Estimating the Unit Costs of Healthcare Service Delivery in India: Addressing Information Gaps for Price Setting and Health Technology Assessment.

BACKGROUND: India's flagship National Health insurance programme (AB-PMJAY) requires accurate cost information for evidence-based decision-making, strategic purchasing of health services and setting reimbursement rates. To address the challenge of limited health service cost data, this study used econometric methods to identify determinants of cost and estimate unit costs for each Indian state. METHODS: Using data from 81 facilities in six states, models were developed for inpatient and outpatient services at primary and secondary level public health facilities. A best-fit unit cost function was identified using guided stepwise regression and combined with data on health service infrastructure and utilisation to predict state-level unit costs. RESULTS: Health service utilisation had the greatest influence on unit cost, while number of beds, facility level and the state were also good predictors. For district hospitals, predicted cost per inpatient admission ranged from 1028 (313-3429) Indian Rupees (INR) to 4499 (1451-14,159) INR and cost per outpatient visit ranged from 91 (44-196) INR to 657 (339-1337) INR, across the states. For community healthcare centres and primary healthcare centres, cost per admission ranged from 412 (148-1151) INR to 3677 (1359-10,055) INR and cost per outpatient visit ranged from 96 (50-187) INR to 429 (217-844) INR. CONCLUSION: This is the first time cost estimates for inpatient admissions and outpatient visits for all states have been estimated using standardised data. The model demonstrates the usefulness of such an approach in the Indian context to help inform health technology assessment, budgeting and forecasting, as well as differential pricing, and could be applied to similar country contexts where cost data are limited.

Acupuncture price in forty-one metropolitan regions in the United States: An out-of-pocket cost analysis based on OkCopay.com.

Few studies have focused on the cost of acupuncture treatments although acupuncture has become popular in the United States (U.S.). The purpose of the current study was to examine the out-of-pocket costs incurred from acupuncture services based on an online website, OkCopay.com. We examined descriptive statistics (range, median and 20% intervals) for the cost of acupuncture "first-time visits" and "follow-up visits" in 41 metropolitan regions in the U.S. The acupuncture prices of 723 clinics throughout 39 metropolitan regions were included, except for Birmingham, Alabama and Detroit, Michigan as there was no online data available at the time of the study for these two regions. The cost range for a first-time acupuncture visit was $15-400; the highest median was $150 in Charleston, South Carolina, while the lowest was $45 in St. Louis, Missouri. The top 10 cities for the highest median were: Baltimore, Washington, D.C., New York, San Francisco, San Jose, Boston, Atlanta, Seattle, Portland and Indianapolis, with the median $120, while the median for all 723 clinics was $112. For the follow-up visits, the cost range was $15-300; the highest median was $108 in Charleston, South Carolina, and the lowest $40 in Miami, Florida. The 10 cities with highest median follow-up acupuncture visit costs were: New York, Baltimore, New Orleans, Washington, D.C., Philadelphia, San Francisco, San Jose, Seattle, Boston and Atlanta, with the median $85, while for all 723 clinics the median price was $80. The estimation of the average gross annual income of each acupuncturist from the regions studied was $95,760, while the total annual cost of patients seeking acupuncture services in the U.S. was about $3.5 billion in 2018.

Comparing costs of a senior wellness care redesign in group and independent physician practices of an accountable care organization.

Primary care redesign for older adult patients is currently ongoing in countries with aging populations. One of the main challenges of this type of transformations is how to estimate implementation costs in different types of health care delivery organizations. This study compares start-up and incremental expenses of implementing a primary care redesign across 2 organization types: integrated group (n = 31) practices and independent practice association (IPA) sites (n = 213). Administrators involved with implementing the redesign completed a cost capture template to quantifying expenses. The potential impact of measurement error, recollection bias, and implementation models across sites and geographic regions was examined in sensitivity analyses. Marginal start-up and incremental expenses were higher for Group sites ($122-$328) compared to IPA sites ($31-$227). Group and IPA sites, however, implemented the redesign with different intensities. According to our analyses, if IPA sites implemented the redesign with the same intensity as Group sites, marginal costs would have been $5 to $13 higher for IPA sites than for Group sites. This study shows how a flexible approach to estimate the cost of a wellness care redesign is needed when the intensity of the transformation differs across 2 different types of health care organizations.

