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Deviandri R, van der Veen HC, Purba AKR, Icanervilia AV, Lubis AM, van den Akker-Scheek I, Postma MJ. Cost-utility analysis of early reconstruction surgery versus conservative treatment for anterior cruciate ligament injury in a lower-middle income country. BMC Health Serv Res 2024; 24:784. [PMID: 38982438 PMCID: PMC11234700 DOI: 10.1186/s12913-024-11212-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 06/17/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND The ideal approach for treating anterior cruciate ligament (ACL) injury is still disputed. This study aimed to determine the more cost-effective strategy by comparing early ACL reconstruction (ACLR) surgery to conservative treatment (rehabilitation with optional delayed reconstruction) for ACL injury in a lower/middle-income country (LMIC), Indonesia. METHODS A decision tree model was constructed for cost-utility analysis of early ACLR versus conservative treatment. The transition probabilities between states were obtained from the literature review. Utilities were measured by the EQ-5D-3 L from a prospective cohort study in a local hospital. The costs were obtained from a previous study that elaborated on the burden and cost of ACLR in Indonesia. Effectiveness was expressed in quality-adjusted life years gained (QALYs). Principal outcome measure was the incremental cost-effectiveness ratios (ICER). Willingness-to-pay was set at US$12,876 - three times the Indonesian GDP per capita in 2021 - the currently accepted standard in Indonesia as suggested by the World Health Organization Choosing Interventions that are Cost-Effective criterion (WHO-CHOICE). RESULTS The early ACLR group showed an incremental gain of 0.05 QALYs over the conservative treatment group, with a higher overall cost to society of US$976. The ICER of ACLR surgery was US$19,524 per QALY, above the WTP threshold of US$12,876. The ICER was sensitive to cost of conservative treatment, cost of ACLR, and rate of cross-over to delayed ACLR numbers in the conservative treatment group. Using the WTP threshold of US$12,876, the probability of conservative treatment being preferred over early ACLR was 64%. CONCLUSIONS Based on the current model, early ACLR surgery does not seem more cost-effective compared to conservative treatment for ACL injury patients in Indonesia. Because the result was sensitive to the rate of cross-over probabilities from the conservative treatment alone to delayed ACLR, a future study with a long-term perspective is needed to further elucidate its impact.
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Affiliation(s)
- Romy Deviandri
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
- Department of Surgery-Faculty of Medicine, Universitas Riau, Arifin Achmad Hospital, Diponegoro street no 1, Pekanbaru, 28133, Indonesia.
- Division of Orthopedics-Sports Injury, Fit Centre Institute, Pekanbaru, Indonesia.
| | - Hugo C van der Veen
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Abdul Khairul R Purba
- Department of Pharmacology and Therapy, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Ajeng V Icanervilia
- Department of Radiology, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Andri Mt Lubis
- Department of Orthopedics-Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Inge van den Akker-Scheek
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maarten J Postma
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Economics, Econometrics & Finance, Faculty of Economics & Business, University of Groningen, Groningen, The Netherlands
- Department of Pharmacology & Therapy, Universitas Airlangga, Surabaya, Indonesia
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
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Limato R, Broom A, Nelwan EJ, Hamers RL. A qualitative study of barriers to antimicrobial stewardship in Indonesian hospitals: governance, competing interests, cost, and structural vulnerability. Antimicrob Resist Infect Control 2022; 11:85. [PMID: 35701826 PMCID: PMC9195390 DOI: 10.1186/s13756-022-01126-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 05/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) is one of the leading global public health threats of the 21st Century. Antimicrobial stewardship (AMS) programmes have been shown to improve antibiotic use and clinical outcomes in high-income settings, but context-specific evidence is lacking on the value and effectiveness of current AMS programmes in low-resource settings. This study sought to explore context-specific underlying barriers to AMS implementation in Indonesian hospitals with a focus on governance practices and structural vulnerabilities. METHODS We conducted semi-structured interviews with physicians, surgeons, clinical microbiologists, pharmacists, AMS team leaders, hospital managers, medical students, and national AMR stakeholders, and performed a thematic analysis. RESULTS Based on 51 interviews conducted between January and October 2020, four main barriers to AMS implementation were evident in the participants' experiences: (1) Ineffective resourcing and institutional buy-in regarding mandatory AMS under hospital accreditation; (2) Entangled priorities to generate profits and interprofessional relationships between doctors and hospital managers or AMS leaders; (3) Cost-prohibitive bacterial culture testing and thresholds of national health insurance coverage; (4) Unreliable infrastructures, including microbiology laboratory and surgical facilities, ensuring high antibiotic usage to cover structural vulnerabilities. CONCLUSIONS Limited progress will be made with implementing AMS in Indonesian hospitals, and in settings with similar structural features, without addressing concerns around governance, competing interests, cost and structural vulnerabilities.
