The cost of diagnostic uncertainty: a prospective economic analysis of febrile children attending an NHS emergency department

Abstract Background: Paediatric fever is a common cause of emergency department (ED) attendance. A lack of prompt and definitive diagnostics makes it difficult to distinguish viral from potentially life-threatening bacterial causes, necessitating a cautious approach. This may result in extended periods of observation, additional radiography, and the precautionary use of antibiotics (ABs) prior to evidence of bacterial foci. This study examines resource use, service costs, and health outcomes. Methods: We studied an all-year prospective, comprehensive, and representative cohort of 6518 febrile children (aged < 16 years), attending Alder Hey Children’s Hospital, an NHS-affiliated paediatric care provider in the North West of England, over a 1-year period. Performing a time-driven and activity-based micro-costing, we estimated the economic impact of managing paediatric febrile illness, with focus on nurse/clinician time, investigations, radiography, and inpatient stay. Using bootstrapped generalised linear modelling (GLM, gamma, log), we identified the patient and healthcare provider characteristics associated with increased resource use, applying retrospective case-note identification to determine rates of potentially avoidable AB prescribing. Results: Infants aged less than 3 months incurred significantly higher resource use than any other age group, at £1000.28 [95% CI £82.39–£2993.37] per child, (p < 0.001), while lesser experienced doctors exhibited 3.2-fold [95% CI 2.0–5.1-fold] higher resource use than consultants (p < 0.001). Approximately 32.4% of febrile children received antibiotics, and 7.1% were diagnosed with bacterial infections. Children with viral illnesses for whom antibiotic prescription was potentially avoidable incurred 9.9-fold [95% CI 6.5–13.2-fold] cost increases compared to those not receiving antibiotics, equal to an additional £1352.10 per child, predominantly resulting from a 53.9-h increase in observation and inpatient stay (57.1 vs. 3.2 h). Bootstrapped GLM suggested that infants aged below 3 months and those prompting a respiratory rate ‘red flag’, treatment by lesser experienced doctors, and Manchester Triage System (MTS) yellow or higher were statistically significant predictors of higher resource use in 100% of bootstrap simulations

Equity and efficiency preferences of health policy makers in China - a stated preference analysis

Background Macroeconomic growth in China enables significant progress in health care and public health. It faces difficult choices regarding access, quality and affordability, while dealing with the increasing burden of chronic diseases. Policymakers are pressured to make complex decisions while implementing health strategies. This study shows how this process could be structured and reports the specific equity and efficiency preferences among Chinese policymakers.Methods In total, 78 regional, provincial and national level policymakers with considerable experience participated in a discrete choice experiment, weighting the relative importance of six policy attributes describing equity and efficiency. Results from a conditional logistic model are presented for the six criteria, measuring the associated weights. Observed and unobserved heterogeneities were incorporated and tested in the model. Findings are used to give an example of ranking health interventions in relation to the present disease burden in China.Results In general, respondents showed strong preference for efficiency criteria i.e. total beneficiaries and cost-effectiveness as the most important attributes in decision making over equity criteria. Hence, priority interventions would be those conditions that are most prevalent in the country and cost least per health gain.Conclusion Although efficiency criteria override equity ones, major health threats in China would be targeted. Multicriteria decision analysis makes explicit important trade-offs between efficiency and equity, leading to explicit, transparent and rational policy makin

Healthcare Costs and Life-years Gained From Treatments Within the Advancing Cryptococcal Meningitis Treatment for Africa (ACTA) Trial on Cryptococcal Meningitis: A Comparison of Antifungal Induction Strategies in Sub-Saharan Africa

Background Mortality from cryptoccocal meningitis remains high. The ACTA trial demonstrated that, compared with 2 weeks of amphotericin B (AmB) plus flucystosine (5FC), 1 week of AmB and 5FC was associated with lower mortality and 2 weeks of oral flucanozole (FLU) plus 5FC was non-inferior. Here, we assess the cost-effectiveness of these different treatment courses. Methods Participants were randomized in a ratio of 2:1:1:1:1 to 2 weeks of oral 5FC and FLU, 1 week of AmB and FLU, 1 week of AmB and 5FC, 2 weeks of AmB and FLU, or 2 weeks of AmB and 5FC in Malawi, Zambia, Cameroon, and Tanzania. Data on individual resource use and health outcomes were collected. Cost-effectiveness was measured as incremental costs per life-year saved, and non-parametric bootstrapping was done. Results Total costs per patient were US $1442 for 2 weeks of oral FLU and 5FC,$1763 for 1 week of AmB and FLU, $1861 for 1 week of AmB and 5FC,$2125 for 2 weeks of AmB and FLU, and $2285 for 2 weeks of AmB and 5FC. Compared to 2 weeks of AmB and 5FC, 1 week of AmB and 5FC was less costly and more effective and 2 weeks of oral FLU and 5FC was less costly and as effective. The incremental cost-effectiveness ratio for 1 week of AmB and 5FC versus oral FLU and 5FC was US$208 (95% confidence interval $91–1210) per life-year saved. Conclusions Both 1 week of AmB and 5FC and 2 weeks of Oral FLU and 5FC are cost-effective treatments

