OBJECTIVE:

To compare the cost-effectiveness of hepatitis B virus (HBV) control strategies combining universal vaccination with hepatitis B immunoglobulin (HBIG) treatment for neonates of carrier mothers.

METHODS:

Drawing on Taiwan's experience, we developed a decision-analytic model to estimate the clinical and economic outcomes for 4 strategies: (1) strategy V-universal vaccination; (2) strategy S-V plus screening for hepatitis B surface antigen (HBsAg) and HBIG treatment for HBsAg-positive mothers' neonates; (3) strategy E-V plus screening for hepatitis B e-antigen (HBeAg), HBIG for HBeAg-positive mothers' neonates; (4) strategy S&E-V plus screening for HBsAg then HBeAg, HBIG for all HBeAg-positive, and some HBeAg-negative/HBsAg-positive mothers' neonates.

RESULTS:

Strategy S averted the most infections, followed by S&E, E, and V. In most cases, the more effective strategies were also more costly. The willingness-to-pay (WTP) above which strategy S was cost-effective rose as carrier rate declined and was <$4000 per infection averted for carrier rates >5%. The WTP below which strategy V was optimal also increased as carrier rate declined, from $1400 at 30% carrier rate to $3100 at 5% carrier rate. Strategies involving E were optimal for an intermediate range of WTP that narrowed as carrier rate declined.

CONCLUSIONS:

HBIG treatment for neonates of HBsAg carrier mothers is likely to be a cost-effective addition to universal vaccination, particularly in settings with adequate health care infrastructure. Targeting HBIG to neonates of higher risk HBeAg-positive mothers may be preferred where WTP is moderate. However, in very resource-limited settings, universal vaccination alone is optimal.

OBJECTIVE:

To compare the cost-effectiveness of hepatitis B virus (HBV) control strategies combining universal vaccination with hepatitis B immunoglobulin (HBIG) treatment for neonates of carrier mothers.

METHODS:

BACKGROUND: In resource-limited settings, HIV budgets are flattening or decreasing. A policy of discontinuing antiretroviral therapy (ART) after HIV treatment failure was modeled to highlight trade-offs among competing policy goals of optimizing individual and population health outcomes.

METHODS:

In settings with two available ART regimens, we assessed two strategies: (1) continue ART after second-line failure (Status Quo) and (2) discontinue ART after second-line failure (Alternative). A computer model simulated outcomes for a single cohort of newly detected, HIV-infected individuals. Projections were fed into a population-level model allowing multiple cohorts to compete for ART with constraints on treatment capacity. In the Alternative strategy, discontinuation of second-line ART occurred upon detection of antiretroviral failure, specified by WHO guidelines. Those discontinuing failed ART experienced an increased risk of AIDS-related mortality compared to those continuing ART.

RESULTS:

At the population level, the Alternative strategy increased the mean number initiating ART annually by 1,100 individuals (+18.7%) to 6,980 compared to the Status Quo. More individuals initiating ART under the Alternative strategy increased total life-years by 15,000 (+2.8%) to 555,000, compared to the Status Quo. Although more individuals received treatment under the Alternative strategy, life expectancy for those treated decreased by 0.7 years (-8.0%) to 8.1 years compared to the Status Quo. In a cohort of treated patients only, 600 more individuals (+27.1%) died by 5 years under the Alternative strategy compared to the Status Quo. Results were sensitive to the timing of detection of ART failure, number of ART regimens, and treatment capacity. Although we believe the results robust in the short-term, this analysis reflects settings where HIV case detection occurs late in the disease course and treatment capacity and the incidence of newly detected patients are stable.

CONCLUSIONS:

In settings with inadequate HIV treatment availability, trade-offs emerge between maximizing outcomes for individual patients already on treatment and ensuring access to treatment for all people who may benefit. While individuals may derive some benefit from ART even after virologic failure, the aggregate public health benefit is maximized by providing effective therapy to the greatest number of people. These trade-offs should be explicit and transparent in antiretroviral policy decisions.

BACKGROUND: In resource-limited settings, HIV budgets are flattening or decreasing. A policy of discontinu... (more »)

BACKGROUND: Women in Nigeria face some of the highest maternal mortality risks in the world. We explore the benefits and cost-effectiveness of individual and integrated packages of interventions to prevent pregnancy-related deaths.

METHODS:

We adapt a previously validated maternal mortality model to Nigeria. Model outcomes included clinical events, population measures, costs, and cost-effectiveness ratios. Separate models were adapted to Southwest and Northeast zones using survey-based data. Strategies consisted of improving coverage of effective interventions, and could include improved logistics.

