Cost analysis of large-scale implementation of the 'Helping Babies Breathe' newborn resuscitation-training program in Tanzania.

BACKGROUND: Helping Babies Breathe (HBB) has become the gold standard globally for training birth-attendants in neonatal resuscitation in low-resource settings in efforts to reduce early newborn asphyxia and mortality. The purpose of this study was to do a first-ever activity-based cost-analysis of at-scale HBB program implementation and initial follow-up in a large region of Tanzania and evaluate costs of national scale-up as one component of a multi-method external evaluation of the implementation of HBB at scale in Tanzania. METHODS: We used activity-based costing to examine budget expense data during the two-month implementation and follow-up of HBB in one of the target regions. Activity-cost centers included administrative, initial training (including resuscitation equipment), and follow-up training expenses. Sensitivity analysis was utilized to project cost scenarios incurred to achieve countrywide expansion of the program across all mainland regions of Tanzania and to model costs of program maintenance over one and five years following initiation. RESULTS: Total costs for the Mbeya Region were $202,240, with the highest proportion due to initial training and equipment (45.2%), followed by central program administration (37.2%), and follow-up visits (17.6%). Within Mbeya, 49 training sessions were undertaken, involving the training of 1,341 health providers from 336 health facilities in eight districts. To similarly expand the HBB program across the 25 regions of mainland Tanzania, the total economic cost is projected to be around $4,000,000 (around $600 per facility). Following sensitivity analyses, the estimated total for all Tanzania initial rollout lies between $2,934,793 to $4,309,595. In order to maintain the program nationally under the current model, it is estimated it would cost $2,019,115 for a further one year and $5,640,794 for a further five years of ongoing program support. CONCLUSION: HBB implementation is a relatively low-cost intervention with potential for high impact on perinatal mortality in resource-poor settings. It is shown here that nationwide expansion of this program across the range of health provision levels and regions of Tanzania would be feasible. This study provides policymakers and investors with the relevant cost-estimation for national rollout of this potentially neonatal life-saving intervention.

The future of monitoring in clinical research - a holistic approach: linking risk-based monitoring with quality management principles.

Since several years risk-based monitoring is the new "magic bullet" for improvement in clinical research. Lots of authors in clinical research ranging from industry and academia to authorities are keen on demonstrating better monitoring-efficiency by reducing monitoring visits, monitoring time on site, monitoring costs and so on, always arguing with the use of risk-based monitoring principles. Mostly forgotten is the fact, that the use of risk-based monitoring is only adequate if all mandatory prerequisites at site and for the monitor and the sponsor are fulfilled.Based on the relevant chapter in ICH GCP (International Conference on Harmonisation of technical requirements for registration of pharmaceuticals for human use - Good Clinical Practice) this publication takes a holistic approach by identifying and describing the requirements for future monitoring and the use of risk-based monitoring. As the authors are operational managers as well as QA (Quality Assurance) experts, both aspects are represented to come up with efficient and qualitative ways of future monitoring according to ICH GCP.

Strategy for the treatment of chronic leg wounds: a new model in Poland.

AIM: The aim of the present study was to implement and evaluate a system of care for patients with chronic leg ulceration (CLU) in Poland. METHODS: All patients within two defined geographical areas in Poland were identified for inclusion in the study. A model of care was developed based on guidelines, including the appropriate education of health professionals treating patients, access to non-invasive methods to determine the ulcer aetiology, compression therapy in those with proven venous ulceration. RESULTS: In total 309 patients were identified with CLU at the start of the study (120 men, 189 women). Both regions had a similar profile of patients having a median (IQR) duration of ulceration of 96 (30-168) months. Most (75.7%) patients were assessed using clinical signs and symptoms alone, with a mean (SD) number of treatments per week at 1.8 (1.9) visits. Two years after implementation, the numbers of patients had reduced to 205 (86 men, 119 women) a reduction of 33%. Post implementation more patients were treated at home (49.3% versus 19.5%) with a corresponding reduction in those seen at health centres (35.6% versus 63.3%). The mean (SD) number of visits was reduced to 1.3 (0.7). During implementation the healing rate at 30 weeks improved from 73.3% to 82.9%, with a corresponding reduction in amputations from 6.3% to 2.1%. While the cost per patient was higher post-implementation, the overall cost of treating patients within the service reduced from €3847 to €2913 per week. CONCLUSION: The development and implementation of an evidence based system of care for patients with CLU in Poland is both clinically and cost effective. This may be used as a model for other regions of Poland.

Is computer aided detection (CAD) cost effective in screening mammography? A model based on the CADET II study.

BACKGROUND: Single reading with computer aided detection (CAD) is an alternative to double reading for detecting cancer in screening mammograms. The aim of this study is to investigate whether the use of a single reader with CAD is more cost-effective than double reading. METHODS: Based on data from the CADET II study, the cost-effectiveness of single reading with CAD versus double reading was measured in terms of cost per cancer detected. Cost (Pound (£), year 2007/08) of single reading with CAD versus double reading was estimated assuming a health and social service perspective and a 7 year time horizon. As the equipment cost varies according to the unit size a separate analysis was conducted for high, average and low volume screening units. One-way sensitivity analyses were performed by varying the reading time, equipment and assessment cost, recall rate and reader qualification. RESULTS: CAD is cost increasing for all sizes of screening unit. The introduction of CAD is cost-increasing compared to double reading because the cost of CAD equipment, staff training and the higher assessment cost associated with CAD are greater than the saving in reading costs. The introduction of single reading with CAD, in place of double reading, would produce an additional cost of £227 and £253 per 1,000 women screened in high and average volume units respectively. In low volume screening units, the high cost of purchasing the equipment will results in an additional cost of £590 per 1,000 women screened.One-way sensitivity analysis showed that the factors having the greatest effect on the cost-effectiveness of CAD with single reading compared with double reading were the reading time and the reader's professional qualification (radiologist versus advanced practitioner). CONCLUSIONS: Without improvements in CAD effectiveness (e.g. a decrease in the recall rate) CAD is unlikely to be a cost effective alternative to double reading for mammography screening in UK. This study provides updated estimates of CAD costs in a full-field digital system and assessment cost for women who are re-called after initial screening. However, the model is highly sensitive to various parameters e.g. reading time, reader qualification, and equipment cost.

