Cost and health-related quality of life for children hospitalized with respiratory syncytial virus in Central China

Background

The economic burden of respiratory syncytial virus (RSV) infection and its impact on health-related quality of life (HRQoL) are not well-understood in China. This study assessed total cost and HRQoL for children hospitalized with RSV in Central China.

Methods

Based on a prospective case series study in Henan Province in 2020–2021, inpatients aged 0–59 months with RSV-related acute respiratory infections (ARIs) were included into analysis. Total cost included direct medical cost (sum of medical cost before and during hospitalization), direct non-medical cost, and indirect cost. Direct medical cost during hospitalization data were extracted from the hospital information system. Other costs and HRQoL status were obtained from a telephone survey conducted in the caregivers of the enrolled patients.

Results

Among 261 RSV-infected inpatients, caregivers of 170 non-severe cases (65.1%, 170/261) were successfully interviewed. Direct medical cost per episode was 1055.3 US dollars (US$) (95% CI: 998.2–1112.5 US$). Direct non-medical cost and indirect cost per episode were 83.6 US$ (95% CI: 77.5–89.7 US$) and 162.4 US$ (95% CI: 127.9–197.0 US$), respectively. Quality adjusted life years (QALY) loss for non-severe RSV hospitalization was 8.9 × 10⁻³ (95% CI: 7.9 × 10⁻³–9.9 × 10⁻³). The majority of inpatients were <1 year of age comprising significantly higher cost and more QALY loss than older children.

Conclusions

RSV-associated hospitalization poses high economic and health burden in Central China particularly for children <1 year old. Our findings are crucial for determining the priority of interventions and allocation of health resources.     

Economic analysis of a pragmatic randomised trial of home visits by a nurse to elderly people with hypertension in Mexico

OBJECTIVE: To analyse the costs and the effectiveness of an intervention of home visits made by nurses to elderly people versus usual care given by the family medicine units. MATERIAL AND METHODS: A sample of 4,777 subjects aged 60 years and over covered by the Mexican Institute of Social Security (Instituto Mexicano del Seguro Social, IMSS) were screened. Those with a systolic and/or diastolic blood pressure level higher or equal than 160/90 mm Hg were randomly allocated to the intervention or control groups. The intervention consisted of visits at home by nurses who gave health and lifestyle advice to the participants. The economic evaluation was considered from a health services and patient perspective. Direct and indirect costs were calculated as incremental. Effectiveness was measured in terms of cost per millimetre of mercury reduced. RESULTS: Three hundred and forty five participants were allocated to the intervention group and compared with 338 controls. At the end of the intervention period the difference in the mean change in systolic blood pressure was 3.31 mm Hg (95% CI 6.32, 0.29; p = 0.03) comparing with the control group. In diastolic blood pressure the difference was 3.67 (95% CI 5.22, 2.12; p < 0.001). The total cost of the intervention was 101 901.66 pesos. The intervention cost per patient was 34.61 pesos (US$3.78), (CI 95% 34.44, 35.46). The cost-effectiveness ratios was 10.46 pesos (US$1.14) for systolic (CI 95% 129.31, 5.51) and 9.43 (US$1.03) for diastolic (CI 95% 19.90, 2.49). CONCLUSIONS: The reduction in blood pressure obtained may well justify the small incremental cost of the intervention.     

Short communication: The cost-effectiveness of cutaneous leishmaniasis patient management during an epidemic in Chaparral, Colombia in 2004

We calculated ranges for the cost per disability adjusted life year (DALY) averted for cutaneous leishmaniasis (CL) treatment during an ongoing epidemic of CL in Chaparral, Colombia. Using operational clinical and cost data, we calculated that the cost of treating leishmaniasis patients with standard pentavalent antimony was US$345 (95% CI 277-488) per patient treated and cured. The cost per DALY averted per patient cured with antimony was estimated to be approximately US$15 000 (95% CI 12 226-21 532).     

