EDITORIAL
INT J TUBERC LUNG DIS 19(2):127 Q 2015 The Union http://dx.doi.org/10.5588/ijtld.14.0761
Treating multidrug-resistant tuberculosis in community settings: a wise investment Of the 450 000 new cases of multidrug-resistant tuberculosis (MDR-TB) estimated to have arisen globally in 2012, fewer than 17% (77 000) received second-line treatment.1 Historically, most MDR patients were not treated because they were not diagnosed with MDR: 82% of cases diagnosed and notified received treatment with second-line drugs. However, with the development and global scale-up of rapid tests for Mycobacterium tuberculosis drug resistance, diagnostics will no longer be the bottleneck for MDR-TB treatment. Countries will need to confront the challenge of expanding access to treatment for increasing numbers of patients with MDR-TB. The costs and capacity of health systems to meet this swelling demand will undoubtedly be the focus of intense budget debates in Ministries of Health around the world. In this issue of the Journal, Sinanovic and colleagues identify an opportunity to achieve muchneeded cost savings in drug-resistant TB care. Drawing upon data derived from a cohort of patients receiving drug-resistant TB treatment under a decentralized model in Khayelitsha, Cape Town,2 and applying unit costing approaches, the authors estimated the cost per patient treated under four models of care: a fully hospitalized model, in which patients are hospitalized until culture conversion; two partially decentralized models; and a fully decentralized (community-based) model, as utilized in Khayelitsha. The first critical finding is that under a fully hospitalized model—as is perhaps the norm in most countries—the costs associated with 4-month hospitalization alone accounted for over 40% of the total costs of care. Decentralized care under the three alternative models would reduce costs by 36–42%, potentially saving South Africa $80 million annually. Importantly, the specific approach to decentralization doesn’t appear to substantially impact costs—the key is drastically shortening initial hospitalization. When the extensively drug-resistant (XDR) TB epidemic was identified in South Africa just under a decade ago, a predominantly hospital-based model of treatment for drug-resistant TB was standard. Many treatment sites for drug-resistant TB had lengthy waiting lists for admission and therapy.3 A movement towards community-based therapy emerged, but concerns were expressed about the safety and public health risks of treating patients in community settings. Fortunately, as with drug-susceptible TB, effective therapy for drug-resistant TB rapidly renders individuals non-infectious.4 Several communitybased models, like that of Khayelitsha, have demon-
strated that drug-resistant TB can be safely treated in community settings, even among human immunodeficiency virus co-infected individuals.5 Decentralized therapy puts less strain on patients and, as shown in this study, can avert substantial costs. Unfortunately, decentralization alone doesn’t fully address South Africa’s critical default problem— over 20% in published cohorts, and 31% in the Khayelitsha cohort.6 The cost savings from reduced hospitalization should be applied to strategies providing economic, nutritional and social support for MDR-TB patients throughout therapy. Such strategies have been associated with default rates of ,5% elsewhere in Africa.7,8 As the need for access to MDR-TB treatment rapidly grows, redirecting resources from hospital-based care towards comprehensive community-based services may enable programs to contain costs and expand capacity, while providing high-quality, patient-centered care. JASON R. ANDREWS, MD, SM* JASON E. STOUT, MD, MHS† *Stanford University School of Medicine Stanford, California †Duke University Medical Center Durham, North Carolina, USA e-mail: [email protected] Conflicts of interest: none declared.
References 1 World Health Organization. Global Tuberculosis Report 2013. WHO/HTM/TB/2013.11. Geneva, Switzerland: WHO, 2013. 2 Sinanovic E, Ramma L, Vassall A, et al. Impact of reduced hospitalization on the cost of treatment for drug-resistant tuberculosis in South Africa. Int J Tuberc Lung Dis 2015: 19: 172–178. 3 Goemaere E, Ford N, Berman D, McDermid C, Cohen R. XDRTB in South Africa: detention is not the priority. PLoS Med 2007; 4(4): e162. 4 Dharmadhikari A S, Mphahlele M, Venter K, et al. Rapid impact of effective treatment on transmission of multidrug-resistant tuberculosis. Int J Tuberc Lung Dis 2014; 18: 1019–1025. 5 Brust J C M, Shah N S, van der Merwe T L, et al. Adverse events in an integrated home-based treatment program for MDR-TB and HIV in KwaZulu-Natal, South Africa. J Acquir Immune Defic Syndr 2013; 62: 436–440. 6 Cox H, Hughes J, Daniels J, et al. Community-based treatment of drug-resistant tuberculosis in Khayelitsha, South Africa. Int J Tuberc Lung Dis 2014; 18: 441–448. 7 Kokebu D, Hurtado R, Ejara E D, et al. Treatment outcomes from a collaborative multidrug-resistant tuberculosis treatment program in Ethiopia. Int J Tuberc Lung Dis 2013: 17 (Suppl 2): S237. 8 Satti H, McLaughlin M M, Hedt-Gauthier B, et al. Outcomes of multidrug-resistant tuberculosis treatment with early initiation of antiretroviral therapy for HIV co-infected patients in Lesotho. PLOS ONE 2012; 7(10): e46943.
