Cost-effectiveness of treating multidrug-resistant tuberculosis
Cost-effectiveness of treating multidrug-resistant tuberculosis
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DOI：
10.1371/journal.pmed.0030241
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发表时间：
2006-07-01
期刊：
影响因子：
15.8
通讯作者：
Weinstein, Milton C.
中科院分区：
文献类型：
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作者：
Resch, Stephen C.;Salomon, Joshua A.;Weinstein, Milton C.
尽管存在有效的药物治疗，但结核病（TB）每年在全世界造成200万人死亡。有效的治疗是复杂的多药耐药结核病（耐药结核病）菌株，只对二线药物。我们预计的健康效益和成本效益，使用药物敏感性测试和二线药物在中低收入环境中的高水平的耐多药结核病。方法和结果我们开发了一个动态的结核病状态转换模型。在基础病例分析中，对模型进行了校准，以接近秘鲁的结核病流行情况，该情况下，涂阳结核病发病率为120/100，000，耐多药结核病占流行病例的4.5%。次要分析考虑了其他设置。对以下战略进行了评价：直接观察治疗（DOTS）下给予的一线药物，既往治疗病例的当地标准化二线药物（STR 1），既往治疗的经检测证实的MDR TB病例的当地标准化二线药物（STR 2），既往治疗病例的综合药物敏感性检测和个体化治疗（ITR 1），对所有病例进行全面的药物敏感性检测和个体化治疗（ITR 2）。结果是避免每例结核病死亡的成本和获得每质量调整生命年（QALY）的成本。我们发现，与仅使用一线药物的策略相比，一线治疗失败后使用二线药物方案的策略具有高度的成本效益。在我们的基础病例中，与DOTS相比，对确诊的耐多药结核病例（STR 2）进行标准化二线治疗的成本-效果比增加了720美元/QALY（8，700美元/避免死亡）。与STR 2相比，一线治疗失败后的MDR TB个体化二线药物治疗（ITR 1）提供了更多的获益，每QALY增加成本990美元（每避免死亡12，000美元）。个体化治疗策略（ITR 2）的一个更积极的版本，其中新的和以前治疗的病例都进行了耐多药结核病的检测，与ITR 1相比，每QALY的成本效益比增加了11，000美元（每避免死亡160，000美元）。STR 2和ITR 1战略仍然具有成本效益的治疗成本，有效性，耐多药结核病的患病率和transmission.Conclusions使用二线药物治疗耐多药结核病的假设范围广泛，具有很高的成本效益在秘鲁。在其他情况下，使用二线药物的策略的吸引力将取决于结核病的发病率，耐多药负担，和可用的预算，但模拟结果表明，个性化的方案将在广泛的情况下具有成本效益。
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 per QALY ($8,700 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 per QALY ($12,000 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 per QALY ($160,000 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.