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The economic cost and cost-effectiveness of treatment strategies and care models to reduce the burden of multi-drug resistant tuberculosis

Rosu, Laura (2023) The economic cost and cost-effectiveness of treatment strategies and care models to reduce the burden of multi-drug resistant tuberculosis, Thesis (Doctoral), Liverpool School of Tropical Medicine.

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Tuberculosis (TB) is one of the main causes of death in many low-middle-income countries (LMIC). It can exacerbate poverty, food insecurity and malnutrition and multi-faceted approaches are required to tackle the TB epidemic. Multidrug-resistant tuberculosis (MDR-TB) is caused by TB bacteria that is resistant to at least isoniazid and rifampicin, the two most potent and widely used TB drugs. As the global TB incidence is falling at just 2% per year, new ways of addressing the disease must be found. Economic evaluation of alternative treatment strategies and care models is vital to inform policy and implementation, with the goal of maximising the impact on MDR-TB with available resources.
This thesis aimed to contribute to this goal by evaluating the cost effectiveness of two new MDR-TB regimens and comparing the cost of alternative directly-observed treatment (DOT) approaches.
The work 1) showed that a 9-month injectable-containing regimen was cheaper and more effective than the standard-of-care (SOC) in 2011, when the trial began, 2) developed economic evaluation methods for use in the second trial phase, 3) showed that an alternative 9-month all oral regimen is likely not cost-effective compared to the 9-month injectable-containing regimen (tested in the first phase and becoming the new SOC during the second phase) and that a 6-month regimen is likely to be costeffective, 4) showed that patient-centred and hybrid DOT approaches are less costly than SOC, and also 5) proved that digital-DOT or family-observed DOT are also less costly than SOC for the short MDR-TB regimen.
The results of the first paper influenced World Health Organization (WHO) MDR-TB treatment guidelines, which in 2019 recommended the 9-month injectable-containing regimen, mentioning that the reduced cost of the shorter regimen to patients and the health services is expected to favour equity by freeing up resources to cover the care of more patients. The economic evaluation protocol informed the analysis of the second study whose results are published in paper 3. These results were also reviewed by WHO guideline development group. This work had unexpected findings: most previous modelling studies showed that the all-oral short regimen was likely to be cost-effective in all settings, while our study showed that this would not be true for most settings. These economic evaluation results should be used to guide the programmatic implementation of the short all-oral regimen.
Collectively, these studies showed that although MDR-TB treatment is free at the point of care, patients still spend large amounts of money for receiving care and with the majority experiencing catastrophic costs. Thus, as cost and efficacy data on alternative DOT approaches is lacking, two separate modelling approaches (one operational model and one decision tree) were used to compare the cost of patientcentred and digital DOT delivery models with SOC. Results showed that these strategies can reduce patient and health system costs without efficiency-cost trade-offs.
The results of our detailed economic analysis of the economic impact of MDR-TB on patients and their households suggested that effective clinical interventions alone need to be complemented with socioeconomic interventions to end TB.

Item Type: Thesis (Doctoral)
Subjects: WA Public Health > WA 30 Socioeconomic factors in public health (General)
WF Respiratory System > Tuberculosis > WF 200 Tuberculosis (General)
WF Respiratory System > Tuberculosis > WF 310 Therapy
WF Respiratory System > Tuberculosis > WF 315 Diet. Rest. Exercise. Home care
WF Respiratory System > Tuberculosis > WF 360 Drug therapy
Repository link:
Item titleItem URI
Cost of treatment support for multidrug-resistant tuberculosis using patient-centred approaches in Ethiopia: a model-based method
Economic evaluation of shortened, bedaquiline-containing treatment regimens for rifampicin-resistant tuberculosis (STREAM stage 2): a within-trial analysis of a randomised controlled trial
Economic evaluation protocol of a short, all-oral bedaquiline-containing regimen for the treatment of rifampicin-resistant tuberculosis from the STREAM trial
Economic evaluation of short treatment for multidrug-resistant tuberculosis, Ethiopia and South Africa: the STREAM trial
Faculty: Department: Clinical Sciences & International Health > Clinical Sciences Department
Depositing User: Lynn Roberts-Maloney
Date Deposited: 11 Oct 2023 10:36
Last Modified: 11 Jan 2024 04:12


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