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Conradi N, Opoka RO, Mian Q, Conroy AL, Hermann LL, Charles O, Amone J, Nabwire J, Lee BE, Saleh A, Mandhane P, Namasopo S, Hawkes MT. Solar-powered O 2 delivery for the treatment of children with hypoxaemia in Uganda: a stepped-wedge, cluster randomised controlled trial. Lancet 2024; 403:756-765. [PMID: 38367643 DOI: 10.1016/s0140-6736(23)02502-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 11/05/2023] [Accepted: 11/06/2023] [Indexed: 02/19/2024]
Abstract
BACKGROUND Supplemental O2 is not always available at health facilities in low-income and middle-income countries (LMICs). Solar-powered O2 delivery can overcome gaps in O2 access, generating O2 independent of grid electricity. We hypothesized that installation of solar-powered O2 systems on the paediatrics ward of rural Ugandan hospitals would lead to a reduction in mortality among hypoxaemic children. METHODS In this pragmatic, country-wide, stepped-wedge, cluster randomised controlled trial, solar-powered O2 systems (ie, photovoltaic cells, battery bank, and O2 concentrator) were sequentially installed at 20 rural health facilities in Uganda. Sites were selected for inclusion based on the following criteria: District Hospital or Health Centre IV with paediatric inpatient services; supplemental O2 on the paediatric ward was not available or was unreliable; and adequate space to install solar panels, a battery bank, and electrical wiring. Allocation concealment was achieved for sites up to 2 weeks before installation, but the study was not masked overall. Children younger than 5 years admitted to hospital with hypoxaemia and respiratory signs were included. The primary outcome was mortality within 48 h of detection of hypoxaemia. The statistical analysis used a linear mixed effects logistic regression model accounting for cluster as random effect and calendar time as fixed effect. The trial is registered at ClinicalTrials.gov, NCT03851783. FINDINGS Between June 28, 2019, and Nov 30, 2021, 2409 children were enrolled across 20 hospitals and, after exclusions, 2405 children were analysed. 964 children were enrolled before site randomisation and 1441 children were enrolled after site randomisation (intention to treat). There were 104 deaths, 91 of which occurred within 48 h of detection of hypoxaemia. The 48 h mortality was 49 (5·1%) of 964 children before randomisation and 42 (2·9%) of 1440 (one individual did not have vital status documented at 48 h) after randomisation (adjusted odds ratio 0·50, 95% CI 0·27-0·91, p=0·023). Results were sensitive to alternative parameterisations of the secular trend. There was a relative risk reduction of 48·7% (95% CI 8·5-71·5), and a number needed to treat with solar-powered O2 of 45 (95% CI 28-230) to save one life. Use of O2 increased from 484 (50·2%) of 964 children before randomisation to 1424 (98·8%) of 1441 children after randomisation (p<0·0001). Adverse events were similar before and after randomisation and were not considered to be related to the intervention. The estimated cost-effectiveness was US$25 (6-505) per disability-adjusted life-year saved. INTERPRETATION This stepped-wedge, cluster randomised controlled trial shows the mortality benefit of improving O2 access with solar-powered O2. This study could serve as a model for scale-up of solar-powered O2 as one solution to O2 insecurity in LMICs. FUNDING Grand Challenges Canada and The Women and Children's Health Research Institute.
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Affiliation(s)
- Nicholas Conradi
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Robert O Opoka
- Department of Paediatrics and Child Health, Mulago Hospital and Makerere University, Kampala, Uganda; Global Health Uganda, Kampala, Uganda
| | - Qaasim Mian
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Andrea L Conroy
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Olaro Charles
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Jackson Amone
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | | | - Bonita E Lee
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Abdullah Saleh
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Piush Mandhane
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Sophie Namasopo
- Ministry of Health, Kabale, Uganda; Kabale Regional Referral Hospital, Kabale, Uganda
| | - Michael T Hawkes
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada; Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, AB, Canada; School of Public Health, University of Alberta, Edmonton, AB, Canada; Stollery Science Lab, Edmonton, AB, Canada; Women and Children's Health Research Institute, Edmonton, AB, Canada.
