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Using a decision tree and a Markov model, we analyzed the ten-year cost-effectiveness of two regimens for adult MDR-TB patients from the health system’s perspective. Two regimens were used to treat a hypothetical cohort of 1,000 patients with MDR-TB who met the treatment standards[5] according to the technical Guide for Tuberculosis Prevention and Control in China (Table 1). The conventional regimen (CR) contained no Bedaquiline and lasted for 16 months. For the Bedaquiline regimen (BR), depending on the sensitivity of fluoroquinolone and previous usage of the secondary-line drug, three different treatment courses were employed [16]. There were 45% patients receiving a short-course treatment lasting nine months, whereas 30% and 25% of patients receiving a long-course treatment lasting 18 and 20 months, respectively. Once XDR-TB has developed during treatment, the recommended treatment guidelines will be adhered to.
Regimen MDR-TB treatment Portion and duration XDR-TB treatment Conventional
regimen6 ZKm(Am)Lfx(Mfx)Cs(PAS,E)Pto
/18ZLfx(Mfx)Cs(PAS,E)Pto100%;
16 months12ZCmMfxPASCs(Pto)Clr(Amx/Clv)/
18ZMfxPASCs(Pto)Clr(Amx/Clv).
30 monthsBedaquiline
regimenshort-course regimen for fluoroquinolone-sensitive
patients: [4-6BdqAmLfx(Mfx)CfzZHhighPtoE/
5Lfx(Mfx)CfzZE];45%;
9 monthsthe course duration is extended to
30 months.long-course regimen for fluoroquinolone-
sensitive patients, [6Lfx(Mfx)BdqLzd(Cs)Cfz/
12Lfx(Mfx)Cfz Lzd(Cs)]30%;
18 monthslong-course regimen for fluoroquinolone
resistance [6Bdq Lzd(Dlm)CfzCs/14Lzd(Dlm)CfzCs]25%;
20 monthsNote. MDR, Multidrug-resistant; TB, Tuberculosis; XDR, Extensively drug-resistant; Z, Pyrazinamide; Km, Kanamycin; Am, Amikacin; Cm, Capreomycin; Lfx, Levofloxacin; Mfx, Moxifloxacin; Cs, Cycloserine; PAS, Para aminosalicylic acid; E, Ethambutol; Pto, Prothionicotinamide; BDQ, Bedaquiline; Cfz, Chlorofazimin; Hhigh, High dose isoniazid; Clr, Clarithromycin; Amx/Clv, Amoxicillin/clavulanic acid; Lzd, Linezolid; Dlm, Delamani. Table 1. Treatment regimens of MDR-TB and XDR-TB patients
The simulation model computed cumulative quality-adjusted life years (QALY) and direct medical cost per capita. The ICER was computed and compared to the willingness-to-pay (WTP) threshold recommended by WHO [17] (WTP = 1× per capita GDP/QALY, 72,450 yuan/QALY in 2020)[18], although there is no official WTP threshold in China.
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On the basis of published models [7-15], a cohort-based Markov state transition model [19] was constructed to simulate the prognosis of two cohorts of MDR-TB patients treated with two regimens over ten years with a 28-day cycle length. The model’s structure consists of nine fundamental health states (Figure 1). Positive states for sputum culture(SC+) include “MDR” “XDR” “Sputum recurrence positive”“Termination of treatment” and “Palliative care”. Sputum culture negative states(SC-) include “sputum conversion” and “cure”. “Death” is an absorbing state (Figure 1).
Figure 1. Schematic Diagram of Markov Mode. MDR-TB, Multidrug-resistant tuberculosis; XDR-TB, Extensively drug-resistant tuberculosis.
The cohort initially entered the “MDR” state and received initial treatment; they may remain in the original state, develop into XDR-TB, or convert to SC(-) in each cycle. The remaining “MDR” patients would receive palliative care (identified as “treatment failure”) after the treatment course. The SC(-) patients may be related to SC(+) or XDR, and those who did not relapse until the end of treatment entered the “cure” state. Patients who relapsed to SC(+) continued the prescribed course (secondary treatment), during which they may convert to PC(-) once more, be cured, have their treatment terminated, or enter palliative care after the therapy course. Patients may relapse to PC(+) within two years after the cure, and the same treatment plan is prescribed for relapses. Meanwhile, patients with XDR may experience PC(-) and get cured after treatment or failure of treatment. Death is possible in all states. In the simulation, the objective of drug treatment was to induce sputum culture conversion (transition to sputum culture converted MDR-TB) in the patient cohort and maintain a converted state until treatment completion and assumed cure of MDR-TB.
Once converted to PC(-), patients with a history of relapse will remain PC(-) and be cured upon completion of the entire treatment. MDR and XDR infectiousness fell outside the scope of this model. It was assumed that complications and adverse reactions to treatment would not affect the health utility and cost.
