Cost-effectiveness of a medication event monitoring system for tuberculosis management in Morocco

PLOS ONE RESEARCH ARTICLE Cost-effectiveness of a medication event monitoring system for tuberculosis management in Morocco Jangmi Yang1☯, Hae-Young Kim2☯, Seup Park3, Ilham Sentissi4, Nathan Green5, Byung Kwon Oh3, Yujin Kim1, Kyung Hyun Oh6,7, Eunseong Paek3, Young Joon Park3, InHwan Oh8, Seung Heon Lee ID3,9* a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 OPEN ACCESS Citation: Yang J, Kim H-Y, Park S, Sentissi I, Green N, Oh BK, et al. (2022) Cost-effectiveness of a medication event monitoring system for tuberculosis management in Morocco. PLoS ONE 17(4): e0267292. https://doi.org/10.1371/journal. pone.0267292 Editor: Kevin Schwartzman, McGill University, CANADA 1 National Evidence Based Health Care Collaborating Agency, Seoul, Republic of Korea, 2 Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States of America, 3 Global Care International, Seoul, Republic of Korea, 4 Chief Public Health Service and Epidemiological Surveillance, Moroccan League Against Tuberculosis (Ligue Marocaine de Lute Contre la Tuberculosis, LMCT), Rabat, Morocco, 5 Department of Statistical Science, University College London, London, United Kingdom, 6 Korean Institute of Tuberculosis, Korean National Tuberculosis Association, Cheongju, Republic of Korea, 7 End TB and Leprosy Unit, World Health Organization Regional Office for the Western Pacific, Manila, Philippines, 8 Department of Preventive Medicine, School of Medicine, Kyung Hee University, Seoul, Republic of Korea, 9 Division of Pulmonary, Sleep and Critical Care Medicine, Department of Internal Medicine, Korea University Ansan Hospital, Ansan-City, Republic of Korea ☯ These authors contributed equally to this work. * Abstract Background Digital health technologies have been used to enhance adherence to TB medication, but the cost-effectiveness remains unclear. Received: January 4, 2022 Accepted: April 5, 2022 Methods Published: April 19, 2022 We used the real data from the study conducted from April 2014 to December 2020 in Morocco using a smart pillbox with a web-based medication monitoring system, called Medication Event Monitoring Systems (MEMS). Cost-effectiveness was evaluated using a decision analysis model including Markov model for Multi-drug resistant (MDR) TB from the health system perspective. The primary outcome was the incremental cost-effectiveness ratio (ICER) per disability adjusted life-year (DALY) averted. Two-way sensitive analysis was done for the treatment success rate between MEMS and standard of care. Copyright: © 2022 Yang et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All data generated or analysed during this study are included in this article. Further specific data is available on request, because the data contain potentially identifying patient information. For researchers who meet the criteria for access to confidential data, the data are available from the Global Care International (, ). Funding: S. Park, E. Paek, and Y. J. Park received support from the Korea International Cooperation Agency (KOICA) fund (2014-0027/2018-031). S. H. Results The average total per-patient health system costs for treating a new TB patient under MEMS versus standard of care were $398.70 and $155.70, respectively. The MEMS strategy would reduce the number of drug-susceptible TB cases by 0.17 and MDR-TB cases by 0.01 per patient over five years. The ICER of MEMS was $434/DALY averted relative to standard of care, and was most susceptible to the TB treatment success rate of both strategies followed by the managing cost of MEMS. PLOS ONE | https://doi.org/10.1371/journal.pone.0267292 April 19, 2022 1 / 12 PLOS ONE Lee received a grant from the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health and Welfare, Republic of Korea (Grant number: HI20C1068). The roles of funders were monitoring the outcomes. Competing interests: The authors have declared that no competing interests exist. Cost-effective intervention for TB control Conclusion MEMS is considered cost-effective for managing infectious active TB in Morocco. Introduction Tuberculosis (TB) is the leading cause of mortality among infectious diseases, accounting for 1.5 million deaths worldwide in 2018 [1]. In high TB burden countries, the successful completion of TB treatment is one of the critical TB control strategies to prevent TB transmission through the community [2]. Poor adherence to TB treatment can increase the risk of treatment failure, relapse, as well as the development of drug resistance [3]. However, adherence to TB treatment is often suboptimal despite various treatment interventions, including directly observed treatment (DOT). Recently, digital health technologies and management have been used to enhance adherence to TB medication. Many studies have reported that digital adherence technology (DAT) substantially improved adherence [4] and led to cost savings up to 58% compared to traditional DOT [5]. In 2017, the World Health Organization (WHO) reported that DAT for TB treatment can be used as a substitute of traditional DOTS [6] and recommended its implementation as part of national tuberculosis control programs (NTP) [5]. In order to scale up DAT at a national level, it is important to understand the cost-effectiveness of DAT [7], considering TB burden and the strategic TB program in a given setting [8]. Furthermore, financial and case management strategies should be reassessed to accomplish the goals of global TB strategy [9]. In Morocco, where TB incidence in 2018 was 99/100,000 nationwide and 130/100,000 in cities like Kenitra [10], the overall treatment success rate was 84%, and the loss to follow-up (non-adherence) rate was as high as 15% [11]. We previously reported the demonstrable effectiveness of a smart pillbox (SP) with a web-based medication monitoring system, called a Medication Event Monitoring System (MEMS), as a tailored adherencemonitoring intervention to improve patients’ adherence to TB treatment among active TB patients in Morocco [12]. We used the epidemiological and cost data from this study to evaluate the cost-effectiveness of MEMS to monitor TB treatment among infectious active TB patients in Morocco. Methods KOICA project in Morocco The study was conducted in Salé, Morocco by the Korean International Cooperation Agency (KOICA) in collaboration with Global Care International and the Ministry of Health and Welfare of Morocco from April 2014 to December 2020. Briefly, the study enrolled and provided patients a smart pillbox with a web-based medication monitoring system, called MEMS, which reminded patients to take medication at certain times [13]. (...truncated)