The effect of interrupted 5-day training on Integrated Management of Neonatal and Childhood Illness on the knowledge and skills of primary health care workers.

The conventional 8-day Integrated Management of Neonatal and Childhood Illness (IMNCI) training package poses several operational constraints, particularly due to its long duration. A 5-day training package was developed and administered in an interrupted mode of 3 days and 2 days duration with a break of 4 days in-between, in a district of Haryana state in northern India. Improvement in the knowledge and skills of 50 primary health care workers following the interrupted 5-day training was compared with that of 35 primary health care workers after the conventional 8-day IMNCI training package. The average score increased significantly (P < 0.05) from 46.3 to 74.6 in 8-day training and from 40.0 to 73.2 in 5-day training. Knowledge score improved for all health conditions, like anaemia, diarrhoea, immunization, malnutrition, malaria, meningitis and possible severe bacterial infection, and for breastfeeding in 8-day as well as in 5-day training. Average skills score for respiratory problems increased from 38 to 57 in 8-day training and from 41 to 91 in 5-day training. Corresponding increases in skill scores for diarrhoea assessment were from 28 to 67 and 48 to 75, and for breastfeeding assessment from 33 to 84 and 42 to 86 in 8-day and 5-day training, respectively. Average counselling skill score also rose from 42 to 89 in 8-day and from 37 to 70 in 5-day training. A direct cost saving of US$813 for a batch of 25 trainees and an indirect cost saving of 3 days per trainee and resource person makes the interrupted 5-day IMNCI training more cost-effective.

[Dynamic evaluation of the effects of quality management]. / Dynamische Evaluierung der Effekte von Qualitätsmanagement.

PURPOSE: Evaluation of the effects of quality management over time at a radiology department. MATERIALS AND METHODS: Data concerning the performance of the department, entered on a monthly basis, will be compared with entries in the error report system on the basis of time series analysis (regression models taking seasons and auto-correlation effects into account). The observation period consists of 46 homogeneous monthly time pulses. RESULTS: Effects of the suggestions and the total number of reports in the quality assurance system on the performance of the department can be observed with a two-month delay. This association is statistically highly significant (p < 0.01) and, because of the procedures used, not attributable to general developmental trends, seasonal fluctuations or autoregressive processes. CONCLUSION: Evaluation of quality assurance measures is a well justified demand and should be based on the analysis of data collected from quality assurance systems operating on a continuous basis over a long period of time. The analysis of data from a radiology department shows that quality assurance is reflected in the performance of the department.

An economic analysis of midwifery training programmes in South Kalimantan, Indonesia.

In order to improve the knowledge and skills of midwives at health facilities and those based in villages in South Kalimantan, Indonesia, three in-service training programmes were carried out during 1995-98. A scheme used for both facility and village midwives included training at training centres, peer review and continuing education. One restricted to village midwives involved an internship programme in district hospitals. The incremental cost-effectiveness of these programmes was assessed from the standpoint of the health care provider. It was estimated that the first scheme could be expanded to increase the number of competent midwives based in facilities and villages in South Kalimantan by 1% at incremental costs of US$ 764.6 and US$ 1175.7 respectively, and that replication beyond South Kalimantan could increase the number of competent midwives based in facilities and villages by 1% at incremental costs of US$ 1225.5 and US$ 1786.4 per midwife respectively. It was also estimated that the number of competent village midwives could be increased by 1% at an incremental cost of US$ 898.1 per intern if replicated elsewhere, and at a cost of US$ 146.2 per intern for expanding the scheme in South Kalimantan. It was not clear whether the training programmes were more or less cost-effective than other safe motherhood interventions because the nature of the outcome measures hindered comparison.

The cost and value of pre-registration clinical placements for Project 2000 students.

The research outlined in this article was commissioned by the Sheffield and North Trent College of Nursing and Midwifery to explore the cost implications of pre-registration clinical placements in the context of Project 2000. The authors outline the methodology and findings of an exercise designed to collect relevant cost information which was not readily available. On the basis of these findings, they suggest that: at 1995/1996 pay and prices, clinical placements cost the education provider approximately pound 890 per student per annum; in terms of real resources, the value to service providers of the service contribution made by second- and third-year nursing and midwifery students on ward-based placements outweighs the value of the time spent by qualified staff on their supervision and education. Once the funding assumptions underlying the introduction of Project 2000 have been taken into account, second- and third-year nursing and midwifery students benefit the service provider by on average pound 3.46 for every hour they spend in an unrostered ward-based placement. The service contribution made by students in community-based clinical placements cannot free staff time in the same way as on the wards and, because qualified staff in these areas are generally more highly graded, the value of the time they spend on the supervision and education of students on placement is higher than in ward-based placements. Second- and third-year students therefore appear to cost the service provider on average pound 0.48 for each hour they spend in a community-based placement. It was not possible to determine whether this cost translates into a reduction in patient contacts.