Costs and coverage of reproductive health interventions in three rural refugee-affected districts, Uganda

BACKGROUND: Uganda has hosted an estimated 200,000 refugees in post-emergency phase settlements interspersed within host communities since 1990. However, refugee health service runs parallel to host in most refugee-affected districts. The process of integration of health services began in 1999. OBJECTIVE: To estimate and compare the costs and coverage of reproductive health (RH) interventions in refugee and host populations in three rural West Nile refugee-affected districts of Uganda. METHODS: Data on costs of RH interventions were collected through a survey in 38/116 (33%) health facilities (3 public hospitals and 35 health centres). Data on coverage of RH interventions were collected from all 116 health facilities in the three rural refugee-affected districts for 2 years, 2003 and 2004. RESULTS: The costs and coverage of RH interventions significantly varied between population categories and among levels of refugee and host health facilities. Per capita cost of health care is 2.7 times higher for the refugee than the host population (US$13.12 vs. US$4.85). The cost per RH intervention is higher in the refugee than in the host health system (US$3.02 vs. US$2.73). Significantly more refugees attend antenatal care [99.4% (95% CI, 97.5-100) vs. 53.5% (53.22-53.78); P < 0.0001]. The proportion of births in health facilities was significantly greater among refugees [37.3% (36.12-38.48) vs. 15.2% (15.01-15.39); P < 0.05]. Major obstetrical interventions for absolute maternal indications were significantly more frequent among refugees than the host population living in the same region [1.02% (0.79-1.25) vs. 0.85% (0.80-0.90); P < 0.05]. CONCLUSIONS: Our study has shown higher costs and coverage in refugee than host health services. The findings suggest policy recommendations for improving the capacity, financing, organization and the performance of host health system in the refugee-affected settings.     

Out‐of‐pocket costs for paediatric admissions in district hospitals in Kenya

Objective To describe out‐of‐pocket costs of inpatient care for children under 5 years of age in district hospitals in Kenya. Methods A total of 256 caretakers of admitted children were interviewed in 2‐week surveys conducted in eight hospitals in four provinces in Kenya. Caretakers were asked to report care seeking behaviour and expenditure related to accessing inpatient care. Family socio‐economic status was assessed through reported expenditure in the previous month. Results Seventy eight percent of caretakers were required to pay user charges to access inpatient care for children. User charges (mean, US$ 8.1; 95% CI, 6.4–9.7) were 59% of total out‐of‐pocket costs, while transport costs (mean, US$ 4.9; 95% CI, 3.9–6.0) and medicine costs (mean, US$ 0.7; 95% CI, 0.5–1.0) were 36% and 5%, respectively. The mean total out‐of‐pocket cost per paediatric admission was US$ 14.1 (95% CI, 11.9–16.2). Out‐of‐pocket expenditures on health were catastrophic for 25.4% (95% CI, 18.4–33.3) of caretakers interviewed. Out‐of‐pocket expenditures were regressive, with a greater burden being experienced by households with lower socio‐economic status. Conclusion Despite a policy of user fee exemption for children under 5 years of age in Kenya, our findings show that high unofficial user fees are still charged in district hospitals. Financing mechanisms that will offer financial risk protection to children seeking care need to be developed to remove barriers to child survival.     

Economic burden of influenza‐associated hospitalizations and outpatient visits in Bangladesh during 2010

Objective

Understanding the costs of influenza-associated illness in Bangladesh may help health authorities assess the cost-effectiveness of influenza prevention programs. We estimated the annual economic burden of influenza-associated hospitalizations and outpatient visits in Bangladesh.

Design

From May through October 2010, investigators identified both outpatients and inpatients at four tertiary hospitals with laboratory-confirmed influenza infection through rRT-PCR. Research assistants visited case-patients'' homes within 30 days of hospital visit/discharge and administered a structured questionnaire to capture direct medical costs (physician consultation, hospital bed, medicines and diagnostic tests), direct non-medical costs (food, lodging and travel) and indirect costs (case-patients'' and caregivers'' lost income). We used WHO-Choice estimates for routine healthcare service costs. We added direct, indirect and healthcare service costs to calculate cost-per-episode. We used median cost-per-episode, published influenza-associated outpatient and hospitalization rates and Bangladesh census data to estimate the annual economic burden of influenza-associated illnesses in 2010.

