Utilisation of pathology procedures in the South African private pathology sector between 2003 and 2005

Objective. To analyse the patterns of pathology procedures performed in  the private pathology sector in South Africa. To determine what the differences between the individual practices are and to attempt to explain any differences.Design. A retrospective analysis of claims from pathology laboratories  submitted by electronic interface to a medical aid administrator between  January 2003 up to December 2005 were analysed. The data were sorted according to the practice number of the pathology laboratory and referring doctor, account number, laboratory number, beneficiary number and the origin of the claim (in hospital or out of hospital). The number of claims for every procedure was compared across different laboratories.Results. Sufficient data were available on 5.4 million claim lines over the 3-year period (92% of the total lines submitted over the period). The total amount claimed increased by 2.5% and 9.9%, the number of test  procedures increased by 1.4% and 17.7%, and the number of accounts  increased by 4.8% and 0.9% in 2004 and 2005 respectively. These  increases occurred despite a decrease in active beneficiaries of 1.6% and 4.0% in 2004 and 2005. The average cost per active beneficiary per month varied between R494 and R611 in 2005. A relatively few common test procedures (30) contributed disproportionately to the total number of procedures (67.8%) and cost (56.9%) of laboratory testing. The utilisation of individual procedures varied between laboratories with large differences in the performance of common tests such as erythrocyte sedimentation rate, reticulocyte count, protein electrophoresis and creatinine.Conclusion. The differences in the cost of pathology claims between individual laboratories were larger than expected. There was evidence of inappropriate test utilisation. Part of the differences between laboratories under control of the laboratories and are a result of request form design, test profile content and reflexing of tests

Is scaling up enough to curb the HIV epidemic in southern Africa?

We highlight key insights and provide some food for thought on 'Scaling up for success', the theme of the 4th Southern African AIDS Conference (Durban, 31 March - 3 April 2009), where over 4 000 scientists, field workers and activists presented and discussed research findings and best practices for HIV prevention, treatment and care in southern Africa

Investigating viral parameter dependence on cell and viral life cycle assumptions

Student Number: 9811822T - MSc Dissertation - School of Computational and Applied Mathematics - Faculty of ScienceThis dissertation reviews population dynamic type models of viral infection and introduces some new models to describe strain competition and the infected cell lifecycle. Laboratory data from a recent clinical trial, tracking drug resistant virus in patients given a short course of monotherapy is comprehensively analysed, paying particular attention to reproducibility. A Bayesian framework is introduced, which facilitates the inference of model parameters from the clinical data. It appears that the rapid emergence of resistance is a challenge to popular unstructured models of viral infection, and this challenge is partly addressed. In particular, it appears that minimal ordinary differential equations, with their implicit exponential lifetime (constant hazard) distributions in all compartments, lack the short transient timescales observed clinically. Directions for future work, both in terms of obtaining more informative data, and developing more systematic approaches to model building, are identified

Malaria intervention scale-up in Africa : effectiveness predictions for health programme planning tools, based on dynamic transmission modelling

Scale-up of malaria prevention and treatment needs to continue to further important gains made in the past decade, but national strategies and budget allocations are not always evidence-based. Statistical models were developed summarizing dynamically simulated relations between increases in coverage and intervention impact, to inform a malaria module in the Spectrum health programme planning tool.; The dynamic Plasmodium falciparum transmission model OpenMalaria was used to simulate health effects of scale-up of insecticide-treated net (ITN) usage, indoor residual spraying (IRS), management of uncomplicated malaria cases (CM) and seasonal malaria chemoprophylaxis (SMC) over a 10-year horizon, over a range of settings with stable endemic malaria. Generalized linear regression models (GLMs) were used to summarize determinants of impact across a range of sub-Sahara African settings.; Selected (best) GLMs explained 94-97 % of variation in simulated post-intervention parasite infection prevalence, 86-97 % of variation in case incidence (three age groups, three 3-year horizons), and 74-95 % of variation in malaria mortality. For any given effective population coverage, CM and ITNs were predicted to avert most prevalent infections, cases and deaths, with lower impacts for IRS, and impacts of SMC limited to young children reached. Proportional impacts were larger at lower endemicity, and (except for SMC) largest in low-endemic settings with little seasonality. Incremental health impacts for a given coverage increase started to diminish noticeably at above ~40 % coverage, while in high-endemic settings, CM and ITNs acted in synergy by lowering endemicity. Vector control and CM, by reducing endemicity and acquired immunity, entail a partial rebound in malaria mortality among people above 5 years of age from around 5-7 years following scale-up. SMC does not reduce endemicity, but slightly shifts malaria to older ages by reducing immunity in child cohorts reached.; Health improvements following malaria intervention scale-up vary with endemicity, seasonality, age and time. Statistical models can emulate epidemiological dynamics and inform strategic planning and target setting for malaria control

Cost-effective interventions for breast cancer, cervical cancer, and colorectal cancer : new results from WHO-CHOICE