RESULTS:

Increasing family planning was the most effective individual intervention to reduce pregnancy-related mortality, was cost saving in the Southwest zone and cost-effective elsewhere, and prevented nearly 1 in 5 abortion-related deaths. However with a singular focus on family planning and safe abortion mortality reduction would plateau below MDG 5. Strategies that could prevent 4 out of 5 maternal deaths included an integrated and stepwise approach that includes increased skilled deliveries, facility births, access to antenatal/postpartum care, improved recognition of referral need, transport, and availability quality of EmOC in addition to family planning and safe abortion. The economic benefits of these strategies ranged from being cost-saving to having incremental cost-effectiveness ratios less than $500 per YLS, well below Nigeria's per capita GDP.

CONCLUSIONS:

Early intensive efforts to improve family planning and control of fertility choices, accompanied by a stepwise effort to scale-up capacity for integrated maternal health services over several years, will save lives and provide equal or greater value than many public health interventions we consider among the most cost-effective (e.g., childhood immunization).

BACKGROUND: Women in Nigeria face some of the highest maternal mortality risks in the world. We explore th... (more »)

BACKGROUND: Chronic fatigue syndrome (CFS) is a debilitating chronic illness affecting at least 4 million people in the United States. Understanding its cost improves decisions regarding resource allocation that may be directed towards treatment and cure, and guides the evaluation of clinical and community interventions designed to reduce the burden of disease.

METHODS: This research estimated direct and indirect costs of CFS and the impact on educational attainment using a population-based, case-control study between September 2004 and July 2005, Georgia, USA. Participants completed a clinical evaluation to confirm CFS, identify other illnesses, and report on socioeconomic factors. We estimated the effect of CFS on direct medical costs (inpatient hospitalizations, provider visits, prescription medication spending, other medical supplies and services) and loss in productivity (employment and earnings) with a stratified sample (n=500) from metropolitan, urban, and rural Georgia. We adjusted medical costs and earnings for confounders (age, sex, race/ethnicity, education, and geographic strata) using econometric models and weighted estimates to reflect response-rate adjusted sampling rates.

RESULTS: Individuals with CFS had mean annual direct medical costs of $5,683. After adjusting for confounding factors, CFS accounted for $3,286 of these costs (p < 0.01), which were driven by increased provider visits and prescription medication use. Nearly one-quarter of these expenses were paid directly out-of pocket by those with CFS. Individuals with CFS reported mean annual household income of $23,076. After adjustment, CFS accounted for $8,554 annually in lost household earnings (p < 0.01). Lower educational attainment accounted for 19% of the reduction in earnings associated with CFS.

CONCLUSIONS: Study results indicate that chronic fatigue syndrome may lead to substantial increases in healthcare costs and decreases in individual earnings. Studies have estimated up to 2.5% of non-elderly adults may suffer from CFS. In Georgia, a state with roughly 5.5 million people age 18-59, illness could account for $452 million in total healthcare expenditures and $1.2 billion of lost productivity.

BACKGROUND: Chronic fatigue syndrome (CFS) is a debilitating chronic illness affecting at least 4 million people in the United States. Understanding its cost improves decisions regarding resource allocation that may be direct... (more »)

BACKGROUND:

Many hospitals require all operative specimens be sent to pathologists for routine examination. Although previous studies indicate this practice increases medical cost, it remains unclear whether it alters patient management and whether it is cost-effective.

QUESTIONS/PURPOSES:

We therefore (1) determined the rate of discordance between clinical and histologic examinations of routine operative specimens during elective primary arthroplasties, (2) determined the cost of routine histologic screening, and (3) estimated its cost-effectiveness in terms of cost per quality-adjusted life year gained, as compared with gross examination or no examination.

METHODS:

We retrospectively reviewed medical records of 1247 patients who underwent 1363 routine elective primary total joint arthroplasties between January 18, 2006 and March 15, 2010. We compared preoperative, postoperative, and histologic diagnoses for each patient and categorized them into three classes: concordant (clinical and histologic diagnoses agreed), discrepant (diagnoses differed but with no resultant change in treatment), and discordant (diagnoses differed with resultant change in treatment). Medicare reimbursements were determined through the pathology department's administrative office.

RESULTS:

In 1363 cases, 1335 (97.9%) clinical and histologic diagnoses were concordant, 28 (2.1%) were discrepant, and none were discordant. Total reimbursement for routine pathological examination was $139,532, or $102.37 per specimen. The average cost to identify each discrepant case was $4983.29. Routine histologic examination did not alter patient management, and there was no direct gain in quality-adjusted life years.

CONCLUSIONS:

Our observations show routine histologic examinations of routine operative specimens during elective primary arthroplasties increase medical cost but rarely alter patient management and are not cost-effective.

