Rapid cost-effectiveness analysis: hemodialysis versus peritoneal dialysis for patients with acute kidney injury in Rwanda

BACKGROUND

To ensure the long-term sustainability of its Community-Based Health Insurance scheme, the Government of Rwanda is working on using Health Technology Assessment (HTA) to prioritize its resources for health. The objectives of the study were to rapidly assess (1) the cost-effectiveness and (2) the budget impact of providing PD versus HD for patients with acute kidney injury (AKI) in the tertiary care setting in Rwanda.

METHODS

A rapid cost-effectiveness analysis for patients with AKI was conducted to support prioritization. An 'adaptive' HTA approach was undertaken by adjusting the international Decision Support Initiative reference case for time and data constraints. Available local and international data were used to analyze the cost-effectiveness and budget impact of peritoneal dialysis (PD) compared with hemodialysis (HD) in the tertiary hospital setting.

RESULTS

The analysis found that HD was slightly more effective and slightly more expensive in the payer perspective for most patients with AKI (aged 15-49). HD appeared to be cost-effective when only comparing these two dialysis strategies with an incremental cost-effectiveness ratio of 378,174 Rwandan francs (RWF) or 367 United States dollars (US$), at a threshold of 0.5 × gross domestic product per capita (RWF 444,074 or US$431). Sensitivity analysis found that reducing the cost of HD kits would make HD even more cost-effective. Uncertainty regarding PD costs remains. Budget impact analysis demonstrated that reducing the cost of the biggest cost driver, HD kits, could produce significantly more savings in five years than switching to PD. Thus, price negotiations could significantly improve the efficiency of HD provision.

CONCLUSION

Dialysis is costly and covered by insurance in many countries for the financial protection of patients. This analysis enabled policymakers to make evidence-based decisions to improve the efficiency of dialysis provision.

ROAD2H: Development and evaluation of an open-source explainable artificial intelligence approach for managing co-morbidity and clinical guidelines

Introduction

Clinical decision support (CDS) systems (CDSSs) that integrate clinical guidelines need to reflect real-world co-morbidity. In patient-specific clinical contexts, transparent recommendations that allow for contraindications and other conflicts arising from co-morbidity are a requirement. In this work, we develop and evaluate a non-proprietary, standards-based approach to the deployment of computable guidelines with explainable argumentation, integrated with a commercial electronic health record (EHR) system in Serbia, a middle-income country in West Balkans.

Methods

We used an ontological framework, the Transition-based Medical Recommendation (TMR) model, to represent, and reason about, guideline concepts, and chose the 2017 International global initiative for chronic obstructive lung disease (GOLD) guideline and a Serbian hospital as the deployment and evaluation site, respectively. To mitigate potential guideline conflicts, we used a TMR-based implementation of the Assumptions-Based Argumentation framework extended with preferences and Goals (ABA+G). Remote EHR integration of computable guidelines was via a microservice architecture based on HL7 FHIR and CDS Hooks. A prototype integration was developed to manage chronic obstructive pulmonary disease (COPD) with comorbid cardiovascular or chronic kidney diseases, and a mixed-methods evaluation was conducted with 20 simulated cases and five pulmonologists.

Results

Pulmonologists agreed 97% of the time with the GOLD-based COPD symptom severity assessment assigned to each patient by the CDSS, and 98% of the time with one of the proposed COPD care plans. Comments were favourable on the principles of explainable argumentation; inclusion of additional co-morbidities was suggested in the future along with customisation of the level of explanation with expertise.

Conclusion

An ontological model provided a flexible means of providing argumentation and explainable artificial intelligence for a long-term condition. Extension to other guidelines and multiple co-morbidities is needed to test the approach further.

The epidemiological and economic burden of diabetes in Ghana: A scoping review to inform health technology assessment

Diabetes remains one of the four major causes of morbidity and mortality globally among non-communicable diseases (NCDs. It is predicted to increase in sub-Saharan Africa by over 50% by 2045. The aim of this study is to identify, map and estimate the burden of diabetes in Ghana, which is essential for optimising NCD country policy and understanding existing knowledge gaps to guide future research in this area. We followed the Arksey and O'Malley framework for scoping reviews. We searched electronic databases including Medline, Embase, Web of Science, Scopus, Cochrane and African Index Medicus following a systematic search strategy. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews was followed when reporting the results. A total of 36 studies were found to fulfil the inclusion criteria. The reported prevalence of diabetes at national level in Ghana ranged between 2.80%- 3.95%. At the regional level, the Western region reported the highest prevalence of diabetes: 39.80%, followed by Ashanti region (25.20%) and Central region at 24.60%. The prevalence of diabetes was generally higher in women in comparison to men. Urban areas were found to have a higher prevalence of diabetes than rural areas. The mean annual financial cost of managing one diabetic case at the outpatient clinic was estimated at GHS 540.35 (2021 US $194.09). There was a paucity of evidence on the overall economic burden and the regional prevalence burden. Ghana is faced with a considerable burden of diabetes which varies by region and setting (urban/rural). There is an urgent need for effective and efficient interventions to prevent the anticipated elevation in burden of disease through the utilisation of existing evidence and proven priority-setting tools like Health Technology Assessment (HTA).

A Scoping Review and Taxonomy of Epidemiological-Macroeconomic Models of COVID-19

OBJECTIVES

The COVID-19 pandemic placed significant strain on many health systems and economies. Mitigation policies decreased health impacts but had major macroeconomic impact. This article reviews models combining epidemiological and macroeconomic projections to enable policy makers to consider both macroeconomic and health objectives.

METHODS

A scoping review of epidemiological-macroeconomic models of COVID-19 was conducted, covering preprints, working articles, and journal publications. We assessed model methodologies, scope, and application to empirical data.

RESULTS

We found 80 articles modeling both the epidemiological and macroeconomic outcomes of COVID-19. Model scope is often limited to the impact of lockdown on health and total gross domestic product or aggregate consumption and to high-income countries. Just 14% of models assess disparities or poverty. Most models fall under 4 categories: compartmental-utility-maximization models, epidemiological models with stylized macroeconomic projections, epidemiological models linked to computable general equilibrium or input-output models, and epidemiological-economic agent-based models. We propose a taxonomy comparing these approaches to guide future model development.

CONCLUSIONS

The epidemiological-macroeconomic models of COVID-19 identified have varying complexity and meet different modeling needs. Priorities for future modeling include increasing developing country applications, assessing disparities and poverty, and estimating of long-run impacts. This may require better integration between epidemiologists and economists.

Health technology assessment (HTA) readiness in Uganda: stakeholder's perceptions on the potential application of HTA to support national universal health coverage efforts

INTRODUCTION

Health technology assessment (HTA) is an area that remains less implemented in low- and lower middle-income countries. The aim of the study is to understand the perceptions of stakeholders in Uganda toward HTA and its role in decision making, in order to inform its potential implementation in the country.

METHODS

The study takes a cross-sectional mixed methods approach, utilizing an adapted version of the International Decision Support Initiative questionnaire with both semi-structured and open-ended questions. We interviewed thirty key informants from different stakeholder institutions in Uganda that support policy and decision making in the health sector.

RESULTS

All participants perceived HTA as an important tool for decision making. Allocative efficiency was regarded as the most important use of HTA receiving the highest average score (8.8 out of 10), followed by quality of healthcare (7.8/10), transparency (7.6/10), budget control (7.5/10), and equity (6.5/10). There was concern that some of the uses of HTA may not be achieved in reality if there was political interference during the HTA process. The study participants identified development partners as the most likely potential users of HTA (66.7 percent of participants), followed by Ministry of Health (43.3 percent).

CONCLUSION

Interviewed stakeholders in Uganda viewed the role of HTA positively, suggesting that there exists a promising environment for the establishment and operationalization of HTA as a tool for decision making within the health sector. However, sustainable development and application of HTA in Uganda will require adequate capacity both to undertake HTAs and to support their use and uptake.

