Cost-effectiveness analysis of revised WHO guidelines for management of childhood pneumonia in 74 Countdown countries

Systematic review of economic evaluations for paediatric pulmonary diseases

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.

Estimated global public health and economic impact of COVID-19 vaccines in the pre-omicron era using real-world empirical data

BACKGROUND

Limited data are available describing the global impact of COVID-19 vaccines. This study estimated the global public health and economic impact of COVID-19 vaccines before the emergence of the Omicron variant.

METHODS

A static model covering 215 countries/territories compared the direct effects of COVID-19 vaccination to no vaccination during 13 December 2020-30 September 2021. After adjusting for underreporting of cases and deaths, base case analyses estimated total cases and deaths averted, and direct outpatient and productivity costs saved through averted health outcomes. Sensitivity analyses applied alternative model assumptions.

RESULTS

COVID-19 vaccines prevented an estimated median (IQR) of 151.7 (133.7-226.1) million cases and 620.5 (411.1-698.1) thousand deaths globally through September 2021. In sensitivity analysis applying an alternative underreporting assumption, median deaths averted were 2.1 million. Estimated direct outpatient cost savings were $21.2 ($18.9-30.9) billion and indirect savings of avoided productivity loss were $135.1 ($121.1-206.4) billion, yielding a total cost savings of $155 billion globally through averted infections.

CONCLUSIONS

Using a conservative modeling approach that considered direct effects only, we estimated that COVID-19 vaccines have averted millions of infections and deaths, generating billions of cost savings worldwide, which underscore the continued importance of vaccination in public health response to COVID-19.

Comprehensive league table of cost-utility ratios: A systematic review of cost-effectiveness evidence for health policy decisions in India

Background and objectives

Although a relatively recent concept for developing countries, the developed world has been using League Tables as a policy guiding tool for a comprehensive assessment of health expenditures; country-specific "League tables" can be a very useful tool for national healthcare planning and budgeting. Presented herewith is a comprehensive league table of cost per Quality Adjusted Life Years (QALY) or Disability Adjusted Life Years (DALY) ratios derived from Health Technology Assessment (HTA) or economic evaluation studies reported from India through a systematic review.

Methods

Economic evaluations and HTAs published from January 2003 to October 2019 were searched from various databases. We only included the studies reporting common outcomes (QALY/DALY) and methodology to increase the generalizability of league table findings. To opt for a uniform criterion, a reference case approach developed by Health Technology Assessment in India (HTAIn) was used for the reporting of the incremental cost-effectiveness ratio. However, as, most of the articles expressed the outcome as DALY, both (QALY and DALY) were used as outcome indicators for this review.

Results

After the initial screening of 9,823 articles, 79 articles meeting the inclusion criteria were selected for the League table preparation. The spectrum of intervention was dominated by innovations for infectious diseases (33%), closely followed by maternal and child health (29%), and non-communicable diseases (20%). The remaining 18% of the interventions were on other groups of health issues, such as injuries, snake bites, and epilepsy. Most of the interventions (70%) reported DALY as an outcome indicator, and the rest (30%) reported QALY. Outcome and cost were discounted at the rate of 3 by 73% of the studies, at 5 by 4% of the studies, whereas 23% of the studies did not discount it. Budget impact and sensitivity analysis were reported by 18 and 73% of the studies, respectively.

Interpretation and conclusions

The present review offers a reasonably coherent league table that reflects ICER values of a range of health conditions in India. It presents an update for decision-makers for making decisions about resource allocation.