Results

We interviewed 132 outpatients and 41 hospitalized patients. The median cost of an influenza-associated outpatient visit was US$4.80 (IQR = 2.93–8.11) and an influenza-associated hospitalization was US$82.20 (IQR = 59.96–121.56). We estimated that influenza-associated outpatient visits resulted in US$108 million (95% CI: 76–147) in direct costs and US$59 million (95% CI: 37–91) in indirect costs; influenza-associated hospitalizations resulted in US$1.4 million (95% CI: 0.4–2.6) in direct costs and US$0.4 million (95% CI: 0.1–0.8) in indirect costs in 2010.

Conclusions

In Bangladesh, influenza-associated illnesses caused an estimated US$169 million in economic loss in 2010, largely driven by frequent but low-cost outpatient visits.     

The Economic Impact of Cystic Echinococcosis in Rio Negro Province,Argentina

Cystic echinococcosis (CE), a parasitic zoonosis with substantial human health and economic consequences, is highly endemic in Rio Negro Province, Argentina. The objective of this study was to estimate the direct and indirect human and livestock-associated monetary losses attributable to CE, in Rio Negro Province, for the year 2010. Human costs were estimated using data obtained from hospital chart reviews, patient interviews, and government reports. Livestock-associated losses were estimated using data from government reports and scientific publications. Spreadsheet models were developed utilizing Latin Hypercube sampling to account for uncertainty in the input parameters. In 2010, the estimated total cost of CE, in Rio Negro Province, ranged from US$4,234,000 (95% credible interval [CI]: US$2,709,000–US$6,226,000) to US$5,897,000 (95% CI: US$3,452,000–US$9,105,000), with livestock-associated losses representing between 80% and 94% of the total losses, depending on whether non-healthcare-seeking human cases were included and if livestock slaughter values were adjusted to account for underreporting. These estimates suggest that CE is responsible for considerable human and livestock-associated monetary losses in Rio Negro Province. Stakeholders and policymakers can use these data to better allocate public health and agricultural resources for this region.     

Follow-up of a low cost latrine promotion programme in one district of Amhara, Ethiopia: characteristics of early adopters and non-adopters

Objectives  To verify reported construction of 22 385 household latrines in 2004, after community mobilization, as part of a trachoma control programme in one district of Amhara, Ethiopia, and to explore characteristics of early latrine adopters and non-adopters.
Methods  We used a two-stage cluster sample survey design to randomly select eight sub-districts and 160 households listed as having built a latrine, and visited them to verify presence and use. Household heads were interviewed to determine latrine cost and knowledge, attitude and practice regarding latrines. Non-latrine adopting neighbours were interviewed for comparison. We estimated district latrine ownership and calculated adjusted odds ratios for factors associated with latrine use.
Results  Latrines were present in 87% (95% CI 77–97) of listed households; 90% (81–99) were in use. Among all district residents we estimated ownership as 50.2% (44–56) and use as 45.2% (36–55). Of latrine owners who had built in 2004, 69% (53/77) had spent nothing on their latrine, those who paid spent an average of US$4.0 [standard deviation (SD) US$3.6]; overall the median cost was US$0 and the mean US$0.80 (SD US$1.7). Household heads adopting latrines were 1.9 times (95% CI 1.3–2.8) more likely to have any education and 1.5 times (95% CI 1.1–2.0) more likely to have a larger family than non-adopting neighbours. Cleanliness (48%, 56/116) and health benefits (42%, 49/116) were the most frequently reported advantages of latrines.
Conclusion  The latrine promotion programme dramatically increased latrine access and use at very low cost. The method of community mobilization used could be an effective way of reaching millennium development sanitation targets.     

