Projecting the potential impact of the Cap-Score™ on Clinical Pregnancy, Live Births, and Medical Costs in Couples with Unexplained Infertility.

Purpose The Cap-Score™ was developed to assess the capacitation status of men, thereby enabling personalized management of unexplained infertility by choosing timed intrauterine insemination (IUI), versus immediate in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) in individuals with a low Cap-Score™. The objective of this study was to estimate the differences in outcomes and costs comparing the use of the Cap-Score™ with timed IUI (CS-TI) and the standard of care (SOC), which was assumed to be three IUI cycles followed by three IVF-ICSI cycles. Methods We developed and parameterized a decision-analytic model of management of unexplained infertility for women based on data from the published literature. We calculated the clinical pregnancy rates, live birth rates, and medical costs comparing CS-TI and SOC. We used Monte Carlo simulation to quantify uncertainty in projected estimates and performed univariate sensitivity analysis. Results Compared to SOC, CS-TI was projected to increase the pregnancy rate by 1–26%, marginally reduce live birth rates by 1–3% in couples with women below 40 years, increase live birth rates by 3–7% in couples with women over 40 years, reduce mean medical costs by $4000–$19,200, reduce IUI costs by $600–$1370, and reduce IVF costs by $3400–$17,800, depending on the woman’s age. Conclusion The Cap-Score™ is a potentially valuable clinical tool for management of unexplained infertility because it is projected to improve clinical pregnancy rates, save money, and, depending on the price of the test, increase access to treatment for infertility

A cost-effectiveness tool to guide the prioritization of interventions for rheumatic fever and rheumatic heart disease control in African nations

Author Summary: Rheumatic heart disease is a major cause of cardiovascular morbidity and mortality in Africa. Although there are effective medications and surgical procedures for rheumatic heart disease, they are under-used. What is more, these interventions can be expensive--even if they are feasible and effective. Unfortunately, there are currently very few economic studies on rheumatic heart disease, leaving ministries of health with little guidance on how to choose among various interventions and allocate resources to control programs. Our study describes the methods and data we used to develop a cost-effectiveness analysis tool that was intended specifically for decision-making in African countries. In our study, we also illustrate, in a hypothetical low-income African country, how the tool could be used. In our illustrative example, a prevention-oriented approach would save money in the long term, although other interventions could be cost-effective and feasible if enough financial resources were present. These findings contrast with previous studies and make a strong case that rheumatic heart disease prevention could be a high-priority intervention in Africa. We are making our tool publicly available and anticipate that ministries of health will use it as they develop or expand their rheumatic heart disease control programs

Estimating the costs of induced abortion in Uganda: A model-based analysis

<p>Abstract</p> <p>Background</p> <p>The demand for induced abortions in Uganda is high despite legal and moral proscriptions. Abortion seekers usually go to illegal, hidden clinics where procedures are performed in unhygienic environments by under-trained practitioners. These abortions, which are usually unsafe, lead to a high rate of severe complications and use of substantial, scarce healthcare resources. This study was performed to estimate the costs associated with induced abortions in Uganda.</p> <p>Methods</p> <p>A decision tree was developed to represent the consequences of induced abortion and estimate the costs of an average case. Data were obtained from a primary chart abstraction study, an on-going prospective study, and the published literature. Societal costs, direct medical costs, direct non-medical costs, indirect (productivity) costs, costs to patients, and costs to the government were estimated. Monte Carlo simulation was used to account for uncertainty.</p> <p>Results</p> <p>The average societal cost per induced abortion (95% credibility range) was $177 ($140-$223). This is equivalent to$64 million in annual national costs. Of this, the average direct medical cost was $65 ($49-86) and the average direct non-medical cost was $19 ($16-$23). The average indirect cost was$92 ($57-$139). Patients incurred $62 ($46-$83) on average while government incurred$14 ($10-$20) on average.</p> <p>Conclusion</p> <p>Induced abortions are associated with substantial costs in Uganda and patients incur the bulk of the healthcare costs. This reinforces the case made by other researchers--that efforts by the government to reduce unsafe abortions by increasing contraceptive coverage or providing safe, legal abortions are critical.</p

