台灣肺結核都治計畫的成本及成本效果分析

Costs and Cost Effectiveness of Directly Observed Therapy Short-Course (DOTS) for Pulmonary Tuberculosis in Taiwan

目的：本研究目的在於探討台灣對於肺結核實施社區關懷員都治計畫的成本效果評估。方法：我們自疾病管制局結核病資料庫分析2005年沒有實施都治計畫的肺結核病人及2006有參與都治計畫的肺結核病人追蹤12個月。運用決策樹分析都治計畫對肺結核個案的成本效果，以及以馬可夫決策模式推估實施都治計畫對一群40至44歲的5,000位結核病人族群，其十年及終生（約三十年）的影響。本研究以社會觀點討論，折現值採3%。結果：比較2005年沒有實施都治計畫的肺結核病人及2006有參與都治計畫的肺結核病人，發現參與都治計畫的肺結核病人有較高的成功率（80.26% vs 69.27%）以及較低的死亡率（14.58% vs 26.44%）。成本效果分析亦顯示都治計畫的實施不僅成本較低，且效果較高，成本效果比為111,991元，明顯優於沒有實施都治計畫的成本效果比143,349元。對這群40至44歲的5,000位開放性肺結核病人族群，實施都治計畫可增加550位治療成功，減少593位死亡，並且一年可節省47,246,625.5元。馬可夫決策模式估計都治計畫對結核病族群的影響，不論十年、二十年及三十年，因為都治計畫的實施，總成本都比較低，且隨著都治計畫參與率越高，總成本越低。再者，治療成功及且持續緩解的人數也隨著都治計畫參與率越高而增加。結核病死亡的人數也隨著都治計畫參與率越高而降低。結論：台灣實施都治計畫是一符合成本效果的好政策。

Objectives. The aim of the study was to explore the cost effectiveness of the Directly Observed Therapy Short-Course (DOTS) for pulmonary tuberculosis (TB) by community health workers in Taiwan. Methods. We analyzed TB cases treated in 2005 and in 2006 who had been followed up for 12 months from Taiwan's National TB computer registry database. The study further evaluated the cost effectiveness of the DOTS program by using decision analysis, and estimated the impact of DOTS program on a hypothetic TB cohort for 10 years and lifetime using Markov simulation model. Discount rate was introduced by 3% and cost evaluation was adopted from societal perspectives. Results. Comparing the treatment outcome of infectious TB patients in 2005 and in 2006, the DOTS treatment success rate was higher than that of non-DOTS (80.26% vs 69.27%) and the mortality rate on DOTS was lower than that on non-DOTS (14.58% vs 26.44%). Moreover, DOTS strategy was more cost effective than non-DOTS strategy. The average cost-effectiveness ratio on DOTS strategy was calculated to be 111,991 NTD per treatment success, which is lower than 143,349 NTD per treatment success on non-DOTS. Based on hypothetic cohort of 5000 with infectious TB, implementing DOTS can increase treatment success by 550 persons and decrease deaths by 593. The use of DOTS can save 47,246,625.5 NTD a year. Markov simulation model displayed that the overall costs of implementing DOTS were lower than that of non-DOTS. Moreover, overall costs were progressively lowered by increasing participation rate in DOTS for 10, 20 and 30 years. Furthermore, the number of TB deaths after the implementation of a DOTS program was lower than that of a non-DOTS program. In addition, the number of TB treatment successes and remissions became higher as participation rate in DOTS increased for 10, 20 and 30 years. Conclusions. The DOTS program implemented in Taiwan seems cost effective.