Cost-effectiveness of malaria intermittent preventive treatment in infants (IPTi) in Mozambique and the United Republic of Tanzania

Objective

To estimate the cost-effectiveness of malaria intermittent preventive treatment in infants (IPTi) using sulfadoxine-pyrimethamine (SP).

Methods

In two previous IPTi trials in Ifakara (United Republic of Tanzania) and Manhiça (Mozambique), SP was administered three times to infants before 9 months of age through the Expanded Programme on Immunization. Based on the efficacy results of the intervention and on malaria incidence in the target population, an estimate was made of the number of clinical malaria episodes prevented. This number and an assumed case-fatality rate of 1.57% were used, in turn, to estimate the number of disability-adjusted life years (DALY) averted and the number of deaths averted. The cost of the intervention, including start-up and recurrent costs, was then assessed on the basis of these figures.

Findings

The cost per clinical episode of malaria averted was US$ 1.57 (range: US$ 0.8–4.0) in Ifakara and US$ 4.73 (range: US$ 1.7–30.3) in Manhiça; the cost per DALY averted was US$ 3.7 (range: US$ 1.6–12.2) in Ifakara and US$ 11.2 (range: US$ 3.6–92.0) in Manhiça; and the cost per death averted was US$ 100.2 (range: US$ 43.0–330.9) in Ifakara and US$ 301.1 (range: US$ 95.6–2498.4) in Manhiça.

Conclusion

From the health system and societal perspectives, IPTi with SP is expected to produce health improvements in a cost-effective way. From an economic perspective, it offers good value for money for public health programmes.     

Economic evaluation of neonatal care packages in a cluster-randomized controlled trial in Sylhet,Bangladesh

Objective

To evaluate and compare the cost-effectiveness of two strategies for neonatal care in Sylhet division, Bangladesh.

Methods

In a cluster-randomized controlled trial, two strategies for neonatal care – known as home care and community care – were compared with existing services. For each study arm, economic costs were estimated from a societal perspective, inclusive of programme costs, provider costs and household out-of-pocket payments on care-seeking. Neonatal mortality in each study arm was determined through household surveys. The incremental cost-effectiveness of each strategy – compared with that of the pre-existing levels of maternal and neonatal care – was then estimated. The levels of uncertainty in our estimates were quantified through probabilistic sensitivity analysis.

Findings

The incremental programme costs of implementing the home-care package were 2939 (95% confidence interval, CI: 1833–7616) United States dollars (US$) per neonatal death averted and US$ 103.49 (95% CI: 64.72–265.93) per disability-adjusted life year (DALY) averted. The corresponding total societal costs were US$ 2971 (95% CI: 1844–7628) and US$ 104.62 (95% CI: 65.15–266.60), respectively. The home-care package was cost-effective – with 95% certainty – if healthy life years were valued above US$ 214 per DALY averted. In contrast, implementation of the community-care strategy led to no reduction in neonatal mortality and did not appear to be cost-effective.

Conclusion

The home-care package represents a highly cost-effective intervention strategy that should be considered for replication and scale-up in Bangladesh and similar settings elsewhere.     

Cost-effectiveness of parenteral artesunate for treating children with severe malaria in sub-Saharan Africa

Objective

To explore the cost-effectiveness of parenteral artesunate for the treatment of severe malaria in children and its potential impact on hospital budgets.

Methods

The costs of inpatient care of children with severe malaria were assessed in four of the 11 sites included in the African Quinine Artesunate Malaria Treatment trial, conducted with over 5400 children. The drugs, laboratory tests and intravenous fluids provided to 2300 patients from admission to discharge were recorded, as was the length of inpatient stay, to calculate the cost of inpatient care. The data were matched with pooled clinical outcomes and entered into a decision model to calculate the cost per disability-adjusted life year (DALY) averted and the cost per death averted.

Findings

The mean cost of treating severe malaria patients was similar in the two study groups: 63.5 United States dollars (US$) (95% confidence interval, CI: 61.7–65.2) in the quinine arm and US$ 66.5 (95% CI: 63.7–69.2) in the artesunate arm. Children treated with artesunate had 22.5% lower mortality than those treated with quinine and the same rate of neurological sequelae: (artesunate arm: 2.3 DALYs per patient; quinine arm: 3.0 DALYs per patient). Compared with quinine as a baseline, artesunate showed an incremental cost per DALY averted and an incremental cost per death averted of US$ 3.8 and US$ 123, respectively.

