Academic journal article Bulletin of the World Health Organization

Cost-Comparison of Different Management Policies for Tuberculosis Patients in Italy

Academic journal article Bulletin of the World Health Organization

Cost-Comparison of Different Management Policies for Tuberculosis Patients in Italy

Article excerpt


The competition of health programmes for limited economic resources within national health systems has spawned an abundance of studies on economic evaluation in health care. Economic evaluation is the comparative analysis of alternative courses of action in terms of costs and consequences, and is most useful when preceded by evaluation of efficiency and effectiveness (1). In the last few years a slowdown or reversal in the decline of tuberculosis (TB) rates has been observed in industrialized countries, the reasons being mainly attributed to increased immigration, poverty, intravenous drug abuse, and infection with human immunodeficiency virus (HIV) (2, 3). WHO is promoting a strategy of TB control based on rapid case detection predominantly through case finding among symptomatic patients self-reporting to health services and supervised administration of standardized short-course chemotherapy, preferably on an ambulatory basis (4). Although in developing countries the treatment of TB cases is among the most cost-effective health interventions, there have been few analyses of the cost-effectiveness of TB control in low-prevalence countries (5, 6). The aim of the present study was to perform an economic analysis in Italy, where TB control efforts were recently revitalized (7), both from the perspective of the resource-allocating authority (i.e. Ministry of Health) and in the broader social context. This study comprises (i) a cost description based on present policy applied to a significant sample of TB patients nationwide (admission and directly observed treatment (DOT) during the initial intensive phase of treatment); and (ii) a cost-comparison analysis of two alternative programmes: current policy and a policy oriented more towards outpatient care (both offering the option of including or not including DOT outside hospital admission, plus incentives) were compared in terms of cost per case cured. The cost-comparison analysis included indirect costs (such as loss of productivity) in considerations of the broader social perspective.


Setting and coverage

In Italy (in 1995: population, 57.2 million; notified TB cases: 9.8 per 100 000 all types; 2.5 per 100 000 new sputum smear-positive), decentralized TB control efforts based on regional programmes started operating in 1990 (7). As part of the first TB project of the Istituto Superiore de Sanita (technical branch of the Ministry of Health), data from a national network of TB units belonging to the AIPO (Italian Society of Hospital Pneumonologists) network were collected prospectively beginning in 1995.

Data were collected from 41 TB-reporting units nationwide, selected on the basis of their willingness to participate, the geographical location of the units (15 in the north, 13 in the centre, and 13 in the south and islands) and their features (17 outpatient units, 10 inpatient units, 14 in- and outpatient units). The network, with a catchment area of 20 million inhabitants, covered about one-quarter of all TB cases notified in Italy every year. Additional information on the TB units and on treatment outcomes is summarized in Table 1.

Table 1. Characteristics of TB units and treatment results of the baseline scenario, stratified by in- and outpatients, Italy, 1995

Inpatients                Inpatients   Outpatients

Total no. of units           24            17
No. in catchment area        18            15
 (> 100 000 population)
No. in catchment area         6             2
 (<100 000 population)
No. of patients             365           317
% of patients                53.5          46.5
Treatment success (%)        73            95.2
Deaths (%)                    7.1           0
Failures (%)                  0.5           0.3
Defaulters (%)               12.3           3.8
Transferred out              7.1            0.7

Forms, timeliness, and flow of reporting

All patients detected at the participating units from 1 January to 31 December 1995 were enrolled. …

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