Search

Background: Cost effectiveness analyses (CEAs) are widely used to evaluate the opportunity cost of health care investments. However, few functions that take equity concerns into account are available for such CEA methods, and these concerns are therefore at risk of being disregarded. Among the functions that have been developed, most focus on the distribution of health gains, as opposed to the distribution of lifetime health. This is despite the fact that there are good reasons to give higher priority to individuals and groups with a low quality adjusted life expectancy from birth (QALE). Also, an even distribution of health gains may imply an uneven distribution of lifetime health. Methods: We develop a systematic and explicit approach that allows for the inclusion of lifetime health concerns in CEAs, by creating a new priority weight function, PW = α+(t-γ)·C·e-β·(t-γ), where t is the health measure. PW has several desirable properties. First, it is continuous and smooth, ensuring that people with similar health characteristics are treated alike. For example, those who achieve 50 QALE should be treated similarly to those who achieve 49.9 QALE. Second, it is flexible regarding shape and outcome measure (i.e., caters to other measures than QALE), so that a broad range of values may be modelled. Third, the coefficients have distinct roles. This allows for the easy manipulation of the PW's shape. In order to demonstrate how PW may be applied, we use data from a previous study and estimated the coefficients of PW based on two approaches. Conclusions: Equity concerns are important when conducting CEAs, which means that suitable PWs should be developed. We do not intend to determine which PW is the most appropriate, but to illustrate how a flexible general PW can be estimated based on empirical data. [ABSTRACT FROM AUTHOR]

Objective: We examined the incremental cost-effectiveness between two mHealth programs, implemented from 2011 to 2015 in rural Bangladesh: (1) Comprehensive mCARE package as an intervention group and (2) Basic mCARE package as a control group. Methods: Both programs included a core package of census enumeration and pregnancy surveillance provided by an established cadre of digitally enabled community health workers (CHWs). In the comprehensive mCARE package, short message service (SMS) and home visit reminders were additionally sent to pregnant women (n = 610) and CHWs (n = 70) to promote the pregnant women’s care-seeking of essential maternal and newborn care services. Economic costs were assessed from a program perspective inclusive of development, start-up, and implementation phases. Effects were calculated as disability adjusted life years (DALYs) and the number of newborn deaths averted. For comparative purposes, we normalized our evaluation to estimate total costs and total newborn deaths averted per 1 million people in a community for both groups. Uncertainty was assessed using probabilistic sensitivity analyses with Monte Carlo simulation. Results: The addition of SMS and home visit reminders based on a mobile phone-facilitated pregnancy surveillance system was highly cost effective at a cost per DALY averted of $31 (95% uncertainty range: $19–81). The comprehensive mCARE program had at least 88% probability of being highly cost-effective as compared to the basic mCARE program based on the threshold of Bangladesh’s GDP per capita. Conclusion: mHealth strategies such as SMS and home visit reminders on a well-established pregnancy surveillance system may improve service utilization and program cost-effectiveness in low-resource settings. [ABSTRACT FROM AUTHOR]

Background: Repetitive transcranial magnetic stimulation (rTMS) is an evidence-based treatment for depression that is increasingly implemented in healthcare systems across the world. A new form of rTMS called intermittent theta burst stimulation (iTBS) can be delivered in 3 min and has demonstrated comparable effectiveness to the conventional 37.5 min 10Hz rTMS protocol in patients with depression. Objectives: To compare the direct treatment costs per course and per remission for iTBS compared to 10Hz rTMS treatment in depression. Methods: We conducted a cost analysis from a healthcare system perspective using patient-level data from a large randomized non-inferiority trial (THREE-D). Depressed adults 18 to 65 received either 10Hz rTMS or iTBS treatment. Treatment costs were calculated using direct healthcare costs associated with equipment, coils, physician assessments and technician time over the course of treatment. Cost per remission was estimated using the proportion of patients achieving remission following treatment. Deterministic sensitivity analyses and non-parametric bootstrapping was used to estimate uncertainty. Results: From a healthcare system perspective, the average cost per patient was USD$1,108 (SD 166) for a course of iTBS and $1,844 (SD 304) for 10Hz rTMS, with an incremental net savings of $735 (95% CI 688 to 783). The average cost per remission was $3,695 (SD 552) for iTBS and $6,146 (SD 1,015) for 10Hz rTMS, with an average incremental net savings of $2,451 (95% CI 2,293 to 2,610). Conclusions: The shorter session durations and treatment capacity increase associated with 3 min iTBS translate into significant cost-savings per patient and per remission when compared to 10Hz rTMS. [ABSTRACT FROM AUTHOR]

Background: Indonesia has one of the fastest growing HIV epidemics in Asia, which mainly concentrates within risk groups. Several strategies are available to combat this epidemic, like outreach to Men who have Sex with Men (MSM) and transgender, Harm Reduction Community Meetings (HRCMs) for Injecting Drug Users (IDUs), and Information, Education and Communication (IEC) programs at Maternal & Child Health Posts (MCHPs). Reliable cost data are currently not present, hampering HIV/AIDS priority setting. The aim of this study thus is to assess the societal costs of outreach programs to MSM and transgender, HRCMs for IDUs and IEC at MCHPs in Bandung, Indonesia in 2016. Methods: The societal costs were collected in Bandung from April until May 2017. Health care costs were collected by interviewing stakeholders, using a micro-costing approach. Non-health care costs were determined by conducting surveys within the target groups of the interventions. Results: The societal costs of the outreach program were US$ 347,199.03 in 2016 and US$ 73.72 per reached individual. Moreover, the cost of HRCM for IDUs were US$ 48,618.31 in 2016 and US$ 365.55 per community meeting. For the IEC program at MCHPs, US$ 337.13 was paid in 2016 and the cost per visitor were US$ 0.51. Conclusion: This study provides valuable insights in the costs of outreach to MSM and transgender, HRCMs for IDUs and IEC at MCHPs. Policy makers can use these results in setting priorities within Indonesia. Data on effectiveness of interventions is necessary to make conclusive statements regarding cost-effectiveness and priority of interventions. [ABSTRACT FROM AUTHOR]

Background: Day care services aim to offer meaningful activities and a safe environment for the attendees and a respite for family caregivers while being cost effective. This study compares the use of formal and informal care in users and non-users of day care centres designed for persons with dementia. Method: Users of day care designed for dementia (DC group) and non-users (NDC group) were followed over a period of 24 months or until nursing home admission (NHA) respectively death. Demographic and clinical characteristics were collected at baseline and after 12 and 24 months. The use of care was recorded by Resource Utilization in Dementia (RUD). Results: A total of 257 persons with dementia participated in the study, 181 in the DC group and 76 in the NDC group. Users of day care centres cause higher costs due to the expenses for day care, while neither the use of home nursing, secondary care, informal care nor the time until NHA did show any differences between users and non-users. The overall costs were higher in the DC group at baseline and after 12 months, but this difference was no longer present at the end of the two-year study period. Conclusion: Our results indicate no potential cost-saving effect of day care designed for people with dementia, as the use of day care did neither result in a reduced use of care nor in a delay of NHA. Future research should balance the non-monetary benefits of day care against its costs for a full cost-effectiveness analysis, most favourable in a RCT-design. [ABSTRACT FROM AUTHOR]

