Costs of Dengue Control Activities and Hospitalizations in the Public Health Sector during an Epidemic Year in Urban Sri Lanka

Background

Reported as a public health problem since the 1960s in Sri Lanka, dengue has become a high priority disease for public health authorities. The Ministry of Health is responsible for controlling dengue and other disease outbreaks and associated health care. The involvement of large numbers of public health staff in dengue control activities year-round and the provision of free medical care to dengue patients at secondary care hospitals place a formidable financial burden on the public health sector.

Methods

We estimated the public sector costs of dengue control activities and the direct costs of hospitalizations in Colombo, the most heavily urbanized district in Sri Lanka, during the epidemic year of 2012 from the Ministry of Health’s perspective. The financial costs borne by public health agencies and hospitals are collected using cost extraction tools designed specifically for the study and analysed retrospectively using a combination of activity-based and gross costing approaches.

Results

The total cost of dengue control and reported hospitalizations was estimated at US$3.45 million (US$1.50 per capita) in Colombo district in 2012. Personnel costs accounted for the largest shares of the total costs of dengue control activities (79%) and hospitalizations (46%). The results indicated a per capita cost of US$0.42 for dengue control activities. The average costs per hospitalization ranged between US$216–609 for pediatric cases and between US$196–866 for adult cases according to disease severity and treatment setting.

Conclusions

This analysis is a first attempt to assess the economic burden of dengue response in the public health sector in Sri Lanka. Country-specific evidence is needed for setting public health priorities and deciding about the deployment of existing or new technologies. Our results suggest that dengue poses a major economic burden on the public health sector in Sri Lanka.     

The Relationship between Body Mass Index and Hospitalisation Rates,Days in Hospital and Costs: Findings from a Large Prospective Linked Data Study

Background

Internationally there is limited empirical evidence on the impact of overweight and obesity on health service use and costs. We estimate the burden of hospitalisation—admissions, days and costs—associated with above-normal BMI.

Methods

Population-based prospective cohort study involving 224,254 adults aged ≥45y in Australia (45 and Up Study). Baseline questionnaire data (2006-2009) were linked to hospitalisation and death records (median follow-up 3.42y) and hospital cost data. The relationships between BMI and hospital admissions and days were modelled using zero-inflated negative binomial regression; generalised gamma models were used to model costs. Analyses were stratified by sex and age (45-64, 65-79, ≥80y), and adjusted for age, area of residence, education, income, smoking, alcohol-intake and private health insurance status. Population attributable fractions were also calculated.

Results

There were 459,346 admissions (0.55/person-year) and 1,483,523 hospital days (1.76/person-year) during follow-up. For ages 45-64y and 65-79y, rates of admissions, days and costs increased progressively with increments of above-normal BMI. Compared to BMI 22.5-<25kg/m², rates of admissions and days were 1.64-2.54 times higher for BMI 40-50kg/m²; costs were 1.14-1.24 times higher for BMI 27.5-<30kg/m², rising to 1.77-2.15 times for BMI 40-50kg/m². The BMI-hospitalisation relationship was less clear for ≥80y. We estimated that among Australians 45-79y, around 1 in every 8 admissions are attributable to overweight and obesity (2% to overweight, 11% to obesity), as are 1 in every 6 days in hospital (2%, 16%) and 1 in every 6 dollars spent on hospitalisation (3%, 14%).

Conclusions

The dose-response relationship between BMI and hospital use and costs in mid-age and older Australians in the above-normal BMI range suggests even small downward shifts in BMI among these people could result in considerable reductions in their annual health care costs; whether this would result in long-term savings to the health care system is not known from this study.     

Scaling Up Family Planning to Reduce Maternal and Child Mortality: The Potential Costs and Benefits of Modern Contraceptive Use in South Africa

Introduction

Family planning contributes significantly to the prevention of maternal and child mortality. However, many women still do not use modern contraception and the numbers of unintended pregnancies, abortions and subsequent deaths are high. In this paper, we estimate the service delivery costs of scaling up modern contraception, and the potential impact on maternal, newborn and child survival in South Africa.

