Cost-effectiveness of intensive care for hospitalized COVID-19 patients: experience from South Africa

BACKGROUND

Given projected shortages of critical care capacity in public hospitals during the COVID-19 pandemic, the South African government embarked on an initiative to purchase this capacity from private hospitals. In order to inform purchasing decisions, we assessed the cost-effectiveness of intensive care management for admitted COVID-19 patients across the public and private health systems in South Africa.

METHODS

Using a modelling framework and health system perspective, costs and health outcomes of inpatient management of severe and critical COVID-19 patients in (1) general ward and intensive care (GW + ICU) versus (2) general ward only (GW) were assessed. Disability adjusted life years (DALYs) were evaluated and the cost per admission in public and private sectors was determined. The model made use of four variables: mortality rates, utilisation of inpatient days for each management approach, disability weights associated with severity of disease, and the unit cost per general ward day and per ICU day in public and private hospitals. Unit costs were multiplied by utilisation estimates to determine the cost per admission. DALYs were calculated as the sum of years of life lost (YLL) and years lived with disability (YLD). An incremental cost-effectiveness ratio (ICER) - representing difference in costs and health outcomes of the two management strategies - was compared to a cost-effectiveness threshold to determine the value for money of expansion in ICU services during COVID-19 surges.

RESULTS

A cost per admission of ZAR 75,127 was estimated for inpatient management of severe and critical COVID-19 patients in GW as opposed to ZAR 103,030 in GW + ICU. DALYs were 1.48 and 1.10 in GW versus GW + ICU, respectively. The ratio of difference in costs and health outcomes between the two management strategies produced an ICER of ZAR 73,091 per DALY averted, a value above the cost-effectiveness threshold of ZAR 38,465.

CONCLUSIONS

Results indicated that purchasing ICU capacity from the private sector during COVID-19 surges may not be a cost-effective investment. The 'real time', rapid, pragmatic, and transparent nature of this analysis demonstrates an approach for evidence generation for decision making relating to the COVID-19 pandemic response and South Africa's wider priority setting agenda.

P0956HOW DO MARKERS OF FRAILTY VARY ACROSS KIDNEY DISEASE TRAJECTORY? A MULTICENTRE CROSS-SECTIONAL STUDY OF 4736 PATIENTS

Background and Aims

Frailty is a complex health state of increased vulnerability to stressors and is common in those with chronic kidney disease (CKD). Frailty is strongly associated with progressive renal impairment and independently linked with adverse outcomes in all stages of CKD such as disability, falls, hospitalisation, and mortality. How frailty varies across the disease trajectory is not well-defined, particularly in those with early stages of disease. Identifying those with CKD who may be at risk of becoming frail could inform the early intervention and understanding how frailty changes across the disease spectrum may aid better future management of these patients.

Method

This is a secondary analysis of data of n=4736 CKD patients (42% female, mean age 59.7 (SD: 16.3) years) from a prospective observational study of physical activity behaviours. A modified assessment of frailty (based on the Fried phenotype model) was conducted across each of the CKD stages ((n=262 CKD stage 1/2, n=678 CKD stage 3, n=610 CKD stage 4/5, n=1094 haemodialysis (HD), n=177 peritoneal dialysis (PD), n=1915 transplant (TX)). Markers of frailty were defined as (1) poor endurance (defined as a VO2 peak of <20ml/kg/min estimated from the Duke Activity Index Scale); (2) low physical activity level (classified as ‘insufficiently active’ using General Practice Physical Activity Questionnaire); and (3) slowness (self-reported slow walking pace (less than 3mph)). Participants were classified as ‘frail’ if ≥2 markers were present. Frequency analysis and chi-squared tests were conducted to identify and compare patients with ≥2 markers of frailty across the disease trajectory. Binominal logistical regression was performed to determine which factors were associated with being frail.

