**2. Costs of health system of Brazil**

Takahashi et al. 2008; Rosen, Taylor et al. 2010; Shi, Hodges et al. 2010; Vassall, van Kampen et al. 2011; Fitzpatrick and Floyd 2012; Lienhardt, Raviglione et al. 2012; Manda‐ lakas, Hesseling et al. 2012). In a recent study we compared the cost-effectiveness of di‐ rect microscopy by Ziehl Neelsen staining (AFB smear) with *in house* polymerase chain reaction (PCR) and with culture on the first sputum specimen collection, including staff costs, using culture and clinical evaluation as the gold standard (Scherer, Sperhacke et al. 2009). In contrast to the cost-effectiveness analysis described by van Cleef et al. in a ref‐ erence ambulatory clinic in Kenya, where only culture for mycobacteria was used as the gold standard (Roos, van Cleeff et al. 1998; van Cleeff, Kivihya-Ndugga et al. 2005). The cost-effectiveness of the AFB smear plus PCR dot-blot strategy described in recent study was similar to other strategies, when lower TB prevalence made PCR more expensive for diagnosis of PTB (Roos, van Cleeff et al. 1998; van Cleeff, Kivihya-Ndugga et al. 2005).

The mathematical models may be particularly useful for predicting the long term tenden‐ cy of occurrence of the infection or disease. These models can simulate situations epide‐ miological and preventive or curative interventions beyond their theoretical impact in reducing the problem. Such predictive models properly formulated and fed with consis‐ tent data, may assist the processes of planning and management in public health. Cur‐ rently several strategies have allowed the use of Multiple Logistic Regression (MLR) in the construction of predictive models. Models of decisions trees are also used for classifi‐ cation decision making or to provide a decision algorithm for the clinical management of

For developing countries, the emergence of continuous technological innovation represents a double burden. The rapid diffusion of scientific and technical information that are ob‐ served now and monetary action multinational companies create a local demand for innova‐ tion by health professionals, the media and more informed portions of the population,

Many factors limit the realization of a health technology assessment (HTA) analysis, as the lack of human resources, infrastructure or budget or due to lack of evidence or infor‐

Another obvious problem is that often decisions are based on scientific evidence coming from developed countries and often in settings where the incidence of disease differs effu‐

Given this scenario health managers are often between two objectives: they have to in‐ corporate new and more costly technologies to improve the health of the population and at the same time are responsible for the financial sustainability and access equity of this

Beyond the suffering caused directly by the disease, TB is requiring significant portions of the public budget in developing countries. It is estimated that by 2015 they will be required investments around \$12 billion for control of diseases such as AIDS, TB and Malaria. The increased costs involved in care and control of TB are due also to the increasing number of

(Scherer et. aL., 2009).

432 Tuberculosis - Current Issues in Diagnosis and Management

mation costs.

infectious diseases.(Aguiar, Almeida et al. 2012)

which further strains the health care system.

sively of Brazilian and Latin American scenario.

in the system health.(Project 2005)

In order to describe the costs of Health system of Brazil, we evaluate the costs directs of di‐ agnosis and treatment of screening of 1000 hypothetical patients suspects of Pulmonary Tu‐ berculosis in according with clinical and laboratory Brazilian recommendations for treatment (Tuberculose 2004; Conde, Melo et al. 2009).

The cost components for each clinical and laboratory procedures of screening included costs incurred by the patient, laboratory costs, drugs, consumables and equipment costs. The strategy for screening was the same recommended for Brazilian Public Health System.

Clinical, radiological and laboratory staff costs were calculated from the salary base of Rio Grande do Sul (State of Extreme South of Brazi) in 2011.

For each procedure, costs were attributed based on procedure costs of the Brazilian Public Health System.

Running costs (material costs were used for each 1000 tests evaluated) included all laborato‐ ry materials used in procedures.

All costs were expressed in US\$, using an exchange rate of US\$ 1= R\$ 1,72 (REAIS), the aver‐ age exchange rate from 2010 to 2011. In the treatment costs, those were evaluated related to the treatment of inpatients and outpatients. To estimate the values that are spent by the pub‐ lic health system of Brazil with the monitoring and control of TB in a hospital and an outpa‐ tient unit, we simulated two different scenarios:

Table 1A shows the costs at the health service level and Table 1B shows costs due to labora‐ tory investment. The AFB smear plus Culture require (US\$ 39,535) for equipment. Table 1C

> Staff Cost per day (US\$)

Economic Evaluation of Diagnosis Tuberculosis in Hospital Setting

Running costs per 1000 suspects (US\$)

2 16,151 67 30

AFB smear plus Culture (US\$) (outpatients and inpatients) Time spent until access to result (days)

http://dx.doi.org/10.5772/54479

435

Running costs per examination (US\$)

