Total Program Costs Research Articles

Costs and cost-effectiveness of training traditional birth attendants to reduce neonatal mortality in the Lufwanyama Neonatal Survival study (LUNESP).

BackgroundThe Lufwanyama Neonatal Survival Project (“LUNESP”) was a cluster randomized, controlled trial that showed that training traditional birth attendants (TBAs) to perform interventions targeting birth asphyxia, hypothermia, and neonatal sepsis reduced all-cause neonatal mortality by 45%. This companion analysis was undertaken to analyze intervention costs and cost-effectiveness, and factors that might improve cost-effectiveness.Methods and FindingsWe calculated LUNESP's financial and economic costs and the economic cost of implementation for a forecasted ten-year program (2011–2020). In each case, we calculated the incremental cost per death avoided and disability-adjusted life years (DALYs) averted in real 2011 US dollars. The forecasted 10-year program analysis included a base case as well as ‘conservative’ and ‘optimistic’ scenarios. Uncertainty was characterized using one-way sensitivity analyses and a multivariate probabilistic sensitivity analysis. The estimated financial and economic costs of LUNESP were $118,574 and $127,756, respectively, or $49,469 and $53,550 per year. Fixed costs accounted for nearly 90% of total costs. For the 10-year program, discounted total and annual program costs were $256,455 and $26,834 respectively; for the base case, optimistic, and conservative scenarios, the estimated cost per death avoided was $1,866, $591, and $3,024, and cost per DALY averted was $74, $24, and $120, respectively. Outcomes were robust to variations in local costs, but sensitive to variations in intervention effect size, number of births attended by TBAs, and the extent of foreign consultants' participation.ConclusionsBased on established guidelines, the strategy of using trained TBAs to reduce neonatal mortality was ‘highly cost effective’. We strongly recommend consideration of this approach for other remote rural populations with limited access to health care.

Treating chronic hepatitis in Asian and Pacific Island populations: A comparison of program costs according to current treatment guidelines.

193 Background: Hepatitis B (HBV) infection is endemic in many Asian and Pacific Island countries, with 25-40% of chronic hepatitis B (CHB) patients developing cirrhosis or hepatocellular cancer (HCC). Increased migration from high HBV prevalence countries leads to Vietnamese-born Americans and Australians 11-13 times more likely to develop HCC than other groups. As antiviral therapy is more cost-effective than HCC screening, we developed a program of hepatitis B screening, monitoring and treatment targeting high–risk populations in Sydney aged >35 years (the median age for HBeAg sero-conversion in Asian populations). Here we compare estimated program costs using guidelines for HBV treatment in hepatitis B e antigen negative populations. Methods: Using a Markov model, we modelled CHB disease progression and management costs using guidelines published by the American, European and Asian Pacific Associations for the Study of Liver Disease (AASLD, EASL and APASL) and algorithms created by US hepatology experts and our B Positive program, using different levels of alanine aminotransferase (ALT) for treatment initiation. We factored in costs for CHB screening and surveillance for liver damage provided by specialists and/or primary care providers, including CHB and HCC treatment, individualised by viral load and ALT levels. Costs were discounted by 5% and calculated in Australian dollars (AUD); incremental costs used AASLD guidelines as a baseline. Results: Assuming a 25% enrolment in our target population of patients with CHB in South West Sydney followed up for 50 years, total program costs would amount to 9,205,680 AUD. Using AASLD guidelines, estimated cost would amount to 6,344 AUD per patient. APASL guidelines lead to a 132% cost rise, the B Positive program costs 152% more, while the US algorithm and EASL are associated with a 221% cost increment to achieve the equivalent cost/QALY. Conclusions: While the AASLD guidelines appear to be the least costly, uncertainties about “ideal” ALT and viral load levels for treatment initiation and the extent of the benefit conferred in terms of HCC cases averted will need to be resolved to inform large-scale prevention programs.

