Economic analysis of a new four-panel rapid screening test in antenatal care in Kenya, Rwanda, and Uganda.

BACKGROUND: We performed an economic analysis of a new technology used in antenatal care (ANC) clinics, the ANC panel. Introduced in 2019-2020 in five Rwandan districts, the ANC panel screens for four infections [hepatitis B virus (HBV), human immunodeficiency virus (HIV), malaria, and syphilis] using blood from a single fingerstick. It increases the scope and sensitivity of screening over conventional testing. METHODS: We developed and applied an Excel-based economic and epidemiologic model to perform cost-effectiveness and cost-benefit analyses of this technology in Kenya, Rwanda, and Uganda. Costs include the ANC panel itself, its administration, and follow-up treatment. Effectiveness models predicted impacts on maternal and infant mortality and other outcomes. Key parameters are the baseline prevalence of each infection and the effectiveness of early treatment using observations from the Rwanda pilot, national and international literature, and expert opinion. For each parameter, we found the best estimate (with 95% confidence bound). RESULTS: The ANC panel averted 92 (69-115) disability-adjusted life years (DALYs) per 1,000 pregnant women in ANC in Kenya, 54 (52-57) in Rwanda, and 258 (156-360) in Uganda. Net healthcare costs per woman ranged from $0.53 ($0.02-$4.21) in Kenya, $1.77 ($1.23-$5.60) in Rwanda, and negative $5.01 (-$6.45 to $0.48) in Uganda. Incremental cost-effectiveness ratios (ICERs) in dollars per DALY averted were $5.76 (-$3.50-$11.13) in Kenya, $32.62 ($17.54-$46.70) in Rwanda, and negative $19.40 (-$24.18 to -$15.42) in Uganda. Benefit-cost ratios were $17.48 ($15.90-$23.71) in Kenya, $6.20 ($5.91-$6.45) in Rwanda, and $25.36 ($16.88-$33.14) in Uganda. All results appear very favorable and cost-saving in Uganda. CONCLUSION: Though subject to uncertainty, even our lowest estimates were still favorable. By combining field data and literature, the ANC model could be applied to other countries.

The Impact of Behavioral Economics-Based Counseling and Mobile Phone Text Educational and Reminder Messages on the Use of Modern Family Planning in Jordan: A Cluster Randomized Controlled Trial.

BACKGROUND: Favorable attitudes toward modern family planning methods (MFPMs) among Jordanian and Syrian women do not always translate into behavioral changes, and the availability and cost of MFPMs do not appear to be related to either prior stalls in fertility rates in Jordan or to the current and likely temporary decline in fertility rates. This study aimed to determine whether behavioral economics (BE)-based family planning interventions influence the use of any family planning method, MFPMs use, continuation of MFPMs use, and pregnancy rates among women in Jordan. The BE-based family planning interventions included personalized text messaging and augmented counseling based on framing and identity-priming BE principles, with their effects tested over a 9-month period in the postpartum period following the birth of a child. METHODS: A parallel-group cluster randomized controlled trial was conducted to compare two interventions, augmented counseling based on framing and identity-priming BE principles and personalized mobile phone text messages reminders, aiming to improve the utilization of MFPMs among postpartum women over status quo family planning services in comprehensive health centers in the north of Jordan. RESULTS: In total, 1032 participated in the study: 295 women in the control group; 326 women in Intervention Group 1, which received only augmented counseling; and 411 women in intervention Group 2, which received augmented counseling and monthly text messages. The rates of using MFPMs in the counseling group and the counseling and messages group 3 months (54.7% and 57.1%, respectively), 6 months (50.0% and 51.7%, respectively), and 9 months (49.5% and 52.0%, respectively) were significantly higher than the rates among women in the control group (40.6% at 3 months, 37.6% at 6 months, and 34.3% at 9 months). Overall, 26.8% of women in the control group, 42.1% of women in the counseling-only group, and 45.2% of women in the counseling and messages group used MFPMs continuously for all 9 months. At 9 months, the pregnancy rate was significantly much higher in the control group (13.7%) compared to women in the counseling-only group (7.0%) and to women in the counseling and messages group (7.4%). CONCLUSIONS: Simple BE-based interventions can be effective methods for enhancing the use of MFPMs and maintaining the anticipated decline in Jordan's total fertility rate.

Cost-Effectiveness of Expanding Access to Primary Health Care in Rural Rwanda by Adding Laboratory-Equipped Health Posts: A Prospective, Controlled Study.

