A cost-effectiveness analysis of surgical care delivery in Eastern Uganda-a societal perspective.

BACKGROUND: The mismatch between the global burden of surgical disease and global health funding for surgical illness exacerbates disparities in surgical care access worldwide. Amidst competing priorities, governments need to rationally allocate scarce resources to address local needs. To build an investment case for surgery, economic data on surgical care delivery is needed. This study focuses on femur fractures. METHODS: This prospective cohort study at Soroti Regional Referral Hospital (SRRH), captured demographic, clinical, and cost data from all surgical inpatients and their caregivers at SRRH from February 2018 through July 2019. We performed descriptive and inferential analyses. We estimated the cost effectiveness of intramedullary nailing relative to traction for femur fractures by using primary data and making extrapolations using regional data. RESULTS: Among the 546 patients, 111 (20.3%) had femur fractures and their median [IQR] length of hospitalization was 27 days [14, 36 days]. The total societal cost and Quality Adjusted Life Year (QALY) gained was USD 61,748.10 and 78.81 for femur traction and USD 23,809 and 85.47 for intramedullary nailing. Intramedullary nailing was dominant over traction of femur fractures with an Incremental Cost Effectiveness Ratio of USD 5,681.75 per QALY gained. CONCLUSION: Femur fractures are the most prevalent and most expensive surgical condition at SRRH. Relative to intramedullary nailing, the use of femur traction at SRRH is not cost effective. There is a need to explore and adopt more cost-effective approaches like internal fixation.

Coverage of social assistance in Ethiopia during the COVID-19 pandemic: a time-to-event analysis.

OBJECTIVE: In a pandemic, government assistance is essential to support the most vulnerable households as they face health and economic challenges. However, government assistance is effective only when it reaches vulnerable households in time. In this paper, we estimated the timeliness of government assistance for the most vulnerable households (ie, the poor households) in Ethiopia during its COVID-19 response of 2020. In particular, we conducted a time-to-event analysis to compare the time to receive government assistance between poor and non-poor households in Ethiopia. METHODS: We used a semiparametric Cox proportional model to evaluate whether the time to first receipt of government assistance during the COVID-19 response in 2020 differed between poor and non-poor Ethiopian households. We used the Schoenfeld test to check the proportionality assumption and conducted the stratified Cox regression analysis to adjust for non-proportional variables. The data from World Bank's High-Frequency Phone Surveys on COVID-19 and the 2019 Ethiopian Socioeconomic Survey were used for this analysis. RESULTS: We found that the poor households in rural areas were 88% (HR: 1.88; 95% CI: 1.19 to 2.98) more likely to receive government assistance than non-poor households at any point within 10 months after the start of the pandemic. However, there was no significant difference between urban poor and non-poor households' likelihood of receiving government assistance during this timeframe. CONCLUSION: The Ethiopian government has leveraged its existing social protection network to quickly reach poor households in rural areas during the COVID-19 response of 2020. The country will need to continue strengthening and scaling the existing social protection systems to accurately target the wider vulnerable population in urban areas.

Investing in late-stage clinical trials and manufacturing of product candidates for five major infectious diseases: a modelling study of the benefits and costs of investment in three middle-income countries.

BACKGROUND: Investing in late-stage clinical trials, trial sites, and production capacity for new health products could improve access to vaccines, therapeutics, and infectious disease diagnostics in middle-income countries. This study assesses the case for such investment in three of these countries: India, Kenya, and South Africa. METHODS: We applied investment case modelling and assessed how many cases, deaths, and disability-adjusted life years (DALYs) could be averted from the development and manufacturing of new technologies (therapeutics and vaccines) in these countries from 2021 to 2036, for five diseases-HIV, tuberculosis, malaria, pneumonia, and diarrhoeal diseases. We also estimated the economic benefits that might accrue from making these investments and we developed benefit-cost ratios for each of the three middle-income countries. Our modelling applies two investment case perspectives: a societal perspective with all costs and benefits measured at the societal level, and a country perspective to estimate how much health and economic benefit accrues to each middle-income country for every dollar invested in clinical trials and manufacturing by the middle-income country government. For each perspective, we modelled two scenarios: one that considers only domestic health and economic benefits; and one that includes regional health and economic benefits. In the regional scenarios, we assumed that new products developed and manufactured in India would benefit eight countries in south Asia, whereas new products developed and manufactured in Kenya would benefit all 21 countries in the Common Market for Eastern and Southern Africa (COMESA). We also assumed that all 16 countries in the Southern African Development Community (SADC) would benefit from products developed and manufactured in South Africa. FINDINGS: From 2021 to 2036, product development and manufacturing in Kenya could avert 4·44 million deaths and 206·27 million DALYs in the COMESA region. In South Africa, it could prevent 5·19 million deaths and 253·83 million DALYs in the SADC region. In India, it could avert 9·76 million deaths and 374·42 million DALYs in south Asia. Economic returns would be especially high if new tools were produced for regional markets rather than for domestic markets only. Under a societal perspective, regional returns outweigh investments by a factor of 20·51 in Kenya, 33·27 in South Africa, and 66·56 in India. Under a country perspective, the regional benefit-cost ratios amount to 60·71 in India, 8·78 in Kenya, and 11·88 in South Africa. INTERPRETATION: Our study supports the creation of regional hubs for clinical trials and product manufacturing compared with narrow national efforts. FUNDING: Bill & Melinda Gates Foundation.

