Comparison of trust in public vs private health care providers in rural Cambodia

How trust in providers affects health care-seeking behaviour is not well understood. Focus groups and household surveys were conducted in Cambodia to examine how villagers describe their trust in public and private providers, and to assess whether a difference exists in provider trust levels. Our findings suggest the reasons for trusting public and private providers differ, and that villagers' trust in and relationship with providers is one of the important considerations affecting where they seek care. People believed that public providers were 'honest' and 'sincere', did not 'bad mouth people' and explained the 'status of [the] disease'. Villagers trusted public providers for their skills and abilities, and for an effective referral system. In contrast, respondents noted that seeing private providers was 'comfortable and easy', that they 'come to our home' and patients can 'owe [them] some money'. Private providers were trusted for being very friendly and approachable, extremely thorough and careful, and easy to contact. Among those who sought care in the past 30 days, trust in the health care provider was listed as the fifth and second most important consideration for choosing public or private providers, respectively. This study illustrates the importance of trust as a unique concept that can affect people's choice of health care providers in a low-income country.

DRG coding practice: a nationwide hospital survey in Thailand

Background

Diagnosis Related Group (DRG) payment is preferred by healthcare reform in various countries but its implementation in resource-limited countries has not been fully explored.

Objectives

This study was aimed (1) to compare the characteristics of hospitals in Thailand that were audited with those that were not and (2) to develop a simplified scale to measure hospital coding practice.

Methods

A questionnaire survey was conducted of 920 hospitals in the Summary and Coding Audit Database (SCAD hospitals, all of which were audited in 2008 because of suspicious reports of possible DRG miscoding); the questionnaire also included 390 non-SCAD hospitals. The questionnaire asked about general demographics of the hospitals, hospital coding structure and process, and also included a set of 63 opinion-oriented items on the current hospital coding practice. Descriptive statistics and exploratory factor analysis (EFA) were used for data analysis.

Results

SCAD and Non-SCAD hospitals were different in many aspects, especially the number of medical statisticians, experience of medical statisticians and physicians, as well as number of certified coders. Factor analysis revealed a simplified 3-factor, 20-item model to assess hospital coding practice and classify hospital intention.

Conclusion

Hospital providers should not be assumed capable of producing high quality DRG codes, especially in resource-limited settings.

During the 'decade of vaccines,' the lives of 6.4 million children valued at $231 billion could be saved

Governments constantly face the challenge of determining how much they should spend to prevent premature deaths and suffering in their populations. In this article we explore the benefits of expanding the delivery of life-saving vaccines in seventy-two low- and middle-income countries, which we estimate would prevent the deaths of 6.4 million children between 2011 and 2020. We present the economic benefits of vaccines by using a "value of statistical life" approach, which is based on individuals' perceptions regarding the trade-off between income and increased risk of mortality. Our analysis shows that the vaccine expansion described above corresponds to $231 billion (uncertainty range: $116-$614 billion) in the value of statistical lives saved. This analysis complements results from analyses based on other techniques and is the first of its kind for immunizations in the world's poorest countries. It highlights the major economic benefits made possible by improving vaccine coverage.

A systematic review of economic evaluations of health and health-related interventions in Bangladesh

BACKGROUND

Economic evaluation is used for effective resource allocation in health sector. Accumulated knowledge about economic evaluation of health programs in Bangladesh is not currently available. While a number of economic evaluation studies have been performed in Bangladesh, no systematic investigation of the studies has been done to our knowledge. The aim of this current study is to systematically review the published articles in peer-reviewed journals on economic evaluation of health and health-related interventions in Bangladesh.

METHODS

Literature searches was carried out during November-December 2008 with a combination of key words, MeSH terms and other free text terms as suitable for the purpose. A comprehensive search strategy was developed to search Medline by the PubMed interface. The first specific interest was mapping the articles considering the areas of exploration by economic evaluation and the second interest was to scrutiny the methodological quality of studies. The methodological quality of economic evaluation of all articles has been scrutinized against the checklist developed by Evers Silvia and associates.

