Key actors' perspectives on cost-effectiveness analysis in Uganda: a cross-sectional survey

Cost-effectiveness analysis of Smart Triage, a data-driven pediatric sepsis triage platform in Eastern Uganda

BACKGROUND

Sepsis, characterized by organ dysfunction due to presumed or proven infection, has a case-fatality over 20% in severe cases in low-and-middle income countries. Early diagnosis and treatment have proven benefits, prompting our implementation of Smart Triage at Jinja Regional Referral Hospital in Uganda, a program that expedites treatment through a data-driven triage platform. We conducted a cost-effectiveness analysis of Smart Triage to explore its impact on patients and inform multicenter scale up.

METHODS

The parent clinical trial for Smart Triage was pre-post in design, using the proportion of children receiving sepsis treatment within one hour as the primary outcome, a measure linked to mortality benefit in existing literature. We used a decision-analytic model with Monte Carlo simulation to calculate the cost per year-of-life-lost (YLL) averted of Smart Triage from societal, government, and patient perspectives. Healthcare utilization and lost work for seven days post-discharge were translated into costs and productivity losses via secondary linkage data.

RESULTS

In 2021 United States dollars, Smart Triage requires an annuitized program cost of only $0.05 per child, but results in $15.32 saved per YLL averted. At a willingness-to-pay threshold of only $3 per YLL averted, well below published cost-effectiveness threshold estimates for Uganda, Smart Triage approaches 100% probability of cost-effectiveness over the baseline manual triage system. This cost-effectiveness was observed from societal, government, and patient perspectives. The cost-effectiveness observed was driven by a reduction in admission that, while explainable by an improved triage mechanism, may also be partially attributable to changes in healthcare utilization influenced by the coronavirus pandemic. However, Smart Triage remains cost-effective in sensitivity analyses introducing a penalty factor of up to 50% in the reduction in admission.

CONCLUSION

Smart Triage's ability to both save costs and avert YLLs indicates that patients benefit both economically and clinically, while its high probability of cost-effectiveness strongly supports multicenter scale up. Areas for further research include the incorporation of years lived with disability when sepsis disability weights in low-resource settings become available and analyzing budget impact during multicenter scale up.

TRIAL REGISTRATION

NCT04304235 (registered on 11/03/2020, clinicaltrials.gov).

Economic evaluations of tobacco control interventions in low- and middle-income countries: a systematic review

BACKGROUND AND AIMS

Tobacco consumption and its associated adverse outcomes remain major public health issues, particularly in low- and middle-income countries. This systematic review aimed to identify and critically assess full economic evaluations for tobacco control interventions in low- and middle-income countries.

METHODS

Electronic databases, including EMBASE, MEDLINE and PsycINFO and the grey literature, were searched using terms such as 'tobacco', 'economic evaluation' and 'smoking' from 1994 to 2020. Study quality was assessed using the Consensus Health Economic Criteria and the Philips checklist. Studies were included which were full economic evaluations of tobacco control interventions in low- and middle-income settings. Reviews, commentaries, conference proceedings and abstracts were excluded. Study selection and quality assessment were conducted by two reviewers independently. A narrative synthesis was conducted to synthesize the findings of the studies.

RESULTS

This review identified 20 studies for inclusion. The studies evaluated a wide range of interventions, including tax increase, nicotine replacement therapy (nicotine patch/gum) and financial incentives. Overall, 12 interventions were reported to be cost-effective, especially tax increases for tobacco consumption and cessation counselling. There were considerable limitations regarding data sources (e.g. using cost data from other countries or assumptions due to the lack of local data) and the model structure; sensitivity analyses were inadequately described in many studies; and there were issues around the transferability of results to other settings. Additionally, the affordability of the interventions was only discussed in two studies.

CONCLUSIONS

There are few high-quality studies of the cost-effectiveness of tobacco use control interventions in low- and middle-income countries. The methodological limitations of the existing literatures could affect the generalizability of the findings.

Health technology assessment in sub-Saharan Africa: a descriptive analysis and narrative synthesis

Background

Countries in Sub-Saharan Africa (SSA) are moving towards universal health coverage. The process of Health Technology Assessment (HTA) can support decisions relating to benefit package design and service coverage. HTA involves institutional cooperation with agreed methods and procedural standards. We systematically reviewed the literature on policies and capacity building to support HTA institutionalisation in SSA.