Results

Across the total cohort, the majority (56%) of patients exhibited ≥2 markers of frailty. The presence of frailty increased concurrently with disease decline (39% CKD stage 1/2, 58% CKD stage 3, 74% CKD stage 4/5, 76% HD, 66% PD, 39% TX). The prevalence of frailty was significantly higher in patients in CKD stage 3, CKD stage 4/5, HD and PD patients when compared to CKD stage 1/2 and TX patients (p<.001). Frailty was significantly higher in patients in CKD stage 4/5 and on HD compared to those in CKD stage 3 (p<.001). Patients who were female (OR = 1.42 [1.23 to 1.65] p<.001), older (OR= 1.05 [1.05 to 1.06] p <.001), and of non-white ethnicity (OR = 2.41 [2.00 to 2.90] p<.001) had an increased likelihood of being frail. Increased number of comorbidities (OR = 1.26 [1.18 to 1.34] p<.001) were associated with an increased likelihood of being frail (Figure 1).

Conclusion

The proportion of patients with ≥2 markers of frailty increased with disease progression until it reached a peak in HD with almost 8 out of 10 HD patients exhibiting frailty. Frailty prevalence was reduced in those with a renal TX. Over half of those in CKD stage 3 and three-quarters with CKD stage 4/5 had ≥2 markers of frailty present. Worryingly, markers of frailty were present early in the disease process with over 1/3 of patients with CKD stage 1/2 classified as frail by this modified phenotype model. Age, sex, ethnicity, and number of comorbidities were associated with the likelihood of being frail. It is important that healthcare providers actively attempt to identify patients at risk of frailty to ensure appropriate interventions addressing risk factors that may exacerbate the progression of frailty can be implemented.

MO023SARCOPENIA, CHRONIC KIDNEY DISEASE AND RISK OF MORTALITY: FINDINGS FROM 426,839 INDIVIDUALS IN THE UK BIOBANK

Background and Aims

Sarcopenia describes a degenerative and generalised skeletal muscle disorder involving the loss of muscle mass and function. In studies of the general population, sarcopenia is associated with adverse outcomes including falls, functional decline, frailty, and mortality. However it remains an under-recognised yet important clinical problem in an ever-increasing ageing and multimorbid renal population. Whilst sarcopenia has been widely studied in end-stage renal disease, there is limited evidence of its prevalence and effects in those not requiring dialysis, particularly in large cohort studies and using the latest sarcopenia definitions. Using the UK Biobank, we aimed to identify the prevalence of sarcopenia in individuals with non-dialysis CKD and its association with mortality.

Method

426,839 participants were categorised into a CKD (defined as eGFR <60ml/min/1.73m2 not requiring dialysis) and a non-CKD comparative group (no evidence of CKD). Sarcopenia was diagnosed using criteria from the EWGSOP2: ‘probable sarcopenia’ (low handgrip strength (HGS) <27 and 16kg, males and females respectively); ‘confirmed sarcopenia’ (low HGS plus low muscle mass, appendicular lean mass <7.0 and 5.5 kg/m2 as measured by bioelectrical impedance); and ‘severe sarcopenia’ (low HGS and muscle mass plus slow gait speed). Patients requiring existing renal replacement therapy were excluded. All-cause mortality was extracted from data linkage to national death records with a median follow up of 9.0 years. Data were analysed using Cox survival models.

Results

CKD (non-dialysis dependent) was identified in n=7,623 individuals (mean age 62.7 (±5.9) years, 44% male, eGFR 52.5 (±7.7) ml/min/1.73m2) compared to n=419,216 in the non-CKD comparative group (mean age 56.1 (±8.1) years, 47% male). ‘Probable sarcopenia’ was identified in 9% of individuals with CKD compared to 5% in those without CKD (P<0.001). ‘Confirmed sarcopenia’ was observed in 0.3% of those with CKD (vs. 0.2% in the non-CKD group, P<0.001). 0.2% of CKD patients satisfied all three criteria (‘severe sarcopenia’) compared to 0.03% in those without CKD (P<0.001). In CKD, sarcopenia was significantly associated with all-cause mortality: ‘probable sarcopenia’, unadjusted hazard ratio (HR) 1.95 (95%CI 1.57 to 2.42), P<0.001 (Figure 1); ‘confirmed sarcopenia’, HR 5.1 (2.5 to 10.3) P<0.001; ‘severe sarcopenia’, HR 5.1 (1.9 to 13.5) P=0.001.

