Stated preferences for anti-malarial drug characteristics in Zomba, a malaria endemic area of Malawi

Background The evidence on determinants of individuals’ choices for anti-malarial drug treatments is scarce. This study sought to measure the strength of preference for adult antimalarial drug treatment attributes of heads of urban, rural and peri-urban households in a resource-limited malaria-endemic area of sub-Saharan Africa. Methods Discrete choice experiments were conducted with 508 heads of household interviewed face-to-face for a household population survey of health-seeking behavior in Zomba District, Malawi. The interviews were held in Chichewa and the choice experiment questions were presented with cartoon aids. The anti-malarial drug attributes included in the stated preference experiment were: speed of fever resolution, side effects (pruritus) risk, protection (duration of prophylactic effect), price, duration of treatment course and recommendation by a health professional. Sixteen treatment profiles from a fractional factorial design by orthogonal array were paired into choice scenarios, and scenarios were randomly assigned to participants so that each participant was presented with a series of eight pairwise choice scenarios. Respondents had the option to state indifference between the two profiles or decline to choose. Data were analysed in a mixed logit model, with normally distributed coefficients for all six attributes. Results The sex ratio was balanced in urban areas, whereas 63% of participants in rural areas were male. The proportion of individuals with no education was considerably higher in the rural group (25%) than in the urban (5%) and peri-urban (6%) groups. All attributes investigated had the expected influence, and traded-off in most respondents’ choices. There were heterogeneous effects of price, pruritus risk, treatment recommendation by a professional, and duration of prophylaxis across respondents, only partly explained by their differences in education, household per capita expenditure, sex and age. Individuals´ demand elasticity (simulated median, inter-quartile range) was highest (most responsive) to speed of symptom resolution (0.88, 0.80-0.89) and pruritus risk (0.25, 0.08-0.62). Conclusions Most adult antimalarial users are willing to use treatments without recommendation from health professional, and may be influenced by price. Future studies should investigate the magnitude of differences in price and treatment attribute sensitivity between adult anti-malarial drug users in rural, peri-urban and urban areas in order to determine optimal price subsidies

Cost effectiveness analysis of clinically driven versus routine laboratory monitoring of antiretroviral therapy in Uganda and Zimbabwe.

BACKGROUND: Despite funding constraints for treatment programmes in Africa, the costs and economic consequences of routine laboratory monitoring for efficacy and toxicity of antiretroviral therapy (ART) have rarely been evaluated. METHODS: Cost-effectiveness analysis was conducted in the DART trial (ISRCTN13968779). Adults in Uganda/Zimbabwe starting ART were randomised to clinically-driven monitoring (CDM) or laboratory and clinical monitoring (LCM); individual patient data on healthcare resource utilisation and outcomes were valued with primary economic costs and utilities. Total costs of first/second-line ART, routine 12-weekly CD4 and biochemistry/haematology tests, additional diagnostic investigations, clinic visits, concomitant medications and hospitalisations were considered from the public healthcare sector perspective. A Markov model was used to extrapolate costs and benefits 20 years beyond the trial. RESULTS: 3316 (1660LCM;1656CDM) symptomatic, immunosuppressed ART-naive adults (median (IQR) age 37 (32,42); CD4 86 (31,139) cells/mm(3)) were followed for median 4.9 years. LCM had a mean 0.112 year (41 days) survival benefit at an additional mean cost of $765 [95$7386 [3277,dominated] per life-year gained and $7793 [4442,39179] per quality-adjusted life year gained. Routine toxicity tests were prominent cost-drivers and had no benefit. With 12-weekly CD4 monitoring from year 2 on ART, low-cost second-line ART, but without toxicity monitoring, CD4 test costs need to fall below$3.78 to become cost-effective (<3xper-capita GDP, following WHO benchmarks). CD4 monitoring at current costs as undertaken in DART was not cost-effective in the long-term. CONCLUSIONS: There is no rationale for routine toxicity monitoring, which did not affect outcomes and was costly. Even though beneficial, there is little justification for routine 12-weekly CD4 monitoring of ART at current test costs in low-income African countries. CD4 monitoring, restricted to the second year on ART onwards, could be cost-effective with lower cost second-line therapy and development of a cheaper, ideally point-of-care, CD4 test

Safety and Effectiveness of Statins for Prevention of Recurrent Myocardial Infarction in 12 156 Typical Older Patients: A Quasi-Experimental Study.

