Preliminary results:�Cost of delivering 3HP versus 6H in Karachi Pakistan

Courtney Yuen

April 27, 2020

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Household contact management

• Household contacts of TB patients are at high risk for developing TB themselves
• High probability of recent infection
• Best practice is to evaluate all for TB disease; preventive therapy can then prevent disease in those who are infected but not sick

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Figure from Trauer JM et al. Chest 2016; 149(2):516-525.

0-4 years old

5-14 years old

≥15 years old

Days since infection

Barriers to completion of preventive therapy

• 2 systematic reviews: low completion reported globally
• Infected contacts, mostly high-income countries: 29% completion
• Young child contacts, LMIC: most studies reported <50% completion

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• Commonly reported barriers to treatment completion
• Length of treatment
• Side effects

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Alsdurf et al. Lancet Infect Dis. 2016; 16(11):1269-1278

Szkwarko et al. PLoS One. 2017; 12(8):e0182185

Better treatment completion with shorter regimens

Cruz et al. Pediatrics. 2018; 141(2):e21072838

Macaraig et al. IJTLD 2018; 22(11):1344-1349

Ronald et al. Eur Respir J. 2020; DOI: 10.1183/13993003.02048-2019

Percentage of patients completing treatment under programmatic conditions

Medications for shorter regimens cost more

• Global drug facility prices (2020)
• 6H = 180 daily doses x 300 mg INH = $3-7
• 4R = 120 daily doses x 600 mg RIF = $24-30
• 3HP = 12 weekly doses x (900 mg RPT + 900 mg INH) = $46

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But cost of delivery is more than medications

Figure from Denholm JT et al. Intern Med J 2017;47(12):1433-1436

Cost (CAD) per completed course

Medications

Pathology testing

Radiology

Outpatient visits

Inpatient admission

Total costs

9H

3HP

Unanswered questions

• How much does it cost to implement good contact management, including preventive therapy in a high-burden setting?

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• How much of that cost is the medications?

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• Does 6H or 3HP cost more to deliver effectively?

Study objectives

• Evaluate the total economic cost per completed course of preventive therapy at the Indus Hospital
• Economic cost is a cost to society, not the same as financial cost to a program
• Cost per completed course is a measure of effective delivery (how much is spent per desired outcome)

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• Compare the cost per completed course of 6H versus 3HP
• Assess the breakdown of costs by category – how significant is the difference in the cost of the drugs?

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Components of economic costs

• System-level costs for 6 building blocks of WHO health system framework:
• Medication-associated costs
• Service delivery
• Health workforce
• Financing
• Leadership and governance
• Health information systems

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• Patient-level costs
• Transport, food/drink during travel
• Fees paid for services or medications
• Lost wages due to time dedicated to visit

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The Indus Hospital in Karachi, Pakistan

• Indus Hospital is a private tertiary care hospital providing free services (funded through donations)
• TB Program started in collaboration with National TB Program in November 2007

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Indus Hospital TB program

Indus Hospital TB program

Indus Hospital TB preventive therapy program

• Program has treated >30,000 people with TB preventive therapy since 2017
• Part of Zero TB Karachi initiative
• Preventive therapy offered to contacts of patients with drug-susceptible and drug-resistant TB, but only drug-susceptible TB included in this analysis

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• 6H was standard regimen for drug-susceptible TB contacts until May 2017, then 3HP became standard
• Both treatment self-administered
• Monthly visits for follow-up and medication refill

Study population

• DS-TB contacts who initiated preventive therapy at Indus Hospital during October 2016–February 2018

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• Costs considered from initial evaluation to rule out active TB disease to end of preventive therapy
• We capture total cost to get contact into care, rule out TB, initiate and follow-up preventive therapy

Patients receiving 6H and 3HP

Patients initiating DS-TB preventive therapy during �October, 2016 – February, 2018

Children defined as <15 years old; 3HP was not used for children <2 years old

Medication-associated costs: methods

• Used GDF drug prices since program obtained drugs from GDF
• 100 mg INH uncoated tablets, 150 mg rifapentine tablets
• Adjusted to 2019 USD
• Intention is to include cost of medication plus cost of shipping; however, we are still collecting data on shipping costs

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• Assumed one complete course per patient initiating treatment
• Good practice is to set aside full course of medication for each patient initiating treatment to avoid treatment interruptions in case of stock-outs

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Medication-associated costs

Child regimen cost based on average pediatric dose since pediatric dosing is determined by weight

Non-medication associated costs: methods

• Obtained from Indus Hospital financial administration:
• Staff effort toward preventive therapy program and proportionate salary allocation
• Standard costs for tests involved in ruling out TB
• Health information systems costs (including cost of developing new EMR)
• Utilities and capital costs

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• Calculate an average cost per visit by dividing total program costs by number of visits
• Distributes all costs evenly across patient visits for simplicity

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Non-medication health systems costs

*Cost of rent for a comparable space is pending

Non-medication health systems costs

Costs incurred by patients: methods

• Survey administered to 100 adult patients and guardians of children receiving preventive therapy
• Time of two-way travel to hospital and time spent in clinic
• Money spent on transport, food, and drinks for family during journey
• Money spent on medical procedures or medications (outside Indus Hospital)
• Interviewee income (used to calculate lost wages)

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• Lost wages calculation
• Assumes interviewee + half the other members of party are wage-earning
• Sensitivity analysis considers only one person in party as wage-earning

Costs incurred by patients

Average values across 100 surveys

Cost per course completed for 6H or 3HP

Medication costs × patients starting treatment

Non-medication health system costs per visit × number of visits

Cost per visit incurred by patients × number of visits

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Total costs

Cost per course completed

*Medication shipping costs and rent costs for facility still pending

Sensitivity analysis without EMR development

*Medication shipping costs and rent costs for facility still pending

Cost drivers

Conclusions

• 3HP drugs have higher price, but cost of effective delivery is lower
• Increased completion with 3HP drives lower cost per completed course
• Medication costs comprise <20% of total economic cost

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• Costs incurred by patients are substantial, even with free treatment
• Major driver is lost wages given 1.5 hours in transit and 3 hours at hospital
• Total costs incurred by families to come to hospital are comparable to cost of 3HP medications

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Acknowledgements

Chunling Lu

HMS, BWH

Hamidah Hussain

IRD

Arman Majidulla

IRD

Funding: TB MAC (Bill & Melinda Gates Foundation OPP1084276)