The Hospital for Sick Children Technology Assessment at SickKids (TASK) FULL REPORT

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1 The Hospital for Sick Children Technology Assessment at SickKids (TASK) FULL REPORT WILL THE GROWTH SPURT CONTINUE? TRENDS IN CHILD HEALTH ECONOMIC EVALUATION: 1980 TO 2013 Authors: Shannon Sullivan, PhD Independent Consultant Wendy J. Ungar, MSc, PhD Child Health Evaluative Sciences, The Hospital for Sick Children Corresponding Author: Wendy J. Ungar, MSc, PhD The Hospital for Sick Children Peter Gilgan Centre for Research and Learning 11th floor, 686 Bay Street Toronto, ON, Canada M5G 0A4 tel: (416) , extension , fax: (416) , Report No Date: January 25, 2016 Available at:

2 ACKNOWLEDGEMENTS This research was supported with funding from The Hospital for Sick Children Research Institute. The following individuals are acknowledged with gratitude for their substantial contribution to the PEDE Project: Kate Tsiplova, Sarah Costa, Pooyeh Graili, Seija Kromm, Shayanthan Parameswaran, Richard Zur, Heather Burnett, and Elizabeth Uleryk. We thank Ms. Jeri Danyleyko and Christine Millan for administrative and technical support. CONFLICTS OF INTEREST The authors have no conflicts of interest to disclose.

3 TABLE OF CONTENTS ACKNOWLEDGEMENTS... ii LIST OF TABLES... iv LIST OF FIGURES... vi ABBREVIATIONS... vii 1 INTRODUCTION METHODS Data Source and Study Selection Search Strategy Data Collection Data Analysis RESULTS Volume of Publications Analytic Technique Journal Type Intervention Type Outcome Measures Age Group Disease category Target Population DISCUSSION Key Findings Comparison with Literature Strengths and Limitations Policy Implications and Future Research...40 REFERENCES...42 iii

4 LIST OF TABLES Table 1. Publications per 10-year period (n=2630)... 5 Table 2. Publications per 10-year interval by analytic technique (n=2630)... 7 Table 3. Publications in early ( ) and late ( ) periods by analytic technique (n=2630)... 7 Table 4. Publications in early ( ) and late ( ) periods by journal type (n=2630)... 9 Table 5. Publications by journal type and by analytic technique ( ) (n=2630 records) 10 Table 6. Publications in early ( ) and late ( ) periods by intervention type (n=2630)...11 Table 7. Publications by intervention type and by analytic technique ( ) (n=2630 records)...12 Table 8. Publications in early ( ) and late ( ) periods by outcome category (n=2630)...14 Table 9. Number of publications by outcome category and by analytic technique (n=2630 records)...15 Table 10. Publications in early ( ) and late ( ) periods by age category (n=2630 records*)...16 Table 11. Publications by intervention type and by age group (n=2630 records)...17 Table 12 Publications by summary outcome and by age group (n=2630 records)...19 Table 13. Publications in early ( ) and late ( ) periods by ICD9/10 disease category (n=2630)...21 Table 14. Publications by ICD-9/10 disease classification and by analytic technique (n=2630 records)...23 Table 15. Publications by ICD-9/10 disease classification and by intervention type (n=2630 records)...25 Table 16. Publications by ICD-9/10 disease classification and by age group (n=2630 records).29 Table 17. Publications by the ten most frequent target populations ( )...31 Table 18. Publications by the most frequent target populations ( )...32 Table 19. Publications by the ten most frequent target populations ( )...32 Table 20. Publications by the ten most frequent target populations ( )...33 Table 21. Publications by the ten most frequent target populations ( )...33 iv

5 Table 22. Most frequent target populations within infective and parasitic class ( ) (n=329 records)...34 Table 23. Most frequent target populations within pregnancy, childbirth and puerperium class ( ) (n=189 records)...34 Table 24. Most frequent target populations within certain conditions originating in the perinatal period ( ) (n=100 records)...35 Table 25. Most frequent target populations within congenital anomalies class ( ) (n=188 records)...35 Table 26. Most frequent target populations within health prevention ( ), (n=833 records)...36 Table 27. Most frequent target populations within health treatment ( ), (n=637 records)...36 Table 28. Most frequent target populations within detection ( ), (n=418 records)...36 v

