South African healthcare reforms towards universal healthcare - where to next?

The National Assembly approval of the National Health Insurance (NHI) Bill represents an important milestone, but there are many uncertainties concerning its implementation and timeline. The challenges faced by the South African healthcare system are huge, and we cannot afford to wait for NHI to address them all. It is critical that the process of strengthening the health system to advance universal healthcare (UHC) begins now, and there are several viable initiatives that can be implemented without delay. This article examines potential scenarios after the Bill is passed and ways in which UHC could be advanced. It begins with an overview of the trajectory of health system reform since 1994, then examines the scenarios that may emerge once the Bill is passed by Parliament and makes a case for finding ways in which UHC could be advanced within the country, regardless of any legal or financial barriers that may delay or limit NHI implementation.

Recommendations for Emerging Good Practice and Future Research in Relation to Family and Caregiver Health Spillovers in Health Economic Evaluations: A Report of the SHEER Task Force

BACKGROUND

Omission of family and caregiver health spillovers from the economic evaluation of healthcare interventions remains common practice. When reported, a high degree of methodological inconsistency in incorporating spillovers has been observed.

AIM

To promote emerging good practice, this paper from the Spillovers in Health Economic Evaluation and Research (SHEER) task force aims to provide guidance on the incorporation of family and caregiver health spillovers in cost-effectiveness and cost-utility analysis. SHEER also seeks to inform the basis for a spillover research agenda and future practice.

METHODS

A modified nominal group technique was used to reach consensus on a set of recommendations, representative of the views of participating subject-matter experts. Through the structured discussions of the group, as well as on the basis of evidence identified during a review process, recommendations were proposed and voted upon, with voting being held over two rounds.

RESULTS

This report describes 11 consensus recommendations for emerging good practice. SHEER advocates for the incorporation of health spillovers into analyses conducted from a healthcare/health payer perspective, and more generally inclusive perspectives such as a societal perspective. Where possible, spillovers related to displaced/foregone activities should be considered, as should the distributional consequences of inclusion. Time horizons ought to be sufficient to capture all relevant impacts. Currently, the collection of primary spillover data is preferred and clear justification should be provided when using secondary data. Transparency and consistency when reporting on the incorporation of health spillovers are crucial. In addition, given that the evidence base relating to health spillovers remains limited and requires much development, 12 avenues for future research are proposed.

CONCLUSIONS

Consideration of health spillovers in economic evaluations has been called for by researchers and policymakers alike. Accordingly, it is hoped that the consensus recommendations of SHEER will motivate more widespread incorporation of health spillovers into analyses. The developing nature of spillover research necessitates that this guidance be viewed as an initial roadmap, rather than a strict checklist. Moreover, there is a need for balance between consistency in approach, where valuable in a decision making context, and variation in application, to reflect differing decision maker perspectives and to support innovation.

Real-time fetal brain tracking for functional fetal MRI

PURPOSE

To improve motion robustness of functional fetal MRI scans by developing an intrinsic real-time motion correction method. MRI provides an ideal tool to characterize fetal brain development and growth. It is, however, a relatively slow imaging technique and therefore extremely susceptible to subject motion, particularly in functional MRI experiments acquiring multiple Echo-Planar-Imaging-based repetitions, for example, diffusion MRI or blood-oxygen-level-dependency MRI.

METHODS

A 3D UNet was trained on 125 fetal datasets to track the fetal brain position in each repetition of the scan in real time. This tracking, inserted into a Gadgetron pipeline on a clinical scanner, allows updating the position of the field of view in a modified echo-planar imaging sequence. The method was evaluated in real-time in controlled-motion phantom experiments and ten fetal MR studies (17 + 4-34 + 3 gestational weeks) at 3T. The localization network was additionally tested retrospectively on 29 low-field (0.55T) datasets.

RESULTS

Our method achieved real-time fetal head tracking and prospective correction of the acquisition geometry. Localization performance achieved Dice scores of 84.4% and 82.3%, respectively for both the unseen 1.5T/3T and 0.55T fetal data, with values higher for cephalic fetuses and increasing with gestational age.

CONCLUSIONS

Our technique was able to follow the fetal brain even for fetuses under 18 weeks GA in real-time at 3T and was successfully applied "offline" to new cohorts on 0.55T. Next, it will be deployed to other modalities such as fetal diffusion MRI and to cohorts of pregnant participants diagnosed with pregnancy complications, for example, pre-eclampsia and congenital heart disease.

Following in Banting's footsteps or straying from the path? Observations from contemporary diabetes innovation

While advancements in the treatment of diabetes continue to rapidly evolve, many of the newer technologies have financial barriers to care, opposing the egalitarian ethos of Banting who sold his patent on insulin for a nominal cost to allow it to be made widely available. Inequity in access to new therapies drives disparity in diabetes burden with potential for these gaps to widen in the future. The 2023 International Conference on Advanced Technologies and Treatments of Diabetes (ATTD) presented ground-breaking and current research in diabetes technology. Oral presentations of the ATTD conference 2023 were analyzed to describe what percentage of speakers discussed equity in their talks. Overall, less than a quarter of presenters discussed equity, though there was regional variation. To ensure that diabetes technologies reduce disparity and improve outcomes, we encourage future speakers at diabetes (technology) conferences to consider equity of diabetes care and incorporate this into their presentations.

The cost of public health interventions to respond to the 10th Ebola outbreak in the Democratic Republic of the Congo

The 10th Ebola virus disease (EVD) outbreak in the Democratic Republic of the Congo (DRC) drew substantial attention from the international community, which in turn invested more than US$1 billion in EVD control over two years (2018-2020). This is the first EVD outbreak to take place in a conflict area, which led to a shift in strategy from a pure public health response (PHR) to a multisectoral humanitarian response. A wide range of disease control and mitigation activities were implemented and were outlined in the five budgeted Strategic Response Plans used throughout the 26 months. This study used the budget/expenditure and output indicators for disease control and mitigation interventions compiled by the government of DRC and development and humanitarian partners to estimate unit costs of key Ebola control interventions. Of all the investment in EVD control, 68% was spent on PHR. The remaining 32% covered security, community support interventions for the PHR. The disbursement for the public health pillar was distributed as follows: (1) coordination (18.8%), (2), clinical management of EVD cases (18.4%), (3) surveillance and vaccination (15.9%), (4) infection prevention and control/WASH (13.8%) and (5) risk communication (13.7%). The unit costs of key EVD control interventions were as follows: US$66 182 for maintaining a rapid response team per month, US$4435 for contact tracing and surveillance per identified EVD case, US$1464 for EVD treatment per case, US$59.4 per EVD laboratory test, US$120.7 per vaccinated individual against EVD and US$175.0 for mental health and psychosocial support per beneficiary. The estimated unit costs of key EVD disease control interventions provide crucial information for future infectious disease control planning and budgeting, as well as prioritisation of disease control interventions.

Building implementable packages for universal health coverage

Since no country or health system can provide every possible health service to everyone who might benefit, the prioritisation of a defined subset of services for universal availability is intrinsic to universal health coverage (UHC). Creating a package of priority services for UHC, however, does not in itself benefit a population-packages have impact only through implementation. There are inherent tensions between the way services are formulated to facilitate criteria-driven prioritisation and the formulations that facilitate implementation, and service delivery considerations are rarely well incorporated into package development. Countries face substantial challenges bridging from a list of services in a package to the elements needed to get services to people. The failure to incorporate delivery considerations already at the prioritisation and design stage can result in packages that undermine the goals that countries have for service delivery. Based on a range of country experiences, we discuss specific choices about package structure and content and summarise some ideas on how to build more implementable packages of services for UHC, arguing that well-designed packages can support countries to bridge effectively from intent to implementation.

Cost utility and budget impact analysis of dexamethasone compared with bortezomib and lenalidomide for the treatment of second line multiple myeloma from a South African public health perspective

BACKGROUND

Multiple myeloma is an incurable haematological malignancy that is associated with a high probability of relapse. The survival of relapsed patients has been greatly improved by the development of novel drugs such as lenalidomide and bortezomib. We assessed the cost-effectiveness of these drugs as second-line treatment for relapsed/refractory multiple myeloma (RRMM) patients in the South African public health care system.