Bisoborwa G, Sillah JS, W. Muriithi A, Nirina Razakasoa H, Bigirimana F. High impact health service interventions for attainment of UHC in Africa: A systematic review

African countries have prioritized the attainment of targets relating to Universal Health Coverage (UHC), Health Security (HSE) and Coverage of Health Determinants (CHD)to attain their health goals. Given resource constraints, it is important to prioritize implementation of health service interventions with the highest impact. This is important to be identified across age cohorts and public health functions of health promotion, disease prevention, diagnostics, curative, rehabilitative and palliative interventions. We therefore explored the published evidence on the effectiveness of existing health service interventions addressing the diseases and conditions of concern in the Africa Region, for each age cohort and the public health functions. Six public health and economic evaluation databases, reports and grey literature were searched. A total of 151 studies and 357 interventions were identified across different health program areas, public health functions and age cohorts. Of the studies, most were carried out in the African region (43.5%), on communicable diseases (50.6%), and non-communicable diseases (36.4%). Majority of interventions are domiciled in the health promotion, disease prevention and curative functions, covering all age cohorts though the elderly cohort was least represented. Neonatal and communicable conditions dominated disease burden in the early years of life and non-communicable conditions in the later years. A menu of health interventions that are most effective at averting disease and conditions of concern across life course in the African region is therefore consolidated. These represent a comprehensive evidence-based set of interventions for prioritization by decision makers to attain desired health goals. At a country level, we also identify principles for identifying priority interventions, being the targeting of higher implementation coverage of existing interventions, combining interventions across all the public health functions-not focusing on a few functions, provision of subsidies or free interventions and prioritizing early identification of high-risk populations and communities represent these principles.

Improving WHO's understanding of WHO guideline uptake and use in Member States: a scoping review

Background

WHO publishes public health and clinical guidelines to guide Member States in achieving better health outcomes. Furthermore, WHO’s Thirteenth General Programme of Work for 2019–2023 prioritizes strengthening its normative functional role and uptake of normative and standard-setting products, including guidelines at the country level. Therefore, understanding WHO guideline uptake by the Member States, particularly the low- and middle-income countries (LMICs), is of utmost importance for the organization and scholarship.

Methods

We conducted a scoping review using a comprehensive search strategy to include published literature in English between 2007 and 2020. The review was conducted between May and June 2021. We searched five electronic databases including CINAHL, the Cochrane Library, PubMed, Embase and Scopus. We also searched Google Scholar as a supplementary source. The review adhered to the PRISMA-ScR (PRISMA extension for scoping reviews) guidelines for reporting the searches, screening and identification of evaluation studies from the literature. A narrative synthesis of the evidence around key barriers and challenges for WHO guideline uptake in LMICs is thematically presented.

Results

The scoping review included 48 studies, and the findings were categorized into four themes: (1) lack of national legislation, regulations and policy coherence, (2) inadequate experience, expertise and training of healthcare providers for guideline uptake, (3) funding limitations for guideline uptake and use, and (4) inadequate healthcare infrastructure for guideline compliance. These challenges were situated in the Member States’ health systems. The findings suggest that governance was often weak within the existing health systems amongst most of the LMICs studied, as was the guidance provided by WHO’s guidelines on governance requirements. This challenge was further exacerbated by a lack of accountability and transparency mechanisms for uptake and implementation of guidelines. In addition, the WHO guidelines themselves were either unclear and were technically challenging for some health conditions; however, WHO guidelines were primarily used as a reference by Member States when they developed their national guidelines.

Conclusions

The challenges identified reflect the national health systems’ (in)ability to allocate, implement and monitor the guidelines. Historically this is beyond the remit of WHO, but Member States could benefit from WHO implementation guidance on requirements and needs for successful uptake and use of WHO guidelines.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-022-00899-y.

Cost-effectiveness of pulse oximetry and integrated management of childhood illness for diagnosing severe pneumonia