Conclusion

In the largest cohort of its kind, probable sarcopenia was present in 9% of individuals with non-dialysis CKD. The risk of sarcopenia was significantly higher in those with CKD than those without. Regardless of criteria used, CKD patients with sarcopenia were approximately 2-5 times more likely to die than those without sarcopenia. Worryingly, the risk of sarcopenia was elevated even in patients with early stage mild to moderate CKD. Our results show that sarcopenia, including just the presence of low muscle strength, is an important predictor of mortality in early non-dialysis CKD. Measuring sarcopenia as standard practice may identify those most at risk of future adverse events and in need of appropriate interventions to mitigate its negative effects.

P1851INCREASING CO-MORBIDITY REDUCES A PATIENT'S ABILITY TO SELF-MANAGE: AN OBSERVATIONAL STUDY IN NON-DIALYSIS CKD PATIENTS

Background and Aims

Co-morbidity is high in CKD patients and associated with greater mortality and disease burden. Increased burden from other health conditions, as well as CKD, may impact the successful self-management of a patient’s health. A patient’s perceived ability to self-manage their condition can be assessed through the concept of ‘Patient Activation (PA)’ which encompasses a patient’s knowledge, skills, and confidence to undertake self-management tasks. Low PA is associated with poor self-reported health, greater renal impairment, and increased hospitalisation rates. Understanding PA may help the development and initiation of self-management interventions (e.g., low ‘activated’ individuals may require further education on their condition(s) whilst high ‘activated’ patients may require better support in maintaining their current lifestyle). This study aimed to assess how co-morbidity may influence PA and sought to identify which conditions, in exception to CKD, impact PA the most. This may help identify how co-morbidities affect patient’s ability self-manage successfully and aid the development of individualised intervention.

Method

The Patient Activation Measure (PAM), a validated 13 item questionnaire, assessed patient activation by measuring patients perceived ability to self-manage their condition. Results categorise participants into four activation categories (1 to 4; low to high). 152 non-dialysis CKD patients (52.6% female, age 67.9 (SD:12.7) years, eGFR 42.2 (SD:18.6) ml/min) provided self-reported information about their co-morbidities, and completed the PAM. Data was analysed by general linear modelling adjusting for age, sex and eGFR.

Results

134/152 (88.2%) of patients were multi-morbid, defined as 2 or more conditions including CKD, with a mean of 2.1 (SD:1.4) comorbidities. Increasing co-morbidities were associated with reduced PAM score (p=0.009). PAM scores decreased from 67.96 (SE:3.68) in patients with no other co-morbidities to 55.57 (SE:2.81) with 4+ co-morbidities; a reduction from PA level 4 (high) to 2 (low) respectively. The co-morbidities which explained the largest variance in PAM score were diabetes (β=-.193, p=.021), respiratory conditions (β=-.184, p=.37), and MSK conditions (β=-.154, p=.081). No other conditions were predictive of PAM score.

Conclusion

Co-morbidity in non-dialysis CKD patients is high and is associated with reduced PA (i.e. the perceived ability of patients to self-manage their condition(s)). We identified that CKD patients with diabetes, respiratory, and musculoskeletal conditions found it more difficult to self-manage their co-existing conditions. Individuals with musculoskeletal or respiratory conditions may perceive poor self-management ability due to this conditions impact on function (e.g. physical activity limitations) and/or quality of life (e.g. symptoms or sleep). Diabetes could challenge perceived self-management ability due to its chronicity, management complexity (e.g. medication regimens and side effects) and demoralising health sequelae (e.g. cardiovascular risk).

P0269SYMPTOM-BURDEN IN PEOPLE LIVING WITH FRAILTY AND CHRONIC KIDNEY DISEASE

Background and Aims

Patients with chronic kidney disease (CKD) report high symptom-burden that adversely affects health-related quality of life (HRQOL). Frailty is an independent predictor of poor HRQOL in those with CKD.

Although there is a clear relationship between frailty and HRQOL in patients with CKD, the associated relationship with symptom experience is not well understood. Understanding how living with both frailty and CKD influences symptom-burden could inform management strategies that improve HRQOL of this vulnerable patient group. This study’s aim was to evaluate the symptom experience of patients living with frailty and CKD.