Predictors of HIV prevention knowledge and sexual behaviors among students at Makerere University Kampala, Uganda

Background: Prior reviews argue that unsafe sexual behaviors and poor HIV knowledge significantly increase the probability of acquiring HIV infections among adolescents. This study assessed the predictors of HIV prevention knowledge and sexual behaviors among Makerere university students in Uganda. &nbsp; Methods: We performed a cross-sectional survey. We performed a normality test using Shapiro Wilk test on knowledge score. Results revealed that knowledge score was not normally distributed. The study used two sample Wilcoxon Rank Sum and Kruskal Wallis Rank tests to assess the effect of HIV knowledge on demographic characteristics and sexual behaviors. Post-hoc tests were conducted using Bonferroni correction. Spearman rank correlation test was used for continuous variables while Chi-square and Fisher’s tests were used for categorical variables to assess the relationship between demographic characteristics and sexual behaviors. &nbsp; &nbsp; Results: We report results for 1337 students. The mean age was 21.2SD (1.6) and more than half 700(52.4%) were male students. The median HIV prevention knowledge score of students was 13 IQR (11-15) in the range of 0 to 18. Males significantly scored higher than females (13.0 IQR (12-15) vs. 12.0 IQR (10-14) p=0.000), an increase in age was associated with higher knowledge scores (Rho = 0.101, p = 0.000). &nbsp;&nbsp;Students in the third year of study significantly scored higher than those in the first year, and government-sponsored students scored higher than the privately sponsored students. HIV knowledge was also significantly associated with sexual experience, and condom use at univariate level but insignificant at multiple level analysis. Males were more likely to have ever had sex (31.7% vs. 12.7%) and ever used a condom (63% vs. 55%) than females respectively &nbsp; Conclusion: Our findings suggest that Makerere University students possessed good knowledge on HIV. There is evidence of an association between student’s knowledge, and demographic characteristics and a few sexual behaviors. Future behavioral and educational programs that target both sexually and non-sexually experienced students should address the gender differences

Potential Cost-Effectiveness of Universal Access to Modern Contraceptives in Uganda

<div><h3>Background</h3><p>Over two thirds of women who need contraception in Uganda lack access to modern effective methods. This study was conducted to estimate the potential cost-effectiveness of achieving universal access to modern contraceptives in Uganda by implementing a hypothetical new contraceptive program (NCP) from both societal and governmental (Ministry of Health (MoH)) perspectives.</p> <h3>Methodology/Principal Findings</h3><p>A Markov model was developed to compare the NCP to the status quo or current contraceptive program (CCP). The model followed a hypothetical cohort of 15-year old girls over a lifetime horizon. Data were obtained from the Uganda National Demographic and Health Survey and from published and unpublished sources. Costs, life expectancy, disability-adjusted life expectancy, pregnancies, fertility and incremental cost-effectiveness measured as cost per life-year (LY) gained, cost per disability-adjusted life-year (DALY) averted, cost per pregnancy averted and cost per unit of fertility reduction were calculated. Univariate and probabilistic sensitivity analyses were performed to examine the robustness of results. Mean discounted life expectancy and disability-adjusted life expectancy (DALE) were higher under the NCP vs. CCP (28.74 vs. 28.65 years and 27.38 vs. 27.01 respectively). Mean pregnancies and live births per woman were lower under the NCP (9.51 vs. 7.90 and 6.92 vs. 5.79 respectively). Mean lifetime societal costs per woman were lower for the NCP from the societal perspective ($1,949 vs.$1,987) and the MoH perspective ($636 vs.$685). In the incremental analysis, the NCP dominated the CCP, i.e. it was both less costly and more effective. The results were robust to univariate and probabilistic sensitivity analysis.</p> <h3>Conclusion/Significance</h3><p>Universal access to modern contraceptives in Uganda appears to be highly cost-effective. Increasing contraceptive coverage should be considered among Uganda's public health priorities.</p> </div