Cost of treating chronic hepatitis B: Comparison of current treatment guidelines

To compare program costs of chronic hepatitis B (CHB) screening and treatment using Australian and other published CHB treatment guidelines. Economic modeling demonstrated that in Australia a strategy of hepatocellular cancer (HCC) prevention in patients with CHB is more cost-effective than current standard care, or HCC screening. Based upon this model, we developed the B positive program to optimize CHB management of Australians born in countries of high CHB prevalence. We estimated CHB program costs using the B positive program algorithm and compared them to estimated costs of using the CHB treatment guidelines published by the Asian-Pacific, American and European Associations for the Study of Liver Disease (APASL, AASLD, EASL) and those suggested by an independent United States hepatology panel. We used a Markov model that factored in the costs of CHB screening and treatment, individualized by viral load and alanine aminotransferase levels, and calculated the relative costs of program components. Costs were discounted by 5% and calculated in Australian dollars (AUD). Using the B positive algorithm, total program costs amount to 13,979,224 AUD, or 9634 AUD per patient. The least costly strategy is based upon using the AASLD guidelines, which would cost 34% less than our B positive algorithm. Using the EASL and the United States Expert Group guidelines would increase program costs by 46%. The largest expenditure relates to the cost of drug treatment (66.9% of total program costs). The contribution of CHB surveillance (20.2%) and HCC screening and surveillance (6.6%) is small--and together they represent only approximately a quarter of the total program costs. The significant cost variations in CHB screening and treatment using different guidelines are relevant for clinicians and policy makers involved in designing population-based disease control programs.

Introduction of the Tools for Economic Analysis of Patient Management Interventions in Heart Failure Costing Tool

Background— Patient-centered health care interventions, such as heart failure disease management programs, are under increasing pressure to demonstrate good value. Variability in costing methods and assumptions in economic evaluations of such interventions limit the comparability of cost estimates across studies. Valid cost estimation is critical to conducting economic evaluations and for program budgeting and reimbursement negotiations. Methods and Results— Using sound economic principles, we developed the Tools for Economic Analysis of Patient Management Interventions in Heart Failure (TEAM-HF) Costing Tool, a spreadsheet program that can be used by researchers and health care managers to systematically generate cost estimates for economic evaluations and to inform budgetary decisions. The tool guides users on data collection and cost assignment for associated personnel, facilities, equipment, supplies, patient incentives, miscellaneous items, and start-up activities. The tool generates estimates of total program costs, cost per patient, and cost per week and presents results using both standardized and customized unit costs for side-by-side comparisons. Results from pilot testing indicated that the tool was well-formatted, easy to use, and followed a logical order. Cost estimates of a 12-week exercise training program in patients with heart failure were generated with the costing tool and were found to be consistent with estimates published in a recent study. Conclusions— The TEAM-HF Costing Tool could prove to be a valuable resource for researchers and health care managers to generate comprehensive cost estimates of patient-centered interventions in heart failure or other conditions for conducting high-quality economic evaluations and making well-informed health care management decisions.

Economic returns to investment in AIDS treatment in low and middle income countries.

Since the early 2000s, aid organizations and developing country governments have invested heavily in AIDS treatment. By 2010, more than five million people began receiving antiretroviral therapy (ART) – yet each year, 2.7 million people are becoming newly infected and another two million are dying without ever having received treatment. As the need for treatment grows without commensurate increase in the amount of available resources, it is critical to assess the health and economic gains being realized from increasingly large investments in ART. This study estimates total program costs and compares them with selected economic benefits of ART, for the current cohort of patients whose treatment is cofinanced by the Global Fund to Fight AIDS, Tuberculosis and Malaria. At end 2011, 3.5 million patients in low and middle income countries will be receiving ART through treatment programs cofinanced by the Global Fund. Using 2009 ART prices and program costs, we estimate that the discounted resource needs required for maintaining this cohort are $14.2 billion for the period 2011–2020. This investment is expected to save 18.5 million life-years and return $12 to $34 billion through increased labor productivity, averted orphan care, and deferred medical treatment for opportunistic infections and end-of-life care. Under alternative assumptions regarding the labor productivity effects of HIV infection, AIDS disease, and ART, the monetary benefits range from 81 percent to 287 percent of program costs over the same period. These results suggest that, in addition to the large health gains generated, the economic benefits of treatment will substantially offset, and likely exceed, program costs within 10 years of investment.