Salaries of all staff per year (US\$)

> Annualization Years

Culturea 39,535 <sup>5</sup> 12,507 12.50

b Income loss of patients was calculated from monthly salary base of Brazil (US\$207) and was based on proportional days spent by patients until access to the result of each laboratory procedure. Patient costs were estimated using the average of two visits to the laboratory for AFB smear and culture procedures for outpatients; Travel cost was consid‐ ered as US\$ 1.4 (one bus ticket ). Food was considered as US\$ 10 per meal. Base salary in Brazil was considered (US\$ 10 per day /20 days of the work). For inpatients was considered just income loss; Staff costs in the laboratory were based on proportional days spent on each laboratory procedure; Costs of consumables and equipment were provided by the

We annualized the capital cost of the equipment for 5 years, according to the literature [25].

Building costs were not included. Opportunity costs were not applicable.

**C. Estimated costs incurred by patients, including costs for travel, food and income lossd**

shows costs incurred by patients.

Staff Number

Equipment (US\$)

Travel 1,390 Food 10,000 Income Lossc 310,000

Total patients Cost 341,000

**Table 1.** Estimative of Costs in US\$ in Tuberculosis Diagnosis in Brazil

program as well as by the manufacturer.

Microscopic and Laminar Flow Cabinets,;. Other equipments were not included,

**A. Health service costs**

AFB smear plus Culture

AFB smear plus

a

**B. Laboratory costs**


The number of days considered to calculate the costs related to the treatment of inpatients they were considered as the same days that were spent in laboratory procedure.

It was hypothesized that the time to detect *Mycobacterium tuberculosis* in sputum culture from patients with pulmonary tuberculosis may be a better indicator for the duration of time of hospitalization(Ritchie, Harrison et al. 2007).

The time to detect *M. tuberculosis* in the culture was 30 days in this study. This cohort is the same as previous published by our group [20]. This value was used as the standard at which release from isolation could be permitted (Scherer, Sperhacke et al. 2007)

The time spent on laboratory procedure to provide access to the result of the laboratory technique was assumed to be 30 days for AFB smear plus culture. The number of days con‐ sidered to calculate costs was the same as those spent on laboratory procedure. The number of days considered to calculate the cost of patient travel costs was assumed to be 2 days for AFB smear plus culture.

Total treatment included clinical officer and hospital costs, assuming cost per pill, to be US\$ 0.22, using 3 pills per day, during 180 days; hospital room costs, US\$ 7/day; costs with salary of clinical staff and clinical consultation, US\$ 2.52 per patient and clinical nursing consulta‐ tion, US\$ 2.52 per patient.

Assuming that, during the treatment (6 months), in ambulatory situation, 6 AFB smear test, 6 chest radiographs, 6 consult of nurse and 2 consult of clinical were performed, we used this parameters to estimate the costs of ambulatory following the Brazilian recommenda‐ tions for treatment (Tuberculose 2004).

Assuming that, during the hospitalization (30 days), 4 AFB smear tests, 4 chest radio‐ graphs, 30 nurse and physician consultations were performed, we used these parameters to estimate the costs of inpatient assistance in hospital, following the Brazilian recom‐ mendations for treatment (Tuberculose 2004; Conde, Melo et al. 2009). Staff salaries for the physician, nurse and radiologist were considered to be US\$ 11,163 per year, and for the chest radiograph technician, the salary was US\$ 4,988 per year. The work days were considered 20 days for all staff.

The days of admission to the hospital were considered to be the same number of days spent on each laboratory procedure. All estimated costs reflect an estimative of the public health system of Brazil expenses with the monitoring and control of TB.

The costs were expressed per 1000 suspects, according to the specific bibliographic refer‐ ences for economic analyses, thus, allowing the best decision for investment to be made (Petitti 2000).

Table 1A shows the costs at the health service level and Table 1B shows costs due to labora‐ tory investment. The AFB smear plus Culture require (US\$ 39,535) for equipment. Table 1C shows costs incurred by patients.

the treatment of inpatients and outpatients. To estimate the values that are spent by the pub‐ lic health system of Brazil with the monitoring and control of TB in a hospital and an outpa‐

The number of days considered to calculate the costs related to the treatment of inpatients

It was hypothesized that the time to detect *Mycobacterium tuberculosis* in sputum culture from patients with pulmonary tuberculosis may be a better indicator for the duration of time

The time to detect *M. tuberculosis* in the culture was 30 days in this study. This cohort is the same as previous published by our group [20]. This value was used as the standard at which

The time spent on laboratory procedure to provide access to the result of the laboratory technique was assumed to be 30 days for AFB smear plus culture. The number of days con‐ sidered to calculate costs was the same as those spent on laboratory procedure. The number of days considered to calculate the cost of patient travel costs was assumed to be 2 days for