LEVEL OF EVIDENCE:

Level I, economic and decision analyses. See Guidelines for Authors for a complete description of levels of evidence.

BACKGROUND:

Many hospitals require all operative specimens be sent to pathologists for routine examination. Although previous studies indicate this practice increases medical cost, it remains unclear whether it alters patient managemen... (more »)

Since the early 2000s, aid organizations and developing country governments have invested heavily in AIDS treatment. By 2010, more than five million people began receiving antiretroviral therapy (ART) - yet each year, 2.7 million people are becoming newly infected and another two million are dying without ever having received treatment. As the need for treatment grows without commensurate increase in the amount of available resources, it is critical to assess the health and economic gains being realized from increasingly large investments in ART. This study estimates total program costs and compares them with selected economic benefits of ART, for the current cohort of patients whose treatment is cofinanced by the Global Fund to Fight AIDS, Tuberculosis and Malaria. At end 2011, 3.5 million patients in low and middle income countries will be receiving ART through treatment programs cofinanced by the Global Fund. Using 2009 ART prices and program costs, we estimate that the discounted resource needs required for maintaining this cohort are $14.2 billion for the period 2011-2020. This investment is expected to save 18.5 million life-years and return $12 to $34 billion through increased labor productivity, averted orphan care, and deferred medical treatment for opportunistic infections and end-of-life care. Under alternative assumptions regarding the labor productivity effects of HIV infection, AIDS disease, and ART, the monetary benefits range from 81 percent to 287 percent of program costs over the same period. These results suggest that, in addition to the large health gains generated, the economic benefits of treatment will substantially offset, and likely exceed, program costs within 10 years of investment.

Since the early 2000s, aid organizations and developing country governments have invested heavily in AIDS treatment. By 2010, more than five million people began receiving antiretroviral therapy (ART) - yet each year, 2... (more »)

BACKGROUND: New technologies are available to reduce or prevent retained surgical sponges (RSS), but their relative cost effectiveness are unknown. We developed an empirically calibrated decision-analytic model comparing standard counting against alternative strategies: universal or selective x-ray, bar-coded sponges (BCS), and radiofrequency-tagged (RF) sponges. METHODS: Key model parameters were obtained from field observations during a randomized-controlled BCS trial (n = 298), an observational study of RSS (n = 191,168), and clinical experience with BCS (n approximately 60,000). Because no comparable data exist for RF, we modeled its performance under 2 alternative assumptions. Only incremental sponge-tracking costs, excluding those common to all strategies, were considered. Main outcomes were RSS incidence and cost-effectiveness ratios for each strategy, from the institutional decision maker's perspective. RESULTS: Standard counting detects 82% of RSS. Bar coding prevents > or =97.5% for an additional $95,000 per RSS averted. If RF were as effective as bar coding, it would cost $720,000 per additional RSS averted (versus standard counting). Universal and selective x-rays for high-risk operations are more costly, but less effective than BCS-$1.1 to 1.4 million per RSS event prevented. In sensitivity analyses, results were robust over the plausible range of effectiveness assumptions, but sensitive to cost. CONCLUSION: Using currently available data, this analysis provides a useful model for comparing the relative cost effectiveness of existing sponge-tracking strategies. Selecting the best method for an institution depends on its priorities: ease of use, cost reduction, or ensuring RSS are truly "never events." Given medical and liability costs of >$200,000 per incident, novel technologies can substantially reduce the incidence of RSS at an acceptable cost.

BACKGROUND: New technologies are available to reduce or prevent retained surgical sponges (RSS), but their relative cost effectiveness are unknown. We developed an empirically calibrated decision-analytic model comparing standard counting again... (more »)

The "overall sufficiency of planned construction [for the California Department of Corrections and Rehabilitation (CDCR)], the appropriate distribution of long-term and short-term beds, and the estimated number of LTC [long term care] patients requiring each of these three levels of service intensity" are assessed (p. v). Seven sections are contained in this report: executive summary; purpose and background; project data set; development of the assessment tools and the data collection protocol; primary data collection findings regarding medical bed census and general population assessments; estimates of LTC need in the prison population; projected growth in LTC needs for CDCR inmates; and discussion. There is a proposed need for 5,000 new medical beds occurring over the next ten years. Accession Number: 022549

The "overall sufficiency of planned construction [for the California Department of Corrections and Rehabilitation (CDCR)], the appropriate distribution of long-term and short-term beds, and the... (more »)

