Cost of treating inpatient falciparum malaria on the Thai-Myanmar border

Although falciparum malaria is an entirely preventable and treatable disease, it caused an estimated 627,000 deaths in 2012 [1]. Malaria also has a devastating economic [2] and social impact [3], being both a root cause and consequence of poverty, contributing to the vicious cycle of poverty and ill health. In endemic countries malaria is a common cause of inpatient admissions and as access to health care improves with economic development, a larger proportion of patients with severe malaria are likely to be admitted in time to receive potentially life-saving treatment. Providing the most efficacious treatment to these patients will improve survival.

Parenteral artesunate has been shown to be considerably superior to quinine in the management of severe malaria, with a reduction in mortality from 10.9% to 8.5% in Africa [4] and from 22% to 15% in Asia [5]. Subsequent cost-effectiveness analyses confirmed the economic superiority of artesunate over quinine in the management of malaria in both the African [6] and Asian [7] settings, with an incremental cost per death averted of approximately $150 in both settings, and is therefore highly cost-effective.

Despite these demonstrated benefits and WHO endorsements, parenteral artesunate is the recommended first-line treatment for patients with severe malaria in a small number of endemic and non-endemic countries, including only two countries in sub-Saharan Africa [1]. One possible reason for this slow uptake is the prima facie notion that artesunate (US$ 2.3 per vial) is costlier than quinine (US$ 0.2 per vial) [8] and would therefore pose a substantial economic burden to healthcare systems. While previous economic evaluations [6, 7] found the costs of admission for the two regimens were comparable, but they did not benefit from detailed data on the resources used to manage malaria admissions. This study estimates and compares the costs of treating adult malaria inpatients in a hospital on the Thai-Myanmar border with either parenteral artesunate or quinine, building on a detailed account of the resources used in caring for these patients.

Of the 100 patients for whom data were available, the majority of patients were male (75%) and the mean age was 32 years (IQR: 22–41 years). Fifty-seven percent of the patients originated from Myanmar. Karen and Burmese ethnic groups were most common, at 28 and 27%, respectively. Almost all patients of Myanmar origin worked as general labourers. Among the 100 admissions, 59 were classified as severe malaria [15] and 41 had uncomplicated malaria but required parenteral therapy because of hyperparasitaemia or inability to take oral medication.

Of all admitted malaria patients, 29 were treated with parenteral quinine and 71 by parenteral artesunate (the imbalanced distribution is due to inclusion of 34 patients treated with artesunate alone but not those in the artesunate + quinine arm in the same study [12]). The overall mortality rate amongst all patients was 8% (95% CI 3-13%). In the artesunate group 4% (95% CI 0-7%) died as compared with 17% (95% CI 3-30%) of patients receiving quinine. Length of hospital stay was different in the two groups, with a mean of seven days (95% CI 5.3-9.3) in the quinine group as compared with four days (95% CI 3.4-4.6) for artesunate. This difference was apparent for patients with uncomplicated malaria treated with quinine as compared with artesunate (4.1 vs 2.7 days; P = <0.001) but was not significantly different in severe malaria patients (6.8 vs 5.4 days; P = 0.37). In patients who died, the mean time from the start of anti-malarial treatment to death was 70 hours; this was shorter in quinine-treated patients at 27 hours (95% CI 12–45) than artesunate-treated patients at 140 hours (95% CI 31–323).

While the cost of medication is lower in patients receiving quinine, all other costs were considerably higher in quinine-treated patients. The mean total admission cost per patient treated with quinine was almost 30% higher than for patients treated with artesunate, but this was not statistically significant (P = 0.37). Table 1 presents the individual component costs and full admission costs for patients treated with artesunate or quinine, in total and stratified by severity.For patients with severe malaria the mean total admission cost was similar in the two arms. In the quinine group, the mean total admission cost per patient was $298 (95% CI: 203–438) whilst for artesunate patients it was US$284 (95% CI: 281–407) (P = 0.869). Figures 1 shows the proportional contribution of each component to total admission costs. The main cost component was services, accounting for almost 40% of total admission costs.

In addition to the activities included in services cost category, patients receiving quinine required considerably more nursing and physician time, as indicated by 1.5 to 3 times as many nursing monitoring activities. The time spent by physicians attending to patients treated with quinine appeared to be higher as indicated by the larger number of pages in their records. These differences are explained by the longer duration of admission and were not evident when compared on a per-day basis. Table 2 shows the breakdown in monitoring activities between the two arms.

There are numerous reasons that could explain the slow uptake of artesunate in national treatment guidelines and routine use, including the need for re-training and establishing new procurement and distribution systems, as well as clinician resistance to change. Given the untapped potential gains offered by artesunate these all require urgent attention. Here simply focus on the perception that malaria admissions treated with artesunate might be costlier as a barrier to implementation. While this study confirms the higher cost of medication in patients treated with artesunate, the study finds no evidence of higher total admission costs, with some indication of cost savings for patients treated with artesunate. This can be explained to a great extent by the shorter time to discharge and associated service costs as well as the lower quantity of disposables and fluids required for administering artesunate.

The estimated admission costs of inpatients with malaria in this study are higher than those calculated in previous studies [6, 7]. In addition to the more detailed methods used here that could capture a broader range of inputs, the differences might be explained by the use of hospital price list as unit costs, which could be higher than their economic value. Despite total costs per admission for both treatment groups being higher in this study, the difference between the treatment groups is non-significant, with some indication of lower costs for patients treated with artesunate. The incremental cost per DALY averted, therefore, will remain very low, as indicated in other studies, or potentially negative, implying that treatment with artesunate dominates quinine being both less costly and more effective.

This study finds no evidence for a difference in total economic cost of care between inpatients treated with quinine and those treated with artesunate, despite substantial differences in drug prices. This analysis has certain limitations including small sample size, the age of the data used and the use of hospital price list as a proxy for health system costs. Nevertheless, the global uptake (or lack thereof) is of major importance in global health. This study, with its limitations, suggests that financial considerations should not prevent the switch from quinine to artesunate for the treatment of malaria admissions.