METHODS

We modelled 3 treatment strategies for second-line RRMM treatment: dexamethasone (standard of care), bortezomib (BORT) and lenalidomide plus dexamethasone (LEN/DEX) from the South African public health perspective. For each strategy we modelled a hypothetical cohort of relapsed/refractory multiple myeloma patients using a three-state Markov model over a 15-year time horizon. Efficacy and utilization data were obtained from the MM009/010 and APEX trials and external studies. Price and cost data were from local sources and presented in 2021 South African Rands. Outcomes were reported in quality adjusted life years (QALYs). Incremental cost effectiveness ratios (ICERs) were calculated for BORT and LEN/DEX and compared to a local cost-effectiveness threshold of R38 500 per DALY averted using the assumption that 1 DALY averted is equal to 1 QALY gained. A budget impact analysis was conducted to evaluate the financial impact of the introduction of BORT and LEN/DEX, respectively. Deterministic sensitivity analysis was undertaken to account for parameter uncertainties.

RESULTS

The modelled total costs of DEX, BORT and LEN/DEX were estimated to be R8 312, R234 996 and R1 135 323, respectively. DEX treatment provided 1.14 QALYs while BORT and LEN/DEX treatments provided 1.49 and 2.22 QALYs, respectively. The ICER of BORT versus DEX was R654 649 and that of LEN/DEX versus BORT was R1 225 542. Both BORT and LEN/DEX treatments were not cost-effective relative to a cost-effectiveness threshold of R38 500 per DALY averted. Both BORT and LEN/DEX significantly increase the 1 year budget-cost of RRMM treatment.

CONCLUSION

Both BORT and LEN/DEX treatments are unlikely to be cost-effective strategies for second-line treatment of RRMM in South Africa. The results indicate that the drug prices of lenalidomide and bortezomib are key drivers of value for money. Price reductions could potentially make BORT more cost-effective.

Data‐driven motion‐corrected brain MRI incorporating pose‐dependent B 0 fields

Purpose

To develop a fully data‐driven retrospective intrascan motion‐correction framework for volumetric brain MRI at ultrahigh field (7 Tesla) that includes modeling of pose‐dependent changes in polarizing magnetic (B₀) fields.

Theory and Methods

Tissue susceptibility induces spatially varying B₀ distributions in the head, which change with pose. A physics‐inspired B₀ model has been deployed to model the B₀ variations in the head and was validated in vivo. This model is integrated into a forward parallel imaging model for imaging in the presence of motion. Our proposal minimizes the number of added parameters, enabling the developed framework to estimate dynamic B₀ variations from appropriately acquired data without requiring navigators. The effect on data‐driven motion correction is validated in simulations and in vivo.

Results

The applicability of the physics‐inspired B₀ model was confirmed in vivo. Simulations show the need to include the pose‐dependent B₀ fields in the reconstruction to improve motion‐correction performance and the feasibility of estimating B₀ evolution from the acquired data. The proposed motion and B₀ correction showed improved image quality for strongly corrupted data at 7 Tesla in simulations and in vivo.

Conclusion

We have developed a motion‐correction framework that accounts for and estimates pose‐dependent B₀ fields. The method improves current state‐of‐the‐art data‐driven motion‐correction techniques when B₀ dependencies cannot be neglected. The use of a compact physics‐inspired B₀ model together with leveraging the parallel imaging encoding redundancy and previously proposed optimized sampling patterns enables a purely data‐driven approach.

COVID-19 hospitalization and mortality and hospitalization-related utilization and expenditure: Analysis of a South African private health insured population

Background

Evidence on the risk factors for COVID-19 hospitalization, mortality, hospital stay and cost of treatment in the African context is limited. This study aims to quantify the impact of known risk factors on these outcomes in a large South African private health insured population.

Methods and findings

This is a cross sectional analytic study based on the analysis of the records of members belonging to health insurances administered by Discovery Health (PTY) Ltd. Demographic data for 188,292 members who tested COVID-19 positive over the period 1 March 2020–28 February 2021 and the hospitalization data for these members up until 30 June 2021 were extracted. Logistic regression models were used for hospitalization and death outcomes, while length of hospital stay and (log) cost per patient were modelled by negative binominal and linear regression models. We accounted for potential differences in the population served and the quality of care within different geographic health regions by including the health district as a random effect. Overall hospitalization and mortality risk was 18.8% and 3.3% respectively. Those aged 65+ years, those with 3 or more comorbidities and males had the highest hospitalization and mortality risks and the longest and costliest hospital stays. Hospitalization and mortality risks were higher in wave 2 than in wave 1. Hospital and mortality risk varied across provinces, even after controlling for important predictors. Hospitalization and mortality risks were the highest for diabetes alone or in combination with hypertension, hypercholesterolemia and ischemic heart disease.

Conclusions

These findings can assist in developing better risk mitigation and management strategies. It can also allow for better resource allocation and prioritization planning as health systems struggle to meet the increased care demands resulting from the pandemic while having to deal with these in an ever-more resource constrained environment.

MO598: Coping Strategies During the COVID-19 Pandemic: Influence of Patient Activation in People Living With Kidney Disease

BACKGROUND AND AIMS

Patient activation refers to the knowledge, skills and confidence needed to manage one's health [1]. Higher patient activation is associated with better health outcomes in long-term conditions [2] such as kidney disease (KD). The COVID-19 pandemic has presented a myriad of additional challenges for people living with KD. Individuals may display different coping strategies in response to stressful and difficult circumstances such as health management during the pandemic [3]. Our group conducted a multicentre survey to evaluate the impact of the pandemic on kidney patient experiences, lifestyle and health care. As part of this larger study, we hypothesized that higher patient activation may be associated with more effective coping strategies. The purpose of this analysis was to explore coping styles utilised during the pandemic across different levels of patient activation in people with nondialysis CKD (ND-CKD) and kidney transplant recipients (KTR).

METHOD

214 ND-CKD and KTR participants [50.9% male, mean age 60.71 (SD 14.15) years, 56.1% KTRs] completed the Patient Activation Measure (PAM-13). Participants were categorised into ‘low’ and ‘high’ activation based on their PAM-13 score (levels 1–2 as low; 3–4 as high). Coping strategies were assessed using the Brief-COPE questionnaire and categorised into adaptive coping (active coping, information support, positive reframing, planning, emotional support, humour, acceptance and religion) and maladaptive coping (venting, self-blame, self-distraction, denial, substance use and behavioral disengagement) strategies. Chi-square tests were conducted to compare coping strategies used by low- and high-activated patients.

RESULTS

Most participants were classified as having ‘high’ activation levels (n = 164, 77%). Table 1 shows the three most frequently used adaptive and maladaptive coping strategies across activation levels. A significantly greater proportion of those with high activation used acceptance (P = 0.006), active coping (P = 0.045) and positive reframing (P = 0.031) as coping strategies. No significance was observed between maladaptive coping strategies and activation level.

CONCLUSION

The most commonly reported coping strategy was ‘acceptance’ for individuals with high and low activation. The findings suggest that a higher proportion of people with high patient activation used adaptive coping strategies. Worryingly, regardless of activation level, about a third of participants used substance use (i.e. alcohol and drugs) as a form of coping. Identifying people with lower activation in KD can indicate the need for additional support to help them cope in challenging circumstances. Interventions to improve activation may assist in developing effective coping strategies.

MO595: Utility and Construct Validity of the SARC-F Instrument in Patients With Non-Dialysis CKD

BACKGROUND AND AIMS

Protein energy wasting (PEW), and cachexia is common in people with non-dialysis chronic kidney disease (CKD) and it can lead to reduced muscle mass and physical function (also termed sarcopenia). There are no well-established, simple and reliable methods for identifying cases of sarcopenia. The SARC-F questionnaire is recommended to pre-screen for sarcopenia. However, the utility and construct validity of the SARC-F in nondialysis CKD patients is yet to be investigated, particularly whether the SARC-F can correctly identify poor physical performance—a key element of the sarcopenia phenotype in patients with CKD. The aim of the present analysis was to establish the utility and construct validity of the SARC-F in people with CKD, as well as to investigate which items of the SARC-F are the most impactful in predicting sarcopenia, assessed by the 60 second sit to stand test (STS60).

