Forecasting burden of long-term disability from neonatal conditions: results from the Projahnmo I trial, Sylhet, Bangladesh

Trends in Prevalence and Disability-Adjusted Life-Years of Alzheimer's Disease and Other Dementias in China from 1990 to 2019

INTRODUCTION

China has the largest population of people with dementia in the world and is estimated to have approximately a quarter of the entire population with dementia worldwide, bringing a heavy burden on the public and healthcare systems. We aimed to analyze the burden of Alzheimer's disease and other dementias in China over the past three decades.

METHODS

The data on disease burden owing to Alzheimer's disease and other dementias in China from 1990 to 2019 were extracted from the Global Burden of Disease (GBD) 2019 datasets. The estimated annual percentage changes (EAPCs) were calculated to assess the temporal trends, and the ratio of years lived with disability (YLDs) to disability-adjusted life-years (DALYs) was used as an indicator to evaluate the healthcare system.

RESULT

In China, the overall age-standardized rates (ASRs) of the prevalence and DALYs of Alzheimer's disease and other dementias increased from 1990 to 2019, and their EAPCs were 0.66 (95% confidence interval [CI], 0.57-0.75) and 0.26 (95% CI, 0.21-0.31), respectively. ASRs and the total number of dementia in females remained higher than in males, but the upward trend in ASRs among men was more pronounced than in women. The female-to-male ratio of the age-standardized DALY rate peaked in the 75-79 year age group in 2019 (female-to-male ratio of 1.32). The YLDs:DALYs ratio in China experienced a gradual increase and finally stayed above the global average since 2011.

CONCLUSION

China has experienced a remarkably rising burden of dementia over the past three decades. The more significant burden of dementia was in females, but the potentially increasing burden of dementia in males cannot be underestimated.

The economic burden incurred by families caring for a young child with developmental disability in Uganda

Each year, nearly 30 million children globally are at risk of developmental difficulties and disability as a result of newborn health conditions, with the majority living in resource-constrained countries. This study estimates the annual cost to families related to caring for a young child with developmental disability in Uganda. Nested within a feasibility trial of early care and support for young children with developmental disabilities, this sub-study estimated the cost of illness, the cost of paternal abandonment of the caregiver and the affordability of care by household. Seventy-three caregivers took part in this sub-study. The average annual cost of illness to families was USD 949. The main cost drivers were the cost of seeking care and income lost due to loss of employment. Households caring for a child with a disability spent more than the national average household expenditure, and the annual cost of illness for all households was more than 100% of the national GDP per capita. In addition, 84% of caregivers faced economic consequences and resorted to wealth-reducing coping strategies. Families caring for a child with severe impairment incurred USD 358 more on average than those with mild or moderate impairment. Paternal abandonment was common (31%) with affected mothers losing an average of USD 430 in financial support. Caring for a young child with developmental disability was unaffordable to all the study households. Programmes of early care and support have the potential to reduce these financial impacts. National efforts to curb this catastrophic health expenditure are necessary.

mCARE, a digital health intervention package on pregnancy surveillance and care-seeking reminders from 2018 to 2027 in Bangladesh: a model-based cost-effectiveness analysis

OBJECTIVE

We estimated the cost-effectiveness of a digital health intervention package (mCARE) for community health workers, on pregnancy surveillance and care-seeking reminders compared with the existing paper-based status quo, from 2018 to 2027, in Bangladesh.

INTERVENTIONS

The mCARE programme involved digitally enhanced pregnancy surveillance, individually targeted text messages and in-person home-visit to pregnant women for care-seeking reminders for antenatal care, child delivery and postnatal care.

STUDY DESIGN

We developed a model to project population and service coverage increases with annual geographical expansion (from 1 million to 10 million population over 10 years) of the mCARE programme and the status quo.

MAJOR OUTCOMES

For this modelling study, we used Lives Saved Tool to estimate the number of deaths and disability-adjusted life years (DALYs) that would be averted by 2027, if the coverage of health interventions was increased in mCARE programme and the status quo, respectively. Economic costs were captured from a societal perspective using an ingredients approach and expressed in 2018 US dollars. Probabilistic sensitivity analysis was undertaken to account for parameter uncertainties.

