Snyder D C, Chin D P
California Department of Health Services, Tuberculosis Control Branch, Berkeley, CA, USA.
Am J Respir Crit Care Med. 1999 Aug;160(2):582-6. doi: 10.1164/ajrccm.160.2.9901049.
To determine the incremental cost of directly observed therapy (DOT) for patients with tuberculosis at low risk for treatment default, we applied a model of DOT effectiveness to 1,377 low-risk patients in California during 1995. The default rate for this cohort, which consisted of those with no recent history of substance abuse, homelessness, or incarceration, was 1.7%. The model predicted that DOT and self-administered therapy (SAT) cured 93.1 and 90.8% of these patients, respectively. DOT would initially cost $1.83 million more than SAT, but avert $569,191 in treatment cost for relapse cases and their contacts, for a net incremental cost of $1.27 million ($919 per patient treated), or $40,620 per additional case cured. The cost-effectiveness of DOT was sensitive to the default rate and relapse rate after completing SAT. DOT would generate cost savings only when the default and relapse rates were more than 32.2 and 9.2%, respectively. Given the low default rate and resulting high incremental cost of DOT, provision of DOT to low-risk patients in California should be evaluated in the context of resource availability, competing program priorities, and program success in completing self-administered therapy with a low relapse rate.
为确定针对治疗依从性低风险的结核病患者直接观察治疗（DOT）的增量成本，我们于1995年将DOT有效性模型应用于加利福尼亚州的1377名低风险患者。该队列由近期无药物滥用、无家可归或无监禁史的患者组成，其治疗依从率为1.7%。模型预测，DOT和自我给药治疗（SAT）分别治愈了这些患者中的93.1%和90.8%。DOT最初的成本将比SAT高出183万美元，但可避免复发病例及其接触者569,191美元的治疗成本，净增量成本为127万美元（每位接受治疗的患者919美元），或每多治愈一例患者成本为40,620美元。DOT的成本效益对SAT完成后的治疗依从率和复发率敏感。只有当治疗依从率和复发率分别超过32.2%和9.2%时，DOT才会产生成本节约。鉴于治疗依从率低以及由此导致的DOT增量成本高，在加利福尼亚州为低风险患者提供DOT应结合资源可用性、相互竞争的项目优先级以及以低复发率完成自我给药治疗的项目成功率来评估。
