Cost-effectiveness of implementing risk-based cardiovascular disease (CVD) management using updated WHO CVD risk prediction charts in India.

INTRODUCTION: The World Health Organization (WHO) has released the updated cardiovascular disease (CVD) risk prediction charts in 2019 for each of the 21 Global Burden of Disease regions. The WHO advocates countries to implement population-based CVD risk assessment and management using these updated charts for preventing and controlling CVDs. OBJECTIVE: To assess the cost-effectiveness of implementing risk-based CVD management using updated WHO CVD risk prediction charts in India. METHODS: We developed a decision tree combined with Markov Model to simulate implementing two community-based CVD risk screening strategies (interventions) compared with the current no-screening scenario. In the first strategy, the whole population is initially screened using the WHO non-lab-based CVD risk assessment method, and those with ≥10% CVD risk are subjected to WHO lab-based CVD risk assessment (two-stage screening). In the second strategy, the whole population is subjected only to the lab-based CVD risk assessment (single-stage screening). A mathematical cohort of those aged ≥40 years with no history of CVD events was simulated over a lifetime horizon with three months of cycle length. Data for the model were derived from a primary study and secondary sources. Incremental cost-effectiveness ratios (ICERs) were determined for the screening strategies and sensitivity analyses. RESULTS: The discounted Incremental cost-effectiveness ratio per QALY gained for both the two-stage (US$ 105; ₹ 8,656) and single-stage (US$ 1073; ₹ 88,588) screening strategies were cost-effective at an implementation effect of 40% when compared with no screening scenario. Implementing CVD screening strategies are estimated to cause substantial reduction in the number of CVD events in the population compared to the no screening scenario. CONCLUSION: In India, both CVD screening strategies would be cost-effective, and implementing the two-staged screening would be more cost-effective. Our findings support implementing population-based CVD screening in India. Future studies shall assess the budget impact of these strategies at different implementation coverage levels.

Adaptive Health Technology Assessment: A Scoping Review of Methods.

OBJECTIVES: Health technology assessment (HTA) is an established mechanism for explicit priority setting to support universal health coverage. However, full HTA requires significant time, data, and capacity for each intervention, which limits the number of decisions it can inform. Another approach systematically adapts full HTA methods by leveraging HTA evidence from other settings. We call this "adaptive" HTA (aHTA), although in settings where time is the main constraint, it is also called "rapid HTA." METHODS: The objectives of this scoping review were to identify and map existing aHTA methods, and to assess their triggers, strengths, and weaknesses. This was done by searching HTA agencies' and networks' websites, and the published literature. Findings have been narratively synthesized. RESULTS: This review identified 20 countries and 1 HTA network with aHTA methods in the Americas, Europe, Africa, and South-East Asia. These methods have been characterized into 5 types: rapid reviews, rapid cost-effectiveness analyses, rapid manufacturer submissions, transfers, and de facto HTA. Three characteristics "trigger" the use of aHTA instead of full HTA: urgency, certainty, and low budget impact. Sometimes, an iterative approach to selecting methods guides whether to do aHTA or full HTA. aHTA was found to be faster and more efficient, useful for decision makers, and to reduce duplication. Nevertheless, there is limited standardization, transparency, and measurement of uncertainty. CONCLUSIONS: aHTA is used in many settings. It has potential to improve the efficiency of any priority-setting system, but needs to be better formalized to improve uptake, particularly for nascent HTA systems.

Resource use, availability and cost in the provision of critical care in Tanzania: a systematic review.