Pneumonia is a major killer of children younger than five years old. In resource constrained health facilities, the capacity to diagnose severe pneumonia is low. Therefore, it is important to identify technologies that improve the diagnosis of severe pneumonia at the lowest incremental cost. The objective of this study was to conduct a health economic evaluation of standard integrated management of childhood illnesses (IMCI) guideline alone and combined use of standard IMCI guideline and pulse oximetry in diagnosing childhood pneumonia. This is a cluster-randomized controlled trial conducted in health centres in southern Ethiopia. Two methods of diagnosing pneumonia in children younger than five years old at 24 health centres are analysed. In the intervention arm, combined use of the pulse oximetry and standard IMCI guideline was used. In the control arm, the standard IMCI guideline alone was used. The primary outcome was cases of diagnosed severe pneumonia. Provider and patient costs were collected. A probabilistic decision tree was used in analysis of primary trial data to get incremental cost per case of diagnosed severe pneumonia. The proportion of children diagnosed with severe pneumonia was 148/928 (16.0%) in the intervention arm and 34/876 (4.0%) in the control arm. The average cost per diagnosed severe pneumonia case was USD 25.74 for combined use of pulse oximetry and standard IMCI guideline and USD 17.98 for standard IMCI guideline alone. The incremental cost of combined use of IMCI and pulse oximetry was USD 29 per extra diagnosed severe pneumonia case compared to standard IMCI guideline alone. Adding pulse oximetry to the diagnostic toolkit in the standard IMCI guideline could detect and treat one more child with severe pneumonia for an additional investment of USD 29. Better diagnostic tools for lower respiratory infections are important in resource-constrained settings, especially now during the COVID-19 pandemic.

National Current Care Guidelines for paediatric lower respiratory tract infections reduced the use of chest radiographs but local variations were observed

AIM

Our aim was to evaluate the impact of the 2014 Finnish Current Care Guidelines for paediatric lower respiratory tract infections (LRTIs), particularly on taking of chest radiographs.

METHODS

This study used official national data and regional (Pirkanmaa) data on children aged 0-16 years who underwent chest radiographs in 2011 and 2015. We also collected data for LRTI diagnoses from local registers, including prescribed antibiotics and taking of chest radiographs. The local cohort comprised children aged 0-15 who presented to the primary care emergency room or to the hospital emergency department (Tampere university hospital) in November-December 2012-2015.

RESULTS

Chest radiographs for Finnish children aged 0-16 fell from 2011 to 2015: by 15.9% nationally and by 16.9% in Pirkanmaa. When asylum seekers with chest radiographs for tuberculosis screening were excluded, the estimated national reduction was 29.9%. In the local cohort, chest radiographs increased from 82 to 139 (69.5%) between 2012/2013 and 2014/2015 as the occurrence of community-acquired pneumonia (CAP) increased. However, the proportion of patients with CAP who had chest radiograph taken tended to decrease from 84.6% to 71.3% (p = 0.078).

CONCLUSION

Decreases in national and regional chest imaging trends were observed after the 2014 guidance for children`s LRTI was introduced.

Reducing regional health inequality: a sub-national distributional cost-effectiveness analysis of community-based treatment of childhood pneumonia in Ethiopia

Background

Increasing the coverage of community-based treatment of childhood pneumonia (CCM) is part of the strategy to improve child survival, increase life-expectancy at birth and promote equity in Ethiopia. However, full coverage of CCM has not been reached in any regions of the country. There are no sub-national cost-effectiveness analyses available to inform decision makers on the most equitable scale up strategy.

Objectives

Our first objective is to estimate the sub-national cost-effectiveness and the interindividual inequality impacts of scaling up CCM coverages to 90% in each region. Our second objective is to explore the costs, health effects, and geographical inequality impacts associated with three scale-up scenarios promoting different policy-aims: maximizing health, reducing geographical inequalities, and achieving 90% universal coverage.

Methods

We used Markov modelling to estimate the sub-national cost-effectiveness of CCM in each region. All data were collected through literature review and adjusted to the region-specific proportions of the rural population. Health effects were modeled as life years gained and under-five deaths averted. Interindividual and geographical inequality impacts were measured by the GINI index applied to health. In scenario analysis we explored three different scale-up strategies: 1) maximizing health by prioritizing the regions where the intervention was the most cost-effective, 2) reducing geographical inequalities by prioritizing the regions with high baseline under-five mortality rate (U5MR), and 3) universal upscaling to 90% coverage in all the regions.