Methods

A total of 353 participants were recruited between February 2018 and October 2018 to this cross-sectional observational study. Participants completed physical activity (GP Physical Activity Questionnaire [GPPAQ]), cardiopulmonary fitness (Duke Activity Status Index, providing estimated VO2 peak), symptom-burden (Kidney Symptom Questionnaire [KSQ]) and HRQOL (Short Form 12 [SF-12]) questionnaires. Frailty was assessed using a modified Frailty Phenotype comprising 3 self-report components:

1) weakness/slowness defined as a SF-12 Physical Functioning score <75; 2) low physical activity defined as ‘inactive’ by the GPPAQ; and 3) exhaustion defined as a SF-12 Vitality score <55. Participants were categorised as frail if ≥2 components were present. Multiple imputation was performed for data considered to be either missing completely at random or missing at random. Regression analyses were used to assess the association between frailty, symptom-burden and HRQOL. Principal Component Analysis (PCA) was performed to explore symptom clusters experienced by non-frail and frail participants.

Results

Two hundred and twenty-five (64%) participants were categorised as frail. Frail participants were significantly older (77.7 vs. 71.5 years, p<0.001) and had a significantly lower eGFR (45.8 vs. 50.9 mL/min/1.73m2, p<0.001), albumin concentration (39.2 vs. 41.4 g/L, p<0.001) and estimated VO2 peak (21.7 vs. 33.9 mL/kg/min, p<0.001) than non-frail participants. Frailty, when adjusted for age, sex, eGFR and haemoglobin, was independently associated with higher KSQ total symptom score (p<0.001) and lower SF-12 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores (p<0.001 and p=0.001, respectively). Lower eGFR was associated with higher KSQ total symptom score (p=0.004) and lower SF-12 PCS score (p=0.01). Frailty, when adjusted for age, sex, eGFR and haemoglobin, was independently associated with a two- to over five-fold increase in odds of experiencing all reported symptoms frequently, except loss of appetite and urinary frequency. Lower eGFR was only associated with increased odds of reporting frequent loss of muscle strength (p=0.04). PCA revealed two symptom clusters for non-frail participants and three symptom clusters for frail participants. Both non-frail and frail participants had symptom clusters associated with sleep disturbance and musculoskeletal symptoms. There was an additional unique symptom cluster (comprising loss of appetite, tiredness, feeling cold and poor concentration) experienced by frail participants.

Conclusion

Frailty is an independent predictor of high symptom-burden and poor HRQOL. Furthermore, symptom experience for people living with frailty and CKD is distinct from non-frail individuals, reporting a unique symptom cluster that may be a consequence of the frailty syndrome itself. This group of patients should be offered a holistic assessment so that problematic symptoms can be identified and addressed early before they impact more significantly on HRQOL. Future efforts should be focused on evaluating holistic models of care, such as the comprehensive geriatric assessment, for patients living with frailty and CKD.

The Secure Anonymised Information Linkage databank Dementia e-cohort (SAIL-DeC)

Introduction

The rising burden of dementia is a global concern, and there is a need to study its causes, natural history and outcomes. The Secure Anonymised Information Linkage (SAIL) Databank contains anonymised, routinely-collected healthcare data for the population of Wales, UK. It has potential to be a valuable resource for dementia research owing to its size, long follow-up time and prospective collection of data during clinical care.

Objectives

We aimed to apply reproducible methods to create the SAIL dementia e-cohort (SAIL-DeC). We created SAIL-DeC with a view to maximising its utility for a broad range of research questions whilst minimising duplication of effort for researchers.

Methods

SAIL contains individual-level, linked primary care, hospital admission, mortality and demographic data. Data are currently available until 2018 and future updates will extend participant follow-up time. We included participants who were born between 1st January 1900 and 1st January 1958 and for whom primary care data were available. We applied algorithms consisting of International Classification of Diseases (versions 9 and 10) and Read (version 2) codes to identify participants with and without all-cause dementia and dementia subtypes. We also created derived variables for comorbidities and risk factors.

Results

From 4.4 million unique participants in SAIL, 1.2 million met the cohort inclusion criteria, resulting in 18.8 million person-years of follow-up. Of these, 129,650 (10%) developed all-cause dementia, with 77,978 (60%) having dementia subtype codes. Alzheimer's disease was the most common subtype diagnosis (62%). Among the dementia cases, the median duration of observation time was 14 years.

Conclusion

We have created a generalisable, national dementia e-cohort, aimed at facilitating epidemiological dementia research.

