High use of private providers for first healthcare seeking by drug-resistant tuberculosis patients: a cross-sectional study in Yangon, Myanmar.

BACKGROUND: Drug resistance is a growing challenge to tuberculosis (TB) control worldwide, but particularly salient to countries such as Myanmar, where the health system is fragmented across the public and private sector. A recent systematic review has identified a critical lack of evidence for local policymaking, particularly in relation to drivers of drug-resistance that could be the target of preventative efforts. To address this gap from a health systems perspective, our study investigates the healthcare-seeking behavior and preferences of recently diagnosed patients with drug-resistant tuberculosis (DR-TB), focusing on the use of private versus public healthcare providers. METHODS: The study was conducted in ten townships across Yangon with high DR-TB burden. Patients newly-diagnosed with DR-TB by GeneXpert were enrolled, and data on healthcare-seeking behavior and socio-economic characteristics were collected from patient records and interviews. A descriptive analysis of healthcare-seeking behavior was followed by the investigation of relationships between socio-economic factors and type of provider visited upon first feeling unwell, through univariate logistic regressions. RESULTS: Of 202 participants, only 8% reported first seeking care at public facilities, while 88% reported seeking care at private facilities upon first feeling unwell. Participants aged 25-34 (Odds Ratio = 0.33 [0.12-0.95]) and males (Odds Ratio = 0.39 [0.20-0.75]) were less likely to visit a private clinic or hospital than those aged 18-24 and females, respectively. In contrast, participants with higher income were more likely to utilize private providers. Prior to DR-TB diagnosis, 86% of participants took medications from private providers. After DR-TB diagnosis, only 7% of participants continued to take medications from private providers. CONCLUSION: In urban Myanmar, most patients shifted to being managed exclusively in the public sector after being formally diagnosed with DR-TB. However, since the vast majority of DR-TB patients first visited private providers in the period leading to diagnosis, related issues such as unregulated quality of care, potential delays to diagnosis, and lack of care continuity may greatly influence the emergence of drug-resistance. A greater understanding of the health system and these healthcare-seeking behaviors may simultaneously strengthen TB control programmes and reduce government and out-of-pocket expenditures on the management of DR-TB

Evaluating the cost-effectiveness of lifestyle modification versus metformin therapy for the prevention of diabetes in Singapore.

BACKGROUND: In Singapore, as diabetes is an increasingly important public health issue, the cost-effectiveness of pursuing lifestyle modification programs and/or alternative prevention strategies is of critical importance for policymakers. While the US Diabetes Prevention Program (DPP) compared weight loss through lifestyle modification with oral treatment of diabetes drug metformin to prevent/delay the onset of type 2 diabetes in pre-diabetic subjects, no data on either the actual or potential cost effectiveness of such a program is available for East or South-east Asian populations. This study estimates the 3-year cost-effectiveness of lifestyle modification and metformin among pre-diabetic subjects from a Singapore health system and societal perspective. METHODOLOGY: Cost effectiveness was analysed from 2010-2012 using a decision-based model to estimate the rates of getting diabetes, healthcare costs and health-related quality of life. Cost per quality-adjusted life year (QALY) was estimated using costs relevant to the time horizon of the study from Singapore. All costs are expressed in 2012 US dollars. PRINCIPAL FINDINGS: The total economic cost for non-diabetic subjects from the societal perspective was US$25,867, US$28,108 and US$26,177 for placebo, lifestyle modification and metformin intervention respectively. For diabetic patients, the total economic cost from the societal perspective was US$32,921, US$35,163 and US$33,232 for placebo, lifestyle modification and metformin intervention respectively. Lifestyle modification relative to placebo is likely to be associated with an incremental cost per QALY gained at US$36,663 while that of metformin intervention is likely to be US$6,367 from a societal perspective. CONCLUSION: Based on adaptation of the DPP data to local conditions, both lifestyle modification and metformin intervention are likely to be cost-effective and worth implementing in Singapore to prevent or delay the onset of type 2 diabetes. However, the cost of lifestyle modification from the societal perspective would have to be reduced in order to match the cost-effectiveness of metformin intervention

Two-way sensitivity analysis of the effectiveness between metformin intervention and lifestyle modification from health system perspective.

<p>QALY: quality adjusted life years.</p><p>Two-way sensitivity analysis of the effectiveness between metformin intervention and lifestyle modification from health system perspective.</p

Breakdown of cost among individuals with and without diabetes from base-case analysis (in 2012US$).

<p>Breakdown of cost among individuals with and without diabetes from base-case analysis (in 2012US$).</p

One-way sensitivity analysis of lifestyle modification’s effectiveness.

<p>QALY: quality adjusted life years; ICER: incremental cost-effectiveness ratio (in 2012US$ per QALY).</p><p>One-way sensitivity analysis of lifestyle modification’s effectiveness.</p

Model input parameters for 3 years.

<p>NGR: normal glucose regulation.</p><p>* Linear extrapolation used.</p>†<p> Health system perspective = total direct medical cost = intervention+care outside DPP.</p>‡<p> Societal perspective = total direct medical cost+direct nonmedical cost+indirect cost.</p><p>Model input parameters for 3 years.</p

Two-way sensitivity analysis of the effectiveness between metformin intervention and lifestyle modification from societal perspective.

<p>QALY: quality adjusted life years.</p><p>Two-way sensitivity analysis of the effectiveness between metformin intervention and lifestyle modification from societal perspective.</p

Base-case cost-effectiveness analysis with deterministic sensitivity analysis from a health system perspective.

<p>QALY: quality adjusted life years; ICER: incremental cost-effectiveness ratio (in 2012US$ per QALY).</p><p>* Baseline+a ratio of 2.3 for direct cost of diabetic to non-diabetic medical care expense.</p><p>Base-case cost-effectiveness analysis with deterministic sensitivity analysis from a health system perspective.</p

3-year decision tree for comparing cost-effectiveness of alternative interventions for a pre-diabetic subject.

<p>3-year decision tree for comparing cost-effectiveness of alternative interventions for a pre-diabetic subject.</p