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Pradhan M, Waghmare KT, Alghabshi R, Almahdouri F, Al Sawafi KM, M I, Alhadhramy AM, AlYaqoubi ER. Exploring the Economic Aspects of Hospitals: A Comprehensive Examination of Relevant Factors. Cureus 2024; 16:e54867. [PMID: 38533171 PMCID: PMC10964728 DOI: 10.7759/cureus.54867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2024] [Indexed: 03/28/2024] Open
Abstract
Financial limitations in the hospital industry have the potential to exacerbate healthcare disparities, impede investments in cutting-edge medical treatments, as well as impair patient outcomes. The interdependent connection between a hospital economy and the general well-being of the community highlights the necessity of careful financial oversight and inventive healthcare policies. Effective collaboration among policymakers, healthcare administrators, and stakeholders is imperative in the development of sustainable economic models that give equal weight to fiscal prudence and optimal patient outcomes. This article aims to underscore the pivotal importance of strategic fund allocation guided by hospital administrators, accentuating several key initiatives capable of revolutionizing healthcare delivery and elevating the institution's stature within the medical community. The other important aspects discussed here are fund allocation in hospitals, the boom of online consultations, and emphasis on the use of sustainable and cost-effective modalities of energy.
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Affiliation(s)
- Madhur Pradhan
- Obstetrics and Gynaecology, Khoula Hospital, Muscat, OMN
| | | | | | | | | | - Iman M
- Obstetrics and Gynaecology, Khoula Hospital, Muscat, OMN
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Chitando M, Cleary S, Cunnama L. Systematic review of economic evaluations for paediatric pulmonary diseases. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2023; 21:27. [PMID: 37121992 PMCID: PMC10149023 DOI: 10.1186/s12962-023-00423-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 01/24/2023] [Indexed: 05/02/2023] Open
Abstract
BACKGROUND Paediatric pulmonary diseases are the leading causes of mortality amongst children under five globally. Economic evaluations (EEs) seek to guide decision-makers on which health care interventions to adopt to reduce the paediatric pulmonary disease burden. This study aims to systematically review economic evaluations on different aspects of the inpatient management of paediatric pulmonary diseases globally. METHODS We systematically reviewed EEs published between 2010 and 2020, with a subsequent search conducted for 2020-2022. We searched PubMed, Web of Science, MEDLINE, Paediatric Economic Database Evaluation (PEDE) and the Cochrane library. We extracted data items guided by the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. We collected qualitative and quantitative data which we analysed in Microsoft Excel and R software. RESULTS Twenty-two articles met the inclusion criteria. Six of the articles were cost-effectiveness analyses, six cost-utility analyses, two cost-minimisation analyses and eight cost analyses. Twelve articles were from high-income countries (HICs) and ten were from low- and middle-income countries (LMICs). Eight articles focused on asthma, eleven on pneumonia, two on asthma and pneumonia, and one on tuberculosis. CONCLUSION Conducting more EEs for paediatric pulmonary diseases in LMICs could allow for more evidence-based decision-making to improve paediatric health outcomes.
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Affiliation(s)
- Mutsawashe Chitando
- Health Economics Unit and Division, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa.