Background: The efficacy and safety of antibiotic treatment for uncomplicated acute appendicitis has been established at long-term follow-up with the majority of recurrences shown to occur within the first year. Overall costs of antibiotics are significantly lower compared with appendectomy at short-term follow-up, but long-term durability of these cost savings is unclear. The study objective was to compare the long-term overall costs of antibiotic therapy versus appendectomy in the treatment of uncomplicated acute appendicitis in the APPAC (APPendicitis ACuta) trial at 5 years. Methods and findings: This multicentre, non-inferiority randomized clinical trial randomly assigned 530 adult patients with CT-confirmed uncomplicated acute appendicitis to appendectomy or antibiotic treatment at six Finnish hospitals. All major costs during the 5-year follow-up were recorded, whether generated by the initial visit and subsequent treatment or possible recurrent appendicitis. Between November 2009 and June 2012, 273 patients were randomized to appendectomy and 257 to antibiotics. The overall costs of appendectomy were 1.4 times higher (p<0.001) (€5716; 95% CI: €5510 to €5925) compared with antibiotic therapy (€4171; 95% CI: €3879 to €4463) resulting in cost savings of €1545 per patient (95% CI: €1193 to €1899; p<0.001) in the antibiotic group. At 5 years, the majority (61%, n = 156) of antibiotic group patients did not undergo appendectomy. Conclusions: At 5-year follow-up antibiotic treatment resulted in significantly lower overall costs compared with appendectomy. As the majority of appendicitis recurrences occur within the first year after the initial antibiotic treatment, these results suggest that treating uncomplicated acute appendicitis with antibiotics instead of appendectomy results in lower overall costs even at longer-term follow-up. [ABSTRACT FROM AUTHOR]

Background: Hepatitis B is a viral infection requiring specific serologic testing to diagnose the stage of the disease. There are many tests which can be ordered in a variety of combinations. This study aimed to assess routine Hepatitis B screening practices in a tertiary care centre and determine the diagnostic and economic benefits of protocolized ordering. Methods: We evaluated all measurements of Hepatitis B total core antibodies, core IgM antibodies, surface antibodies and surface antigens performed at our institution between January 1, 2015 and December 31, 2015. We also recorded secondary testing (envelope antigens and antibodies, and viral DNA). Costs were estimated using provincial insurance reimbursement values. Using the subset of patients who received complete testing, we developed a reflexive screening protocol to minimize costs while simultaneously improving diagnostic utility. Results: 30,335 hepatitis B tests were performed at an estimated total cost of $584,683. 53.9% of patients were screened with a single test. 29% of patients who received secondary testing had no evidence of exposure on primary testing. Using the protocol of initial testing of total core antibody and surface antibody with reflexive testing, we would save an estimated $181,632 (95% CI $154,201.90 –$208,910.50) per year while providing more complete information. Interpretation: Screening practices for Hepatitis B are frequently inadequate to diagnose and stage the infection and often included unnecessary testing. Protocolization of Hepatitis B testing could limit this practice while resulting in significantly lower costs. [ABSTRACT FROM AUTHOR]

Background: Drug resistant-tuberculosis is a growing burden on the South African health care budget. In response the National Department of Health implemented two important strategies in 2011; universal access to drug-sensitivity testing for rifampicin with Xpert MTB/RIF as the first-line diagnostic test for TB; and decentralization of treatment for RR/MDR-TB to improve access and reduce costs of treatment. Objective: Estimate the costs by treatment outcome of decentralized care for rifampicin and multi-drug resistant tuberculosis under routine conditions. The study was set at an outpatient drug resistant-tuberculosis treatment facility at a public academic hospital in Johannesburg, South Africa. During the study period 18–24 month long course treatment was offered for rifampicin-resistant and multi-drug-resistant tuberculosis. Methods: Data are from a prospective observational cohort study. Costs of treatment were estimated from the provider perspective using bottom-up micro-costing. Costs were estimated as patient-level resource use multiplied by the unit cost of the resource. Clinic visits, drugs, laboratory tests, and total days hospitalized were collected from patients' medical records. Staff time was estimated through a time and motion study. A successful treatment outcome was defined as cure or completion of the regimen. Results: We enrolled 124 patients with 52% having a successful outcome. The average total cost/patient for all patients was $3,430 and $4,530 for successfully treated patients. The largest contributors to total cost across all outcomes were drugs (43%) and staff (28%). The average cost to achieve a successful outcome including all patients who started treatment ("production cost") in the cohort is $6,684. Conclusions: Decentralized, outpatient RR/MDR-TB care under South Africa's 2011 strategy costs 74% less per patient than the previous strategy of inpatient care. The treatment cost of RR/MDR-TB is primarily driven by drug and staff costs, which are in turn dependant on treatment length. [ABSTRACT FROM AUTHOR]

Introduction: In 2016, for the very first time, the Ministry of Health in Zambia implemented a reactive outbreak response to control the spread of cholera and vaccinated at-risk populations with a single dose of Shancol—an oral cholera vaccine (OCV). This study aimed to assess the costs of cholera illness and determine the cost-effectiveness of the 2016 vaccination campaign. Methodology: From April to June 2017, we conducted a retrospective cost and cost-effectiveness analysis in three peri-urban areas of Lusaka. To estimate costs of illness from a household perspective, a systematic random sample of 189 in-patients confirmed with V. cholera were identified from Cholera Treatment Centre registers and interviewed for out-of-pocket costs. Vaccine delivery and health systems costs were extracted from financial records at the District Health Office and health facilities. The cost of cholera treatment was derived by multiplying the subsidized cost of drugs by the quantity administered to patients during hospitalisation. The cost-effectiveness analysis measured incremental cost-effectiveness ratio—cost per case averted, cost per life saved and cost per DALY averted—for a single dose OCV. Results: The mean cost per administered vaccine was US$1.72. Treatment costs per hospitalized episode were US$14.49–US$18.03 for patients ≤15 years old and US$17.66–US$35.16 for older patients. Whereas households incurred costs on non-medical items such as communication, beverages, food and transport during illness, a large proportion of medical costs were borne by the health system. Assuming vaccine effectiveness of 88.9% and 63%, a life expectancy of 62 years and Gross Domestic Product (GDP) per capita of US$1,500, the costs per case averted were estimated US$369–US$532. Costs per life year saved ranged from US$18,515–US$27,976. The total cost per DALY averted was estimated between US$698–US$1,006 for patients ≤15 years old and US$666–US$1,000 for older patients. Conclusion: Our study determined that reactive vaccination campaign with a single dose of Shancol for cholera control in densely populated areas of Lusaka was cost-effective. [ABSTRACT FROM AUTHOR]