Background: Following the adoption of the Global Action Plan for the Prevention and Control of NCDs 2013-2020, an update to the Appendix 3 of the action plan was requested by Member States in 2016, endorsed by the Seventieth World Health Assembly in May 2017 and provides a list of recommended NCD interventions. The main contribution of this paper is to present results of analyses identifying how decision makers can achieve maximum health gain using the cancer interventions listed in the Appendix 3. We also present methods used to calculate new WHO-CHOICE cost-effectiveness results for breast cancer, cervical cancer, and colorectal cancer in Southeast Asia and eastern sub-Saharan Africa. Methods: We used "Generalized Cost-Effectiveness Analysis" for our analysis which uses a hypothetical null reference case, where the impacts of all current interventions are removed, in order to identify the optimal package of interventions. All health system costs, regardless of payer, were included. Health outcomes are reported as the gain in healthy life years due to a specific intervention scenario and were estimated using a deterministic state-transition cohort simulation (Markov model). Results: Vaccination against human papillomavirus (two doses) for 9-13-year-old girls (in eastern sub-Saharan Africa) and HPV vaccination combined with prevention of cervical cancer by screening of women aged 30-49 years through visual inspection with acetic acid linked with timely treatment of pre-cancerous lesions (in Southeast Asia) were found to be the most cost effective interventions. For breast cancer, in both regions the treatment of breast cancer, stages I and II, with surgery ± systemic therapy, at 95% coverage, was found to be the most cost-effective intervention. For colorectal cancer, treatment of colorectal cancer, stages I and II, with surgery ± chemotherapy and radiotherapy, at 95% coverage, was found to be the most cost-effective intervention. Conclusion: The results demonstrate that cancer prevention and control interventions are cost-effective and can be implemented through a step-wise approach to achieve maximum health benefits. As the global community moves toward universal health coverage, this analysis can support decision makers in identifying a core package of cancer services, ensuring treatment and palliative care for all

Evaluating the Cost-Effectiveness of Pre-Exposure Prophylaxis (PrEP) and Its Impact on HIV-1 Transmission in South Africa

The original publication is available at http:/www.plosone.orgBackground: Mathematical modelers have given little attention to the question of how pre-exposure prophylaxis (PrEP) may impact on a generalized national HIV epidemic and its cost-effectiveness, in the context of control strategies such as condom use promotion and expanding ART programs. Methodology/Principal Findings: We use an age- and gender-structured model of the generalized HIV epidemic in South Africa to investigate the potential impact of PrEP in averting new infections. The model utilizes age-structured mortality, fertility, partnership and condom use data to model the spread of HIV and the shift of peak prevalence to older age groups. The model shows that universal PrEP coverage would have to be impractically high to have a significant effect on incidence reduction while ART coverage expands. PrEP targeted to 15-35-year-old women would avert 10%-25% (resp. 13%-28%) of infections in this group and 5%-12% (resp. 7%-16%) of all infections in the period 2014-2025 if baseline incidence is 0.5% per year at 2025 (resp. 0.8% per year at 2025). The cost would be $12,500-$20,000 per infection averted, depending on the level of ART coverage and baseline incidence. An optimistic scenario of 30%-60% PrEP coverage, efficacy of at least 90%, no behavior change among PrEP users and ART coverage less than three times its 2010 levels is required to achieve this result. Targeting PrEP to 25-35-year-old women (at highest risk of infection) improves impact and cost-effectiveness marginally. Relatively low levels of condom substitution (e.g., 30%) do not nullify the efficacy of PrEP, but reduces cost-effectiveness by 35%-40%. Conclusions/Significance: PrEP can avert as many as 30% of new infections in targeted age groups of women at highest risk of infection. The cost-effectiveness of PrEP relative to ART decreases rapidly as ART coverage increases beyond three times its coverage in 2010, after which the ART program would provide coverage to more than 65% of HIV+ individuals. To have a high relative cost-effective impact on reducing infections in generalized epidemics, PrEP must utilize a window of opportunity until ART has been scaled up beyond this level. © 2010 Pretorius et al.Publishers' Versio

Does the Spectrum model accurately predict trends in adult mortality? Evaluation of model estimates using empirical data from a rural HIV community cohort study in north-western Tanzania.

Introduction : Spectrum epidemiological models are used by UNAIDS to provide global, regional and national HIV estimates and projections, which are then used for evidence-based health planning for HIV services. However, there are no validations of the Spectrum model against empirical serological and mortality data from populations in sub-Saharan Africa. Methods : Serologic, demographic and verbal autopsy data have been regularly collected among over 30,000 residents in north-western Tanzania since 1994. Five-year age-specific mortality rates (ASMRs) per 1,000 person years and the probability of dying between 15 and 60 years of age (45Q15,) were calculated and compared with the Spectrum model outputs. Mortality trends by HIV status are shown for periods before the introduction of antiretroviral therapy (1994-1999, 2000-2005) and the first 5 years afterwards (2005-2009). Results : Among 30-34 year olds of both sexes, observed ASMRs per 1,000 person years were 13.33 (95% CI: 10.75-16.52) in the period 1994-1999, 11.03 (95% CI: 8.84-13.77) in 2000-2004, and 6.22 (95% CI; 4.75-8.15) in 2005-2009. Among the same age group, the ASMRs estimated by the Spectrum model were 10.55, 11.13 and 8.15 for the periods 1994-1999, 2000-2004 and 2005-2009, respectively. The cohort data, for both sexes combined, showed that the 45Q15 declined from 39% (95% CI: 27-55%) in 1994 to 22% (95% CI: 17-29%) in 2009, whereas the Spectrum model predicted a decline from 43% in 1994 to 37% in 2009. Conclusion : From 1994 to 2009, the observed decrease in ASMRs was steeper in younger age groups than that predicted by the Spectrum model, perhaps because the Spectrum model under-estimated the ASMRs in 30-34 year olds in 1994-99. However, the Spectrum model predicted a greater decrease in 45Q15 mortality than observed in the cohort, although the reasons for this over-estimate are unclear