Building toolkits for COPD exacerbations: lessons from the past and present

In the nineteenth century, it was recognised that acute attacks of chronic bronchitis were harmful. 140 years later, it is clearer than ever that exacerbations of chronic obstructive pulmonary disease (ECOPD) are important events. They are associated with significant mortality, morbidity, a reduced quality of life and an increasing reliance on social care. ECOPD are common and are increasing in prevalence. Exacerbations beget exacerbations, with up to a quarter of in-patient episodes ending with readmission to hospital within 30 days. The healthcare costs are immense. Yet despite this, the tools available to diagnose and treat ECOPD are essentially unchanged, with the last new intervention (non-invasive ventilation) introduced over 25 years ago.An ECOPD is 'an acute worsening of respiratory symptoms that results in additional therapy'. This symptom and healthcare utility-based definition does not describe pathology and is unable to differentiate from other causes of an acute deterioration in breathlessness with or without a cough and sputum. There is limited understanding of the host immune response during an acute event and no reliable and readily available means to identify aetiology or direct treatment at the point of care (POC). Corticosteroids, short acting bronchodilators with or without antibiotics have been the mainstay of treatment for over 30 years. This is in stark contrast to many other acute presentations of chronic illness, where specific biomarkers and mechanistic understanding has revolutionised care pathways. So why has progress been so slow in ECOPD? This review examines the history of diagnosing and treating ECOPD. It suggests that to move forward, there needs to be an acceptance that not all exacerbations are alike (just as not all COPD is alike) and that clinical presentation alone cannot identify aetiology or stratify treatment.

Adherence to the iDSI reference case among published cost-per-DALY averted studies

BACKGROUND

The iDSI reference case, originally published in 2014, aims to improve the quality and comparability of cost-effectiveness analyses (CEA). This study assesses whether the development of the guideline is associated with an improvement in methodological and reporting practices for CEAs using disability-adjusted life-years (DALYs).

METHODS

We analyzed the Tufts Medical Center Global Health CEA Registry to identify cost-per-DALY averted studies published from 2011 to 2017. Among each of 11 principles in the iDSI reference case, we translated all methodological specifications and reporting standards into a series of binary questions (satisfied or not satisfied) and awarded articles one point for each item satisfied. We then calculated methodological and reporting adherence scores separately as a percentage of total possible points, measured as normalized adherence score (0% = no adherence; 100% = full adherence). Using the year 2014 as the dissemination period, we conducted a pre-post analysis. We also conducted sensitivity analyses using: 1) optional criteria in scoring, 2) alternate dissemination period (2014-2015), and 3) alternative comparator classification.

RESULTS

Articles averaged 60% adherence to methodological specifications and 74% adherence to reporting standards. While methodological adherence scores did not significantly improve (59% pre-2014 vs. 60% post-2014, p = 0.53), reporting adherence scores increased slightly over time (72% pre-2014 vs. 75% post-2014, p<0.01). Overall, reporting adherence scores exceeded methodological adherence scores (74% vs. 60%, p<0.001). Articles seldom addressed budget impact (9% reporting, 10% methodological) or equity (7% reporting, 7% methodological).

CONCLUSIONS

The iDSI reference case has substantial potential to serve as a useful resource for researchers and policy-makers in global health settings, but greater effort to promote adherence and awareness is needed to achieve its potential.

Do dental undergraduates think that Thiel-embalmed cadavers are a more realistic model for teaching exodontia?

INTRODUCTION

Teaching exodontia to novice undergraduates requires a realistic model. Thiel-embalmed cadavers retain the flexibility of the soft tissues and could be used to teach exodontia.

OBJECTIVE

The objective was to determine whether Thiel-embalmed cadavers were perceived to be a more realistic model by undergraduates in comparison with mannequins.

MATERIALS AND METHODS

Over a period of 4 years (2011-2014), students were randomly assigned into two groups: those taught exodontia on mannequins only (NT) and those who also experienced cadaveric teaching (T). This was followed by an assessment.

RESULTS

There were 174 students in the T group and 108 in the NT group. Sixty-five per cent of the T group and 69% of the NT group provided feedback. Ninety-eight per cent (98%) felt that they had been advantaged by being included in the group compared with 95% in the NT who felt disadvantaged. The majority (98%) thought that using the cadavers was advantageous and gave a realistic feel for soft tissue management (89%) and that it was similar to managing a patient (81%). Self-reported confidence in undertaking an extraction was not different between the two groups (P=.078), and performance in the extraction assessment was not significantly different between the two groups over the 4 years (P=.8).

