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

Ryan R Thompson; Alex Kityamuwesi; Alice Kuan; Denis Oyuku; Austin Tucker; Olivia Ferguson; Lynn Kunihira Tinka; Rebecca Crowder; Stavia Turyahabwe; Adithya Cattamanchi; David W Dowdy; Achilles Katamba; Hojoon Sohn

doi:10.1016/j.jval.2021.12.002

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

Value Health. 2022 Jun;25(6):924-930. doi: 10.1016/j.jval.2021.12.002. Epub 2022 Jan 6.

Authors

Affiliations

¹ Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
² Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda.
³ Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
⁴ Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA.
⁵ Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA.
⁶ Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda; National Tuberculosis and Leprosy Program, Uganda Ministry of Health, Kampala, Uganda.
⁷ 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.
⁸ Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda.
⁹ Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda; Clinical Epidemiology and Biostatistics Unit, Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.
¹⁰ Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. Electronic address: hsohn6@jhu.edu.

PMID: 35667781
DOI: 10.1016/j.jval.2021.12.002

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: 99DOTS; cost analysis; cost-effectiveness analysis; digital adherence technology; tuberculosis.

Publication types

Randomized Controlled Trial
Research Support, Non-U.S. Gov't

MeSH terms

Budgets
Cost-Benefit Analysis
Humans
Technology
Tuberculosis* / drug therapy
Uganda