Floyd K, Skeva J, Nyirenda T, Gausi F, Salaniponi F
Stop TB Department, World Health Organization, Geneva, Switzerland.
Int J Tuberc Lung Dis. 2003 Sep;7(9 Suppl 1):S29-37.
Lilongwe District, Malawi.
To assess the cost and cost-effectiveness of new treatment strategies for new pulmonary tuberculosis patients, introduced in 1997.
For new smear-positive pulmonary patients, two strategies were compared: 1) the strategy used until the end of October 1997, involving 2 months of hospitalisation at the beginning of treatment, and 2) a new decentralised strategy introduced in November 1997, in which patients were given the choice of in- or outpatient care during the first 2 months of treatment. For new smear-negative pulmonary patients, the two strategies compared were 1) the strategy used until the end of October 1997, which did not require any direct observation of treatment (DOT) and 2) a new community-based strategy introduced in November 1997, which required DOT by a community member 'guardian' or a health worker for the first 2 months of treatment. Costs were analysed from the perspective of health services, patients, and the community in 1998 US dollars, using standard methods. Cost-effectiveness was calculated as the cost per patient cured (smear-positive cases) and as the cost per patient completing treatment (new smear-negative cases).
For new smear-positive patients, the cost per patient treated was dollars 456 with the conventional hospital-based strategy, and dollars 106 with the new decentralised strategy. Costs fell by 54% for health services and 58% for patients. The cost per patient cured was dollars 787 for the conventional hospital-based strategy, and dollars 296 for decentralised treatment. For smear-negative patients, the cost per patient treated was dollars 67 with the conventional unsupervised strategy, and dollars 101 with the community-based DOT strategy. Costs increased for health services, patients and guardians. Cost-effectiveness was similar with both strategies, at around dollars 200 per patient completing treatment. When new smear-positive and new smear-negative patients were considered together, the new strategies were associated with a 50% reduction in total annual costs.
There is a strong economic case for expansion of decentralisation and community-based DOT in Malawi. Further investment in training and programme supervision may help to increase effectiveness.
马拉维利隆圭区。
评估1997年引入的针对新发肺结核患者的新治疗策略的成本及成本效益。
对于新的涂片阳性肺结核患者，比较了两种策略：1）1997年10月底前使用的策略，即在治疗开始时住院2个月；2）1997年11月引入的新的分散式策略，即患者在治疗的前2个月可选择住院或门诊治疗。对于新的涂片阴性肺结核患者，比较的两种策略为：1）1997年10月底前使用的策略，该策略无需任何直接监督治疗（DOT）；2）1997年11月引入的新的基于社区的策略，该策略要求社区成员“监护人”或卫生工作者在治疗的前2个月进行DOT。采用标准方法，从卫生服务、患者和社区的角度以1998年美元分析成本。成本效益计算为每治愈一名患者（涂片阳性病例）的成本以及每完成治疗一名患者（新的涂片阴性病例）的成本。
对于新的涂片阳性患者，采用传统的基于医院的策略，每名接受治疗患者的成本为456美元，而采用新的分散式策略为106美元。卫生服务成本下降了54%，患者成本下降了58%。采用传统的基于医院的策略，每治愈一名患者的成本为787美元，分散式治疗为296美元。对于涂片阴性患者，采用传统的无监督策略，每名接受治疗患者的成本为67美元，采用基于社区的DOT策略为101美元。卫生服务、患者和监护人的成本均有所增加。两种策略的成本效益相似，每完成治疗一名患者约为200美元。当将新的涂片阳性和新的涂片阴性患者综合考虑时，新策略使年度总成本降低了50%。
在马拉维，扩大分散式和基于社区的DOT有充分的经济理由。在培训和项目监督方面的进一步投资可能有助于提高有效性。