Methods

The Family Planning model in Spectrum was used to project the impact of modern contraception on pregnancies, abortions and births in South Africa (2015-2030). The contraceptive prevalence rate (CPR) was increased annually by 0.68 percentage points. The Lives Saved Tool was used to estimate maternal and child deaths, with coverage of essential maternal and child health interventions increasing by 5% annually. A scenario analysis was done to test impacts when: the change in CPR was 0.1% annually; and intervention coverage increased linearly to 99% in 2030.

Results

If CPR increased by 0.68% annually, the number of pregnancies would reduce from 1.3 million in 2014 to one million in 2030. Unintended pregnancies, abortions and births decrease by approximately 20%. Family planning can avert approximately 7,000 newborn and child and 600 maternal deaths. The total annual costs of providing modern contraception in 2030 are estimated to be US$33 million and the cost per user of modern contraception is US$7 per year. The incremental cost per life year gained is US$40 for children and US$1,000 for mothers.

Conclusion

Maternal and child mortality remain high in South Africa, and scaling up family planning together with optimal maternal, newborn and child care is crucial. A huge impact can be made on maternal and child mortality, with a minimal investment per user of modern contraception.     

Who Are the High-Cost Users? A Method for Person-Centred Attribution of Health Care Spending

Objective

To develop person-centered episodes of care (PCE) for community-dwelling individuals in the top fifth percentile of Ontario health care expenditures in order to: (1) describe the main clinical groupings for spending; and (2) identify patterns of spending by health sector (e.g. acute care, home care, physician billings) within and across PCE.

Data sources

Data were drawn from population-based administrative databases for all publicly funded health care in Ontario, Canada in 2010/11.

Study design

This study is a retrospective cohort study.

Data collection/extraction methods

A total of 587,982 community-dwelling individuals were identified among those accounting for the top 5% of provincial health care expenditures between April 1, 2010 and March 31, 2011. PCE were defined as starting with an acute care admission and persisting through subsequent care settings and providers until individuals were without health system contact for 30 days. PCE were classified according to the clinical grouping for the initial admission. PCE and non-PCE costs were calculated and compared to provide a comprehensive measurement of total health system costs for the year.

Principal findings

Among this community cohort, 697,059 PCE accounted for nearly 70% ($11,815.3 million (CAD)) of total annual publicly-funded expenditures on high-cost community-dwelling individuals. The most common clinical groupings to start a PCE were Acute Planned Surgical (35.2%), Acute Unplanned Medical (21.0%) and Post-Admission Events (10.8%). Median PCE costs ranged from $3,865 (IQR = $1,712-$10,919) for Acute Planned Surgical to $20,687 ($12,207-$39,579) for Post-Admission Events. Inpatient acute ($8,194.5 million) and inpatient rehabilitation ($434.6 million) health sectors accounted for the largest proportions of allocated PCE spending over the year.

Conclusions

Our study provides a novel methodological approach to categorize high-cost health system users into meaningful person-centered episodes. This approach helps to explain how costs are attributable within individuals across sectors and has applications in episode-based payment formulas and quality monitoring.     

Counting the Cost of Diabetes in the Solomon Islands and Nauru

Aim

To determine the costs associated with diabetes to governments, people with diabetes and their carers, and its impact on quality of life in two Pacific Island countries—the Solomon Islands and Nauru.

Materials and Methods

This cross-sectional cost of illness study was conducted on 330 people with type 2 diabetes (197 from the Solomon Islands and 133 from Nauru) using a structured cost of illness survey questionnaire adapted from the Australian DiabCo$t study. Quality of life was measured by the EQ-5D Visual Analogue Scale.