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Affiliation(s)
- Ralalicia Limato
- Eijkman-Oxford Clinical Research Unit, Jl. Diponegoro No. 69, Jakarta, 10430, Indonesia.
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, New Richards Building, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LG, UK.
| | - Alex Broom
- Sydney Centre for Healthy Societies, School of Social and Political Sciences, The University of Sydney, Level 3, Social Sciences Building, Sydney, NSW, 2006, Australia
| | - Erni J Nelwan
- Faculty of Medicine, Universitas Indonesia, Jl. Salemba Raya 6, Jakarta, 10430, Indonesia
- Division of Infectious Diseases, Department of Internal Medicine, Cipto Mangunkusumo National General Hospital, Jl. P. Diponegoro no 71 RW 5, Jakarta, 10430, Indonesia
| | - Raph L Hamers
- Eijkman-Oxford Clinical Research Unit, Jl. Diponegoro No. 69, Jakarta, 10430, Indonesia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, New Richards Building, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LG, UK
- Faculty of Medicine, Universitas Indonesia, Jl. Salemba Raya 6, Jakarta, 10430, Indonesia
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Lashari Y, Rochmanti M, Purba AKR, Notobroto HB, Sarassari R, Kuntaman K. The Economic Impact of Carbapenem Resistant-Non Lactose Fermenter and Enterobacteriaceae Infections on Hospital Costs in Dr. Soetomo General Academic Hospital Surabaya, Indonesia. Antibiotics (Basel) 2022; 11:694. [PMID: 35625338 PMCID: PMC9137956 DOI: 10.3390/antibiotics11050694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/04/2022] [Accepted: 05/17/2022] [Indexed: 02/05/2023] Open
Abstract
Background: Carbapenem resistant-non lactose fermenter (CR-NLF) and Carbapenem resistant-Enterobacteriaceae (CR-E) bacterial infections are likely to be a global threat to people’s health. However, studies on the economic impacts according to the hospital setting are very scarce. The study aimed to explore the impact of CR-NLF (Acinetobacter baumannii = CRAB) & Pseudomonas aeruginosa = CRPA) and CR-E (Escherichia coli = CREC) & Klebsiella pneumoniae = CRKP) infections on hospital costs from a payer perspective among patients admitted to Dr.Soetomo Hospital, Surabaya, Indonesia. Methods: In the retrospective case-control study, medical records of all included patients hospitalized during 2018−2021 were reviewed for CRAB, CRPA, CREC, CRKP, and carbapenem sensitive (CSAB, CSPA, CSEC, CSKP) were collected. We retrieved the data of age, gender, clinical specimen, dates of admission, and discharge status. The outcomes of interest were hospital length of stay and hospitalization cost. Results: The cost for CR-NLFs infections was higher than carbapenem sensitive, $3026.24 versus $1299.28 (p < 0.05). There was no significant difference between CR-E against carbapenem sensitive. It showed that the highest impact of the cost was CRAB, followed by CRPA, CRKP, and CREC. The bed, antibiotics, pharmacy, and diagnostic costs of CR-NLFIs were significantly higher than CR-E. Conclusion: This study showed that the hospital cost and expenditure of CR-NLFs per patient were higher than CS. The hospital cost per patient for CR-NLF was higher than CR-E.
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Affiliation(s)
- Yasmeen Lashari
- Doctoral Program, Faculty of Medicine, Universitas Airlangga, Surabaya 60286, Indonesia;
| | - Maftuchah Rochmanti
- Division of Pharmacology, Department of Anatomy, Histology and Pharmacology, Faculty of Medicine, Universitas Airlangga, Surabaya 60286, Indonesia; (M.R.); (A.K.R.P.)
| | - Abdul Khairul Rizki Purba
- Division of Pharmacology, Department of Anatomy, Histology and Pharmacology, Faculty of Medicine, Universitas Airlangga, Surabaya 60286, Indonesia; (M.R.); (A.K.R.P.)
| | - Hari Basuki Notobroto
- Department of Biostatistics and Population, Faculty of Public Health, Universitas Airlangga, Surabaya 60286, Indonesia;
| | - Rosantia Sarassari
- Clinical Microbiology Specialist Program, Faculty of Medicine, Universitas Airlangga, Surabaya 60286, Indonesia;
| | - Kuntaman Kuntaman
- Department of Medical Microbiology, Faculty of Medicine, Universitas Airlangga, Surabaya 60286, Indonesia
- Dr. Soetomo General Academic Hospital, Surabaya 60286, Indonesia
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