BACKGROUND: Development of new, effective, and affordable tuberculosis (TB) therapies has been identified as a critical priority for global TB control. As new candidates emerge from the global TB drug pipeline, the potential impacts of novel, shorter regimens on TB incidence and mortality have not yet been examined. METHODS AND FINDINGS: We used a mathematical model of TB to evaluate the expected benefits of shortening the duration of effective chemotherapy for active pulmonary TB. First, we considered general relationships between treatment duration and TB dynamics. Next, as a specific example, we calibrated the model to reflect the current situation in the South-East Asia region. We found that even with continued and rapid progress in scaling up the World Health Organization's DOTS strategy of directly observed, short-course chemotherapy, the benefits of reducing treatment duration would be substantial. Compared to a baseline of continuing DOTS coverage at current levels, and with currently available tools, a 2-mo regimen introduced by 2012 could prevent around 20% (range 13%-28%) of new cases and 25% (range 19%-29%) of TB deaths in South-East Asia between 2012 and 2030. If effective treatment with existing drugs expands rapidly, overall incremental benefits of shorter regimens would be lower, but would remain considerable (13% [range 8%-19%] and 19% [range 15%-23%] reductions in incidence and mortality, respectively, between 2012 and 2030). A ten-year delay in the introduction of new drugs would erase nearly three-fourths of the total expected benefits in this region through 2030. CONCLUSIONS: The introduction of new, shorter treatment regimens could dramatically accelerate the reductions in TB incidence and mortality that are expected under current regimens-with up to 2- or 3-fold increases in rates of decline if shorter regimens are accompanied by enhanced case detection. Continued progress in reducing the global TB burden will require a balanced approach to pursuing new technologies while promoting wider implementation of proven strategies.

BACKGROUND: Development of new, effective, and affordable tuberculosis (TB) therapies has been identified as a critical priority for global TB control. As new candidates emerge from the global TB drug pipeline, the potential impacts of novel, s... (more »)

Antiretroviral therapy (ART) initiated on a prenatal basis in HIV-infected pregnant women is a highly effective method for preventing mother-to-child HIV transmission. We developed a decision analytic model to project the clinical and economic outcomes of alternative HIV screening strategies (voluntary prenatal screening [VPS], routine prenatal screening [RPS], and mandatory newborn screening [MNS]) for a high-risk population of incarcerated pregnant women. Data for the decision model came from the HIV voluntary counseling and testing program at Connecticut's sole correctional facility for women and a comprehensive anonymously linked serosurvey of all inmates who entered the facility during the 2-year period beginning in October 1994. Based on serosurvey results, in the absence of any HIV screening program, 2.5 cases of pediatric HIV infection would be expected per 1000 pregnancies. Multiplied by the discounted lifetime cost per case of $247,000, this translates to a cost of $624 per testing-eligible prison entrant. Entrants were considered eligible if they were pregnant and their HIV status was unknown. MNS would save money, cost $364 per eligible entrant, and simultaneously reduce the rate of infections to 1.1 per 1000 pregnancies. Doing both MNS and RPS is most effective in reducing the rate of new infections (down to 0.2 per 1000 pregnancies). It would, however, increase costs to $430 per eligible entrant. This would result in an incremental cost of $73,603 per additional pediatric HIV case averted when compared with MNS alone. If mandatory newborn testing was not considered a feasible option, RPS would dominate VPS and would be cost-saving compared with no screening. RPS compares favorably with alternative uses of HIV prevention and treatment resources. In correctional facilities where voluntary newborn screening is already in place, our findings show that there remains a small marginal benefit to be realized from switching to RPS. In settings where HIV screening policies are not in place, however, the implementation of RPS can be expected to significantly reduce pediatric HIV cases and net health care expenditures.

Antiretroviral therapy (ART) initiated on a prenatal basis in HIV-infected pregnant women is a highly effective method for preventing mother-to-child HIV transmission. We developed a decision analytic model to project the clinical and economic ... (more »)

Frankia strains are actinomycetes that fix N2 in root nodules of plants classified in eight families of the Angiospermae. The wide variety of plants infected has raised questions about the ecology and diversity of Frankia symbionts, and their co-evolution with actinorhizal plants. Partial sequencing was done of the small subunit (16S) rRNA gene from Frankia endophytes present in the root nodules of Alnus cordata, A. glutinosa, A. viridis, Casuarina equisetifolia, Coriaria arborea, C. plumosa, and Elaeagnus pungens growing in New Zealand. With the exceptions of the Coriaria spp., all of the plants are exotic to New Zealand. Analysis of the 16S rRNA gene indicates that the exotic species were nodulated by Frankia strains that cluster with strain groups previously shown to be typical for each actinorhizal host. Frankia in 12 native Coriaria spp. nodules yielded two sequences differing in only one position, suggesting a relatively low diversity compared with the exotic species.

Frankia strains are actinomycetes that fix N2 in root nodules of plants classified in eight families of the Angiospermae. The wide variety of plants infected has raised questions about the ecology and diversity of Frankia symbion... (more »)