| | - Susan Cleary
- Health Economics Unit and Division, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa
| | - Lucy Cunnama
- Health Economics Unit and Division, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa
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Smith V, Changoor A, McDonald C, Barash D, Olayo B, Adudans S, Nelson T, Reynolds C, Cainer M, Stunkel J. A Comprehensive Approach to Medical Oxygen Ecosystem Building: An Implementation Case Study in Kenya, Rwanda, and Ethiopia. GLOBAL HEALTH, SCIENCE AND PRACTICE 2022; 10:GHSP-D-21-00781. [PMID: 36951289 PMCID: PMC9771461 DOI: 10.9745/ghsp-d-21-00781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 10/24/2022] [Indexed: 11/23/2022]
Abstract
Medical oxygen is an essential treatment for life-threatening hypoxemic conditions and is commonly indicated for the clinical management of most leading causes of mortality in children aged younger than 5 years, obstetric complications at delivery, and surgical procedures. In resource-constrained settings, access to medical oxygen is unreliable due to cost, distance from production centers, undermaintained infrastructure, and a fragmented supply chain. To increase availability of medical oxygen in underserved communities, Assist International, the GE Foundation, Grand Challenges Canada, the Center for Public Health and Development (Kenya), Health Builders (Rwanda), and the National Ministries of Health and Regional Health Bureaus in Kenya, Rwanda, and Ethiopia partnered to implement a social enterprise model for the production and distribution of medical oxygen to hospitals at reduced cost. This model established pressure swing adsorption (PSA) plants at large referral hospitals and equipped them to serve as localized supply hubs to meet regional demand for medical oxygen while using revenues from cylinder distribution to subsidize ongoing costs. Since 2014, 4 PSA plants have successfully been established and sustained using a social enterprise model in Siaya, Kenya; Ruhengeri, Rwanda; and Amhara Region, Ethiopia. These plants have cumulatively delivered more than 209,708 cylinders of oxygen to a network of 183 health care facilities as of October 2022. In Ethiopia, this model costs an estimated US$7.34 per patient receiving medical oxygen over a 20-year time horizon. Altogether, this business model has enabled the sustainable provision of medical oxygen to communities with populations totaling more than 33 million people, including an estimated 5 million children aged younger than 5 years.
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Affiliation(s)
| | | | | | | | - Bernard Olayo
- Center for Public Health and Development, Nairobi, Kenya
| | - Steve Adudans
- Academy for Novel Channels in Health and Operations Research (ACANOVA Africa), Nairobi, Kenya
| | - Tyler Nelson
- Health Systems Work, Inc., Kigali, Rwanda; Formerly of Health Builders, Kigali, Rwanda
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Mian Q, Rahman Malik SMM, Alinor MA, Hossain MS, Sharma JK, Hassan OM, Ahmed AM, Jama AA, Okello AJ, Namasopo S, Opoka RO, Conradi N, Saleh A, Conroy AL, Hawkes MT. Implementation of solar powered oxygen delivery in a conflict zone: preliminary findings from Somalia on feasibility and usefulness. Med Confl Surviv 2022; 38:140-158. [PMID: 35730216 DOI: 10.1080/13623699.2022.2081056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Access to therapeutic oxygen in low-resource settings remains a significant global problem. Solar powered oxygen (SPO2) delivery is a reliable and cost-effective solution. We followed implementation research methodology to gather data on engineering parameters (remote monitoring), nurse training (before and after knowledge questionnaire), patients treated with SPO2 (descriptive case series), and qualitative user feedback (focus group discussions). In January 2021, SPO2 was installed at Hanano General Hospital in Dusamareb, Galmudug State, Somalia, in a conflict-affected region. Daily photovoltaic cell output (median 8.0 kWh, interquartile range (IQR) 2.6-14) exceeded the electrical load from up to three oxygen concentrators (median 5.0 kWh, IQR 0.90-12). Over the first six months after implementation, 114 patients (age 1 day to 89 years, 54% female) were treated for hypoxaemic illnesses, including COVID-19, pneumonia, neonatal asphyxia, asthma, and trauma. Qualitative end user feedback highlighted SPO2 acceptability. Violent conflict was identified as a contextual factor affecting local oxygen needs. We provide the preliminary findings of this implementation research study and describe the feasibility, fidelity, rapid adoption, usefulness, and acceptability of SPO2 in a low-resource setting characterized by violent conflict during the COVID-19 pandemic. Our findings demonstrated the lifesaving feasibility of SPO2 in volatile settings.
