Household Financial Burden and Treatment Non-adherence among Multidrug-resistant Tuberculosis in Guizhou, China

Abstract

Background Multi-drug resistant tuberculosis (MDR-TB) threatens global public health, which is a chronic infectious disease spread via the air caused by Mycobacterium tuberculosis (MTB) and is resistant to at least two anti-TB drugs: isoniazid and rifampin. Treating MDR-TB lasts for two years and incurs high costs. Unaffordable payment can worsen socioeconomic situation of patients and their families, even pushing them into a catastrophic poverty-disease circle, which may result in poor treatment adherence of patients. Non-adherence promotes the spread of MDR-TB and the emergence of extensively drug-resistant TB (XDR-TB). Thus, to reduce threats of MDR-TB, it is necessary to quantify financial burden due to MDR-TB treatment and identify the main drivers leading to catastrophic costs so as to prioritize targeted interventions that can help minimize the financial burden of affected households. Meanwhile, quantifying the incidence of treatment non- adherence in these patients and understand their underlying reasons for non- adherence can contribute to the implementation of targeted interventions and to reduce MDR-TB epidemic globally. Objectives We aims to: 1) assess current household financial burden due to MDR-TB treatment and coping mechanism during the first-year treatment in Guizhou province; 2) assess MDR-TB patients' treatment non-adherence which consist of treatment interruption and drug use (under-use, over-use and correct use);further identify main reasons and predictors for serious treatment interruption, and document the level of agreement of classification for drug use between self-report and pill count. Methods A cross-sectional study combining hospital-based interviews and home-based pill count was conducted from January to August 2018. Data about financial burden of 161 households affected by MDR-TB during patients' first year treatment were collected in two MDR-TB designated hospitals in Guizhou from interviews using a structured questionnaire. Direct medical costs were verified with medical records and insurance. Household financial burden was quantified by total cost and cost components. Meanwhile, three indicators are used to measure financial burden: 1) catastrophic total costs (CTC, household's income as denominator); 2) catastrophic health expenditure (CHE I, household's expenditure as denominator; CHE II, household's capacity to pay as denominator); 3) impoverishment. Predictors for CTC and CHE were explored. Coping mechanism against financial burden was documented. Treatment interruption was determined from patient's medical records and interviews using a structured questionnaire among 202 patients treated at one designated hospital. The overall and drug-specific incidence of short (<14 days) and serious (>14 days) treatment interruption among MDR-TB patients were estimated. Main reasons and predictors for serious interruption were identified. Concordance of pills counted with self-reports for each drug use within one month was assessed for a subgroup of 202 patients at their homes using kappa statistics. Results Of 161 patients treated in two hospitals and completed the first year treatment, average total costs was US$8,266 and included 72% direct medical costs, 5% direct non-medical costs and 23% indirect costs. 37% of direct medical costs were covered by insurance. Overall, the incidence of CTC, CHE I and CHE II was 87.0%, 71.4% and 68.3%. Both incidence and intensity for three defined catastrophic costs decreased when a household's income increased. 22.4% households were pushed into poverty after health payment. In order to cope with the financial burden, 37% of households tried to save money, 39% reduced daily expenses and 63% were forced to borrow money. Five significant determinants of catastrophic costs were low household income, absence of students in a family, hospital length of stay, male gender, and job/productivity loss. Of 202 patients treated in one hospital, the incidence of short and serious treatment interruption was 37.6% and 28.7%, respectively. Adverse drug reactions (ADRs) and financial hardship were the top two reasons for serious interruption. Amikacin and cycloserine had the highest rate of specific drug interruption (18.3% and 10.2%, respectively). ADRs (ORadj: 2.82, 95% CI: 1.41- 5.61), monthly out-of-pocket expenses exceeding 250 US dollars (ORadj: 2.27, 95% CI: 1.14-4.50), and baseline co-morbidities (ORadj: 2.53, 95% CI: 1.19-5.38) were significantly associated with serious treatment interruption. For a subgroup of 202 patients above, 111 patients were assessed for pill count at their home. Of them, 5.4% had perfect drug adherence, 54.1% had drug under-use, 6.3% had drug over-use, and 34.2% had both problems. The respective number from self-reports was 7.2%, 56.8%, 5.4% and 30.6%. The two methods gave an acceptable level of agreement for most of the drugs (kappa: 0.52-0.95). Conclusions High financial burden and serious treatment non-adherence among MDR-TB patients were found in Guizhou. In order to minimize the financial burden of affected households and improve treatment adherence of patients, cost-mitigation and social protection policies should be introduced for MDR-TB patients and their families, including preparing a uniform and comprehensive insurance package for MDR-TB to sufficiently cover direct medical costs, providing pro-poor assistance policies to protect poor families against catastrophic payments, and periodically monitoring costs due to MDR-TB treatment with the introduction of new drugs. In addition, monitoring ADRs closely, revision of drug regimen are also needed. Patient's self-reports may be a cost-saving method to monitor monthly drug under- use and over-use in clinical settings.