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TB Notes 4, 2003

UPDATE FROM THE CLINICAL AND HEALTH SYSTEMS RESEARCH BRANCH 

Potential Cost Savings by TB Treatment Regimen Choice

Revised TB treatment recommendations published in June 2003 included the 4-month continuation-phase use of once-weekly rifapentine and isoniazid for patients at low risk for treatment relapse or failure1 (i.e., adult, HIV-negative patients with noncavitary pulmonary TB whose 2-month sputum smear is negative for acid fast bacilli, for a total of 6 months of therapy.) The availability of this and other regimens provides alternatives that allow providers to tailor treatment to patient characteristics in order to enhance safety, tolerability, and adherence. The regimens also provide opportunities for cost savings for TB programs.

Chart 1 lists the various regimens for treatment of culture-positive pulmonary TB caused by drug-susceptible organisms. There are four initial-phase regimens, each associated with one, two, or three options for the continuation phase. Regimens 1-3 last 6 months, with regimen 4 lasting 9 months and reserved for patients who cannot take pyrazinamide.

Chart 2 presents estimated costs per patient to TB programs and to society to implement the various regimens. Since the medications have different costs and since treatment can be administered daily, three times weekly, biweekly, or once weekly, it is helpful to view the total costs associated with each regimen. Direct costs are those incurred by TB programs for medications and personnel in conducting directly observed therapy (DOT). Total costs add patient productivity losses to the direct costs to estimate the costs to society. All doses are assumed to be administered by DOT. The costs of DOT were estimated by applying the Medicare allowable charge for a home DOT visit ($49)2 and converting it to a cost by multiplying it by 0.502, which is the average cost-to-charge ratio for pulmonary diseases.3 Patient productivity losses are estimated based on computations of a daily wage from the Bureau of Labor Statistics Average Weekly Earnings,4 adjusted upwards by 22 percent to include benefits.5 Since most TB programs purchase their medications through the Public Health Service (PHS), estimates of PHS prices are used. All costs are reported in 2001 dollars.

In the initial phase, assuming doses for an average 70-kg person, the standard regimen of 2 months of daily HRZE costs approximately $1,200 in direct costs and $2,400 total. The least costly of the three regimens for non–pyrazinamide-resistant disease is 2 weeks of daily (5 days per week) isoniazid (H), rifampin (R), pyrazinamide (Z), and ethambutol (E), followed by 6 weeks of biweekly HRZE, at approximately $700 in direct costs and $1,400 total — about 42 percent less than the cost of the standard daily regimen. Next least costly is the regimen of 2 months of thrice-weekly HRZE, at $800 in direct and $1,500 in total costs, which is 36% less costly than the standard regimen.

Among the 4-month continuation-phase regimens, the standard daily regimen of HR costs approximately $2,300 in direct costs and $5,000 total. The newly recommended regimen of 4 months of once-weekly H and rifapentine (RPT) is the least costly, at $600 in direct costs and $1,100 total. This regimen is 78 percent less costly than the standard continuation-phase regimen. Next, at 60 percent less costly than the standard, is biweekly HR, at $900 in direct and $2,000 in total costs. It is followed by thrice-weekly HR, at $1,400 in direct costs and $3,000 total, a 40 percent cost savings over the standard.

Combining initial- and continuation-phase regimens, the standard daily regimen of 2 months of HRZE followed by 4 months of daily HR, each dose provided by DOT, costs approximately $3,500 in direct costs and $7,400 total. The least costly option is 2 weeks of daily HRZE followed by 6 weeks of biweekly HRZE followed by once-weekly H/RPT. This regimen costs the TB program about $1,300 and costs society about $2,500, for a cost savings of 66 percent over the standard daily 6-month regimen. Combining the same .5HRZE/1.5HRZE2 initial phase with biweekly HR for the continuation phase is the second least costly, for a savings of 54% over the standard regimen. An initial phase of daily HRZE followed by a continuation phase of once-weekly H/RPT results in cost savings of 52%. Next is the standard daily initial phase combined with biweekly HR in the continuation phase, for a cost savings of 40 percent. An initial phase provided thrice weekly followed by a continuation phase also provided thrice weekly results in nearly similar savings of 39 percent.

While cost savings could be achieved by TB programs using less costly alternatives to the standard regimen, care must be taken to match the correct regimen to patient characteristics to minimize the risk of active TB relapse or treatment failure. The continuation-phase regimen of once-weekly H/RPT is only recommended for HIV-negative patients with drug-susceptible TB disease that does not show cavitation and is not sputum-smear positive after 2 months of treatment. Also, the biweekly HR continuation-phase regimen is not recommended for HIV-infected patients whose CD4 cell count is less than 100 per ml. However, the number of TB patients who are eligible to receive the least costly regimens is considerable and cost savings can be substantial. Adherence may also be enhanced by use of the intermittent regimens.

