tb health systems research prof richard coker

TB Health Systems Research

Prof Richard Coker

1-2 August 2013

NTPs University of Public Health, Yangon

MDRTB epidemic in New York City, 1989-93

• Overcrowding • Homelessness • Criminal justice• HIV • Unemployment• Financial probs • Dysfunctional HS

Cost of case management. Samara, Russia

Costs are spread across a number of years starting from treatment and shifting to managing chronic and social conditions

Costs are driven by hospitalisation, both for BK+ and BK- cases.

Bed days in all TB facilities & TB beds (r= 0.99; P<0.0001)

Seasonality of admission and discharge

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Hospitals admit more patients in the cold seasons and discharge patients in spring and in summer months. The unusual prevailing discharge in Decembers is related to the retrospective payment system

Coker, Atun, McKee. Hlth Sys and the Challenge of CD. 2008

Financing

Organisational arrangements

Resource allocation

Provision

Equity (access and coverage)

Choice

Efficiency

Effectiveness

Health

Financial risk protection

Consumer satisfaction

Levers Intermediate goals Goals

Socio-demographic Technological

Economic Political

The External Context

Coker et al. Int J Health Plann Mgmt 2004

Output (O),completion of

treatment courses

Regularity (R)e.g. patient adherence to

treatment (i.e. DOT component of DOTS)

Mechanism (M),e.g. visiting nurses,

CCT, other incentives

Context (C)

Input (I) e.g. smear positive

cases of TB

Overall project design

Case-control study with

nested cohort

Economic analysis

Gender analysis

Situational Analysis

• Study will commence with initial situational analysis

• Characterize health system, programs and other relevant environmental factors in both country settings

• Provide common grounding framework and input to all three study components with an emphasis on understanding incentives at patient, community and health system level

Gender dimensions of TB susceptibility, detection, and outcomes

TB Control in Myanmar & Yunnan Province, China


Background

TB is certainly a gender-biased, and is probably a sex-biased, infection…there

is a need for such differences to be incorporated into models for TB

control and forecasting

“ “

(Rhines 2013: 106)

Background

(WHO 2012)

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male:female ratios for newly notified TB (high-burden countries , 2011)

Background

Genuine differences in infection rates?

Artefact of reporting?

Research Design

Biological mechanisms may actually account for a significant part of the

difference between male and female susceptibility to TB

(Neyrolles et al 2009: 1)

“ “Possible role for hormones, sex-related genetic background / genetic regulations, metabolism, anatomy of upper airway / respiratory tract

Research Design

You see, only bad women have this disease. . . . Those who drink, smoke, and

have illicit relations with men. . . Community needs to boycott them completely as a form

of punishment for their doing.

(Basu Khan 2011: 8)

““

Research Design

RQ1Research Design: RQ’s

What differences are observed in the recorded occurrence of TB infection among men and women (disaggregated by age) in the study settings? Do these differences vary among the wider population and the pre-identified “at risk groups”?


Do the gender roles and relations dominant in the study settings differentiate men’s and women’s risks of exposure to, and potentially of transmission of, TB (disaggregated by age and attendant to pre-identified risk groups)?


Do the gender roles and relations dominant in the study settings differentiate men’s and women’s ability to access effective diagnostics and sustained treatment for TB (disaggregated by age and attendant to pre-identified risk groups)?


Is social stigma of TB gender-differentiated in the study settings? What effects does stigma have for men’s and women’s ability to access and maintain effective TB treatment?


How is gender acknowledged and operationalised in existing education and outreach programmes intended to prevent and / or encourage treatment for TB infection?

Research Design

Analysis at patient, community, healthcare provider and health system levels

• Routine secondary data

• Carefully designed micro-level survey

• Detailed field study

Two study rounds: 2013/4 and 2015, 6 to 8 weeks

Research Design

Survey module within cohort studyi) Household demographics and individual characteristics ii) Perceptions and experiences of access to, and utilisation of, healthcare

iii) Direct and / or indirect experiences of TB symptoms / infection / testing / diagnosis / treatment / and out-reach programmes

iv) Perceptions of the causes of disease (including TB and HIV) and the types of people perceived as most at risk

v) Attitudes about wider gender roles and relations

Research Design

Qualitative narrative analysis of individual attitudes and social norms regarding TB

Organised around primary data from semi-structured interviews (n = 40), informal group discussions (n = 10), and participant observation in a variety of key settings

ECONOMIC EVALUATION


Background

• Economic evaluation is important for resource allocation decisions

• However, very little economic evaluation of MDR-TB treatment– WHO GRADE evidence on economic evaluation of MDR-TB :“extremely low”– Fitzpatrick and Floyd(2010) systematic review : only 4 relevant/admissible studies

• Different country settings / program models /timeframes/costs (Estonia, Peru, Russia & the Philippines)

• Existing cases/ extrapolation to others suggests that treatment programs can generally be cost-effective– Cost per DALY estimates $143 - $745 in 2005 USD

• Larger issues:– Need to consider interactions between TB, MDR-TB and HIV transmission, which affects

outcome/cost dimensions over sustained period of time – The role of transmission (elimination, containment, mitigation, over what period?)