There is limited evidence on statin risk and effectiveness for patients aged 80+. We estimated risk of recurrent myocardial infarction, muscle-related and other adverse events, and statin-related incremental costs in "real-world" older patients treated with statins versus no statins.This article is freely available via Open Access. Click on the 'Additional Link' above to access the full-text from the publisher's site.Published (Open Access

Occupational, Sectoral and Firm Level Sorting Among Overweight and Obese Individuals in the UK Labour Market

Individuals sort across various occupations (professional vs. manual work), sectors of the economy (private vs. public), and firms (large vs. small). This sorting is driven by individual worker productivity and the labour demand for the corresponding skills. Earlier studies on the impact of obesity on employment outcomes have neither accounted for occupation, sector or firm size-specific obesity penalties nor whether obese persons are more likely to be employed in certain occupations, firms and economic sectors. In a seminal contribution, Rooth (2008) observes that restaurant work has the highest share of obese employees and also the highest obesity penalties. We build on this result and explore occupational, sectoral and firm level sorting in the UK labour market using the British Household Panel Survey (BHPS). More specifically, we aim to shed light on the question of whether higher weight men and women are by and large relegated to different occupations, firms and economic sectors than lower weight counterparts. Occupational, sectoral and firm size sorting is analysed using multinomial logit and probit regressions. Given the possibility of a reverse causal relationship between occupation, firm size, economic sector and obesity, we use child’s BMI as an instrument for individual’s body weight. We estimate the model using the control function approach. To investigate the non-linear relationship between BMI and wages, we use a semi-parametric instrumental variable approach using the Robinson’s double residual method whereby we estimate wage differences relative to wages at a BMI of 23 for women and 27 for men. There are 6,248 men and 7,563 women in the sample with an average age of 42 for both men and women. The test of endogeneity indicates that respondent’s BMI is exogenous in the occupation equation. Results using multinomial logit regression suggest that compared to normal weight men, obese men are less likely to choose a semi-skilled occupation compared to a skilled occupation (RRR: 0.66; CI: 0.55 and 0.80), while the average marginal effects from the IV regression suggest that it is unclear whether higher weight would increase or decrease the predicted probability of working in a skilled occupation for men (AME: -0.09; CI: -0.45 and 0.28). For women, the results of the multinomial logit regression suggest that as body mass index increases, women are more likely to be employed in skilled jobs compared to semi-skilled (RRR: 0.97; CI: 0.95 and 0.99). Similarly, the IV results suggest that, a one unit increase in a woman’s BMI results in an increase in the probability of being employed in a skilled occupation (AME: 0.13; CI: 0.05 and 0.22). These findings suggest that overweight/obese men and women are more likely to be in jobs which have been previously observed in the literature to be most adversely affected in terms of obesity penalties

Health Seeking Behavior after Fever Onset in a Malaria-Endemic Area of Malawi

Informal sources of care may lead to ineffective use of anti-malarial drugs. A survey conducted in Malawi estimated the frequency of use of informal and formal services, medications, and household costs. A total of 508 household interviews were conducted. Treatment with an anti-malarial was reported in 24% of young children accessing the informal sector and in 91% accessing formal services. Informal care was associated with shorter travel and waiting times, a lower proportion of carers of feverish adults missing work or studies and losing earnings, and a lower proportion of older children missing studies or work. Total out of pocket costs of fever episodes constitutes between 9% and 14% in young children and 18% in adults of their total available resources. Patients may perceive informal services to be associated with opportunity cost advantages: however, these may be associated with health risks of inadequate prescribing, particularly in young children

Do time trade-off values fully capture attitudes that are relevant to health-related choices?

