Transcript 1 - IHPP
-Thailand Policy decision on multi drug resistant(MDR), Program Health Policy International -Thailand Program Policy Health International 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 Program Health Policy International -Thailand Program Policy Health International -Thailand Outline of presentation • • • • • Background information Methodologies Research findings Conclusion and discussion. Policy recommendations 2 Program Health Policy International -Thailand Program Policy Health International -Thailand 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) • • • [Ref] 1. Centers for Disease Control and Prevention., Multidrug-Resistant Tuberculosis (MDR TB) Fact Sheet. 2011. 2. World Health Organization., Press release: WHO Global Task Force outlines measures to combat XDR-TB 3 worldwide. 2006. Program Health Policy International -Thailand Program Policy Health International -Thailand 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. 4 Program Health Policy International -Thailand Program Policy Health International -Thailand 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. 5 Program Health Policy International -Thailand Program Policy Health International -Thailand 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 MDRTB screening. 6 Program Health Policy International -Thailand Program Policy Health International -Thailand 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 7H10, 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 discussion and inductive conclusion to formulate the policy recommendations. 7 Program Health Policy International -Thailand Program Policy Health International -Thailand 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 8 Program Health Policy International -Thailand Program Policy Health International -Thailand Methods (2) Use only direct medical cost: COST • LAB: Department of Medical Science, Ministry of public health, Thailand • Drug cost: Chest disease institute. • Department of Medical Science, Ministry of public health, Thailand Lab’s duration • Expert panel’s adjustment • Systematic review on MODS. 9 Program Health Policy International -Thailand Program Policy Health International -Thailand Comparison among MDR Screening and treatment choices Sputum AFB still be POSITIVE. Standard 2 months of standard TB treatment L-J technique 6 Weeks(4-8 Weeks) Culture waiting period(4-8 weeks) Start MDR-TB treatment Start MDR-TB treatment 7H10 6 Weeks(4-8 Weeks) Start MDR-TB treatment MODs 6 Days Gene technique 1 Day Start MDR-TB treatment Start MDR-TB treatment 10 Program Health Policy International -Thailand Program Policy Health International Research findings -Thailand Program Health Policy International -Thailand Program Policy Health International -Thailand 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 12 Program Health Policy International -Thailand Program Policy Health International -Thailand MDR diagnosed Lab duration and cost comparison 7 6 Baht Weeks 6 6 ฿600.00 5 ฿700.00 ฿600.00 ฿500.00 4 ฿400.00 3 ฿300.00 2 ฿200.00 0.86 1 0 ฿50.00 ฿50.00 ฿50.00 L-J MODs 7H-10 Lab period(Weeks) 0.14 ฿100.00 ฿0.00 Gene technique Lab cost(Baht) 13 Program Health Policy International -Thailand Program Policy Health International -Thailand 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. 14 Program Health Policy International -Thailand Program Policy Health International -Thailand 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. 15 Program Health Policy International -Thailand Program Policy Health International -Thailand Conclusions • Although MODS is the most cost-benefit 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. 16 Program Health Policy International -Thailand Program Policy Health International Policy recommendations -Thailand Program Health Policy International -Thailand Program Policy Health International -Thailand 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. 18 Program Health Policy International -Thailand Program Policy Health International -Thailand 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. 19 Program Health Policy International -Thailand Program Policy Health International -Thailand 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 20 development. 21 Program Health Policy International -Thailand Program Policy Health International -Thailand Program Health Policy International -Thailand Program Policy Health International -Thailand 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 22