Background: In South Africa, 600–700 new cases of paediatric cancers have been reported every year for the past 25 years, and in the year 2000, HIV/AIDS was responsible for 42,479 deaths in children under five. These children need intermediate care but research in the field is lacking, with the few costing studies conducted in South Africa reporting a range of inpatient day costs. Methods: A retrospective cost analysis for the period April 2014-March 2015 was undertaken from the provider perspective in the public sector, using a step down costing approach. Costs of paediatric intermediate care were estimated for an intermediate care facility (ICF) and a tertiary hospital in Cape Town. Costs were inflated to 2016 prices and reported in US dollars. Results: Cost per inpatient day was $713.09 at the hospital and $695.17 at the ICF for any child requiring care at these institutions. The cost for a paediatric patient who is HIV/TB co-infected was $7 130.94 and $6 951.67 at the hospital and ICF respectively, assuming an average length of stay of 10 days. For a patient with terminal brain carcinoma the cost was $19 966.63 and $19 464.69 at the hospital and ICF respectively, assuming an average length of stay of 28 days. Personnel costs accounted for 60% and 17% of the total cost at the hospital and ICF respectively. Overhead costs accounted for 12.33% at the ICF and 4.48% at the hospital. Conclusions: The drivers of cost are not uniform across settings. Providing intermediate care at an ICF could be less costly than providing this care at a hospital, however more in-depth analysis is needed. The costs presented in this study were considerably higher than those found in other studies, however, the paucity of cost data available in this area makes comparisons difficult. [ABSTRACT FROM AUTHOR]

Introduction: Health interventions implemented with self-help groups (SHGs) enhance the relevance and acceptability of the health services. The Parivartan program was implemented in eight districts of Bihar with women’s self-help groups to increase adoption of maternal and newborn health behaviors through layering health behavior change communication. This study estimates the cost and cost-effectiveness of a health behavior change program with SHGs in Bihar. Methods: Cost analysis was conducted from a provider’s perspective. All costs have been presented in US dollars for the purpose of international comparisons and converted to constant values. The effectiveness estimate was based on the reported changes in select newborn care practices. A decision model approach was used to estimate the potential number of neonatal deaths averted based on adoption of key newborn care practices. Using India’s life expectancy of 65 years, cost per life year saved was calculated. A one-way sensitivity analysis was conducted using the upper and lower estimates for various variables in the model, and functionality of SHGs. Results: The cost of forming an SHG group was US$254 and that of reaching a woman within the group was US$19. The unit cost for delivering health interventions through the Parivartan program was US$148 per group and US$11 per woman reached. During an 18 months period, Parivartan program reached around 17,120 SHGs and an estimated 20,544 pregnant women resulting in an estimated prevention of 23 neonatal deaths at a cost of US$3,825 per life year saved. Conclusion: SHGs can be an effective platform to increase uptake of women’s health interventions and follow-up care, and also to broaden their utility beyond microfinance, particularly when they operate at a larger scale. [ABSTRACT FROM AUTHOR]

Background: The objective of the present study was to evaluate effectiveness, complications and cost-effectiveness of any surgical or non-surgical treatment for radius or ulna fractures in elderly patients. Secondary objectives were to analyze present treatment traditions of distal radius fractures (DRF) in Sweden and to calculate resource usage for its treatment. Methods and findings: The assessment contains a systematic review of clinical and health economic studies comparing treatment options for radius or ulna fractures. The results regarding the effectiveness of the treatments are summarized in meta-analyses. In addition, the assessment contains a cost analysis for different treatment options commonly used for DRF care, and an analysis of registry data on the incidence and treatment of DRF. In total 31 randomized controlled trials were included in meta-analyses. When comparing functional outcome for plate fixation versus non-surgical treatment for DRF, there were no clinically important differences at one-year follow-up (mean difference [MD], -3.29, 95% CI, -7.03; 0.44). Similar results were found when comparing plating and percutaneous methods with respect to functional outcome (standardized mean difference [SMD], -0.07, 95% CI, -0.21; 0.07) and grip strength (MD, -3.47, 95% CI, -11.21; 4.28). There were no differences for minor complications, (risk difference [RD], -0.01, 95% CI, -0.07; 0.05) whereas major complications were less common for the percutaneous group, (RD, 0.02, 95% CI, 0.02; 0.03). Given the low number of studies, the evidence above was rated as moderate certainty. The cost for plate fixation versus plaster cast was estimated to 1698 compared to 137 US dollars. For DRF, plate fixation increased in Sweden between 2005 and 2013, and was the most common surgical method in 2013. Conclusions: Surgical treatment of moderately displaced distal radius fractures in elderly patients offers no clear benefit compared to non-surgical treatment. Plating procedures have become more common during the second millennium and involve higher costs and higher risk of major complications than percutaneous options. [ABSTRACT FROM AUTHOR]

Maternal health still remains a major challenge in almost all developing countries. In Myanmar, the country met only 62% of its target for the maternal mortality rate (130 per 100,000 live birth) even though proportion of skilled birth attendant (SBA) and antenatal care (ANC) coverage was 80% in 2015. Despite the estimated large maternal complications, most maternal healthcare program ignored the burden of those morbidity because of limited understanding of the incidence and prevalence of morbidity conditions and cost of those morbidity burdens on society. The present study provides a general idea of the scope of obstetric complication, incidence of obstetric complication, and cost of those morbidity burdens on society. We conducted a retrospective incidence-based cost of illness study related to obstetric complication from the healthcare system perspective at 25 bedded township hospital in Yedashae during the fiscal year of 2015–2016. For the cost of obstetric complication, average treatment cost was 26.83 USD (±8.59). When looking by disease category, average treatment cost for incomplete abortion was 35.45 USD (±1.75); pelvic inflammatory disease (PID) was 16.01 USD; pregnancy-induced hypertension (PIH) was 21.02 USD (±4.68); ante-partum hemorrhage (APH) was 14.24(± 0.25); post-partum hemorrhage (PPH) was 27.04 USD (±1.56); prolonged labor was 37.55 USD (±0.42); and septicemia was 16.51 USD (±2.15). Significant predicting variables in obstetric complication cost model were incomplete abortion, prolonged labor, post-partum hemorrhage (PPH), pregnancy induced hypertension (PIH), patient age and septicemia. From this study, we can summarize the most frequently occurred obstetric complication in that township area, actual cost burden of those complications and obstetric complication cost model which can be useful for hospital financial management. This study can be considered as a starting point for cost of illness analysis in Myanmar to prioritize and target specific health problem at a country level for policy maker to set priorities for health care intervention. [ABSTRACT FROM AUTHOR]