GRADE guidance 23: considering cost-effectiveness evidence in moving from evidence to health-related recommendations

BACKGROUND

This is the 23rd in a series of articles describing the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to grading the certainty of evidence and strength of recommendations for systematic reviews, health technology assessments, and clinical guideline development.

OBJECTIVES

We outline how resource utilization and cost-effectiveness analyses are integrated into health-related recommendations, using the GRADE Evidence to Decision (EtD) frameworks.

STUDY DESIGN AND SETTING

Through iterative discussions and refinement, in-person, and online meetings, and through e-mail communication, we developed draft guidance to incorporate economic evidence in the formulation of health-related recommendations. We developed scenarios to operationalize the guidance. We presented a summary of the results to members of the GRADE Economic Evaluation Project Group.

RESULTS

We describe how to estimate the cost of preventing (or achieving) an event to inform assessments of cost-effectiveness of alternative treatments, when there are no published economic evaluations. Evidence profiles and Summary of Findings tables based on systematic reviews of cost-effectiveness analyses can be created to provide top-level summaries of results and quality of multiple published economic evaluations. We also describe how this information could be integrated in GRADE's EtD frameworks to inform health-related recommendations. Three scenarios representing various levels of available cost-effectiveness evidence were used to illustrate the integration process.

CONCLUSION

This GRADE guidance provides practical information for presenting cost-effectiveness data and its integration in the development of health-related recommendations, using the EtD frameworks.

Adaptive Health Technology Assessment: A Scoping Review of Methods

OBJECTIVES

Health technology assessment (HTA) is an established mechanism for explicit priority setting to support universal health coverage. However, full HTA requires significant time, data, and capacity for each intervention, which limits the number of decisions it can inform. Another approach systematically adapts full HTA methods by leveraging HTA evidence from other settings. We call this "adaptive" HTA (aHTA), although in settings where time is the main constraint, it is also called "rapid HTA."

METHODS

The objectives of this scoping review were to identify and map existing aHTA methods, and to assess their triggers, strengths, and weaknesses. This was done by searching HTA agencies' and networks' websites, and the published literature. Findings have been narratively synthesized.

RESULTS

This review identified 20 countries and 1 HTA network with aHTA methods in the Americas, Europe, Africa, and South-East Asia. These methods have been characterized into 5 types: rapid reviews, rapid cost-effectiveness analyses, rapid manufacturer submissions, transfers, and de facto HTA. Three characteristics "trigger" the use of aHTA instead of full HTA: urgency, certainty, and low budget impact. Sometimes, an iterative approach to selecting methods guides whether to do aHTA or full HTA. aHTA was found to be faster and more efficient, useful for decision makers, and to reduce duplication. Nevertheless, there is limited standardization, transparency, and measurement of uncertainty.

CONCLUSIONS

aHTA is used in many settings. It has potential to improve the efficiency of any priority-setting system, but needs to be better formalized to improve uptake, particularly for nascent HTA systems.

Economic evaluations of non-communicable diseases conducted in Sub-Saharan Africa: a critical review of data sources

BACKGROUND

Policymakers in sub-Saharan Africa (SSA) face challenging decisions regarding the allocation of health resources. Economic evaluations can help decision makers to determine which health interventions should be funded and or included in their benefits package. A major problem is whether the evaluations incorporated data from sources that are reliable and relevant to the country of interest. We aimed to review the quality of the data sources used in all published economic evaluations for cardiovascular disease and diabetes in SSA.

METHODS

We systematically searched selected databases for all published economic evaluations for CVD and diabetes in SSA. We modified a hierarchy of data sources and used a reference case to measure the adherence to reporting and methodological characteristics, and descriptively analysed author statements.

RESULTS

From 7,297 articles retrieved from the search, we selected 35 for study inclusion. Most were modelled evaluations and almost all focused on pharmacological interventions. The studies adhered to the reporting standards but were less adherent to the methodological standards. The quality of data sources varied. The quality level of evidence in the data domains of resource use and costs were generally considered of high quality, with studies often sourcing information from reliable databases within the same jurisdiction. The authors of most studies referred to data sources in the discussion section of the publications highlighting the challenges of obtaining good quality and locally relevant data.

CONCLUSIONS

The data sources in some domains are considered high quality but there remains a need to make substantial improvements in the methodological adherence and overall quality of data sources to provide evidence that is sufficiently robust to support decision making in SSA within the context of UHC and health benefits plans. Many SSA governments will need to strengthen and build their capacity to conduct economic evaluations of interventions and health technology assessment for improved priority setting. This capacity building includes enhancing local infrastructures for routine data production and management. If many of the policy makers are using economic evaluations to guide resource allocation, it is imperative that the evidence used is of the feasibly highest quality.

Evaluation framework study assessing the role, applicability and adherence to good practice of planning support tools for allocation of development aid for health in low-income and middle-income countries

OBJECTIVES

Allocation of development aid for health is controversial and challenging. In recent years, several planning-software tools have promised to help decision-makers align resource allocation with their objectives, more clearly connect prioritisation to evidence and local circumstances, and increase transparency and comparability. We aim to explore these tools to provide insight into their fitness for purpose and suggest future directions to fulfil that promise.

DESIGN

We identified seven tools that met the inclusion criteria and developed an evaluation framework to compare them along two dimensions for assessing fitness for purpose: ability to produce analyses adhering to principles laid out in the International Decisions Support Initiative (iDSI) Reference Case for health economic evaluations; and resources required, including expertise and time. We extracted information from documentation and tool use and sent this information to tool developers for confirmation.

RESULTS

We categorise the tools into evidence-generating ones, evidence-syntheses ones and process support ones. Tools' fitness for purpose varies by the context, technical capacity and time limitation. The tools adhere to several reference case principles but often not to all of them. The source and underlying assumptions of prepopulated data are often opaque. Comparing vertical interventions across diseases and health system strengthening ones remains challenging.

CONCLUSIONS

The plethora of tools that aid priority setting in different ways is encouraging. Developers and users should place further emphasis on their ability to produce analyses that adhere to prioritisation principles. Opportunities for further development include using evidence-generating tools and multicriteria decision analysis approaches complimentarily. However, maintaining tool simplicity should also be considered to allow wider access.

Assessing the impacts of COVID-19 vaccination programme's timing and speed on health benefits, cost-effectiveness, and relative affordability in 27 African countries

BACKGROUND

The COVID-19 vaccine supply shortage in 2021 constrained roll-out efforts in Africa while populations experienced waves of epidemics. As supply improves, a key question is whether vaccination remains an impactful and cost-effective strategy given changes in the timing of implementation.

METHODS

We assessed the impact of vaccination programme timing using an epidemiological and economic model. We fitted an age-specific dynamic transmission model to reported COVID-19 deaths in 27 African countries to approximate existing immunity resulting from infection before substantial vaccine roll-out. We then projected health outcomes (from symptomatic cases to overall disability-adjusted life years (DALYs) averted) for different programme start dates (01 January to 01 December 2021, n = 12) and roll-out rates (slow, medium, fast; 275, 826, and 2066 doses/million population-day, respectively) for viral vector and mRNA vaccines by the end of 2022. Roll-out rates used were derived from observed uptake trajectories in this region. Vaccination programmes were assumed to prioritise those above 60 years before other adults. We collected data on vaccine delivery costs, calculated incremental cost-effectiveness ratios (ICERs) compared to no vaccine use, and compared these ICERs to GDP per capita. We additionally calculated a relative affordability measure of vaccination programmes to assess potential nonmarginal budget impacts.

RESULTS

Vaccination programmes with early start dates yielded the most health benefits and lowest ICERs compared to those with late starts. While producing the most health benefits, fast vaccine roll-out did not always result in the lowest ICERs. The highest marginal effectiveness within vaccination programmes was found among older adults. High country income groups, high proportions of populations over 60 years or non-susceptible at the start of vaccination programmes are associated with low ICERs relative to GDP per capita. Most vaccination programmes with small ICERs relative to GDP per capita were also relatively affordable.