Reducing financial barriers to emergency obstetric care: experience of cost-sharing mechanism in a district hospital in Burkina Faso

OBJECTIVE: To describe the implementation of a cost-sharing system for emergency obstetric care in an urban health district of Ouagadougou, Burkina Faso and analyse its results after 1 year of activity. METHODS: Service availability and use, service quality, knowledge of the cost-sharing system in the community and financial viability of the system were measured before and after the system was implemented. Different sources of data were used: community survey, anthropological study, routine data from hospital files and registers and specific data collected on major obstetric interventions (MOI) in all the hospitals utilized by the district population. Direct costs of MOI were collected for each patient through an individual form and monitored during the year 2005. Rates of MOI for absolute maternal indications (AMI) were calculated for the period 2003-2005. RESULTS: The direct cost of a MOI was on average 136US$, including referral cost. Through the cost-sharing system this amount was shared between families (46US$), health centres (15US$), Ministry of Health (38US$) and local authority (37US$). The scheme was started in January 2005. The rate of cost recovery was 91.3% and the balance at the end of 2005 was slightly positive (4.7% of the total contribution). The number of emergency referrals by health centres increased from 84 in 2004 to 683 in 2005. MOI per 100 expected births increased from 1.95% in 2003 to 3.56% in 2005 and MOI for AMI increased from 0.75% to 1.42%. CONCLUSIONS: The dramatic increase in MOI suggests that the cost-sharing scheme decreased financial and geographical barriers to emergency obstetric care. Other positive effects on quality of care were documented but the sustainability of such a system remains uncertain in the dynamic context of Burkina Faso (decentralization).     

Health care costs associated with clinic visits for prevention of mother-to-child transmission of HIV in Dar es Salaam,Tanzania

Early and appropriate antenatal care (ANC) is key for the effectiveness of prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV). We evaluated the importance of ANC visits and related service costs for women receiving option B⁺ to prevent mother-to-child transmission (MTCT) of HIV in Tanzania.A cost analysis from a health care sector perspective was conducted using routine data of 2224 pregnant women newly diagnosed with HIV who gave birth between August 2014 and May 2016 in Dar es Salaam, Tanzania. We evaluated risk of infant HIV infection at 12 weeks postnatally in relation to ANC visits (<4 vs ≥4 visits). Costs for service utilisation were estimated through empirical observations and the World Health Organisation Global Price Reporting Mechanism.Mean gestational age at first ANC visit was 22 (±7) weeks. The average number of ANC/prevention of MTCT visits among the 2224 pregnant women in our sample was 3.6 (95% confidence interval [CI] 3.6–3.7), and 57.3% made ≥4 visits. At 12 weeks postnatally, 2.7% (95% CI 2.2–3.6) of HIV exposed infants had been infected. The risk of MTCT decreased with the number of ANC visits: 4.8% (95% CI 3.6–6.4) if the mother had <4 visits, and 1.0% (95% CI 0.5–1.7) at ≥4. The adjusted MTCT rates decreased by 51% (odds ratio 0.49, 95% CI 0.31–0.77) for each additional ANC visit made. The potential cost-saving was 2.2 US$ per woman at ≥4 visits (84.8 US$) compared to <4 visits (87.0 US$), mainly due to less defaulter tracing.Most pregnant women living with HIV in Dar es Salaam initiated ANC late and >40% failed to adhere to the recommended minimum of 4 visits. Improved ANC attendance would likely lead to fewer HIV-infected infants and reduce both short and long-term health care costs due to less spending on defaulter tracing and future treatment costs for the children.     

Costing of services under National Tuberculosis Elimination Program at public health facilities of northern India

BackgroundCosting of resources helps to measure financial implications and effective utilization of resources of national programs. As there is limited evidence about cost per service, current study was done to assess the cost of services under National Tuberculosis Elimination Program (NTEP) at Community Health Centres (CHCs) and Primary Health Centres (PHCs) of northern state of India.Material and methodsCross-sectional study carried out in two districts and from each district eight CHCs and PHCs were randomly selected.ResultsMean annual cost of providing NTEP services at CHCs and PHCs were US$5243.1 (95%CI: 3008.0–7225.4) and US$1031.9 (95%CI: 669.1–1447.1) respectively. Across both centres human resource contributes to the most (CHC: 72.9%; PHC: 85.9%). One way sensitivity analysis was carried out for all health facilities and observed that human resource cost influences most cost per treated case by providing services under NTEP. Although relatively very less but cost of drugs also influences cost per treatment.ConclusionCost of delivering services was high for CHCs as compared to PHCs. At both types of health facilities, human resource contributes the most to cost of delivering services under the program.     

