Two Korean government agencies have inconsistent guidelines for testing tuberculosis, although the World Health Organization is recommending a rapid drug susceptibility testing (DST) to cut TB incidence. The two health bodies are the Korea Centers for Disease Control and Prevention (KCDC) and the Health Insurance Review and Assessment Service (HIRA).

The WHO recommended conducting a rapid DST on adults and children at the time of TB diagnosis in the 2016 guidelines. In the following year, the Ministry of Health and Welfare and the KCDC revised their TB guidelines by the WHO’s updates.

However, HIRA is still applying the 2013 guidelines, cutting reimbursements for rapid DSTs. Such reimbursement cut is causing a backlash from doctors.

KDCD revised TB guidelines in 2017, following WHO’s advice

TB is highly contagious. Once tubercular bacillus is detected in a patient, it is essential to determine whether the patient is resistant or not quickly.

To do so, a physician conducts a rapid DST. It is possible to check the tolerance in one day at the earliest, or within one week, which helps a doctor how to treat the patient and assess the risk of the patient.

For the needs of a quick check on the patient, the WHO in 2016 recommended a rapid DST “at the time of TB diagnosis.”

The American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA) also recommended in January 2017 to do rapid DSTs on people who were born in a country with at least a moderate TB incidence more than 20 per 100,000 people or those who have lived in such country for at least a year.

According to the KCDC, the number of TB patients in Korea reached 28,161 in 2017, which makes the nation’s TB incidence 55 per 100,000. Under the guidelines of ATS and IDSA, Korea is subject to rapid DSTs. If U.S.-visiting Koreans have suspected TB, they must do a rapid DST.

In 2017, the KCDC accepted the WHO guidelines. The new KCDC guidelines said Physicians should perform a rapid DST for rifampin and isoniazid on smear-positive specimens or cultured TB strains in cases of suspected multidrug-resistant TB and retreatment. In other circumstances, a rapid DST can be done early to detect multi-resistant TB.”

HIRA still applies 2013 criteria, cuts reimbursements

Korea Biomedical Review has confirmed, however, HIRA was cutting reimbursements for rapid DSTs based on the 2013 guidelines.

Under the HIRA’s criteria, rapid DSTs can be performed only in the following cases; when drug-resistant TB is suspected in patients with recurrence or treatment failure or those who re-registered after discontinuation of treatment; when TB strains are still positive even after one month of treatment, with worsening clinical symptoms or evidence of radiological weakness; when the patient has life-threatening TB infections such as TB meningitis, miliary TB, bronchial TB, TB in infants and immunodeficiency patients; and when a family member of healthcare provider who has contacted with a multidrug-resistant TB patient is infected with TB.

HIRA’s criteria are significantly lagging behind the WHO’s latest guidelines and contradict the Korean government’s aim to shake off its label as having the highest TB incidence rate among members of the Organization for Economic Cooperation and Development.

Moreover, the HIRA was cutting 20 percent of reimbursements on rapid DSTs.

“TB incidence is going down with the government’s efforts, but the number of drug-resistant TB patients is still too high,” said a professor of respiratory medicine at a university hospital in Seoul. “Even though we can do rapid DSTs, the HIRA is cutting reimbursements based on the old guidelines.”

He went on to say, “Our hospital has been performing rapid DSTs on every patient with tubercle bacillus cultures, according to the latest guidelines of the KCDC. Then, we faced an 18.8 percent cut in reimbursements. This is not only unfair but inconsistent with the government’s policy of combating TB.”

Noting that he could not understand why the government cut only 20 percent, not 100 percent, he said, “I don’t understand what kind of criteria was applied in such cuts. Such reduction in reimbursements makes us frustrated.”

KCDC, HIRA face criticism from physicians

The KCDC and the HIRA belatedly began discussing the inconsistency issue, as the medical community raised criticism.

“Although I haven’t found out the situation exactly yet, I recently met HIRA officials and talked about the criteria for reimbursements on rapid DSTs,” said an official at the TB/AIDS department at the KCDC. “To change reimbursement criteria, we need to find out how often the tests are done in the medical field. In May, we will compare our data with that of the HIRA.”

The official went on to say, “We are aware that we need to improve the criteria for rapid DSTs. To do so, we need discussions with the health and welfare ministry. Before that, we should do paperwork.”

The HIRA also said it would review revising the reimbursement criteria, after finding out how rapid DSTs are performed.

An official at the reimbursement criteria department at the HIRA said, “We will investigate whether physicians have difficulties coming from the old criteria and whether there is a need for improvement in the criteria.” TB is a nationally-managed disease. If the medical community gives us good suggestions, the agency will be able to improve the criteria reasonably,” he added.

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