CONCLUSION

Although ICERs increased significantly as vaccination programmes were delayed, programmes starting late in 2021 may still generate low ICERs and manageable affordability measures. Looking forward, lower vaccine purchasing costs and vaccines with improved efficacies can help increase the economic value of COVID-19 vaccination programmes.

Online physical exercise intervention in older adults during lockdown: Can we improve the recipe?

BACKGROUND

Recorded and live online physical exercise (PE) interventions are known to provide health benefits. However, the effects of prioritizing the number of live or recorded sessions remain unclear.

AIMS

To explore which recorded-live sessions ratio leads to the best implementation and benefits in older adults.

METHODS

Forty-six community-dwelling adults (> 60y.o.) were randomized into two groups completing a 12-week online PE intervention. Each group had a different ratio of live-recorded online sessions as follows: Live-Recorded-Live sessions (LRL; n = 22) vs. Recorded-Live-Recorded sessions (RLR; n = 24).

RESULTS

Drop-out rates did not reach significance (LRL:14% vs. RLR: 29%, p = 0.20), and adherence was similar (> 85%) between groups. Both groups reported similar levels of satisfaction (> 70%), enjoyment (> 75%), and perceived exertion (> 60%). Both groups increased physical health and functional capacities, with greater improvements in muscle power (LRL: LRL: + 35 ± 16.1% vs. RLR: + 7 ± 13.9%; p = 0.010) and endurance (LRL: + 34.7 ± 15.4 vs. RLR: + 27.0 ± 26.5, p < 0.001) in the LRL group.

DISCUSSION

Both online PE intervention modalities were adapted to the participants' capacities and led to a high level of enjoyment and retention. The greater physical improvements observed in the LRL group are likely due to the higher presence of the instructor compared to the RLR group. Indeed, participants received likely more feedback to appropriately adjust postures and movements, increasing the quality of the exercises.

CONCLUSION

When creating online PE interventions containing both recorded and live sessions, priority should be given to maximizing the number of live sessions and not the number of recorded sessions.

Clinical and laboratory parameters associated with pregnancy outcomes in patients undergoing frozen euploid blastocyst transfer

RESEARCH QUESTION

Which factors impact on clinical pregnancy rate (CPR) and live birth rates (LBR) in euploid frozen embryo transfer (eFET) cycles?

DESIGN

Retrospective observational study including 1660 eFET cycles with 2439 euploid blastocysts, from November 2016 to December 2020. The impact of clinical and laboratory parameters on CPR, biochemical miscarriage rate (BMR), clinical miscarriage rate (CMR) and LBR was evaluated.

RESULTS

CPR per transfer was 63.4%, LBR per transfer 51.6%. CPR and LBR were significantly higher when double embryo transfer (DET) was performed (71.6% versus 57.7%, P < 0.001; 55.2% versus 49.1%, P = 0.016, respectively). However, pregnancy loss was significantly higher in the DET group (28.8% versus 22.8%, P = 0.02). When patients were classified by body mass index (BMI), no differences were observed for CPR, but CMR was lower (P < 0.001) and LBR higher (p = 0.031) for the normal BMI group. The natural cycle protocol revealed lower CMR (P < 0.001) and lower pregnancy loss (P < 0.001); subsequently, higher LBR (57.6%, 48.8%, 45.0%, P = 0.001) compared with hormonal replacement protocol and stimulated cycle. Day of trophectoderm biopsy affected CPR (P < 0.001) and LBR (P < 0.001), yet no differences were observed for BMR, CMR or pregnancy loss. The multivariate analysis showed that day 6/7 embryos had lower probabilities for pregnancy; overweight and obesity had a negative impact on LBR, and natural cycle improved LBR (adjusted odds ratio 1.445, 95% confidence interval 0.519-0.806).

CONCLUSIONS

Day of biopsy affected CPR, while BMI and endometrial preparation protocol were associated with LBR in eFET. DET should be discouraged as it will increase the risk of pregnancy loss. Women with higher BMI should be aware of the higher risk of pregnancy loss and lower LBR even though a euploid blastocyst is transferred.

P-589 Natural endometrial preparation for single euploid frozen embryo transfer increases the likelihood of live birth in obese patients

Study question

Does a natural endometrial preparation for single euploid frozen embryo transfer increase the odds of live birth (LB) in obese patients?

Summary answer

Compared to an artificial approach, a natural endometrial preparation for single euploid frozen embryo transfer improves the odds of LB in obese patients.

What is known already

Several protocols to prepare the endometrium for frozen embryo transfer have been described with comparable clinical outcomes, and no individual protocol has been demonstrated to be superior. Likewise, no specific patient group has been defined that can substantially benefit from a natural endometrial preparation. Despite obesity being linked to adverse clinical outcomes, observational studies and clinical trials have traditionally included participants with normal weight when comparing protocols, resulting in obese patients being underrepresented in clinical research. Therefore, studies focusing on endometrial preparation protocols for frozen embryo transfer that include obese patients are required.

Study design, size, duration

This study involved the analysis of a retrospective dataset including 975 single euploid frozen embryo transfer cycles performed at two tertiary referral centers between March 2017 and November 2019. The primary outcome was LB after natural and artificial endometrial preparation. Participants were stratified according to the World Health Organization Body mass index (BMI) classification into three groups (G): G1: Normal-weight ≤24.9 (n = 390), G2: Overweight 25 to 29.9 (n = 332), and G3: Obese ≥30 (n = 253).

Participants/materials, setting, methods

Cycles included infertility patients attempting a single euploid frozen blastocyst transfer under natural (n = 324) or artificial (n = 651) endometrial preparation. PGT-A was performed after trophectoderm biopsy using Next-Generation Sequencing. Spontaneous LH rise confirmed ovulation for natural endometrial preparation, and embryo transfer occurred five days after initial progesterone elevation. Hormones were measured from blood samples. For artificial preparation, embryo transfer was performed after oral estradiol and 120-hour vaginal progesterone exposure. All participants received luteal phase support.

Main results and the role of chance

Within each BMI group, no statistically significant differences in age were observed in patients between a natural and artificial endometrial preparation: G1 (33.5±5.1 vs. 32.7±5.2 years; p = 0.13), G2 (34.5±4.9 vs. 33.9±5.8 years; p = 0.39), and G3 (35.6±4.9 vs. 34.3±5.6 years; p = 0.1). Similarly, no statistically significant differences were observed regarding implantation rates: G1 (60% vs 57.1%; p = 0.57), G2 (54.8% vs 55.7%; p = 0.88), and G3 (64.3% vs 51.4%; p = 0.07). LB rates remained constant across all BMI groups when a natural preparation was conducted: G1 [56.66% (n = 85/150)], G2 [49.03% (n = 51/104)], and G3 [58.57% (n = 41/70)]. We observed a decrease in LB rates in G3 when an artificial endometrial preparation was performed: G1 [47.5% (n = 114/240)], G2 [44.73% (n = 102/228)], and G3 [34.42% (n = 63/183)]. The positive impact of a natural preparation on LB rates was more significant in G3, showing a 24% difference of effect between the natural and artificial endometrial preparations. Univariate logistic regression analysis showed a statistically significant difference in the primary outcome (LB) when a natural endometrial preparation was conducted in G3 (OR 2.69, 95% CI 1.53-4.74; p = 0.001), with no differences found in G1 (OR 1.45, 95% CI 0.96-2.18; p = 0.08) and G2 (OR 1.19, 95% CI 0.75-1.89; p = 0.73).

Limitations, reasons for caution

This study could be subject to bias due to its retrospective nature. Sperm quality was not considered for the present study.

Wider implications of the findings

Obese women appear to be the patient group that can obtain benefit from a natural endometrial preparation for frozen embryo transfer by increasing the odds of LB. Future prospective studies should confirm this hypothesis. A natural approach might be unfeasible in a subgroup of obese patients due to anovulatory cycles.

