Economic evaluations of non-communicable disease interventions

Background Demographic projections suggest a major increase in non-communicable disease (NCD) mortality over the next two decades in developing countries. In a climate of scarce resources, policy-makers need to know which interventions represent value for money. The prohibitive cost of performing multiple economic evaluations has generated interest in transferring the results of studies from one setting to another. This paper aims to bridge the gap in the current literature by critically evaluating the available published data on economic evaluations of NCD interventions in developing countries. Methods We identified and reviewed the methodological quality of 32 economic evaluations of NCD interventions in developing countries. Developing countries were defined according to the World Bank classification for low- and lower middle-income countries. We defined NCDs as the 12 categories listed in the 1993 World Bank report Investing in Health. English language literature was searched for the period January 1984 and January 2003 inclusive in Medline, Science Citation Index, HealthStar, NHS Economic Evaluation Database and Embase using medical subheading terms and free text searches. We then assessed the quality of studies according to a set of pre-defined technical criteria. Results We found that the quality of studies was poor and resource allocation decisions made by local and global policy-makers on the basis of this evidence could be misleading. Furthermore we have identified some clear gaps in the literature, particularly around injuries and strategies for tackling the consequences of the emerging tobacco epidemic. Conclusion In the face of poor evidence the role of so-called generalised cost-effectiveness analyses has an important role to play in aiding public health decision-making at the global level. Further research is needed to investigates the causes of variation among cost, effects and cost-effectiveness data within and between settings. Such analyses still need to take a broad view, present data in a transparent manner and take account of local constraints

Urbanization and non-communicable disease mortality in Thailand: an ecological correlation study.

This study provides strong evidence from an LMIC that urbanization is associated with mortality from three lifestyle-associated diseases at an ecological level. Furthermore, our data suggest that both average household income and number of doctors per population are important factors to consider in ecological analyses of mortality

Quantifying uncertainty in health impact assessment: a case-study example on indoor housing ventilation.

Quantitative health impact assessment (HIA) is increasingly being used to assess the health impacts attributable to an environmental policy or intervention. As a consequence, there is a need to assess uncertainties in the assessments because of the uncertainty in the HIA models. In this paper, a framework is developed to quantify the uncertainty in the health impacts of environmental interventions and is applied to evaluate the impacts of poor housing ventilation. The paper describes the development of the framework through three steps: (i) selecting the relevant exposure metric and quantifying the evidence of potential health effects of the exposure; (ii) estimating the size of the population affected by the exposure and selecting the associated outcome measure; (iii) quantifying the health impact and its uncertainty. The framework introduces a novel application for the propagation of uncertainty in HIA, based on fuzzy set theory. Fuzzy sets are used to propagate parametric uncertainty in a non-probabilistic space and are applied to calculate the uncertainty in the morbidity burdens associated with three indoor ventilation exposure scenarios: poor, fair and adequate. The case-study example demonstrates how the framework can be used in practice, to quantify the uncertainty in health impact assessment where there is insufficient information to carry out a probabilistic uncertainty analysis

Health funder requirements for data management and sharing

A set of guides that describe data management and sharing requirements established by funding agencies that support LSHTM research projects

Artemisinin resistance in Plasmodium falciparum malaria.