Conclusion

Artesunate is a highly cost-effective and affordable alternative to quinine for treating children with severe malaria. The budgetary implications of adopting artesunate for routine use in hospital-based care are negligible.     

Prioritizing risk factors to identify preventive interventions for economic assessment

Objective

To explore a risk factor approach for identifying preventive interventions that require more in-depth economic assessment, including cost-effectiveness analyses.

Methods

A three-step approach was employed to: (i) identify the risk factors that contribute most substantially to disability-adjusted life years (DALYs); (ii) re-rank these risk factors based on the availability of effective preventive interventions warranting further cost-effectiveness analysis (and in some instances on evidence from existing cost-effectiveness analyses); and (iii) re-rank these risk factors in accordance with their relative contribution to health inequalities. Health inequalities between the Māori and non-Māori populations in New Zealand were used by way of illustration.

Findings

Seven of the top 10 risk factors prioritized for research on preventive interventions in New Zealand were also among the 10 risk factors most highly ranked as contributing to DALYs in high-income countries of the World Health Organization’s Western Pacific Region. The final list of priority risk factors included tobacco use; alcohol use; high blood pressure; high blood cholesterol; overweight/obesity, and physical inactivity. All of these factors contributed to health inequalities. Effective interventions for preventing all of them are available, and for each risk factor there is at least one documented cost-saving preventive intervention.

Conclusion

The straightforward approach to prioritizing risk factors described in this paper may be applicable in many countries, and even in those countries that lack the capacity to perform additional cost-effectiveness analyses, this approach will still make it possible to determine which cost-effective interventions should be implemented in the short run.     

Cost-effectiveness analysis of malaria interventions using disability adjusted life years: a systematic review

Background

Malaria continues to be a public health problem despite past and on-going control efforts. For sustenance of control efforts to achieve the malaria elimination goal, it is important that the most cost-effective interventions are employed. This paper reviews studies on cost-effectiveness of malaria interventions using disability-adjusted life years.

Methods

A review of literature was conducted through a literature search of international peer-reviewed journals as well as grey literature. Searches were conducted through Medline (PubMed), EMBASE and Google Scholar search engines. The searches included articles published in English for the period from 1996 to 2016. The inclusion criteria for the study were type of malaria intervention, year of publication and cost-effectiveness ratio in terms of cost per DALY averted. We included 40 studies which specifically used the DALY metric in cost-effectiveness analysis (CEA) of malaria interventions.

Results

The majority of the reviewed studies (75%) were done using data from African settings with the majority of the interventions (60.0%) targeting all age categories. Interventions included case treatment, prophylaxis, vector control, insecticide treated nets, early detection, environmental management, diagnosis and educational programmes. Sulfadoxine–pyrimethamine was the most common drug of choice in malaria prophylaxis, while artemisinin-based combination therapies were the most common drugs for case treatment. Based on guidelines for CEA, most interventions proved cost-effective in terms of cost per DALYs averted for each intervention.

Conclusion

The DALY metric is a useful tool for determining the cost-effectiveness of malaria interventions. This paper demonstrates the importance of CEA in informing decisions made by policy makers.

     

Equity in maternal and child health in Thailand

Objective

To assess equity in health outcomes and interventions for maternal and child health (MCH) services in Thailand.

Methods

Women of reproductive age in 40 000 nationally representative households responded to the Multiple Indicator Cluster Survey in 2005–2006. We used a concentration index (CI) to assess distribution of nine MCH indicator groups across the household wealth index. For each indicator we also compared the richest and poorest quintiles or deciles, urban and rural domiciles, and mothers or caregivers with or without secondary school education.

Findings

Child underweight (CI: −0.2192; P < 0.01) and stunting (CI: −0.1767; P < 0.01) were least equitably distributed, being disproportionately concentrated among the poor; these were followed by teenage pregnancy (CI: −0.1073; P < 0.01), and child pneumonia (CI: −0.0896; P < 0.05) and diarrhoea (CI: −0.0531; P < 0.1). Distribution of the MCH interventions was fairly equitable, but richer women were more likely to receive prenatal care and delivery by a skilled health worker or in a health facility. The most equitably distributed interventions were child immunization and family planning. All undesirable health outcomes were more prevalent among rural residents, although the urban–rural gap in MCH services was small. Where mothers or caregivers had no formal education, all outcome indicators were worse than in the group with the highest level of education.