RESULT

Of 1784 potential articles 12 were accepted for inclusion. Ten studies described the competing alternatives clearly and only two articles stated the perspective of their articles clearly. All studies included direct cost, incurred by the providers. Only one study included the cost of community donated resources and volunteer costs. Two studies calculated the incremental cost effectiveness ratio (ICER). Six of the studies applied some sort of sensitivity analysis. Two of the studies discussed financial affordability of expected implementers and four studies discussed the issue of generalizability for application in different context.

CONCLUSION

Very few economic evaluation studies in Bangladesh are found in different areas of health and health-related interventions, which does not provide a strong basis of knowledge in the area. The most frequently applied economic evaluation is cost-effectiveness analysis. The majority of the studies did not follow the scientific method of economic evaluation process, which consequently resulted into lack of robustness of the analyses. Capacity building on economic evaluation of health and health-related programs should be enhanced.

Health system costs of menstrual regulation and care for abortion complications in Bangladesh

CONTEXT

Treatment of complications of unsafe abortion can be a significant financial drain on health system resources, particularly in developing countries. In Bangladesh, menstrual regulation is provided by the government as a backup to contraception. The comparison of economic costs of providing menstrual regulation care with those of providing treatment of abortion complications has implications for policy in Bangladesh and internationally.

METHODS

Data on incremental costs of providing menstrual regulation and care for abortion complications were collected through surveys of providers at 21 public-sector facilities in Bangladesh. These data were entered into an abortion-oriented costing spreadsheet to estimate the health system costs of providing such services.

RESULTS

The incremental costs per case of providing menstrual regulation care in 2008 were 8-13% of those associated with treating severe abortion complications, depending on the level of care. An estimated 263,688 menstrual regulation procedures were provided at public-sector facilities in 2008, with incremental costs estimated at US$2.2 million, and 70,098 women were treated for abortion-related complications in such facilities, with incremental costs estimated at US$1.6 million.

CONCLUSION

The provision of menstrual regulation averts unsafe abortion and associated maternal morbidity and mortality, and on a per case basis, saves scarce health system resources. Increasing access to menstrual regulation would enable more women to obtain much-needed care and health system resources to be utilized more efficiently.

Effect of a nutrition supplement and physical activity program on pneumonia and walking capacity in Chilean older people: a factorial cluster randomized trial

BACKGROUND

Ageing is associated with increased risk of poor health and functional decline. Uncertainties about the health-related benefits of nutrition and physical activity for older people have precluded their widespread implementation. We investigated the effectiveness and cost-effectiveness of a national nutritional supplementation program and/or a physical activity intervention among older people in Chile.

METHODS AND FINDINGS

We conducted a cluster randomized factorial trial among low to middle socioeconomic status adults aged 65-67.9 years living in Santiago, Chile. We randomized 28 clusters (health centers) into the study and recruited 2,799 individuals in 2005 (~100 per cluster). The interventions were a daily micronutrient-rich nutritional supplement, or two 1-hour physical activity classes per week, or both interventions, or neither, for 24 months. The primary outcomes, assessed blind to allocation, were incidence of pneumonia over 24 months, and physical function assessed by walking capacity 24 months after enrollment. Adherence was good for the nutritional supplement (~75%), and moderate for the physical activity intervention (~43%). Over 24 months the incidence rate of pneumonia did not differ between intervention and control clusters (32.5 versus 32.6 per 1,000 person years respectively; risk ratio = 1.00; 95% confidence interval 0.61-1.63; p = 0.99). In intention-to-treat analysis, after 24 months there was a significant difference in walking capacity between the intervention and control clusters (mean difference 33.8 meters; 95% confidence interval 13.9-53.8; p = 0.001). The overall cost of the physical activity intervention over 24 months was US$164/participant; equivalent to US$4.84/extra meter walked. The number of falls and fractures was balanced across physical activity intervention arms and no serious adverse events were reported for either intervention.

