Cost-effectiveness of community health worker versus home-based guardians for directly observed treatment of tuberculosis in Vitória, Espírito Santo State, Brazil Custo-efetividade dos agentes comunitários de saúde versus supervisores domiciliares

The objective of this study was to compare the costs and outcomes associated with guardiansupervised directly observed treatment relative to the standard of care Directly Observed Therapy, Short Course (DOTS) provided by community health workers (CHW). New cases of culturepositive pulmonary tuberculosis (TB) treated in Vitória, Espírito Santo State, Brazil, between January 2005 and December 2006 were interviewed and chose their preferred treatment strategy. Costs incurred by providers and patients (and patients’ families) were estimated, and cost-effectiveness was assessed by comparing costs per successfully treated patient. 130 patients were included in the study; 84 chose CHW-supervised DOTS and 46 chose guardian-supervised DOTS. 45 of 46 (98%) patients treated with guardian-supervised DOTS were cured or completed treatment compared to 70/84 (83%) of the CHW-supervised patients (p = 0.01). Logistic regression showed only the strategy of supervision to be a significant association with treatment outcome, with guardian-supervised care strongly protective. Cost per patient treated with guardian-supervised DOTS was US$398, compared to US$548 for CHW-supervised DOTS. The guardian-supervised DOTS is an attractive option to complement CHW-supervised DOTS. Tuberculosis; Cost-Benefit Analysis; Effectiveness Introduction Tuberculosis (TB) is a serious public health problem, especially in developing countries. Brazil occupies the 16th position among the 22 high-burden countries that comprise 80% of the estimated cases in the world 1. The primary TB control policy endorsed by the World Health Organization (WHO) and the International Union against Tuberculosis and Lung Disease is DOTS (Directly Observed Therapy, Short-Course). The DOTS includes five elements. Among them, directly observed treatment is a key component. Current technical manuals define directly observed treatment as direct supervision of medication ingestion by a treatment supporter who is acceptable and accountable to the patient and to the health system 2. The treatment supporter could be a heath professional, community health worker, or a family member 2,3,4,5. There is evidence to support the effectiveness of the overall DOTS strategy and direct observation of treatment from a number of observation studies 6,7,8,9. However, a systematic review 10 of the evidence for direct observation from randomized controlled trials found that although one trial 11 demonstrated significant improvements in cure and treatment, two other trials found similar outcomes for directly observed and self administered patient treatment groups 12,13. Furthermore, directly observed treatment incurs considerable costs to the patient for direct 944 ARTIGO ARTICLE TWO STRATEGIES FOR TUBERCULOSIS CONTROL 945 Cad. Saúde Pública, Rio de Janeiro, 27(5):944-952, mai, 2011 observation 14 and requires considerable healthcare resources, particularly in countries where the prevalence of TB is high. Although there is by no means a consensus, some observational studies and clinical trials 3,4,5,15 have shown that treatment completion rates were significantly greater when treatment was supervised by a family member, compared to supervision by health professionals. In a controlled trial in Nepal, treatment supervision by family members was as effective as treatment supervised by health professionals 4. In Brazil, two observational studies evaluated the use of family members as directly observed treatment supervisors suggested that the strategy was effective, feasible, and affordable 5,15,16,17. Other studies worldwide found that community health supervision of TB patients have been piloted in a variety of settings with successful results in cure rate 18,19,20,21,22,23. Efforts to expand directly observed treatment to more health facilities have been limited by scarce resources and understaffing, making it a high priority to identify new approaches to directly observed treatment that maintain effectiveness and utilize fewer resources. One such approach could be training home supervisors (guardian-supervised) to provide directly observed treatment. However, little is known about the cost-effectiveness of this option in Brazil. Comparing the costs and outcomes of guardiansupervised directly observed treatment to those associated with the standard of care may assist policy makers in decision-making and in the rational allocation of scarce health resources. We conducted this study to compare the costs and outcomes associated with community health worker (CHW)-supervised and guardian-supervised directly observed treatment in Vitória, the capital of the state of Espírito Santo, Brazil.