METHOD

146 non-dialysis CKD patients (94 (64%) males, age 60.63 (±14.4) years,  eGFR range 15–59 mL/min/1.73 m²) filled out the SARC-F questionnaire and completed the 60-s sit to stand test (STS60), a well-established assessment of physical performance. There are five SARC-F components: ‘strength’, ‘assistance with walking’, ‘rise from a chair’, ‘climbing stairs’ and ‘falls’. The scores range from 0 to 10, with 0 to 2 points for each component. A score ≥4 is predictive of sarcopenia and poor outcome. Score distribution was explored via frequency analysis to establish floor or ceiling effect(s) (≥15%). Construct validity between the SARC-F components and STS60 performance was assessed by Spearman's rank correlation. General linear modeling was used to determine significant predictors for STS60 performance. Linear regression was used to investigate whether SARC-F total scores were a predictor for STS60 performance.

RESULTS

Sarcopenia was present in 16 out of the 146 (10.9%) patients. Floor and ceiling effects of each SARC-F item, and SARC-F total scores, are presented in Figure 1. All items as well as SARC-F total scores showed a floor effect with more than 50% of patients scoring ‘None’ on each item and thus had ‘0’ in total scores (Figure 1). The ‘climbing stairs’ item displayed the highest (r = −0.584, P < 0.001) association with STS60 performance, followed by SARC-F total scores (r = −0.583, P < 0.001), ‘strength’ (r = −0.470, P < 0.001), ‘assistance in walking’ (r = −.457, P < 0.001), ‘rise from a chair’ (r = –0.424, P < 0.001) and ’falls’ (r = –0.282, P = 0.002). The ‘climbing stairs’ item was a significant predictor for STS60 performance (Table 2), and SARC-F total scores were a significant predictor for STS60 performance (P < 0.001, R = 0.375, Β = −0.48–26.891).

CONCLUSION

The present data suggest that the ‘climbing stairs’ component of the SARC-F, as well as total SARC-F scores are valid predictors for lower body physical performance. This suggests that the SARC-F has limited ability to screen for lower body strength, and thus it may not be adequate to screen for sarcopenia. These results could be explained by the significant floor effect exhibited. It is also surprising that the ‘Rise from a chair’ item did not show higher association with, and predictive ability for STS60 performance. This item showed the second to highest floor effect which could contribute to this result. Thus, caution should be applied when using the SARC-F for sarcopenia screening especially in clinical populations where protein energy wasting may be present.

MO1052: Feasibility of ‘Smile-K’, a Remote Randomized Controlled Trial of an Online Self-Management Programme for People Living with Kidney Disease

BACKGROUND AND AIMS

It is desirable for people with non-dialysis chronic kidney disease (ND-CKD) to take an active role in the management of their own health, but this requires the appropriate knowledge, skills and confidence (termed patient activation) to effectively self-manage. Currently, there is a lack of resources available to improve self-management behaviours and actively involve individuals in their own healthcare. Our group has developed a 10-week online self-management programme for people with non-dialysis CKD, called ‘My Kidneys & Me’ (MK&M), currently undergoing evaluation in the ‘SMILE-K’ multi-centre randomized control trial (RCT), which is conducted entirely online (remotely). The primary outcome of ‘SMILE-K’ is patient activation, but to ensure that the full-scale trial protocol is feasible and to minimize methodological weaknesses, we conducted a nested single-blind pilot with feasibility outcomes. Here we report the results of the nested pilot and preliminary usage data for ‘MK&M’.

METHOD

The ‘SMILE-K’ trial employs an entirely remote recruitment method, with a 2:1 randomization into intervention and control arms. The first 60 participants were included in the nested pilot and followed up for 10-weeks. Assessment surveys, including the Patient Activation Measure, were conducted electronically at baseline (pre-randomization) and 10 weeks later. Progression criteria were set a priori, using the ‘red’ (stop), ‘amber’ (make changes) and ‘green’ (go) system to specify targets for progression, based on recruitment rates, acceptability of recruitment and randomization methods, the feasibility and acceptability of outcome assessments, and engagement with and usage of ‘MK&M’.

RESULTS

Of the first 128 people approached who expressed interest in ‘SMILE-K’, 77/128 (60%) consented to participate. Of these, 60/77 (78%) completed the baseline

outcome survey and were subsequently randomized and included in the pilot. The average age of pilot participants was 63 (range: 20–88) years and 63% (n = 38) were male. Sending study invitations via post was the most common method of recruitment, although additional discussion of the study with potential participants (either face-to-face or via telephone) increased recruitment rates. All of the pre-specified ‘stop’ progression criteria thresholds were exceeded, indicating that the full planned RCT is feasible. Access to and engagement with ‘MK&M’ were high, with 36/41 (88%) participants activating their accounts and logging in. Participants logged into ‘MK&M’ a mean of 35 times during the 10-week follow-up period and spent a mean of 14 min/login.

CONCLUSION

This nested pilot study provided evidence for the feasibility of the full-scale ‘SMILE-K’ trial. Numerous lessons were learnt from conducting this entirely remote trial design, and from the pilot findings, we identified areas for improvement and have made subsequent small amendments to the trial protocol to improve the delivery of ‘MK&M’ and ‘SMILE-K’. The ‘SMILE-K’ trial is currently ongoing, and we anticipate that the results will be available in 2023.

MO588: Is The ‘Short-Form 12 Health Survey’ A Valid Assessment of Physical Function in People Living with Chronic Kidney Disease?

BACKGROUND AND AIMS

Compromised physical function is well-recognised in chronic kidney disease (CKD) and is associated with reduced quality of life (QoL) and poor outcome. CKD is often considered to be the model of ‘accelerated aging,’ thus quick and reliable measurements of physical function are essential as part of healthy aging in the CKD population. However, monitoring physical function via objective assessments can be impractical in clinical and some research settings. The ‘Short-Form 12 Health Survey’ (SF-12) is a commonly used self-report instrument to assess the quality of life, and it has also been used to assess physical health and function through its physical component subscale (PCS), and the physical function domain (PF). However, the validity of the SF-12 against objective physical function tests is unknown. In this analysis, we aimed to validate the SF-12 against multiple objective physical function measures.

METHOD

Forty-six non-dialysis CKD non-dialysis patients (21 men, mean age: 66.8 (±11.7) years, eGFR 42.8 (±19.6) mL/min/1.73 m2) completed the SF-12 and performed objective physical function tests [short physical performance

battery (SPPB), sit to stand 60 (STS60), sit to stand 5 (STS5), timed up and go (TUAG), gait speed and handgrip strength (HGS)]. Based on these tests, patients were categorised into having ‘low’ and ‘normal’ physical function via previously established reference points. To establish construct validity, partial correlation adjusted for age, eGFR and sex were conducted. The predictive ability of the SF-12 was assessed by receiver operating curves (ROC) and the area under curve (AUC), as well as sensitivity (%) and specificity (%).

RESULTS

The PF domain and PCS subscale had moderate to strong correlation with the SPPB (r = 0.455, P = 0.010 and r = 0.432, P = 0.012), and the STS60 (r = 0.659, P = 0.000 and r = 0.729, P < 0.000) tests and a moderate negative correlation with the STS5 (r= −0.431, P = 0.022 and r = −0.471, P = 0.009). PCS was also associated with gait speed (r = 0.369, P = 0.41). The ability of the PF domain and PCS subscale to predict physical function was ‘Fair’ (P = 0.03) and ‘Good’ (P = 0.01) based on the STS60 test but not the other tests (Table 1). A cut off score, for the PF domain, using Youden's J statistics was determined at a 0.343 with a score of 75 (sensitivity: 76% and specificity: 58%). A cut off score for the PCS component, was determined at Youden's J of 0.400 with score of ≤41.04 (sensitivity: 65% and specificity: 75%).

CONCLUSION

These data demonstrate that the SF-12 PF domain and PCS component have adequate construct validity when compared with lower body functional tests such as the STS60, STS5 or the SPPB. The PF domain demonstrated a fair accuracy while the PCS component showed good accuracy to predict ‘low’ and ‘normal’ functional status based on the STS60 test. These data also confirm previously assumed cut off point of 75 scores on the SF-12 PF domain, and it also introduces a cut-off point of ≤41.04 scores for the SF-12 PCS subscale to predict low physical function in this population. Thus, the SF-12 may be an adequate tool to measure perceived functional status in nondialysis CKD patients. Therefore, it could be a useful instrument to measure physical function as well as QoL as core components of healthy aging in this population.