CONCLUSIONS

Chile's nutritional supplementation program for older people is not effective in reducing the incidence of pneumonia. This trial suggests that the provision of locally accessible physical activity classes in a transition economy population can be a cost-effective means of enhancing physical function in later life.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN 48153354.

The effect of maternal tetanus immunization on children's schooling attainment in Matlab, Bangladesh: follow-up of a randomized trial

We investigate the effects of antenatal maternal vaccination against tetanus on the schooling attained by children in Bangladesh. Maternal vaccination prevents the child from acquiring tetanus at birth through blood infection and substantially reduces infant mortality and may prevent impairment in children who would otherwise acquire tetanus but survive. We follow up on a 1974 randomized trial of maternal tetanus vaccination, looking at outcomes for children born in the period 1975-1979. We find significant schooling gains from maternal tetanus vaccination for children whose parents had no schooling, showing a large impact on a small number of children. Our findings make a case for investments in maternal tetanus vaccination as a method of improving schooling and eventual economic outcomes.

Cost-effectiveness of community-based management of acute malnutrition in Malawi

This study assessed the cost-effectiveness of community-based management of acute malnutrition (CMAM) to prevent deaths due to severe acute malnutrition among children under-five. The analysis used a decision tree model to compare the costs and effects of two options to treat severe acute malnutrition: existing health services with CMAM vs existing health services without CMAM. The model used outcome and cost data from a CMAM programme in Dowa district, Malawi and a set of key assumptions regarding treatment-seeking behaviour and mortality outcomes. Under our 'base case' scenario, we found that CMAM cost US$42 per disability-adjusted life year (DALY) averted (2007 US$) and US$493 per DALY averted under an assumed 'worst case' scenario for each variable. The results suggest that CMAM was highly cost-effective in the 'base case' as defined by the World Health Organization, as the cost per DALY falls well below Malawi's 2007 gross national income (GNI) per capita of US$250, and is within the range of DALYs reported for other child health interventions. Under a hypothetical 'worst case' for all variables, the model indicates CMAM is still cost-effective. The results indicate the decision to scale-up CMAM within essential health services in Dowa was a cost-effective one and that scaling up CMAM in similar contexts is also likely to be cost-effective. However, several contextual and programmatic factors should be considered when generalizing to diverse contexts.

The cost-effectiveness of rotavirus vaccination in Malawi

BACKGROUND

Rotarix (GlaxoSmithKline), a newly licensed rotavirus vaccine requiring 2 doses, may have the potential to save hundreds of thousands of lives in Africa. Nations such as Malawi, where Rotarix is currently under phase III investigation, may nevertheless face difficult economic choices in considering vaccine adoption.

METHODS

The cost-effectiveness of implementing a Rotarix vaccine program in Malawi was estimated using published estimates of rotavirus burden, vaccine efficacy, and health care utilization and costs.

RESULTS

With 49.5% vaccine efficacy, a Rotarix program could avert 2582 deaths annually. With GAVI Alliance cofinancing, adoption of Rotarix would be associated with a cost of $5.07 per disability-adjusted life-year averted. With market pricing, Rotarix would be associated with a base case cost of $74.73 per disability-adjusted life-year averted. Key variables influencing results were vaccine efficacy, under-2 rotavirus mortality, and program cost of administering each dose.

CONCLUSIONS

Adopting Rotarix would likely be highly cost-effective for Malawi, particularly with GAVI support. This finding holds true across uncertainty ranges for key variables, including efficacy, for which data are becoming available.

Quantification of condylar resorption in temporomandibular joint osteoarthritis

OBJECTIVE

This study was performed to determine the condylar morphologic variation of osteoarthritic (OA) and asymptomatic temporomandibular joints (TMJs) and to determine its correlation with pain intensity and duration.

