A Systematic Review of the Direct and Indirect Costs among Tuberculosis Patients

 

Susi Ari Kristina¹*, Tri Murti Andayani¹, Galih Putri Wulandari²

¹Health Technology Assessment and Pharmacoeconomics Research Center, Faculty of Pharmacy,

Universitas Gadjah Mada

¹Health Technology Assessment and Pharmacoeconomics Research Center, Faculty of Pharmacy,

Universitas Gadjah Mada

²Research Assistant, Department of Pharmaceutics, Faculty of Pharmacy, Universitas Gadjah Mada

 

ABSTRACT:

Tuberculosis (TB) is one of the top ten leading death diseases in the world. The economic burden of TB disease predicted could reach USD 16.7 trillion in 2050. This study aims to present the cost of TB treatment by direct and indirect cost of TB disease with systematic review form. A systematic review was performed on Pub Med, Science Direct and Google Scholar during the period 2008-2018. Combination key terms such as “tuberculosis” OR “TB” AND “economic burden” OR “financial burden” OR “cost” OR “cost of illness” AND “direct cost” AND “indirect cost” were used for the search. Original articles published in English and reported both direct and indirect cost of tuberculosis treatment in a population were included. A total of 36 studies were retrieved, 8 studies were finally selected that met all eligibility criteria which reported both direct and indirect cost of tuberculosis treatment in the several countries. From the review, we summarize that direct cost of tuberculosis ranged from USD34.91 to USD 2, 680 and indirect cost was between USD 161 and USD 3, 739.21. This study shows that cost of tuberculosis treatment imposes a huge economic burden in terms of provider, societal, and patients. An effort to improve the tuberculosis patient’s adherence is a suitable preventive strategic to reduce the economic burden.

 

 

INTRODUCTION:

Tuberculosis (TB) is one of the top ten leading death diseases in the world. Based on World Health Organization (WHO) data, in 2017about 10 million people suffered TB and 1.6 million died with TB disease. The largest number of TB incidence occurs in the South-East Asia and Western Pacific regions¹.

 

Tuberculosis (TB) is defined as a communicable infectious diseases caused by Mycobacterium tuberculosis². TB id divided in two categories, namely pulmonary and extrapulmonary.

 

Primary TB pneumonia, TB pleurisy, cavity TB, military TB, and laryngeal TB included in the pulmonary TB, while lymph node disease, TB peritonitis, TB pericarditis, osetal TB, renal TB, adrenal TB, and TB meningitis falls into the extrapulmonary TB category^3,4. M. tuberculosis can be spread through the air by coughing or sneezing and by close contact with TB patient as the most way of people get the infection. Therefore, TB is very easy to be transmitted from one person to another person⁵. All age groups are at risk, but TB mostly affects adults in their most productive years⁶.

 

In the TB treatment, there are two phase. First phase is an intensive phase and the second is continuation phase. In the intensive phase, patients took four essential drugs for TB treatment which are rifampicin, isoniazid, pyrazinamid and ethambutol for at least two months. In the continuation phase, patients took the regimen medication consisting of rifampicin and isoniazid for at least four months⁷. For isoniazid consumption, patients were also given pyridoxine to prevent peripheral neuropathy which associated with isoniazid⁸. Due to long duration of treatment, the risks on incompliance were arise^9,10, especially for patients with lower knowledge and awareness on tuberculosis treatment^11,12.

 

By those regimens with long period of treatment and complications^13,14, TB disease drive patient in medical poverty trap^15,16. TB Alliance predicted economic burden of TB disease could reach USD 16.7 trillion in 2050¹⁷. In the previous studies noted that TB required USD 616 billion of world economy between 2000 and 2015. Several countries in Southeast Asia and Africa exceed 1% till 3% of gross economic domestic product for TB disease¹⁸. Therefore, WHO planned to conducts 95% reduction of TB death and 90% of TB incidence listed in Sustainable Development Goals¹.

 

This study aims to present the cost of TB treatment by direct and indirect cost of TB disease with systematic review form. The summarized of available studies may provide a high level of evidence on the economic burden of TB disease in order to help decision makers to develop any appropriate policies related to TB management.

 

METHODS:

This study is a systematic review to provide latest cost of tuberculosis treatment by 3 main steps to formulate the result studies. First we identify and select related research about our topic. Second, we assess the retrieved research that met all eligibility criteria. Third, we made the review and data extraction for each study.