Universal health coverage and chronic conditions

The upcoming UN high-level meeting on universal health coverage in September, 2019, aims to provide a developmental framework for international and national agendas on universal prevention and treatment packages and financial protection.Universal coverage of prevention and treatment of chronic diseases is a relevant topic in view of rising non-communicable disease epidemics in the world's ageing population

Prevalence and determinants of pre-hypertension and hypertension among the adults in rural Bangladesh: findings from a community-based study

Background The people of low and middle income countries bear about 80% of the global burden of diseases that are attributable to high blood pressure. Hypertensive people contribute half of this burden; the rest is among the people with lesser degrees of high blood pressure. Prehypertension elevates the risk of CVD, and that of end-stage renal disease. Bangladesh is a developing country, with more than 75% of the population live in rural area. This study aims to determine the prevalence and predictors of pre-hypertension and hypertension among the adults in rural Bangladesh. Methods A cross-sectional study of major non-communicable disease risk factors (tobacco and alcohol use, fruit and vegetable intake, physical activity) was conducted in rural surveillance sites of Bangladesh. In addition to the self-reported information on risk factors, height and weight, and blood pressure were measured during household visits using standard protocols of the WHO STEPwise approach to Surveillance. The study population included 6,094 men and women aged 25 years and above. Adjusted and unadjusted logistic regression analyses were performed to evaluate the association of prehypertension and hypertension with various factors. Results The prevalence of pre-hypertension and hypertension was 31.9% and 16.0%, respectively. The men had a higher prevalence (33.6%) of pre-hypertension compared to the women (30.3%). Multivariate analysis showed that increasing age [OR 2.30 (1.84-2.87)] and higher BMI [OR 4.67 (3.35-6.51) were positively associated with pre-hypertension. For hypertension, multivariate analysis showed that increasing age [OR 4.48 (3.38-5.94)] and higher BMI (specially the overweight category) was positively associated. Significant linear relationships of prehypertension were found with age [P for trend < 0.0001] and BMI [P for trend < 0.0001]. Linear regression for hypertension shows significant association with age [P for trend < 0.0001] but not with BMI [P for trend 0.3783]. Conclusion Approximately one third and one-sixth of the adult population of rural Bangladesh are affected with pre-hypertension and hypertension, respectively. This poses a great challenge ahead, as most of the people with pre-hypertension will progress towards hypertension until otherwise undergo in any pharmacological or lifestyle intervention

Mental disorders in Bangladesh: a systematic review

Background Mental disorders constitute a major public health problem globally with higher burden in low and middle-income countries. In Bangladesh, systematically-collected data on mental disorders are scarce and this leaves the extent of the problem not so well defined. We reviewed the literature on mental health disorders in Bangladesh to summarize the available data and identify evidence gaps. Methods We identified relevant literature on mental disorders within Bangladesh published between 1975 and October, 2013 through a systematic and comprehensive search. Relevant information from the selected articles was extracted and presented in tables. Results We identified 32 articles which met our pre-defined eligibility criteria. The reported prevalence of mental disorders varied from 6.5 to 31.0% among adults and from 13.4 to 22.9% among children. Some awareness regarding mental health disorders exists at community level. There is a negative attitude towards treatment of those affected and treatment is not a priority in health care delivery. Mental health services are concentrated around tertiary care hospitals in big cities and absent in primary care. Conclusions The burden of mental disorders is high in Bangladesh, yet a largely unrecognized and under-researched area. To improve the mental health services in Bangladesh, further well-designed epidemiological and clinical research are needed

Integrated care for human immunodeficiency virus, diabetes and hypertension in Africa

The rising burden from non-communicable diseases (NCDs) poses a huge challenge for health care delivery in Africa, where health systems are already struggling with the long-term care requirements for the millions of people now on antiretroviral therapy requiring regular visits to health facilities for monitoring, adherence support and drugs. The HIV chronic disease management programme is comparatively well-funded, well-organised and well-informed and offers many insights and opportunities for the expansion of NCD prevention and treatment services. Some degree of human immunodeficiency virus (HIV) and NCD service integration is essential, but how to do this without risking the HIV treatment gains is unclear. Both HIV and NCD services must expand within a resource-constrained environment and policymakers are in urgent need of evidence to guide cost-effective and acceptable changes in these health services