STUDY DESIGN

Three-dimensional surface models of mandibular condyles were constructed from cone-beam computerized tomography images of 29 female patients with TMJ OA (Research Diagnostic Criteria for Temporomandibular Disorders group III) and 36 female asymptomatic subjects. Shape correspondence was used to localize and quantify the condylar morphology. Statistical analysis was performed with multivariate analysis of covariance analysis, using Hotelling T(2) metric based on covariance matrices, and Pearson correlation.

RESULTS

The OA condylar morphology was statistically significantly different from the asymptomatic condyles (P < .05). Three-dimensional morphologic variation of the OA condyles was significantly correlated with pain intensity and duration.

CONCLUSION

Three-dimensional quantification of condylar morphology revealed profound differences between OA and asymptomatic condyles, and the extent of the resorptive changes paralleled pain severity and duration.

An internal health systems research portfolio assessment of a low-income country research institution

BACKGROUND

In order to determine the type and amount of health systems research being conducted within ICDDR,B (also known as the Centre), a leading research institution in Bangladesh, an internal review of all on-going research protocols was conducted in September 2007.

METHODS

A review of all ongoing research protocols within the Centre was conducted. The names of the investigators and the institutional divisions of the protocols were removed in order to decrease the amount of reviewer bias. The building blocks of the World Health Organization's "Framework for Action" on health systems was used to categorize the protocols considered to be health systems research projects. Several additional items were collected, e.g. the highest level of education completed by the Principal Investigator. A total dollar value was placed on the health systems research portfolio of the institution based on the budgets of the selected protocols.

RESULTS

As of September 2007 16 out of 118 (13.5%) reviewed protocols were considered to be health systems research projects. Results of the six building blocks of the health system categorization demonstrated that a majority of these protocols involved elements of health services delivery. There was very little engagement in more downstream systems and policy research that involved leadership and governance of the health system. Eleven of the HSR studies were local in scope, while there was only one study that has a multinational focus. The Centre's total dollar value for the health systems research project portfolio added up to US$ 3,723,331.

CONCLUSIONS

This internal review can serve as a snap shot of on-going activities, and as a baseline for future assessments against which to monitor progress in the area of health systems research. Further, it can serve as a model for other institutions striving to assess and develop health systems research programmes and capacity.

Financing children's vaccines

A 2006 Commonwealth Association of Paediatric Gastroenterology and Nutrition workshop on financing children's vaccines highlighted the potential for vaccines to control diarrhoea and other diseases as well as spur economic development through better health. Clear communication of vaccination value to decision-makers is required, together with sustainable funding mechanisms. GAVI and partners have made great progress providing funding for vaccines for children in the poorest countries but other solutions may be required to achieve the same gains in middle- and high-income countries. World Health Organization has a wealth of freely available country-level data on immunisation that academics and advocates can use to communicate the economic and health benefits of vaccines to decision-makers.

Are vaccination programmes delivered by lay health workers cost-effective? A systematic review

BACKGROUND

A recently updated Cochrane systematic review on the effects of lay or community health workers (LHWs) in primary and community health care concluded that LHW interventions could lead to promising benefits in the promotion of childhood vaccination uptake. However, understanding of the costs and cost-effectiveness of involving LHWs in vaccination programmes remains poor. This paper reviews the costs and cost-effectiveness of vaccination programme interventions involving LHWs.

METHODS

Articles were retrieved if the title, keywords or abstract included terms related to 'lay health workers', 'vaccination' and 'economics'. Reference lists of studies assessed for inclusion were also searched and attempts were made to contact authors of all studies included in the Cochrane review. Studies were included after assessing eligibility of the full-text article. The included studies were then reviewed against a set of background and technical characteristics.

RESULTS

Of the 2616 records identified, only three studies fully met the inclusion criteria, while an additional 11 were retained as they included some cost data. Methodologically, the studies were strong but did not adequately address affordability and sustainability and were also highly heterogeneous in terms of settings and LHW outcomes, limiting their comparability. There were insufficient data to allow any conclusions to be drawn regarding the cost-effectiveness of LHW interventions to promote vaccination uptake. Studies focused largely on health outcomes and did illustrate to some extent how the institutional characteristics of communities, such as governance and sources of financial support, influence sustainability.