 

 

Study identification:

PubMed, Science Direct and Google Scholar databases were initially searched in January 2019. We performed a literature search for published articles were limited in English to select the studies related to direct and indirect cost of tuberculosis treatment of particular study population. The time frame for the analysis was studies conducted from 2008 to 2018. Key terms used for the search were as follows: “tuberculosis” OR “TB” AND “economic burden” OR “financial burden” OR “cost” OR “cost of illness” AND “direct cost” AND “indirect cost”. As for the inclusion and exclusion criteria were shown in Table 1.

 

Table 1. Inclusion and exclusion criteria for the retrieved articles

Inclusion Criteria	Exclusion Criteria
1.  Published in the English language 2.  Time frame year from 2008 - 2018 3.  Report cost of tuberculosis treatment 4.  Available in full-text	1.   Review articles, letters and comments 2.   Exclusively related to MDR/XDR case, HIV/AIDS or other disease 3.   Not mentions both direct and indirect cost of tuberculosis treatment

 

Study Retrieved Process:

A total of 36 studies were initially retrieved. After further tracking references from the retrieved studies, only 8 studies were finally selected that met all eligibility criteria. The other 28 studies were excluded due to the review articles, studies related to MDR/XDR case and/or HIV/AIDS, the full-text cannot be accessed, not mentioning both direct and indirect cost or unclear cost items and duplicate topic of the articles. The PRISMA diagram of retrieved studies is shown in Figure 1.

 

Figure 1. PRISMA diagram of retrieved studies.

 

Data extraction:

Data from included studies were independently extracted by two researchers. The data were extracted on issues of methodology and the studies result concern on direct and indirect cost tuberculosis treatment. Any non-agreement on the extracted data was resolved by discussion among the authors.

 

RESULTS:

Literature Search:

A total of 36 articles were retrieved from the combined searches from PubMed, Science Direct and Google Scholar. The retrieved studies consisted of varied number of population and all conducted from the different countries. Title and abstract of the 28 identified articles were independently assessed by two authors and finally there were 8 articles were included in the review. The included studies were conducted in 7 countries namely Iran^19,20, Malaysia²¹, India²², Netherlands²³, Benin²⁴, Kenya²⁵ and Cyprus²⁶. Half of the studies were published in the last five years^19,20,24,26. The summary of characteristics of the included studies can be seen in the Table 2.

 

Table 2. Characteristic of included studies

 

Methodological characteristics:

In the included articles, there were various perspectives to observe the TB treatment. One study measure economic burden from provider side¹⁹, four studies from societal side^20-22,26, and the remaining studies from patient side^23-25. The various method also done for getting the reliable data. There were three studies with retrospective study^19,21,26, four studies by cross-sectional study^22-25 and the remaining study using descriptive analytical study²⁰. The summary of methodology of included studies is shown in Table 3.

 

Table 3. Methodology of included studies

 

Demographic analysis:

Our findings show that six of eight studies mentioned that TB patients was male^21-26. Seven of eight studies mentioned that TB patients were 14-65 years old^20-26. Half of included studies mentioned that TB patients completed the primary and secondary schools^21,22,24,25.

 

Cost of tuberculosis treatment:

In this study, TB treatments assessed both of direct and indirect cost. The included studies conducted from various countries that have a difference in the economic burden of tuberculosis treatment. There were three countries in the four studies that higher in the direct cost ^19,20,24,26 and four studies were higher at indirect cost^{21-23, 25}. The cost in the included studies stated in two types of currency, there are USD in seven studies^19-22,24-26 and Euro in another study²³ which has been converted to USD currency in the year study done (2009). Resume of the studies’ characteristics can be seen in Table 4.

 

After reviewed, there were variation items used to calculate both direct and indirect cost of tuberculosis treatment. Table 5 shows the component of cost in the included studies.

 

Table 4. Resume of the included studies

Author, Year	Country	Number of patients	Time Frame	Direct cost (USD)	Indirect cost (USD)
Bay, 201719	Golestan, Iran	45	April, 2013 to December, 2015	1, 226	183
Elamin, 200821	Malaysia	201	May 2002 to August 2003	290.5	625.9
Hasoumi, 201420	Tehran, Iran	121	2011	2, 680	503
John, 200922	India	100	July to November 2007	34.91	526.87
Kik, 200923	Netherlands	60	April to October 2007	507.08	3, 739.21
Laokri, 201424	Benin	245	August, 2008 to February, 2009	264.8	161
Mauch, 201125	Kenya	208	September 2008	55.8	294.2
Zannetos, 201826	Cyprus	55	January 1 to December 31, 2009	11, 030	1, 820

 