The cost of providing comprehensive HIV treatment in PEPFAR-supported programs

PEPFAR, national governments, and other stakeholders are investing unprecedented resources to provide HIV treatment in developing countries. This study reports empirical data on costs and cost trends in a large sample of HIV treatment sites. In 2006-2007, we conducted cost analyses at 43 PEPFAR-supported outpatient clinics providing free comprehensive HIV treatment in Botswana, Ethiopia, Nigeria, Uganda, and Vietnam. We collected data on HIV treatment costs over consecutive 6-month periods starting from scale-up of dedicated HIV treatment services at each site. The study included all patients receiving HIV treatment and care at study sites [62,512 antiretroviral therapy (ART) and 44,394 pre-ART patients]. Outcomes were costs per patient and total program costs, subdivided by major cost categories. Median annual economic costs were US$ 202 (2009 USD) for pre-ART patients and US$ 880 for ART patients. Excluding antiretrovirals, per patient ART costs were US$ 298. Care for newly initiated ART patients cost 15-20% more than for established patients. Per patient costs dropped rapidly as sites matured, with per patient ART costs dropping 46.8% between first and second 6-month periods after the beginning of scale-up, and an additional 29.5% the following year. PEPFAR provided 79.4% of funding for service delivery, and national governments provided 15.2%. Treatment costs vary widely between sites, and high early costs drop rapidly as sites mature. Treatment costs vary between countries and respond to changes in antiretroviral regimen costs and the package of services. Whereas cost reductions may allow near-term program growth, programs need to weigh the trade-off between improving services for current patients and expanding coverage to new patients.

Costing Human Rights and Community Support Interventions as a Part of Universal Access to HIV Treatment and Care in a Southern African Setting

Expanding access to antiretroviral therapy (ART) has both individual health benefits and potential to decrease HIV incidence. Ensuring access to HIV services is a significant human rights issue and successful programmes require adequate human rights protections and community support. However, the cost of specific human rights and community support interventions for equitable, sustainable and non-discriminatory access to ART are not well described. Human rights and community support interventions were identified using the literature and through consultations with experts. Specific costs were then determined for these health sector interventions. Population and epidemic data were provided through the Statistics South Africa 2009 national mid-year estimates. Costs of scale up of HIV prevention and treatment were taken from recently published estimates. Interventions addressed access to services, minimising stigma and discrimination against people living with HIV, confidentiality, informed consent and counselling quality. Integrated HIV programme interventions included training for counsellors, ‘Know Your Rights’ information desks, outreach campaigns for most at risk populations, and adherence support. Complementary measures included post-service interviews, human rights abuse monitoring, transportation costs, legal assistance, and funding for human rights and community support organisations. Other essential non-health sector interventions were identified but not included in the costing framework. The annual costs for the human rights and community support interventions are United States (US) $63.8 million (US $1.22 per capita), representing 1.5% of total health sector HIV programme costs. Respect for human rights and community engagement can be understood both as an obligation of expanded ART programmes and as a critically important factor in their success. Basic rights-based and community support interventions constitute only a small percentage of overall programmes costs. ART programs should consider measuring the cost and impact of human rights and community support interventions as key aspects of successful programme expansion.

3.2.2 A More Flexible Approach to Valuing Flexibility

AbstractThe DOD routinely demonstrates its capability to develop phenomenal systems; however, these accomplishments are often tarnished by substantial cost and schedule overruns. While defense policies are continually being revised to address these problems, many believe that a more fundamental source of these overruns is the lack of flexibility in the systems being developed. But providing justification to invest in flexibility is a tough sell, as stakeholders struggle to quantitatively demonstrate the potential return on investment. Therefore, this paper introduces an alternative methodology for valuing the inherent ability of a system or design to accommodate change. The proposed methodology is essentially a modification of the current life cycle model and is premised on the notion that the need for capability changes in a program arise in a stochastic manner that can be incorporated into a continually updated, expected value model presented in terms of total program cost.