CONCLUSION

The included studies suggest that conventional economic evaluations, particularly cost-effectiveness analyses, generally focus too narrowly on health outcomes, especially in the context of vaccination promotion and delivery at the primary health care level by LHWs. Further studies on the costs and cost-effectiveness of vaccination programmes involving LHWs should be conducted, and these studies should adopt a broader and more holistic approach.

Prevalence of antibiotic-resistant Salmonella in fish in Guangdong, China

INTRODUCTION

This study examines fish from freshwater aquaculture operations in Guangdong Province, China, to determine the prevalence of antibiotic-resistant Salmonella isolates. This information can help identify risks of human exposure to Salmonella and guide decisions of whether to include farmed fish samples in routine food surveillance for Salmonella.

METHODS

One hundred live freshwater-farmed finfish were sampled from several stalls at two wholesale and four retail markets in Guangzhou from June to July 2008. Isolation and antibiotic sensitivity testing was done according to the U.S. FDA Bacteriological Analytical Manual. Antibiotic sensitivity testing was done using the Kirby Bauer disk diffusion method.

RESULTS

All five Salmonella isolates were susceptible to neomycin, cefotaxime, and cefepime and resistant to erythromycin and penicillin. The most resistant isolate was susceptible to 7 of the 16 antibiotics tested.

DISCUSSION

The estimated prevalence of Salmonella is 5% (95% CI: 2-11%) in live finfish from markets in Guangzhou, China. All five isolates were not susceptible to three or more antibiotics. Three of the five isolates had decreased susceptibility to nitrofurantoin, suggesting illegal use of nitrofurans in food animal production, and surveillance of resistance to this class of antibiotics is warranted. We suggest aquaculture-producing countries where there may be high antibiotic use to add farmed fish products to the list of foods they include in Salmonella surveillance. This would help evaluate human health risks posed by antibiotic-resistant bacteria in farmed fish products.

WHO Guide for standardisation of economic evaluations of immunization programmes

Traditional EPI vaccines are considered to be among the most efficient uses of scarce health care resources. Today, there are many under-used and new vaccines available. In the short- to medium-term, these vaccines will not cost the few cents per dose the traditional vaccines do, but will be 'multi-dollar' vaccines. Decision-makers will need information, among other things, on their relative cost-effectiveness. A number of reviews have indicated that there is scope for improving the transparency, completeness and comparability of economic evaluations of vaccination programmes. Thus, there is a need to improve the quality of economic evaluations of vaccination programmes. Adherence to general guidelines would increase the quality, interpretability and transferability of future analyses. However, there is reason to believe that there might also be a need for more specific advice for vaccination programmes. For example, there are inconsistencies in the methods used to estimate the future benefits of vaccination programmes and the relative efficiency of these programmes can be sensitive to some of the more controversial aspects of general guidelines, such as the inclusion of indirect costs and the discounting of health outcomes. This guide has been developed in order to meet the needs of decision-makers for relevant, reliable and consistent economic information. They aim to provide clear and concise, practical and high quality guidance for those who conduct economic evaluations.

Directing diarrhoeal disease research towards disease-burden reduction

Despite gains in controlling mortality relating to diarrhoeal disease, the burden of disease remains unacceptably high. To refocus health research to target disease-burden reduction as the goal of research in child health, the Child Health and Nutrition Research Initiative developed a systematic strategy to rank health research options. This priority-setting exercise included listing of 46 competitive research options in diarrhoeal disease and their critical and quantitative appraisal by 10 experts based on five criteria for research that reflect the ability of the research to be translated into interventions and achieved disease-burden reduction. These criteria included the answerability of the research questions; the efficacy and effectiveness of the intervention resulting from the research; the maximal potential for disease-burden reduction of the interventions derived from the research; the affordability, deliverability, and sustainability of the intervention supported by the research; and the overall effect of the research-derived intervention on equity. Experts scored each research option independently to delineate the best investments for diarrhoeal disease control in the developing world to reduce the burden of disease by 2015. Priority scores obtained for health policy and systems research obtained eight of the top 10 rankings in overall scores, indicating that current investments in health research are significantly different from those estimated to be the most effective in reducing the global burden of diarrhoeal disease by 2015.