Comparisons of hospital output in Canada: national and international perspectives.

Current cost-based approach in measuring health care output does not allow decomposition of health care expenditure into price and output components. In this paper we propose an episode-based direction measurement method which closely resembles the concept of output in the system of national accounts. Using data from the Canadian Institute for Health Information, we calculate a quality unadjusted output index of the Canadian hospital sector for the periods 1996-2005. The result shows that total output increases at an average annual growth rate of 1.49%. We expect that with the quality adjustment the actual rate is higher. This is in contrast with the long-held assumption that health care productivity growth is zero. Our results provide key information on the ongoing health care policy debate.

High quality, patient centred and coordinated care for Alstrom syndrome: a model of care for an ultra-rare disease.

BACKGROUND: Patients with rare and ultra-rare diseases make heavy demands on the resources of both health and social services, but these resources are often used inefficiently due to delays in diagnosis, poor and fragmented care. We analysed the national service for an ultra-rare disease, Alstrom syndrome, and compared the outcome and cost of the service to the standard care. METHODS: Between the 9th and 26th of March 2014 we undertook a cross-sectional study of the UK Alstrom syndrome patients and their carers. We developed a semi-structured questionnaire to assess our rare patient need, quality of care and costs incurred to patients and their careers. In the UK all Alstrom syndrome patients are seen in two centres, based in Birmingham, and we systematically evaluated the national service and compared the quality and cost of care with patients' previous standard of care. RESULTS: One quarter of genetically confirmed Alstrom syndrome UK patients were enrolled in this study. Patients that have access to a highly specialised clinical service reported that their care is well organised, personalised, holistic, and that they have a say in their care. All patients reported high level of satisfaction in their care. Patient treatment compliance and clinic attendance was better in multidisciplinary clinic than the usual standard of NHS care. Following a variable costing approach based on personnel and consumables' cost, our valuation of the clinics was just under £700/patient/annum compared to the standard care of £960/patient/annum. Real savings, however, came in terms of patients' quality of life. Furthermore there was found to have been a significant reduction in frequency of clinic visits and ordering of investigations since the establishment of the national service. CONCLUSIONS: Our study has shown that organised, multidisciplinary "one stop" clinics are patient centred and individually tailored to the patient need with a better outcome and comparable cost compared with the current standard of care for rare disease. Our proposed care model can be adapted to several other rare and ultra-rare diseases.

Factors associated with the financial performance of spring-calving, pasture-based dairy farms.