A comparative analysis of the cost-effectiveness of treatment based on parasitological and symptomatic screening for Schistosoma mansoni in Burundi

OBJECTIVES: To assess the cost-effectiveness of three alternative screening strategies in delivering treatment to patients presenting with symptoms suggestive of S. mansoni, using data collected from 17 PHCCs in the Rusizi Plain, Burundi. The three strategies were: (1) screening all symptomatic patients using a Kato-Katz smear and treating only the ones found positive; (2) treating all symptomatic patients or (3) treating only those presenting with symptoms of severe diarrhoea (blood in stool). METHODS: The database consisted of 41 051 visits of symptomatic patients to the 17 PHCCs during 1990. Effectiveness was measured as the number of infected patients treated (gold standard: 25-mg Kato-Katz smear). Cost-effectiveness ratios (CERs) (cost in US$ per infected patient treated) were used to compare the control strategies. Sensitivity analysis was performed to assess the effect of drug price and prevalence of infection on the CERs. RESULTS: The overall prevalence of S. mansoni infection was 9.5% (95% CI = 9.1%, 9.9%). Treating only those with severe symptoms of infection would have left 92% of infected patients untreated. Performing a Kato-Katz smear to confirm the diagnosis was more cost-effective than treating all symptomatic patients on a presumptive basis, with CERs of 4.2 US$ and 12.43 US$ per infected person treated, respectively. Sensitivity analysis showed that, for a cost of 0.99 US$ per dose of praziquantel, the Kato-Katz option remained the most cost-effective approach for prevalences under 76%. For a drug price of 0.21 US$ per dose, both strategies would have become equivalent. The latter value varied extensively per PHCC (range 0.17 US$ to 0.51 US$), due to the different prevalences of infection (range 0.5% to 34.3%). CONCLUSION: We found that using severe diarrhoea as an indicator for infection was not appropriate, and that screening symptomatic patients with the Kato-Katz method remained the most cost-effective approach in the given setting. The CER of treating all symptomatic patients on a presumptive basis depended very much on the drug price and the endemic level.     

Feasibility of a community health worker strategy for providing near and appropriate treatment of malaria in southeast Nigeria: an analysis of activities, costs and outcomes

RATIONALE: Community health workers (CHWs) could be used to bring appropriate and timely treatment of malaria closer to home and there is the need to increase the body of knowledge about the feasibility of implementing the strategy. OBJECTIVE: To determine the processes, costs and outcomes of design and implementation of a strategy based on use of CHWs for near and appropriate treatment of malaria. METHODS: The CHW strategy was implemented in two villages (Adu and Ahani) in Enugu state, southeast Nigeria. Adu and Ahani have a population of approximately 3500 and 5000 residents, respectively. The study was conducted in four phases: (1) baseline survey; (2) design; (3) implementation, supervision and monitoring; and (4) evaluation. Interactive meeting with all the stakeholders were used to fine-tune the design of the CHW strategy. Community members that were selected by the project team with the help of community leaders were trained to become CHWs and their remuneration was through commissions on their drug sales. Community and provider's financial and non-financial costs of the startegy were computed. RESULTS: Non-financial costs were the highest contributor to consumer costs, while financial costs constituted more than 90% of provider costs. The total consumer cost in Ahani was US$2548, while the consumer cost in Adu was US$1585. The total provider cost in Ahani was US$4515, while in Adu it was US$4302. The unit cost cost per villager was US$1.40 in Ahani and US$1.70 in Adu, while the unit financial consumer cost per treated patient was $0.05 in both villages, respectively. The CHWs were acceptable to the people and had an increased market share out of existing malaria treatment provision strategies. CONCLUSION: The cost of starting up the CHW strategy is low and should be affordable to malaria control programs and communities. The CHW strategy is also economically viable and a potential cost-effective source for providing timely, and appropriate treatment of malaria in rural areas. It should be fine-tuned and added to malaria control armamenterium in Nigeria and other parts of sub-Saharan Africa.     