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Affiliation(s)
- Qaasim Mian
- Department of Paediatrics, University of Alberta, Edmonton, Canada
| | | | | | | | | | - Osman Moallim Hassan
- Chief of Staff of the Presidency of the Galmudug State of Somalia, Dhusamareb, Somalia
| | | | | | - Andrew J Okello
- Centre for International Programs & Linkages, Somali International University, Mogadishu, Somalia.,Research Unit, The Jassa Centre, Nairobi, Kenya
| | - Sophie Namasopo
- Department of Paediatrics, Jinja Regional Referral Hospital, Jinja, Uganda
| | - Robert O Opoka
- Department of Paediatrics and Child Health, Mulago Hospital and Makerere University, Kampala, Uganda
| | - Nicholas Conradi
- Department of Paediatrics, University of Alberta, Edmonton, Canada
| | - Abdullah Saleh
- Department of Paediatrics, University of Alberta, Edmonton, Canada
| | - Andrea L Conroy
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Michael T Hawkes
- Department of Pediatrics, Department of Medical Microbiology and Immunology, School of Public Health, University of Alberta, Edmonton, Canada.,Stollery Science Lab, Women and Children's Health Research Institute, Edmonton, Canada
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Lam F, Stegmuller A, Chou VB, Graham HR. Oxygen systems strengthening as an intervention to prevent childhood deaths due to pneumonia in low-resource settings: systematic review, meta-analysis and cost-effectiveness. BMJ Glob Health 2021; 6:bmjgh-2021-007468. [PMID: 34930758 PMCID: PMC8689120 DOI: 10.1136/bmjgh-2021-007468] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/24/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Increasing access to oxygen services may improve outcomes among children with pneumonia living in low-resource settings. We conducted a systematic review to estimate the impact and cost-effectiveness of strengthening oxygen services in low-income and middle-income countries with the objective of including oxygen as an intervention in the Lives Saved Tool. DESIGN We searched EMBASE and PubMed on 31 March 2021 using keywords and MeSH terms related to 'oxygen', 'pneumonia' and 'child' without restrictions on language or date. The risk of bias was assessed for all included studies using the quality assessment tool for quantitative studies, and we assessed the overall certainty of the evidence using Grading of Recommendations, Assessment, Development and Evaluations. Meta-analysis methods using random effects with inverse-variance weights was used to calculate a pooled OR and 95% CIs. Programme cost data were extracted from full study reports and correspondence with study authors, and we estimated cost-effectiveness in US dollar per disability-adjusted life-year (DALY) averted. RESULTS Our search identified 665 studies. Four studies were included in the review involving 75 hospitals and 34 485 study participants. We calculated a pooled OR of 0.52 (95% CI 0.39 to 0.70) in favour of oxygen systems reducing childhood pneumonia mortality. The median cost-effectiveness of oxygen systems strengthening was $US62 per DALY averted (range: US$44-US$225). We graded the risk of bias as moderate and the overall certainty of the evidence as low due to the non-randomised design of the studies. CONCLUSION Our findings suggest that strengthening oxygen systems is likely to reduce hospital-based pneumonia mortality and may be cost-effective in low-resource settings. Additional implementation trials using more rigorous designs are needed to strengthen the certainty in the effect estimate.