CONCLUSION

The Thiel-embalmed cadavers were well received by the students who found it a more realistic model for exodontia than a mannequin, even though this did not impact on their performance in a following assessment. Future work on these cadavers may be expanded to include surgical procedures.

Strengthening health technology assessment systems in the global south: a comparative analysis of the HTA journeys of China, India and South Africa

BACKGROUND

Resource allocation in health is universally challenging, but especially so in resource-constrained contexts in the Global South. Pursuing a strategy of evidence-based decision-making and using tools such as Health Technology Assessment (HTA), can help address issues relating to both affordability and equity when allocating resources. Three BRICS and Global South countries, China, India and South Africa have committed to strengthening HTA capacity and developing their domestic HTA systems, with the goal of getting evidence translated into policy. Through assessing and comparing the HTA journey of each country it may be possible to identify common problems and shareable insights.

OBJECTIVES

This collaborative paper aimed to share knowledge on strengthening HTA systems to enable enhanced evidence-based decision-making in the Global South by: Identifying common barriers and enablers in three BRICS countries in the Global South; and Exploring how South-South collaboration can strengthen HTA capacity and utilisation for better healthcare decision-making.

METHODS

A descriptive and explorative comparative analysis was conducted comprising a Within-Case analysis to produce a narrative of the HTA journey in each country and an Across-Case analysis to explore both knowledge that could be shared and any potential knowledge gaps.

RESULTS

Analyses revealed that China, India and South Africa share many barriers to strengthening and developing HTA systems such as: (1) Minimal HTA expertise; (2) Weak health data infrastructure; (3) Rising healthcare costs; (4) Fragmented healthcare systems; and (5) Significant growth in non-communicable diseases. Stakeholder engagement and institutionalisation of HTA were identified as two conducive factors for strengthening HTA systems.

CONCLUSION

China, India and South Africa have all committed to establishing robust HTA systems to inform evidence-based priority setting and have experienced similar challenges. Engagement among countries of the Global South can provide a supportive platform to share knowledge that is more applicable and pragmatic.

Economic Evaluation in Ethiopian Healthcare Sector Decision Making: Perception, Practice and Barriers

BACKGROUND

Globally, economic evaluation (EE) is increasingly being considered as a critical tool for allocating scarce healthcare resources. However, such considerations are less documented in low-income countries, such as in Ethiopia. In particular, to date there has been no assessment conducted to evaluate the perception and practice of and barriers to health EE.

OBJECTIVE

This paper assesses the use and perceptions of EE in healthcare decision-making processes in Ethiopia.

METHODS

In-depth interview sessions with decision makers/healthcare managers and program coordinators across six regional health bureaus were conducted. A qualitative analysis approach was conducted on three thematic areas.

RESULTS

A total of 57 decision makers/healthcare managers were interviewed from all tiers of the health sector in Ethiopia, ranging from the Federal Ministry of Health down to the lower levels of the health facility pyramid. At the high-level healthcare decision-making tier, only 56 % of those interviewed showed a good understanding of EE when explaining in terms of cost and consequences of alternative courses of action and value for money. From the specific program perspective, 50 % of the prevention of mother-to-child transmission of HIV/AIDS program coordinators indicated the relevance of EE to program planning and decision making. These respondents reported a limited application of costing studies on the HIV/AIDS prevention and control program, which were most commonly used during annual planning and budgeting.

CONCLUSION

The study uncovered three important barriers to growth of EE in Ethiopia: a lack of awareness, a lack of expertise and skill, and the traditional decision-making culture.

Strengthening expertise for health technology assessment and priority-setting in Africa

BACKGROUND

Achieving sustainable universal health coverage depends partly on fair priority-setting processes that ensure countries spend scarce resources wisely. While general health economics capacity-strengthening initiatives exist in Africa, less attention has been paid to developing the capacity of individuals, institutions and networks to apply economic evaluation in support of health technology assessment and effective priority-setting.

OBJECTIVE

On the basis of international  lessons, to identify how research organisations and partnerships could contribute to capacity strengthening for health technology assessment and priority-setting in Africa.