Results

There were 330 respondents (50% female; mean duration of diabetes 10.9 years; mean age 52.6 years). The estimated annual national cost of diabetes incurred by the Solomon Islands government was AUD12.8 million (AUD281 per person/year) and by Nauru government was AUD1.2 million (AUD747 per person/year). The major contribution to the government costs was inpatient services cost (71% in the Solomon Islands and 83% in Nauru). Annual expenditure for diabetes was approximately 20% of the governments’ annual health care expenditure. Considerable absenteeism and retirement from work due to diabetes was found.

Conclusions

This study found substantial public and personal costs associated with diabetes. The findings provide objective data on which health policy, funding and planning decisions about the prevention and control of diabetes in the Solomon Islands and Nauru can be reliably based and subsequently evaluated.     

The Economic Burden Attributable to a Child’s Inpatient Admission for Diarrheal Disease in Rwanda

Background

Diarrhea is one of the leading causes of childhood morbidity and mortality. Hospitalization for diarrhea can pose a significant burden to health systems and households. The objective of this study was to estimate the economic burden attributable to hospitalization for diarrhea among children less than five years old in Rwanda. These data can be used by decision-makers to assess the impact of interventions that reduce diarrhea morbidity, including rotavirus vaccine introduction.

Methods

This was a prospective costing study where medical records and hospital bills for children admitted with diarrhea at three hospitals were collected to estimate resource use and costs. Hospital length of stay was calculated from medical records. Costs incurred during the hospitalization were abstracted from the hospital bills. Interviews with the child’s caregivers provided data to estimate household costs which included transport costs and lost income. The portion of medical costs borne by insurance and household were reported separately. Annual economic burden before and after rotavirus vaccine introduction was estimated by multiplying the reported number of diarrhea hospitalizations in public health centers and district hospitals by the estimated economic burden per hospitalization. All costs are presented in 2014 US$.

Results

Costs for 203 children were analyzed. Approximately 93% of the children had health insurance coverage. Average hospital length of stay was 5.3 ± 3.9 days. Average medical costs for each child for the illness resulting in a hospitalization were $44.22 ± $23.74 and the total economic burden was $101, of which 65% was borne by the household. For households in the lowest income quintile, the household costs were 110% of their monthly income. The annual economic burden to Rwanda attributable to diarrhea hospitalizations ranged from $1.3 million to $1.7 million before rotavirus vaccine introduction.

Conclusion

Households often bear the largest share of the economic burden attributable to diarrhea hospitalization and the burden can be substantial, especially for households in the lowest income quintile.     

Reducing Sexual Violence by Increasing the Supply of Toilets in Khayelitsha,South Africa: A Mathematical Model

Background

Sexual violence is a major public health issue, affecting 35% of women worldwide. Major risk factors for sexual assault include inadequate indoor sanitation and the need to travel to outdoor toilet facilities. We estimated how increasing the number of toilets in an urban township (Khayelitsha, South Africa) might reduce both economic costs and the incidence and social burden of sexual assault.

Methods

We developed a mathematical model that links risk of sexual assault to the number of sanitation facilities and the time a woman must spend walking to a toilet. We defined a composite societal cost function, comprising both the burden of sexual assault and the costs of installing and maintaining public chemical toilets. By expressing total social costs as a function of the number of available toilets, we were able to identify an optimal (i.e., cost-minimizing) social investment in toilet facilities.

Findings

There are currently an estimated 5600 toilets in Khayelitsha. This results in 635 sexual assaults and US$40 million in combined social costs each year. Increasing the number of toilets to 11300 would minimize total costs ($35 million) and reduce sexual assaults to 446. Higher toilet installation and maintenance costs would be more than offset by lower sexual assault costs. Probabilistic sensitivity analysis shows that the optimal number of toilets exceeds the original allocation of toilets in the township in over 80% of the 5000 iterations of the model.

Interpretation

Improving access to sanitation facilities in urban settlements will simultaneously reduce the incidence of sexual assaults and overall cost to society. Since our analysis ignores the many additional health benefits of improving sanitation in resource-constrained urban areas (e.g., potential reductions in waterborne infectious diseases), the optimal number of toilets identified here should be interpreted as conservative.     