Cost Effectiveness of a Pharmacy-Only Refill Program in a Large Urban HIV/AIDS Clinic in Uganda

HIV/AIDS clinics in Uganda and other low-income countries face increasing numbers of patients and workforce shortages. We performed a cost-effectiveness analysis comparing a Pharmacy-only Refill Program (PRP), a form of task-shifting, to the Standard of Care (SOC) at a large HIV/AIDS clinic in Uganda, the Infectious Diseases Institute (IDI). The PRP was started to reduce workforce shortages and optimize patient care by substituting pharmacy visits for SOC involving monthly physician visits for accessing antiretroviral medicines.We used a retrospective cohort analysis to compare the effectiveness of the PRP compared to SOC. Effectiveness was defined as Favorable Immune Response (FIR), measured as having a CD4 lymphocyte count of over 500 cells/µl at follow-up. We used multivariate logistic regression to assess the difference in FIR between patients in the PRP and SOC. We incorporated estimates of effectiveness into an incremental cost-effectiveness analysis performed from a limited societal perspective. We estimated costs from previous studies at IDI and conducted univariate and probabilistic sensitivity analyses. We identified 829 patients, 578 in the PRP and 251 in SOC. After 12.8 months (PRP) and 15.1 months (SOC) of follow-up, 18.9% of patients had a FIR, 18.6% in the PRP and 19.6% in SOC. There was a non-significant 9% decrease in the odds of having a FIR for PRP compared to SOC after adjusting for other variables (OR 0.93, 95% CI 0.55-1.58). The PRP was less costly than the SOC (US$520 vs. 655 annually, respectively). The incremental cost-effectiveness ratio comparing PRP to SOC was US$ 13,500 per FIR. PRP remained cost-effective at univariate and probabilistic sensitivity analysis.The PRP is more cost-effective than the standard of care. Similar task-shifting programs might help large HIV/AIDS clinics in Uganda and other low-income countries to cope with increasing numbers of patients seeking care

Health gains and fi nancial risk protection aff orded by public fi nancing of selected interventions in Ethiopia: an extended cost-eff ectiveness analysis

Background The way in which a government chooses to fi nance a health intervention can aff ect the uptake of health interventions and consequently the extent of health gains. In addition to health gains, some policies such as public fi nance can insure against catastrophic health expenditures. We aimed to evaluate the health and fi nancial risk protection benefi ts of selected interventions that could be publicly fi nanced by the government of Ethiopia. Methods We used extended cost-eff ectiveness analysis to assess the health gains (deaths averted) and fi nancial risk protection aff orded (cases of poverty averted) by a bundle of nine (among many other) interventions that the Government of Ethiopia aims to make universally available. These nine interventions were measles vaccination, rotavirus vaccination, pneumococcal conjugate vaccination, diarrhoea treatment, malaria treatment, pneumonia treatment, caesarean section surgery, hypertension treatment, and tuberculosis treatment. Findings Our analysis shows that, per dollar spent by the Ethiopian Government, the interventions that avert the most deaths are measles vaccination (367 deaths averted per $100 000 spent), pneumococcal conjugate vaccination (170 deaths averted per$100 000 spent), and caesarean section surgery (141 deaths averted per $100 000 spent). The interventions that avert the most cases of poverty are caesarean section surgery (98 cases averted per$100 000 spent), tuberculosis treatment (96 cases averted per $100 000 spent), and hypertension treatment (84 cases averted per$100 000 spent). Interpretation Our approach incorporates fi nancial risk protection into the economic evaluation of health interventions and therefore provides information about the effi ciency of attainment of both major objectives of a health system: improved health and fi nancial risk protection. One intervention might rank higher on one or both metrics than another, which shows how intervention choice—the selection of a pathway to universal health coverage—might involve weighing up of sometimes competing objectives. This understanding can help policy makers to select interventions to target specifi c policy goals (ie, improved health or fi nancial risk protection). It is especially relevant for the design and sequencing of universal health coverage to meet the needs of poor populations