Peer referral for HIV case-finding among men who have sex with men

OBJECTIVE: To evaluate the effectiveness and cost-effectiveness of a health department-based peer referral program for identifying previously undiagnosed cases of HIV among men who have sex with men (MSM). DESIGN AND METHODS: Between 2002 and 2005, 283 MSM peer recruiters were enrolled in a public health program in King County, Washington, USA. Peer recruiters were enrolled from a sexually transmitted disease (STD) clinic, an HIV clinic, via media advertisements and through collaboration with community-based organizations (CBO). The peer recruiters underwent a brief training and were then paid US$ 20 for each peer they referred to be tested for HIV, STD and viral hepatitis. Peers were paid US$ 20 for being tested. The main outcome measure was the number of new cases of HIV identified and cost per case of HIV identified. RESULTS: Recruiters referred 498 peers for HIV, STD and hepatitis testing. Among 438 peers not previously diagnosed with HIV, 22 (5%) were HIV positive, of whom 18 received their HIV test results. Other infections were variably prevalent among tested peers: gonorrhea [23/307 (8%)], chlamydia [6/285 (2%)], syphilis [1/445 (0.2%)], hepatitis C [61/198 (31%)], surface antigen positive hepatitis B [8/314 (3%)]. Excluding the costs of testing for viral hepatitis and STDs other than HIV, the cost per new HIV case identified was US$ 4929. During the same period, the cost per new case of HIV detected through bathhouse-based HIV testing and through the county's largest CBO-based HIV testing program were US$ 8250 and US$ 11 481, respectively. CONCLUSIONS: Peer referral is an effective means of identifying new cases of HIV among MSM.     

Nosocomial Pneumonia: A Cost-of-Illness Analysis

Background: We investigated incremental cost of nosocomial pneumonia (NP) from the perspective of a hospital and health insurance funds. Patients and Methods: The incremental cost was determined by calculating total costs for pneumonia patients and controls using prospective and retrospective matched-pairs analysis with 29 and 37 matched pairs, respectively. Results: Compared to controls, patients who developed pneumonia had to be on artificial ventilation 5 days longer, needed markedly more intensive care with 6.55 additional days in intensive care. Excess cost per pneumonia patient amounted to DM 14,606 (95% CI: DM 5,285–23,927) from the hospital's perspective and to DM 7,988 (95% CI: DM 5,281–10,894) according to statutory insurance charges. According to the retrospective analysis carried out on the neurosurgical and neurological intensive care wards, pneumonia patients were ventilated 5 days longer than patients without pneumonia, needed more intensive care over 30 days and had an additional 14.03 days of intensive care and 10.14 more days in hospital. Excess cost per patient was DM 29,610 (95% CI: DM 23,054–36,174) from the hospital's perspective and DM 18,000 (95% CI: 14,855–21,020) according to the statutory insurance criteria. Conclusion: The study gives insight into the structure of incremental cost caused by NP and shows that based on a conservative cost calculation the incremental cost per NP patient is higher for the hospital than for health insurance funds which indicates a significant financial deficit for the hospital. Antibiotics and microbiology together only contribute 6.8% to incremental cost. Therefore in a cost saving initiative their close relationship to length of hospitalization must be considered. Received: July 5, 2000 · Revision accepted: January 9, 2002     

COVID-19 in real world: Survival and medical costs of hospitalized patients in Brazil´s first wave