Objectives: Highly resistant microorganisms (HRMOs) are of high concern worldwide and are becoming increasingly less susceptible for antibiotics. To study the cost effectiveness of infection prevention measures in long-term care, it is essential to first fully understand the impact of HRMOs. The objective of this study is to identify the costs associated with outbreaks caused by Methicillin-resistant Staphylococcus aureus (MRSA) in Dutch long-term care facilities (LTCF). Methods: After an outbreak of MRSA, Dutch LTCF can submit a reimbursement form to the Dutch Healthcare Authority (“Nederlandse Zorgautoriteit”; NZa) to get a part of the total costs reimbursed. In this study, we requested NZa forms for financial impact analysis. Details regarding the costs of the outbreak have been extracted from these forms and additionally specific LTCF have been visited in person to validate the data. Results: 34 complete reimbursement forms from the period between 2011 and 2016 were received from the NZa and have been included. The median cost per patient per day was estimated at €83.80, varying between €16.89 and €1,820.09. We validated five reimbursement forms by visiting the facility and recalculating the costs. We found a non-significant positive difference of €26.07 compared with the original data (p = 0.068). Conclusions: This study is to our knowledge the first to give a national overview of total costs associated with an MRSA outbreak in LTCF in the Netherlands. Overall, costs per patient per day seem lower than in a hospital setting, although total costs are much higher due to the long term of care. [ABSTRACT FROM AUTHOR]

Background: Symptoms indicating acute coronary syndrome are commonly seen in emergency rooms, but only 10% of patients are actually diagnosed with acute myocardial infarction (AMI). The Guidelines for the diagnosis of patients with suspected AMI include either multiple testing of cardiac troponin (cTN) or a single combined test of cTN and copeptin, which facilitates earlier diagnosis or exclusion of AMI. The aim of the present analysis was to investigate the impact of combined copeptin/cTN testing on health care resource consumption and related costs both during and after initial hospital treatment. Methods and results: The analysis was based on the BIC-8 trial and financial data of participating study sites. A cost analysis was carried out primarily from the hospital perspective and secondarily from the perspective of German statutory health insurers. The underlying assumptions of the investigation were tested for robustness in additional sensitivity analyses. In total, the data of 713 patients (n = 359 combined copeptin/cTN testing, n = 354 serial cTN testing) were evaluated. From a hospital perspective, the combined copeptin/cTN testing showed a reduced number of medical procedures and a lower frequency of inpatient admissions. The average staff time was significantly reduced by a mean of 49 minutes (95% confidence interval (CI) 46 to 53) per patient, accompanied by a significant mean reduction of 131 minutes (95%CI 104 to 158) in the time patients stayed in the emergency room. The initial hospital treatment was less cost-intensive. Over the entire study period, no significant cost differences were observed between the groups for health insurance. Conclusion: The combined copeptin/cTN testing has the potential to save costs and staff time in acute care and for the entire hospital stay. The primary explanations for these findings are early identification and ruling out patients without AMI along with the associated reduced need for acute medical treatment. Trial registration: ClinicalTrials.gov [ABSTRACT FROM AUTHOR]

Background: This study aims to examine the costs associated with a Hospital in the Nursing Home (HiNH) program in Queensland Australia directed at patients from residential aged care facilities (RACFs) with emergency care needs. Methods: A cost analysis was undertaken comparing the costs under the HiNH program and the current practice, in parallel with a pre-post controlled study design. The study was conducted in two Queensland public hospitals: the Royal Brisbane and Women’s Hospital (intervention hospital) and the Logan Hospital (control hospital). Main outcome measures were the associated incremental costs or savings concerning the HiNH program provision and the acute hospital care utilisation over one year after intervention. Results: The initial deterministic analysis calculated the total induced mean costs associated with providing the HiNH program over one year as AU$488,116, and the total induced savings relating to acute hospital care service utilisation of AU$8,659,788. The total net costs to the health service providers were thus calculated at -AU$8,171,671 per annum. Results from the probabilistic sensitivity analysis (based on 10,000 simulations) showed the mean and median annual net costs associated with the HiNH program implementation were -AU$8,444,512 and–AU$8,202,676, and a standard deviation of 2,955,346. There was 95% certainty that the values of net costs would fall within the range from -AU$15,018,055 to -AU$3,358,820. Conclusions: The costs relating to implementing the HiNH program appear to be much less than the savings in terms of associated decreases in acute hospital service utilisation. The HiNH service model is likely to have the cost-saving potential while improving the emergency care provision for RACF residents. [ABSTRACT FROM AUTHOR]

Real time PCR has become a dominant method for the highly sensitive detection of pathogens in clinical material. Real time PCR can generate a fluorescence signal by using fluorescence labelled probes, allowing us to detect and semi quantify the amount of amplified DNA. Here we test the variability of the detection system and cost implications of three different versions of the LightCycler® 480 (LC480), focusing on the intensity of fluorescence and Cq in monoplex and multiplex rtPCRs. For gastro-intestinal pathogens there was no correlation between the intensity of fluorescence and the Cq value in the different LC480 types. For probes with the dyes FAMTM, HEXTM, Cy5 and Red610 a higher fluorescence intensity was seen in LC480 type II and III compared to LC480 type I. After lowering the probe concentration for the Cy5 dye three-fold (from 0.3μM to 0.1μM) the Cq value remains the same and the intensity of fluorescence decreases. For the LC480 type II and III the difference in fluorescence intensity was much more extreme. The concentration of the different labelled probes can be lowered at least six-fold in LC480 type II and III cyclers while maintaining a fluorescence intensity as high as achieved in the LC480 type I with undiluted probe. In conclusion, the strength of the fluorescence signal of the LightCycler® 480 type III is superior to that of LightCycler® 480 types I and II, allowing the use of lower probe concentrations for all dyes, particularly for the dyes Red610 and Cy5. This results in a two thirds reduction in PCR probe costs. Switching to these newer machines for real-time PCR can reduce dye labelled probe consumption and thus reduce costs significantly. [ABSTRACT FROM AUTHOR]

Background: Providing HIV testing at health facilities remains the most common approach to ensuring access to HIV treatment and prevention services for the millions of undiagnosed HIV-infected individuals in sub-Saharan Africa. We sought to explore the costs of providing these services across three southern African countries with high HIV burden. Methods: Primary costing studies were undertaken in 54 health facilities providing HIV testing services (HTS) in Malawi, Zambia and Zimbabwe. Routinely collected monitoring and evaluation data for the health facilities were extracted to estimate the costs per individual tested and costs per HIV-positive individual identified. Costs are presented in 2016 US dollars. Sensitivity analysis explored key drivers of costs. Results: Health facilities were testing on average 2290 individuals annually, albeit with wide variations. The mean cost per individual tested was US$5.03.9 in Malawi, US$4.24 in Zambia and US$8.79 in Zimbabwe. The mean cost per HIV-positive individual identified was US$79.58, US$73.63 and US$178.92 in Malawi, Zambia and Zimbabwe respectively. Both cost estimates were sensitive to scale of testing, facility staffing levels and the costs of HIV test kits. Conclusions: Health facility based HIV testing remains an essential service to meet HIV universal access goals. The low costs and potential for economies of scale suggests an opportunity for further scale-up. However low uptake in many settings suggests that demand creation or alternative testing models may be needed to achieve economies of scale and reach populations less willing to attend facility based services. [ABSTRACT FROM AUTHOR]