The Urgent Need to Increase Support for the NIHʼs MD–PhD Student Fellowships

In Reply: Fifty years ago, the first small MD-PhD programs were established with the goal of expanding the physician–scientist workforce by combining the best parts of medical and graduate education. As MD-PhD programs have grown, so has the tradition of granting students full fellowships that pay for both graduate school and medical school and provide a stipend. Mr. Samarasinghe expresses his concerns about the recent decision by the National Institutes of Neurological Disorders and Stroke (NINDS) to discontinue a program that helps defray medical school costs for MD-PhD students. He also voices his concern about the adverse impact of this and other recent federal funding decisions on the career choices made by students planning to become physician–scientists. As program directors, we share these concerns. Intentionally or not, the NINDS decision raises an important question, which is how best to cover the costs of training the next generation of physician–investigators. There is broad agreement that future physician–scientists should be relieved of as much of their training costs as possible so that large debts incurred during medical school do not push them into private practice. The NIH loan repayment program was established with this in mind, but since it kicks in years after the debts are incurred, it may not have the same impact on career planning as would avoiding debt to begin with. Although not the only way to train physician–scientists, recent data show that most MD-PhD program alumni are engaged in academic medicine and biomedical research.1 MD-PhD training takes about eight years and is expensive.1 Institutional Medical Scientist Training Program (MSTP) grants from the National Institute of General Medical Sciences cover some of the costs and provide a strong incentive to create high-quality, integrated MD-PhD training programs. However, MSTP grants typically cover less than 25% of total program costs. The remainder comes from a combination of university funds, research grants, private foundations, and individual fellowships that students compete for nationally. Each of these has a role, and any future expansion of the physician–scientist workforce will require all of them. In 2005 the National Academy called for a 20% increase in support for physician–scientist training programs.2 Individual fellowships offered by NIH institutes are one way to do this and, when combined with other outreach efforts, can help institutes achieve their goal of attracting promising physician–scientists into research and clinical fields aligned with the institute's mission. Physician–scientists play a vital role across the entire spectrum of biomedical investigation that includes basic, translational, patient-oriented, and effectiveness research. We applaud Mr. Samarasinghe's efforts to bring his important concerns to greater public notice. Lawrence F. Brass, MD, PhD Professor of medicine and director, Medical Scientist Training Program, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; [email protected]. Olaf S. Andersen, MD Professor of physiology and biophysics and director, Weill Cornell/Rockefeller/Sloan-Kettering Tri-Institutional MD-PhD Program, Weill Cornell Medical College, New York, New York. Myles H. Akabas, MD, PhD Professor of physiology and biophysics and director, Medical Scientist Training Program, Albert Einstein College of Medicine, Bronx, New York.

Benchmarking That Matters: A Proposed New Direction for Clinical Engineering

Benchmarking, not a new concept to clinical engineering (CE) managers, continues to be redefined and promoted as a “must have” by CE professionals. How we use benchmarking and how we should use benchmarking is the crux of this article. We need to prioritize and focus our resources in a way that matters most to our fellow caregivers and patients. There is a lot of valuable information to be gained from benchmarking articles offered by AAMI, ECRI Institute, and trade journals. And, as one might expect, there is a wide range of suggestions within the CE community as to which benchmarks are the most important, how to collect the data, and how various benchmarks can or should be used to support the growth and further development of a CE department. All too often, those of us responsible for managing CE departments fall into the trap of collecting and presenting data simply because we have always done it. This practice is truly a “sacred cow.” Why do we collect data? We do it to justify our existence, to prove our worth, and/or in an attempt to justify needed additional resources. We have been guilty of this for the past 30 years. We have always generated a yearend report for senior management in an attempt to wow them with all kinds of data: preventive maintenance (PM) compliance, response time, open vs. closed work orders, productivity, cost-of-service ratio, in-house vs. vendor repairs, etc., all nicely tabulated and formatted to identify trends. Impressive, no? Yet, can we really see significant, actionable outcomes when looking at year-to-year comparisons? Surely some metrics go up, some go done, others barely change. Then we compare our data by looking at similar metrics from other organizations. Interpretations of the results dissipate into concerns over data accuracy and integrity. After all, our CE profession can’t even agree on how to count devices (is it one monitor, or one with five modules); what purchase cost to use (list price vs. our negotiated top-secret price); or how to define a productive employee (captured work hours or available hours). With all these benchmarking variations and ambiguities of how and what to measure, is it any wonder that it has been challenging for CE professionals to determine how best to use them? Depending on how our numbers compare, we can look either better or worse than the CE program across town. Yet, both can have little or an unquantifiable impact on the quality of care and on the staff efficiencies of those we serve. Using our sacred cow benchmarks, we just don’t know.

Consumer-operated service programs: Monetary and donated costs and cost-effectiveness.