RESULTS

We estimated the mCARE programme to avert 3076 deaths by 2027 at an incremental cost of $43 million relative to the status quo, which is translated to $462 per DALY averted. The societal costs were estimated to be $115 million for mCARE programme (48% of which are programme costs, 35% user costs and 17% provider costs). With the continued implementation and geographical scaling-up, the mCARE programme improved its cost-effectiveness from $1152 to $462 per DALY averted from 5 to 10 years.

CONCLUSION

Mobile phone-based pregnancy surveillance systems with individually scheduled text messages and home-visit reminder strategies can be highly cost-effective in Bangladesh. The cost-effectiveness may improve as it promotes facility-based child delivery and achieves greater programme cost efficiency with programme scale and sustainability.

Costs and cost-effectiveness analyses of mCARE strategies for promoting care seeking of maternal and newborn health services in rural Bangladesh

Objective

We examined the incremental cost-effectiveness between two mHealth programs, implemented from 2011 to 2015 in rural Bangladesh: (1) Comprehensive mCARE package as an intervention group and (2) Basic mCARE package as a control group.

Methods

Both programs included a core package of census enumeration and pregnancy surveillance provided by an established cadre of digitally enabled community health workers (CHWs). In the comprehensive mCARE package, short message service (SMS) and home visit reminders were additionally sent to pregnant women (n = 610) and CHWs (n = 70) to promote the pregnant women’s care-seeking of essential maternal and newborn care services. Economic costs were assessed from a program perspective inclusive of development, start-up, and implementation phases. Effects were calculated as disability adjusted life years (DALYs) and the number of newborn deaths averted. For comparative purposes, we normalized our evaluation to estimate total costs and total newborn deaths averted per 1 million people in a community for both groups. Uncertainty was assessed using probabilistic sensitivity analyses with Monte Carlo simulation.

Results

The addition of SMS and home visit reminders based on a mobile phone-facilitated pregnancy surveillance system was highly cost effective at a cost per DALY averted of $31 (95% uncertainty range: $19–81). The comprehensive mCARE program had at least 88% probability of being highly cost-effective as compared to the basic mCARE program based on the threshold of Bangladesh’s GDP per capita.

Conclusion

mHealth strategies such as SMS and home visit reminders on a well-established pregnancy surveillance system may improve service utilization and program cost-effectiveness in low-resource settings.

Incremental cost and cost-effectiveness of low-dose, high-frequency training in basic emergency obstetric and newborn care as compared to status quo: part of a cluster-randomized training intervention evaluation in Ghana

BACKGROUND

Low-dose, high-frequency (LDHF) training is a new approach best practices to improve clinical knowledge, build and retain competency, and transfer skills into practice after training. LDHF training in Ghana is an opportunity to build health workforce capacity in critical areas of maternal and newborn health and translate improved capacity into better health outcomes.

METHODS

This study examined the costs of an LDHF training approach for basic emergency obstetric and newborn care and calculates the incremental cost-effectiveness of the LDHF training program for health outcomes of newborn survival, compared to the status quo alternative of no training. The costs of LDHF were compared to costs of traditional workshop-based training per provider trained. Retrospective program cost analysis with activity-based costing was used to measure all resources of the LDHF training program over a 3-year analytic time horizon. Economic costs were estimated from financial records, informant interviews, and regional market prices. Health effects from the program's impact evaluation were used to model lives saved and disability-adjusted life years (DALYs) averted. Uncertainty analysis included one-way and probabilistic sensitivity analysis to explore incremental cost-effectiveness results when fluctuating key parameters.

RESULTS

For the 40 health facilities included in the evaluation, the total LDHF training cost was $823,134. During the follow-up period after the first LDHF training-1 year at each participating facility-approximately 544 lives were saved. With deterministic calculation, these findings translate to $1497.77 per life saved or $53.07 per DALY averted. Probabilistic sensitivity analysis, with mean incremental cost-effectiveness ratio of $54.79 per DALY averted ($24.42-$107.01), suggests the LDHF training program as compared to no training has 100% probability of being cost-effective above a willingness to pay threshold of $1480, Ghana's gross national income per capita in 2015.

CONCLUSION

This study provides insight into the investment of LDHF training and value for money of this approach to training in-service providers on basic emergency obstetric and newborn care. The LDHF training approach should be considered for expansion in Ghana and integrated into existing in-service training programs and health system organizational structures for lower cost and more efficiency at scale.