Conclusion

Equity of coverage in key MCH services is high throughout Thailand. Inequitable health outcomes are largely due to socioeconomic factors, especially differences in the educational level of mothers or caregivers.     

Estimated incidence of influenza-virus-associated severe pneumonia in children in El Salvador, 2008�C2010

Objective

To estimate the incidence of influenza-virus-associated severe pneumonia among Salvadorian children aged < 5 years.

Methods

Data on children aged < 5 years admitted with severe pneumonia to a sentinel hospital in the western region were collected weekly. Nasal and oropharyngeal swab specimens were collected from a convenience sample of case patients for respiratory virus testing. A health-care utilization survey was conducted in the hospital catchment area to determine the proportion of residents who sought care at the hospital. The incidence of influenza-virus-associated severe pneumonia among all Salvadorian children aged < 5 years was estimated from surveillance and census data, with adjustment for health-care utilization. Influenza virus strains were characterized by the United States Centers for Disease Control and Prevention to determine their correspondence with northern and southern hemisphere influenza vaccine formulations.

Findings

Physicians identified 2554 cases of severe pneumonia. Samples from 608 cases were tested for respiratory viruses and 37 (6%) were positive for influenza virus. The estimated incidence of influenza-virus-associated severe pneumonia was 3.2 cases per 1000 person–years (95% confidence interval, CI: 2.8–3.7) overall, 1.5 cases per 1000 person–years (95% CI: 1.0–2.0) during 2008, 7.6 cases per 1000 person–years (95% CI: 6.5–8.9) during 2009 and 0.6 cases per 1000 person–years (95% CI: 0.3–1.0) during 2010. Northern and southern hemisphere vaccine formulations matched influenza virus strains isolated during 2008 and 2010.

Conclusion

Influenza-virus-associated severe pneumonia occurred frequently among young Salvadorian children during 2008–2010. Antigens in northern and southern hemisphere influenza vaccine formulations corresponded to circulating strains.     

Evaluating the cost-effectiveness of combination antiretroviral therapy for the prevention of mother-to-child transmission of HIV in Uganda

Objective

To model the cost-effectiveness in Uganda of combination antiretroviral therapy (ART) to prevent mother-to-child transmission of human immunodeficiency virus (HIV).

Methods

The cost-effectiveness of ART was evaluated on the assumption that ART reduces the risk of an HIV-positive pregnant woman transmitting HIV to her baby from 40% (when the woman is left untreated) to 25.8%, 17.4% and 3.8%, respectively, when the woman is given: (i) single-dose nevirapine (at an estimated total drug cost of 0.06 United States dollars [US$]); (ii) dual therapy with zidovudine and lamivudine for 7 weeks (at a total drug cost of US$ 15.63); or (iii) ART for 18 months (at a total annual cost of US$ 469.77). Lifetime ART (US$ 6883), recommended for pregnant women with < 350 CD4+ T lymphocytes per mm³, was assumed to give the same reduction in transmission risk in each subsequent pregnancy.

Findings

Compared with single-dose nevirapine, dual therapy and no therapy, 18 months of ART averted 5.21, 3.22 and 8.58 disability-adjusted life years (DALYs), respectively, at a cost of US$ 46, US$ 99 and US$ 34 per DALY averted. The corresponding figures for lifetime ART are, respectively, 19.20, 11.87 and 31.60 DALYs averted, at a cost of US$ 205, US$ 354 and US$ 172 per DALY averted.

Conclusion

In Uganda, ART appears highly cost-effective for the prevention of mother-to-child HIV transmission, even if continued over the patients’ lifetimes. Given the additional public health benefits of ART, efforts to ensure that all HIV-positive pregnant women have access to lifelong ART should be intensified.     

Community case management of childhood illnesses: policy and implementation in Countdown to 2015 countries

Objective

To explore the policies for, and implementation of, the community case management (CCM) of childhood illnesses in the 68 countries that were prioritized by the “Countdown to 2015” initiative in 2008.