Trial registration number

not applicable

P-358 Effect of endometrial thickness on biochemical pregnancy rate: an analysis of 1534 frozen euploid embryo transfers

Study question

Can a thick endometrial lining measured prior to embryo transfer be considered a protective factor against Biochemical Pregnancy (BP)?

Summary answer

The risk of BP is independent of Endometrial Thickness (EMT), but rather dependent of the type of endometrial preparation and parity.

What is known already

Higher EMT prior to embryo transfer is associated with better clinical outcomes in general, like higher implantation and livebirth, and lower miscarriage rates. But up to our knowledge, no studies evaluated the effect of EMT on BP per say.

Study design, size, duration

This is a two-center retrospective observational study including a total of 1534 euploid Frozen Embryo Transfer (FET) cycles between March 2017 and March 2020 at ART Fertility Clinics Muscat, Oman and Abu Dhabi, UAE. BP is defined as blood beta-hCG &gt;15 mIU/ml on day 12 post FET, that is progressively decreasing, with no evidence of gestational sac on ultrasound.

Participants/materials, setting, methods

The study group consisted of 112 cases of BP, while the control group consisted of the remaining 1422 FET’s that led to different clinical outcomes. EMT was measured by transvaginal ultrasound on the day of progesterone rise (±1 day); that rise was either spontaneous in Natural Cycles (NC), or iatrogenic in Hormone Replacement Therapy (HRT) cycles. Euploidy status of the embryos was assessed by NGS analysis of trophectoderm biopsies. Bivariate and multivariate analyses were conducted.

Main results and the role of chance

There was no difference in mean EMT between the study and the control groups (7.55 vs. 7.68 mm, p = 0.154).

Looking at the association of different variables with the rate of BP, there was no effect of age, BMI, AMH, number of embryos transferred, degree of blastocyst expansion, inner cell mass or trophectoderm grade, day of biopsy, nor presence of blood or mucus on the transfer catheter. However, patients on HRT cycles had significantly higher rates of BP compared to NC (8.42% vs. 4.99%, p = 0.015). Also, those with a previous livebirth had higher rates of BP compared to nulliparous women (8.7% vs. 5.39%, p = 0.014).

The distribution of BP showed that 54.5% occurred with EMT &lt;7.5 mm, 34.8% with EMT 7.5-9 mm, and 10.7% with EMT &gt;9 mm. These represents respectively 8.16%, 6.68%, and 5.94% of the total sample. This decreasing trend of BP with increasing EMT didn’t reach statistical significance (p = 0.429). Univariate analysis comparing the risk of BP in FET’s done with lower and higher EMT to those performed at 7.5-9 mm yielded similar conclusion: OR = 1.24 [0.82-1.88] for &lt;7.5 mm, and OR = 0.88 [0.45-1.72] for &gt;9 mm.

Controlling for different confounders, HRT cycles and multiparity remained as independent risk factors for BP.

Limitations, reasons for caution

Inter-observer variability in EMT measurement and the transfer technique, the retrospective nature of the study, and the lack of data on the mode of delivery of parous women could all have interfered with the conclusion.

Wider implications of the findings

The reduced adverse clinical outcomes with NC shed light on the role of the corpus luteum in the early phases of implantation, and some potential secreted mediators other than progesterone. Besides, the effect of previous deliveries on the endometrium and its receptivity needs further investigation.

Trial registration number

not applicable

P-628 Do ovarian reserve markers and female age predict the rate of euploid blastocysts in IVF/ICSI cycles?

Study question

Are female age and ovarian reserve markers (anti-Mullerian hormone (AMH) and Antral Follicle Count (AFC)), able to predict euploid blastocyst rate in IVF/ICSI cycles?

Summary answer

Female age, serum AMH, AFC and the number of mature oocytes collected during IVF/ICSI cycles significantly affect the rate of euploid blastocysts

What is known already

The age-associated decline in female reproduction has been clearly demonstrated, due to the reduction of the ovarian reserve and the increased risk of chromosomal abnormality occurring in the oocyte. Lately, it has been debated whether a reduced ovarian reserve, independently of age, could be associated with higher aneuploidy rate in embryos. Ovarian reserve can now be accurately measured by serum AMH levels and AFC, both markers with similar high reliability.

Study design, size, duration

This analysis includes data from 10556 blastocysts after preimplantation genetic testing for aneuploidy (PGT-A) with Next Generation Sequencing (NGS). Embryos were obtained from 2564 IVF/ICSI cycles of infertile couples, at ART Fertility Clinics UAE, from November 2016 to December 2020.

Participants/materials, setting, methods

10556 blastocysts with chromosomal information for ploidy were included, mosaic and non-informative embryos were excluded. Trophectoderm biopsy was performed on day 5, 6 or 7 blastocysts. Serum AMH concentrations were measured by Elecsys® AMH automated assay (Cobas 601 platform, Roche®) for all patients in a single laboratory. AFC (sum of small antral follicles in both ovaries) was evaluated with transvaginal 2D-sonography (Voluson E8, GE Healthcare). Ethical approval was obtained from the Research Ethics Committee (REFA023b).

Main results and the role of chance

Patients’ characteristics are described as mean ± SD (min-max): age: 34.72±6.13(18-50), years of infertility: 3.43±3.43(0-25), AMH: 2.52±2.70ng/mL(0.01-23.00), AFC: 11.57±7.86(0-61), body mass index (BMI): 28.57±4.83Kg/m2(14.34-44.96), Metaphase II (MII) inseminated oocytes: 10.11±6.53(1-50), 2PN embryos 7.32±5.12(1-42), blastocysts 4.12±3.21(1-26). Fertilization rate was 73.31%(±19.30), blastulation rate 61.05%(±25.69) and euploidy rate 39.42%(±35.24).

A significant negative Pearson correlation coefficient was found between age and euploidy rate (ρ=-0.5398, p &lt; 0.001). AMH, AFC and total of MII inseminated oocytes showed a significant positive Pearson correlation coefficient with euploid rate (AMH:ρ=0.2076, p &lt; 0.001; AFC: ρ = 0.2578, p &lt; 0.001; MII:ρ=0.2036, p &lt; 0.001). Linear regression analysis was conducted to evaluate the predictability of the variables on euploid rate. As expected, age clearly had a negative impact (Coef=-3.10, Std. Err=0.10, p &lt; 0.0001). A positive effect was observed for AMH (Coef=2.75, Std. Err=0.31, p &lt; 0.0001), AFC (Coef=1.16, Std. Err=0.09, p &lt; 0.0001), number of MII inseminated oocytes (Coef=1.10, Std. Err=0.10, p &lt; 0.0001) and 2PN embryos (Coef=1.43, Std. Err=0.13, p &lt; 0.0001). For patients &gt;35 years old and AMH lower than 1.3 ng/mL, euploid rate was significantly lower compared with the patients &gt;35 years old and AMH equal or higher than 1.3 ng/mL (21.2% vs 25.5%, p = 0.0192).

Limitations, reasons for caution

Despite the large number of cycles and embryos included, the retrospective study design is a limitation.

Wider implications of the findings

Ovarian reserve is not only a quantitative, but also a qualitative biomarker of oocyte-embryo competence. Cumulative success rates for IVF/ICSI cycles are dependent on the availability of euploid blastocysts. Age and ovarian reserve markers should be combined for adequate counselling.

Trial registration number

Not applicable

O-255 Clinical and laboratory factors associated with pregnancy outcomes in patients undergoing frozen euploid blastocyst transfer

Study question

Which variables do have an impact on the pregnancy and live birth rates (LBR) when euploid frozen embryo transfers (FET) are performed?

Summary answer

Day of trophectoderm biopsy, Body Mass Index (BMI) and endometrial preparation protocol have an impact on pregnancy rate (PR) and LBR in FET cycles.

What is known already

Preimplantation genetic testing for aneuploidy (PGT-A) and morphological grading of embryos are the two main criteria to select a blastocyst from a pool of embryos, having the highest implantation potential. However, other clinical and laboratory variables might play a crucial role for a successful outcome when top quality euploid embryos are transferred in a FET cycle. It has been described that higher BMI increases the odds for miscarriage when compared with non-obese women.