Examine cost differences between Consumer Operated Service Programs (COSPs) as possibly determined by a) size of program, b) use of volunteers and other donated resources, c) cost-of-living differences between program locales, d) COSP model applied, and e) delivery system used to implement the COSP model. As part of a larger evaluation of COSP, data on operating costs, enrollments, and mobilization of donated resources were collected for eight programs representing three COSP models (drop-in centers, mutual support, and education/advocacy training). Because the 8 programs were operated in geographically diverse areas of the US, costs were examined with and without adjustment for differences in local cost of living. Because some COSPs use volunteers and other donated resources, costs were measured with and without these resources being monetized. Scale of operation also was considered as a mediating variable for differences in program costs. Cost per visit, cost per consumer per quarter, and total program cost were calculated separately for funds spent and for resources donated for each COSP. Differences between COSPs in cost per consumer and cost per visit seem better explained by economies of scale and delivery system used than by cost-of-living differences between program locations or COSP model. Given others' findings that different COSP models produce little variation in service effectiveness, minimize service costs by maximizing scale of operation while using a delivery system that allows staff and facilities resources to be increased or decreased quickly to match number of consumers seeking services.

Risk Planning and Management for the Panama Canal Expansion Program

In April 2006, the Panama Canal Authority formally proposed a major expansion of the canal to increase its capacity and make it more productive, safe, and efficient. This proposal included cost and schedule estimates for completing the expansion and was supported overwhelmingly by the citizens of Panama in an October 2006 public referendum. Given the conceptual level of design at the time of the proposal and the inherent uncertainty in a project of this magnitude at the early stages of engineering, a comprehensive risk analysis was performed to develop a contingency model for the total expansion program cost and schedule. This contingency model is based on a Monte Carlo simulation of the cost and schedule estimates, taking into account the most significant risks identified for the project. The resulting model provides contingency assessments for duration and total cost and sensitivity analysis of the risks; it also allows for multiple scenario planning and ultimately supports overall risk management. This paper presents a project case study that focuses on the contingency model development and the resulting risk management and contingency resolution processes.

Cost-effectiveness of Using Social Networks to Identify Undiagnosed HIV Infection Among Minority Populations

In 2003, the Centers for Disease Control and Prevention launched the Advancing HIV Prevention project to implement new strategies for diagnosing human immunodeficiency virus (HIV) infections outside medical settings and prevent new infections by working with HIV-infected persons and their partners. : To assess the cost and effectiveness of a social network strategy to identify new HIV diagnoses among minority populations. Four community-based organizations (CBOs) in Boston, Philadelphia, and Washington, District of Columbia, implemented a social network strategy for HIV counseling and testing from October 2003 to December 2005. We used standardized cost collection forms to collect program costs attributable to staff time, travel, incentives, test kits, testing supplies, office space, equipment, and utilities. The CBOs used the networks of high-risk and HIV-infected persons (recruiters) who referred their partners and associates for HIV counseling and testing. We obtained HIV-testing outcomes from project databases. Number of HIV tests, number of new HIV-diagnoses notified, total program cost, cost per person tested, cost per person notified of new HIV diagnosis. Two CBOs, both based in Philadelphia, identified 25 and 17 recruiters on average annually and tested 136 and 330 network associates, respectively. Among those tested, 12 and 13 associates were notified of new HIV diagnoses (seropositivity: 9.8%, 4.4%). CBOs in Boston, Massachusetts, and Washington, District of Columbia, identified 26 and 24 recruiters per year on average and tested 228 and 123 network associates. Among those tested, 12 and 11 associates were notified of new HIV diagnoses (seropositivity: 5.1%, 8.7%). The cost per associate notified of a new HIV diagnosis was $11 578 and $12 135 in Philadelphia, and $16 437 and $16 101 in Boston, Massachusetts, and Washington, District of Columbia. The cost of notifying someone with a new HIV diagnosis using social networks varied across sites. Our analysis provides useful information for program planning and evaluation.

A Retrospective Economic Analysis of the Ontario Red Fox Oral Rabies Vaccination Programme

Ontario initiated a red fox (Vulpes vulpes) oral rabies vaccination (ORV) programme in 1989. This study utilized a benefit-cost analysis to determine if this ORV programme was economically worthwhile. Between 1979 and 1989, prior to ORV baiting, the average annual human post-exposure treatments, positive red fox rabies diagnostic tests and indemnity payments for livestock lost to rabies were 2248, 1861 and $246,809, respectively. After baiting, from 1990 to 2000, a 35%, 66% and 41% decrease in post-exposure treatments, animal rabies tests and indemnity payments was observed, respectively. These reductions were viewed as benefits of the ORV programme, whereas total costs were those associated with ORV baiting. Multiple techniques were used to estimate four different benefit streams and the total estimated benefits ranged from $35,486,316 to $98,413,217. The annual mean ORV programme cost was $6,447,720, with total programme costs of $77,372,637. The average benefit-cost ratios over the analysis period were .49, 1.06, 1.27 and 1.36, indicating overall programme efficiency in three of the four conservative scenarios.