INT J TUBERC LUNG DIS 19(2):127 Q 2015 The Union http://dx.doi.org/10.5588/ijtld.14.0761
Treating multidrug-resistant tuberculosis in community settings: a wise investment Of the 450 000 new cases of multidrug-resistant tuberculosis (MDR-TB) estimated to have arisen globally in 2012, fewer than 17% (77 000) received second-line treatment.1 Historically, most MDR patients were not treated because they were not diagnosed with MDR: 82% of cases diagnosed and notified received treatment with second-line drugs. However, with the development and global scale-up of rapid tests for Mycobacterium tuberculosis drug resistance, diagnostics will no longer be the bottleneck for MDR-TB treatment. Countries will need to confront the challenge of expanding access to treatment for increasing numbers of patients with MDR-TB. The costs and capacity of health systems to meet this swelling demand will undoubtedly be the focus of intense budget debates in Ministries of Health around the world. In this issue of the Journal, Sinanovic and colleagues identify an opportunity to achieve muchneeded cost savings in drug-resistant TB care. Drawing upon data derived from a cohort of patients receiving drug-resistant TB treatment under a decentralized model in Khayelitsha, Cape Town,2 and applying unit costing approaches, the authors estimated the cost per patient treated under four models of care: a fully hospitalized model, in which patients are hospitalized until culture conversion; two partially decentralized models; and a fully decentralized (community-based) model, as utilized in Khayelitsha. The first critical finding is that under a fully hospitalized model—as is perhaps the norm in most countries—the costs associated with 4-month hospitalization alone accounted for over 40% of the total costs of care. Decentralized care under the three alternative models would reduce costs by 36–42%, potentially saving South Africa $80 million annually. Importantly, the specific approach to decentralization doesn’t appear to substantially impact costs—the key is drastically shortening initial hospitalization. When the extensively drug-resistant (XDR) TB epidemic was identified in South Africa just under a decade ago, a predominantly hospital-based model of treatment for drug-resistant TB was standard. Many treatment sites for drug-resistant TB had lengthy waiting lists for admission and therapy.3 A movement towards community-based therapy emerged, but concerns were expressed about the safety and public health risks of treating patients in community settings. Fortunately, as with drug-susceptible TB, effective therapy for drug-resistant TB rapidly renders individuals non-infectious.4 Several communitybased models, like that of Khayelitsha, have demon-
strated that drug-resistant TB can be safely treated in community settings, even among human immunodeficiency virus co-infected individuals.5 Decentralized therapy puts less strain on patients and, as shown in this study, can avert substantial costs. Unfortunately, decentralization alone doesn’t fully address South Africa’s critical default problem— over 20% in published cohorts, and 31% in the Khayelitsha cohort.6 The cost savings from reduced hospitalization should be applied to strategies providing economic, nutritional and social support for MDR-TB patients throughout therapy. Such strategies have been associated with default rates of ,5% elsewhere in Africa.7,8 As the need for access to MDR-TB treatment rapidly grows, redirecting resources from hospital-based care towards comprehensive community-based services may enable programs to contain costs and expand capacity, while providing high-quality, patient-centered care. JASON R. ANDREWS, MD, SM* JASON E. STOUT, MD, MHS† *Stanford University School of Medicine Stanford, California †Duke University Medical Center Durham, North Carolina, USA e-mail: [email protected] Conflicts of interest: none declared.
References 1 World Health Organization. Global Tuberculosis Report 2013. WHO/HTM/TB/2013.11. Geneva, Switzerland: WHO, 2013. 2 Sinanovic E, Ramma L, Vassall A, et al. Impact of reduced hospitalization on the cost of treatment for drug-resistant tuberculosis in South Africa. Int J Tuberc Lung Dis 2015: 19: 172–178. 3 Goemaere E, Ford N, Berman D, McDermid C, Cohen R. XDRTB in South Africa: detention is not the priority. PLoS Med 2007; 4(4): e162. 4 Dharmadhikari A S, Mphahlele M, Venter K, et al. Rapid impact of effective treatment on transmission of multidrug-resistant tuberculosis. Int J Tuberc Lung Dis 2014; 18: 1019–1025. 5 Brust J C M, Shah N S, van der Merwe T L, et al. Adverse events in an integrated home-based treatment program for MDR-TB and HIV in KwaZulu-Natal, South Africa. J Acquir Immune Defic Syndr 2013; 62: 436–440. 6 Cox H, Hughes J, Daniels J, et al. Community-based treatment of drug-resistant tuberculosis in Khayelitsha, South Africa. Int J Tuberc Lung Dis 2014; 18: 441–448. 7 Kokebu D, Hurtado R, Ejara E D, et al. Treatment outcomes from a collaborative multidrug-resistant tuberculosis treatment program in Ethiopia. Int J Tuberc Lung Dis 2013: 17 (Suppl 2): S237. 8 Satti H, McLaughlin M M, Hedt-Gauthier B, et al. Outcomes of multidrug-resistant tuberculosis treatment with early initiation of antiretroviral therapy for HIV co-infected patients in Lesotho. PLOS ONE 2012; 7(10): e46943.