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Affiliation(s)
- Felix Lam
- Clinton Health Access Initiative, Boston, Massachusetts, USA
| | - Angela Stegmuller
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Victoria B Chou
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Hamish R Graham
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, University College Hospital Ibadan, Ibadan, Nigeria
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Utility of solar-powered oxygen delivery in a resource-constrained setting. Pulmonology 2021:S2531-0437(21)00224-5. [PMID: 34937668 DOI: 10.1016/j.pulmoe.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 11/10/2021] [Accepted: 11/20/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Pneumonia is a leading cause of childhood mortality globally. Children with severe pneumonia associated with hypoxaemia require oxygen (O2) therapy, which is scarce across resource-constrained countries. Solar-powered oxygen (SPO2) is a novel technology developed for delivering therapeutic O2 in resource-constrained environments. RESEARCH QUESTION Is the introduction of SPO2 associated with a reduction in mortality, relative to the existing practice? STUDY DESIGN This was a pragmatic, quasi-experimental study comparing mortality amongst children < 5 years of age with hypoxaemic respiratory illness before and after the installation of SPO2 in two resource-constrained hospitals. METHODS Participants were children < 5 years old admitted with acute hypoxaemic respiratory illness. The intervention was SPO2, installed at two resource-constrained hospitals. The primary outcome was 30-day mortality. Secondary outcomes included in-hospital mortality (time to death), length of hospital stay among survivors, duration of O2 therapy (time to wean O2), and O2 delivery system failure(s). RESULTS Mortality amongst children admitted with acute hypoxaemic respiratory illness decreased from 30/50 (60%) pre-SPO2 to 15/50 (30%) post-SPO2 (relative risk reduction 50%, 95%CI 19 - 69, p = 0.0049). The post-SPO2 period was consistently associated with decreased mortality in statistical models adjusting for potential confounding factors. Likewise, survival curves pre- and post- SPO2 differed significantly (hazard ratio 0.39, 95% CI 0.20 - 0.74, p = 0.0043). A reduction in the frequency of O2 delivery interruptions due to fuel shortages and multiple patients needing the concentrator at once was observed, explaining the mortality reduction. INTERPRETATION Solar-powered oxygen installation was associated with decreased mortality in resource-constrained settings.
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Siu J, Jackson LJ, Bensassi S, Manjang B, Manaseki-Holland S. Cost-effectiveness of a weaning food safety and hygiene programme in rural Gambia. Trop Med Int Health 2021; 26:1624-1633. [PMID: 34672047 DOI: 10.1111/tmi.13691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The main objective of the economic evaluation was to determine the cost-effectiveness of a weaning food safety and hygiene programme in reducing rates of diarrhoea compared with the control in rural Gambia. METHODS The public health intervention, using critical control points and motivational drivers, was evaluated in a cluster randomised controlled trial at 6- and 32-month follow-up. An economic evaluation was undertaken alongside the RCT with data collected prospectively from a societal perspective. Decision-analytic modelling was used to explore cost-effectiveness over a longer time period (4 years). RESULTS Direct out-of-pocket healthcare expenditure for households due to diarrhoea was large. The intervention significantly reduced reported childhood diarrhoeal episodes after 6 months (incident risk ratio = 0.40, 95% CI 0.33, 0.49) and 2 years after the intervention (incident risk ratio = 0.68, 95% CI 0.46, 1.02). The within-trial analysis found that the intervention led to total savings of 8064 dalasi 6 months after the intervention and 4224 dalasi 2 years after the intervention. Based on the model results, if the intervention is successful in maintaining the reduction in the risk of diarrhoea, the ICER is US$ 814 per DALY avoided over 4 years. This is cost-effective. CONCLUSIONS This study suggests that there are substantial household costs associated with diarrhoeal episodes in children. The within-trial analysis and model results suggest that the community-based approach to improving weaning food hygiene and safety is likely to be cost-effective compared with control.
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Affiliation(s)
- Jade Siu
- Economics Department, Business School, College of Social Sciences, University of Birmingham, Birmingham, UK
| | - Louise J Jackson
- Health Economics Unit, Institute of Applied Health Research, School of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Sami Bensassi
- Management Department, Business School, College of Social Sciences, University of Birmingham, Birmingham, UK
| | - Buba Manjang
- Public Health Services, Directorate of Public Health and Social Welfare, Ministry of Health of the Government of Gambia, Banjul, The Gambia
| | - Semira Manaseki-Holland
- Institute of Applied Health Research, School of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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