Perlman D C, Gourevitch M N, Trinh C, Salomon N, Horn L, Des Jarlais D C
Beth Israel Medical Center, First Avenue at 16th Street, New York City, NY 10003, USA.
J Urban Health. 2001 Sep;78(3):550-67. doi: 10.1093/jurban/78.3.550.
This study examined whether costs associated with tuberculosis (TB) screening and directly observed preventive therapy (DOPT) among drug injectors attending a syringe exchange are justified by cases and costs of active TB cases prevented and examined the impact of monetary incentives to promote adherence on cost-effectiveness. We examined program costs and projected savings using observed adherence and prevalence rates and literature estimates of isoniazid (INH) preventive therapy efficacy, expected INH hepatoxicity rates, and TB treatment costs; we conducted sensitivity analyses for a range of INH effectiveness, chest X-ray (CXR) referral adherence, and different strategies regarding anergy among persons affected with human immunodeficiency virus (HIV). For 1,000 patients offered screening, incorporating real observed program adherence rates, the program would avert $179,934 in TB treatment costs, for a net savings of $123,081. Assuming a modest risk of TB among HIV-infected anergic persons, all strategies with regard to anergy were cost saving, and the strategy of not screening for anergy and not providing DOPT to HIV-infected anergic persons resulted in the greatest cost savings. If an incentive of $25 per person increased CXR adherence from the observed 31% to 50% or 100%, over a 5-year follow-up the net cost savings would increase to $170,054 and $414,856, respectively. In this model, TB screening and DOPT at a syringe exchange is a cost-effective intervention and is cost-saving compared to costs of treating active TB cases that would have occurred in the absence of the intervention. This model is useful in evaluating the cost impact of planned program refinements, which can then be tested. Monetary incentives for those referred for screening CXRs would be justified on a cost basis if they had even a modest beneficial impact on adherence.
本研究探讨了在注射器交换项目中，与结核病（TB）筛查及直接观察下的预防治疗（DOPT）相关的成本，是否能通过预防的活动性结核病例数及成本来证明其合理性，并研究了金钱激励措施对促进依从性进而对成本效益的影响。我们利用观察到的依从率和患病率，以及异烟肼（INH）预防治疗效果、预期的INH肝毒性率和结核病治疗成本的文献估计值，来研究项目成本和预计节省情况；我们针对一系列INH有效性、胸部X线（CXR）转诊依从性以及针对感染人类免疫缺陷病毒（HIV）者的无反应性的不同策略进行了敏感性分析。对于1000名接受筛查的患者，纳入实际观察到的项目依从率后，该项目可避免179,934美元的结核病治疗成本，净节省123,081美元。假设HIV感染的无反应性者患结核病的风险适中，所有关于无反应性的策略都能节省成本，且不对无反应性进行筛查且不给HIV感染的无反应性者提供DOPT的策略节省成本最多。如果每人25美元的激励措施能使CXR依从率从观察到的31%提高到50%或100%，在5年的随访中，净成本节省将分别增加到170,054美元和414,856美元。在此模型中，注射器交换项目中的结核病筛查和DOPT是一种具有成本效益的干预措施，与在无该干预情况下治疗活动性结核病例的成本相比可节省成本。该模型有助于评估计划中的项目改进的成本影响，随后可对其进行测试。如果对转诊进行CXR筛查者的金钱激励措施对依从性哪怕只有适度的有益影响，从成本角度来看也是合理的。