Methods

In 2009–2010, community approaches concerning CCM policy and implementation, the roles of community health workers (CHWs) and the availability of medicines for the treatment of malaria, diarrhoea, pneumonia and neonatal infections were investigated by sending questionnaires to implementers and policy-makers and through telephone discussions with appropriate researchers and experts.

Findings

Of the 59 countries that responded, 81%, 75%, 54% and 14% had a policy for the CCM of diarrhoea, malaria, pneumonia and neonatal infections, respectively. Only three (6%) of the 53 malaria-endemic countries providing responses had policies for all four of these conditions, although 17 (32%) had CCM policies for malaria, diarrhoea and pneumonia. Some CCM of childhood illnesses was being implemented – more commonly for diarrhoea and malaria than for pneumonia or neonatal infections – in 88% of the countries providing responses. According to the responses received, CHWs administered the recommended treatments for diarrhoea, malaria or pneumonia in 34% (17/50), 100% (41/41) and 100% (34/34) of the countries implementing CCM of these conditions, respectively. Common programme concerns were drug supplies, quality of care and CHW incentives, training and supervision.

Conclusion

Despite progress, further efforts are needed towards policy reform and the expansion of CCM programmes. Ensuring the availability of recommended medicines and operational research, to assure quality, remain priorities.     

Potential impact of single-risk-factor versus total risk management for the prevention of cardiovascular events in Seychelles

Objective

To assess the prevalence of cardiovascular (CV) risk factors in Seychelles, a middle-income African country, and compare the cost-effectiveness of single-risk-factor management (treating individuals with arterial blood pressure ≥ 140/90 mmHg and/or total serum cholesterol ≥ 6.2 mmol/l) with that of management based on total CV risk (treating individuals with a total CV risk ≥ 10% or ≥ 20%).

Methods

CV risk factor prevalence and a CV risk prediction chart for Africa were used to estimate the 10-year risk of suffering a fatal or non-fatal CV event among individuals aged 40–64 years. These figures were used to compare single-risk-factor management with total risk management in terms of the number of people requiring treatment to avert one CV event and the number of events potentially averted over 10 years. Treatment for patients with high total CV risk (≥ 20%) was assumed to consist of a fixed-dose combination of several drugs (polypill). Cost analyses were limited to medication.

Findings

A total CV risk of ≥ 10% and ≥ 20% was found among 10.8% and 5.1% of individuals, respectively. With single-risk-factor management, 60% of adults would need to be treated and 157 cardiovascular events per 100 000 population would be averted per year, as opposed to 5% of adults and 92 events with total CV risk management. Management based on high total CV risk optimizes the balance between the number requiring treatment and the number of CV events averted.

Conclusion

Total CV risk management is much more cost-effective than single-risk-factor management. These findings are relevant for all countries, but especially for those economically and demographically similar to Seychelles.     

The effectiveness of chronic care management for heart failure: meta-regression analyses to explain the heterogeneity in outcomes

Objective

To support decision making on how to best redesign chronic care by studying the heterogeneity in effectiveness across chronic care management evaluations for heart failure.

Data Sources

Reviews and primary studies that evaluated chronic care management interventions.

Study Design

A systematic review including meta-regression analyses to investigate three potential sources of heterogeneity in effectiveness: study quality, length of follow-up, and number of chronic care model components.

Principal Findings

Our meta-analysis showed that chronic care management reduces mortality by a mean of 18 percent (95 percent CI: 0.72–0.94) and hospitalization by a mean of 18 percent (95 percent CI: 0.76–0.93) and improves quality of life by 7.14 points (95 percent CI: −9.55 to −4.72) on the Minnesota Living with Heart Failure questionnaire. We could not explain the considerable differences in hospitalization and quality of life across the studies.

Conclusion

Chronic care management significantly reduces mortality. Positive effects on hospitalization and quality of life were shown, however, with substantial heterogeneity in effectiveness. This heterogeneity is not explained by study quality, length of follow-up, or the number of chronic care model components. More attention to the development and implementation of chronic care management is needed to support informed decision making on how to best redesign chronic care.     

Case-control study of blood lead levels and attention deficit hyperactivity disorder in Chinese children

Background

Attention deficit/hyperactivity disorder (ADHD) and lead exposure are high-prevalence conditions among children.

Objective

Our goal was to investigate the association between ADHD and blood lead levels (BLLs) in Chinese children, adjusting for known ADHD risk factors and potential confounding variables.