Using allocative efficiency analysis to inform health benefits package design for progressing towards Universal Health Coverage: Proof-of-concept studies in countries seeking decision support

BACKGROUND

Countries are increasingly defining health benefits packages (HBPs) as a way of progressing towards Universal Health Coverage (UHC). Resources for health are commonly constrained, so it is imperative to allocate funds as efficiently as possible. We conducted allocative efficiency analyses using the Health Interventions Prioritization tool (HIPtool) to estimate the cost and impact of potential HBPs in three countries. These analyses explore the usefulness of allocative efficiency analysis and HIPtool in particular, in contributing to priority setting discussions.

METHODS AND FINDINGS

HIPtool is an open-access and open-source allocative efficiency modelling tool. It is preloaded with publicly available data, including data on the 218 cost-effective interventions comprising the Essential UHC package identified in the 3rd Edition of Disease Control Priorities, and global burden of disease data from the Institute for Health Metrics and Evaluation. For these analyses, the data were adapted to the health systems of Armenia, Côte d'Ivoire and Zimbabwe. Local data replaced global data where possible. Optimized resource allocations were then estimated using the optimization algorithm. In Armenia, optimized spending on UHC interventions could avert 26% more disability-adjusted life years (DALYs), but even highly cost-effective interventions are not funded without an increase in the current health budget. In Côte d'Ivoire, surgical interventions, maternal and child health and health promotion interventions are scaled up under optimized spending with an estimated 22% increase in DALYs averted-mostly at the primary care level. In Zimbabwe, the estimated gain was even higher at 49% of additional DALYs averted through optimized spending.

CONCLUSIONS

HIPtool applications can assist discussions around spending prioritization, HBP design and primary health care transformation. The analyses provided actionable policy recommendations regarding spending allocations across specific delivery platforms, disease programs and interventions. Resource constraints exacerbated by the COVID-19 pandemic increase the need for formal planning of resource allocation to maximize health benefits.

MO612THE ROLE OF MECHANICAL MUSCLE POWER IN PHYSICAL DYSFUNCTION: A MODEL FOR TAILORING RESISTANCE-BASED REHABILITATION IN CHRONIC KIDNEY DISEASE

Background and Aims

Individuals living with CKD are characterised by adverse changes in physical function. Knowledge of the factors that mediate impairments in physical functioning is crucial for developing effective interventions that preserve mobility and future independence. Mechanical muscle power describes the rate of performing work and is the product of muscular force and velocity of contraction. Muscle power has been shown to have stronger associations with functional limitations and mortality than sarcopenia in older adults. In CKD, the role of mechanical muscle power is poorly understood and is overlooked as a target in many rehabilitation programmes, often at the expense of muscle mass or strength. The aims of this study were to 1) explore the prevalence of low absolute mechanical power, low relative mechanical power, and low specific mechanical power in CKD; and 2) investigate the association of mechanical power with the ability to complete activities of daily living and physical performance.

Method

Mechanical muscle power (relative, allometric, specific) was calculated using the sit-to-stand-5 (STS5) test as per previously validated equations. Legs lean mass was derived from regional analyses conducted using bioelectrical impedance analysis (BIA). Physical performance was assessed using two objective tests: usual gait speed and the ‘time-up-and-go’ (TUAG) test. Self-reported activities of daily living (ADLs) were assessed via the Duke Activity Status Index (DASI). Balance and postural stability (postural sway and velocity) was assessed using a FysioMeter. Sex-specific tertiles were used to determine low, medium and high levels of relative STS power and its main components.

Results

102 participants with non-dialysis CKD were included (mean age: 62.0 (±14.1) years, n=49 males (48%), mean eGFR: 38.0 (±21.5) ml.min.1.73m2). The mean estimated relative power was 3.1 (±1.5) W.kg in females and 3.3 (±1.3) W.kg in males. Low relative power was found in 35/102 (34%) patients. Relative power was a significant independent predictor of self-reported ADLs (via the DASI) (B=.413, P=.004), and performance on the TUAG (B=-.719, P<.001) and gait speed (B=.404, P=.003) tests. Skeletal muscle mass was not associated with the DASI or any of the objective function tests

Conclusion

Patients presenting with low muscle power would benefit from participation in appropriate interventions designed to improve the physiological components accounting for low relative muscle power. Assessment of power can be used to tailor renal rehabilitation programmes as shown in Figure 1. Incorporation of power-based training, a novel type of strength training, designed by manipulating traditional strength training variables and primarily movement velocity and training intensity may present the best strategy for improving physical function in CKD.

MO1036DEVELOPMENT OF A DIGITAL SELF-MANAGEMENT EDUCATION PROGRAMME TO IMPROVE HEALTH BEHAVIOURS IN PEOPLE WITH NON-DIALYSIS CKD

Background and Aims

Appropriate disease and healthcare management are key behaviours for health optimisation in people with long-term conditions including CKD. Effective self-management of health requires appropriate knowledge, skills and confidence. Digital health interventions are potentially appealing tools to improve knowledge and self-management behaviours, as well as actively involving individuals in their healthcare, particularly in the post-COVID-19 era. However, the development strategies and processes behind such interventions are poorly defined. Here we describe the systematic development of a digital self-management programme for people living with non-dialysis CKD which includes novel approaches to improving self-management and health behaviours.

Method

Intervention mapping (IM) was used to guide the development of a digital self-management programme called ‘My Kidneys and Me’ (MK&M) to ensure that it can be implemented in clinical practice. The development process was guided by the first four steps of IM: (1) establish multidisciplinary and patient and public involvement (PPI) steering groups to describe the context of the intervention and programme goals; (2) identify objectives and determinants at early design stages to maintain a focus on the strategies adopted; (3) generate the programme components underpinned by appropriate psychological theories and models; (4) develop the programme content and describe the iterative process of refining the content and format of the digital programme for evaluation and implementation. The last two steps (adoption, implementation, and evaluation plan) will be evaluated alongside a forthcoming trial.

Results

A multidisciplinary steering group was formed consisting of 23 healthcare professionals, researchers, and digital health experts who provided expertise in the clinical and psychosocial aspects of CKD, self-management, digital health, and behaviour change research. A PPI steering group of 12 patients and family members identified the needs and priorities of MK&M, providing feedback at relevant time points.

As a result of previous literature and input from both steering groups, MK&M was developed with the aim to improve and maintain self-management behaviours, including to improve knowledge, promote self-care skill, increase self-efficacy, improve well-being, and increase physical activity. These target behaviours were translated into key programme goals: 1) increase patient activation; 2) reduce health risks; 3) manage symptoms; and 4) increase physical function.

Based on patient input and needs, MK&M was designed to comprise educational (Learn about …) and behaviour change (How to …) sessions, health trackers (e.g. blood pressure, weight, fruit and veg consumption), symptom tracker, exercise trackers, goal setting features, and social support. For example, to improve symptom management behaviours, patients can use MK&M to: 1) learn about symptoms associated with CKD and strategies to help manage these symptoms; 2) learn how to recognise and keep track of their symptoms so that they can modify their lifestyle accordingly and speak to their healthcare professional if needed; 3) track their symptoms using a bespoke tool.

Conclusion

Applying the IM framework enabled us to systematically use theory, empirical evidence, and practical perspectives in the development of MK&M. Our evidence- and theory-based online self-management programme provides ongoing support and guidance to people with CKD. The efficacy of MK&M to improve patient self-management behaviour is being studied in a multi-site RCT in the UK.

MO615SUPPORT FOR CHRONIC KIDNEY DISEASE PATIENTS DURING COVID-19: PERSPECTIVES FROM PATIENTS, FAMILY AND HEALTHCARE PROFESSIONALS

Background and Aims

Patients with non-dialysis chronic kidney disease (CKD patients) require specialised management, including routine clinical visits, laboratory measures, and medication adjustments. Inevitably, the COVID-19 pandemic has resulted in changes to delivery of care in a bid to prevent virus transmission in this clinically vulnerable group. The extent of the impact of any changes in support provision for patients is largely unknown. The study aimed to capture the views of CKD patients, family or other significant person in their lives (SO), and nephrology healthcare professionals (HCPs) on how patients’ healthcare needs were and could be supported during this time.