Table 5. Direct and indirect cost items

Author, Year	Direct cost item	Indirect cost item
Bay, 201719	Human resources, medicines, physicians consultation, hospitalization, laboratory & radiology, consumable materials, transportation	Depreciation costs, energy, supportive activity center cost
Elamin, 200821	Cost of hospitalization, medications, diagnostic laboratory tests, X-ray films, reagents, the cost of time incurred by health personnel, cost of transportation to the clinic and back home, meals and telephone, electricity and water bills	The cost of time away from work or lost of productivity
Hasoumi, 201420	Visit to the doctor, tests, drugs, nursing at home, surgery and hospitalization, travelling	Lost income
John, 200922	Travel costs, registration and paperwork fees, consultation fees, blood test fees, medication fees, X-ray fees, food costs and other costs	Travel time for return trips to clinics/hospital, waiting time and time for consultation with a physician, nurse or treatment supporter
Kik, 200923	The costs of transportation to health facilities, costs of extra food (bought during waiting time at the health facility), extra expenditures related to hospitalization (which were not covered by the health insurance) or over the counter medication (such as vitamin B6).	Visits to the health facilities and hospitalization as well as other time lost due to the inability to work as a result of the illness
Laokri, 201424	TB care and control affordability	The time lost by the patient, guardian and informal caregiver because of travel to seek care, waiting for consultation, or illness
Mauch, 201125	Health care costs such as tests, administrative charges and medicines taken for TB symptoms. Prior to receiving a TB diagnosis; transport costs to and from health facilities; and associated food and accommodation costs	Income lost due to TB
Zannetos, 201826	Hospitalization, hospital outpatient care (visits to the doctor, either specialist or general practitioner), nonpharmacological interventions (inpatient and outpatient laboratory and radiology tests), pharmacological treatment, hospitalization monitoring and nursing at home, transportation, meals and possible co-payment of medical treatment and drugs by the patients	The loss of production for the economy due to the absence from the workplace on sick leave by a patient.

 

DISCUSSION:

This findings demonstrates that cost of tuberculosis treatment imposes a huge economic burden in terms of provider, societal, and patient both direct and indirect cost. For the direct costs are about USD 34.91 till USD 2,680 and for the indirect cost are between USD 161 and USD 3,739.21. This range showed that the burden depend on the type of treatment given to patients.

 

Every country has different strategies to manage financing of tuberculosis treatment²⁷. Especially, in the universal health coverage era, many policy-makers take the strategic benefit package for their residents and also for the government²⁸. Pharmacoeconomic analysis used to select the wise policies which are not load the condition of economic’s country.The pharmacoeconomic parameter has strong internal validity of cost effectiveness²⁹.

 

Based on the review, countries have greater direct costs caused by several factors. First, the component of medical costs is directly affected by the length of treatment and secondly, for non-medical cost expenses affected by transportation costs. Oppositely, in the countries which have higher indirect costs were related to time lost which set off inability to work.

 

Some recommendations which are appropriate to generalize are to reduce the significant rate of economic burden or to conduct the alternative treatment with medicinal plant used³⁰. In the previous studies, there are some recommendations for TB management. For untreated people but they have family who suffer TB, they have to keep the good ventilation and adequate light for the house to reduce the bacterial development³¹. For active TB patients, they should be treated with potent agent to cleanse the bacterial and make the direct observation to see the infection Government need to involve collaboration from health care professionals to give the best treatment for patient³². For patient MDR/XDR TB cases, we have to change the medicine rapidly based on the guideline and adjusted with patient’s clinical history³³.

 

Based on this review, the most beneficial management for patients, provider, and government is an effort to improve the patient’s adherence in undergoing the TB treatment^34-36. This is related to various benefits that can be obtained by various parties. For example to patients, they do not need to consume the medicine for a longer time and also they do not need to spend a lot of money and time to reach health care facilities. For the provider side, in addition to reducing the operational costs needed for checking sputum or lungs profiles, this effort also can help to reduce the incidence of antibiotic resistance in TB patients. For the government itself, this effort is very useful for the process of procurement of package drugs provided for TB patients so that it can lighten the country's economic burden.

The limitation of this study is about the variation of costing method among studies. There were differences in the components used in the calculation for both direct costs and indirect costs. Moreover, the differences of the result study might arise from different study settings, time of determination as cost is time-sensitive, and the type of TB cases included in the studies.

 

CONCLUSION:

The cost of tuberculosis treatment imposes a huge economic burden in terms of provider, societal, and patient. An effort to improve the tuberculosis patient’s adherence is a suitable preventive strategic if implemented to reduce the burden.

 

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Received on 31.05.2019           Modified on 25.06.2019

Accepted on 30.07.2019         © RJPT All right reserved