Total treatment included clinical officer and hospital costs, assuming cost per pill, to be US\$ 0.22, using 3 pills per day, during 180 days; hospital room costs, US\$ 7/day; costs with salary of clinical staff and clinical consultation, US\$ 2.52 per patient and clinical nursing consulta‐

Assuming that, during the treatment (6 months), in ambulatory situation, 6 AFB smear test, 6 chest radiographs, 6 consult of nurse and 2 consult of clinical were performed, we used this parameters to estimate the costs of ambulatory following the Brazilian recommenda‐

Assuming that, during the hospitalization (30 days), 4 AFB smear tests, 4 chest radio‐ graphs, 30 nurse and physician consultations were performed, we used these parameters to estimate the costs of inpatient assistance in hospital, following the Brazilian recom‐ mendations for treatment (Tuberculose 2004; Conde, Melo et al. 2009). Staff salaries for the physician, nurse and radiologist were considered to be US\$ 11,163 per year, and for the chest radiograph technician, the salary was US\$ 4,988 per year. The work days were

The days of admission to the hospital were considered to be the same number of days spent on each laboratory procedure. All estimated costs reflect an estimative of the public health

The costs were expressed per 1000 suspects, according to the specific bibliographic refer‐ ences for economic analyses, thus, allowing the best decision for investment to be made

system of Brazil expenses with the monitoring and control of TB.

they were considered as the same days that were spent in laboratory procedure.

release from isolation could be permitted (Scherer, Sperhacke et al. 2007)

tient unit, we simulated two different scenarios:

434 Tuberculosis - Current Issues in Diagnosis and Management

of hospitalization(Ritchie, Harrison et al. 2007).

AFB smear plus culture.

tion, US\$ 2.52 per patient.

tions for treatment (Tuberculose 2004).

considered 20 days for all staff.

(Petitti 2000).

**a.** TB cases diagnosed in hospital wards (hospitalized patients) **b.** TB cases diagnosed in outpatient environment (outpatients).



a Microscopic and Laminar Flow Cabinets,;. Other equipments were not included,

b Income loss of patients was calculated from monthly salary base of Brazil (US\$207) and was based on proportional days spent by patients until access to the result of each laboratory procedure. Patient costs were estimated using the average of two visits to the laboratory for AFB smear and culture procedures for outpatients; Travel cost was consid‐ ered as US\$ 1.4 (one bus ticket ). Food was considered as US\$ 10 per meal. Base salary in Brazil was considered (US\$ 10 per day /20 days of the work). For inpatients was considered just income loss; Staff costs in the laboratory were based on proportional days spent on each laboratory procedure; Costs of consumables and equipment were provided by the program as well as by the manufacturer.

**Table 1.** Estimative of Costs in US\$ in Tuberculosis Diagnosis in Brazil

We annualized the capital cost of the equipment for 5 years, according to the literature [25]. Building costs were not included. Opportunity costs were not applicable.


The total cost (in US\$) related to the treatment (no hospitalized patients) for AFB smear plus Culture was US\$ 2,771. The cost related to the treatment of hospitalized patients, for AFB smear plus Culture strategy was US\$ 4,686. The cost related to the treatment of (no hospitalized pa‐

Economic Evaluation of Diagnosis Tuberculosis in Hospital Setting

http://dx.doi.org/10.5772/54479

437

However, in a context of advanced technologies for the diagnosis of tuberculosis, economic resources has always limited the incorporation and diffusion of new technologies produced and validated by the academy. It is a challenge for health systems worldwide, and in many cases, the cause of serious sustainability problems.(Taylor, Drummond et al. 2004; King, Griffin et al. 2006; Mason, Weatherly et al. 2007; Hughes, Tilson et al. 2009; Weatherly,

The decisions related to incorporation, acquisition, reimbursement or coverage of new tech‐ nologies and those that determine the way in which they should be used are the most im‐ portant in the health system and should be taken in general and the management of health

The health systems of different countries are diverse with respect to decisions about incor‐ porating technologies and expectations of service users. Tough choices are faced by manag‐ ers at all levels of the health system. This reality makes the TB every year, become more difficult for the system to provide the user with the most effective intervention theoretically available, depending on the pressures placed on the health system in relation to increased costs, the training of human resources, needs updating certification and regulatory instru‐

Attempts to improve the acceptability of resource allocation decisions around new health technologies have spanned many years, fields and disciplines. Various theories of decision making have been tested and methods piloted, but, despite their availability, evidence of sustained uptake is limited. Since the challenge of determining which of many technologies to fund is one that healthcare systems have faced since their inception, an analysis of actual processes, criticisms confronted and approaches used to manage them may serve to guide the development of an 'evidence-informed' decision-making framework for improving the

[1] WHO (2010). "Global tuberculosis control: key findings from the December 2009

tients) and (hospitalized patients), for AFB smear plus Culture strategy was US\$ 7,456.