—Reported by Suzanne Marks, MPH, MA
Div of TB Elimination

References

  1. American Thoracic Society, CDC, and the Infectious Diseases Society of America. Treatment of tuberculosis. MMWR 2003;52(No. RR-11): 1-80.
  2. 2001 Physicians Fee and Coding Guide. Augusta, GA: Health Care Consultants of America, Inc; 2002.
  3. The DRG Handbook: Comparative Clinical and Financial Standards. Miami, FL: Ernst & Young LLP; 1997: 21.
  4. US Dept. of Labor, Bureau of Labor Statistics. Average Weekly Earnings of Production Workers. Average for 2001 (www.bls.gov).
  5. Grosse SD. Appendix I: Productivity Loss Tables. In Haddix AC, Teustch SM, Corso PS. Prevention Effectiveness: A Guide to Decision Analysis and Economic Evaluation. Second edition. New York, NY: Oxford University Press; 2003.

Chart 1 from the revised TB treatment recommendation lists the various regimens for treatment of culture-positive pulmonary TB caused by drug-susceptible organisms.

Chart 2 below shows the estimated costs per patient of using the various TB treatment regimens.

TB Treatment Regimen Implementation Costs

Regimen

Total Doses

Est. PHS Tot Med Cost

Estimated DOT Personnel Cost

Estimated Patient Productivity Loss

 Est. Direct Costs

Est. Total Cost

Percent
Cost Reduction
From Daily Standard

Population

Active TB, Initial phase

 

 

 

 

 

 

 

 

1

2HRZE (300 mg, 600 mg, 1500 mg, 1200 mg)

40

$235

$984

$1,195

$1,219

$2,414

 

 

4

2HRE (300 mg, 600 mg, 1200 mg)

40

$137

$984

$1,195

$1,121

$2,316

4.08%

 

3

2HRZE3 (900 mg, 600 mg, 2500 mg, 2000 mg)

24

$221

$590

$717

$811

$1,528

36.69%

 

2

.5HRZE/1.5HRZE2 (300,600,1500,1200/900,600,3000,2800)

22

$198

$541

$657

$739

$1,396

42.17%

 

 

Active TB, Continuation Phase

 

 

 

 

 

 

 

 

4a

7HR (300 mg, 600 mg)

155

$173

$3,813

$4,630

$3,985

$8,616

-72.22%

 

1a

4HR (300 mg, 600 mg)

90

$100

$2,214

$2,689

$2,314

$5,003

 

 

4b

7HR2 (900 mg, 600 mg)

62

$78

$1,525

$1,852

$1,603

$3,455

30.93%

 

3a

4HR3 (900 mg, 600 mg)

54

$68

$1,328

$1,613

$1,396

$3,009

39.84%

 

1b,2a

4HR2 (900 mg, 600 mg)

36

$45

$886

$1,075

$931

$2,006

59.90%

 

1c,2b

4HRPT1 (900 mg, 600 mg)

18

$140

$443

$538

$583

$1,121

77.60%

 

 

Active TB, Initial and Continuation Phases Together

 

 

 

 

 

 

 

 

4/4a

2HRE/7HR

195

$309

$4,797

$5,825

$5,106

$10,932

-47.39%

 

1/1a

2HRZE/4HR

130

$336

$3,198

$3,884

$3,533

$7,417

 

Drug Susceptible (DS)

4/4b

2HRE/7HR2

102

$215

$2,509

$3,047

$2,724

$5,771

22.19%

 

3/3a

2HRZE3/4HR3

78

$289

$1,919

$2,330

$2,208

$4,538

38.82%

 

1/1b

2HRZE/4HR2

76

$281

$1,869

$2,270

$2,150

$4,421

40.40%

DS pts except HIV+ with <100 CD4

1/1c

2HRZE/4HRPT1

58

$375

$1,427

$1,733

$1,802

$3,535

52.34%

DS  pts, HIV-, non-cavitary, not culture positive at 2 mo.

2/2a

.5HRZE/1.5HRZE2/4HR2

58

$243

$1,427

$1,733

$1,670

$3,402

54.13%

DS pts except HIV+ with <100 CD4

2/2b

.5HRZE/1.5HRZE2/4HRPT1

40

$338

$984

$1,195

$1,322

$2,517

66.07%

DS  pts, HIV-, non-cavitary, not culture positive at 2 mo.

Estimates provided by Suzanne Marks, MPH, MA
Personnel costs are estimates based on the Medicare allowable charge for a home DOT visit ($49), converted to a cost (multiply by 0.502)
Patient productivity losses are estimated to be one quarter day's earnings, using average weekly earnings adjusted to include benefits
Direct costs are total costs minus patient productivity losses. Costs are in 2001 dollars

 


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