Cost-Effectiveness of Screening and Treating Foreign-Born Students for Tuberculosis before Entering the United States

Introduction

The Centers for Disease Control and Prevention is considering implementation of overseas medical screening of student-visa applicants to reduce the numbers of active tuberculosis cases entering the United States.

Objective

To evaluate the costs, cases averted, and cost-effectiveness of screening for, and treating, tuberculosis in United States-bound students from countries with varying tuberculosis prevalence.

Methods

Costs and benefits were evaluated from two perspectives, combined and United States only. The combined perspective totaled overseas and United States costs and benefits from a societal perspective. The United States only perspective was a domestic measure of costs and benefits. A decision tree was developed to determine the cost-effectiveness of tuberculosis screening and treatment from the combined perspective.

Results

From the United States only perspective, overseas screening programs of Chinese and Indian students would prevent the importation of 157 tuberculosis cases annually, and result in $2.7 million in savings. From the combined perspective, screening programs for Chinese students would cost more than $2.8 million annually and screening programs for Indian students nearly $440,000 annually. From the combined perspective, the incremental cost for each tuberculosis case averted by screening Chinese and Indian students was $22,187 and $15,063, respectively. Implementing screening programs for German students would prevent no cases in most years, and would result in increased costs both overseas and in the United States. The domestic costs would occur because public health departments would need to follow up on students identified overseas as having an elevated risk of tuberculosis.

Conclusions

Tuberculosis screening and treatment programs for students seeking long term visas to attend United States schools would reduce the number of tuberculosis cases imported. Implementing screening in high-incidence countries could save the United States millions of dollars annually; however there would be increased costs incurred overseas for students and their families.     

Redrawing the US Obesity Landscape: Bias-Corrected Estimates of State-Specific Adult Obesity Prevalence

Background

State-level estimates from the Centers for Disease Control and Prevention (CDC) underestimate the obesity epidemic because they use self-reported height and weight. We describe a novel bias-correction method and produce corrected state-level estimates of obesity and severe obesity.

Methods

Using non-parametric statistical matching, we adjusted self-reported data from the Behavioral Risk Factor Surveillance System (BRFSS) 2013 (n = 386,795) using measured data from the National Health and Nutrition Examination Survey (NHANES) (n = 16,924). We validated our national estimates against NHANES and estimated bias-corrected state-specific prevalence of obesity (BMI≥30) and severe obesity (BMI≥35). We compared these results with previous adjustment methods.

Results

Compared to NHANES, self-reported BRFSS data underestimated national prevalence of obesity by 16% (28.67% vs 34.01%), and severe obesity by 23% (11.03% vs 14.26%). Our method was not significantly different from NHANES for obesity or severe obesity, while previous methods underestimated both. Only four states had a corrected obesity prevalence below 30%, with four exceeding 40%–in contrast, most states were below 30% in CDC maps.

Conclusions

Twelve million adults with obesity (including 6.7 million with severe obesity) were misclassified by CDC state-level estimates. Previous bias-correction methods also resulted in underestimates. Accurate state-level estimates are necessary to plan for resources to address the obesity epidemic.     

Costs and Cost Effectiveness of Three Approaches for Cervical Cancer Screening among HIV-Positive Women in Johannesburg,South Africa

Background

South Africa has high rates of HIV and HPV and high incidence and mortality from cervical cancer. However, cervical cancer is largely preventable when early screening and treatment are available. We estimate the costs and cost-effectiveness of conventional cytology (Pap), visual inspection with acetic acid (VIA) and HPV DNA testing for detecting cases of CIN2+ among HIV-infected women currently taking antiretroviral treatment at a public HIV clinic in Johannesburg, South Africa.

Methods

Method effectiveness was derived from a validation study completed at the clinic. Costs were estimated from the provider perspective using micro-costing between June 2013-April 2014. Capital costs were annualized using a discount rate of 3%. Two different service volume scenarios were considered. Threshold analysis was used to explore the potential for reducing the cost of HPV DNA testing.