Pilot evaluation of the psychometric properties of a self-medication Risk Assessment Tool among elderly patients in a community setting

<p>Abstract</p> <p>Background</p> <p>Although community pharmacists in the United Kingdom are expected to assess elderly patients' needs for additional support in managing their medicines, there is limited data on potentially useful assessment tools. We sought to evaluate a 13-item assessment instrument among community dwelling elderly patients, 65 years and above. The instrument is composed of a cognitive risk sub-scale of 6 items and a physical risk sub-scale of 7 items.</p> <p>Findings</p> <p>The instrument was administered to elderly patients in a survey performed in a community to the west of Glasgow, Scotland. The survey recruited 37 participants, 31 from 4 community pharmacies and 6 patients whose medication management tasks were managed by the West Glasgow Community Health and Care Partnership (managed patients). Community pharmacists independently rated 29 of the 37 participants' comprehension of, and dexterity in handling their medicines. We assessed scale reliability, convergent validity and criterion validity. In sub-analyses, we assessed differences in scores between the managed patients and those recruited from the community pharmacies, and between multi-compartment compliance aid users and non-users. The instrument showed satisfactory internal consistency (Cronbach's alpha of 0.792 for 13-item scale). There was significant strong negative correlation between the cognitive risk sub-scores and community pharmacists' assessment of comprehension (ρ = -0.546, p = 0.0038); and physical risk sub-scores and community pharmacists' assessment of dexterity (ρ = -0.491, p = 0.0093). The Area Under the Receiver Operator Characteristic Curve (AUC ± SE; 95%CI) showed that the instrument had good discriminatory capacity (0.86 ± 0.07; 0.68, 0.96). The best cut-off (sensitivity, specificity) was ≥4 (65%, 100%). In the sub-analyses, managed patients had significantly higher cognitive risk sub-scores (6.5 versus 4.0, p = 0.0461) compared to non-managed patients. There was a significant difference in total risk score (4 versus 2, p = 0.0135) and cognitive risk sub-score (4 versus 1.5, p = 0.0029) between users and non-users of multi-compartment compliance aids.</p> <p>Conclusions</p> <p>This instrument shows potential for use in identifying elderly patients who may have problems managing their own medicines in the community setting. However, more robust validity and reliability assessments are needed prior to introduction of the tool into routine practice.</p

Expanding global access to essential medicines: investment priorities for sustainably strengthening medical product regulatory systems.

Access to quality-assured medical products improves health and save lives. However, one third of the world's population lacks timely access to quality-assured medicines while estimates indicate that at least 10% of medicine in low- and middle-income countries (LMICs) are substandard or falsified (SF), costing approximately US$ 31 billion annually. National regulatory authorities are the key government institutions that promote access to quality-assured medicines and combat SF medical products but despite progress, regulatory capacity in LMICs is still insufficient. Continued and increased investment in regulatory system strengthening (RSS) is needed. We have therefore reviewed existing global normative documents and resources and engaged with our networks of global partners and stakeholders to identify three critical challenges being faced by NRAs in LMICs that are limiting access to medical products and impeding detection of and response to SF medicines. The challenges are; implementing value-added regulatory practices that best utilize available resources, a lack of timely access to new, quality medical products, and limited evidence-based data to support post-marketing regulatory actions. To address these challenges, we have identified seven focused strategies; advancing and leveraging convergence and reliance initiatives, institutionalizing sustainability, utilizing risk-based approaches for resource allocation, strengthening registration efficiency and timeliness, strengthening inspection capacity and effectiveness, developing and implementing risk-based post-marketing quality surveillance systems, and strengthening regulatory management of manufacturing variations. These proposed solutions are underpinned by 13 focused recommendations, which we believe, if financed, technically supported and implemented, will lead to stronger health system and as a consequence, positive health outcomes