To improve access to affordable primary health care and preventive services, in 2019 Rwanda's Ministry of Health inaugurated eight laboratory-equipped second-generation health posts (SGHPs) in the Bugesera District. Patient fees through Rwanda's insurance system (mutuelles) funded most operational costs through a public-private partnership. This prospective, controlled trial evaluated the posts' impact and cost-effectiveness. Our evaluation matched the rural cells containing these posts to eight control cells in Bugesera without formal health posts. We assessed costs using 2 years of financial data; accessed use statistics at SGHPs, health centers, and in the international literature; interviewed 1,952 randomly selected residents; conducted eight focus groups; and performed difference-in-differences regressions and survival analyses. Second-generation health posts increased primary care use by 1.83 outpatient visits per person per year (P < 0.0001). Of the 10 prevention indicators compared with trends, two improved significantly with SGHPs (two showed nonsignificant improvements), and one indicator experienced a significant deterioration. Second-generation health posts generated health improvements at a low cost and achieved a small, but favorable, 5% margin of revenues over financial costs. Second-generation health posts produced a very favorable incremental cost-effectiveness ratio of only $101 per disability-adjusted life year averted-only 13% of Rwanda's per-capita gross national income. In conclusion, SGHPs improved substantially the quantity of affordable outpatient care per person. However, net impacts on quality and completeness of care and prevention, although favorable, were small. For further improvements in access and quality of care, Rwanda's health authorities may wish to incentivize quality and strengthen coordination with other health system components.

On the cost-effectiveness of insecticide-treated wall liner and indoor residual spraying as additions to insecticide treated bed nets to prevent malaria: findings from cluster randomized trials in Tanzania.

BACKGROUND: Despite widespread use of long-lasting insecticidal nets (LLINs) and other tools, malaria caused 409,000 deaths worldwide in 2019. While indoor residual spraying (IRS) is an effective supplement, IRS is moderately expensive and logistically challenging. In endemic areas, IRS requires yearly application just before the main rainy season and potential interim reapplications. A new technology, insecticide-treated wall liner (ITWL), might overcome these challenges. METHODS: We conducted a 44-cluster two-arm randomized controlled trial in Muheza, Tanzania from 2015 to 2016 to evaluate the cost and efficacy of a non-pyrethroid ITWL to supplement LLINs, analyzing operational changes over three installation phases. The estimated efficacy (with 95% confidence intervals) of IRS as a supplement to LLINs came mainly from a published randomized trial in Muleba, Tanzania. We obtained financial costs of IRS from published reports and conducted a household survey of a similar IRS program near Muleba to determine household costs. The costs of ITWL were amortized over its 4-year expected lifetime and converted to 2019 US dollars using Tanzania's GDP deflator and market exchange rates. RESULTS: Operational improvements from phases 1 to 3 raised ITWL coverage from 35.1 to 67.1% of initially targeted households while reducing economic cost from $34.18 to $30.56 per person covered. However, 90 days after installing ITWL in 5666 households, the randomized trial was terminated prematurely because cone bioassay tests showed that ITWL no longer killed mosquitoes and therefore could not prevent malaria. The ITWL cost $10.11 per person per year compared to $5.69 for IRS. With an efficacy of 57% (3-81%), IRS averted 1162 (61-1651) disability-adjusted life years (DALYs) per 100,000 population yearly. Its incremental cost-effectiveness ratio (ICER) per DALY averted was $490 (45% of Tanzania's per capita gross national income). CONCLUSIONS: These findings provide design specifications for future ITWL development and implementation. It would need to be efficacious and more effective and/or less costly than IRS, so more persons could be protected with a given budget. The durability of a previous ITWL, progress in non-pyrethroid tools, economies of scale and competition (as occurred with LLINs), strengthened community engagement, and more efficient installation and management procedures all offer promise of achieving these goals. Therefore, ITWLs merit ongoing study. FIRST POSTED: 2015 ( NCT02533336 ).

Cost of Dengue Illness in Indonesia across Hospital, Ambulatory, and not Medically Attended Settings.

