Reaching Absent and Refusing Individuals During Home-Based HIV Testing Through Self-Testing—at What Cost?

Introduction: In the HOSENG trial (NCT03598686), the secondary distribution of oral self-tests for persons absent or refusing to test during a home-based HIV testing campaign in rural Lesotho resulted in an increase in testing coverage of 21% compared to a testing campaign without secondary distribution. This study aims to determine the per patient costs of both HOSENG trial arms.Method: We conducted a micro-costing study to estimate the cost of home-based HIV testing with (HOSENG intervention arm) and without (HOSENG control arm) secondary self-test distribution from a provider's perspective. A mixture of top-down and bottom-up costing was used. We estimated both the financial and economic per patient costs of each possible testing cascade scenario. The costs were adjusted to 2018 US$.Results: The overall provider cost for delivering the home-based HIV testing with secondary distribution was US$36,481 among the 4,174 persons enumerated and 3,094 eligible for testing in the intervention villages compared to US$28,620 for 3,642 persons enumerated and 2,727 eligible for testing in the control. The cost per person eligible for testing was US$11.79 in the intervention vs. US$10.50 in the control. This difference was mainly driven by the cost of distributed oral self-tests. The cost per person tested was, however, lower in intervention villages (US$15.70 vs. US$22.15) due to the higher testing coverage achieved through self-test distribution. The cost per person confirmed new HIV+ was US$889.79 in the intervention and US$753.17 in the control.Conclusion: During home-based HIV testing in Lesotho, the secondary distribution of self-tests for persons absent or refusing to test during the visit reduced the costs per person tested and thus presents a promising add-on for such campaigns.Trial Registration:https://ClinicalTrials.gov/, identifier: NCT03598686

OB Nest randomized controlled trial: a cost comparison of reduced visit compared to traditional prenatal care

Background Traditional prenatal care includes up to 13 in person office visits, and the cost of this care is not well-described. Alternative models are being explored to better meet the needs of patients and providers. OB Nest is a telemedicine-enhanced program with a reduced frequency of in-person prenatal visits. The cost implications of connected care services added to prenatal care packages are unclear. Methods Using data from the OB Nest randomized, controlled trial we analyzed the provider and staff time associated with prenatal care in the traditional and OB Nest models. Fewer visits were required for OB Nest, but given the compensatory increase in connected care activity and supplies, the actual cost difference is not known. Nursing and provider staff time was prospectively recorded for all patients enrolled in the OB Nest clinical trial. Published 2015 national wages for healthcare workers were used to calculate the actual labor cost of providing either traditional or OB Nest prenatal care in 2015 US dollars. Overhead expenses and opportunity costs were not considered. Results Total provider cost was decreased caring for the OB Nest participants, but nursing cost was increased. OB Nest care required an average of 160.8 (+/− 45.0) minutes provider time and 237 (+/− 25.1) minutes nursing time, compared to 215.0 (+/− 71.6) and 99.6 (+/− 29.7) minutes for traditional prenatal care (P < 0.01). This translated into decreased provider cost and increased nursing cost (P < 0.01). Supply costs increased, travel costs declined, and overhead costs declined in the OB Nest model. Conclusions In this trial, labor cost for OB Nest prenatal care was 34% higher than for traditional prenatal care. The increased cost is largely attributable to additional nursing connected care time, and in some practice settings may be offset by decreased overhead costs and increased provider billing opportunities. Future efforts will be focused on development of digital solutions for some routine nursing tasks to decrease the overall cost of the model. Trial registrations ClinicalTrials.gov Identifier: NCT02082275.

OB Nest Randomized Controlled Trial: A Cost Comparison of Reduced Visit Compared to Traditional Prenatal Care

BackgroundTraditional prenatal care includes up to 13 in person office visits, and the cost of this care is not well-described. Alternative models are being explored to better meet the needs of patients and providers. OB Nest is a telemedicine-enhanced program with a reduced frequency of in-person prenatal visits. The cost implications of connected care services added to prenatal care packages are unclear.MethodsUsing data from the OB Nest randomized, controlled trial we analyzed the provider and staff time associated with prenatal care in the traditional and OB Nest models. Fewer visits were required for OB Nest, but given the compensatory increase in connected care activity and supplies, the actual cost difference is not known.Nursing and provider staff time was prospectively recorded for all patients enrolled in the OB Nest clinical trial. Published 2015 national wages for healthcare workers were used to calculate the actual labor cost of providing either traditional or OB Nest prenatal care in 2015 US dollars. Overhead expenses and opportunity costs were not considered.ResultsTotal provider cost was decreased caring for the OB Nest participants, but nursing cost was increased. OB Nest care required an average of 160.8 (+/- 45.0) minutes provider time and 87.8 (+/- 25.1) minutes nursing time, compared to 215.0 (+/- 71.6) and 99.6 (+/- 29.7) minutes for traditional prenatal care (P<0.01). This translated into decreased provider cost and increased nursing cost (P<0.01). Supply costs increased, travel costs declined, and overhead costs declined in the OB Nest model. ConclusionsIn this trial, labor cost for OB Nest prenatal care was 34% higher than for traditional prenatal care. The increased cost is largely attributable to additional nursing connected care time, and in some practice settings may be offset by decreased overhead costs and increased provider billing opportunities. Future efforts will be focused on development of digital solutions for some routine nursing tasks to decrease the overall cost of the model. Trial Registrations: ClinicalTrials.gov Identifier: NCT02082275