As land becomes a limiting resource for pasture-based dairy farming, the inclusion of purchased supplementary feeds to increase milk production per cow (through greater dry matter intake) and per hectare (through increased stocking rate) is often proposed as a strategy to increase profitability. Although a plausible proposition, virtually no analysis has been done on the effect of such intensification on the profitability of commercial pasture-based dairy farm businesses. The objective of this study was to characterize the average physical and financial performance of dairy systems differing in the proportion of the cow's diet coming from grazed pasture versus purchased supplementary feeds over 4 yr, while accounting for any interaction with geographic region. Physical, genetic, and financial performance data from 1,561 seasonal-calving, pasture-based dairy farms in Ireland were available between the years 2008 and 2011; data from some herds were available for more than 1 yr of the 4-yr study period, providing data from 2,759 dairy farm-years. The data set was divided into geographic regions, based on latitude, rainfall, and soil characteristics that relate to drainage; these factors influence the length of the pasture growth season and the timing of turnout to pasture in spring and rehousing in autumn. Farms were also categorized by the quantity of feed purchased; farms in which cows received <10, 11-20, 21-30, or >30% of their annual feed requirements from purchased feed were considered to be categories representative of increasing levels of system intensification. Geographic region was associated with differences in grazing days, pasture harvested per hectare, milk production per cow and per hectare, and farm profitability. Farms in regions with longer grazing seasons harvested a greater amount of pasture [an additional 19kg of dry matter (DM)/ha per grazing day per hectare], and greater pasture harvested was associated with increased milk component yield per hectare (58.4kg of fat and 51.4kg of protein more per tonne of DM pasture harvested/ha) and net profit per hectare (€268/ha more per tonne of DM harvested). Milk yield and yield of milk components per cow and per hectare increased linearly with increased use of purchased feed (additional 30.6kg of milk fat and 26.7kg of milk protein per tonne of DM purchased feed per hectare), but, on average, pasture harvested/hectare and net profit/hectare declined (-0.60 t of DM/ha and -€78.2/ha, respectively) with every tonne of DM supplementary feed purchased per hectare. The results indicate an effect of purchased feeds not usually accounted for in marginal economic analyses (e.g., milk to feed price ratio): the decline in pasture harvested/hectare, with the costs of producing the unutilized pasture in addition to the cost of feed resulting in a lower profit. In conclusion, greater milk component yields per cow were associated with increased profit per hectare, and a greater use of purchased feeds was associated with an increase in the yield of milk components. However, on average, increasing yield of milk components through the supply of purchased feeds to pasture-based cows was associated with a decline in pasture harvested per hectare and profitability. The decline in pasture harvested per hectare with increased use of purchased supplements per cow is probably the primary reason for the low milk production response and the failure to capitalize on the potential benefits of purchased supplements, with the associated costs of growing the unutilized pasture, in conjunction with increased nonfeed variable and fixed costs outweighing the increased milk production and revenue from supplementation. Farmers considering intensification through use of purchased supplements to increase the stock-carrying capacity of the farm (i.e., stocking rate) must ensure that they focus on management of pasture and total cost control to capture the potential benefits of supplementary feed use.

Descripción de los resultados y costes de una intervención preventiva a nivel respiratorio en el anciano institucionalizado: ensayo controlado aleatorizado / Cost-consequence analysis of respiratory preventive intervention among institutionalized older people: Randomized controlled trial

Introducción. En el anciano institucionalizado con limitación funcional se evidencia una mayor reducción de la funcionalidad de la musculatura respiratoria (MR). Los objetivos de este estudio son evaluar los resultados y costes de una intervención de entrenamiento de la MR mediante Pranayama en población anciana institucionalizada con limitación funcional. Material y métodos. Estudio controlado aleatorizado desarrollado en ancianos institucionalizados con limitación para la deambulación (n = 54). La intervención consistió en el entrenamiento de la MR mediante Pranayama, durante 6 semanas (5 sesiones/semana). Los resultados se midieron en relación con la función de la MR mediante las presiones inspiratoria y espiratoria máximas y la ventilación máxima voluntaria, en 4 tiempos. También se valoró la satisfacción percibida por el grupo experimental (GE) a través de un cuestionario ad hoc. Se estimaron los costes directos e indirectos de la intervención desde la perspectiva social. Resultados. El GE reveló una mejora significativa de la fuerza (presiones inspiratoria y espiratoria máximas) y de la resistencia (ventilación máxima voluntaria) de la MR. Además, un 92% del GE refirió una satisfacción alta. Los costes sociales totales, directos e indirectos, ascendieron a 21.678 Euros. Conclusiones. Esta evaluación revela que los resultados en términos de la función de la MR son significativos, que la intervención es bien tolerada y valorada por el residente, y los costes de la intervención son moderados (AU)

Introduction. The institutionalized elderly with functional impairment show a greater decline in respiratory muscle (RM) function. The aims of the study are to evaluate outcomes and costs of RM training using Pranayama in institutionalized elderly people with functional impairment. Material and methods. A randomized controlled trial was conducted on institutionalized elderly people with walking limitation (n = 54). The intervention consisted of 6 weeks of Pranayama RM training (5 times/week). The outcomes were measured at 4 time points, and were related to RM function: the maximum respiratory pressures and the maximum voluntary ventilation. Perceived satisfaction in the experimental group (EG) was assessed by means of an ad hoc questionnaire. Direct and indirect costs were estimated from the social perspective. Results. The GE showed a significant improvement related with strength (maximum respiratory pressures) and endurance (maximum voluntary ventilation) of RM. Moreover, 92% of the EG reported a high satisfaction. The total social costs, direct and indirect, amounted to Euros 21,678. Conclusions. This evaluation reveals that RM function improvement is significant, that intervention is well tolerated and appreciated by patients, and the intervention costs are moderate (AU)