Development and validation of DeciBHAL-US: A novel microsimulation model of hearing loss across the lifespan in the United States.

BACKGROUND: Hearing loss affects over 50% of people in the US across their lifespan and there is a lack of decision modeling frameworks to inform optimal hearing healthcare delivery. Our objective was to develop and validate a microsimulation model of hearing loss across the lifespan in the US. METHODS: We collaborated with the Lancet Commission on Hearing Loss to outline model structure, identify input data sources, and calibrate/validate DeciBHAL-US (Decision model of the Burden of Hearing loss Across the Lifespan). We populated the model with literature-based estimates and validated the conceptual model with key informants. We validated key model endpoints to the published literature, including: 1) natural history of sensorineural hearing loss (SNHL), 2) natural history of conductive hearing loss (CHL), and 3) the hearing loss cascade of care. We reported the coefficient of variance root mean square error (CV-RMSE), considering values ≤15% to indicate adequate fit. FINDINGS: For SNHL prevalence, the CV-RMSE for model projected male and female age-specific prevalence compared to sex-adjusted National Health and Nutrition Examination Survey (NHANES) data was 4.9 and 5.7%, respectively. Incorporating literature-based age-related decline in SNHL, we validated mean four-frequency average hearing loss in the better ear (dB) among all persons to longitudinal data (CV-RMSE=11.3%). We validated the age-stratified prevalence of CHL to adjusted NHANES data (CV-RMSE=10.9%). We incorporated age- and severity-stratified time to first hearing aid (HA) use data and HA discontinuation data (adjusted for time-period of use) and validated to NHANES estimates on the prevalence of adult HA use (CV-RMSE=10.3%). INTERPRETATION: Our results indicate adequate model fit to internal and external validation data. Future incorporation of cost and severity-stratified utility data will allow for cost-effectiveness analysis of US hearing healthcare interventions across the lifespan. Further research might expand the modeling framework to international settings. FUNDING: This study was funded by the National Institute on Deafness and Other Communication Disorders and the National Institute on Aging (3UL1-TR002553-03S3 and F30 DC019846).

Evidence gaps in economic analyses of hearing healthcare: A systematic review.

BACKGROUND: Hearing loss is a common and costly medical condition. This systematic review sought to identify evidence gaps in published model-based economic analyses addressing hearing loss to inform model development for an ongoing Lancet Commission. METHODS: We searched the published literature through 14 June 2020 and our inclusion criteria included decision model-based cost-effectiveness analyses that addressed diagnosis, treatment, or prevention of hearing loss. Two investigators screened articles for inclusion at the title, abstract, and full-text levels. Data were abstracted and the studies were assessed for the qualities of model structure, data assumptions, and reporting using a previously published quality scale. FINDINGS: Of 1437 articles identified by our search, 117 unique studies met the inclusion criteria. Most of these model-based analyses were set in high-income countries (n = 96, 82%). The evaluated interventions were hearing screening (n = 35, 30%), cochlear implantation (n = 34, 29%), hearing aid use (n = 28, 24%), vaccination (n = 22, 19%), and other interventions (n = 29, 25%); some studies included multiple interventions. Eighty-six studies reported the main outcome in quality-adjusted or disability-adjusted life-years, 24 of which derived their own utility values. The majority of the studies used decision tree (n = 72, 62%) or Markov (n = 41, 35%) models. Forty-one studies (35%) incorporated indirect economic effects. The median quality rating was 92/100 (IQR:72-100). INTERPRETATION: The review identified a large body of literature exploring the economic efficiency of hearing healthcare interventions. However, gaps in evidence remain in evaluation of hearing healthcare in low- and middle-income countries, as well as in investigating interventions across the lifespan. Additionally, considerable uncertainty remains around productivity benefits of hearing healthcare interventions as well as utility values for hearing-assisted health states. Future economic evaluations could address these limitations. FUNDING: NCATS 3UL1-TR002553-03S3.

Association between cardiovascular risk factors and the diameter of the main pulmonary artery in asymptomatic population in the Appalachian region.