Methods for economic evaluation of a factorial-design cluster randomised controlled trial of a nutrition supplement and an exercise programme among healthy older people living in Santiago, Chile: the CENEX study

Background

In an effort to promote healthy ageing and preserve health and function, the government of Chile has formulated a package of actions into the Programme for Complementary Food in Older People (Programa de Alimentación Complementaria para el Adulto Mayor - PACAM). The CENEX study was designed to evaluate the impact, cost and cost-effectiveness of the PACAM and a specially designed exercise programme on pneumonia incidence, walking capacity and body mass index in healthy older people living in low- to medium-socio-economic status areas of Santiago. The purpose of this paper is to describe in detail the methods that will be used to estimate the incremental costs and cost-effectiveness of the interventions.

Methods and design

The base-case analysis will adopt a societal perspective, including the direct medical and non-medical costs borne by the government and patients. The cost of the interventions will be calculated by the ingredients approach, in which the total quantities of goods and services actually employed in applying the interventions will be estimated, and multiplied by their respective unit prices. Relevant information on costs of interventions will be obtained mainly from administrative records. The costs borne by patients will be collected via exit and telephone interviews. An annual discount rate of 8% will be used, consistent with the rate recommended by the Government of Chile. All costs will be converted from Chilean Peso to US dollars with the 2007 average period exchange rate of US$1 = 522.37 Chilean Peso. To test the robustness of model results, we will vary the assumptions over a plausible range in sensitivity analyses.

Discussion

The protocol described here indicates our intent to conduct an economic evaluation alongside the CENEX study. It provides a detailed and transparent statement of planned data collection methods and analyses.

Trial registration

ISRCTN48153354

Trust in the context of community-based health insurance schemes in Cambodia: villagers' trust in health insurers

OBJECTIVE

To understand the role and influence of villagers' trust for the health insurer on enrollment in a community-based health insurance (CBHI) scheme in Cambodia.

METHODOLOGY/APPROACH

This study was conducted in northwest Cambodia where a CBHI scheme operates with the highest enrollment rates in the country. A mixed method approach was employed to gauge how individuals in the community trust the health insurer, and whether this plays a role in their decisions to enroll in CBHI schemes. Focus groups and household surveys were carried out to identify and measure trust levels, and to explore the association between insurer trust and enrollment in CBHI schemes.

FINDINGS

Although villagers generally trusted the health insurance organization, villagers with poor experiences with other organizations in the past were less willing to trust the insurer. Insurer trust represented a combination of interpersonal and impersonal trust. After controlling for demographic factors, health care utilization, and household socioeconomic status, insurer trust levels for villagers who newly enrolled (RRR = 1.07, p < 0.001) and renewed insurance (RRR = 1.15, p < 0.001) were significantly higher than those who never enrolled in CBHI schemes.

IMPLICATIONS FOR POLICY

This study illustrates the relationship between CBHI enrollment and villagers' trust for the health insurer in a low-income, post-conflict country. It highlights the need for staff of health insurance organizations to place greater emphasis on building trusting interpersonal relationships with villagers. Understanding the nature of trust for the health insurer is essential to improve health insurance enrollment and protect people in poor rural communities against the impact of health-related shocks.