Ácido tranexámico en cirugía ortopédica / Tranexamic acid in orthopedic surgery

El sangrado perioperatorio en ocasiones conduce a transfusiones sanguíneas no exentas de complicaciones y riesgos, con un alto gasto sanitario. Entre otros métodos de prevención, el tratamiento con ácido tranexámico (TXA) ha mostrado ser efectivo en la disminución de las pérdidas sanguíneas quirúrgicas y especialmente en el postoperatorio inmediato. Al respecto, los estudios que lo han evaluado en cirugía ortopédica muestran su eficacia y seguridad, administrado por vía tanto intravenosa como intraarticular. Las dosis habituales por vía intravenosa evaluadas oscilan entre 10 y 20 mg/kg, o en dosis fijas de 1 a 2 g, mientras por vía intraarticular varía entre 250 mg y 3 g. El TXA como antifibrinolítico tiene un potencial efecto trombótico y está contraindicado en aquellos pacientes con riesgo o antecedentes de trombosis. Su administración por vía tópica podría ser más segura aunque se precisan estudios que lo confirmen (AU)

Perioperative bleeding may require blood transfusions, which are sometimes not without complications and risks, with the subsequent increase in health care costs. Among other prevention methods, treatment with tranexamic acid (ATX) has shown to be effective in reducing surgical blood loss, especially in the immediate postoperative period. In this regard, studies evaluating ATX in orthopedic surgery show that it is effective and safe when administered intravenously or intra-articularly. The usual evaluated intravenous doses range between 10 mg/Kg and 20 mg/kg or a fixed dose of 1 g to 2 g; while intra-articularly, it varies between 250 mg and 3 g. ATX, as an anti-fibrinolytic has a potential thrombotic effect, thus it is contraindicated in those patients at risk or with a history of thrombosis. Its topical administration may be safer, but studies are needed to confirm this (AU)

A cost-utility analysis of alternative drug regimens for newly diagnosed severe lupus nephritis patients in Thailand.

OBJECTIVE: The aim of this study was to assess the value of four drug regimens for newly diagnosed severe LN from a societal perspective. METHODS: A model-based cost-utility analysis was devised to measure lifetime costs and health outcomes. Current treatment options consisting of different combinations of i.v. CYC, AZA and MMF were compared with a baseline regimen of i.v. CYC in both the induction and maintenance phases. Resource use and costs were derived from medical records reviews and databases. Event rates were elicited from randomized controlled trials. Relative treatment effects were obtained from meta-analyses. Health utilities were obtained from a real cohort of patients to estimate the outcome of quality-adjusted life years. RESULTS: It was found that a treatment regimen that combined i.v. CYC in the induction phase with AZA in the maintenance phase was cost saving compared with the baseline regimen. Treatment with i.v. CYC in the induction phase and MMF in the maintenance phase and treatment with MMF in the induction phase and a reduced dose of the same in the maintenance phase turned out to be a negatively dominated regimen. CONCLUSION: In the Thai context, the combination of i.v. CYC for the induction phase followed by AZA for the maintenance phase should be considered as the first-line therapy for newly diagnosed severe LN, as it seems to be the most cost-saving regimen.