OBJECTIVES: Critical care is essential in saving lives of critically ill patients, however, provision of critical care across lower resource settings can be costly, fragmented and heterogenous. Despite the urgent need to scale up the provision of critical care, little is known about its availability and cost. Here, we aim to systematically review and identify reported resource use, availability and costs for the provision of critical care and the nature of critical care provision in Tanzania. DESIGN: This is a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA SOURCES: Medline, Embase and Global Health databases were searched covering the period 2010 to 17 November 2020. ELIGIBILITY CRITERIA: We included studies that reported on forms of critical care offered, critical care services offered and/or costs and resources used in the provision of care in Tanzania published from 2010. DATA EXTRACTION AND SYNTHESIS: Quality assessment of the articles and data extraction was done by two independent researchers. The Reference Case for Estimating the Costs of Global Health Services and Interventions was used to assess quality of included studies. A narrative synthesis of extracted data was conducted. Costs were adjusted and reported in 2019 US$ and TZS using the World Bank GDP deflators. RESULTS: A total 31 studies were found to fulfil the inclusion and exclusion criteria. Critical care identified in Tanzania was categorised into: intensive care unit (ICU) delivered critical care and non-ICU critical care. The availability of ICU delivered critical care was limited to urban settings whereas non-ICU critical care was found in rural and urban settings. Paediatric critical care equipment was more scarce than equipment for adults. 15 studies reported on the costs of services related to critical care yet no study reported an average or unit cost of critical care. Costs of medication, equipment (eg, oxygen, personal protective equipment), services and human resources were identified as inputs to specific critical care services in Tanzania. CONCLUSION: There is limited evidence on the resource use, availability and costs of critical care in Tanzania. There is a strong need for further empirical research on critical care resources availability, utilisation and costs across specialties and hospitals of different level in low/middle-income countries like Tanzania to inform planning, priority setting and budgeting for critical care services. PROSPERO REGISTRATION NUMBER: CRD42020221923.

Role of healthcare cost accounting in pricing and reimbursement in low-income and middle-income countries: a scoping review.

OBJECTIVES: Progress towards universal health coverage (UHC) requires evidence-based policy including good quality cost data systems. Establishing these systems can be complex, resource-intensive and take time. This study synthesises evidence on the experiences of low-income and middle-income countries (LMICs) in the institutionalisation of cost data systems to derive lessons for the technical process of price-setting in the context of UHC. DESIGN: A scoping review and narrative synthesis of publicly available information. DATA SOURCES: PubMed, MEDLINE, EconLit, the Web of Science and grey literature searched from January 2000 to April 2021. ELIGIBILITY CRITERIA: English-language papers published since 2000 that identified and/or described development of and/or methods used to estimate or inform national tariffs for hospital reimbursement in LMICs. Papers were screened by two independent reviewers. DATA EXTRACTION AND SYNTHESIS: Extraction was performed by one reviewer and checked by the second reviewer on: the method and outputs of cost data collection; commentary on the use of cost data; description of the technical process of tariff setting; and strengths and challenges of the approach. Evidence was summarised using narrative review. RESULTS: Thirty of 484 papers identified were eligible. Fourteen papers reported on primary cost data collection; 18 papers explained how cost evidence informs tariff-setting. Experience was focused in Asia (n=22) with countries at different stages of developing cost systems. Experiences on cost accounting tend to showcase country costing experiences, methods and implementation. There is little documentation how data have been incorporated into decision making and price setting. Where cost information or cost systems have been used, there is improved transparency in decision making alongside increased efficiency. CONCLUSIONS: There are widely used and accepted methods for generating cost information. Countries need to build sustainable cost systems appropriate to their settings and budgets and adopt transparent processes and methodologies for translating costs into prices.

Models of COVID-19 vaccine prioritisation: a systematic literature search and narrative review.