BACKGROUND: Artemisinin-based combination therapies are the recommended first-line treatments of falciparum malaria in all countries with endemic disease. There are recent concerns that the efficacy of such therapies has declined on the Thai-Cambodian border, historically a site of emerging antimalarial-drug resistance. METHODS: In two open-label, randomized trials, we compared the efficacies of two treatments for uncomplicated falciparum malaria in Pailin, western Cambodia, and Wang Pha, northwestern Thailand: oral artesunate given at a dose of 2 mg per kilogram of body weight per day, for 7 days, and artesunate given at a dose of 4 mg per kilogram per day, for 3 days, followed by mefloquine at two doses totaling 25 mg per kilogram. We assessed in vitro and in vivo Plasmodium falciparum susceptibility, artesunate pharmacokinetics, and molecular markers of resistance. RESULTS: We studied 40 patients in each of the two locations. The overall median parasite clearance times were 84 hours (interquartile range, 60 to 96) in Pailin and 48 hours (interquartile range, 36 to 66) in Wang Pha (P<0.001). Recrudescence confirmed by means of polymerase-chain-reaction assay occurred in 6 of 20 patients (30%) receiving artesunate monotherapy and 1 of 20 (5%) receiving artesunate-mefloquine therapy in Pailin, as compared with 2 of 20 (10%) and 1 of 20 (5%), respectively, in Wang Pha (P=0.31). These markedly different parasitologic responses were not explained by differences in age, artesunate or dihydroartemisinin pharmacokinetics, results of isotopic in vitro sensitivity tests, or putative molecular correlates of P. falciparum drug resistance (mutations or amplifications of the gene encoding a multidrug resistance protein [PfMDR1] or mutations in the gene encoding sarco-endoplasmic reticulum calcium ATPase6 [PfSERCA]). Adverse events were mild and did not differ significantly between the two treatment groups. CONCLUSIONS: P. falciparum has reduced in vivo susceptibility to artesunate in western Cambodia as compared with northwestern Thailand. Resistance is characterized by slow parasite clearance in vivo without corresponding reductions on conventional in vitro susceptibility testing. Containment measures are urgently needed. (ClinicalTrials.gov number, NCT00493363, and Current Controlled Trials number, ISRCTN64835265.

Views of NHS commissioners on commissioning support provision. Evidence from a qualitative study examining the early development of clinical commissioning groups in England

Objective: The 2010 healthcare reform in England introduced primary care-led commissioning in the National Health Service (NHS) by establishing clinical commissioning groups (CCGs). A key factor for the success of the reform is the provision of excellent commissioning support services to CCGs. The Government's aim is to create a vibrant market of competing providers of such services (from both for-profit and not-for-profit sectors). Until this market develops, however, commissioning support units (CSUs) have been created from which CCGs are buying commissioning support functions. This study explored the attitudes of CCGs towards outsourcing commissioning support functions during the initial stage of the reform. Design: The research took place between September 2011 and June 2012. We used a case study research design in eight CCGs, conducting in-depth interviews, observation of meetings and analysis of policy documents. Setting/participants: We conducted 96 interviews and observed 146 meetings (a total of approximately 439 h). Results: Many CCGs were reluctant to outsource core commissioning support functions (such as contracting) for fear of losing local knowledge and trusted relationships. Others were disappointed by the absence of choice and saw CSUs as monopolies and a recreation of the abolished PCTs. Many expressed doubts about the expectation that outsourcing of commissioning support functions will result in lower administrative costs. Conclusions: Given the nature of healthcare commissioning, outsourcing vital commissioning support functions may not be the preferred option of CCGs. Considerations of high transaction costs, and the risk of fragmentation of services and loss of trusted relationships involved in short-term contracting, may lead most CCGs to decide to form long-term partnerships with commissioning support suppliers in the future. This option, however, limits competition by creating ‘network closure’ and calls into question the Government's intention to create a vibrant market of commissioning support provision

Genetic analysis reveals the complex structure of HIV-1 transmission within defined risk groups

We explored the epidemic history of HIV-1 subtype B in the United Kingdom using statistical methods that infer the population history of pathogens from sampled gene sequence data. Phylogenetic analysis of HIV-1 pol gene sequences from Britain showed at least six large transmission chains, indicating a genetically variable, but epidemiologically homogeneous, epidemic among men having sex with men. Through coalescent-based analysis we showed that these chains arose through separate introductions of subtype B strains into the United Kingdom in the early-to-mid 1980s. After an initial period of exponential growth, the rate of spread generally slowed in the early 1990s, which is more likely to correlate with behaviour change than with reduced infectiousness resulting from highly active antiretroviral therapy. Our results provide new insights into the complexity of HIV-1 epidemics that must be considered when developing HIV monitoring and prevention initiatives