Background: Human papillomavirus (HPV) has proven to be the cause of several severe clinical conditions on the cervix, vulva, vagina, anus, oropharynx and penis. Several studies have assessed the costs of cervical lesions, cervical cancer (CC), and genital warts. However, few have been done in Africa and none in Swaziland. Cost analysis is critical in providing useful information for economic evaluations to guide policymakers concerned with the allocation of resources in order to reduce the disease burden. Materials and methods: A prevalence-based cost of illness (COI) methodology was used to investigate the economic burden of HPV-related diseases. We used a top-down approach for the cost associated with hospital care and a bottom-up approach to estimate the cost associated with outpatient and primary care. The current study was conducted from a provider perspective since the state bears the majority of the costs of screening and treatment in Swaziland. All identifiable direct medical costs were considered for cervical lesions, cervical cancer and genital warts, which were primary diagnoses during 2015. A mix of bottom up micro-costing ingredients approach and top-down approaches was used to collect data on costs. All costs were computed at the price level of 2015 and converted to dollars ($). Results: The total annual estimated direct medical cost associated with screening, managing and treating cervical lesions, CC and genital warts in Swaziland was $16 million. The largest cost in the analysis was estimated for treatment of high-grade cervical lesions and cervical cancer representing 80% of the total cost ($12.6 million). Costs for screening only represented 5% of the total cost ($0.9 million). Treatment of genital warts represented 6% of the total cost ($1million). Conclusion: According to the cost estimations in this study, the economic burden of HPV-related cervical diseases and genital warts represents a major public health issue in Swaziland. Prevention of HPV infection with a national HPV immunization programme for pre-adolescent girls would prevent the majority of CC related deaths and associated costs. [ABSTRACT FROM AUTHOR]

Introduction: Urine neutrophil gelatinase-associated lipocalin (uNGAL) is a sensitive and specific diagnostic test for acute kidney injury (AKI) in the Emergency Department (ED), but its economic impact has not been investigated. We hypothesized that uNGAL used in combination with serum creatinine (sCr) would reduce costs in the management of AKI in patients presenting to the ED in comparison to using sCr alone. Materials and methods: A cost simulation model was developed for clinical algorithms to diagnose AKI based on sCr alone vs. uNGAL plus sCr (uNGAL+sCr). A cost minimization analysis was performed to determine total expected costs for patients with AKI. uNGAL test characteristics were validated with eight-hundred forty-nine patients with sCr ≥1.5 from a completed study of 1635 patients recruited from EDs at two U.S. hospitals from 2007–8. Biomarker test, AKI work-up, and diagnostic imaging costs were incorporated. Results: For a hypothetical cohort of 10,000 patients, the model predicted that the expected costs were $900 per patient (pp) in the sCr arm and $950 in the uNGAL+sCr arm. uNGAL+sCr resulted in 1,578 fewer patients with delayed diagnosis and treatment than sCr alone (2,013 vs. 436 pts) at center 1 and 1,973 fewer patients with delayed diagnosis and treatment than sCr alone at center 2 (2,227 vs. 254 patients). Although initial evaluation costs at each center were $50 pp higher in with uNGAL+sCr, total costs declined by $408 pp at Center 1 and by $522 pp at Center 2 due to expected reduced delays in diagnosis and treatment. Sensitivity analyses confirmed savings with uNGAL + sCr for a range of cost inputs. Discussion: Using uNGAL with sCr as a clinical diagnostic test for AKI may improve patient management and reduce expected costs. Any cost savings would likely result from avoiding delays in diagnosis and treatment and from avoidance of unnecessary testing in patients given a false positive AKI diagnosis by use of sCr alone. [ABSTRACT FROM AUTHOR]

Dried blood spot (DBS) sampling for the purpose of therapeutic drug monitoring can be an attractive alternative for conventional blood sampling, especially in children. This study aimed to compare all costs involved in conventional sampling versus DBS home sampling in two pediatric populations: renal transplant patients and hemato-oncology patients. Total costs were computed from a societal perspective by adding up healthcare cost, patient related costs and costs related to loss of productivity of the caregiver. Switching to DBS home sampling was associated with a cost reduction of 43% for hemato-oncology patients (€277 to €158) and 61% for nephrology patients (€259 to €102) from a societal perspective (total costs) per blood draw. From a healthcare perspective, costs reduced with 7% for hemato-oncology patients and with 21% for nephrology patients. Total savings depend on the number of hospital visits that can be avoided by using home sampling instead of conventional sampling. [ABSTRACT FROM AUTHOR]

Background: The literature remains conflicted regarding the most effective way to screen for MRSA. This study was designed to assess costs associated with universal versus risk factor-based screening for the reduction of nosocomial MRSA transmission. Methods: The study was conducted at The Ottawa Hospital, a large multi-centre tertiary care facility with approximately 47,000 admissions annually. From January 2006-December 2007, patients underwent risk factor-based screening for MRSA on admission. From January 2008 to August 2009 universal MRSA screening was implemented. A comparison of costs incurred during risk factor-based screening and universal screening was conducted. The model incorporated probabilities relating to the likelihood of being tested and the results of polymerase chain reaction (PCR) testing with associated effects in terms of MRSA bacteremia and true positive and negative test results. Inputted costs included laboratory testing, contact precautions and infection control, private room costs, housekeeping, and length of hospital stay. Deterministic sensitivity analyses were conducted. Results: The risk factor-based MRSA screening program screened approximately 30% of admitted patients and cost the hospital over $780 000 annually. The universal screening program screened approximately 83% of admitted patients and cost over $1.94 million dollars, representing an excess cost of $1.16 million per year. The estimated additional cost per patient screened was $17.76. Conclusion: This analysis demonstrated that a universal MRSA screening program was costly from a hospital perspective and was previously known to not be clinically effective at reducing MRSA transmission. These results may be useful to inform future model-based economic analyses of MRSA interventions. [ABSTRACT FROM AUTHOR]

