A pharmacy too far? Equity and spatial distribution of outcomes in the delivery of subsidized artemisinin-based combination therapies through private drug shops

BACKGROUND: Millions of individuals with malaria-like fevers purchase drugs from private retailers, but artemisinin-based combination therapies (ACTs), the only effective treatment in regions with high levels of resistance to older drugs, are rarely obtained through these outlets due to their relatively high cost. To encourage scale up of ACTs, the Affordable Medicines Facility--malaria is being launched to subsidize their price. The Government of Tanzania and the Clinton Foundation piloted this subsidized distribution model in two Tanzanian districts to examine concerns about whether the intervention will successfully reach poor, rural communities. METHODS: Stocking of ACTs and other antimalarial drugs in all retail shops was observed at baseline and in four subsequent surveys over 15 months. Exit interviews were conducted with antimalarial drug customers during each survey period. All shops and facilities were georeferenced, and variables related to population density and proximity to distribution hubs, roads, and other facilities were calculated. To understand the equity of impact, shops stocking ACTs and consumers buying them were compared to those that did not, according to geographic and socioeconomic variables. Patterning in ACT stocking and sales was evaluated against that of other common antimalarials to identify factors that may have impacted access. Qualitative data were used to assess motivations underlying stocking, distribution, and buying disparities. RESULTS: Results indicated that although total ACT purchases rose from negligible levels to nearly half of total antimalarial sales over the course of the pilot, considerable geographic variation in stocking and sales persisted and was related to a variety of socio-spatial factors; ACTs were stocked more often in shops located closer to district towns (p<0.01) and major roads (p<0.01) and frequented by individuals of higher socioeconomic status (p<0.01). However, other antimalarial drugs displayed similar patterning, indicating the existence of underlying disparities in access to antimalarial drugs in general in these districts. CONCLUSIONS: As this subsidy model is scaled up across multiple countries, these results confirm the potential for increased ACT usage but suggest that additional efforts to increase access in remote areas will be needed for the scale-up to have equitable impact. TRIAL REGISTRATION: Current Controlled Trials ISRCTN39125414

Bundled Payments in Total Joint Arthroplasty: Targeting Opportunities for Quality Improvement and Cost Reduction

BACKGROUND: Understanding the type and magnitude of services that patients receive postdischarge and the financial impact of readmissions is crucial to assessing the feasibility of accepting bundled payments. QUESTIONS/PURPOSES: The purposes of this study were to (1) determine the cost and service components of a 30-day total joint arthroplasty (TJA) episode of care; (2) analyze the portion of the total payment that is used for postdischarge services, including home care; and (3) to evaluate the frequency of readmissions and their impact on total episode-of-care payments. METHODS: All payments to Medicare providers (hospitals, postacute care facilities, physicians, and other healthcare providers) for services beginning with the index procedure and extending 30-days postdischarge were analyzed for 250 Medicare beneficiaries undergoing primary or revision TJA from a single institution over a 12 months. Payments and services were aggregated by procedure type and categorized as index procedure, postacute care, and related hospital readmissions. RESULTS: Mean episode-of-care payments ranged from USD 25,568 for primary TJA in patients with no comorbidities to USD 50,648 for revision TJA in patients with major comorbidities or complications, with wide variability within and across procedures. Postdischarge payments accounted for 36% of total payments. A total of 49% of patients were transferred to postacute care facilities, accounting for 70% of postdischarge payments. The overall 30-day unplanned readmission rate was 10%, accounting for 11% of postdischarge payments. CONCLUSIONS: Episode-of-care payments for TJAs vary widely depending on the type of procedure, patient comorbidities and complications, discharge disposition, and readmission rates. Postdischarge care accounted for more than one-third of total episode payments and varied substantially across patients and procedures. LEVEL OF EVIDENCE: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence

Purchase of anti-malarials by exit interview customers by district, August 2007 and August 2008.

<p>Purchase of anti-malarials by exit interview customers by district, August 2007 and August 2008.</p

Location of project districts by role in study.

<p>The red areas denote the two intervention districts, while the green area shows the control district.</p

Stocking and sales of subsidized ACTs at drug shops in intervention districts.

<p>All <i>duka la dawa baridi</i> (DLDB) in Maswa (top) and Kongwa (bottom) districts are mapped as either white (ACTs not in stock at time of survey) or black (ACTs in stock) circles. Data is shown at baseline (August '07) and two periods during implementation (November '07 and August '08). Districts are divided into 10 km² squares, with the total volume of adult equivalent doses of ACTs sold in that area over the preceding four weeks shown by the color of shading as follows: Tan = 1 to 50 doses sold; Orange = 51 to 250 doses; Light red = 251 to 500 doses; and Dark red = 501 to 10,000 doses.</p