Análise dos custos de pacientes internados na Santa Casa Misericórdia de Campo Grande, tratados com e sem auxílio de oxigenoterapia hiperbárica / Cost analysis in patients admitted to the Santa Casa Misericórdia de Campo Grande, treated with and without the aid of hyperbaric oxygen therapy

INTRODUÇÃO: As queimaduras estão entre as principais causas externas de morte no Brasil, geram enormes gastos financeiros e são responsáveis por sequelas físicas, psicológicas e sociais. O Objetivo deste estudo foi comparar os dois grupos de pacientes queimados com e sem tratamento coadjuvante com Oxigenoterapia Hiperbárica, assim como, realizar uma análise dos custos. MÉTODOS: Foi realizado estudo retrospectivo, período de 2011 a 2013, selecionando, 20 pacientes com queimaduras moderadas e graves, internados na Santa Casa de Misericórdia de Campo Grande, tratados com auxílio de OHB (grupo I) e 22 pacientes sem auxílio de OHB (grupo II). RESULTADOS: A maioria dos pacientes pertencia ao sexo masculino, 24 pacientes (57,1%). O agente etiológico mais frequente nos dois grupos foi produtos inflamáveis com 56,6% dos casos. A idade média do grupo I foi de 26,6 e a do grupo II 23,3, predominando a faixa etária entre 13 e 35 anos 50,4% dos pacientes. Custo médio final por paciente do Grupo I foi R$17.292,00, e grupo II R$25.360 (p=0,028). CONCLUSÃO: Concluímos que, no nosso serviço, o grupo de pacientes com queimaduras moderadas e graves tratados com auxílio da Oxigenioterapia Hiperbárica teve um menor número de procedimentos cirúrgicos, como enxertos e desbridamento, e menor tempo de internação, levando a uma economia importante dos gastos hospitalares.

INTRODUCTION: Burns are among the leading external causes of death in Brazil, generating huge costs and having physical, psychological, and social consequences. The objective of this study was to compare two groups of burn patients, i.e., those with and those without adjuvant treatment with hyperbaric oxygen (HBO) therapy and to perform a cost analysis. METHODS: A retrospective study was carried out between 2011 and 2013, comparing 20 patients with moderate to severe burns who were hospitalized at the Santa Casa de Misericórdia de Campo Grande and treated with HBO (group I) and 22 patients treated without HBO (group II). RESULTS: Most of the patients, i.e., 24 (57.1%), were male. Flammable product was the most frequent etiologic agent in both groups, accounting for 56.6% of the burn cases. The average age of group I patients was of 26.6 years and that of group II was of 23.3 years, with a prevalence (50.4%) of those aged between 13 and 35 years. The average final cost per patient was R$17,292.00 for group I and R$25,360 for group II (p = 0.028). CONCLUSION: We conclude that, in our service, patients presenting moderate and severe burns and treated with HBO therapy underwent a lower number of surgical procedures, e.g., grafts and debridement that allowed reduced hospitalization time and led to significant savings in hospital costs.

Cost-utility analysis of a telerehabilitation program: a case study of COPD patients.

OBJECTIVE: The present study seeks to conduct cost-utility analysis (CUA) of the Danish TELEKAT (Telehomecare, Chronic Patients and the Integrated Healthcare System) project. The TELEKAT project seeks to test and develop a preventive home monitoring concept across sectors for chronic obstructive pulmonary disease (COPD) patients. The concept of the TELEKAT project is to reduce admissions by enabling the COPD patients to conduct self-monitoring and maintain rehabilitation activities in their own home. COPD patients with severe and very severe COPD were included in the study. SUBJECTS AND METHODS: This economic evaluation follows international guidelines for the conduction of a CUA alongside a clinical randomized controlled trial. The analysis is based on a health sector perspective. RESULTS: The mean incremental cost efficiency ratio, located in the southeast quadrant, shows that telerehabilitation is less costly and more effective than the rehabilitation given to the control group. The telerehabilitation program produces more value for money and generates savings on healthcare budgets. CONCLUSIONS: The telerehabilitation program appears to be more cost-effective than the conventional rehabilitation program for COPD patients. Further studies of cost-effectiveness with a focus on large-scale studies are needed.

Cost-analysis of PCR-guided pre-emptive antibiotic treatment of Staphylococcus aureus infections: an analytic decision model.

