Cost-effectiveness of various tuberculosis control strategies in Thailand.

OBJECTIVE To evaluate the cost-effectiveness of different tuberculosis control strategies in Thailand. METHODS Different tuberculosis control strategies, which included health-worker, community-member, and family-member directly observed treatment (DOT) and a mobile phone "contact-reminder" system, were compared with self-administered treatment (SAT). Cost-effectiveness analysis was undertaken by using a decision tree model. Costs (2005 international dollars [I$]) were calculated on the basis of treatment periods and treatment outcomes. Health outcomes were estimated over the lifetime of smear-positive pulmonary tuberculosis patients in disability-adjusted life years (DALYs) averted on the basis of Thai evidence on the efficacy of the selected strategies. RESULTS Cost-effectiveness results indicate no preference for any strategy. The uncertainty ranges surrounding the health benefits were wide, including a sizeable probability that SAT could lead to more health gain than DOT strategies. The health gain for family-member DOT was 9400 DALYs (95% uncertainty interval -7200 to 25,000), for community-member DOT was 13,000 DALYs (95% uncertainty interval -21,000 to 37,000), and for health-worker DOT was 7900 DALYs (95% uncertainty interval -50,000 to 43,000). There were cost savings (from less multi-drug resistant tuberculosis treatment) associated with family-member DOT (-I$9 million [95% uncertainty interval -I$12 million to -I$5 million]) because the trial treatment failure rate was significantly lower than that for SAT. The mobile phone reminder system was not cost-effective, because the mortality rate associated with it was much higher than that associated with other treatment strategies. CONCLUSIONS Because of the large uncertainty intervals around health gain for DOT strategies, it remains inconclusive whether DOT strategies are more cost-effective than SAT. It is evident, however, that family-member DOT is a cost-saving intervention.