Methods

We conducted a pair-matching case–control study with 630 ADHD cases and 630 non-ADHD controls 4–12 years of age, matched on the same age, sex, and socioeconomic status. The case and control children were systematically evaluated via structured diagnostic interviews, including caregiver interviews, based on the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., revised criteria (DSM-IV-R). We evaluated the association between BLLs and ADHD using the Pearson chi-square test for categorical variables and the Student t-test for continuous data. We then performed conditional multiple variables logistic regression analyses with backward stepwise selection to predict risk factors for ADHD.

Results

There was a significant difference in BLLs between ADHD cases and controls. ADHD cases were more likely to have been exposed to lead during childhood than the non-ADHD control subjects, with adjustment for other known risk factors [children with BLLs ≥ 10 μg/dL vs. ≤ 5 μg/dL; OR = 6.0; 95% confidence interval (CI) = 4.10–8.77, p < 0.01; 5–10 μg/dL vs.≤ 5 μg/dL, OR = 4.9; 95% CI = 3.47–6.98, p < 0.01]. These results were not modified by age and sex variables.

Conclusions

This was the largest sample size case–control study to date to study the association between BLLs and ADHD in Chinese children. ADHD may be an additional deleterious outcome of lead exposure during childhood, even when BLLs are < 10 μg/dL.     

The Relationship Between Disability-Adjusted Life Years of Cataracts and Ambient Erythemal Ultraviolet Radiation in China

Background

Cataracts are one of the major public health problems worldwide. Ultraviolet radiation (UVR) is one of the risk factors for cataract development. We analyzed the relationship between disability-adjusted life year (DALY) rates of cataracts and UVR exposure in China.

Methods

DALY rates of cataracts and UVR exposure in 31 regions of China were calculated based on data from the Second China National Sample Survey on Disability and the United States’ National Aeronautics and Space Administration database. The relationship between the DALY rates of cataracts and UVR was estimated by Spearman rank correlation analysis and linear regression analysis.

Results

The elderly (≥65 years) had higher DALY rates of cataracts than the whole population. The DALY rate of cataracts in the agricultural population was higher than that observed in the non-agricultural population. The DALY rates of cataracts were positively associated with UVR The DALY rates of cataracts in regions with higher UVR were higher than those in regions with lower UVR. An increase in the daily ambient erythemal UVR of 1000 J/m² was associated with an increase in the DALY rates of cataracts by 92 DALYs/100 000 (R² = 0.676) among the whole population, 34 DALYs/100 000 among the population <65 years old (R² = 0.423), 607 DALYs/100 000 among the population aged 65–74 years (R² = 0.617), and by 1342 DALYs/100 000 among the population ≥75 years old (R² = 0.758).

Conclusions

DALY rates of cataracts increased with increases in UVR exposure in 31 regions of China. Greater exposure to UVR increases the disease burden of cataracts in the whole population, especially in the elderly and among the agricultural population.Key words: cataract, UVR exposure, disease burden, DALYs     

Examining the Association between Utilization Management and Downstream Cardiovascular Imaging

Objectives

To examine the association of echocardiography utilization management (EUM) program with downstream cardiac imaging utilization.

Data Sources/Study Setting

Administrative claims data from commercial health plans in Indiana, Ohio, Kentucky, Wisconsin, and Georgia.

Study Design

Patients undergoing index cardiovascular imaging with no imaging in the preceding year were identified (N = 112,308). Claims-derived cardiac risk scores were used for one-to-one propensity score matching of patients subject to EUM to patients without EUM (n = 96,906). Downstream cardiac imaging utilization for 12–24 months postindex imaging was analyzed using generalized linear models and Cox proportional hazards model.

Principal Findings

Downstream cardiac imaging tests were performed for 10,630 (21.9 percent) and 12,012 (24.8 percent) patients in the EUM and non-EUM groups, respectively. At 12-month follow-up, adjusted utilization was 15.2 (95 percent CI, 7.6–22.5) tests per 1,000 initially tested patients lower in the EUM group (p < .001). The likelihood of obtaining downstream cardiac imaging in the EUM group was 7.0 percent lower than the non-EUM group (hazard ratio: 0.930; 95 percent CI, 0.897–0.964, p < .001).