Informed decisions concerning emerging technologies against dengue require knowledge about the disease's economic cost and each stakeholder's potential benefits from better control. To generate such data for Indonesia, we reviewed recent literature, analyzed expenditure and utilization data from two hospitals and two primary care facilities in Yogyakarta city, and interviewed 67 dengue patients from hospital, ambulatory, and not medically attended settings. We derived the cost of a dengue episode by outcome, setting, and the breakdown by payer. We then calculated aggregate Yogyakarta and national costs and 95% uncertainty intervals (95% UIs). Dengue costs per nonfatal case in hospital, ambulatory, not medically attended, and overall average settings were US$316.24 (95% UI: $242.30-$390.18), US$22.45 (95% UI: $14.12-$30.77), US$7.48 (95% UI: $2.36-$12.60), and US$50.41 (95% UI: $35.75-$65.07), respectively. Costs of nonfatal episodes were borne by the patient's household (37%), social contributors (relatives and friends, 20%), national health insurance (25%), and other sources (government, charity, and private insurance, 18%). After including fatal cases, the average cost per episode became $90.41 (95% UI: $72.79-$112.35). Indonesia had an estimated 7.535 (95% UI: 1.319-16.513) million dengue episodes in 2017, giving national aggregate costs of $681.26 (95% UI: $232.28-$2,371.56) million. Unlike most previous research that examined only the formal medical sector, this study included the estimated 63% of national dengue episodes that were not medically attended. Also, this study used actual costs, rather than charges, which generally understate dengue's economic burden in public facilities. Overall, this study found that Indonesia's aggregate cost of dengue was 73% higher than previously estimated, strengthening the need for effective control.

Embryo donation: Survey of in-vitro fertilization (IVF) patients and randomized trial of complimentary counseling.

DESIGN: This study surveyed patients with stored frozen embryos and developed and tested an intervention through a randomized trial to support subjects to consider embryo disposition options (EDOs), especially donation for family building. METHODS: Based on a review of literature on EDOs, the authors developed and mailed a 2-page anonymous survey to 1,053 patients in Massachusetts (USA) to elicit their feelings about their stored embryos. Target patients had embryos cryopreserved for ≥1 year and had not indicated an EDO. Survey respondents were next randomized between usual care (control arm) or an offer of complimentary counseling and educational support regarding EDOs. These counseling sessions were conducted by a licensed mental health professional specializing in infertility treatment. RESULTS: Despite telephone reminders, only 21.3% of patients responded, likely reflecting most patients' reluctance to address EDOs. Respondents endorsed an average of 2 of the 5 EDOs, with the following percentages supporting each option: store for future attempts (82%), continue storage (79%), donate to research (29%), discard (14%), and donate for family building (13%). When asked their opinions towards embryo donation to another couple, 78% of patients agreed that donation is a way to help another couple, 48% would consider embryo donation to another family if they had a better understanding of the process, and 38% would be willing to consider donation if they were not going to use the embryos themselves, but 73% expressed discomfort with donation. In the randomized trial, 7.8% of intervention subjects (n = 8) obtained counseling sessions compared to 0.0% (none) of usual care subjects (p = 0.0069). Counseling participants valued not only discussing EDOs, but also assistance in expressing their feelings and differences with their partners. CONCLUSION: Improvement in counseling rates over the control arm suggests that free professional counseling is a small, but likely effective, step towards deciding on an EDO. ClinicalTrials.gov Identifier: NCT01883934 (Frozen embryo donation study).

Broken smiles: The impact of untreated dental caries and missing anterior teeth on employment.

OBJECTIVES: We aimed to quantify the impact of dental caries and missing anterior teeth on employment, estimate the impact of a routine dental visit on the health of anterior teeth, and the benefits of expanding dental coverage for nonelderly adults. METHODS: We used the 2013-2014 Continuous National Health and Nutritional Examination Survey to develop a dental problem index (DPI) using tooth counts and tooth surface conditions. We estimated the impact of DPI on employment with logistic regression, controlling for seven demographic and socioeconomic covariates. We used a routine dental visit within 6 months as a proxy for access to dental services, and a linear regression to predict the DPI score for an average individual with and without a recent routine dental visit. We then computed the incremental probability of employment associated with a recent routine dental visit. Finally, we estimated the additional number of working age adults who might become employed due to improved access to dental services. RESULTS: The probability of being employed was negatively associated with poor oral health: a one-point increase in DPI decreased the odds of being employed by 7.70 percent (CI: 5.15-10.19%). Having a routine dental visit had a negative and statistically significant impact on DPI [-0.41 (CI: -0.68 to -0.14)]. The incremental probability of employment associated with a routine dental visit was 0.62 percent (CI: 0.21-1.03%). CONCLUSIONS: Oral health in the United States is worse among minorities and poor than among other residents. The benefits associated with access to dental care should justify expanding dental services.

How useful are current caries risk assessment tools in informing the oral health care decision-making process?