Introduction: Falls are the leading cause of injury in older people. Reducing falls could reduce financial pressures on health services. We carried out this research to develop a falls risk model, using routine primary care and hospital data to identify those at risk of falls, and apply a cost analysis to enable commissioners of health services to identify those in whom savings can be made through referral to a falls prevention service. Methods: Multilevel logistical regression was performed on routinely collected general practice and hospital data from 74751 over 65’s, to produce a risk model for falls. Validation measures were carried out. A cost-analysis was performed to identify at which level of risk it would be cost-effective to refer patients to a falls prevention service. 95% confidence intervals were calculated using a Monte Carlo Model (MCM), allowing us to adjust for uncertainty in the estimates of these variables. Results: A risk model for falls was produced with an area under the curve of the receiver operating characteristics curve of 0.87. The risk cut-off with the highest combination of sensitivity and specificity was at p = 0.07 (sensitivity of 81% and specificity of 78%). The risk cut-off at which savings outweigh costs was p = 0.27 and the risk cut-off with the maximum savings was p = 0.53, which would result in referral of 1.8% and 0.45% of the over 65’s population respectively. Above a risk cut-off of p = 0.27, costs do not exceed savings. Conclusions: This model is the best performing falls predictive tool developed to date; it has been developed on a large UK city population; can be readily run from routine data; and can be implemented in a way that optimises the use of health service resources. Commissioners of health services should use this model to flag and refer patients at risk to their falls service and save resources. [ABSTRACT FROM AUTHOR]

During a force-matched bilateral task, when pain is induced in one limb, a shift of load to the non-painful leg is classically observed. This study aimed to test the hypothesis that this adaptation to pain depends on the mechanical efficiency of the non-painful leg. We studied a bilateral plantarflexion task that allowed flexibility in the relative force produced with each leg, but constrained the sum of forces from both legs to match a target. We manipulated the mechanical efficiency of the non-painful leg by imposing scaling factors: 1, 0.75, or 0.25 to decrease mechanical efficiency (Decreased efficiency experiment: 18 participants); and 1, 1.33 or 4 to increase mechanical efficiency (Increased efficiency experiment: 17 participants). Participants performed multiple sets of three submaximal bilateral isometric plantarflexions with each scaling factor during two conditions (Baseline and Pain). Pain was induced by injection of hypertonic saline into the soleus. Force was equally distributed between legs during the Baseline contractions (laterality index was close to 1; Decreased efficiency experiment: 1.16±0.33; Increased efficiency experiment: 1.11±0.32), with no significant effect of Scaling factor. The laterality index was affected by Pain such that the painful leg contributed less than the non-painful leg to the total force (Decreased efficiency experiment: 0.90±0.41, P<0.001; Increased efficiency experiment: 0.75±0.32, P<0.001), regardless of the efficiency (scaling factor) of the non-painful leg. When compared to the force produced during Baseline of the corresponding scaling condition, a decrease in force produced by the painful leg was observed for all conditions, except for scaling 0.25. This decrease in force was correlated with a decrease in drive to the soleus muscle. These data highlight that regardless of the overall mechanical cost, the nervous system appears to prefer to alter force sharing between limbs such that force produced by the painful leg is reduced relative to the non-painful leg. [ABSTRACT FROM AUTHOR]

Background: Tuberculosis (TB) remains a significant health problem in the Canadian Arctic. Substantial health system delays in TB diagnosis can occur, in part due to the lack of capacity for onsite microbiologic testing. A study recently evaluated the yield and impact of a rapid automated PCR test (Xpert®MTB/RIF) for the diagnosis of TB in Iqaluit (Nunavut). We conducted an economic analysis to evaluate the expected cost relative to the expected reduction in time to treatment initiation, with the addition of Xpert®MTB/RIF to the current diagnostic and treatment algorithms used in this setting. Methods: A decision analysis model compared current microbiologic testing to a scenario where Xpert®MTB/RIF was added to the current diagnostic algorithm for active TB, and incorporated costs and clinical endpoints from the Iqaluit study. Several sensitivity analyses that considered alternative use were also considered. We estimated days to TB diagnosis and treatment initiation, health system costs, and the incremental cost per treatment day gained for each individual evaluated for possible TB. Results: With the addition of Xpert®MTB/RIF, costs increased while days to TB treatment initiation were reduced. The incremental cost per treatment day gained (per individual investigated for TB) was $164 (95% uncertainty range $85, $452). In a sensitivity analysis that considered hospital discharge after a single negative Xpert®MTB/RIF, the Xpert®MTB/RIF scenario was cost saving. Interpretation: Adding Xpert®MTB/RIF to the current diagnostic algorithm for TB in Nunavut appears to reduce time to diagnosis and treatment at reasonable cost. It may be especially well suited to overcome some of the other logistical barriers that are unique to this and other remote communities. [ABSTRACT FROM AUTHOR]

Muscles attach to bones via tendons that stretch and recoil, affecting muscle force generation and metabolic energy consumption. In this study, we investigated the effect of tendon compliance on the metabolic cost of running using a full-body musculoskeletal model with a detailed model of muscle energetics. We performed muscle-driven simulations of running at 2–5 m/s with tendon force–strain curves that produced between 1 and 10% strain when the muscles were developing maximum isometric force. We computed the average metabolic power consumed by each muscle when running at each speed and with each tendon compliance. Average whole-body metabolic power consumption increased as running speed increased, regardless of tendon compliance, and was lowest at each speed when tendon strain reached 2–3% as muscles were developing maximum isometric force. When running at 2 m/s, the soleus muscle consumed less metabolic power at high tendon compliance because the strain of the tendon allowed the muscle fibers to operate nearly isometrically during stance. In contrast, the medial and lateral gastrocnemii consumed less metabolic power at low tendon compliance because less compliant tendons allowed the muscle fibers to operate closer to their optimal lengths during stance. The software and simulations used in this study are freely available at simtk.org and enable examination of muscle energetics with unprecedented detail. [ABSTRACT FROM AUTHOR]

The ecological impacts of alien species invasion are a major threat to global biodiversity. The increasing number of invasion events by alien species and the high cost and difficulty of eradicating invasive species once established require the development of new methods and tools for predicting the most susceptible areas to invasion. Invasive pollinators pose serious threats to biodiversity and human activity due to their close relationship with many plants (including crop species) and high potential competitiveness for resources with native pollinators. Although at an early stage of expansion, the bumblebee species Bombus terrestris is becoming a representative case of pollinator invasion at a global scale, particularly given its high velocity of invasive spread and the increasing number of reports of its impacts on native bees and crops in many countries. We present here a methodological framework of habitat suitability modeling that integrates new approaches for detecting habitats that are susceptible to Bombus terrestris invasion at a global scale. Our approach did not include reported invaded locations in the modeling procedure; instead, those locations were used exclusively to evaluate the accuracy of the models in predicting suitability over regions already invaded. Moreover, a new and more intuitive approach was developed to select the models and evaluate different algorithms based on their performance and predictive convergence. Finally, we present a comprehensive global map of susceptibility to Bombus terrestris invasion that highlights priority areas for monitoring. [ABSTRACT FROM AUTHOR]