Methods

We systematically reviewed the literature by searching major databases (PubMed, Embase, etc.) until June 2019 using terms considering three aspects: HTA; health policy, decision making; and SSA. We quantitatively extracted and descriptively analysed content and conducted a narrative synthesis eliciting themes from the selected literature, which varied in study type and apporach.

Results

Half of the 49 papers identified were primary research studies and mostly qualitative. Five countries were represented in six of ten studies; South Africa, Ghana, Uganda, Cameroon, and Ethiopia. Half of first authors were from SSA. Most informants were policy makers. Five themes emerged: (1) use of HTA; (2) decision-making in HTA; (3) values and criteria for setting priority areas in HTA; (4) involving stakeholders in HTA; and (5) specific examples of progress in HTA in SSA. The first one was the main theme where there was little use of evidence and research in making policy. The awareness of HTA and economic evaluation was low, with inadequate expertise and a lack of local data and tools.

Conclusions

Despite growing interest in HTA in SSA countries, awareness remains low and HTA-related activities are uncoordinated and often disconnected from policy. Further training and skills development are needed, firmly linked to a strategy focusing on strengthening within-country partnerships, particularly among researchers and policy makers. The international community has an important role here by supporting policy- relevant technical assistance, highlighting that sustainable financing demands evidence-based processes for effective resource allocation, and catalysing knowledge-sharing opportunities among countries facing similar challenges.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12962-021-00293-5.

A Cost-Effectiveness Analysis of a Pediatric Operating Room in Uganda

This study examines the cost-effectiveness of constructing a dedicated pediatric operating room (OR) in Uganda, a country where access to surgical care is limited to 4 pediatric surgeons serving a population of over 20 million children under 15 years of age.

METHODS

A simulation model using a decision tree template was developed to project the cost and disability-adjusted life-years saved by a pediatric OR in a low-income setting. Parameters are informed by patient outcomes of the surgical procedures performed. Costs of the OR equipment and a literature review were used to calculate the incremental cost-effectiveness ratio of a pediatric OR. One-way and probabilistic sensitivity analysis were performed to assess parameter uncertainty. Economic monetary benefit was calculated using the value of a statistical life approach.

RESULTS

A pediatric OR averted a total of 6,447 disability-adjusted life-years /year (95% uncertainty interval 6,288-6,606) and cost $41,182/year (UI 40,539-41,825) in terms of OR installation. The pediatric operating room had an incremental cost-effectiveness ratio of $6.39 per disability-adjusted life-year averted (95% uncertainty interval of 6.19-6.59), or $397.95 (95% uncertainty interval of 385.41-410.67) per life saved based on the country's average life expectancy in 2015. These values were well within the WHO guidelines of cost-effectiveness threshold. The net economic benefit amounted to $5,336,920 for a year of operation, or $16,371 per patient. The model remained robust with one-way and probabilistic sensitivity analyses.

CONCLUSION

The construction of a pediatric operating room in Uganda is a cost-effective and worthwhile investment, endorsing future decisions to enhance pediatric surgical capacity in the resource-limited settings of Sub-Saharan Africa.

The Development of the Guide to Economic Analysis and Research (GEAR) Online Resource for Low- and Middle-Income Countries' Health Economics Practitioners: A Commentary

Public health authorities around the world are increasingly using economic evaluation to set priorities and inform decision making in health policy, especially in the development of health benefit packages. Nevertheless, researchers in low- and middle-income countries (LMICs) encounter many barriers when conducting economic evaluations. In 2015, the Health Intervention and Technology Assessment Program identified key technical and context-specific challenges faced in conducting and using health economic evaluations in LMICs. On the basis of these research findings, the Guide to Economic Analysis and Research (GEAR) online resource (www.gear4health.com) was developed as a reliable aid to researchers in LMICs that would help overcome those challenges. Funded by the Thailand Research Fund and the Bill and Melinda Gates Foundation, GEAR is a free online resource that provides a visual aid tool for planning economic evaluation studies (GEAR mind maps), a repository of national and international economic evaluation guidelines (GEAR guideline comparison), and an active link to a network of volunteer international experts (GEAR: Ask an expert). GEAR will evolve over time to provide relevant, reliable, and up-to-date information through inputs from its users (e.g., periodic survey on methodological challenges) and experts (e.g., in responding to users' questions). The objective of this commentary was to give a brief description of the development and key features of this unique collective information hub aimed at facilitating high-quality research and empowering health care decision makers and stakeholders to use economic evaluation evidence.