Conclusions

Downstream cardiac imaging is relatively common among commercially insured patients. Every 10 initial diagnostic tests yielded two downstream imaging tests in first 24 months. EUM program was associated with lower volumes of downstream imaging.     

Cost-effectiveness of artemisinin combination therapy for uncomplicated malaria in children: data from Papua New Guinea

Objective

To compare the cost–effectiveness of conventional antimalarial therapy with that of three artemisinin combination treatment regimens in children from Papua New Guinea aged 6 to 60 months.

Methods

An incremental cost–effectiveness analysis was performed using data from 656 children with Plasmodium falciparum and/or P. vivax malaria who participated in a large intervention trial in two clinics in northern Papua New Guinea. The children were randomized to one of the following groups: (i) conventional treatment with chloroquine plus sulfadoxine plus pyrimethamine (CQ+S+P); (ii) artesunate plus S plus P; (iii) dihydroartemisinin plus piperaquine (DHA+PQ); and (iv) artemether plus lumefantrine (A+L). For treatment outcomes, World Health Organization definitions were used. The cost of transport between home and the clinic plus direct health-care costs served as a basis for determining each regimen’s incremental cost per incremental treatment success relative to CQ+S+P by day 42 and its cost per life year saved.

Findings

A+L proved to be the most effective regimen against P. falciparum malaria and was highly cost-effective at 6.97 United States dollars (US$) per treatment success (about US$ 58 per life year saved). DHA+PQ was the most effective regimen against P. vivax malaria and was more cost-effective than CQ+S+P.

Conclusion

A+L and DHA+PQ are highly cost-effective regimens for the treatment of paediatric P. falciparum and P. vivax malaria, respectively, in parts of Papua New Guinea. Future research will be required to determine if these findings hold true for other territories in Asia and Oceania with similar malaria epidemiology.     

Racial/Ethnic Differences in Receipt of Timely Adjuvant Therapy for Older Women with Breast Cancer: Are Delays Influenced by the Hospitals Where Patients Obtain Surgical Care?

Objective

To examine whether hospitals where patients obtain care explain racial/ethnic differences in treatment delay.

Data Source

Surveillance, Epidemiology, and End Results data linked with Medicare claims.

Study Design

We examined delays in adjuvant chemotherapy or radiation for women diagnosed with stage I–III breast cancer during 1992–2007. We used multivariable logistic regression to assess the probability of delay by race/ethnicity and included hospital fixed effects to assess whether hospitals explained disparities.

Principal Findings

Among 54,592 women, black (11.9 percent) and Hispanic (9.9 percent) women had more delays than whites (7.8 percent, p < .0001). After adjustment, black (vs. white) women had higher odds of delay (odds ratio = 1.25, 95 percent confidence interval = 1.10–1.42), attenuated somewhat by including hospital fixed effects (OR = 1.17, 95 percent CI = 1.02–1.33).

Conclusions

Hospitals are the important contributors to racial disparities in treatment delay.     

Child maltreatment prevention: a systematic review of reviews

Objective

To synthesize recent evidence from systematic and comprehensive reviews on the effectiveness of universal and selective child maltreatment prevention interventions, evaluate the methodological quality of the reviews and outcome evaluation studies they are based on, and map the geographical distribution of the evidence.

Methods

A systematic review of reviews was conducted. The quality of the systematic reviews was evaluated with a tool for the assessment of multiple systematic reviews (AMSTAR), and the quality of the outcome evaluations was assessed using indicators of internal validity and of the construct validity of outcome measures.

Findings

The review focused on seven main types of interventions: home visiting, parent education, child sex abuse prevention, abusive head trauma prevention, multi-component interventions, media-based interventions, and support and mutual aid groups. Four of the seven – home-visiting, parent education, abusive head trauma prevention and multi-component interventions – show promise in preventing actual child maltreatment. Three of them – home visiting, parent education and child sexual abuse prevention – appear effective in reducing risk factors for child maltreatment, although these conclusions are tentative due to the methodological shortcomings of the reviews and outcome evaluation studies they draw on. An analysis of the geographical distribution of the evidence shows that outcome evaluations of child maltreatment prevention interventions are exceedingly rare in low- and middle-income countries and make up only 0.6% of the total evidence base.