The aim of this study is to examine whether rapid polymerase chain reaction (PCR)-based screening is a cost-efficient tool to optimize pre-emptive antibiotic therapy of methicillin-resistant and methicillin-sensitive Staphylococcus aureus (MRSA and MSSA, respectively) infections. A decision analytic cost model was developed, based on data from the peer-reviewed literature. Sensitivity analyses were undertaken to investigate the impact of variation in the MRSA rate, cost ratio of the cost of inappropriate antibiotic therapy to the cost of appropriate antibiotic therapy, PCR test cost, and total hospital costs per case. At a current MRSA rate of 24.5 % in Germany, PCR-guided treatment regimens are cost-efficient compared to empirical strategies. The costs of alternative treatment strategies differ, on average, up to 1,780 per case. An empirical MRSA treatment strategy is least costly when the cost ratio is less than 1.06. When the total hospital cost per MRSA case is increased, pre-emptive MSSA treatment with PCR tests achieves the lowest average cost. Early verification and adaptation of an initial pre-emptive antibiotic treatment of S. aureus infections using PCR-based tests are advantageous in Germany and other European countries. PCR tests, accordingly, should be considered as elements in antimicrobial stewardship programs.

Entrenamiento de los músculos respiratorios: ¿sí o no? / Respiratory muscle training: yes or no?

Introducción Existen numerosos ensayos clínicos y experimentales que han puesto en evidencia los beneficios del entrenamiento de los músculos respiratorios (EMR) en pacientes con enfermedades crónicas respiratorias o extrapulmonares. Específicamente, estos estudios han demostrado que el entrenamiento de músculos inspiratorios y espiratorios mediante la respiración ante cargas específicas y controladas produce beneficios funcionales clínicamente relevantes, predecibles y mesurables. A pesar de esta relativa plétora de información respecto a la función y a la estructura muscular respiratoria, hay todavía algunos interrogantes pendientes de contestar que parecen justificar la controversia entre defensores y detractores del EMR. Objetivo El objetivo de este trabajo es revisar críticamente la información disponible para ofrecer un instrumento de consenso basado en la evidencia que oriente el EMR hacia decisiones clínicas y farmacoeconómicas relevantes. Conclusión Este artículo se centra en 5 grupos de cuestiones en los campos de la investigación fisiopatológica, básica, clínica, traslacional y farmacoeconómica del EMR en pacientes con enfermedades respiratorias y en atletas de élite(AU)

Introduction It is clear that circumstantial, experimental and clinical trial evidences support respiratory muscle training as a beneficial strategy in patients with chronic respiratory disease. In recent years, a number of studies have demonstrated that, when training loads are controlled, inspiratory and expiratory muscle training result in important functional benefits. Nevertheless, despite this relative plethora of information regarding not only respiratory muscle function but also structure, there are critical and valuable questions that still remain to be answered and appear to stimulate controversies around the rationale for respiratory muscle training. These controversies translate into the fact that respiratory muscle training has both detractors and defenders in the context of rehabilitation. Objective One critical point is how detractors and defenders can reach an evidence-based consensus to orientate respiratory muscle training towards clinically and pharmaco-economically relevant decisions. Conclusion This article focuses in five groups of questions on the fields of physiopathological, basic, clinical, and pharmaco-economic research regarding respiratory muscle training in patients with respiratory diseases and elite sport athletes(AU)

Cost comparison of curative therapies for localized prostate cancer in Japan: a single-institution experience.

PURPOSE: In addition to open surgery, curative therapies for prostate cancer now include endoscopic surgery and radiation therapies. Because of the expansion and subdivision of treatment methods for prostate cancer, the medical fee point schedule in Japan was revised in fiscal year 2006. We examined changes in medical income and expenditure after this revision of the medical fee system. MATERIALS AND METHODS: We studied income and expenditure, after institution of the new medical fee schedule, for the five types of therapies for prostate cancer performed at our hospital: two surgical therapies (radical retropubic prostatectomy and laparoscopic prostatectomy) and three radiation therapies (three-dimensional conformal radiation therapy, (192)Ir high-dose-rate brachytherapy, and (125)I low-dose-rate brachytherapy). RESULTS: Low-dose-rate brachytherapy was found to be associated with a profit of yen199 per patient. Laparoscopic prostatectomy, a highly advanced medical treatment that the fee revision changed from a partially insured to an insured procedure, yielded a profit of yen75,672 per patient. However, high-dose-rate brachytherapy was associated with a loss of yen654,016 per patient. CONCLUSION: Given the loss in hospital income per patient undergoing high-dose-rate brachytherapy, the medical fee point system for this procedure should be reassessed.