Estimating costs of care for meningitis infections in low- and middle-income countries

Meningitis infections are often associated with high mortality and risk of sequelae. The costs of treatment and care for meningitis are a great burden on health care systems, particularly in resource-limited settings. The objective of this study is to review data on the costs of care for meningitis in low- and middle-income countries, as well as to show how results could be extrapolated to countries without sound data. We conducted a systematic review of the literature from six databases to identify studies examining the cost of care in low- and middle-income countries for all age groups with suspected, probable, or confirmed meningitis. We extracted data on treatment costs and sequelae by infectious agent and/or pathogen, where possible. Using multiple regression analysis, a relationship between hospital costs and associated determinants was investigated in order to predict costs in countries with missing data. This relationship was used to predict treatment costs for all 144 low- and middle-income countries. The methodology of conducting a systematic review, extrapolating, and setting up a standard database can be used as a tool to inform cost-effectiveness analyses in situations where cost of care data are poor. Both acute and long-term costs of meningitis could be extrapolated to countries without reliable data. Although only bacterial causes of meningitis can be vaccine-preventable, a better understanding of the treatment costs for meningitis is crucial for low- and middle-income countries to assess the cost-effectiveness of proposed interventions in their country. This cost information will be important as inputs in future cost-effectiveness studies, particularly for vaccines.

Cost and cost-effectiveness of newborn home visits: findings from the Newhints cluster-randomised controlled trial in rural Ghana

Background

Every year, 2·9 million newborn babies die worldwide. A meta-analysis of four cluster-randomised controlled trials estimated that home visits by trained community members in programme settings in Ghana and south Asia reduced neonatal mortality by 12% (95% CI 5–18). We aimed to estimate the costs and cost-effectiveness of newborn home visits in a programme setting.

Methods

We prospectively collected detailed cost data alongside the Newhints trial, which tested the effect of a home-visits intervention in seven districts in rural Ghana and showed a reduction of 8% (95% CI −12 to 25%) in neonatal mortality. The intervention consisted of a package of home visits to pregnant women and their babies in the first week of life by community-based surveillance volunteers. We calculated incremental cost-effectiveness ratios (ICERs) with Monte Carlo simulation and one-way sensitivity analyses and characterised uncertainty with cost-effectiveness planes and cost-effectiveness acceptability curves. We then modelled the potential cost-effectiveness for baseline neonatal mortality rates of 20–60 deaths per 1000 livebirths with use of a meta-analysis of effectiveness estimates.

Findings

In the 49 zones randomly allocated to receive the Newhints intervention, a mean of 407 (SD 18) community-based surveillance volunteers undertook home visits for 7848 pregnant women who gave birth to 7786 live babies in 2009. Annual economic cost of implementation was US$203 998, or $0·53 per person. In the base-case analysis, the Newhints intervention cost a mean of $10 343 (95% CI 2963 to −7674) per newborn life saved, or $352 (95% CI 104 to −268) per discounted life-year saved, and had a 72% chance of being highly cost effective with respect to Ghana's 2009 gross domestic product per person. Key determinants of cost-effectiveness were the discount rate, protective effectiveness, baseline neonatal mortality rate, and implementation costs. In the scenarios modelled with the meta-analysis results, the ICER increased from $127 per life-year saved at a neonatal mortality rate of 60 deaths per 1000 livebirths, to $379 per life-year saved at a rate of 20 deaths per 1000 livebirths. The strategy had at least a 99% probability of being highly cost effective for lower-middle-income countries in all neonatal mortality rate scenarios modelled, and at least a 95% probability of being highly cost effective for low-income countries at neonatal mortality rates of 30 or more deaths per 1000 livebirths.

Interpretation

Our findings show that the seemingly modest mortality reductions achieved by a newborn home-visit strategy might in fact be cost effective. In Ghana, such strategies are also likely to be affordable. Our findings support recommendations from WHO and UNICEF that low-income and middle-income countries implement newborn home visits.

Funding

The Bill & Melinda Gates Foundation, UK Department for International Development, WHO.

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

OBJECTIVE

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

METHODS

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

FINDINGS

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

CONCLUSION

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