Conclusion

Evidence for the effectiveness of four of the seven main types of interventions for preventing child maltreatment is promising, although it is weakened by methodological problems and paucity of outcome evaluations from low- and middle-income countries.     

A comparison of health care use for physician-referred and self-referred episodes of outpatient physical therapy

Objective

To compare patient profiles and health care use for physician-referred and self-referred episodes of outpatient physical therapy (PT).

Data Source

Five years (2003–2007) of private health insurance claims data, from a Midwest insurer, on beneficiaries aged 18–64.

Study Design

Retrospective analyses of health care use of physician-referred (N = 45,210) and self-referred (N = 17,497) ambulatory PT episodes of care was conducted, adjusting for age, gender, diagnosis, case mix, and year.

Data Collection/Extraction

Physical therapy episodes began with the physical therapist initial evaluation and ended on the last date of service before 60 days of no further visits. Episodes were classified as physician-referred if the patient had a physician claim from a reasonable referral source in the 30 days before the start of PT.

Principal Findings

The self-referred group was slightly younger, but the two groups were very similar in regard to diagnosis and case mix. Self-referred episodes had fewer PT visits (86 percent of physician-referred) and lower allowable amounts ($0.87 for every $1.00), after covariate adjustment, but did not differ in related health care utilization after PT.

Conclusions

Health care use during PT episodes was lower for those who self-referred, after adjusting for key variables, but did not differ after the PT episode.     

Cost–effectiveness of a comprehensive programme for drug-resistant tuberculosis in China

Objective

To investigate the cost–effectiveness of a comprehensive programme for drug-resistant tuberculosis launched in four sites in China in 2011.

Methods

In 2011–2012, we reviewed the records of 172 patients with drug-resistant tuberculosis who enrolled in the comprehensive programme and we collected relevant administrative data from hospitals and China’s public health agency. For comparison, we examined a cohort of 81 patients who were treated for drug-resistant tuberculosis in 2006−2009. We performed a cost–effectiveness analysis, from a societal perspective, that included probabilistic uncertainty. We measured early treatment outcomes based on three-month culture results and modelled longer-term outcomes to facilitate estimation of the comprehensive programme’s cost per disability-adjusted life-year (DALY) averted.

Findings

The comprehensive programme cost 8837 United States dollars (US$) per patient treated. Low enrolment rates meant that some fixed costs were higher, per patient, than expected. Although the comprehensive programme appeared 30 times more costly than the previous one, it resulted in greater health benefits. The comprehensive programme, which cost US$ 639 (95% credible interval: 112 to 1322) per DALY averted, satisfied the World Health Organization’s criterion for a very cost–effective intervention.

Conclusion

The comprehensive programme, which included rapid screening, standardized care and financial protection, improved individual outcomes for MDR tuberculosis in a cost-effective manner. To support post-2015 global heath targets, the comprehensive programme should be expanded to non-residents and other areas of China.     

Global magnitude of reported and unreported mesothelioma

Background

Little is known about the global magnitude of mesothelioma. In particular, many developing countries, including some with extensive historical use of asbestos, do not report mesothelioma.

Objectives

We estimated the global magnitude of mesothelioma accounting for reported and unreported cases.

Methods

For all countries with available data on mesothelioma frequency and asbestos use (n = 56), we calculated the 15-year cumulative number of mesotheliomas during 1994–2008 from data available for fewer years and assessed its relationship with levels of cumulative asbestos use during 1920–1970. We used this relationship to predict the number of unreported mesotheliomas in countries for which no information on mesothelioma is available but which have recorded asbestos use (n = 33).

Results

Within the group of 56 countries with data on mesothelioma occurrence and asbestos use, the 15-year cumulative number of mesothelioma was approximately 174,300. There was a statistically significant positive linear relation between the log-transformed national cumulative mesothelioma numbers and the log-transformed cumulative asbestos use (adjusted R² = 0.83, p < 0.0001). Extrapolated to the group of 33 countries without reported mesothelioma, a total of approximately 38,900 (95% confidence interval, 36,700–41,100) mesothelioma cases were estimated to have occurred in the 15-year period (1994–2008).

Conclusions

We estimate conservatively that, globally, one mesothelioma case has been overlooked for every four to five reported cases. Because our estimation is based on asbestos use until 1970, the many countries that increased asbestos use since then should anticipate a higher disease burden in the immediate decades ahead.