A SERVICE IMPROVEMENT OPPORTUNITY FOR PHARMACIST INDEPENDENT PRESCRIBERS? A LITERATURE REVIEW EXAMINING THE RELATIONSHIP BETWEEN POOR DIABETES CONTROL AND THE CO-EXISTENCE OF MENTAL HEALTH ISSUES

Diabetes and mental illness are clinically managed by diverse pathways. However, an association between the two has been observed and evidence is growing that when poorly addressed, therapy adherence is low and outcomes are poor. To date, no intervention has been shown to provide sustained improvements in adherence, outcome, quality of life or provider cost savings. This literature review was undertaken as a foundation to a research project to examine whether there is an opportunity for current independent prescriber pharmacists, with or without further training, could as part of a primary care team, contribute their expertise to achieving better and sustainable outcomes for these conditions, where current treatment models are heavily medication-dependent. It reinforces the idea that these conditions are interlinked but by poorly understood mechanisms and suggests that a new approach is required in order to improve outcomes for this complex patient group.

Cost of preterm birth during initial hospitalization: A care provider’s perspective

ABSTRACTPreterm birth incidence has risen globally and remains a major cause of neonatal mortality despite improved survival. The demand and cost of initial hospitalization has also increased. This study assessed care provider cost in neonatal intensive care units of two hospitals in the state of Kedah, Malaysia. It utilized universal sampling and prospectively followed up preterm infants till discharge. Care provider cost was assessed using mixed method of top down approach and activity based costing. A total of 112 preterm infants were recruited from intensive care (93 infants) and minimal care (19 infants). Majority were from the moderate (23%) and late (36%) preterm groups followed by very preterm (32%) and extreme preterm (9%). Mean total cost per infant increased with level of care and degree of prematurity from MYR 2,751 (MYR 374 - MYR 10,103) for preterm minimal care, MYR 8,478 (MYR 817 - MYR 47,354) for late preterm intensive care to MYR 41,598 (MYR 25,351- MYR 58,828) for extreme preterm intensive care. Mean cost per infant per day increased from MYR 401 (MYR 363- MYR 534), MYR 444 (MYR 354 – MYR 916) to MYR 532 (MYR 443-MYR 939) respectively. Cost was dominated by overhead (fixed) costs for general (hospital), intermediate (clinical support services) and final (NICU) cost centers where it constituted at least three quarters of mean admission cost per infant while the remainder was consumables (variable) costs. Breakdown of overhead cost showed NICU specific overhead contributing at least two thirds of mean admission cost per infant. Personnel salary made up three quarters of NICU specific overhead. Laboratory investigation was the cost driver for consumables ranging from 29% (intensive care) to 84% (minimal care) of mean total consumables cost per infant. Gender, birth weight and length of stay were significant factors and cost prediction was developed with these variables.

Cost-effectiveness and economies of scale of a mass radio campaign to promote household life-saving practices in Burkina Faso

IntroductionChild health promotion through mass media has not been rigorously evaluated for cost-effectiveness in low-income and middle-income countries. We assessed the cost-effectiveness of a mass radio campaign on health-seeking behaviours for child survival within a trial in Burkina Faso and at national scale.MethodsWe collected provider cost data prospectively alongside a 35-month cluster randomised trial in rural Burkina Faso in 2012–2015. Out-of-pocket costs of care-seeking were estimated through a household survey. We modelled intervention effects on child survival based on increased care-seeking and estimated the intervention’s incremental cost-effectiveness ratio (ICER) in terms of the cost per disability-adjusted life year (DALY) averted versus current practice. Model uncertainty was gauged using one-way and probabilistic sensitivity analyses. We projected the ICER of national-scale implementation in five sub-Saharan countries with differing media structures. All costs are in 2015 USD.ResultsThe provider cost of the campaign was $7 749 128 ($9 146 101 including household costs). The campaign broadcast radio spots 74 480 times and 4610 2-hour shows through seven local radio stations, reaching approximately 2.4 million people including 620 000 direct beneficiaries (pregnant women and children under five). It resulted in an average estimated 24% increase in care-seeking for children under five and a 7% reduction in child mortality per year. The ICER was estimated at $94 ($111 including household costs (95% CI −38 to 320)). The projected provider cost per DALY averted of a national level campaign in Burkina Faso, Burundi, Malawi, Mozambique and Niger in 2018–2020, varied between $7 in Malawi to $27 in Burundi.ConclusionThis study suggests that mass-media campaigns can be very cost-effective in improving child survival in areas with high media penetration and can potentially benefit from considerable economies of scale.Trial registration numberNCT01517230; Results.