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Cost and Cost-Effectiveness of a Digital Adherence Technology for Tuberculosis Treatment Support in Uganda

  • Author Footnotes
    ∗ These co-first authors contributed equally to this work.
    Ryan R. Thompson
    Footnotes
    ∗ These co-first authors contributed equally to this work.
    Affiliations
    Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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  • Author Footnotes
    ∗ These co-first authors contributed equally to this work.
    Alex Kityamuwesi
    Footnotes
    ∗ These co-first authors contributed equally to this work.
    Affiliations
    Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
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  • Author Footnotes
    ∗ These co-first authors contributed equally to this work.
    Alice Kuan
    Footnotes
    ∗ These co-first authors contributed equally to this work.
    Affiliations
    Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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  • Denis Oyuku
    Affiliations
    Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
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  • Austin Tucker
    Affiliations
    Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
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  • Olivia Ferguson
    Affiliations
    Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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  • Lynn Kunihira Tinka
    Affiliations
    Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
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  • Rebecca Crowder
    Affiliations
    Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
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  • Stavia Turyahabwe
    Affiliations
    Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda

    National Tuberculosis and Leprosy Program, Uganda Ministry of Health, Kampala, Uganda
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  • Adithya Cattamanchi
    Affiliations
    Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda

    Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
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  • Author Footnotes
    † These co-senior authors contributed equally to this work.
    David W. Dowdy
    Footnotes
    † These co-senior authors contributed equally to this work.
    Affiliations
    Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

    Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
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  • Author Footnotes
    † These co-senior authors contributed equally to this work.
    Achilles Katamba
    Footnotes
    † These co-senior authors contributed equally to this work.
    Affiliations
    Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda

    Clinical Epidemiology and Biostatistics Unit, Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
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  • Author Footnotes
    † These co-senior authors contributed equally to this work.
    Hojoon Sohn
    Correspondence
    Correspondence: Hojoon Sohn, PhD, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, E6039, Baltimore, MD 21205, USA.
    Footnotes
    † These co-senior authors contributed equally to this work.
    Affiliations
    Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
    Search for articles by this author
  • Author Footnotes
    ∗ These co-first authors contributed equally to this work.
    † These co-senior authors contributed equally to this work.
Published:January 06, 2022DOI:https://doi.org/10.1016/j.jval.2021.12.002

      Highlights

      • Digital adherence technologies (DATs) such as 99DOTS hold potential for improving tuberculosis outcomes and provide a less resource-intensive alternative to directly observed therapy.
      • We provide empiric cost estimates from a pragmatic, stepped-wedge randomized trial in Uganda and simulation-based estimates of costs and cost-effectiveness of maintaining a DAT program for 5 years under different scenarios.
      • To the best of our knowledge, this study provides the first trial-based empiric cost and cost-effectiveness estimates of 99DOTS. This study can help funders, ministries of health, and other stakeholders in high-burden areas make informed decisions on integrating DATs like 99DOTS into routine tuberculosis care.

      Abstract

      Objectives

      Digital adherence technologies like 99DOTS are increasingly considered as an alternative to directly observed therapy for tuberculosis (TB) treatment supervision. We evaluated the cost and cost-effectiveness of 99DOTS in a high-TB-burden setting.

      Methods

      We assessed the costs of implementing 99DOTS in Uganda through a pragmatic, stepped-wedge randomized trial. We measured costs from the health system perspective at 5 of 18 study facilities. Self-reported service activity time data were used to assess activity-based service costs; other costs were captured from budgets and key informant discussions using standardized forms. We estimated costs and effectiveness considering the 8-month study period (“trial specific”) and using a 5-year time horizon (“extended activities”), the latter including a “marginal clinic” expansion scenario that ignored above-site implementation costs. Cost-effectiveness was assessed as cost per patient successfully completing treatment, using Monte Carlo simulation, cost-effectiveness acceptability curves, and sensitivity analyses to evaluate uncertainty and robustness of results.

      Results

      The total cost of implementing 99DOTS in the “trial-specific” scenario was $99 554 across 18 clinics (range $3771-$6238 per clinic). The cost per treatment success in the “trial-specific” scenario was $355 (range $229-$394), falling to $59 (range $50-$70) assuming “extended activities,” and $49 (range $42-$57) in the “marginal clinic” scenario. The incremental cost-effectiveness of 99DOTS in the “extended-activity” scenario was $355 per incremental treatment success.

      Conclusions

      Costs and cost-effectiveness of 99DOTS were influenced by the degree to which infrastructure is scaled over time. If sustained and scaled up, 99DOTS can be a cost-effective option for TB treatment adherence support in high-TB-burden settings like Uganda.