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Transition Probability For CR, the sputum culture conversion rate in 0–6 months was extracted from actual Global Fund MDR-TB control program data in China[20] (6,115 MDR-TB patients from six provinces were included from 2006 to 2013). Program data from Dalian[21] and Shanghai[22] were used to determine the 12- and 24-month treatment conversion rates. The conversion rate in 0–6 months for BR was derived from the results of the first single-arm multicenter cohort study in the Chinese population in 2021[23]. Due to a lack of relevant data, we employ hazard ratios of conversion rate (BR vs. CR) in the randomized controlled trial (RCT) study to transform the 12-month and 24-month conversion rates of BR[15]. The same approaches were used to calculate secondary, conversion, and cure rates for XDR treatment. Each state’s mortality rate is determined by its spectrum culture statute. All rates were converted to probability in 4 weeks [24] (Table 2).
Parameter Based value Range Source Probability of sputum culture conversion (in 4 weeks) MDR in CR (0–6 months) 0.0873 0.0786–0.0960 MDR-TB control
program[20]MDR in CR (6–12 months) 0.0535 0.0482–0.0589 MDR-TB control
program[21]MDR in CR (12–24 months) 0.0410 0.0367–0.0451 MDR-TB control
program[22]MDR in BR (0–6 months) 0.1230 0.1107–0.1352 literature[23] Hazard Ratio Probability of Sputum conversion for relapse (Secondary vs. primary treatment) 0.540 0.30–0.95 Literature[25] Probability of Sputum conversion for XDR (XDR vs. MDR) 0.398 0.237–0.670 Literature[25] Probability of Sputum conversion for MDR within 6–24 months (BR vs. CR) 2.440 1.57–3.80 Literature[25] Probability of relapse in BR vs. CR 0.320 0.086–1.069 Literature[25] Other probability (in 4 weeks) Relapse from SC(-) 0.010 0.0091–0.0105 Literature[25] Where: relapse to XDR 0.214 0.1712–0.2354 Literature[25] Relapse after cure 0.002 0.0016–0.0022 Literature[25] MDR to XDR 0.002 0.0016–0.0022 Assuming the same
probability of
relapse after cureStopping treatment 0.006 0.0029–0.0091 Literature[26] Mortality (in 4 weeks) Cured state 0.003 0.0025–0.00384 Literature[27] Uncured states (MDR) 0.021 0.0168–0.0252 Literature[27] Uncured states (XDR) 0.027 0.0215–0.0296 Literature[27] Note. MDR, Multidrug-resistant; XDR, Extensively drug-resistant; BR, Bedaquiline regimen; CR, Conventional regimen. Table 2. Parameters of transition probability
Cost Input This study covered direct medical costs, including drug, outpatient, and hospitalization costs (including treatment monitoring and adverse reaction management). The scope of costing was in accordance with a costing program for managing MDR-TB cases by the China CDC (Table 3).
Parameters Based value Range Source Drug cost of CR (RMB, four weeks) MDR (0–6 months) 2,082.93 1,666.35–2,499.52 China CDC drug
price databaseMDR (7–24 months) 2,559.86 2,047.89–3,071.83 China CDC drug
price databaseXDR (0–18 months) 3,270.62 2,616.50–3,924.75 China CDC drug
price databaseXDR (19–32 months) 2,156.33 1,725.06–2,587.60 China CDC drug
price databaseDrug cost of BR (yuan, four weeks) Bedaquiline price (yuan/100 mg) 350.00 280.00–420.00 China CDC drug
price databaseMDR/XDR (0–6 months) Bedaquiline (0–2 weeks, 200 mg/day) 19,600.00 15,680.00–23,520.00 China CDC drug
price databaseBedaquiline (3–24 weeks, 100 mg 3 times a week) 46,200.00 36,960.00–55,440.00 China CDC drug
price databaseBackground Drugs* 4,013.28 3,210.62–4,815.93 China CDC drug
price databaseMDR/XDR (8–20 months) 2,850.229 2,280.18–3,420.28 China CDC drug
price databaseOutpatient and inpatient (yuan, four weeks) Outpatient 364.5 291.6–437.4 TB costing program[16] Hospitalization 755.78 604.62–906.94 TB costing program[16] Utility weight SC(+) state 0.51 0.41–0.61 Literature[28] SC(-) state 0.88 0.70–0.90 Literature[28] Death 0 – Literature[28] Discount rate (annual) 0.05 0.03–0.08 Literature[29] Note. *Drugs excluding Bedaquiline; MDR, Multidrug-resistant; XDR, Extensively drug-resistant; BR, Bedaquiline regimen; CR, Conventional regimen; SC(+), Sputum culture positive; SC(-), Sputum culture negative. Table 3. Parameters of cost and utility weight
The unit drug cost of a standard course for two regimes was calculated based on treatment guidelines [5]. For BR, short- and long-term unit drug costs were integrated [16]. The prices of anti-TB medications were extracted from the China CDC drug price database and through expert consultation. Moreover, the unit cost of outpatient and inpatient services (excluding anti-TB drugs) was removed from a standard costing program in 2021, which was informed by the clinical pathway of MDR-TB case management in China[16]. The outpatient cost includes bacteriological, imaging, and follow-up examination and adjuvant treatment fees, whereas hospitalization fees include hospital examination, diagnosis, and treatment (including treatment of adverse events).