Study design, size, duration

This analysis includes 1660 FET cycles with data from of pregnancy rates, miscarriage rate and LBR. Embryos were obtained from 2564 IVF/ICSI cycles of couples with primary or secondary infertility at ART Fertility Clinics UAE, from November 2016 to December 2020.

Participants/materials, setting, methods

A total of 1660 FET cycles with 2439 euploid blastocysts were included. FET cycles with mosaic or segmental aneuploid embryos were excluded. PGT-A was performed on trophectoderm cells, using Next Generation Sequencing (NGS). Biopsy was performed on day 5, 6 or 7 blastocysts. Endometrial preparation included ovulatory natural cycles (NC) and hormone replacement therapy (HRT) cycles, chosen according to physician’s discretion. Ethical approval was obtained from the Research Ethics Committee (REFA023b).

Main results and the role of chance

Patients’ characteristics are described as mean±SD (min-max): age: 33.5±5.43(19-47), AMH: 3.30±3.05ng/mL(0.01-23.00), BMI: 27.1±4.87Kg/m2(13.1-43.90), mean number of blastocysts transferred: 1.4±0.49(1-3). Patients were categorized according to age (years) in 4 categories (&lt;30,n=404; 30-34,n=487; 35-40,n=595; &gt;40,n=174) and no association with pregnancy rate (PR, p = 0.856), biochemical miscarriage rate (BMR, p = 0.940), clinical miscarriage rate (CMR, p = 0.06) nor LBR (p = 0.154) was found. BMI (kg/m2) was divided into four groups according to World Health Organization: underweight (&lt;18.5;n=32), normal weight (18.5–24.9;n=555), overweight (25–29.9;n=622), and obese (≥30;n=426). Although no differences were seen for PR or BMR between groups (p = 0.507 and p = 0.343, respectively), CMR was significantly lower for normal BMI group (p &lt; 0.001) and LBR significantly higher when compared to the overweight and obese group (&lt;18.5kg/m2=68.42%; 18.5–24.9kg/m2=68.35%; 25–29.9kg/m2=60.14%; ≥30kg/m2=53.29%; p &lt; 0.001). No differences were observed on the outcomes when AMH was sub-divided as per Bologna Criteria (&lt;1.3ng/mL,n=327; ≥1.3ng/mL,n=1090). Regarding endometrial preparation, NC protocol showed significantly lower BMR and CMR (7.93% vs 12.27%,p=0.026; 8.44% vs 17.97%,p&lt;0.001), and higher LBR (70.33% vs 55.06%,p&lt;0.001) compared to HRT. Day of trophectoderm biopsy had a significant higher PR for day 5 (day 5=75.58% vs day 6=61.1% and day 7=23.81%, p &lt; 0.0001), yet no differences were observed for BMR, CMR nor LBR.

Limitations, reasons for caution

Although the large number of FET included, performed in the same centre with same methodology, the retrospective study design is a limitation. We could not discard other hypothetical variables contributing to miscarriage such as KIR-HLA discrepancies, or other obstetric factors affecting late miscarriage and live birth.

Wider implications of the findings

Evaluating the factors associated with pregnancy outcomes should be considered prior to euploid frozen embryo transfer for personalized treatment approach and adequate blastocyst selection. Women with higher BMI should be aware of higher risk of miscarriage and lower LBR although an euploid blastocyst is transferred.

Trial registration number

not applicable

P-137 ICM and TE quality significantly impact the live birth in euploid frozen blastocyst transfer cycles

Study question

Is the live birth rate (LBR) in euploid frozen blastocyst transfer (FET) affected by the quality of ICM (Inner cell mass) and TE (Trophectoderm)?

Summary answer

ICM and TE significantly impacts the LBR with a decline of LB from 57.3% (ICM-A) to 48.5% (ICM-B) to 22.1% (ICM-C) (p &lt; 0.001)

What is known already

The morphological blastocyst grading system proposed by Gardner-Schoolcraft remains the most accepted system to identify blastocysts with higher implantation potential. It relies on morphological features within the blastocyst, including ICM and TE. Several studies tried to identify the individual contribution of each. However, the conclusions remain contradictory and no clear consensus has yet been achieved. Due to heterogeneity of parameters evaluated between different publications, where embryos with unknown ploidy status were transferred in conjunction with a variability of stimulation protocols and in the number of transferred embryos, the real effect of the ICM and TE is difficult to infer.

Study design, size, duration

This two-center retrospective observational study includes a total of 977 euploid single FET cycles between March 2017 and March 2020 at ART Fertility Clinics Muscat, Oman and Abu Dhabi, UAE.

Participants/materials, setting, methods

Trophectoderm biopsies were analyzed with Next Generation Sequencing (NGS). All blastocysts available on D5 or D6 with a quality ≥ BL3CC were subjected to TE biopsy for PGT-A analysis and LBR was recorded. Vitrification/warming of blastocysts was performed using Cryotop method (Kitazato). Bivariate and multivariate analysis were performed between LB outcomes and ICM and TE grade while controlling for confounding factors.

Main results and the role of chance

A total of 977 single FET cycles were analyzed: 651 in hormone replacement therapy (HRT) and 326 in natural cycle regimen (NC) resulting in a 46.88% LBR. The mean patients’ age was 33.80 years with a mean Body Mass Index (BMI) of 26.80 kg/m2. Though all qualities of ICM and TE were associated with LB, blastocyst ICM-A LBR was statistically significantly higher (57.3%) than ICM-B (48.4%) and ICM-C (22.1%) (p &lt; 0.001). Similarly, blastocyst TE-A LBR was statistically significantly higher (59.2%) than TE- B (48.6%) and TE- C (30.3%) (p &lt; 0.001). Miscarriage rate was similar in all groups.

The grade of ICM and TE were significantly associated with Anti-Mullerian-Hormone (AMH) and day of blastocyst biopsy. Mean AMH (ng/ml) was higher in ICM groups (A: 3.78, B: 3.24, p &lt; 0.001) and TE group (A: 3.63, B: 3.38, p &lt; 0.05) compared to lower grade (ICM-C: 2.86, TE-C: 2.82).

In multivariate analysis, endometrial preparation for FET, BMI and AMH were the parameters influencing LBR: OR:1.45, [CI:1.07-1.96], p &lt; 0.015) for NC; OR 0.96 [CI:0.93-0.99], p = 0.004 for BMI; OR 0.95 [CI:0.90-1.00], p = 0.033 for AMH; Both, ICM-C and TE-C, resulted in a significantly lower chance of LB [ICM: OR 0.32, CI:0.17-0.61, p &lt; 0.001; TE: OR 0.44, CI:0.27-0.73, p = 0.002), compared to grade A.

Limitations, reasons for caution

The retrospective nature of the study and inter-observer variability in blastocyst scoring is a limitation. The physician/embryologist performing the embryo transfer could not been standardized due to the multicenter design. Randomized controlled studies are needed to determine whether ICM or TE should be prioritized in the selection of the blastocyst.

Wider implications of the findings

The ICM and TE scoring in FET may influence the LBR and should be considered as an important factor for the success of embryo transfer cycles. Whether these results can be extrapolated to fresh embryo transfer and to blastocysts with unknown ploidy status, needs further investigation.

Trial registration number

not applicable

The Use of Cost-Effectiveness Thresholds for Evaluating Health Interventions in Low- and Middle-Income Countries From 2015 to 2020: A Review

OBJECTIVES

Evidence-informed priority setting, in particular cost-effectiveness analysis (CEA), can help target resources better to achieve universal health coverage. Central to the application of CEA is the use of a cost-effectiveness threshold. We add to the literature by looking at what thresholds have been used in published CEA and the proportion of interventions found to be cost-effective, by type of threshold.

METHODS

We identified CEA studies in low- and middle-income countries from the Global Health Cost-Effectiveness Analysis Registry that were published between January 1, 2015, and January 6, 2020. We extracted data on the country of focus, type of interventions under consideration, funder, threshold used, and recommendations.