6 LIST OF FIGURES Figure 1 Distribution of economic evaluations in PEDE by year ( )... 8 Figure 2. Analytic technique according to type of intervention studied...13 vi

7 ABBREVIATIONS PEDE CBA CEA CMA CUA HIV HPV ICD QALY QOL RSV WHO Pediatric Economic Database Evaluation cost benefit analysis cost-effectiveness analysis cost-minimization analysis cost-utility analysis human immunodeficiency virus human papilloma virus International Classification of Diseases quality adjusted life year quality of life respiratory syncytial virus World Health Organization vii

8 SUMMARY Introduction Economic evaluations conducted as part of health technology assessments in pediatric populations have unique features compared to those conducted in adults. The Pediatric Economic Database Evaluation (PEDE) project includes a comprehensive database of pediatric health economic evaluations published since The objective was to identify significant trends over time as well as methodological gaps to improve the quality of future studies and evidence for decision-making. Methods Medical and grey literature were searched for pediatric economic evaluations, key characteristics were extracted, frequencies were tabulated and selected cross-tabulations were performed. Differences in study characteristics between early (1980 and1999) and late (2000 and 2013) pediatric economic evaluations were assessed using a chi-squared statistic. Results A total of 2630 pediatric economic evaluations were published between 1980 and 2013 with an average annual growth rate of 15%. Substantially more cost-effectiveness analyses (CEAs) and cost utility analyses (CUAs) were published compared with cost benefit analyses (CBAs) and cost minimization analyses (CMAs) (64.5% and 24.0% versus 7.7% and 3.7%, respectively). This trend was consistent regardless of the type of intervention, disease or age group studied. A trend toward higher proportions of CUAs and CEAs was evident in the later period (X 2 p<0.0001). Other significant trends included more publications in health economics/policy journals and sub-specialty journals in the later period (X 2 p<0.0001), a higher proportion of studies of preventive interventions in the later period (X 2 p<0.0001), and more studies in children and fewer in perinates in the later period (X 2 p<0.0001). Overall the most common disease class studied was infectious diseases (29%). viii

9 Conclusions The field of pediatric economic evaluation continues to grow in volume and methodologic complexity. While CUAs have increased, the quality of CUAs remains unknown. Although most studies are in infectious disease, the volume of publications may not align with emerging child health priorities and target populations, such as adolescent health, injury, developmental disabilities, mental health, and the use of personalized medicine. Increasing economic evaluations in these areas will enhance pediatric decision-making. ix

10 1 INTRODUCTION Health economic evaluations provide a comparison of the costs and health consequences of various interventions in a specified population. Results of economic evaluations are used by health practitioners and decision makers to assist with both clinical treatment and health policy decisions(1, 2). However, economic evaluations conducted in pediatric populations have unique features and challenges when compared with those conducted in adults. This includes the impact of child growth and development on disease processes and intervention effectiveness; a reliance on care-giving adults such as parents and teachers to facilitate access to healthcare services and act as a proxy for reporting health outcomes; the inability to accurately measure preferences for health states for very young children and infants; and the importance of considering lost productivity of caregivers and over a child s lifetime(3-6). The Pediatric Economic Database Evaluation (PEDE) project was developed to identify methodological gaps in order to improve the quality of pediatric economic evaluations. PEDE is a publicly available, searchable, comprehensive database of pediatric economic evaluations published since 1980(7, 8). An initial analysis of pediatric economic evaluations in the database covering the period from 1980 to 1999 indicated that the annual volume of studies was growing but that cost utility analyses were infrequently conducted, suggesting the need for greater methodological developments in ascertaining child health utilities(9). Continuing to monitor trends in pediatric economic evaluations will highlight areas of recent growth in the field as well as identify areas for future methodological developments in pediatric health economics. This could help advance methodologies in child health economic evaluation and ultimately enhance pediatric healthcare decision-making. Although globally infectious diseases have been a key focus in pediatric populations (10), in recent years shifts in priorities in child health include a greater policy emphasis on chronic non-infectious diseases, mental health, and conditions resulting from prematurity of birth(11, 12). There has also been a recent growth in the fields of genetics and personalized medicine for primary and secondary prevention of conditions affecting children over their lifetime (13-15). Economic evaluations of emerging technologies are essential to inform budget allocation decision-making, but it remains unclear whether shifts in child health priorities are reflected in the pediatric health economic literature. 1