Prioritizing Agricultural Lands for Conservation Buffer Placement Using Multiple Criteria1

Qiu, Zeyuan, 2010. Prioritizing Agricultural Lands for Conservation Buffer Placement Using Multiple Criteria. Journal of the American Water Resources Association (JAWRA) 1‐13. DOI: 10.1111/j.1752‐1688.2010.00466.xAbstract: Although conservation buffers are multifunctional, the current conservation buffer planning strategies tend to use a single criterion, most frequently a hydrological or soil condition indicator, to guide conservation buffer placement. This study presents a watershed planning approach that prioritizes agricultural lands for conservation buffers based on multiple selection criteria and applies the approach to Raritan Basin in central New Jersey. The multiple selection criteria include soil erodibility, hydrological sensitivity, wildlife habitat, and impervious surface rate. These criteria capture the conservation buffers’ benefits in reducing soil erosion, controlling runoff generation, enhancing wildlife habitat, and mitigating stormwater impacts, respectively. An expert panel was used to identify and define the section criteria, review the measured values of those criteria, and develop the classification scales that assign the class score to each criterion. The prioritization is based on the summation of the criteria class scores. About one‐third of agricultural lands are prioritized for conservation buffers in Raritan Basin. The total program cost of converting those prioritized agricultural lands to conservation buffers in Raritan Basin is estimated to be between $54.8 and 102.9 million depending on the composition of installed conservation buffer practices.

Cost-utility analysis of methadone maintenance treatment in Lithuania

Economic evaluations in health care involve the identification, measurement, valuation, and then comparison of the costs (inputs) and outcomes of treatments or preventive activities. The aim was to analyze the cost-utility of six-month methadone maintenance treatment program in a Lithuanian primary health care setting. A prospective study design was used. All the information was obtained through the validated questionnaires at the baseline and 3- and 6-month follow-ups. WHOQOL-BREF was used to assess the quality of life; the costs were assessed using the DATCAP methodology from the perspective of a patient and outpatient clinic during follow-up period. A total of 102 opioid-dependent patients were recruited in the study; 512 follow-up patient-months were obtained. The methadone maintenance treatment has significantly improved physical, psychological, and environmental components of quality of life during follow-up. Total program costs were 61 288.87 EUR. Cost paid by a patient comprised about 31% of total program costs. Cost per quality-adjusted life-month (QALM) for physical domain was 2227.55 EUR; for psychological domain, 1879.50 EUR; for social domain, 5467.64 EUR; and for environmental domain, 4626.47 EUR. Costs per QALM and quality-adjusted life-year (QALY) for total quality of life in the maintenance program were 2864.00 EUR and 34 368.00 EUR, respectively. Our results showed that 6-month methadone maintenance program was effective in the terms of quality-of-life improvement. Methadone maintenance treatment program was less effective in terms of cost per QALY.

Cost Effectiveness of Positron Emission Tomography in Patients With Hodgkin's Lymphoma in Unconfirmed Complete Remission or Partial Remission After First-Line Therapy

To assess the cost effectiveness of fluorine-18-fluorodeoxyglucose positron emission tomography (FDG-PET) in patients with Hodgkin's lymphoma (HL) with unconfirmed complete remission (CRu) or partial remission (PR) after first-line treatment. One hundred thirty patients with HL were prospectively studied. After treatment, all patients with CRu/PR were evaluated with FDG-PET. In addition, PET-negative patients were evaluated with standard follow-up, and PET-positive patients were evaluated with biopsies of the positive lesions. Local unit costs of procedures and tests were evaluated. Cost effectiveness was determined by evaluating projected annual economic impact of strategies without and with FDG-PET on HL management. After treatment, CRu/PR was observed in 50 (40.0%) of the 127 patients; the sensitivity, specificity, and positive and negative predictive values of FDG-PET were 100%, 92.0%, 92.3%, and 100%, respectively (accuracy of 95.9%). Local restaging costs without PET were $350,050 compared with $283,262 with PET, a 19% decrease. The incremental cost-effectiveness ratio is -$3,268 to detect one true case. PET costs represented 1% of total costs of HL treatment. Simulated costs in the 974 patients registered in the 2008 Brazilian public health care database showed that the strategy including restaging PET would have a total program cost of $56,498,314, which is $516,942 less than without restaging PET, resulting in a 1% cost saving. FDG-PET demonstrated 95.9% accuracy in restaging for patients with HL with CRu/PR after first-line therapy. Given the observed probabilities, FDG-PET is highly cost effective and would reduce costs for the public health care program in Brazil.