Results

VIA was least costly in both scenarios. In the higher volume scenario, the average cost per procedure was US$ 3.67 for VIA, US$ 8.17 for Pap and US$ 54.34 for HPV DNA. Colposcopic biopsies cost on average US$ 67.71 per procedure. VIA was least sensitive but most cost-effective at US$ 17.05 per true CIN2+ case detected. The cost per case detected for Pap testing was US$ 130.63 using a conventional definition for positive results and US$ 187.52 using a more conservative definition. HPV DNA testing was US$ 320.09 per case detected. Colposcopic biopsy costs largely drove the total and per case costs. A 71% reduction in HPV DNA screening costs would make it competitive with the conservative Pap definition.

Conclusions

Women need access to services which meet their needs and address the burden of cervical dysplasia and cancer in this region. Although most cost-effective, VIA may require more frequent screening due to low sensitivity, an important consideration for an HIV-positive population with increased risk for disease progression.     

Healthcare Service Utilization for Practicing Physicians: A Population-Based Study

Background

Physicians are considered to be the most informed consumers in the use of medical services since they have more information about diseases or medical technology. However, although plenty of researchers have suggested that different medical seeking behavior exists among physicians, very few empirical studies have been conducted to investigate differences in medical utilization between physicians and the general population.

Objective

We explored differences in the utilization of healthcare services between physicians and the general population using a population-based dataset.

Design

A cross-sectional study.

Participants

Data for this study were sourced from the Taiwan Longitudinal Health Insurance Database 2000. We included 1426 physicians and 1426 sex- and age-matched comparison subjects.

Methods

We used Wilcoxon-Mann-Whitney tests to explore differences in variables of healthcare resource utilization between physicians and comparison subjects. We further used Kruskal-Wallis tests to examine differences in variables of healthcare resource utilization between physician practice location and comparison subjects.

Results

We found that physicians had significantly fewer outpatient visits (13.2 vs. 15.7, p<0.001) and significantly lower outpatient costs (US$477 vs. US$680, p<0.001) than comparison subjects. Furthermore, physicians had lower total health service costs than comparison subjects (US$643 vs. US$1066, p<0.001). This indicates that the mean total health service costs in the year 2010 was 1.66-fold greater for comparison subjects than for physicians. We also found that there were significant differences in the mean number of outpatient services (p<0.001), outpatient costs (p = 0.001), inpatients costs (p = 0.018), and total costs (p = 0.001) among office-based physicians, hospital-based physicians, and comparison subjects. Specifically, Scheffe contrast tests showed that office-based physicians had significantly more outpatient visits (19.3 vs.10.7, p<0.001) and significantly higher outpatient costs (US$656 vs. US$402, p<0.001) than hospital-based physicians.

Conclusions

Physicians had less healthcare utilization than comparison subjects. Furthermore, hospital-based physicians had higher inpatient costs and less outpatient services and costs than office-based physicians.     

A Cost-Effectiveness Analysis of a Home-Based HIV Counselling and Testing Intervention versus the Standard (Facility Based) HIV Testing Strategy in Rural South Africa

Introduction

There is growing evidence concerning the acceptability and feasibility of home-based HIV testing. However, less is known about the cost-effectiveness of the approach yet it is a critical component to guide decisions about scaling up access to HIV testing. This study examined the cost-effectiveness of a home-based HIV testing intervention in rural South Africa.

Methods

Two alternatives: clinic and home-based HIV counselling and testing were compared. Costs were analysed from a provider’s perspective for the period of January to December 2010. The outcome, HIV counselling and testing (HCT) uptake was obtained from the Good Start home-based HIV counselling and testing (HBHCT) cluster randomised control trial undertaken in KwaZulu-Natal province. Cost-effectiveness was estimated for a target population of 22,099 versus 23,864 people for intervention and control communities respectively. Average costs were calculated as the cost per client tested, while cost-effectiveness was calculated as the cost per additional client tested through HBHCT.