11 The objectives of this study are to report and evaluate trends in pediatric health economic evaluation over the period of 1980 to The analysis compared study characteristics between two periods: 1980 to 1999 (early period) and 2000 to 2013 (late period). 2

12 2 METHODS 2.1 Data Source and Study Selection The analysis was conducted using the PEDE database, a comprehensive database of all pediatric economic evaluations published since January 1, A publication is eligible to be included in PEDE if one or more comparators exists and descriptions of both costs and health outcomes are present. Eligible studies examined interventions directed at children of any age, or at pregnant or breastfeeding women as long as outcomes were measured in the offspring. The economic evaluation did not have to be the primary objective of the study to be eligible for the database. Detailed inclusion and exclusion criteria for determining eligibility are provided elsewhere (7). Because the database focuses on patient health outcomes rather than the structures and processes of health care, studies of interventions consisting of a guideline, a quality improvement process, or a new operating procedure or policy targeted toward improving practice or efficiency were excluded. Inter-rater reliability training is performed for all reviewers performing citation selection and data extraction to achieve a high level agreement (kappa values >0.9). 2.2 Search Strategy PEDE is updated annually using custom search strategies for retrieval of citations designed to achieve high sensitivity. Economic and medical literature citation databases routinely searched include MEDLINE, CINAHL, EMBASE, IPA, EconLit, the Cochrane Collection, NHS EED, DARE, HTA, and ERIC. Over 73 web sites of HTA agencies and research groups are also searched for inclusion of eligible grey literature. The full search strategy for each citation database is available on request. 2.3 Data Collection The database includes characteristics for each citation and is linked to a searchable bibliographic database containing the full citation information and abstract. Variables extracted for each citation include: year journal type (dentistry, general medicine, health economics/policy/methods, pediatrics/perinatal medicine, pharmacology, public health, sub-specialty medicine, other) target population (free-text) 3

13 disease classification (based on International Classification of Diseases (ICD)-9 Clinical Modification (CM) or ICD-10 schema) age group (perinate, neonate, infant, child, adolescent, adult) intervention(s) studied intervention category (dental, detection, diagnosis, educational, health care delivery, health program, health treatment, health prevention, surgical) health outcome(s) (free-text) analytical technique (CMA, CEA, CUA, CBA) For free-text variables, summary categories are used when possible and recorded in the database. On-line data entry is performed using REDCap, a secure, web-based application designed to support data capture for research studies (16), and data are managed using Microsoft Access (Redmond, WA) and EndNote (Philadelphia, PA). Additional details on the development of the database and variable definitions are provided elsewhere (7, 17). 2.4 Data Analysis Trends in the pediatric economic evaluations were explored by performing one-way frequency distributions and two-way cross-tabulations on variables within the database. Descriptive statistics were used to describe the key characteristics of publications including publication year, disease category, intervention type, outcome measures, age group and target population. Data analyses were performed using Microsoft Excel (Redmond, WA). The trend analysis considered two main periods: 1980 to 1999 (early period) and 2000 to 2013 (late period). Study characteristics were compared between periods using a chi-squared statistic. For the purposes of analysis, only the primary study outcome was considered. 4

14 3 RESULTS Trends over time and difference between early and late intervals are presented for volume of publications, analytic technique, journal type, intervention type, outcome measures, age group, disease category and target population. Select cross-tabulation by age group and by analytic technique are also presented. 3.1 Volume of Publications Between 1980 and 2013, a total of 2630 pediatric economic evaluations were published, with numbers steadily increasing over time (Table 1). Between 1980 and 1989, there were 154 studies published (5.9% of the total), rising to 655 (24.9%) between 1990 and 1999, and increasing again to 1335 (50.8%) between 2000 and Between the four-year period of 2010 and 2013, there were 486 publications (18.5%). The average annual increase in publication volume between 1980 and 2013 was 15.2%. Table 1. Publications per 10-year period (n=2630) Year n % % change % % 325.3% % 103.8% % -- TOTAL % 5

