Affordability of essential medicines: The case of fluoride toothpaste in 78 countries

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Affordability of essential medicines : The case of fluoride toothpaste in 78 countries

Background Fluoride toothpaste (FT) has recently been included in the WHO Model List of Essential Medicines. Whereas it is essential for preventing dental caries, its current affordability around the globe remains unclear. This study aimed to analyse the affordability of FT in as many as possible countries worldwide, to capture the extent of variations in FT affordability between high-, middle- and low-income countries. Methods A standardized protocol was developed to collect country-specific information about the characteristics of the cheapest available FT at a regular point of purchase. 82 members of the WHO Global Oral Health Network of Chief Dental Officers (CDOs), directors of WHO Collaborative Centres and other oral health experts collected data using mobile phone technology. In line with established methodologies to assess affordability, the Fluoride Toothpaste Affordability Ratio (FTAR) was calculated as the expenditure associated with the recommended annual consumption of FT relative to the daily wage of the lowest-paid unskilled government worker (FTAR >1 = unaffordable spending on fluoride toothpaste). Results There are significant differences in the affordability of FT across 78 countries. FT was strongly affordable in high-income countries, relatively affordable in upper middle-income countries, and strongly unaffordable in lower middle-income and low-income countries. The affordability of FT across WHO Regions was dependent upon the economic mix of WHO Regions’ member states. Conclusion FT is still unaffordable for many people, particularly in low-income settings. Strategies to improve the universal affordability of FT should be part of health policy decisions in order to contribute to reducing dental caries as a global public health problem

A systematic review of economic evaluations alongside studies within a trial (SWATs) for improving recruitment and retention in randomised controlled trials

Aim To review the cost-effectiveness of strategies to improve participant recruitment and retention in randomised controlled trials. Methods All included studies from the latest Cochrane recruitment and retention reviews were considered. To identify articles published since the Cochrane reviews, electronic databases were searched until March 2021. Hand searching of conference databases and journals was also undertaken. The inclusion criteria included Studies within a Trial (SWATs). The main outcome was the incremental cost-effectiveness ratio (ICER). Quality assessment of papers used the Cochrane risk of bias 1 tool. The CRD guidance was used to assess the quality of economic evaluation. Random-effect meta-analyses were undertaken. The GRADE certainty of evidence was applied for each strategy, and Trial Forge Guidance 2 was used for strategies included in meta-analyses to evaluate the uncertainty of the findings. Cost-effectiveness ranks summarise the cost-effectiveness of all strategies. Results We identified 6569 records and included 29 SWATs (earliest conducted in 1999 and latest in 2021) including more than 35,800 participants. There is no strategy we would recommend trial teams and researchers adopt with complete statistical certainty. Recruitment strategies which could be cost-effective include financial incentives, trial-branded pens, telephone reminders and pre-notification leaflets. Retention strategies which could be cost-effective include vouchers and trial-branded pens. Conclusion Future SWATs should replicate existing recruitment and retention strategies, rather than evaluate novel ones. We recommend that economic evaluations be carried out alongside all future SWATs, costs and benefits be recorded transparently, and the cost-effectiveness of existing recruitment or retention strategies be evaluated

Effect of sugar-sweetened beverage taxation on sugars intake and dental caries : an umbrella review of a global perspective

Background As part of the Global Strategy on Oral health, the World Health Organization (WHO) is exploring cost-effective interventions for oral health, including taxation on sugar-sweetened beverages (SSBs). To inform this process, this umbrella review aimed to identify the best available estimates pertaining to the impact of SSB taxation on the reduction of sugars intake, and the sugars-caries dose–response, such that estimates of the impact of SSB taxation on averting dental caries in both high (HIC) and low and middle (LMIC) countries be available. Methods The questions addressed were: (1) what are the effects of SSB taxation on consumption of SSBs and (2) sugars? (3) What is the effect on caries of decreasing sugars? and (4) what is the likely impact of a 20% volumetric SSB tax on the number of active caries prevented over 10 years? Data sources included PubMed, Embase, Web of Science, Scopus, CINAHL, Dentistry and Oral Sciences Source, Cochrane Library, Joanna Briggs Institute (JBI) Systematic Review Register, and PROSPERO. The review was conducted with reference to JBI guidelines. The quality of included systematic reviews was assessed using AMSTAR to identify best evidence. Results From 419 systematic reviews identified for questions 1 & 2, and 103 for question 3, 48 (Questions 1 & 2) and 21 (Question 3) underwent full text screening, yielding 14 and five included reviews respectively. Best available data indicated a 10% tax would reduce SSB intake by 10.0% (95% CI: -5.0, 14.7%) in HIC and by 9% (range -6.0 to 12.0%) in LMIC, and that a 20% tax would reduce free sugars intake on average by 4.0 g/d in LMIC and 4.4 g/d in HIC. Based on best available dose response data, this could reduce the number of teeth with caries per adults (HIC and LMIC) by 0.03 and caries occurrence in children by 2.7% (LMIC) and 2.9% (HIC), over a 10-year period. Conclusion Best available data suggest a 20% volumetric SSB tax would have a modest impact on prevalence and severity of dental caries in both HIC and LMIC

The cost-effectiveness of Studies Within A Trial (SWATs) for improving recruitment and retention in randomised trials