Method

CKD patients, their SO (e.g., family member, friend) and HCPs from 10 secondary care sites across England were invited to take part in a bespoke online survey, as part of the DIMENSION-KD portfolio adopted study. Participants responded to yes/no and free-text questions about their satisfaction with available healthcare support (CKD, SO) and patients’ need for additional support (CKD, SO, HCP). Thematic analysis was applied to the free-text responses.

Results

230 CKD patients (mean age 63.8, SD 13.8 years), 67 SO (74% spouses), and 59 HCP of various specialties completed the survey between August and December 2020. 84% of CKD participants felt they could get the support they needed. The most frequent explanation (25%) was that direct contact with a member of their renal team was available when needed. Other explanations included 1. being monitored by the renal team, 2. continuation of regular appointments and having additional treatment when necessary, 3. an accessible local General Practice (GP), and 4. a particularly “helpful” nephrologist or “good relationships” with their doctors. All SO felt the patient could get the help they required. Their explanations were in line with those of CKD patients, i.e., readily available contact and access to the renal team (25%), followed by good relationship or highly positive experience with member(s) of the renal team, regularity of contact/ appointments, and GP accessibility. When asked about additional healthcare information and support they would like, “none” was the most common response by CKD patients (28%), followed by the need for reliable information around COVID-19 and renal conditions, access to local GP, and a reliable point of contact when kidney condition deteriorates. Similarly, for many SO there was no need for additional support, whilst the most often suggested type of support was provision of reliable information on COVID-19 and renal health. For HCP, accessible service and guidance (36%) and psychosocial support for patients (25%) were most frequently cited types of additional support that would benefit patients.

Conclusion

An accessible point of contact for renal care and continuation of regular monitoring of some form emerged as key factors in CKD patient support across the three stakeholder groups. Some needs raised, such as limited access to GP, are relevant to local primary or secondary healthcare services, while practices adopted by some renal teams, such as a number for patients to ring when needed, seemed to offer reassurance and satisfaction among patients and their SO.

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.

Defining trajectories of response in patients with psoriasis treated with biologic therapies

BACKGROUND

The effectiveness and cost-effectiveness of biologic therapies for psoriasis are significantly compromised by variable treatment responses. Thus, more precise management of psoriasis is needed.

OBJECTIVES

To identify subgroups of patients with psoriasis treated with biologic therapies, based on changes in their disease activity over time, that may better inform patient management.

METHODS

We applied latent class mixed modelling to identify trajectory-based patient subgroups from longitudinal, routine clinical data on disease severity, as measured by the Psoriasis Area and Severity Index (PASI), from 3546 patients in the British Association of Dermatologists Biologics and Immunomodulators Register, as well as in an independent cohort of 2889 patients pooled across four clinical trials.

RESULTS

We discovered four discrete classes of global response trajectories, each characterized in terms of time to response, size of effect and relapse. Each class was associated with differing clinical characteristics, e.g. body mass index, baseline PASI and prevalence of different manifestations. The results were verified in a second cohort of clinical trial participants, where similar trajectories following the initiation of biologic therapy were identified. Further, we found differential associations of the genetic marker HLA-C*06:02 between our registry-identified trajectories.

CONCLUSIONS

These subgroups, defined by change in disease over time, may be indicative of distinct endotypes driven by different biological mechanisms and may help inform the management of patients with psoriasis. Future work will aim to further delineate these mechanisms by extensively characterizing the subgroups with additional molecular and pharmacological data.

Cost-effectiveness of intensive care for hospitalized COVID-19 patients: experience from South Africa

BACKGROUND

Given projected shortages of critical care capacity in public hospitals during the COVID-19 pandemic, the South African government embarked on an initiative to purchase this capacity from private hospitals. In order to inform purchasing decisions, we assessed the cost-effectiveness of intensive care management for admitted COVID-19 patients across the public and private health systems in South Africa.

METHODS

Using a modelling framework and health system perspective, costs and health outcomes of inpatient management of severe and critical COVID-19 patients in (1) general ward and intensive care (GW + ICU) versus (2) general ward only (GW) were assessed. Disability adjusted life years (DALYs) were evaluated and the cost per admission in public and private sectors was determined. The model made use of four variables: mortality rates, utilisation of inpatient days for each management approach, disability weights associated with severity of disease, and the unit cost per general ward day and per ICU day in public and private hospitals. Unit costs were multiplied by utilisation estimates to determine the cost per admission. DALYs were calculated as the sum of years of life lost (YLL) and years lived with disability (YLD). An incremental cost-effectiveness ratio (ICER) - representing difference in costs and health outcomes of the two management strategies - was compared to a cost-effectiveness threshold to determine the value for money of expansion in ICU services during COVID-19 surges.

RESULTS

A cost per admission of ZAR 75,127 was estimated for inpatient management of severe and critical COVID-19 patients in GW as opposed to ZAR 103,030 in GW + ICU. DALYs were 1.48 and 1.10 in GW versus GW + ICU, respectively. The ratio of difference in costs and health outcomes between the two management strategies produced an ICER of ZAR 73,091 per DALY averted, a value above the cost-effectiveness threshold of ZAR 38,465.

CONCLUSIONS

Results indicated that purchasing ICU capacity from the private sector during COVID-19 surges may not be a cost-effective investment. The 'real time', rapid, pragmatic, and transparent nature of this analysis demonstrates an approach for evidence generation for decision making relating to the COVID-19 pandemic response and South Africa's wider priority setting agenda.

P0956HOW DO MARKERS OF FRAILTY VARY ACROSS KIDNEY DISEASE TRAJECTORY? A MULTICENTRE CROSS-SECTIONAL STUDY OF 4736 PATIENTS

Background and Aims

Frailty is a complex health state of increased vulnerability to stressors and is common in those with chronic kidney disease (CKD). Frailty is strongly associated with progressive renal impairment and independently linked with adverse outcomes in all stages of CKD such as disability, falls, hospitalisation, and mortality. How frailty varies across the disease trajectory is not well-defined, particularly in those with early stages of disease. Identifying those with CKD who may be at risk of becoming frail could inform the early intervention and understanding how frailty changes across the disease spectrum may aid better future management of these patients.

Method

This is a secondary analysis of data of n=4736 CKD patients (42% female, mean age 59.7 (SD: 16.3) years) from a prospective observational study of physical activity behaviours. A modified assessment of frailty (based on the Fried phenotype model) was conducted across each of the CKD stages ((n=262 CKD stage 1/2, n=678 CKD stage 3, n=610 CKD stage 4/5, n=1094 haemodialysis (HD), n=177 peritoneal dialysis (PD), n=1915 transplant (TX)). Markers of frailty were defined as (1) poor endurance (defined as a VO2 peak of <20ml/kg/min estimated from the Duke Activity Index Scale); (2) low physical activity level (classified as ‘insufficiently active’ using General Practice Physical Activity Questionnaire); and (3) slowness (self-reported slow walking pace (less than 3mph)). Participants were classified as ‘frail’ if ≥2 markers were present. Frequency analysis and chi-squared tests were conducted to identify and compare patients with ≥2 markers of frailty across the disease trajectory. Binominal logistical regression was performed to determine which factors were associated with being frail.

Results

Across the total cohort, the majority (56%) of patients exhibited ≥2 markers of frailty. The presence of frailty increased concurrently with disease decline (39% CKD stage 1/2, 58% CKD stage 3, 74% CKD stage 4/5, 76% HD, 66% PD, 39% TX). The prevalence of frailty was significantly higher in patients in CKD stage 3, CKD stage 4/5, HD and PD patients when compared to CKD stage 1/2 and TX patients (p<.001). Frailty was significantly higher in patients in CKD stage 4/5 and on HD compared to those in CKD stage 3 (p<.001). Patients who were female (OR = 1.42 [1.23 to 1.65] p<.001), older (OR= 1.05 [1.05 to 1.06] p <.001), and of non-white ethnicity (OR = 2.41 [2.00 to 2.90] p<.001) had an increased likelihood of being frail. Increased number of comorbidities (OR = 1.26 [1.18 to 1.34] p<.001) were associated with an increased likelihood of being frail (Figure 1).