Technical and economic feasibility of gradual concentric chambers reactor for sewage treatment in developing countries

A major challenge in developing countries concerning domestic wastewaters is to decrease their treatment costs. In the present study, a new cost-effective reactor called gradual concentric chambers (GCC) was designed and evaluated at lab-scale. The effluent quality of the GCC reactor was compared with that of an upflow anaerobic sludge bed (UASB) reactor. Both reactors showed organic matter removal efficiencies of 90 percent; however, the elimination of nitrogen was higher in the GCC reactor. The amount of biogas recovered in the GCC and the UASB systems was 50 percent and 75 percent of the theoretical amount expected, respectively, and both reactors showed a slightly higher methane production when the feed was supplemented with an additive based on vitamins and minerals. Overall, the economical analysis, the simplicity of design and the performance results revealed that the GCC technology can be of particular interest for sewage treatment in developing countries.

Adherence and costs of micronutrient supplementation in pregnancy in a double-blind, randomized, controlled trial in rural western China.

BACKGROUND: Efforts to determine the impact of prenatal multivitamin supplementation on birth outcome have been carried out in several developing countries. A review of factors that would impact the effectiveness of prenatal supplementation under normal field conditions is currently lacking and will be required for expanded supplementation programs. An efficacy trial of a multiple micronutrient supplement for pregnant women was conducted in rural western China, and additional information on side effects, rates of adherence, program inputs, and cost was also gathered. OBJECTIVES: To examine reports of side effects and rates of adherence to prenatal multiple micronutrient supplementation in comparison with supplementation with folic acid and with iron-folic acid, and to describe inputs and costs associated with prenatal supplementation in China. METHODS: A cluster-randomized, double-blind, controlled trial was conducted in two rural counties in northwest China. All pregnant women in villages were randomly assigned to take daily supplements of folic acid, iron-folic acid, or a recommended daily allowance of 15 vitamins and minerals from enrollment until delivery. Information was collected from the women on side effects and adherence. Program inputs and costs of supplementation were tracked. Descriptive statistics were used for the analysis. The biological effectiveness of prenatal multiple micronutrient supplements is reported elsewhere. RESULTS: Less than 4% of women withdrew from the study because of side effects. Adherence to supplementation was high: the supplements were consumed on more than 90% of the days on which they were available for consumption. The mean number of supplements consumed was high at 165 capsules, and about 40% consumed the recommended 180 supplements during pregnancy. CONCLUSIONS: High adherence to a prenatal supplement schedule can be achieved when mothers have frequent contact with trained health workers and a reliable supply of supplements.

Cost implications of improving the quality of child care using integrated clinical algorithms: evidence from Northeast Brazil.

OBJECTIVES: Previous research has shown that providers trained in the Integrated Management of Childhood Illness offered higher quality care for under-fives than those providing routine care in several settings including Northeast Brazil. The objective of this paper is to examine if such quality improvements adds to total costs or is cost saving. METHODS: The additional costs associated with treating children based on IMCI clinical algorithms in northeast Brazil are estimated by comparing the total costs of under-five care in 22 municipalities with IMCI with 22 matched municipalities providing routine care. Multivariate analysis was also used to isolate the effect of IMCI on costs at primary facilities, controlling for other possible determinants. RESULTS: For 2001, there was no statistically significant difference in the cost per child of caring for under-fives in IMCI municipalities (US$ 95) relative to the comparison municipalities (US$ 98). Moreover, IMCI training had no independent effect on unit costs at primary facilities, the largest component in overall costs per child (79%). Case load was the most important determinant. CONCLUSION: Our findings suggest that scaling up IMCI-based care could increase child health outcomes in Brazil without increasing overall health costs.