Results

Based on effectiveness of 37% in the intervention (HBHCT) arm compared to 16% in control arm, home based testing costs US$29 compared to US$38 per person for clinic HCT. The incremental cost effectiveness per client tested using HBHCT was $19.

Conclusions

HBHCT was less costly and more effective. Home-based HCT could present a cost-effective alternative for rural ‘hard to reach’ populations depending on affordability by the health system, and should be considered as part of community outreach programs.     

The Health Care Cost of Dying: A Population-Based Retrospective Cohort Study of the Last Year of Life in Ontario,Canada

Background

Coordinated and appropriate health care across sectors is an ongoing challenge, especially at the end-of-life. Population-level data on end-of-life health care use and cost, however, are seldom reported across a comprehensive array of sectors. Such data will identify the level of care being provided and areas where care can be optimized.

Methods

This retrospective cohort study identified all deaths in Ontario from April 1, 2010 to March 31, 2013. Using population-based health administrative databases, we examined health care use and cost in the last year of life.

Results

Among 264,755 decedents, the average health care cost in the last year of life was $53,661 (Quartile 1-Quartile 3: $19,568-$66,875). The total captured annual cost of $4.7 billion represents approximately 10% of all government-funded health care. Inpatient care, incurred by 75% of decedents, contributed 42.9% of total costs ($30,872 per user). Physician services, medications/devices, laboratories, and emergency rooms combined to less than 20% of total cost. About one-quarter used long-term-care and 60% used home care ($34,381 and $7,347 per user, respectively). Total cost did not vary by sex or neighborhood income quintile, but were less among rural residents. Costs rose sharply in the last 120 days prior to death, predominantly for inpatient care.

Interpretation

This analysis adds new information about the breadth of end-of-life health care, which consumes a large proportion of Ontario’s health care budget. The cost of inpatient care and long-term care are substantial. Introducing interventions that reduce or delay institutional care will likely reduce costs incurred at the end of life.     

Economic Cost of Campylobacter,Norovirus and Rotavirus Disease in the United Kingdom

Objectives

To estimate the annual cost to patients, the health service and society of infectious intestinal disease (IID) from Campylobacter, norovirus and rotavirus.

Design

Secondary data analysis.

Setting

The United Kingdom population, 2008–9.

Main outcome measures

Cases and frequency of health services usage due to these three pathogens; associated healthcare costs; direct, out-of-pocket expenses; indirect costs to patients and caregivers.

Results

The median estimated costs to patients and the health service at 2008–9 prices were: Campylobacter £50 million (95% CI: £33m–£75m), norovirus £81 million (95% CI: £63m–£106m), rotavirus £25m (95% CI: £18m–£35m). The costs per case were approximately £30 for norovirus and rotavirus, and £85 for Campylobacter. This was mostly borne by patients and caregivers through lost income or out-of-pocket expenditure. The cost of Campylobacter-related Guillain-Barré syndrome hospitalisation was £1.26 million (95% CI: £0.4m–£4.2m).

Conclusions

Norovirus causes greater economic burden than Campylobacter and rotavirus combined. Efforts to control IID must prioritise norovirus. For Campylobacter, estimated costs should be considered in the context of expenditure to control this pathogen in agriculture, food production and retail. Our estimates, prior to routine rotavirus immunisation in the UK, provide a baseline vaccine cost-effectiveness analyses.     

Excess Costs of Comorbidities in Chronic Obstructive Pulmonary Disease: A Systematic Review

Background

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Comorbidities are often reported in patients with COPD and may influence the cost of care. Yet, the extent by which comorbidities affect costs remains to be determined.

Objectives

To review, quantify and evaluate excess costs of comorbidities in COPD.

Methods

Using a systematic review approach, Pubmed and Embase were searched for studies analyzing excess costs of comorbidities in COPD. Resulting studies were evaluated according to study characteristics, comorbidity measurement and cost indicators. Mark-up factors were calculated for respective excess costs. Furthermore, a checklist of quality criteria was applied.