BACKGROUND: Caries risk assessment (CRA) tools could address oral health disparities and enhance the efficiency of the oral health care system. The authors aimed to explore the feasibility and limitations of using clinical CRA tools in informing oral health care policy-making processes. METHODS: The authors used the National Health and Nutrition Examination Survey to construct 10 CRA models from a sample of clinical CRA tools identified from the literature. They used these models to estimate the proportion of publicly insured people aged 1 through 20 years categorized as at low, moderate, and high risk, and they projected their oral health care costs. RESULTS: The authors found substantial variation among the selected models in assigning risk levels. The weighted average proportions (range) of people categorized as at low, moderate, and high risk were 25% (0%-66%), 14% (0%-50%), and 61% (11%-100%), respectively. Depending on the CRA model, the projected annual cost of covering this population ranged from $18 billion to $127 billion. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Developing a valid, evidence-based, accurate, and reliable population-based CRA model could address the variability among clinical CRA tools, improve estimates of dental disease burden, help design targeted oral public health programs, and enable comparative effectiveness analyses among oral health care interventions.

Impact of a Nonfatal Dengue Episode on Disability-Adjusted Life Years: A Systematic Analysis.

As dengue causes about 4,000 symptomatic nonfatal episodes for every dengue death globally, quantitative disability assessments are critical to assess the burden of dengue and the cost-effectiveness of dengue control interventions. This systematic analysis of disability or quality of life lost from a symptomatic nonfatal dengue episode combined a systematic literature review, statistical modeling, and probabilistic sensitivity analyses. We conceptualized a dengue episode as having two phases: acute and persistent symptoms. Our estimates for the acute phase, consisting of onset and recovery periods and defined as the first 20 days (0.054 year), were based on literature review. We searched PubMed, POPLINE, EconLit, Google Scholar, scientific conferences, and other sources, for "dengue" plus "quality of life" or related terms. From 4,322 initial entries, six met our criteria (original studies with empirical data). The median disability-adjusted life year (DALY) burden for the acute phase was 0.011 (95% certainty interval [CI]: 0.006-0.015) for ambulatory episodes, 0.015 (CI: 0.010-0.020) for hospitalized episodes, and 0.012 (CI: 0.006-0.019) overall. Using literature reviews about persistent dengue, we estimated that 34% of episodes experienced persistent symptoms with a median duration of symptoms of 0.087 (CI: 0.040-0.359) year, which resulted in median DALYs of 0.019 (CI: 0.008-0.082). Thus, the overall median DALY burden was 0.031 (CI: 0.017-0.092) for ambulatory episodes, 0.035 (CI: 0.024-0.096) for hospitalized episodes, and 0.032 (CI: 0.018-0.093) overall. Our dengue-specific burden of a dengue episode was 2.1 times the 2013 Global Burden of Disease estimate. These literature-based estimates provide an empirical summary for policy and cost-effectiveness analyses.

Cost-effectiveness of dengue vaccination in ten endemic countries.

Following publication of results from two phase-3 clinical trials in 10 countries or territories, endemic countries began licensing the first dengue vaccine in 2015. Using a published mathematical model, we evaluated the cost-effectiveness of dengue vaccination in populations similar to those at the trial sites in those same Latin American and Asian countries. Our main scenarios (30-year horizon, 80% coverage) entailed 3-dose routine vaccinations costing US$20/dose beginning at age 9, potentially supplemented by catch-up programs of 4- or 8-year cohorts. We obtained illness costs per case, dengue mortality, vaccine wastage, and vaccine administration costs from the literature. We estimated that routine vaccination would reduce yearly direct and indirect illness cost per capita by 22% (from US$10.51 to US$8.17) in the Latin American countries and by 23% (from US$5.78 to US$4.44) in the Asian countries. Using a health system perspective, the incremental cost-effectiveness ratio (ICER) averaged US$4,216/disability-adjusted life year (DALY) averted in the five Latin American countries (range: US$666/DALY in Puerto Rico to US$5,865/DALY in Mexico). In the five Asian countries, the ICER averaged US$3,751/DALY (range: US$1,935/DALY in Malaysia to US$5,101/DALY in the Philippines). From a health system perspective, the vaccine proved to be highly cost effective (ICER under one times the per capita GDP) in seven countries and cost effective (ICER 1-3 times the per capita GDP) in the remaining three countries. From a societal perspective, routine vaccination proved cost-saving in three countries. Including catch-up campaigns gave similar ICERs. Thus, this vaccine could have a favorable economic value in sites similar to those in the trials.