babigumira_oct202011

Potential Cost-Effectiveness of Alternative Implementation Trajectories to Full Coverage of Febrile Illness Rapid Diagnostic Tests (FIRDTs)

Joseph B. Babigumira Global Medicines Program Department of Global Health University of Washington

Project Team • • • • •

Ramanan Laxminarayan – Co-PI Dean Jamison – Co-PI Joseph Babigumira Lou Garrison Hellen Gelband

Agenda 1.

Introduction

2.

Research questions

3.

Proposed comparators

4.

Aspects of study design

5.

Proposed modeling strategy

6.

Costs

7.

Proposed analytic strategy

8.

A note on data sources

9.

Some anticipated challenges

10. Open discussion

Introduction • There is increasing (but not universal) access to ACTs as a replacement for CQ/SP in the treatment of malaria • But access to fever diagnostics in most poor countries is even more limited despite a WHO recommendation of parasitological confirmation of malaria prior to treatment when possible • The sensitivity, specificity, and cost of Rapid Diagnostic Tests (RDTs) have improved substantially in recent years • And with regard to making accurate diagnoses and focusing ACT use, RDTs have proven to be cost-effective in multiple studies • Therefore, with widespread scale-up now a possibility, would the expansion to universal access of rapid diagnostic tests for febrile illnesses in children be a good use of scarce resources?

Research Questions • What is the cost-effectiveness of alternative implementation trajectories to full coverage of Febrile Illness Rapid Diagnostic Tests?

– Expansion in low vs. high transmission areas – Expansion in public vs. private (regulated or unregulated) facilities vs. expansion through community health workers – Expansion with available vs. not available treatment for non-malaria febrile illness

• What is the cost-effectiveness of subsidizing different technologies for febrile illness management – RDTs – ACTs – Antibiotics

Alternative Implementation Trajectories

Febrile Illness Management Options Cost-Effectiveness Analysis Comparators 1.

Presumptive treatment with antimalarial (ACTs or CQ/SP)

2.

Old IMCI – No fever diagnosis/add antibiotic if severe illness

3.

New IMCI – Parasitological testing/antibiotic given to negative patients with severe illness

4.

Parasitological testing/no treatment for negative patients

5.

Parasitological testing/antibiotics given to negative patients

Methods Overview • We propose a disease-based decision-analytic modeling framework.

• The model starts with a child with an acute febrile illness and follows the child's progress over the time horizon of acute illness (max 21 days). Life expectancy for survivors is added to enable calculation of life years and DALYs. • The analysis is performed from both the societal perspective which includes all costs and governmental perspective which includes only the direct medical costs incurred by Ministries of Health.

• Data are obtained from published and unpublished sources.

• The main outcomes of the analysis are cost per life-year (LY) gained, cost per disability-adjusted life-year (DALY) averted.

• The baseline analyses to answer the research questions are one and two way sensitivity analyses as well as threshold analyses to examine the impact (on ICERs) of changing key parameters over their policy-relevant ranges.

Model (Front End)

Presumptive Treatment Arm

Old IMCI

New IMCI

Parasitological Diagnosis (No Treatment if Negative)

Parasitological Diagnosis (Antibiotics if Negative)

Costs Categories • Direct medical costs – Personnel – Diagnostic supplies (including RDTs) – Medicines (ACTs, antibiotics, and analgesics)

• Direct non-medical costs – e.g. transportation to health facilities

• Indirect (productivity) costs • Program costs – Demand creation (e.g. education, transport to remote areas) – Provider behavior change (e.g. education and incentives) – System strengthening (e.g. human resources and infrastructure)

Analytic Strategy (Examples) • Potential cost-effectiveness of expanding to full coverage of FIRDTs in low vs. high transmission areas – One-way sensitivity analysis of impact on ICER of the probability of child with febrile illness living in a high vs. low transmission setting

• Potential cost-effectiveness of expanding to full coverage of FIRDTs in low vs. high transmission areas and public vs. private health facilities – Two-way sensitivity analysis of simultaneous impact on ICER of the probability of child with febrile illness living in a high vs. low transmission setting and visiting public vs. private health facility

Other Analyses • Threshold analyses – The value of different parameters at which ICERs crosses commonlyaccepted cost-effectiveness in different jurisdictions

• Impact of subsidies of different products – Comparison of the change in ICERs with reducing cost of RDTs, ACTs and antibiotics

Data Sources • Probabilities – Published epidemiological analyses – Recently-published Dephi survey of likely health outcomes for untreated acute febrile illness in the tropics (PLoS ONE 6(2): e17439. doi:10.1371/journal.pone.0017439)

• Costs – Published and unpublished sources – Potentially analysis of secondary data or primary surveys

Anticipated Challenges • Base case estimates – The analytic jurisdiction is essentially all the tropics so there is bound to be variability in parameter estimates – What would be the basis for deciding which estimate to use as a base case estimate?

– This underscores the importance of a modeling framework that can be adopted to different jurisdictions

• Some data points will be difficult to estimate e.g.

– Proportion of non-malarial fever requiring an antibiotic – Probability of prescriber and patient compliance to negative results – BUT on-going studies are likely to improve the quality of estimates e.g.

• Studies of non-malaria fever in Ghana, Tanzania and Cambodia • Studies of RDT subsidies in Kenya and Uganda (Clinton Foundation)

Thanks Very Much

Open Discussion, Suggestions ‌