A systematic review of economic evaluation studies of tuberculosis control in high-income countries

Tuberculosis (TB) is a leading cause of death in developing countries and an important health threat in the industrialised world. Ideally, interventions in TB control are effective, acceptable and economically attractive. This review summarises all economic evaluation studies of TB control in high-income countries over the last 20 years. We provide indications on the relative economic attractiveness of TB interventions based on the reported conclusions. A total of 118 studies using different economic evaluation methodologies on a wide range of TB interventions are included. Most studies (70%) were from North America, and about half (47%) concerned interventions among the general population. Even though the large majority of studies (85%) aimed at preventing active TB disease, 44% of these ignored the prevention of secondary infections, thereby underestimating the benefits of the intervention. Choosing a health care instead of a societal perspective (92% vs. 8%) further underestimated the benefits. Moreover, 74 studies (62%) disregarded discounting, and for 9 of them this led to overestimated future costs. In all, 66% of the studies reported conclusions favouring the evaluated intervention, which is modest given that a publishing bias towards favourable results is to be expected. In conclusion, we demonstrate that many studies in this review have put the evaluated TB intervention at a disadvantage by the choice of methodology i.e., underestimating benefits and overestimating costs. This may have led to an overly conservative approach to the introduction of new interventions in TB control.