Conclusion

The proportion of patients with ≥2 markers of frailty increased with disease progression until it reached a peak in HD with almost 8 out of 10 HD patients exhibiting frailty. Frailty prevalence was reduced in those with a renal TX. Over half of those in CKD stage 3 and three-quarters with CKD stage 4/5 had ≥2 markers of frailty present. Worryingly, markers of frailty were present early in the disease process with over 1/3 of patients with CKD stage 1/2 classified as frail by this modified phenotype model. Age, sex, ethnicity, and number of comorbidities were associated with the likelihood of being frail. It is important that healthcare providers actively attempt to identify patients at risk of frailty to ensure appropriate interventions addressing risk factors that may exacerbate the progression of frailty can be implemented.

MO023SARCOPENIA, CHRONIC KIDNEY DISEASE AND RISK OF MORTALITY: FINDINGS FROM 426,839 INDIVIDUALS IN THE UK BIOBANK

Background and Aims

Sarcopenia describes a degenerative and generalised skeletal muscle disorder involving the loss of muscle mass and function. In studies of the general population, sarcopenia is associated with adverse outcomes including falls, functional decline, frailty, and mortality. However it remains an under-recognised yet important clinical problem in an ever-increasing ageing and multimorbid renal population. Whilst sarcopenia has been widely studied in end-stage renal disease, there is limited evidence of its prevalence and effects in those not requiring dialysis, particularly in large cohort studies and using the latest sarcopenia definitions. Using the UK Biobank, we aimed to identify the prevalence of sarcopenia in individuals with non-dialysis CKD and its association with mortality.

Method

426,839 participants were categorised into a CKD (defined as eGFR <60ml/min/1.73m2 not requiring dialysis) and a non-CKD comparative group (no evidence of CKD). Sarcopenia was diagnosed using criteria from the EWGSOP2: ‘probable sarcopenia’ (low handgrip strength (HGS) <27 and 16kg, males and females respectively); ‘confirmed sarcopenia’ (low HGS plus low muscle mass, appendicular lean mass <7.0 and 5.5 kg/m2 as measured by bioelectrical impedance); and ‘severe sarcopenia’ (low HGS and muscle mass plus slow gait speed). Patients requiring existing renal replacement therapy were excluded. All-cause mortality was extracted from data linkage to national death records with a median follow up of 9.0 years. Data were analysed using Cox survival models.

Results

CKD (non-dialysis dependent) was identified in n=7,623 individuals (mean age 62.7 (±5.9) years, 44% male, eGFR 52.5 (±7.7) ml/min/1.73m2) compared to n=419,216 in the non-CKD comparative group (mean age 56.1 (±8.1) years, 47% male). ‘Probable sarcopenia’ was identified in 9% of individuals with CKD compared to 5% in those without CKD (P<0.001). ‘Confirmed sarcopenia’ was observed in 0.3% of those with CKD (vs. 0.2% in the non-CKD group, P<0.001). 0.2% of CKD patients satisfied all three criteria (‘severe sarcopenia’) compared to 0.03% in those without CKD (P<0.001). In CKD, sarcopenia was significantly associated with all-cause mortality: ‘probable sarcopenia’, unadjusted hazard ratio (HR) 1.95 (95%CI 1.57 to 2.42), P<0.001 (Figure 1); ‘confirmed sarcopenia’, HR 5.1 (2.5 to 10.3) P<0.001; ‘severe sarcopenia’, HR 5.1 (1.9 to 13.5) P=0.001.

Conclusion

In the largest cohort of its kind, probable sarcopenia was present in 9% of individuals with non-dialysis CKD. The risk of sarcopenia was significantly higher in those with CKD than those without. Regardless of criteria used, CKD patients with sarcopenia were approximately 2-5 times more likely to die than those without sarcopenia. Worryingly, the risk of sarcopenia was elevated even in patients with early stage mild to moderate CKD. Our results show that sarcopenia, including just the presence of low muscle strength, is an important predictor of mortality in early non-dialysis CKD. Measuring sarcopenia as standard practice may identify those most at risk of future adverse events and in need of appropriate interventions to mitigate its negative effects.

P1851INCREASING CO-MORBIDITY REDUCES A PATIENT'S ABILITY TO SELF-MANAGE: AN OBSERVATIONAL STUDY IN NON-DIALYSIS CKD PATIENTS

Background and Aims

Co-morbidity is high in CKD patients and associated with greater mortality and disease burden. Increased burden from other health conditions, as well as CKD, may impact the successful self-management of a patient’s health. A patient’s perceived ability to self-manage their condition can be assessed through the concept of ‘Patient Activation (PA)’ which encompasses a patient’s knowledge, skills, and confidence to undertake self-management tasks. Low PA is associated with poor self-reported health, greater renal impairment, and increased hospitalisation rates. Understanding PA may help the development and initiation of self-management interventions (e.g., low ‘activated’ individuals may require further education on their condition(s) whilst high ‘activated’ patients may require better support in maintaining their current lifestyle). This study aimed to assess how co-morbidity may influence PA and sought to identify which conditions, in exception to CKD, impact PA the most. This may help identify how co-morbidities affect patient’s ability self-manage successfully and aid the development of individualised intervention.

Method

The Patient Activation Measure (PAM), a validated 13 item questionnaire, assessed patient activation by measuring patients perceived ability to self-manage their condition. Results categorise participants into four activation categories (1 to 4; low to high). 152 non-dialysis CKD patients (52.6% female, age 67.9 (SD:12.7) years, eGFR 42.2 (SD:18.6) ml/min) provided self-reported information about their co-morbidities, and completed the PAM. Data was analysed by general linear modelling adjusting for age, sex and eGFR.

Results

134/152 (88.2%) of patients were multi-morbid, defined as 2 or more conditions including CKD, with a mean of 2.1 (SD:1.4) comorbidities. Increasing co-morbidities were associated with reduced PAM score (p=0.009). PAM scores decreased from 67.96 (SE:3.68) in patients with no other co-morbidities to 55.57 (SE:2.81) with 4+ co-morbidities; a reduction from PA level 4 (high) to 2 (low) respectively. The co-morbidities which explained the largest variance in PAM score were diabetes (β=-.193, p=.021), respiratory conditions (β=-.184, p=.37), and MSK conditions (β=-.154, p=.081). No other conditions were predictive of PAM score.

Conclusion

Co-morbidity in non-dialysis CKD patients is high and is associated with reduced PA (i.e. the perceived ability of patients to self-manage their condition(s)). We identified that CKD patients with diabetes, respiratory, and musculoskeletal conditions found it more difficult to self-manage their co-existing conditions. Individuals with musculoskeletal or respiratory conditions may perceive poor self-management ability due to this conditions impact on function (e.g. physical activity limitations) and/or quality of life (e.g. symptoms or sleep). Diabetes could challenge perceived self-management ability due to its chronicity, management complexity (e.g. medication regimens and side effects) and demoralising health sequelae (e.g. cardiovascular risk).

P0269SYMPTOM-BURDEN IN PEOPLE LIVING WITH FRAILTY AND CHRONIC KIDNEY DISEASE

Background and Aims

Patients with chronic kidney disease (CKD) report high symptom-burden that adversely affects health-related quality of life (HRQOL). Frailty is an independent predictor of poor HRQOL in those with CKD.

Although there is a clear relationship between frailty and HRQOL in patients with CKD, the associated relationship with symptom experience is not well understood. Understanding how living with both frailty and CKD influences symptom-burden could inform management strategies that improve HRQOL of this vulnerable patient group. This study’s aim was to evaluate the symptom experience of patients living with frailty and CKD.

Methods

A total of 353 participants were recruited between February 2018 and October 2018 to this cross-sectional observational study. Participants completed physical activity (GP Physical Activity Questionnaire [GPPAQ]), cardiopulmonary fitness (Duke Activity Status Index, providing estimated VO2 peak), symptom-burden (Kidney Symptom Questionnaire [KSQ]) and HRQOL (Short Form 12 [SF-12]) questionnaires. Frailty was assessed using a modified Frailty Phenotype comprising 3 self-report components:

1) weakness/slowness defined as a SF-12 Physical Functioning score <75; 2) low physical activity defined as ‘inactive’ by the GPPAQ; and 3) exhaustion defined as a SF-12 Vitality score <55. Participants were categorised as frail if ≥2 components were present. Multiple imputation was performed for data considered to be either missing completely at random or missing at random. Regression analyses were used to assess the association between frailty, symptom-burden and HRQOL. Principal Component Analysis (PCA) was performed to explore symptom clusters experienced by non-frail and frail participants.