Cost effectiveness in low- and middle-income countries: a review of the debates surrounding decision rules

Cost-effectiveness analysis (CEA) is increasingly important in public health decision making, including in low- and middle-income countries. The decision makers' valuation of a unit of health gain, or ceiling ratio (lambda), is important in CEA as the relative value against which acceptability is defined, although values are usually chosen arbitrarily in practice. Reference case estimates for lambda are useful to promote consistency, facilitate new developments in decision analysis, compare estimates against benefit-cost ratios from other economic sectors, and explicitly inform decisions about equity in global health budgets. The aim of this article is to discuss values for lambda used in practice, including derivation based on affordability expectations (such as $US150 per disability-adjusted life-year [DALY]), some multiple of gross national income or gross domestic product, and preference-elicitation methods, and explore the implications associated with each approach. The background to the debate is introduced, the theoretical bases of current values are reviewed, and examples are given of their application in practice. Advantages and disadvantages of each method for defining lambda are outlined, followed by an exploration of methodological and policy implications.

Preliminary study of shunt related death in paediatric patients

Hydrocephalus is a condition commonly encountered in paediatric and adult neurosurgery and cerebrospinal fluid (CSF) shunting remains the treatment of choice for many cases. Despite improvements in shunt technology and technique, morbidity and mortality remain. The incidence of early shunt obstruction is high with later failures seen less frequently. This review aims to examine mortality associated with mechanical failure of CSF shunts within Queensland. Neurosurgical and Intensive Care databases were reviewed for cases of mortality associated with shunt failure. Eight cases were identified between the years of 1992 and 2002 with the average age at death 7.7 years. Deaths occurred on average 2 years after last shunt revision. Seven of the eight patients lived outside the metropolitan area. Shunting remains an imperfect means of treating hydrocephalus. Mortality may be encountered at any time post surgery and delays to surgical intervention influence this. Alternative measures such as third ventriculostomy or the placement of a separate access device should be considered. In the event of emergency, a spinal needle could be used to access the ventricle along the course of the ventricular catheter.

Rotavirus vaccination for Hong Kong children: an economic evaluation from the Hong Kong Government perspective

AIMS

To perform an economic analysis of government-funded universal rotavirus vaccination in Hong Kong from the government's perspective.

METHODS

A Markov model of costs and effects (disability averted) associated with universal vaccination was compared with no vaccination. In both strategies, newborns were studied until 5 years of age or until they died, using cost, probability and utility data from the literature. The potential cost savings and cost effectiveness of vaccination were calculated and their sensitivities to changes in vaccine and health care costs, presumed decline in vaccine efficacy over time, and the use of discounting and age weights were determined.

RESULTS

Depending on assumptions, the new rotavirus vaccines would be cost saving to the Hong Kong Government if they cost less than US$40-92 per course. Higher vaccine costs would quickly lead to an incremental cost-effectiveness ratio exceeding that of the gross national product per capita if the mortality rate of rotavirus gastroenteritis remained at zero.

CONCLUSIONS

Based on 2002 demographic, cost and morbidity data and reasonable uncertainty estimates of these variables, a universal rotavirus vaccination programme paid for by the Hong Kong Government is cost neutral at a per course vaccine cost of US$40-92. For a fixed vaccine cost, the potential savings and cost effectiveness of the vaccine increase with higher estimated health care costs and vice versa.

Can a “novice” do aneurysm surgery? Surgical outcomes in a low-volume, non-subspecialised neurosurgical unit

The objective of this paper is to review the results of a junior general neurosurgeon performing aneurysm surgery and compare these to the remainder of his low-volume unit. Prospectively collected data was analysed for 114 aneurysms clipped in 99 patients between July 2001 and May 2005. Overall there was a 0.9% mortality rate and 10.8% complication rate. The favourable outcome rate for the unit was 100% for unruptured aneurysms, 90.4% for grades 1-3 patients and 30% for poor grade patients (grades 4 and 5). The novice neurosurgeon had no mortality and a favourable outcome rate of 94.7% for grades 1-3 patients and 50% for poor grade patients. Acceptable results can be obtained with cerebral aneurysm surgery in a low-volume centre by Australian-trained, non-subspecialty neurosurgeons.