Results

The regional incremental-cost effectiveness ratio (ICER) of scaling up the intervention coverage varied from 26 USD per life year gained in Addis to 199 USD per life year gained in the Southern Nations, Nationalities, and Peoples’ region. Universal upscaling of CCM in all regions would cost about 1.3 billion USD and prevent about 90,000 under-five deaths. This is less than 15,000 USD per life saved and translates to an increase in life expectancy at birth of 1.6 years across Ethiopia. In scenario analysis, we found that prioritizing regions with high U5MR is effective in reducing geographical inequalities, although at the cost of fewer lives saved as compared to the health maximizing strategy.

Conclusions

Our model results illustrate a trade-off between maximizing health and reducing health inequalities, two common policy-aims in low-income settings.

Models for estimating and projecting global, regional and national prevalence and disease burden of asthma: a systematic review

Background

Statistical models are increasingly being used to estimate and project the prevalence and burden of asthma. Given substantial variations in these estimates, there is a need to critically assess the properties of these models and assess their transparency and reproducibility. We aimed to critically appraise the strengths, limitations and reproducibility of existing models for estimating and projecting the global, regional and national prevalence and burden of asthma.

Methods

We undertook a systematic review, which involved searching Medline, Embase, World Health Organization Library and Information Services (WHOLIS) and Web of Science from 1980 to 2017 for modelling studies. Two reviewers independently assessed the eligibility of studies for inclusion and then assessed their strengths, limitations and reproducibility using pre-defined quality criteria. Data were descriptively and narratively synthesised.

Results

We identified 108 eligible studies, which employed a total of 51 models: 42 models were used to derive national level estimates, two models for regional estimates, four models for global and regional estimates and three models for global, regional and national estimates. Ten models were used to estimate the prevalence of asthma, 27 models estimated the burden of asthma – including, health care service utilisation, disability-adjusted life years, mortality and direct and indirect costs of asthma – and 14 models estimated both the prevalence and burden of asthma. Logistic and linear regression models were most widely used for national estimates. Different versions of the DisMod-MR- Bayesian meta-regression models and Cause Of Death Ensemble model (CODEm) were predominantly used for global, regional and national estimates. Most models suffered from a number of methodological limitations – in particular, poor reporting, insufficient quality and lack of reproducibility.

Conclusions

Whilst global, regional and national estimates of asthma prevalence and burden continue to inform health policy and investment decisions on asthma, most models used to derive these estimates lack the required reproducibility. There is a need for better-constructed models for estimating and projecting the prevalence and disease burden of asthma and a related need for better reporting of models, and making data and code available to facilitate replication.

Cost of Respiratory Syncytial Virus-Associated Acute Lower Respiratory Infection Management in Young Children at the Regional and Global Level: A Systematic Review and Meta-Analysis

Background

Respiratory syncytial virus (RSV) is a major cause of acute lower respiratory infection (ALRI) in young children aged <5 years.

Methods

We aimed to identify the global inpatient and outpatient cost of management of RSV-ALRI in young children to assist health policy makers in making decisions related to resource allocation for interventions to reduce severe morbidity and mortality from RSV in this age group. We searched 3 electronic databases including Global Health, Medline, and EMBASE for studies reporting cost data on RSV management in children under 60 months from 2000 to 2017. Unpublished data on the management cost of RSV episodes were collected through collaboration with an international working group (RSV GEN) and claim databases.

Results

We identified 41 studies reporting data from year 1987 to 2017, mainly from Europe, North America, and Australia, covering the management of a total of 365 828 RSV disease episodes. The average cost per episode was €3452 (95% confidence interval [CI], 3265–3639) and €299 (95% CI, 295–303) for inpatient and outpatient management without follow-up, and it increased to €8591(95% CI, 8489–8692) and €2191 (95% CI, 2190–2192), respectively, with follow-up to 2 years after the initial event.