METHODS

A rapid scan was conducted of international formal and grey literature and lessons extracted from the deliberations of two international and regional workshops relating to capacity-building for health technology assessment. 'Capacity' was defined in broad terms, including a conducive political environment, strong public institutional capacity to drive priority-setting, effective networking between experts, strong research organisations and skilled researchers.

RESULTS

Effective priority-setting requires more than high quality economic research. Researchers have to engage with an array of stakeholders, network closely other research organisations, build partnerships with different levels of government and train the future generation of researchers and policy-makers. In low- and middle-income countries where there are seldom government units or agencies dedicated to health technology assessment, they also have to support the development of an effective priority-setting process that is sensitive to societal and government needs and priorities.

CONCLUSIONS

Research organisations have an important role to play in contributing to the development of health technology assessment and priority-setting capacity. In Africa, where there are resource and capacity challenges, effective partnerships between local and international researchers, and with key government stakeholders, can leverage existing skills and knowledge to generate a critical mass of individuals and institutions. These would help to meet the priority-setting needs of African countries and contribute to sustainable universal health coverage.

Structural Characterisation Reveals Mechanism of IL-13-Neutralising Monoclonal Antibody Tralokinumab as Inhibition of Binding to IL-13Rα1 and IL-13Rα2

Interleukin (IL)-13 is a pleiotropic T helper type 2 cytokine frequently associated with asthma and atopic dermatitis. IL-13-mediated signalling is initiated by binding to IL-13Rα1, which then recruits IL-4Rα to form a heterodimeric receptor complex. IL-13 also binds to IL-13Rα2, considered as either a decoy or a key mediator of fibrosis. IL-13-neutralising antibodies act by preventing IL-13 binding to IL-13Rα1, IL-4Rα and/or IL-13Rα2. Tralokinumab (CAT-354) is an IL-13-neutralising human IgG4 monoclonal antibody that has shown clinical benefit in patients with asthma. To decipher how tralokinumab inhibits the effects of IL-13, we determined the structure of tralokinumab Fab in complex with human IL-13 to 2 Å resolution. The structure analysis reveals that tralokinumab prevents IL-13 from binding to both IL-13Rα1 and IL-13Rα2. This is supported by biochemical ligand-receptor interaction assay data. The tralokinumab epitope is mainly composed of residues in helices D and A of IL-13. It is mostly light chain complementarity-determining regions that are driving paratope interactions; the variable light complementarity-determining region 2 plays a key role by providing residue contacts for a network of hydrogen bonds and a salt bridge in the core of binding. The key residues within the paratope contributing to binding were identified as Asp50, Asp51, Ser30 and Lys31. This study demonstrates that tralokinumab prevents the IL-13 pharmacodynamic effect by binding to IL-13 helices A and D, thus preventing IL-13 from interacting with IL-13Rα1 and IL-13Rα2.

The International Decision Support Initiative Reference Case for Economic Evaluation: An Aid to Thought

BACKGROUND

Policymakers in high-, low-, and middle-income countries alike face challenging choices about resource allocation in health. Economic evaluation can be useful in providing decision makers with the best evidence of the anticipated benefits of new investments, as well as their expected opportunity costs-the benefits forgone of the options not chosen. To guide the decisions of health systems effectively, it is important that the methods of economic evaluation are founded on clear principles, are applied systematically, and are appropriate to the decision problems they seek to inform.

METHODS

The Bill and Melinda Gates Foundation, a major funder of economic evaluations of health technologies in low- and middle-income countries (LMICs), commissioned a "reference case" through the International Decision Support Initiative (iDSI) to guide future evaluations, and improve both the consistency and usefulness to decision makers.

RESULTS

The iDSI Reference Case draws on previous insights from the World Health Organization, the US Panel on Cost-Effectiveness in Health Care, and the UK National Institute for Health and Care Excellence. Comprising 11 key principles, each accompanied by methodological specifications and reporting standards, the iDSI Reference Case also serves as a means of identifying priorities for methods research, and can be used as a framework for capacity building and technical assistance in LMICs.

CONCLUSIONS

The iDSI Reference Case is an aid to thought, not a substitute for it, and should not be followed slavishly without regard to context, culture, or history. This article presents the iDSI Reference Case and discusses the rationale, approach, components, and application in LMICs.