ObjectiveTo evaluate survival and direct medical costs of patients admitted in private hospitals with COVID-19 during the first wave.MethodsA retrospective, observational study analyzing survival and the economic data retrieved on hospitalized patients with COVID-19. Data from March 2020 to December 2020. The direct cost of hospitalization was estimated using the microcosting method with each individual hospitalization.Results342 cases were evaluated. Median age of 61.0 (95% CI 57.0‒65.0). 194 (56.7%) were men. The mortality rate was higher in the female sex (p = 0.0037), ICU (p < 0.001), mechanical ventilation (p<0.001) and elderly groups. 143 (41.8%) patients were admitted to the ICU (95% CI 36.6%–47.1%), of which 60 (41.9%) required MV (95% CI 34.0%–50.0%). Global LOS presented median of 6.7 days (95% CI 6.0–7.2). Mean costs were US$ 7,060,00 (95% CI 5,300.94–8,819,00) for each patient. Mean cost for patients discharged alive and patients deceased was US$ 5,475.53 (95% CI 3,692.91–7,258.14) and US$ 12,955.19 (95% CI 8,106.61–17,803.76), respectively (p < 0.001).ConclusionsPatients admitted with COVID-19 in these private hospitals point to great economic impact, mainly in the elderly and high-risk patients. It is key to better understand such costs in order to be prepared to make wise decisions during the current and future global health emergencies.     

Downstream Cascades of Care Following High-Sensitivity Troponin Test Implementation

BackgroundPatients with chest pain are often evaluated for acute myocardial infarction through troponin testing, which may prompt downstream services (cascades) of uncertain value.ObjectivesThis study sought to determine the association of high-sensitivity cardiac troponin (hs-cTn) assay implementation with cascade events.MethodsUsing electronic health record and billing data, this study examined patient-visits to 5 emergency departments from April 1, 2017, to April 1, 2019. Difference-in-differences analysis compared patient-visits for chest pain (n = 7,564) to patient-visits for other symptoms (n = 100,415) (irrespective of troponin testing) before and after hs-cTn assay implementation. Outcomes included presence of any cascade event potentially associated with an initial hs-cTn test (primary), individual cascade events, length of stay, and spending on cardiac services.ResultsFollowing hs-cTn implementation, patients with chest pain had a 2.8% (95% confidence interval [CI]: 0.72% to 4.9%) net increase in experiencing any cascade event. They were more likely to have multiple troponin tests (10.5%; 95% CI: 9.0% to 12.0%) and electrocardiograms (7.1 per 100 patient-visits; 95% CI: 1.8 to 12.4). However, they received net fewer computed tomography scans (?1.5 per 100 patient-visits; 95% CI: ?1.8 to ?1.1), stress tests (?5.9 per 100 patient-visits; 95% CI: ?6.5 to ?5.3), and percutaneous coronary intervention (PCI) (?0.65 per 100 patient-visits; 95% CI: ?1.01 to ?0.30) and were less likely to receive cardiac medications, undergo cardiology evaluation (?3.5%; 95% CI: ?4.5% to 2.6%), or be hospitalized (?5.8%; 95% CI: ?7.7% to ?3.8%). Patients with chest pain had lower net mean length of stay (?0.24 days; 95% CI: ?0.32 to ?0.16) but no net change in spending.ConclusionsHs-cTn assay implementation was associated with more net upfront tests yet fewer net stress tests, PCI, cardiology evaluations, and hospital admissions in patients with chest pain relative to patients with other symptoms.     

The Incremental Cost-Effectiveness of Engaging Private Practitioners to Refer Tuberculosis Suspects to DOTS Services in Jogjakarta,Indonesia

We aimed to evaluate the incremental cost-effectiveness of engaging private practitioners (PPs) to refer tuberculosis (TB) suspects to public health centers in Jogjakarta, Indonesia. Effectiveness was assessed for TB suspects notified between May 2004 and April 2005. Private practitioners referred 1,064 TB suspects, of which 57.5% failed to reach a health center. The smear-positive rate among patients reaching a health center was 61.8%. Two hundred eighty (280) out of a total of 1,306 (21.4%) new smear-positive cases were enrolled through the PPs strategy. The incremental cost-effectiveness ratio per smear-positive case successfully treated for the PPs strategy was US$351.66 (95% CI 322.84–601.33). On the basis of an acceptability curve using the National TB control program''s willingness-to-pay threshold (US$448.61), we estimate the probability that the PPs strategy is cost-effective at 66.8%. The strategy of engaging PPs was incrementally cost-effective, although under specific conditions, most importantly a well-functioning public directly observed treatment, short-course (DOTS) program.