Background: Randomised controlled trials (RCTs) constitute the gold-standard design for evaluating interventions. However, their design, conduct and validity can be threatened by slow recruitment of invited patients and/or attrition of already recruited participants. Given such challenges, the research community is increasingly interested in identifying effective recruitment and retention strategies via the conduct of Studies Within A Trial (SWATs). Aims: This thesis applies economic techniques to demonstrate the significance of trial recruitment and retention, and to introduce economic methods for improving the evaluation of recruitment and retention strategies via SWATs. Methods: The thesis employs a wide range of health economic methods, including decision modelling, costing analysis, systematic review and Value of Information (VoI) analysis. Results: Chapter 2 presents the impact of slow recruitment to the RECOVERY trial generated opportunity costs due to the delayed dissemination of a more cost-effective, available treatment for hospitalised COVID-19 patients. Chapter 3 highlights that participant loss to follow-up from the Occupational Therapist Intervention Study (OTIS) trial generated significant financial costs to the trial team and funder, despite its low attrition rate. Chapter 4 critically appraises the evidence surrounding the cost-effectiveness of recruitment and retention strategies, concluding that no cost-effective strategy exists with high certainty of evidence, due to the limited availability of economic evaluations alongside most SWATs. Finally, considering the limited resources for funding future SWATs, Chapter 5 introduces and applies a Value of Information (VoI) analysis framework to telephone reminders (recruitment strategy) and pens (retention strategy), showing that such a methodology can be feasibly used as a tool, alongside Trial Forge Guidance 2, for prioritising research on recruitment and retention strategies. Conclusion: Integrating economic evaluations into SWATs and using VoI analyses can strengthen future SWAT-related research, allowing trial methodologists to improve the conduct of their studies

Development of a preliminary sizing tool forstrategic decision making in composite fuselages using weight and cost optimization

This study is an attempt to develop a preliminary composite fuselage sizing tool for the decision making process utilizing analytical structural analysis equations and a bottom-up cost approach to estimate weight and cost. Previous research by several authors and companies is reviewed in order to define the knowledge gaps that the project is going to fill. The objectives of this project are divided into two directions. The first one is the weight and cost fuselage design, and the second, is the weight and cost optimization process. After examining the existing literature both from academia and industry a different approach is proposed for each sector. In the structural design an analytical based model is proposed to assess the components integrity while cost equations for fully learned manufacturing processes are used based on the Advanced Composites Cost Estimation Manual (ACCEM). An experience-driven optimization algorithm is proposed afterwards, taking into account manufacturing considerations and design rules of thumb. By combining these tools, a general tool for fuselage design that is completely suited for the preliminary design phase is proposed. Τhe trade-off studies can provide important knowledge on the effect of different decisions and establish new design guidelines. The study concludes that an increase of the number of stiffeners and frames, in a fuselage structure, leads to a general decrease in weight and an increase in manufacturing cost. The addition of more stringers or frames after a certain level leads to an increase in weight, while the cost follows the same trend. The manufacturing constraints and the design rules-of-thumb applied lead to an increase in structural weight. Finally, the comparison between skin-stiffened and sandwich designs, shows that the weight saving potential is comparable for both configurations, and the cost saving potential is higher for the sandwich design.Aerospace Engineerin

WP1: Identifying and prioritising trial recruitment and retention strategies

The Trial Forge SWAT Network and the NIHR-funded Implement SWATs programme established a working group in 2022 to identify and prioritise recruitment and retention strategies for future evaluation using randomised SWAT designs. We searched the NIHR HTA Journals Library to identify published randomised trials. The recruitment and retention strategies used for each trial were extracted by two independent reviewers and categorised, using the Online Resource for Research in Clinical triAls (ORRCA) recruitment and retention domains. Strategies were then ranked according to their frequency of use. We mapped the identified strategies to the Cochrane systematic reviews of recruitment strategies and retention strategies; a systematic review of economic evaluations alongside SWATs; the Prioritising Recruitment in Randomised Trials (PRioRiTy I) and Prioritising Retention in Randomised Trials (PRioRiTy II); the MRC-funded Systematic Techniques for Assisting Recruitment to Trials (MRC START); and PROMoting the use of studies within a trial (PROMETHEUS). A long list of the most frequently used and promising strategies, along with any evidence on their effectiveness or cost-effectiveness was circulated to members of the working group, who independently ranked their top five strategies, along with their justification for choice of each strategy and its ranking. This ranking was discussed iteratively, with input from PPI partners and the wider Trial Forge SWAT Network members, to develop the final priority list

Pancreatic surgery outcomes: multicentre prospective snapshot study in 67 countries

Background: Pancreatic surgery remains associated with high morbidity rates. Although postoperative mortality appears to have improved with specialization, the outcomes reported in the literature reflect the activity of highly specialized centres. The aim of this study was to evaluate the outcomes following pancreatic surgery worldwide.Methods: This was an international, prospective, multicentre, cross-sectional snapshot study of consecutive patients undergoing pancreatic operations worldwide in a 3-month interval in 2021. The primary outcome was postoperative mortality within 90 days of surgery. Multivariable logistic regression was used to explore relationships with Human Development Index (HDI) and other parameters.Results: A total of 4223 patients from 67 countries were analysed. A complication of any severity was detected in 68.7 percent of patients (2901 of 4223). Major complication rates (Clavien-Dindo grade at least IIIa) were 24, 18, and 27 percent, and mortality rates were 10, 5, and 5 per cent in low-to-middle-, high-, and very high-HDI countries respectively. The 90-day postoperative mortality rate was 5.4 per cent (229 of 4223) overall, but was significantly higher in the low-to-middle-HDI group (adjusted OR 2.88, 95 per cent c.i. 1.80 to 4.48). The overall failure-to-rescue rate was 21 percent; however, it was 41 per cent in low-to-middle-compared with 19 per cent in very high-HDI countries.Conclusion: Excess mortality in low-to-middle-HDI countries could be attributable to failure to rescue of patients from severe complications. The authors call for a collaborative response from international and regional associations of pancreatic surgeons to address management related to death from postoperative complications to tackle the global disparities in the outcomes of pancreatic surgery (NCT04652271; ISRCTN95140761)