Previous research has shown that demographics, beliefs, and self-reported own health influence TTO values. Our hypothesis is that attitudes towards length and quality of life influence TTO values, but should no longer affect a set of related choices that are based on respondents’ own TTO scores. A representative sample of 1339 respondents was asked their level of agreement to four statements relating to the importance of quality and length of life. Respondents then went on to value 4 EQ-5D 5L states using an online interactive survey and a related set of 6 pairwise health-related choice questions, set up, so that respondents should be indifferent between choice options. We explored the impact of attitudes using regression analysis for TTO values and a logit model for choices. TTO values were correlated with the attitudes and were found to have a residual impact on the choices. In particular, those respondents who preferred quality of life over length of life gave less weight to the differences in years and more weight to differences in quality of life in these choice. We conclude that although the TTO responses reflect attitudes, these attitudes continue to affect health-related choices

Do time trade-off values fully capture attitudes that are relevant to health-related choices?

Previous research has shown that demographics, beliefs, and self-reported own health influence TTO values. Our hypothesis is that attitudes towards length and quality of life influence TTO values, but should no longer affect a set of related choices that are based on respondents’ own TTO scores. A representative sample of 1339 respondents was asked their level of agreement to four statements relating to the importance of quality and length of life. Respondents then went on to value 4 EQ-5D 5L states using an online interactive survey and a related set of 6 pairwise health-related choice questions, set up, so that respondents should be indifferent between choice options. We explored the impact of attitudes using regression analysis for TTO values and a logit model for choices. TTO values were correlated with the attitudes and were found to have a residual impact on the choices. In particular, those respondents who preferred quality of life over length of life gave less weight to the differences in years and more weight to differences in quality of life in these choice. We conclude that although the TTO responses reflect attitudes, these attitudes continue to affect health-related choices

Penicillin allergy status and its effect on antibiotic prescribing, patient outcomes and antimicrobial resistance (ALABAMA): protocol for a multicentre, parallel-arm, open-label, randomised pragmatic trial

Introduction Incorrect penicillin allergy records are recognised as an important barrier to the safe treatment of infection and affect an estimated 2.7 million people in England. Penicillin allergy records are associated with worse health outcome and antimicrobial resistance. The ALlergy AntiBiotics And Microbial resistAnce (ALABAMA) trial aims to determine if an intervention package, centred around a penicillin allergy assessment pathway (PAAP) initiated in primary care, is safe and effective in improving patient health outcomes and antibiotic prescribing.Methods and analysis The ALABAMA trial is a multicentre, parallel-arm, open-label, randomised pragmatic trial with a nested pilot study. Adults (≥18 years) with a penicillin allergy record and who have received antibiotics in the previous 24 months will be eligible for participation. Between 1592 and 2090 participants will be recruited from participating National Health Service general practices in England. Participants will be randomised to either usual care or intervention to undergo a pre-emptive PAAP using a 1:1 allocation ratio. The primary outcome measure is the percentage of treatment response failures within 28 days of an index prescription. 2090 and 1592 participants are estimated to provide 90% and 80% power, respectively, to detect a clinically important absolute difference of 7.9% in primary outcome at 1 year between groups. The trial includes a mixed-methods process evaluation and cost-effectiveness evaluation.Ethics and dissemination This trial has been approved by London Bridge Research Ethics Committee (ref: 19/LO/0176). It will be conducted in compliance with Good Clinical Practice guidelines according to the Declaration of Helsinki. Informed consent will be obtained from all subjects involved in the study. The primary trial results will be submitted for publication to an international, peer-reviewed journal.Trial registration ISRCTN20579216