Background: Caesarean section (CS) rates continue to evoke worldwide concern because of their steady increase, lack of consensus on the appropriate CS rate and the associated additional short- and long-term risks and costs. We present the latest CS rates and trends over the last 24 years. Methods: We collected nationally-representative data on CS rates between 1990 to 2014 and calculated regional and subregional weighted averages. We conducted a longitudinal analysis calculating differences in CS rates as absolute change and as the average annual rate of increase (AARI). Results: According to the latest data from 150 countries, currently 18.6% of all births occur by CS, ranging from 6% to 27.2% in the least and most developed regions, respectively. Latin America and the Caribbean region has the highest CS rates (40.5%), followed by Northern America (32.3%), Oceania (31.1%), Europe (25%), Asia (19.2%) and Africa (7.3%). Based on the data from 121 countries, the trend analysis showed that between 1990 and 2014, the global average CS rate increased 12.4% (from 6.7% to 19.1%) with an average annual rate of increase of 4.4%. The largest absolute increases occurred in Latin America and the Caribbean (19.4%, from 22.8% to 42.2%), followed by Asia (15.1%, from 4.4% to 19.5%), Oceania (14.1%, from 18.5% to 32.6%), Europe (13.8%, from 11.2% to 25%), Northern America (10%, from 22.3% to 32.3%) and Africa (4.5%, from 2.9% to 7.4%). Asia and Northern America were the regions with the highest and lowest average annual rate of increase (6.4% and 1.6%, respectively). Conclusion: The use of CS worldwide has increased to unprecedented levels although the gap between higher- and lower-resource settings remains. The information presented is essential to inform policy and global and regional strategies aimed at optimizing the use of CS. [ABSTRACT FROM AUTHOR]

This study was designed to compare the efficiency of the Cryotop and Calibrated plastic inoculation loop (CPIL) devices for vitrification of rabbit embryos on in vitro development and implantation rate, offspring rate at birth and embryonic and fetal losses. CPIL is a simple tool used mainly by microbiologists to retrieve an inoculum from a culture of microorganisms. In experiment 1, embryos were vitrified using a Cryotop device and a CPIL device. There were no significant differences in hatched/hatching blastocyst stage rates after 48 h of culture among the vitrified groups (62±4.7% and 62±4.9%, respectively); however, the rates were significantly lower (P<0.05) than those of the fresh group (95±3.4%). In experiment 2, vitrified embryos were transferred using laparoscopic technique. The number of implanted embryos was estimated by laparoscopy as number of implantation sites at day 14 of gestation. At birth, total offspring were recorded. Embryonic and fetal losses were calculated as the difference between implanted embryos and embryos transferred and total born at birth and implanted embryos, respectively. The rate of implantation and development to term was similar between both vitrification devices (56±7.2% and 50±6.8% for implantation rate and 40±7.1% and 35±6.5% for offspring rate at birth); but significantly lower than in the fresh group (78±6.6% for implantation rate and 70±7.2% for offspring rate at birth, P<0.05). Likewise, embryonic losses were similar between both vitrification devices (44±7.2% and 50±6.8%), but significantly higher than in the fresh group (23±6.6%, P < 0.05). However, fetal losses were similar between groups (10±4.4%, 15±4.8% and 8±4.2%, for vitrified, Cryotop or CPIL and fresh, respectively). These results indicate that the CPIL device is as effective as the Cryotop device for vitrification of rabbit embryos, but at a cost of €0.05 per device. [ABSTRACT FROM AUTHOR]

Sex allocation theory assumes that offspring sex (son vs. daughter) has consequences for maternal fitness. The most compelling experiment to test this theory would involve manipulating offspring sex and measuring the fitness consequences of having the “wrong” sex. Unfortunately, the logistical challenges of such an experiment limit its application. In tammar wallabies (Macropus eugenii), previous evidence suggests that mothers in good body condition are more likely to produce sons compared to mothers in poor condition, in support of the Trivers-Willard Hypothesis (TW) of condition-dependent sex allocation. More recently, we have found in our population of tammar wallabies that females with seemingly poor access to resources (based on condition loss over the dry summer) are more likely to produce sons, consistent with predictions from the Local Resource Competition (LRC) hypothesis, which proposes that production of sons or daughters is driven by the level of potential competition between mothers and philopatric daughters. We conducted a cross-fostering experiment in free-ranging tammar wallabies to disassociate the effects of rearing and birthing offspring of each sex. This allowed us to test the prediction of the LRC hypothesis that rearing daughters reduces the future direct fitness of mothers post-weaning and the prediction of the TW hypothesis that rearing sons requires more energy during lactation. Overall, we found limited costs to the mother of rearing the “wrong” sex, with switching of offspring sex only reducing the likelihood of a mother having a pouch young the following year. Thus, we found some support for both hypotheses in that rearing an unexpected son or an unexpected daughter both lead to reduced future maternal fitness. The study suggests that there may be context-specific costs associated with rearing the “wrong” sex. [ABSTRACT FROM AUTHOR]

Background: There is increasing evidence that mobile phone health interventions (“mHealth”) can improve health behaviors and outcomes and are critically important in low-resource, low-access settings. However, the majority of mHealth programs in developing countries fail to reach scale. One reason may be the challenge of developing financially sustainable programs. The goal of this paper is to explore strategies for mHealth program sustainability and develop cost-recovery models for program implementers using 2014 operational program data from Mobile for Reproductive Health (m4RH), a national text-message (SMS) based health communication service in Tanzania. Methods: We delineated 2014 m4RH program costs and considered three strategies for cost-recovery for the m4RH program: user pay-for-service, SMS cost reduction, and strategic partnerships. These inputs were used to develop four different cost-recovery scenarios. The four scenarios leveraged strategic partnerships to reduce per-SMS program costs and create per-SMS program revenue and varied the structure for user financial contribution. Finally, we conducted break-even and uncertainty analyses to evaluate the costs and revenues of these models at the 2014 user volume (125,320) and at any possible break-even volume. Results: In three of four scenarios, costs exceeded revenue by $94,596, $34,443, and $84,571 at the 2014 user volume. However, these costs represented large reductions (54%, 83%, and 58%, respectively) from the 2014 program cost of $203,475. Scenario four, in which the lowest per-SMS rate ($0.01 per SMS) was negotiated and users paid for all m4RH SMS sent or received, achieved a $5,660 profit at the 2014 user volume. A Monte Carlo uncertainty analysis demonstrated that break-even points were driven by user volume rather than variations in program costs. Conclusions: These results reveal that breaking even was only probable when all SMS costs were transferred to users and the lowest per-SMS cost was negotiated with telecom partners. While this strategy was sustainable for the implementer, a central concern is that health information may not reach those who are too poor to pay, limiting the program’s reach and impact. Incorporating strategies presented here may make mHealth programs more appealing to funders and investors but need further consideration to balance sustainability, scale, and impact. [ABSTRACT FROM AUTHOR]

