720 dollars per QALY (8,700 dollars per averted death) compared to DOTS. Individualized second-line drug treatment for MDR TB following first-line failure (ITR1) provided more benefit at an incremental cost of 990 dollars per QALY (12,000 dollars per averted death) compared to STR2. A more aggressive version of the individualized treatment strategy (ITR2), in which both new and previously treated cases are tested for MDR TB, had an incremental cost-effectiveness ratio of 11,000 dollars per QALY (160,000 dollars per averted death) compared to ITR1. The STR2 and ITR1 strategies remained cost-effective under a wide range of alternative assumptions about treatment costs, effectiveness, MDR TB prevalence, and transmission. CONCLUSIONS: Treatment of MDR TB using second-line drugs is highly cost-effective in Peru. In other settings, the attractiveness of strategies using second-line drugs will depend on TB incidence, MDR burden, and the available budget, but simulation results suggest that individualized regimens would be cost-effective in a wide range of situations.
Assuntos
Antituberculosos/uso terapêutico , Modelos Econômicos , Tuberculose Resistente a Múltiplos Medicamentos/economia , Antituberculosos/administração & dosagem , Antituberculosos/classificação , Orçamentos , Análise Custo-Benefício , Países em Desenvolvimento , Terapia Diretamente Observada/economia , Surtos de Doenças , Transmissão de Doença Infecciosa/economia , Transmissão de Doença Infecciosa/prevenção & controle , Custos de Medicamentos , Custos de Cuidados de Saúde , Política de Saúde , Humanos , Renda , Testes de Sensibilidade Microbiana/economia , Mycobacterium tuberculosis/efeitos dos fármacos , Mycobacterium tuberculosis/isolamento & purificação , Peru/epidemiologia , Anos de Vida Ajustados por Qualidade de Vida , Falha de Tratamento , Resultado do Tratamento , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , Tuberculose Resistente a Múltiplos Medicamentos/microbiologia , Tuberculose Resistente a Múltiplos Medicamentos/mortalidade , Tuberculose Resistente a Múltiplos Medicamentos/prevenção & controle , Tuberculose Resistente a Múltiplos Medicamentos/transmissão , Valor da VidaRESUMO
BACKGROUND: Between April 2001 and March 2004, the Directly Observed Therapy-Short course (DOTS) program was successfully implemented by the National Tuberculosis control program, with assistance from the Canadian Lung Association, in three provinces of Ecuador, where 52% of the population of the country reside. METHODS: Markov modelling was used to project TB-related morbidity, mortality and costs if the former TB control program (status quo) had continued or if the newly expanded DOTS program is maintained over 20 years. Extensive sensitivity analyses were used to determine the effect on projected outcomes of varying key assumptions. RESULTS: If DOTS is maintained over the next 20 years, we predict that 18,760 cases and 15,812 TB-related deaths will be prevented, resulting in societal savings of dollars 203 million and government savings of dollars 7.1 million (all costs in dollars US). These findings were robust in extensive sensitivity analyses. Given the initial investment of dollars 3 million for DOTS implementation, this would mean a cost of dollars 190 per life saved. CONCLUSIONS: Implementation of DOTS could yield very substantial public health and economic benefits for Ecuador. These results demonstrate the benefits from Canadian government support for DOTS implementation in low- and middle-income countries.
Assuntos
Controle de Doenças Transmissíveis/economia , Efeitos Psicossociais da Doença , Terapia Diretamente Observada/economia , Tuberculose/tratamento farmacológico , Tuberculose/economia , Canadá , Redução de Custos , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Equador/epidemiologia , Previsões , Humanos , Cadeias de Markov , Desenvolvimento de Programas , Avaliação de Programas e Projetos de Saúde , Anos de Vida Ajustados por Qualidade de Vida , Medição de Risco , Fatores de Tempo , Tuberculose/epidemiologia , Tuberculose/mortalidadeRESUMO
BACKGROUND: We hypothesized that investments to improve the control of tuberculosis in selected high-incidence countries would prove to be cost saving for the United States by reducing the incidence of the disease among migrants. METHODS: Using decision analysis, we estimated tuberculosis-related morbidity, mortality, and costs among legal immigrants and refugees, undocumented migrants, and temporary visitors from Mexico after their entry into the United States. We assessed the current strategy of radiographic screening of legal immigrants plus current tuberculosis-control programs alone and with the addition of either U.S.-funded expansion of the strategy of directly observed treatment, short course (DOTS), in Mexico or tuberculin skin testing to screen legal immigrants from Mexico. We also examined tuberculosis-related outcomes among migrants from Haiti and the Dominican Republic using the same three strategies. RESULTS: As compared with the current strategy, expanding the DOTS program in Mexico at a cost to the United States of 34.9 million dollars would result in 2591 fewer cases of tuberculosis in the United States, with 349 fewer deaths from the disease and net discounted savings of 108 million dollars over a 20-year period. Adding tuberculin skin testing to radiographic screening of legal immigrants from Mexico would result in 401 fewer cases of tuberculosis in the United States but would cost an additional 329 million dollars. Expansion of the DOTS program would remain cost saving even if the initial investment were doubled, if the United States paid for all antituberculosis drugs in Mexico, or if the decline in the incidence of tuberculosis in Mexico was less than projected. A 9.4 million dollars investment to expand the DOTS program in Haiti and the Dominican Republic would result in net U.S. savings of 20 million dollars over a 20-year period. CONCLUSIONS: U.S.-funded efforts to expand the DOTS program in Mexico, Haiti, and the Dominican Republic could reduce tuberculosis-related morbidity and mortality among migrants to the United States, producing net cost savings for the United States.
Assuntos
Terapia Diretamente Observada/economia , Emigração e Imigração , Cooperação Internacional , Pulmão/diagnóstico por imagem , Programas de Rastreamento , Teste Tuberculínico/economia , Tuberculose Pulmonar/prevenção & controle , Antituberculosos/economia , Antituberculosos/uso terapêutico , Redução de Custos , Técnicas de Apoio para a Decisão , República Dominicana , Haiti , Custos de Cuidados de Saúde , Humanos , Incidência , Investimentos em Saúde , Cadeias de Markov , México/epidemiologia , Modelos Econômicos , Radiografia Torácica/economia , Tuberculose Pulmonar/diagnóstico , Tuberculose Pulmonar/economia , Tuberculose Pulmonar/mortalidade , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: DOTS is widely accepted as the most cost-effective strategy for tuberculosis (TB) control. However, there is little published information regarding methods for implementation in middle-income countries. METHODS: Over 3 years, the Canadian Lung Association assisted the Ecuadorian TB programme to implement DOTS for over half the nation's total population. A multilevel strategy developed by a team of Ecuadorian health professionals provided initial, in-service, replica and reinforcement training at the local level, and training at national level for specialist physicians, specialist societies and medical schools. Evaluation was based on international guidelines for case finding, treatment and laboratory quality control, and costs of all implementation activities. RESULTS: By January 2004, DOTS training had been provided to 1954 health professionals and 199 smear microscopy technicians, and DOTS was implemented in all 496 health facilities. Case detection activities at the local level increased substantially. Cure and treatment completion improved to 83% of new cases. Overall concordance of laboratory quality control readings was 98.7%. The total cost of DOTS implementation was US dollar 3 049 585. CONCLUSIONS: To achieve international targets for TB control, DOTS implementation in a middle-income country required intensive training at the local level and at multiple other levels.