Understanding costs

• Country-level data collection– Primary data collection

• Nested cohort study within case-control study for outcomes and service utilization

– Secondary data collection• Expenditure records, interviews with staff and patients,

project records and databases, and the GLC secretariat.

• Literature / assumptions where needed

Proposed Approach

• Outcomes for individual patients– Conversion– Cure– Default– TB and TB-related death rates– HIV-related death rates

• Costs– Individual utilization

• Drugs• Hospital stays• Outpatient services• Laboratory/diagnostic tests• Nutritional/livelihood support • Others

– Specific to program• Program management / administration• Training and technical assistance costs• Vehicles/equipment/ facilities• Advocacy • Others

I: Costs and Outcomes Measurement for Nested Cohort

Descriptive analysis of cost and outcome

dynamics over the study period

Proposed Approach

• Parameterize and calibrate an already published DSTB-MDRTB-HIV model to match existing data or best possible estimates in pre-program period.– Model employs a systems dynamics methodology to account for

interacting variables, interconnected feedback loops involving time delays and non-linear relationships

– Explicitly defines states of prevention, detection, treatment• Project incidence, cure and death rates and DALYS forward for study

horizon for treatment population to generate a base case of “no program”

• Compute cost per death averted/DALY estimates for the program relative to “no program”

• Conduct uncertainty analysis

II: Economic Evaluation

Example of model subsystemMDR TB Transmission

Proposed Approach

Questions to be answered could include• What is the most effective way to allocate a set amount

of funding?– Which % allocation(s) can generate the most deaths

averted? • What is the marginal impact of additional funding?

– How does the maximum potential level of deaths averted vary as the total amount of funding increases?

III: Scenario Analysis

Risk factors for MDR TB in Myanmar: A case-control study


Background

WHO estimates 9,000 MDR-TB cases occur each year, with 1,200 receiving treatment in 2012. • Recent publications have identified several risk factors for MDR

TB in high-risk countries including:– Previous TB treatment– Irregular treatment– Female sex– Non-permanent residents– Urban migration– Alcoholism– Smoking

— Urban residence— Frequent travellers— Younger age— Lack of a sewage system

in the home— HIV status— Lung cavities

Background

A recent case-control study in China showed MDR-TB was independently associated with similar risk factors including retreatment for TB, however it also suggested other factors including:

— Beijing genotype — Symptoms lasting >3 months before first evaluation at the hospital — lack of health insurance

A cross sectional study in Myanmar (2002) showed statistically significant increased odds of MDR TB among previously treated patientsCases also tended to be male and in younger age-groups, although these associations were not statistically significant

Research Questions

What factors are associated with MDR-TB infection in patients previously treated for TB?What factors are associated with MDR-TB infection in patients never before treated for TB?Are risk factors disproportionately distributed between men and women?

Sampling Approach

Study sites: - Clinics in and around Yangon

Cases and controls identified through the NTP:• Cases with MDRTB (previously treated for TB)• Cases with MDRTB (not previously treated)• Controls : drug sensitive TB cases

– Randomly selected from database?– Or time-matched cases e.g. presenting at the clinic in the

same week?

Sampling Approach

9,000 new MDR-TB Cases

1,200 MDR-TB Cases On Treatment

Previously treated MDR-TB Cases

Not previously treated

MDR-TB Cases

Drug Sensitive Controls

400 MDR-TB Cases presenting in and around Yangon

*Data from WHO, 2012. NTP data to inform this?

Non-TB Controls?

Sampling Approach

Recruited cases and controls will be administered a questionnaire to collect socio-economic and epidemiological variables- A subset of cases and controls will be followed up prospectively to collect costing data

Logistic regression analysis will then be carried out to compare new MDR TB case-patients, previously treated MDR TB case-patients, and non-TB controls to identify factors associated with MDR TB.

Additional Analysis?

Samples will be saved on both host and pathogens to be typed by the Genome Institute in Singapore.Would allow investigation of:- Genotype clustering- Virulence factors- Host susceptibility

Discussion

tb health systems research prof richard coker

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