Background: An integrated tiered service delivery model (ITSDM) has been proposed to provide ‘full-coverage’ of CD4 services throughout South Africa. Five tiers are described, defined by testing volumes and number of referring health-facilities. These include: (1) Tier-1/decentralized point-of-care service (POC) in a single site; Tier-2/POC-hub servicing processing <30–40 samples from 8–10 health-clinics; Tier-3/Community laboratories servicing ∼50 health-clinics, processing <150 samples/day; high-volume centralized laboratories (Tier-4 and Tier-5) processing <300 or >600 samples/day and serving >100 or >200 health-clinics, respectively. The objective of this study was to establish costs of existing and ITSDM-tiers 1, 2 and 3 in a remote, under-serviced district in South Africa. Methods: Historical health-facility workload volumes from the Pixley-ka-Seme district, and the total volumes of CD4 tests performed by the adjacent district referral CD4 laboratories, linked to locations of all referring clinics and related laboratory-to-result turn-around time (LTR-TAT) data, were extracted from the NHLS Corporate-Data-Warehouse for the period April-2012 to March-2013. Tiers were costed separately (as a cost-per-result) including equipment, staffing, reagents and test consumable costs. A one-way sensitivity analyses provided for changes in reagent price, test volumes and personnel time. Results: The lowest cost-per-result was noted for the existing laboratory-based Tiers- 4 and 5 ($6.24 and $5.37 respectively), but with related increased LTR-TAT of >24–48 hours. Full service coverage with TAT <6-hours could be achieved with placement of twenty-seven Tier-1/POC or eight Tier-2/POC-hubs, at a cost-per-result of $32.32 and $15.88 respectively. A single district Tier-3 laboratory also ensured ‘full service coverage’ and <24 hour LTR-TAT for the district at $7.42 per-test. Conclusion: Implementing a single Tier-3/community laboratory to extend and improve delivery of services in Pixley-ka-Seme, with an estimated local ∼12–24-hour LTR-TAT, is ∼$2 more than existing referred services per-test, but 2–4 fold cheaper than implementing eight Tier-2/POC-hubs or providing twenty-seven Tier-1/POCT CD4 services. [ABSTRACT FROM AUTHOR]

Introduction: The Centers for Disease Control and Prevention has recommended using a nucleic acid amplification test (NAAT) for diagnosing pulmonary tuberculosis (TB) but there is a lack of data on NAAT cost-effectiveness. Methods: We conducted a prospective cohort study that included all patients with an AFB smear-positive respiratory specimen at Grady Memorial Hospital in Atlanta, GA, USA between January 2002 and June 2008. We determined the sensitivity, specificity, and positive and negative predictive value of a commercially available and FDA-approved NAAT (amplified MTD, Gen-Probe) compared to the gold standard of culture. A cost analysis was performed and included costs related to laboratory tests, hospital charges, anti-TB medications, and contact investigations. Average cost per patient was calculated under two conditions: (1) using a NAAT on all AFB smear-postive respiratory specimens and (2) not using a NAAT. One-way sensitivity analyses were conducted to determine sensitivity of cost difference to reasonable ranges of model inputs. Results: During a 6 1/2 year study period, there were 1,009 patients with an AFB smear-positive respiratory specimen at our public urban hospital. We found the NAAT to be highly sensitive (99.6%) and specific (99.1%) on AFB smear-positive specimens compared to culture. Overall, the positive predictive value (PPV) of an AFB smear-positive respiratory specimen for culture-confirmed TB was 27%. The PPV of an AFB smear-positive respiratory specimen for culture-confirmed TB was significantly higher for HIV-uninfected persons compared to those who were HIV-seropositive (152/271 [56%] vs. 85/445 [19%]; RR = 2.94, 95% CI 2.36–3.65, p<0.001). The cost savings of using the NAAT was $2,003 per AFB smear-positive case. Conclusions: Routine use of the NAAT on AFB smear-positive respiratory specimens was highly cost-saving in our setting at a U.S. urban public hospital with a high prevalence of TB and HIV because of the low PPV of an AFB smear for culture-confirmed TB. [ABSTRACT FROM AUTHOR]

Background: Accurate hospital costs are required for policy-makers, hospital managers and clinicians to improve efficiency and transparency. However, different methods are used to allocate direct costs, and their agreement is poorly understood. The aim of this study was to assess the agreement between bottom-up and top-down unit costs of a large sample of surgical operations in a French tertiary centre. Methods: Two thousand one hundred and thirty consecutive procedures performed between January and October 2010 were analysed. Top-down costs were based on pre-determined weights, while bottom-up costs were calculated through an activity-based costing (ABC) model. The agreement was assessed using correlation coefficients and the Bland and Altman method. Variables associated with the difference between methods were identified with bivariate and multivariate linear regressions. Results: The correlation coefficient amounted to 0.73 (95%CI: 0.72; 0.76). The overall agreement between methods was poor. In a multivariate analysis, the cost difference was independently associated with age (Beta = −2.4; p = 0.02), ASA score (Beta = 76.3; p<0.001), RCI (Beta = 5.5; p<0.001), staffing level (Beta = 437.0; p<0.001) and intervention duration (Beta = −10.5; p<0.001). Conclusions: The ability of the current method to provide relevant information to managers, clinicians and payers is questionable. As in other European countries, a shift towards time-driven activity-based costing should be advocated. [ABSTRACT FROM AUTHOR]

Background: Fourteen African countries are scaling up voluntary medical male circumcision (VMMC) for HIV prevention. Several devices that might offer alternatives to the three WHO-approved surgical VMMC procedures have been evaluated for use in adults. One such device is PrePex, which was prequalified by the WHO in May 2013. We utilized data from one of the PrePex field studies undertaken in Zimbabwe to identify cost considerations for introducing PrePex into the existing surgical circumcision program. Methods and Findings: We evaluated the cost drivers and overall unit cost of VMMC at a site providing surgical VMMC as a routine service (“routine surgery site”) and at a site that had added PrePex VMMC procedures to routine surgical VMMC as part of a research study (“mixed study site”). We examined the main cost drivers and modeled hypothetical scenarios with varying ratios of surgical to PrePex circumcisions, different levels of site utilization, and a range of device prices. The unit costs per VMMC for the routine surgery and mixed study sites were $56 and $61, respectively. The two greatest contributors to unit price at both sites were consumables and staff. In the hypothetical scenarios, the unit cost increased as site utilization decreased, as the ratio of PrePex to surgical VMMC increased, and as device price increased. Conclusions: VMMC unit costs for routine surgery and mixed study sites were similar. Low service utilization was projected to result in the greatest increases in unit price. Countries that wish to incorporate PrePex into their circumcision programs should plan to maximize staff utilization and ensure that sites function at maximum capacity to achieve the lowest unit cost. Further costing studies will be necessary once routine implementation of PrePex-based circumcision is established. [ABSTRACT FROM AUTHOR]