Drummond et al. 2009; Shi, Hodges et al. 2010)

services in particular.(Greenberg, Peterburg et al. 2005)

acceptability of decisions.(Stafinski, Menon et al. 2011)

Lutheran University of Brasil-ULBRA, Canoas/ RS/, Brazil

WHO report." Wkly Epidemiol Rec 85(9): 69-80.

**Author details**

Luciene C. Scherer

**References**

ments, and investment in physical infrastructure (Newhouse 1992)

<sup>a</sup> For each procedure, costs were attributed based on procedure costs of the Brazilian Public Health System (US\$ 1,4 for AFB smear and US\$ 1,9 for Culture) and from CDCT/FEPPS (US\$ 11,7 for PCR dot-blot), assuming investment laborato‐ ry equipment for 5 years; bStaff salary was considered; for laboratory technician, US\$2,860 per year; for Laboratory technologist, US\$6,400 per year. Staff costs in the laboratory were based on proportional days spent on each laborato‐ ry procedure; Staff salary was considered for clinical physician, nurse and radiologist; US\$6,400 per year; for the X-RAY technician, salary was US\$2,860 per year. c The days of admission to the hospital were considered as the same as the days spent on each laboratory procedure. The time spent on each laboratory procedure until access to the result of the laboratory technique was assumed to be 30 days for AFB smear plus Culture. Total treatment included clinical officer and hospital costs, assuming US\$ 0,22 cost per pill, using 3 pills for day, during 180 days; hospital room costs, US\$ 4,16/day; costs of salary of staff clinical; clinical consultation cost, US\$2,52 per patient; clinical nursing consultation, US \$2,52 per patient. Assuming that during the treatment of inpatients (4 months) 4 ZN and 4 chest radiograph were performed, and during the treatment of no- hospitalized patients (6 months) 6 AFB smear and 6 chest radiograph were performed, following the Brazilian recommendations for treatment (Tuberculose 2004);

d Travel was considered 2 days for AFB smear plus Culture strategy. Food and income loss for AFB smear plus Culture strategy was considered 30 days

The health service costs analysis was based on processing 50 AFB smear slides and 14 cultures per day. AFB smear plus Culture was performed by two trained staff.

Running costs were calculated from investments required to examine 1000 smears.

**Table 2.** Total cost of screening for 1000 suspects. The total screening costs to AFB smear plus Culture were US\$ 9,668.815.

The total cost (in US\$) related to the treatment (no hospitalized patients) for AFB smear plus Culture was US\$ 2,771. The cost related to the treatment of hospitalized patients, for AFB smear plus Culture strategy was US\$ 4,686. The cost related to the treatment of (no hospitalized pa‐ tients) and (hospitalized patients), for AFB smear plus Culture strategy was US\$ 7,456.

However, in a context of advanced technologies for the diagnosis of tuberculosis, economic resources has always limited the incorporation and diffusion of new technologies produced and validated by the academy. It is a challenge for health systems worldwide, and in many cases, the cause of serious sustainability problems.(Taylor, Drummond et al. 2004; King, Griffin et al. 2006; Mason, Weatherly et al. 2007; Hughes, Tilson et al. 2009; Weatherly, Drummond et al. 2009; Shi, Hodges et al. 2010)

The decisions related to incorporation, acquisition, reimbursement or coverage of new tech‐ nologies and those that determine the way in which they should be used are the most im‐ portant in the health system and should be taken in general and the management of health services in particular.(Greenberg, Peterburg et al. 2005)

The health systems of different countries are diverse with respect to decisions about incor‐ porating technologies and expectations of service users. Tough choices are faced by manag‐ ers at all levels of the health system. This reality makes the TB every year, become more difficult for the system to provide the user with the most effective intervention theoretically available, depending on the pressures placed on the health system in relation to increased costs, the training of human resources, needs updating certification and regulatory instru‐ ments, and investment in physical infrastructure (Newhouse 1992)

Attempts to improve the acceptability of resource allocation decisions around new health technologies have spanned many years, fields and disciplines. Various theories of decision making have been tested and methods piloted, but, despite their availability, evidence of sustained uptake is limited. Since the challenge of determining which of many technologies to fund is one that healthcare systems have faced since their inception, an analysis of actual processes, criticisms confronted and approaches used to manage them may serve to guide the development of an 'evidence-informed' decision-making framework for improving the acceptability of decisions.(Stafinski, Menon et al. 2011)
