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Health and economic impact of tuberculosis management in Malaysia
thesisposted on 24.02.2017, 01:58 by Fun, Weng Hong
Introduction: Despite all the control efforts made to reduce the prevalence of Tuberculosis (TB) in Malaysia, TB is still a leading cause of mortality among the communicable diseases with a rate of 5.37 per 100,000 population. It has also caused a significant economic burden to the government in the order of USD15 million per year as reported by World Health Organization in 2015. However, the long-term epidemiological and economic burden of TB management has not been established. Objectives: The objectives of this study are to evaluate the health and economic burden of TB management in Malaysia, and the cost-effectiveness of TB control programme by developing a dynamic transmission model. Methodology: A retrospective observational study was conducted in Selangor, including all TB patients first diagnosed in the year 2011. With the collected data, binary logistic regression analysis was carried out to determine the risk factors for incomplete treatment in TB patients. Costing study was also conducted to estimate the cost of TB management. The total cost of TB treatment was calculated by multiplying the frequency of health services utilisation with the unit cost obtained from the Medical Fee Act, 2014. Additionally, a dynamic transmission model was constructed to simulate the natural progression of TB in Malaysia over a 10-year horizon. This model was then used to project the annual rate of TB incidence. This study was conducted from government perspective. Furthermore, we conducted the cost-effectiveness of Xpert MTB/RIF test in Malaysia based on the model built. The results were expressed in cost per disability-adjusted life years (DALYs). A discount rate of 3% was considered for both costs and outcomes. One-way sensitivity analysis and probabilistic sensitivity analysis were performed to ensure consistency and robustness of the model outcomes. Results: A total of 555 cases of TB were identified for this study. On multivariate analysis, risk factors that were significantly associated with incomplete treatment included nationality, occupation and TBIS registry. There were also several factors found, associated with incomplete treatment on univariate analysis which included age, gender, main treatment centre, comorbidities, facility utilisation, HIV/AIDS and distance to main facility. An incomplete treatment would cause the government an average of RM901.63 per patient compared to a completed treatment where RM2,242.02 was needed for a non-hospitalised uncomplicated TB case. A further analysis showed that the cost of treating a case with comorbidities and hospital stays was 4.5 times of the cost of treating an uncomplicated TB case. This cost would further escalate if MDR-TB treatments were required, whereby the cost would be 28.5 times more than treating an uncomplicated TB case. Additionally, our projection suggests that TB notification rate (NR) will increase by 57.64% after 10 years. When this burden was translated into monetary terms, a 19.96% (RM31,876,721) increase in TB budget would be required in 2021 if the control strategies remain unchanged as in 2011. In the base case analysis, the incremental cost-effectiveness ratio was RM47,266.80 for the Xpert scenario versus the current practice, which is slightly more than 1 time gross domestic product (RM41,153.62 per capita in 2014). However, with the current evidence, the probabilistic sensitivity analysis showed that at the willingness to pay (WTP) threshold value of RM30,000 per DALY averted, Xpert scenario was cost effective in more than 95% of all simulations. Thus, it is cost effective to be implemented in Malaysia, provided the WTP threshold is set at 1 time gross domestic product per DALY averted. Conclusions: This study has successfully established the cost of TB management in Malaysia. Hospitalisation appeared to be the major cost drive for TB patients receiving TB treatment, thus strategies that could reduce the length of hospital stay without compromising the quality of care in TB treatments should be considered as future research. The dynamic transmission model has projected that the TB burden would continuously escalate. Thus, the future control strategies and new public health interventions could focus on early detection and treatment of TB such as TB education and adopting new diagnostic tools for rapid detection of TB. These could be the keys to bring Malaysia a step closer to TB elimination.