Cost effectiveness of pneumococcal vaccination among Dutch infants: economic analysis of the seven valent pneumococcal conjugated vaccine and forecast for the 10 valent and 13 valent vaccines

Objectives To update cost effectiveness estimates for the four dose (3+1) schedule of the seven valent pneumococcal conjugated vaccine (PCV-7) in the Netherlands and to explore the impact on cost...

Costs of HIV prevention among out-of-treatment drug-using women: results of a randomized controlled trial.

We developed a micro-costing methodology to estimate the real resource costs consumed by delivery of the National Institute on Drug Abuse (NIDA) Cooperative Agreement Standard Intervention (SI) for human immunodeficiency virus (HIV) prevention, plus two enhanced modules, in a three-arm randomized controlled trial (RCT) among drug-using women. To our knowledge, this is the first micro-costing study of the SI and enhanced modules and the first of its kind targeting drug-using women. We conducted a micro-costing study alongside a three-arm RCT to estimate costs of (1) the modified NIDA SI; (2) the SI and a well woman exam (SI+WWE); and (3) the SI, WWE, and four educational sessions (SI+WWE+4ES) to prevent HIV and sexually transmitted diseases in at-risk, drug-using women in St. Louis, Missouri. The cost of the SI that all 501 participants received was approximately $227 per person. The additional costs for the WWE and 4ES were approximately $145 and $942 per person, respectively. Total program costs for the SI (n = 501) were $113,869; additional costs for the SI+WWE (n = 342) were $49,403 and for the SI+WWE+4ES (n = 170) were $160,189. The main cost component for the SI (64% of total costs) was testing costs, whereas building and facilities costs were the main cost component for the SI+WWE+4ES (75% of total costs). This study provides accurate estimates of the real costs for standard and enhanced HIV interventions for policy makers seeking to implement targeted HIV-prevention programs with scarce resources.

Cost-Effectiveness of Routine Rapid Human Immunodeficiency Virus Antibody Testing Before DNA-PCR Testing for Early Diagnosis of Infants in Resource-Limited Settings

Infants born to HIV-infected women should receive HIV testing to allow early diagnosis and treatment. Recommendations for resource-limited settings stress laboratory-based virologic assays. While effective, these tests are logistically complex and expensive. This study explored the cost-effectiveness of incorporating initial screening with rapid HIV tests (RHT) into the conventional testing algorithm to screen-out HIV-uninfected infants, thereby reducing the need for costly virologic testing. Data on HIV prevalence, RHT sensitivity and specificity, and costs were collected from 820 HIV-exposed children (1.5-18 months) attending 2 postnatal screening programs in Uganda during July 2005 to December 2006. Cost-effectiveness models compared the conventional testing algorithm DNA polymerase chain reaction (DNA-PCR with Roche Amplicor v1.5) with a modified algorithm (initial RHT to screen-out HIV-uninfected infants before DNA-PCR). The model estimated that the conventional algorithm would identify 94.3% (91.8%-94.7%) of HIV-infected infants, compared with 87.8% (79.4%-90.5%) for a modified algorithm using RHT (HIV 1/2 Determine) and excluding the need for DNA-PCR for HIV antibody-negative infants. Costs per infant were $23.47 ($23.32-$23.76) for the conventional algorithm and between $22.75 ($21.89-$23.31) and $7.58 ($6.41-$10.75) for the modified algorithm, depending on infant age and symptoms. Compared with the conventional algorithm, costs per HIV-infected infant identified using the modified algorithm were higher in 1.5-to 3-month-old infants, but significantly lower in 3-month-old and older infants. Models replicating the whole infant testing program showed the modified algorithm would have marginally lower sensitivity, but would reduce total program costs by 27% to 40%, producing an incremental cost-effectiveness ratio of $1489 ($686-$6781) for the conventional versus modified algorithms. Screening infants with RHT before DNA-PCR is cost-effective in infants 3 months old or older. Incorporating RHT into early infant testing programs could improve cost-effectiveness and reduce program costs.