      Keywords

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      References

      1. Global tuberculosis report 2021. World Health Organization.
      2. Uganda national guidelines for tuberculosis control in health care facilities, congregate settings and households. Ministry of Health, Uganda.
      3. Global tuberculosis report 2018. World Health Organization.
        • Wynne A.
        • Richter S.
        • Banura L.
        • Kipp W.
        Challenges in tuberculosis care in Western Uganda: health care worker and patient perspectives.
        Int J Afr Nurs Sci. 2014; 1: 6-10
        • Yellappa V.
        • Lefèvre P.
        • Battaglioli T.
        • Narayanan D.
        • Van der Stuyft P.
        Coping with tuberculosis and directly observed treatment: A qualitative study among patients from South India.
        BMC Health Serv Res. 2016; 16: 283
        • Lei X.
        • Huang K.
        • Liu Q.
        • Jie Y.F.
        • Tang S.L.
        Are tuberculosis patients adherent to prescribed treatments in China? Results of a prospective cohort study.
        Infect Dis Pover. 2016; 5: 38
      4. Treatment for TB disease. US Centers for Disease Control and Prevention.
        • Munro S.A.
        • Lewin S.A.
        • Smith H.J.
        • Engel M.E.
        • Fretheim A.
        • Volmink J.
        Patient adherence to tuberculosis treatment: a systematic review of qualitative research.
        PLoS Med. 2007; 4: e238
        • Alipanah N.
        • Jarlsberg L.
        • Miller C.
        • et al.
        Adherence interventions and outcomes of tuberculosis treatment: a systematic review and meta-analysis of trials and observational studies.
        PLoS Med. 2018; 15e1002595
        • Broomhead S.
        • Mars M.
        Retrospective return on investment analysis of an electronic treatment adherence device piloted in the Northern Cape Province.
        Telemed J Health. 2012; 18: 24-31
        • Park S.
        • Sentissi I.
        • Gil S.J.
        • et al.
        Medication event monitoring system for infectious tuberculosis treatment in Morocco: a retrospective cohort study.
        Int J Environ Res Public Health. 2019; 16: 412
      5. Cross A, Gupta N, Liu B, et al. 99DOTS: a low-cost approach to monitoring and improving medication adherence. In: Proceedings from the Tenth International Conference on Information and Communication Technologies and Development (ICTD 2019); January 4-7, 2019; Ahmedabad, India:1-12.

        • Nsengiyumva N.P.
        • Mappin-Kasirer B.
        • Oxlade O.
        • et al.
        Evaluating the potential costs and impact of digital health technologies for tuberculosis treatment support.
        Eur Respir J. 2018; 521801363
        • Crowder R.
        • Kityamuwesi A.
        • Kiwanuka N.
        • et al.
        Study protocol and implementation details for a pragmatic, stepped-wedge cluster randomised trial of a digital adherence technology to facilitate tuberculosis treatment completion.
        BMJ Open. 2020; 10e039895
        • Cattamanchi A.
        • Crowder R.
        • Kityamuwesi A.
        • et al.
        Digital adherence technology for tuberculosis treatment supervision: a stepped-wedge cluster-randomized trial in Uganda.
        PLoS Med. 2021; 18e1003628
        • Bulage L.
        • Sekandi J.
        • Kigenyi O.
        • Mupere E.
        The quality of tuberculosis services in health care centres in a rural district in Uganda : the providers’ and clients’ perspective.
        Tuberc Res Treat. 2014; 2014685982
        • Patel D.
        • Berger C.A.
        • Kityamuwesi A.
        • et al.
        Iterative adaptation of a tuberculosis digital medication adherence technology to meet user needs: qualitative study of patients and health care providers using human-centered design methods.
        JMIR Form Res. 2020; 4e19270
        • Sohn H.
        • Tucker A.
        • Ferguson O.
        • Gomes I.
        • Dowdy D.
        Costing the implementation of public health interventions in resource-limited settings: a conceptual framework.
        Implement Sci. 2020; 15: 86
      6. Circular standing Instruction No. 5 of 2018 - salary structure for FY 2018/19. Republic of Uganda Ministry of Public Service.
      7. Inflation, GDP deflator (annual %) - Uganda. The World Bank.
      8. Official exchange rate (LCU per US$, period average) - Uganda. The World Bank.
        • Kakinda M.
        • Matovu J.K.B.
        A yield and cost comparison of tuberculosis contact investigation and intensified case finding in Uganda.
        PLoS One. 2020; 15e0234418
        • Muttamba W.
        • Tumwebaze R.
        • Mugenyi L.
        • et al.
        Households experiencing catastrophic costs due to tuberculosis in Uganda: magnitude and cost drivers.
        BMC Public Health. 2020; 20: 1409
        • Laurence Y.V.
        • Griffiths U.K.
        • Vassall A.
        Costs to health services and the patient of treating tuberculosis: a systematic literature review.
        Pharmacoeconomics. 2015; 33: 939-955
      9. Recommendations for investigating contacts of persons with infectious tuberculosis in low- and middle-income countries. World Health Organization.
        https://apps.who.int/iris/handle/10665/77741
        Date accessed: November 17, 2021