Results

Two hundred and twenty-five (64%) participants were categorised as frail. Frail participants were significantly older (77.7 vs. 71.5 years, p<0.001) and had a significantly lower eGFR (45.8 vs. 50.9 mL/min/1.73m2, p<0.001), albumin concentration (39.2 vs. 41.4 g/L, p<0.001) and estimated VO2 peak (21.7 vs. 33.9 mL/kg/min, p<0.001) than non-frail participants. Frailty, when adjusted for age, sex, eGFR and haemoglobin, was independently associated with higher KSQ total symptom score (p<0.001) and lower SF-12 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores (p<0.001 and p=0.001, respectively). Lower eGFR was associated with higher KSQ total symptom score (p=0.004) and lower SF-12 PCS score (p=0.01). Frailty, when adjusted for age, sex, eGFR and haemoglobin, was independently associated with a two- to over five-fold increase in odds of experiencing all reported symptoms frequently, except loss of appetite and urinary frequency. Lower eGFR was only associated with increased odds of reporting frequent loss of muscle strength (p=0.04). PCA revealed two symptom clusters for non-frail participants and three symptom clusters for frail participants. Both non-frail and frail participants had symptom clusters associated with sleep disturbance and musculoskeletal symptoms. There was an additional unique symptom cluster (comprising loss of appetite, tiredness, feeling cold and poor concentration) experienced by frail participants.

Conclusion

Frailty is an independent predictor of high symptom-burden and poor HRQOL. Furthermore, symptom experience for people living with frailty and CKD is distinct from non-frail individuals, reporting a unique symptom cluster that may be a consequence of the frailty syndrome itself. This group of patients should be offered a holistic assessment so that problematic symptoms can be identified and addressed early before they impact more significantly on HRQOL. Future efforts should be focused on evaluating holistic models of care, such as the comprehensive geriatric assessment, for patients living with frailty and CKD.

The Secure Anonymised Information Linkage databank Dementia e-cohort (SAIL-DeC)

Introduction

The rising burden of dementia is a global concern, and there is a need to study its causes, natural history and outcomes. The Secure Anonymised Information Linkage (SAIL) Databank contains anonymised, routinely-collected healthcare data for the population of Wales, UK. It has potential to be a valuable resource for dementia research owing to its size, long follow-up time and prospective collection of data during clinical care.

Objectives

We aimed to apply reproducible methods to create the SAIL dementia e-cohort (SAIL-DeC). We created SAIL-DeC with a view to maximising its utility for a broad range of research questions whilst minimising duplication of effort for researchers.

Methods

SAIL contains individual-level, linked primary care, hospital admission, mortality and demographic data. Data are currently available until 2018 and future updates will extend participant follow-up time. We included participants who were born between 1st January 1900 and 1st January 1958 and for whom primary care data were available. We applied algorithms consisting of International Classification of Diseases (versions 9 and 10) and Read (version 2) codes to identify participants with and without all-cause dementia and dementia subtypes. We also created derived variables for comorbidities and risk factors.

Results

From 4.4 million unique participants in SAIL, 1.2 million met the cohort inclusion criteria, resulting in 18.8 million person-years of follow-up. Of these, 129,650 (10%) developed all-cause dementia, with 77,978 (60%) having dementia subtype codes. Alzheimer's disease was the most common subtype diagnosis (62%). Among the dementia cases, the median duration of observation time was 14 years.

Conclusion

We have created a generalisable, national dementia e-cohort, aimed at facilitating epidemiological dementia research.

Building toolkits for COPD exacerbations: lessons from the past and present

In the nineteenth century, it was recognised that acute attacks of chronic bronchitis were harmful. 140 years later, it is clearer than ever that exacerbations of chronic obstructive pulmonary disease (ECOPD) are important events. They are associated with significant mortality, morbidity, a reduced quality of life and an increasing reliance on social care. ECOPD are common and are increasing in prevalence. Exacerbations beget exacerbations, with up to a quarter of in-patient episodes ending with readmission to hospital within 30 days. The healthcare costs are immense. Yet despite this, the tools available to diagnose and treat ECOPD are essentially unchanged, with the last new intervention (non-invasive ventilation) introduced over 25 years ago.An ECOPD is 'an acute worsening of respiratory symptoms that results in additional therapy'. This symptom and healthcare utility-based definition does not describe pathology and is unable to differentiate from other causes of an acute deterioration in breathlessness with or without a cough and sputum. There is limited understanding of the host immune response during an acute event and no reliable and readily available means to identify aetiology or direct treatment at the point of care (POC). Corticosteroids, short acting bronchodilators with or without antibiotics have been the mainstay of treatment for over 30 years. This is in stark contrast to many other acute presentations of chronic illness, where specific biomarkers and mechanistic understanding has revolutionised care pathways. So why has progress been so slow in ECOPD? This review examines the history of diagnosing and treating ECOPD. It suggests that to move forward, there needs to be an acceptance that not all exacerbations are alike (just as not all COPD is alike) and that clinical presentation alone cannot identify aetiology or stratify treatment.

Adherence to the iDSI reference case among published cost-per-DALY averted studies

BACKGROUND

The iDSI reference case, originally published in 2014, aims to improve the quality and comparability of cost-effectiveness analyses (CEA). This study assesses whether the development of the guideline is associated with an improvement in methodological and reporting practices for CEAs using disability-adjusted life-years (DALYs).

METHODS

We analyzed the Tufts Medical Center Global Health CEA Registry to identify cost-per-DALY averted studies published from 2011 to 2017. Among each of 11 principles in the iDSI reference case, we translated all methodological specifications and reporting standards into a series of binary questions (satisfied or not satisfied) and awarded articles one point for each item satisfied. We then calculated methodological and reporting adherence scores separately as a percentage of total possible points, measured as normalized adherence score (0% = no adherence; 100% = full adherence). Using the year 2014 as the dissemination period, we conducted a pre-post analysis. We also conducted sensitivity analyses using: 1) optional criteria in scoring, 2) alternate dissemination period (2014-2015), and 3) alternative comparator classification.

RESULTS

Articles averaged 60% adherence to methodological specifications and 74% adherence to reporting standards. While methodological adherence scores did not significantly improve (59% pre-2014 vs. 60% post-2014, p = 0.53), reporting adherence scores increased slightly over time (72% pre-2014 vs. 75% post-2014, p<0.01). Overall, reporting adherence scores exceeded methodological adherence scores (74% vs. 60%, p<0.001). Articles seldom addressed budget impact (9% reporting, 10% methodological) or equity (7% reporting, 7% methodological).

CONCLUSIONS

The iDSI reference case has substantial potential to serve as a useful resource for researchers and policy-makers in global health settings, but greater effort to promote adherence and awareness is needed to achieve its potential.

Do dental undergraduates think that Thiel-embalmed cadavers are a more realistic model for teaching exodontia?

INTRODUCTION

Teaching exodontia to novice undergraduates requires a realistic model. Thiel-embalmed cadavers retain the flexibility of the soft tissues and could be used to teach exodontia.

OBJECTIVE

The objective was to determine whether Thiel-embalmed cadavers were perceived to be a more realistic model by undergraduates in comparison with mannequins.

MATERIALS AND METHODS

Over a period of 4 years (2011-2014), students were randomly assigned into two groups: those taught exodontia on mannequins only (NT) and those who also experienced cadaveric teaching (T). This was followed by an assessment.

RESULTS

There were 174 students in the T group and 108 in the NT group. Sixty-five per cent of the T group and 69% of the NT group provided feedback. Ninety-eight per cent (98%) felt that they had been advantaged by being included in the group compared with 95% in the NT who felt disadvantaged. The majority (98%) thought that using the cadavers was advantageous and gave a realistic feel for soft tissue management (89%) and that it was similar to managing a patient (81%). Self-reported confidence in undertaking an extraction was not different between the two groups (P=.078), and performance in the extraction assessment was not significantly different between the two groups over the 4 years (P=.8).