Conclusions

Known risk factors (early and late preterm birth, congenital heart disease, chronic lung disease, intensive care unit admission, and ventilator use) were associated with €4160 (95% CI, 3237–5082) increased cost of hospitalization. The global cost of inpatient and outpatient RSV ALRI management in young children in 2017 was estimated to be approximately €4.82 billion (95% CI, 3.47–7.93), 65% of these in developing countries and 55% of global costs accounted for by hospitalization. We have demonstrated that RSV imposed a substantial economic burden on health systems, governments, and the society.

Dental caries prevention in children and adolescents: a systematic quality assessment of clinical practice guidelines

OBJECTIVES

To evaluate the quality of clinical practice guidelines (CPGs) for dental caries prevention in children and adolescents MATERIALS AND METHODS: We performed a systematic search of CPGs on caries preventive measures between 2005 and 2016. We searched MEDLINE, EMBASE, LILACS, TripDatabase, websites of CPG developers, compilers of CPGs, scientific societies and ministries of health. We included CPGs with recommendations on sealants, fluorides and oral hygiene. Three reviewers independently assessed the included CPGs using the AGREE II instrument. We calculated the standardised scores for the six domains and made a final recommendation about each CPG. Also, we calculated the overall agreement among calibrated reviewers with the intraclass correlation coefficient (ICC).

RESULTS

Twenty-two CPGs published were selected from a total of 637 references. Thirteen were in English and nine in Spanish. The overall agreement between reviewers was very good (ICC = 0.90; 95%CI 0.89-0.92). The mean score for each domain was the following: Scope and purpose 89.6 ± 12%; Stakeholder involvement 55.0 ± 15.6%; Rigour of development 64.9 ± 21.2%; Clarity of presentation 84.8 ± 14.1%; Applicability 30.6 ± 31.5% and Editorial independence 59.3 ± 25.5%. Thirteen CPGs (59.1%) were assessed as "recommended", eight (36.4%) "recommended with modifications" and one (4.5%) "not recommended".

CONCLUSIONS

The overall quality of CPGs in caries prevention was moderate. The domains with greater deficiencies were Applicability, Stakeholder involvement and Editorial independence.

CLINICAL RELEVANCE

Clinicians should use the best available CPGs in dental caries prevention to provide optimal oral health care to patients.

Dental caries prevention in children and adolescents: a systematic quality assessment of clinical practice guidelines

OBJECTIVES

To evaluate the quality of clinical practice guidelines (CPGs) for dental caries prevention in children and adolescents MATERIALS AND METHODS: We performed a systematic search of CPGs on caries preventive measures between 2005 and 2016. We searched MEDLINE, EMBASE, LILACS, TripDatabase, websites of CPG developers, compilers of CPGs, scientific societies and ministries of health. We included CPGs with recommendations on sealants, fluorides and oral hygiene. Three reviewers independently assessed the included CPGs using the AGREE II instrument. We calculated the standardised scores for the six domains and made a final recommendation about each CPG. Also, we calculated the overall agreement among calibrated reviewers with the intraclass correlation coefficient (ICC).

RESULTS

Twenty-two CPGs published were selected from a total of 637 references. Thirteen were in English and nine in Spanish. The overall agreement between reviewers was very good (ICC = 0.90; 95%CI 0.89-0.92). The mean score for each domain was the following: Scope and purpose 89.6 ± 12%; Stakeholder involvement 55.0 ± 15.6%; Rigour of development 64.9 ± 21.2%; Clarity of presentation 84.8 ± 14.1%; Applicability 30.6 ± 31.5% and Editorial independence 59.3 ± 25.5%. Thirteen CPGs (59.1%) were assessed as "recommended", eight (36.4%) "recommended with modifications" and one (4.5%) "not recommended".

CONCLUSIONS

The overall quality of CPGs in caries prevention was moderate. The domains with greater deficiencies were Applicability, Stakeholder involvement and Editorial independence.

CLINICAL RELEVANCE

Clinicians should use the best available CPGs in dental caries prevention to provide optimal oral health care to patients.