Results

Twelve studies were included. Nine evaluated comorbidity specific costs; three examined index-based results. Pneumonia, cardiovascular disease and diabetes were associated with the highest excess costs. The mark-up factors for respective excess costs ranged between 1.5 and 2.5 in the majority of cases. On average the factors constituted a doubling of respective costs in the comorbid case. The main cost driver, among all studies, was inpatient cost. Indirect costs were not accounted for by the majority of studies. Study heterogeneity was high.

Conclusions

The reviewed studies clearly show that comorbidities are associated with significant excess costs in COPD. The inclusion of comorbid costs and effects in future health economic evaluations of preventive or therapeutic COPD interventions seems highly advisable.     

Voluntary medical male circumcision: modeling the impact and cost of expanding male circumcision for HIV prevention in eastern and southern Africa

Background

There is strong evidence showing that voluntary medical male circumcision (VMMC) reduces HIV incidence in men. To inform the VMMC policies and goals of 13 priority countries in eastern and southern Africa, we estimate the impact and cost of scaling up adult VMMC using updated, country-specific data.

Methods and Findings

We use the Decision Makers'' Program Planning Tool (DMPPT) to model the impact and cost of scaling up adult VMMC in Botswana, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe, and Nyanza Province in Kenya. We use epidemiologic and demographic data from recent household surveys for each country. The cost of VMMC ranges from US$65.85 to US$95.15 per VMMC performed, based on a cost assessment of VMMC services aligned with the World Health Organization''s considerations of models for optimizing volume and efficiencies. Results from the DMPPT models suggest that scaling up adult VMMC to reach 80% coverage in the 13 countries by 2015 would entail performing 20.34 million circumcisions between 2011 and 2015 and an additional 8.42 million between 2016 and 2025 (to maintain the 80% coverage). Such a scale-up would result in averting 3.36 million new HIV infections through 2025. In addition, while the model shows that this scale-up would cost a total of US$2 billion between 2011 and 2025, it would result in net savings (due to averted treatment and care costs) amounting to US$16.51 billion.

Conclusions

This study suggests that rapid scale-up of VMMC in eastern and southern Africa is warranted based on the likely impact on the region''s HIV epidemics and net savings. Scaling up of safe VMMC in eastern and southern Africa will lead to a substantial reduction in HIV infections in the countries and lower health system costs through averted HIV care costs. Please see later in the article for the Editors'' Summary.     

Costing Alternative Birth Settings for Women at Low Risk of Complications: A Systematic Review

Background

There is demand from women for alternatives to giving birth in a standard hospital setting however access to these services is limited. This systematic review examines the literature relating to the economic evaluations of birth setting for women at low risk of complications.

Methods

Searches of the literature to identify economic evaluations of different birth settings of the following electronic databases: MEDLINE, CINAHL, EconLit, Business Source Complete and Maternity and Infant care. Relevant English language publications were chosen using keywords and MeSH terms between 1995 and 2015. Inclusion criteria included studies focussing on the comparison of birth setting. Data were extracted with respect to study design, perspective, PICO principles, and resource use and cost data.

Results

Eleven studies were included from Australia, Canada, the Netherlands, Norway, the USA, and the UK. Four studies compared costs between homebirth and the hospital setting and the remaining seven focussed on the cost of birth centre care and the hospital setting. Six studies used a cost-effectiveness analysis and the remaining five studies used cost analysis and cost comparison methods. Eight of the 11 studies found a cost saving in the alternative settings. Two found no difference in the cost of the alternative settings and one found an increase in birth centre care.

Conclusions

There are few studies that compare the cost of birth setting. The variation in the results may be attributable to the cost data collection processes, difference in health systems and differences in which costs were included. A better understanding of the cost of birth setting is needed to inform policy makers and service providers.     