CONCLUSION

The Thiel-embalmed cadavers were well received by the students who found it a more realistic model for exodontia than a mannequin, even though this did not impact on their performance in a following assessment. Future work on these cadavers may be expanded to include surgical procedures.

Strengthening health technology assessment systems in the global south: a comparative analysis of the HTA journeys of China, India and South Africa

BACKGROUND

Resource allocation in health is universally challenging, but especially so in resource-constrained contexts in the Global South. Pursuing a strategy of evidence-based decision-making and using tools such as Health Technology Assessment (HTA), can help address issues relating to both affordability and equity when allocating resources. Three BRICS and Global South countries, China, India and South Africa have committed to strengthening HTA capacity and developing their domestic HTA systems, with the goal of getting evidence translated into policy. Through assessing and comparing the HTA journey of each country it may be possible to identify common problems and shareable insights.

OBJECTIVES

This collaborative paper aimed to share knowledge on strengthening HTA systems to enable enhanced evidence-based decision-making in the Global South by: Identifying common barriers and enablers in three BRICS countries in the Global South; and Exploring how South-South collaboration can strengthen HTA capacity and utilisation for better healthcare decision-making.

METHODS

A descriptive and explorative comparative analysis was conducted comprising a Within-Case analysis to produce a narrative of the HTA journey in each country and an Across-Case analysis to explore both knowledge that could be shared and any potential knowledge gaps.

RESULTS

Analyses revealed that China, India and South Africa share many barriers to strengthening and developing HTA systems such as: (1) Minimal HTA expertise; (2) Weak health data infrastructure; (3) Rising healthcare costs; (4) Fragmented healthcare systems; and (5) Significant growth in non-communicable diseases. Stakeholder engagement and institutionalisation of HTA were identified as two conducive factors for strengthening HTA systems.

CONCLUSION

China, India and South Africa have all committed to establishing robust HTA systems to inform evidence-based priority setting and have experienced similar challenges. Engagement among countries of the Global South can provide a supportive platform to share knowledge that is more applicable and pragmatic.

Economic Evaluation in Ethiopian Healthcare Sector Decision Making: Perception, Practice and Barriers

BACKGROUND

Globally, economic evaluation (EE) is increasingly being considered as a critical tool for allocating scarce healthcare resources. However, such considerations are less documented in low-income countries, such as in Ethiopia. In particular, to date there has been no assessment conducted to evaluate the perception and practice of and barriers to health EE.

OBJECTIVE

This paper assesses the use and perceptions of EE in healthcare decision-making processes in Ethiopia.

METHODS

In-depth interview sessions with decision makers/healthcare managers and program coordinators across six regional health bureaus were conducted. A qualitative analysis approach was conducted on three thematic areas.

RESULTS

A total of 57 decision makers/healthcare managers were interviewed from all tiers of the health sector in Ethiopia, ranging from the Federal Ministry of Health down to the lower levels of the health facility pyramid. At the high-level healthcare decision-making tier, only 56 % of those interviewed showed a good understanding of EE when explaining in terms of cost and consequences of alternative courses of action and value for money. From the specific program perspective, 50 % of the prevention of mother-to-child transmission of HIV/AIDS program coordinators indicated the relevance of EE to program planning and decision making. These respondents reported a limited application of costing studies on the HIV/AIDS prevention and control program, which were most commonly used during annual planning and budgeting.

CONCLUSION

The study uncovered three important barriers to growth of EE in Ethiopia: a lack of awareness, a lack of expertise and skill, and the traditional decision-making culture.

Strengthening expertise for health technology assessment and priority-setting in Africa

BACKGROUND

Achieving sustainable universal health coverage depends partly on fair priority-setting processes that ensure countries spend scarce resources wisely. While general health economics capacity-strengthening initiatives exist in Africa, less attention has been paid to developing the capacity of individuals, institutions and networks to apply economic evaluation in support of health technology assessment and effective priority-setting.

OBJECTIVE

On the basis of international  lessons, to identify how research organisations and partnerships could contribute to capacity strengthening for health technology assessment and priority-setting in Africa.

METHODS

A rapid scan was conducted of international formal and grey literature and lessons extracted from the deliberations of two international and regional workshops relating to capacity-building for health technology assessment. 'Capacity' was defined in broad terms, including a conducive political environment, strong public institutional capacity to drive priority-setting, effective networking between experts, strong research organisations and skilled researchers.

RESULTS

Effective priority-setting requires more than high quality economic research. Researchers have to engage with an array of stakeholders, network closely other research organisations, build partnerships with different levels of government and train the future generation of researchers and policy-makers. In low- and middle-income countries where there are seldom government units or agencies dedicated to health technology assessment, they also have to support the development of an effective priority-setting process that is sensitive to societal and government needs and priorities.

CONCLUSIONS

Research organisations have an important role to play in contributing to the development of health technology assessment and priority-setting capacity. In Africa, where there are resource and capacity challenges, effective partnerships between local and international researchers, and with key government stakeholders, can leverage existing skills and knowledge to generate a critical mass of individuals and institutions. These would help to meet the priority-setting needs of African countries and contribute to sustainable universal health coverage.

Structural Characterisation Reveals Mechanism of IL-13-Neutralising Monoclonal Antibody Tralokinumab as Inhibition of Binding to IL-13Rα1 and IL-13Rα2

Interleukin (IL)-13 is a pleiotropic T helper type 2 cytokine frequently associated with asthma and atopic dermatitis. IL-13-mediated signalling is initiated by binding to IL-13Rα1, which then recruits IL-4Rα to form a heterodimeric receptor complex. IL-13 also binds to IL-13Rα2, considered as either a decoy or a key mediator of fibrosis. IL-13-neutralising antibodies act by preventing IL-13 binding to IL-13Rα1, IL-4Rα and/or IL-13Rα2. Tralokinumab (CAT-354) is an IL-13-neutralising human IgG4 monoclonal antibody that has shown clinical benefit in patients with asthma. To decipher how tralokinumab inhibits the effects of IL-13, we determined the structure of tralokinumab Fab in complex with human IL-13 to 2 Å resolution. The structure analysis reveals that tralokinumab prevents IL-13 from binding to both IL-13Rα1 and IL-13Rα2. This is supported by biochemical ligand-receptor interaction assay data. The tralokinumab epitope is mainly composed of residues in helices D and A of IL-13. It is mostly light chain complementarity-determining regions that are driving paratope interactions; the variable light complementarity-determining region 2 plays a key role by providing residue contacts for a network of hydrogen bonds and a salt bridge in the core of binding. The key residues within the paratope contributing to binding were identified as Asp50, Asp51, Ser30 and Lys31. This study demonstrates that tralokinumab prevents the IL-13 pharmacodynamic effect by binding to IL-13 helices A and D, thus preventing IL-13 from interacting with IL-13Rα1 and IL-13Rα2.

The International Decision Support Initiative Reference Case for Economic Evaluation: An Aid to Thought

BACKGROUND

Policymakers in high-, low-, and middle-income countries alike face challenging choices about resource allocation in health. Economic evaluation can be useful in providing decision makers with the best evidence of the anticipated benefits of new investments, as well as their expected opportunity costs-the benefits forgone of the options not chosen. To guide the decisions of health systems effectively, it is important that the methods of economic evaluation are founded on clear principles, are applied systematically, and are appropriate to the decision problems they seek to inform.

METHODS

The Bill and Melinda Gates Foundation, a major funder of economic evaluations of health technologies in low- and middle-income countries (LMICs), commissioned a "reference case" through the International Decision Support Initiative (iDSI) to guide future evaluations, and improve both the consistency and usefulness to decision makers.

RESULTS

The iDSI Reference Case draws on previous insights from the World Health Organization, the US Panel on Cost-Effectiveness in Health Care, and the UK National Institute for Health and Care Excellence. Comprising 11 key principles, each accompanied by methodological specifications and reporting standards, the iDSI Reference Case also serves as a means of identifying priorities for methods research, and can be used as a framework for capacity building and technical assistance in LMICs.

CONCLUSIONS

The iDSI Reference Case is an aid to thought, not a substitute for it, and should not be followed slavishly without regard to context, culture, or history. This article presents the iDSI Reference Case and discusses the rationale, approach, components, and application in LMICs.