BACKGROUND: How best to prioritise COVID-19 vaccination within and between countries has been a public health and an ethical challenge for decision-makers globally. We reviewed epidemiological and economic modelling evidence on population priority groups to minimise COVID-19 mortality, transmission, and morbidity outcomes. METHODS: We searched the National Institute of Health iSearch COVID-19 Portfolio (a database of peer-reviewed and pre-print articles), Econlit, the Centre for Economic Policy Research, and the National Bureau of Economic Research for mathematical modelling studies evaluating the impact of prioritising COVID-19 vaccination to population target groups. The first search was conducted on March 3, 2021, and an updated search on the LMIC literature was conducted from March 3, 2021, to September 24, 2021. We narratively synthesised the main study conclusions on prioritisation and the conditions under which the conclusions changed. RESULTS: The initial search identified 1820 studies and 36 studies met the inclusion criteria. The updated search on LMIC literature identified 7 more studies. 43 studies in total were narratively synthesised. 74% of studies described outcomes in high-income countries (single and multi-country). We found that for countries seeking to minimise deaths, prioritising vaccination of senior adults was the optimal strategy and for countries seeking to minimise cases the young were prioritised. There were several exceptions to the main conclusion, notably that reductions in deaths could be increased if groups at high risk of both transmission and death could be further identified. Findings were also sensitive to the level of vaccine coverage. CONCLUSION: The evidence supports WHO SAGE recommendations on COVID-19 vaccine prioritisation. There is, however, an evidence gap on optimal prioritisation for low- and middle-income countries, studies that included an economic evaluation, and studies that explore prioritisation strategies if the aim is to reduce overall health burden including morbidity.

Resource availability, utilisation and cost in the provision of critical care in Tanzania: a protocol for a systematic review.

INTRODUCTION: Critical care is essential in saving lives of those that are critically ill, however, provision of critical care can be costly and heterogeneous across lower-resource settings. This paper describes the protocol for a systematic review of the literature that aims to identify the reported costs and resources available for the provision of critical care and the forms of critical care provision in Tanzania. METHODS AND ANALYSIS: The review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three databases (MEDLINE, Embase and Global Health) will be searched to identify articles that report the forms of critical care, resources used in the provision of critical care in Tanzania, their availability and the associated costs. The search strategy will be developed from four key concepts; critical care provision, critical illness, resource use, Tanzania. The articles that fulfil the inclusion and exclusion criteria will be assessed for quality using the Reference Case for Estimating the Costs of Global Health Services and Interventions checklist. The extracted data will be summarised using descriptive statistics including frequencies, mean and median of the quantity and costs of resources used in the components of critical care services, depending on the data availability. This study will be carried out between February and November 2021. ETHICS AND DISSEMINATION: This study is a review of secondary data and ethical clearance was sought from and granted by the Tanzanian National Institute of Medical Research (reference: NIMR/HQ/R.8a/Vol. IX/3537) and London School of Hygiene and Tropical Medicine (ethics ref: 22866). We will publish the review in a peer-reviewed journal as an open access article in addition to presenting the findings at conferences and public scientific gatherings. PROSPERO REGISTRATION NUMBER: The protocol was registered with PROSPERO; registration number: CRD42020221923.

The clinical and cost-effectiveness of supplemental parenteral nutrition in oncology.

BACKGROUND: Clinical guidelines recommend that parenteral nutrition (PN) is added to enteral nutrition (EN; supplemental parenteral nutrition (SPN)) in order to meet energy and protein needs in patients with cancer when EN alone is insufficient. However, although cancer-related malnutrition is common, there is poor awareness of the value of nutritional care, resulting in SPN being chronically underused. METHODS: We performed a targeted literature review and exploratory cost-utility analysis to gather evidence on the clinical effectiveness of SPN, and to estimate the potential cost-effectiveness of SPN versus EN alone in an example cancer setting. RESULTS: The literature review identified studies linking SPN with malnutrition markers, and studies linking malnutrition markers with clinical outcomes. SPN was linked to improvements in body mass index (BMI), fat-free mass, phase angle (PhA) and prealbumin. Of these markers, BMI and PhA were strong predictors of survival. By combining published data, we generated indirect estimates of the overall survival HR associated with SPN; these ranged from 0.80 to 0.99 (mode 0.87). In patients with Stage IV inoperable pancreatic cancer, the incremental cost-effectiveness ratio versus EN alone was estimated to be £41 350 or £91 501 depending on whether nursing and home delivery costs for EN and SPN were combined or provided separately. CONCLUSION: Despite a lack of direct evidence, the results of the literature review demonstrate that SPN may provide important clinical and quality of life benefits to patients with cancer. The potential for any improvement in outcomes in the modelled patient population is very limited, so cost-effectiveness may be greater in patients with less severe disease and other types of cancer.