Cost-effectiveness of response-adapted therapy (RAT) for advanced Hodgkin's Lymphoma compared with conventional treatment in India: a Markov-model based analysis.

Cost effectiveness analysis of interim positron emission tomography (PET-2, done after 2 cycles of chemotherapy) based response adaptive therapy (RAT) approaches in advanced Hodgkin lymphoma (aHL) are not available from an Indian perspective. We used a five-year decision analytics model to assess the cost-effectiveness of the two RAT approaches [(escalation (RAT-1) or de-escalation (RAT-2)] compared with standard care (SOC) in aHL (mean age:35 years). Modelling data was derived from secondary sources and sensitivity analyses were performed to assess the robustness of the model. Net monetary benefit (NMB) gained from RAT2 in Indian rupees (INR) (INR 2,26,896) was higher than the RAT1 (INR 1,83,138) when compared with SOC. Proportion achieving the complete response after initial treatment (CR1) was the key determining factor for the RAT1/2 dominance over SOC. Despite higher initial input costs, response-adapted therapy of aHL was cost-effective by minimizing the cost incurred and disutility experienced during relapse and salvage.

Despite higher initial costs, response-adapted therapy based on the interim PET scan after 2 cycles of chemotherapy was more cost-effective when compared to standard therapy with 6 cycles of ABVD in patients with advanced Hodgkin's lymphoma. Among the RAT approaches, de-escalation (RAT-2) had better cost-effectiveness than the escalation approach (RAT-1).

Hyperbaric oxygen therapy as an adjunct to the standard wound care for the treatment of diabetic foot ulcers in Indian patients: a cost utility analysis.

BACKGROUND: Diabetic foot ulcer (DFU) is a common complication of diabetes. Hyperbaric oxygen therapy (HBOT) is an adjunct treatment that expedites the healing of DFU. AIM: To evaluate the cost-utility of using standard wound care (SWC) plus HBOT as compared to SWC alone for the treatment of DFU from a societal perspective in the Indian context. METHOD: A Markov decision analysis model comparing SWC with and without HBOT was developed. Data for the model were derived from relevant literature and secondary data from India. The main outcome measures were minor and major lower extremity amputations (LEA) averted, incremental quality-adjusted-life-years (QALY) gained, incremental costs, incremental cost-effectiveness ratio (ICER) per amputation averted and ICER per QALY gained. Sensitivity and threshold analyses were also done. RESULT: HBOT, when added to SWC, lowered the proportion of minor LEA and major LEA among patients with DFU by 6.1% and 4.2%, respectively. The discounted ICER was INR 193,939 [95% CI: 186,745-203,753] or US$ 2,621 [95% CI: 2,524-2,753] per QALY gained. CONCLUSION: SWC plus HBOT is not cost-effective in India. Additional information is required on patient experiences with adjunctive HBOT, if it were to be adopted as the standard of care in India.

Cost-Utility Analysis of Dabigatran and Warfarin for Stroke Prevention Among Patients With Nonvalvular Atrial Fibrillation in India.

OBJECTIVES: Dabigatran has a better safety profile and requires less monitoring, but is costlier than warfarin. This study evaluated the cost-utility of dabigatran relative to warfarin for preventing stroke in nonvalvular atrial fibrillation (NVAF) in India. METHODS: A Markov decision analysis model was developed to compare dabigatran (110 or 150 mg twice a day) to warfarin titrated to target prothrombin time in patients with NVAF at high risk of stroke. Model utilities and transition probabilities were based on literature and costs on market prices. Data on out-of-pocket expenses and income lost were taken from a nationally representative survey. We adopted a societal perspective and discounted both costs and outcomes at 3%. Ischemic stroke, intracranial bleed, other major bleeds, and death were outcomes of NVAF. The model projected the costs, life-years, and quality-adjusted life-years (QALYs) for each intervention over a lifetime. We used gross domestic product per capita of India (US dollars [US$]1889) as the cost-effectiveness threshold. Sensitivity analyses were conducted. RESULTS: Treatment with either dose of dabigatran was associated with gain in life-years and QALYs compared with warfarin. The discounted incremental cost-effectiveness ratios/QALYs for both doses of dabigatran (110 mg US$7519; 150 mg US$6634) were above the cost-effectiveness threshold, and the probability of being cost-effective at this threshold was low. Cost of dabigatran was an important factor in determining incremental cost-effectiveness ratio. Price reduction of 150 mg dose by 49% will make it cost-effective. CONCLUSIONS: Dabigatran is not cost-effective in the Indian societal context. Reducing the price of dabigatran 150 mg by half will make it cost-effective.

Economic burden associated with stroke in India: insights from national sample survey 2017-18.

OBJECTIVE: To estimate the out-of-pocket (OOP) expenditure and catastrophic expenditure due to stroke-related hospitalization and determine associated predictors. METHODS: Secondary analysis of household-based survey conducted by National Sample Survey Organization from June 2017 to 2018. RESULTS: A total of 1152 and 407 individuals reported stroke-related hospitalization and outpatient care, respectively, in the survey. Stroke-related hospitalization rate in India is 46 per 100,000 persons. The mean and median expenditure per episode of stroke-related hospitalization was INR 40,360 (US$ 539.75) and INR 17,140 (US$ 229.22), respectively, with significant OOP hospitalization expenditure across wealth quintiles (p < 0.001). About 29% (25-34%) of households seeking stroke treatment in public medical institutions experienced catastrophic expenditure. 37% (34-40%) of households resorted to distress health financing due to stroke-related hospitalization. Medicines accounted on an average 38% and 73% of public sector hospitalization and outpatient care, respectively. Patients treated in a private facility, hospitalized for over 7 days, within the poorest wealth quintiles had higher odds of incurring catastrophic expenditure. CONCLUSION: Economic burden associated with stroke-related hospitalization is substantial in India. The publicly funded health insurance scheme should cover expenses on stroke-related medicines to reduce OOP expenditure of patients seeking treatment in public sector facilities.

10 best resources on power in health policy and systems in low- and middle-income countries.

Power is a critical concept to understand and transform health policy and systems. Power manifests implicitly or explicitly at multiple levels-local, national and global-and is present at each actor interface, therefore shaping all actions, processes and outcomes. Analysing and engaging with power has important potential for improving our understanding of the underlying causes of inequity, and our ability to promote transparency, accountability and fairness. However, the study and analysis of the role of power in health policy and systems, particularly in the context of low- and middle-income countries, has been lacking. In order to facilitate greater engagement with the concept of power among researchers and practitioners in the health systems and policy realm, we share a broad overview of the concept of power, and list 10 excellent resources on power in health policy and systems in low- and middle-income countries, covering exemplary frameworks, commentaries and empirical work. We undertook a two-stage process to identify these resources. First, we conducted a collaborative exercise involving crowdsourcing and participatory validation, resulting in 24 proposed articles. Second, we conducted a structured literature review in four phases, resulting in 38 articles reviewed. We present the 10 selected resources in the following categories to bring out key facets of the literature on power and health policy and systems-(1) Resources that provide an overarching conceptual exploration into how power shapes health policy and systems, and how to investigate it; and (2) examples of strong empirical work on power and health policy and systems research representing various levels of analyses, geographic regions and conceptual understandings of power. We conclude with a brief discussion of key gaps in the literature, and suggestions for additional methodological approaches to study power.