Transcript 1 - IHPP

-Thailand
Policy decision on multi drug resistant(MDR),
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screening: How it comes?
extreme drug resistant(XDR) tuberculosis
Thanawat Wongphan1,2
Pairoj Saonuam3.
Jongkol Lertiendumrong1,
Phusit Prakongsai1
1International
Health Policy Program(IHPP), Nonthaburi, Thailand
Hospital, Saraburi, Thailand
3 Medical Physician, Senior Professional Level National AIDS Management Center (NAMc)
Department of Disease Control,
Ministry of Public Health, Nonthaburi Thailand
2 Banmoh
The First Annual Conference of HTAsiaLink
Grand Pacific Sovereign Hotel, Petchaburi,Thailand
May 14‐16, 2012
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Outline of presentation
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•
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•
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Background information
Methodologies
Research findings
Conclusion and discussion.
Policy recommendations
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Background (1)
• Definition:
• MDR-TB is the tuberculosis which
resists to Rifampicin or Isoniazid.
• XDR is the tuberculosis which resists to
– Rifampicin or Isoniazid
– Quinolone
– At least one injectable
antibiotic(kanamycin, capreomycin or
amikacin)
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•
[Ref]
1. Centers for Disease Control and Prevention., Multidrug-Resistant Tuberculosis (MDR TB) Fact Sheet.
2011.
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Background (2)
• The prevalence of all TB patients in
Thailand is 130,000 cases per year,
and the rate of MDR-TB ranges
from 0 to 14.1 percent of all first
diagnosed TB patients.
• The cost of treatment of MDR or
XDR TB can be more than 100
times when compare to a normal
pulmonary TB.
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Background (3)
• Incidence of MDR-TB in Thailand is
2,900 cases per year and 1,547 of
them are in the first time of
treatment.
• Five percent of all MDR-TB can
develop to XDR-TB in the future.
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Objectives
• To find the ways to increase
potency of TB treatment system
and to decrease incidence rate of
MDR-TB we split the project into 3
parts to answer this
– the most cost-benefit method of
MDR-TB screening
– System gap analysis
– Cost-utility analysis based on dynamic
models on MDR-TB screening.
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Methods (1)
The study is conducted with two methods:
Cost-benefit analysis (CBA) and system gap
analysis.
• The CBA uses the decision tree algorithm
among four choices of MDR-TB
diagnosis: standard culture (L-J),
Overbrooke 7H-10, Microscopic
observation drug susceptibility (MODS),
gene technique and the conservative
technique (work up in all failure cases.).
• The gap analysis uses an expert panel’s
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Methods (2)
Target
population
All TB diagnosis
-Standard procedure
-Lowenstein-Jensen(L-J) in all cases.
Comparator
-Microscopic observation drug
susceptibility(MODS)
-Overbrooke 7H-10
-Gene technique(eg. geneXpert1)
1
is a registered trademark from Cepheid, CA, USA
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Methods (2)
Use only direct medical cost:
•
LAB: Department of Medical
Science, Ministry of public health,
Thailand
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Drug cost: Chest disease institute.
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Department of Medical Science,
Ministry of public health, Thailand
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Expert panel’s adjustment
•
Systematic review on MODS.
COST
Lab’s duration
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Comparison among MDR Screening
and treatment choices
Sputum AFB still be
Standar
POSITIVE.
d
2 months of standard TB
Culture waiting
treatment
period(4-8 weeks)
L-J
techniq
Start MDR-TB
6ueWeeks(4-8
treatment
Weeks)
Start
MDR-TB
treatment
7H10
6 Weeks(4-8
Weeks)
MOD
s
6
Days
Gene
techniq
1 ue
Day
Start MDR-TB
treatment
Start MDR-TB
treatment
Start MDR-TB
treatment
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Research findings
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Incidence of Thai TB patients and
individual cost of treatment.
Cases
100 000
90 000
Cost(Baht)
฿1 200 000,00
93 000
฿1 039 770
฿1 000 000,00
80 000
70 000
฿800 000,00
60 000
฿600 000,00
50 000
40 000
฿400 000,00
30 000
20 000
฿165 455
2 900
10 000
0
฿2 391
normal-TB
MDR-TB
Number of patients
฿200 000,00
145
฿0,00
XDR-TB
Minimum cost of treatment
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MDR diagnosed Lab duration and
cost comparison
7
6
Baht
Weeks
6
6
฿700,00
฿600,00
฿600,00
5
฿500,00
4
฿400,00
3
฿300,00
2
฿200,00
0,86
1
0
0,14
฿50,00
฿50,00
฿50,00
L-J
MODs
7H-10
Lab period(Weeks)
฿100,00
฿0,00
Gene
technique
Lab cost(Baht)
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Cost-Benefit comparison on MDR TB
diagnosis
Diagnosis
procedure
Cost
(Million
Baht)
Benefit
(Million
Baht)
LJ
MODs
7H-10
Gene
technique
4.65
4.65
4.65
55.8
2.38 –
3.30
4.42 6.13
2.38 - 3.30 4.70 - 6.53
*Comparison based on standard TB treatment program.
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Conclusions and discussion
• MDR screening is essential for
all first diagnosed TB cases
because
–it can stop disease-spreading
while patients are being treated
with standard drug regimen,
–decrease drug side effects.
–drug costs and patients’
expenses related to the
inappropriate drugs use.
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Conclusions
• Although MODS is the most costbenefit method but the gap
analysis shows that Thailand has
many semi-liquid culturing
facilities. So it is better to use
them instead of investing more
money to do MODS.
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Policy recommendations
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Specific policies:
1. Enhance capacity of TB treatments in all
modalities.
2. Establish the standardized logistic system of
specimen transfering.
3. Increase support of lung surgery.
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General policies(1):
1. Increase co-operation between units to units
including private sector and supertertiary
hospital.
2. Establish the national MDR, XDR-TB caring
guideline.
3. Concern in some high risk patients eg. HIV.
4. Medical staffs should be refreshed
knowledge and be updated their system's
knowledge.
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General policies(2):
5. Find sources of fund to support the system,
6. Improve the follow up care system,
7. National Health Security Office(NHSO)
should generate the ICT data system to be
used in follow up care of treatment and easy
to monitor,
8. NHSO should support the health staffs in
many roles e.g. funding source for
generating national guideline,
9. Link this treatment system to quality
accreditation to increase sustainable
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development.
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Acknowledgement
• National Health Security Office (NHSO) of
Thailand,
• The Universal Coverage Benefit Package
Subcommittee of NHSO,
• Dr. Charoen Chuchottaworn and Chest
Disease Institute, Ministry of Public Health,
Thailand
• Ms. Kumaree Patchanee, IHPP, Thainad
• Banmoh hospital staff, Saraburi, Thailand
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