Health Utility and Discount Utility weights of each health status were obtained from a study of quality of life on MDR-TB in Thailand[28], which was also referenced in economic research in Korea [12]. Both cost and health utility were discounted at 0.05 annually[29].
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Both probabilistic and deterministic sensitivity analyses were conducted following international recommendations[19]. In a one-way sensitivity analysis, model parameters, and assumptions, such as hazard ratios, transition probabilities, utility weights, discount rates, and drug costs, were varied by 20% or between the 95% confidence interval reported in the literature. To explore the price threshold of Bedaquiline, we conducted a multiple-way sensitivity analysis modifying the price of Bedaquiline in conjunction with the combined variation of top-10 parameters identified in a one-way sensitivity analysis.
A probabilistic sensitivity analysis (PSA) was also performed to estimate the joint parametric uncertainty surrounding the ICER of BR versus CR. The probabilities that BR was considered cost effective at various affordability thresholds (WTP thresholds) were calculated.
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Over a 10-year time horizon, the accumulative sputum culture conversion rate after initial treatment, cure rate, and death rate for BR were 69.88%, 61.00%, and 54.63%, respectively. Compared with CR, the conversion and cure rates for BR increased by 12.09% and 21.8%, respectively, whereas the death rate decreased by 12.8% (Table 4).
Regimen Conversion rate after primary treatment (%) Cure rate (%) Death rate (%) CR 57.79 33.45 73.80 BR 69.88 54.63 61.00 Difference 12.09 21.18 −12.80 Note. BR, Bedaquiline regimen; CR, Conventional regimen. Table 4. Health outcomes of the two regimens (10 years)
The discounted cost for BR was 137,984.25 yuan per capita, an increase of 77,716.05 yuan compared with CR, and the QALYs gained were 3.63 years per capita, an increase of 2.31 QALYs (vs. CR). Meanwhile, the ICER of BR (vs. CR) was 33,700.11 yuan/QALY (Table 5). The BR was deemed cost effective using China’s WTP of 1× per capita GDP in 2020 (WTP = 72,450 yuan/QALY) as a benchmark.
Regimen Cost per capita (yuan) Incremental cost (yuan) QALY per capita (year) Incremental QALY (year) ICER (yuan/QALY) CR 60,268.20 − 1.32 − − BR 137,984.25 77,716.05 3.63 2.31 33,700.11 Note. BR, Bedaquiline regimen; CR, Conventional regimen. ICER, Incremental cost effectiveness ratio. QALY, Quality-adjusted life years. Table 5. Results of cost-effectiveness analysis (10 years)
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In the one-way deterministic sensitivity analysis, the ICER of BR vs. CR was most sensitive to the cost of Bedaquiline, which ranged from 1,7054.70 to 4,0345.51 yuan/QALY. The other two most sensitive parameters were the health utility weight of the sputum-negative state and the discount rate (Figure 2). Results were generally stable within the variation of parameter values, and the BR’s ICERs were cost effective compared to the WTP threshold (WTP = 72,450 yuan/QALY).
In PSA, most ICER results (green dots in Figure 3) were below the WTP of 72,450 yuan/QALY, indicating that the treatment was cost effective. As WTP rises, so does the likelihood that the BR was cost effective. When WTP reached 72,450 yuan/QALY, there was a 99.6% possibility that the Bedaquiline scheme would be cost-effective (Figure 4).
Figure 3. Scatter plot of ICER results of PSA. ICER, incremental cost effectiveness ratio. PSA, probabilistic sensitivity analysis. QALY, quality-adjusted life years.
In the threshold analysis, when the price of Bedaquiline fell to or below 57.21 yuan/tablet (100 mg) (Figure 5), the BR became superior to the CR, meaning it gained more QALY with the same or less cost per capita.
Cost-Effectiveness Analysis of Combined Chemotherapy Regimen Containing Bedaquiline in the Treatment of Multidrug-Resistant Tuberculosis in China
doi: 10.3967/bes2023.061
- Received Date: 2022-08-10
- Accepted Date: 2022-11-28
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Key words:
- Bedaquiline /
- Cost-effectiveness /
- Multidrug-resistant tuberculosis /
- China
Abstract:
Citation: | XU Cai Hong, QIU Ying Peng, HE Zi Long, HU Dong Mei, YUE Xiao, CHEN Zhong Dan, XU Yuan Yuan, ZHAO Yan Lin. Cost-Effectiveness Analysis of Combined Chemotherapy Regimen Containing Bedaquiline in the Treatment of Multidrug-Resistant Tuberculosis in China[J]. Biomedical and Environmental Sciences, 2023, 36(6): 501-509. doi: 10.3967/bes2023.061 |