RESULTS

A total of 230 studies with a total 713 interventions were included in this review; 1 to 3× gross domestic product (GDP) per capita was the most common type of threshold used in judging cost-effectiveness (84.3%). Approximately a third of studies (34.2%) using 1 to 3× GDP per capita applied a threshold at 3× GDP per capita. We have found that no study used locally developed thresholds. We found that 79.3% of interventions received a recommendation as "cost-effective" and that 85.9% of studies had at least 1 intervention that was considered cost-effective. The use of 1 to 3× GDP per capita led to a higher proportion of study interventions being judged as cost-effective compared with other types of thresholds.

CONCLUSIONS

Despite the wide concerns about the use of 1 to 3× GDP per capita, this threshold is still widely used in the literature. Using this threshold leads to more interventions being recommended as "cost-effective." This study further explore alternatives to the 1 to 3× GDP as a decision rule.

Assessing Progress Towards SDGs Implementation Using Multiple Reference Point Based Multicriteria Methods: The Case Study of the European Countries

To achieve the UN 2030 Agenda Goals, and considering their complexity and multidisciplinary, Multi-criteria analysis appears to be a suitable approach to give a true support to public decision makers in defining policy lines. This study focuses on the application of the Multiple Reference Point Weak-Strong Composite Indicators (MRP-WSCI) and its partially compensatory version (MRP-PCI), to assess, in the framework of the UN 2030 Agenda, the sustainability of the 28 members of the European Union (pre-Brexit). Countries were analyzed and compared according to their conditions and progress against the 17 Sustainable Development Goals, considering three reference years: 2007, 2012 and 2017. The analysis shows that Nordic countries reach a good level of global sustainability, with values of the indicators, W-W-W and S-W-W, between 2 and 3; while the States of east Europe, in particular Romania, Bulgaria and Greece, stay at the worst levels, having overall indicators values less than 1.5. Furthermore, the results highlight how countries in the lower group have difficulties especially in social and economic sustainability. On the other hand, states with a good overall condition record the worst results in the environmental dimension, such as the Netherlands, which shows, for the year 2017, a value for this sphere less than 2, while in the other two show a good value (over 2.5).

Health technology assessment capacity at national level in sub-Saharan Africa: an initial survey of stakeholders

Background: Health technology assessment (HTA) is an effective tool for supporting priority setting (PS) in health. Stakeholder groups need to understand HTA appropriate to their role and to interpret and critique the evidence produced. We aimed to rapidly assess current health system priorities and policy areas of demand for HTA in Sub-Saharan Africa, and identify key gaps in data and skills to inform targeted capacity building.

Methods: We revised an existing survey, delivered it to 357 participants, then analysed responses and explored key themes.

Results: There were 51 respondents (14%, 30 full completions) across 14 countries. HTA was considered an important and valuable PS tool with a key role in the design of health benefits packages, clinical guideline development, and service improvement. Medicines were identified as a technology type that would especially benefit from the application of HTA. Using HTA to address safety issues (e.g. low-quality medicines) and value for money concerns was particularly highlighted. The perceived availability and accessibility of suitable local data to support HTA varied widely but was mostly considered inadequate and limited. Respondents also noted a need for training support in research methodology and data gathering.

Conclusions: While important in raising awareness of HTA as a tool for PS, this study had a low response rate, and that respondents were self-selected. A more refined survey will be developed to support engagement strategies and capacity building.

Administration and monitoring of clofazimine for NTM infections in children with and without cystic fibrosis

Few studies have evaluated clofazimine (CLOF) drug monitoring and safety in children. We treated 10 children, 8 with CF, for NTM infection with multiple antimicrobials, including CLOF. All had serial blood CLOF concentrations measured and were followed for adverse events. Despite CLOF dose escalation, most children with CF did not reach a target CLOF concentration. Our data suggest that children with CF may require earlier initiation of CLOF at higher doses than is currently recommended.

P–677 Endometrial thickness, endometrial preparation protocol and number of euploid embryos transferred, significantly impact the live birth in frozen embryo transfer cycles

Study question

Is the live birth rate (LBR) in euploid frozen embryo transfer (FET) cycles affected by the endometrial thickness (EMT)?

Summary answer

A significantly higher LBR was observed in patients with an endometrial thickness of at least 7.5mm (46.24% vs. 54.63%)

What is known already

Parameters assessing the endometrium prior planning a FET include endometrial thickness, pattern and blood flow. The impact of the endometrial thickness on ART outcomes is controversial, with conflicting results published. A recent meta-analysis evaluated whether EMT could predict pregnancy outcomes and suggested that lower EMT was associated with lower incidence of clinical pregnancy rate (CPR), implantation rate (IR) and LBR. Due to heterogeneity of parameters evaluated between different publications, where embryos with unknown ploidy status were transferred, in conjunction with variability of stimulation protocols and the number of embryos transferred, the real effect of the EMT was difficult to infer.

Study design, size, duration

This was a two-center retrospective observational study including a total of 1522 euploid FET cycles between March 2017 and March 2020 at ART Fertility Clinics Muscat, Oman and Abu Dhabi, UAE.

Participants/materials, setting, methods

Trophectoderm biopsies were analyzed with Next Generation Sequencing (NGS). Vitrification/warming of blastocysts was performed using Cryotop method (Kitazato). EMT was measured by vaginal ultrasound prior initiating the progesterone administration (± 1 day) and LBR was recorded. Multivariate analysis was performed between LB outcomes and median EMT while controlling for confounding factors.

Main results and the role of chance

A total of 1522 FET cycles were analyzed: 975 single embryo transfer (SET) and 547 double embryo transfer (DET). The mean age of the patients was 33.38 years with a mean BMI of 27.1 kg/m2. FET were performed in EMT ranging from 3 to 15 mm and 50.52% resulted in a live birth. Though potentially all ranges of EMT were associated with LB, the median EMT in patients with LB was significantly higher than the median EMT of patients without LB (7.6mm vs. 7.4mm; p &lt; 0.001).

The dataset was stratified into two groups based on the median EMT (7.5mm): &lt; 7.5mm (n = 744 cycles) and ≥ 7.5mm (n = 778 cycles). A significantly higher live birth rate was observed in ≥ 7.5mm group (46.24% vs. 54.63%. p = 0.0012).

In multivariate analysis, EMT, FET endometrial preparation protocol, and number of embryos transferred were the main parameters influencing the chance to achieve LB: OR 1.10 [1.01–1.19], p &lt; 0.015 for the EMT; OR 1.84 [1.47–2.30], p &lt; 0.0001 for Natural Cycle protocol and OR 1.55 [1.25–1.93], p &lt; 0.0001 for DET. Intercept 0.18 [0.07–0.44] p &lt; 0.0002. Female age did not reach significance: OR 1.02 [1.00–1.04], p = 0.056.

Limitations, reasons for caution

Besides the retrospective nature of the study, the inter-observer variability in EMT assessment between different physicians is a limitation. The physician and embryologist performing the embryo transfer could not been standardized due to the multicenter design of the study.

Wider implications of the findings: The EMT in FET may influence the LBR and should be considered as an important factor for the success of embryo transfer cycles. Whether these results can be extrapolated to fresh embryo transfer and to blastocysts with unknown ploidy status, needs further investigation.

Trial registration number

Not applicable

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.

External cranial expansion as treatment of intracranial hypertension. Technical note

Intracranial hypertension may be idiopathic or due to multiple etiologies. Some bone dysplasias and chronic shunt overdrainage syndrome may sometimes lead to intracranial hypertension associated with craniocerebral disproportion due to thickening of cranial diploe. The internal cranial expansion procedure has been used for patients with intracranial hypertension, whether or not associated with craniocerebral disproportion. Its purpose is to increase the intracranial volume by drilling down the inner table. This technique enables the craniocerebral disproportion to be improved and intracranial hypertension reduced. In other etiologies of intracranial hypertension with non-thickened diploe, internal cranial expansion may not be enough to resolve the hypertension. For these cases we propose a modification of the technique by expanding the cranial vault outwards; external cranial expansion. We describe this technique as used in a pediatric patient who presented with chronic headache, tonsillar ectopia, and sleep apnea syndrome. This patient also had a multisuture craniosynostosis, a non-thickened diploe, and intracranial hypertension.