BACKGROUND: Pulmonary artery (PA) diameter may be altered in association with cardiovascular (CV) risk factors as noted in aorta in systemic hypertension. The flow of blood from the right ventricle to the PA and all the way to the capillary level depends on the pulmonary vascular resistance and to a lesser extent compliance and impedance of the PA, which are the fundamental conduit for maintenance of the right heart hemodynamics. Our objective is to determine the association between CV risk factors and the main pulmonary artery (MPA) diameter. METHODS: The study population are asymptomatic individuals with no known diagnosis of CV diseases in central Appalachia (n=1,282). Adults aged 18 years or older were eligible for the screening if they were referred by a physician. For self-referral, only males aged ≥45 years and females aged ≥55 years were eligible. Unadjusted and adjusted linear regression analyses were performed. RESULTS: The mean MPA diameter was significantly higher among males compared to females (27.19±4.20 vs. 24.99±3.91 mm, P<0.0001). Participants with diabetes also had wider MPA diameter (26.79±4.56 mm) compared to those without diabetes (25.93±4.11 mm) (P=0.015). Further, hypertensive (26.42±4.15 vs. 25.71±4.21 mm, P=0.002) and obese (27.25±4.11 vs. 25.28±4.07 mm, P<0.0001) participants had significantly wider MPA diameter compared to non-hypertensive and non-obese participants, respectively. Multivariable model showed that age, sex and body mass index (BMI) were significantly associated with MPA diameter. A 1-year increase in age increased MPA diameter by 0.046 mm (P<0.0001). The diameter of MPA was wider among males by 2.16 mm compared to females (P<0.0001). Finally, with one unit increase in BMI, the MPA diameter increased by 0.16 mm (P<0.0001). CONCLUSIONS: MPA diameter was significantly associated with age, sex, and BMI. Further prospective studies are needed to correlate computed tomography (CT) measurement of MPA diameter with pulmonary pressure as assessed by echocardiogram to diagnose pulmonary hypertension (PH).

Obesity and related behaviors among adolescent school boys in Abha City, Southwestern Saudi Arabia.

Using stratified sampling technique 2696 adolescent school boys (aged 11-19 years) in Abha City, Southwestern Saudi Arabia were interviewed and examined for weight and height using standardized techniques. The overall prevalence of obesity and overweight in the present study amounted to 16%. Using logistic regression analysis, lack of exercise practice in the previous week in general [aOR = 1.352, 95% confidence interval (CI) = 1.066-1.941] or in the class (aOR = 1.446, 95% CI = 1.083-1.931) were significantly associated with obesity. The present study showed that obesity among adolescent school boys in Abha City is a public health problem. There is a need for a national program in the country to prevent and control obesity among adolescents. The program should incorporate: dietary management of obesity, promotion of physical activity, health education campaigns and consideration of the possibility of providing facilities for practicing physical activity and exercise in the community.

Prescribing patterns for acute respiratory infections in primary health care, aseer region, saudi arabia.

OBJECTIVE: The objective of this study was to identify the patterns of prescribing for Acute respiratory infections in patients attending primary health care centers in the Aseer region, southwestern Saudi Arabia. MATERIALS #ENTITYSTARTX00026; METHODS: This study was conducted at primary health care centers in the Aseer region during November 2003. A master sheet designed by the investigator was distributed to all the working physicians in the primary health care center in the Aseer region. The master sheet included the age, sex, complaints, signs, clinical diagnosis and the type of medications prescribed. Physicians were asked to include all patients attending on 17(th) November 2003, and send the master sheet to the Technical Supervision Unit at Primary Care Department, General Directorate of Health Affairs. Data of the master sheet was entered and analyzed by using SPSS. RESULTS: The total number of patients attending with acute respiratory infections(ARIs) was 3000 which represented 25% of the patients attending primary health care centers that day. Children formed 60% of the total number of cases. Regarding symptoms and signs, it was found that 70% had a cough, 59% had a runny nose, and 43% had a sore throat . The common cold was the most common diagnosis (42%). Antipyretics, antihistamines, antibiotics and antitussives were prescribed for 78%, 48%, 45% and 25% respectively. Statistical analysis using logistic regression revealed that the higher the temperature, the more severe the throat congestion and the presence of exudates on pharynx, the higher the likelihood to prescribe antibiotics. CONCLUSION: In this study, it was found that the prescription of all drugs for ARIs was still high in spite of the fact that these conditions are self-limiting. To rationalize prescribing for ARI, implementation of the national protocol for diagnosis and treatment of ARIs is mandatory. Further studies to explore the physician's knowledge, attitudes and behavior concerning prescribing for ARI is strongly recommended.