Oral Ondansetron Administration in Emergency Departments to Children with Gastroenteritis: An Economic Analysis

Background

The use of antiemetics for children with vomiting is one of the most controversial decisions in the treatment of gastroenteritis in developed countries. Ondansetron, a selective serotonin receptor antagonist, has been found to be effective in improving the success of oral rehydration therapy. However, North American and European clinical practice guidelines continue to recommend against its use, stating that evidence of cost savings would be required to support ondansetron administration. Thus, an economic analysis of the emergency department administration of ondansetron was conducted. The primary objective was to conduct a cost analysis of the routine administration of ondansetron in both the United States and Canada.

Methods and Findings

A cost analysis evaluated oral ondansetron administration to children presenting to emergency departments with vomiting and dehydration secondary to gastroenteritis from a societal and health care payer''s perspective in both the US and Canada. A decision tree was developed that incorporated the frequency of vomiting, intravenous insertion, hospitalization, and emergency department revisits. Estimates of the monetary costs associated with ondansetron use, intravenous rehydration, and hospitalization were derived from administrative databases or emergency department use. The economic burden in children administered ondansetron plus oral rehydration therapy was compared to those not administered ondansetron employing deterministic and probabilistic simulations. We estimated the costs or savings to society and health care payers associated with the routine administration of ondansetron. Sensitivity analyses considered variations in costs, treatment effects, and exchange rates. In the US the administration of ondansetron to eligible children would prevent approximately 29,246 intravenous insertions and 7,220 hospitalizations annually. At the current average wholesale price, its routine administration to eligible children would annually save society US$65.6 million (US$49.1–US$81.1) and health care payers US$61.1 million (US$46.2–US$76.3). In Canada the administration of ondansetron to eligible children would prevent 4,065 intravenous insertions and 1,003 hospitalizations annually. Its routine administration would annually save society CDN$1.72 million (CDN$1.15–CDN$1.89) and the health care system CDN$1.18 million (CDN$0.88–CDN$1.41).

Conclusions

In countries where intravenous rehydration is often employed, the emergency department administration of oral ondansetron to children with dehydration and vomiting secondary to gastroenteritis results in significant monetary savings compared to a no-ondansetron policy. Please see later in the article for the Editors'' Summary     

The Health System and Population Health Implications of Large-Scale Diabetes Screening in India: A Microsimulation Model of Alternative Approaches

Background

Like a growing number of rapidly developing countries, India has begun to develop a system for large-scale community-based screening for diabetes. We sought to identify the implications of using alternative screening instruments to detect people with undiagnosed type 2 diabetes among diverse populations across India.

Methods and Findings

We developed and validated a microsimulation model that incorporated data from 58 studies from across the country into a nationally representative sample of Indians aged 25–65 y old. We estimated the diagnostic and health system implications of three major survey-based screening instruments and random glucometer-based screening. Of the 567 million Indians eligible for screening, depending on which of four screening approaches is utilized, between 158 and 306 million would be expected to screen as “high risk” for type 2 diabetes, and be referred for confirmatory testing. Between 26 million and 37 million of these people would be expected to meet international diagnostic criteria for diabetes, but between 126 million and 273 million would be “false positives.” The ratio of false positives to true positives varied from 3.9 (when using random glucose screening) to 8.2 (when using a survey-based screening instrument) in our model. The cost per case found would be expected to be from US$5.28 (when using random glucose screening) to US$17.06 (when using a survey-based screening instrument), presenting a total cost of between US$169 and US$567 million. The major limitation of our analysis is its dependence on published cohort studies that are unlikely fully to capture the poorest and most rural areas of the country. Because these areas are thought to have the lowest diabetes prevalence, this may result in overestimation of the efficacy and health benefits of screening.

Conclusions

Large-scale community-based screening is anticipated to produce a large number of false-positive results, particularly if using currently available survey-based screening instruments. Resource allocators should consider the health system burden of screening and confirmatory testing when instituting large-scale community-based screening for diabetes.