Assessing fitness-for-purpose and comparing the suitability of COVID-19 multi-country models for local contexts and users

Background: Mathematical models have been used throughout the COVID-19 pandemic to inform policymaking decisions. The COVID-19 Multi-Model Comparison Collaboration (CMCC) was established to provide country governments, particularly low- and middle-income countries (LMICs), and other model users with an overview of the aims, capabilities and limits of the main multi-country COVID-19 models to optimise their usefulness in the COVID-19 response. Methods: Seven models were identified that satisfied the inclusion criteria for the model comparison and had creators that were willing to participate in this analysis. A questionnaire, extraction tables and interview structure were developed to be used for each model, these tools had the aim of capturing the model characteristics deemed of greatest importance based on discussions with the Policy Group. The questionnaires were first completed by the CMCC Technical group using publicly available information, before further clarification and verification was obtained during interviews with the model developers. The fitness-for-purpose flow chart for assessing the appropriateness for use of different COVID-19 models was developed jointly by the CMCC Technical Group and Policy Group. Results: A flow chart of key questions to assess the fitness-for-purpose of commonly used COVID-19 epidemiological models was developed, with focus placed on their use in LMICs. Furthermore, each model was summarised with a description of the main characteristics, as well as the level of engagement and expertise required to use or adapt these models to LMIC settings. Conclusions: This work formalises a process for engagement with models, which is often done on an ad-hoc basis, with recommendations for both policymakers and model developers and should improve modelling use in policy decision making.

The CONSTANCES Cohort Biobank: An Open Tool for Research in Epidemiology and Prevention of Diseases

“General-purpose cohorts” in epidemiology and public health are designed to cover a broad scope of determinants and outcomes, in order to answer several research questions, including those not defined at study inception. In this context, the general objective of the CONSTANCES project is to set up a large population-based cohort that will contribute to the development of epidemiological research by hosting ancillary projects on a wide range of scientific domains, and to provide public health information. CONSTANCES was designed as a randomly selected sample of French adults aged 18–69 years at study inception; 202,045 subjects were included over an 8-year period. At inclusion, the selected participants are invited to attend one of the 24 participating Health Prevention Centers (HPCs) for a comprehensive health examination. The follow-up includes a yearly self-administered questionnaire, and a periodic visit to an HPC. Procedures have been developed to use the national healthcare databases to allow identification and validation of diseases over the follow-up. The biological collection (serum, lithium heparinized plasma, EDTA plasma, urine and buffy coat) began gradually in June 2018. At the end of the inclusions, specimens from 83,000 donors will have been collected. Specimens are collected according to a standardized protocol, identical in all recruitment centers. All operations relating to bio-banking have been entrusted by Inserm to the Integrated Biobank of Luxembourg (IBBL). A quality management system has been put in place. Particular attention has been paid to the traceability of all operations. The nature of the biological samples stored has been deliberately limited due to the economic and organizational constraints of the inclusion centers. Some research works may require specific collection conditions, and can be developed on request for a limited number of subjects and in specially trained centers. The biological specimens that are collected will allow for a large spectrum of biomarkers studies and genetic and epigenetic markers through candidate or agnostic approaches. By linking the extensive data on personal, lifestyle, environmental, occupational and social factors with the biomarker data, the CONSTANCES cohort offers the opportunity to study the interplays between these factors using an integrative approach and state-of-the-art methods.

What next after GDP-based cost-effectiveness thresholds?

Public payers around the world are increasingly using cost-effectiveness thresholds (CETs) to assess the value-for-money of an intervention and make coverage decisions. However, there is still much confusion about the meaning and uses of the CET, how it should be calculated, and what constitutes an adequate evidence base for its formulation. One widely referenced and used threshold in the last decade has been the 1-3 GDP per capita, which is often attributed to the Commission on Macroeconomics and  WHO guidelines on Choosing Interventions that are Cost Effective (WHO-CHOICE). For many reasons, however, this threshold has been widely criticised; which has led experts across the world, including the WHO, to discourage its use. This has left a vacuum for policy-makers and technical staff at a time when countries are wanting to move towards Universal Health Coverage .

This article seeks to address this gap by offering five practical options for decision-makers in low- and middle-income countries that can be used instead of the 1-3 GDP rule, to combine existing evidence with fair decision-rules or develop locally relevant CETs. It builds on existing literature as well as an engagement with a group of experts and decision-makers working in low, middle and high income countries.

Health technology assessment and priority setting for universal health coverage: a qualitative study of stakeholders' capacity, needs, policy areas of demand and perspectives in Nigeria

INTRODUCTION

Health technology assessment (HTA) is an effective tool to support priority setting and generate evidence for decision making especially en route to achieving universal health coverage (UHC). We assessed the capacity needs, policy areas of demand, and perspectives of key stakeholders for evidence-informed decision making in Nigeria where HTA is still new.

METHODS

We surveyed 31 participants including decision makers, policy makers, academic researchers, civil society organizations, community-based organizations, development partners, health professional organizations. We revised an existing survey to qualitatively examine the need, policy areas of demand, and perspectives of stakeholders on HTA. We then analyzed responses and explored key themes.

RESULTS

Most respondents were associated with organizations that generated or facilitated health services research. Research institutes highlighted their ability to provide expertise and skills for HTA research but some respondents noted a lack of human capacity for HTA. HTA was considered an important and valuable priority-setting tool with a key role in the design of health benefits packages, clinical guideline development, and service improvement. Public health programs, medicines and vaccines were the three main technology types that would especially benefit from the application of HTA. The perceived availability and accessibility of suitable local data to support HTA varied widely but was mostly considered inadequate and limited. Respondents needed evidence on health system financing, health service provision, burden of disease and noted a need for training support in research methodology, HTA and data management.

CONCLUSION

The use of HTA by policymakers and communities in Nigeria is very limited mainly due to inadequate and insufficient capacity to produce and use HTA. Developing sustainable and institutionalized HTA systems requires in-country expertise and active participation from a range of stakeholders. Stakeholder participation in identifying HTA topics and conducting relevant research will enhance the use of HTA evidence produced for decision making. Therefore, the identified training needs for HTA and possible research topics should be considered a priority in establishing HTA for evidence-informed policy making for achieving UHC particularly among the most vulnerable people in Nigeria.

Health technology assessment capacity at national level in sub-Saharan Africa: an initial survey of stakeholders

Background: Health technology assessment (HTA) is an effective tool to support priority setting (PS) in health. Stakeholder groups need to understand HTA appropriate to their role and to interpret and critique the evidence produced. We aimed to rapidly assess current health system priorities and policy areas of demand for HTA in Sub-Saharan Africa, and identify key gaps in data and skills to inform targeted capacity building. Methods: We revised an existing survey, delivered it to 357 participants, then analysed responses and explored key themes. Results: There were 51 respondents (14%) across 14 countries. HTA was considered an important and valuable PS tool with a key role in the design of health benefits packages, clinical guideline development, and service improvement. Medicines were identified as a technology type that would especially benefit from the application of HTA. Using HTA to address safety issues (e.g. low-quality medicines) and value for money concerns was particularly highlighted. The perceived availability and accessibility of suitable local data to support HTA varied widely but was mostly considered inadequate and limited. Respondents also noted a need for training support in research methodology and data gathering. Conclusions: While important in raising awareness of HTA as a tool for PS, this study had a low response rate, and that respondents were self-selected. A more refined survey will be developed to support engagement strategies and capacity building.

Supporting the Development of Evidence-Informed Policy Options: An Economic Evaluation of Hypertension Management in Ghana

OBJECTIVES

Universal healthcare coverage in low- and middle-income countries requires challenging resource allocation decisions. Health technology assessment is one important tool to support such decision making. The International Decision Support Initiative worked with the Ghanaian Ministry of Health to strengthen health technology assessment capacity building, identifying hypertension as a priority topic area for a relevant case study.

METHODS

Based on guidance from a national technical working group of researchers and policy makers, an economic evaluation and budget impact analysis were undertaken for the main antihypertensive medicines used for uncomplicated, essential hypertension. The analysis aimed to address specific policy questions relevant to the National Health Insurance Scheme.

RESULTS

The evaluation found that first-line management of essential hypertension with diuretics has an incremental cost per disability-adjusted life-year avoided of GH¢ 276 ($179 in 2017, 4% of gross national income per capita) compared with no treatment. Calcium channel blockers were more effective than diuretics but at a higher incremental cost: GH¢ 11 061 per disability-adjusted life-year avoided ($7189 in 2017; 160% of gross national income per capita). Diuretics provide better health outcomes at a lower cost than angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or beta-blockers. Budget impact analysis highlighted the potential for cost saving through enhanced price negotiation and increased use of better-value drugs. We also illustrate how savings could be reinvested to improve population health.

CONCLUSIONS

Economic evaluation enabled decision makers to assess hypertension medicines in a Ghanaian context and estimate the impact of using such evidence to change policy. This study contributes to addressing challenges associated with the drive for universal healthcare coverage in the context of constrained budgets.

Squamous cell carcinoma related with dental implants. A clinical cases report

One third of all cases of head and neck carcinoma (CA) concern the oral mucosa. The use of dental implants (DI) for dental rehabilitation is widely extended. However, a few studies have reported some cases with neoplasic alterations, among the tissue surrounding implants. Our aim was to analyze possible alterations at the bone-implant interface in patients with oral squamous cell carcinoma (SCC), providing new evidence that could relate or discard a possible link between these factors. We used, for the first time, different techniques, including electron microscopy and histology, to analyze the implant ´s surface and the surrounding tissue from four clinical cases with neoplasic alterations surrounding DI. Histologically, ample inflammatory tissue was found in direct contact with the implant surface. Surface analysis of this tissue, revealed titanium percentages. According to our study, no oncological relation with deterioration of the implant surface was found, although DI were constantly related with peri-implantitis, a chronic trauma of the oral mucosa that could involve a neoplastic factor.

Key words:Dental implants, carcinoma, peri-implantitis.

Resolution of inflammation during multiple sclerosis

Multiple sclerosis (MS) is a frequent autoimmune demyelinating disease of the central nervous system (CNS). There are three clinical forms described: relapsing-remitting multiple sclerosis (RRMS), the most common initial presentation (85%) among which, if not treated, about half will transform, into the secondary progressive multiple sclerosis (SPMS) and the primary progressive MS (PPMS) (15%) that is directly progressive without superimposed clinical relapses. Inflammation is present in all subsets of MS. The relapsing/remitting form could represent itself a particular interest for the study of inflammation resolution even though it remains incomplete in MS. Successful resolution of acute inflammation is a highly regulated process and dependent on mechanisms engaged early in the inflammatory response that are scarcely studied in MS. Moreover, recent classes of disease-modifying treatment (DMTs) that are effective against RRMS act by re-establishing the inflammatory imbalance, taking advantage of the pre-existing endogenous suppressor. In this review, we will discuss the active role of regulatory immune cells in inflammation resolution as well as the role of tissue and non-hematopoietic cells as contributors to inflammation resolution. Finally, we will explore how DMTs, more specifically induction therapies, impact the resolution of inflammation during MS.

Cost-Effectiveness of Docetaxel and Paclitaxel for Adjuvant Treatment of Early Breast Cancer: Adaptation of a Model-Based Economic Evaluation From the United Kingdom to South Africa

OBJECTIVES

Transferability of economic evaluations to low- and middle-income countries through adaptation of models is important; however, several methodological and practical challenges remain. Given its significant costs and the quality-of-life burden to patients, adjuvant treatment of early breast cancer was identified as a priority intervention by the South African National Department of Health. This study assessed the cost-effectiveness of docetaxel and paclitaxel-containing chemotherapy regimens (taxanes) compared with standard (non-taxane) treatments.

METHODS

A cost-utility analysis was undertaken based on a UK 6-health-state Markov model adapted for South Africa using the Mullins checklist. The analysis assumed a 35-year time horizon. The model was populated with clinical effectiveness data (hazard ratios, recurrence rates, and adverse events) using direct comparisons from clinical trials. Resource use patterns and unit costs for estimating cost parameters (drugs, diagnostics, consumables, personnel) were obtained from South Africa. Uncertainty was assessed using probabilistic and deterministic sensitivity analyses.

RESULTS

The incremental cost per patient for the docetaxel regimen compared with standard treatment was R6774. The incremental quality-adjusted life years (QALYs) were 0.24, generating an incremental cost-effectiveness ratio of R28430 per QALY. The cost of the paclitaxel regimen compared with standard treatment was estimated as -R578 and -R1512, producing an additional 0.03 and 0.025 QALYs, based on 2 trials. Paclitaxel, therefore, appears to be a dominant intervention. The base case results were robust to all sensitivity analyses.

CONCLUSIONS

Based on the adapted model, docetaxel and paclitaxel are predicted to be cost-effective as adjuvant treatment for early breast cancer in South Africa.

The potential of a Technosol and tropical native trees for reclamation of copper-polluted soils

Technosols created to reclaim degraded soils is a promising solution that needs further research. The objectives of the study were: i) to create a Technosol with a very high capacity to immobilize copper from mining, ii) to assess the capacity of the Technosol to immobilize copper after planting two tropical native tree species, and iii) to analyse the capacity of the native trees for extracting copper from polluted soils. Myracrodruon urundeuva (aroeira) and Cedrela fissilis (pink cedar) were planted in pots with Technosol spiked with copper at concentrations of 125, 1525 and 3050 mg Cu kg^-1. Height and stem diameter were measured over 90 days. Biomass and Cu concentration in leaves, stem and roots were determined. Copper was analysed in soils by sequential extraction, as well as in leached water. The Technosol showed a very high capacity to immobilize copper, since 60-80% of the added copper was strongly retained in the soil, mainly by bentonite and carbonates. The Technosol with trees showed the same capacity to immobilize copper as the control, since concentration in shoots was higher than 300 mg Cu kg^-1 and concentration in roots was even higher. These results show that Technosol and both species are useful tools to immobilize copper in polluted soils. Further studies are necessary to determine the total capacity of these trees to immobilize and/or extract copper in the long term and under field conditions.

Screening of native tropical trees for phytoremediation in copper-polluted soils

Due to the limited number of studies on phytoremediation using native tree species in tropical soils, the aim was to identify new phytoremediator species from tropical climate with the purpose of promoting an increase in the diversity of tropical native trees used in phytoremediation projects. Seven native tree species from Brazil were selected: Cedrela fissilis, Handroanthus serratifolius, Copaifera langsdorffii, Hymenaea courbaril, Mimosa caesalpiniifolia, Cecropia sp. and Myracrodruon urundeuva. Seedlings of these species were planted in pots with an unpolluted Arenosol, and then spiked with 60, 100 and 500 mg kg^-1 Cu. Height and stem diameters were measured over 60 days. Biomass and total Cu concentration were determined in leaves, stem and roots. Copper in bulk soils and rhizospheres was analyzed by a sequential extraction method. All species accumulated high concentration of Cu in roots (>300 mg kg^-1), so they could be used as phytostabilizators for this metal. Copper mobilization increased in the rhizospheres, but it was mostly absorbed by roots. Cecropia sp., M. urundeuva and C. langsdorffii are hyperaccumulators of Cu (>300 mg kg^-1 in shoots), so they are potential phytoextractor species. This study evidence the potential of seven tree species native from tropical regions for phytostabilizing copper-polluted soils.