15 3.2 Analytic Technique Economic evaluations are often classified based on the analytic technique. The four main types are cost-effectiveness analysis (CEA), cost-utility analysis (CUA), cost-benefit analysis (CBA), or cost-minimization analysis (CMA). Of the 2,630 economic evaluations included in PEDE, 64.5% are CEAs, 24.0% are CUAs, 7.7% are CBAs, and 3.7% are CMAs. The distribution of the types of analyses have changed significantly over time (X 2 p<0.0001). Both CEAs and CUAs have increased over time while the CMAs and CBAs have decreased. This trend can be observed by looking at 10-year periods and when comparing early (1980 to 1999) versus late (2000 to 2013) periods (Table 2 and Table 3). More recently there has been a trend of decreasing CEAs between 2010 and 2013 compared with earlier decades. This decrease is CEAs was offset by an increase in CUAs during the same period (Figure 1). In 2009, CUA, the approach recommended by economic evaluation guidelines (1, 2), overtook CEA as the most common type of analytic technique for the first time. 6

16 Table 2. Publications per 10-year interval by analytic technique (n=2630) Analytic Technique TOTAL n col% row% n col% row% n col% row% n col% row% n % CBA % 19.2% % 37.9% % 36.5% % 6.4% % CEA % 5.9% % 29.8% % 53.0% % 11.3% % CMA % 11.2% % 42.9% % 43.9% 2 0.4% 2.0% % CUA 4 2.6% 0.6% % 4.9% % 50.3% % 44.1% % TOTAL % 5.9% % 24.9% % 50.8% % 18.5% % Abbreviations: CBA = cost benefit analysis; CEA = cost-effectiveness analysis; CMA = cost-minimization analysis; CUA = cost-utility analysis Table 3. Publications in early ( ) and late ( ) periods by analytic technique (n=2630) Analytic Technique Early ( ) Late ( ) TOTAL n col% row% n col% row% n % CBA % 57.1% % 42.9% % CEA % 35.7% % 64.3% % CMA % 54.1% % 45.9% % CUA % 5.5% % 94.5% % TOTAL % 30.8% % 69.2% % Abbreviations: CBA = cost benefit analysis; CEA = cost-effectiveness analysis; CMA = cost-minimization analysis; CUA = cost-utility analysis 7

17 Number of Economic Evaluations CBA CEA CMA CUA Year of Publication Figure 1 Distribution of economic evaluations in PEDE by year ( ) 3.3 Journal Type Economic evaluations may be published in a variety of journal types given the breadth of topics and analyses that are conducted. Of the eight journal categories (dentistry, general medicine, health economics/policy/methods, pediatrics/perinatal medicine, pharmacology, public health, sub-specialty medicine, other), pediatric economic evaluations were most frequently published in subspecialty medicine journals and pediatrics/perinatal medicine journals (35.3% and 26.2%, respectively). This trend was consistent across both early and late periods (Table 4). However, the overall distribution of the type of journal in which economic evaluations are published changed significantly over time (X 2 p<0.0001). In the late period compared with the early period, publications decreased in general medicine, pediatrics/perinatal medicine and public health journals and increased in health economics/policy/methods journals and sub-specialty medicine journals (Table 4). 8

18 Table 4. Publications in early ( ) and late ( ) periods by journal type (n=2630) Journal Type Early ( ) Late ( ) TOTAL n col% row% n col% row% n % Dentistry % 43.4% % 56.6% % General medicine % 42.5% % 57.5% % Health Economics/ policy/methods % 16.3% % 83.7% % Pediatrics/perinatal medicine % 37.7% % 62.3% % Pharmacology % 40.0% % 60.0% % Public health % 40.6% % 59.4% % Sub-specialty medicine % 22.5% % 77.5% % Other % 20.7% % 79.3% % TOTAL % 30.8% % 69.2% % When the analytic technique used in each of the journal types was considered (Table 5), it was observed that CEAs were most frequently published in subspecialty medicine and pediatric/perinatal journals (33.7% and 30.8%, respectively), while CUAs were most frequently published in subspecialty medicine and health economic methods/policy journals (39.6% and 18.5%, respectively). Across all journal types and periods, CEAs were the most frequently published analytic technique. 9

19 Table 5. Publications by journal type and by analytic technique ( ) (n=2630 records) Journal Type CBA CEA CMA CUA TOTAL n row% col% n row% col% n row% col% n row% col% n % Dentistry % 4.4% % 2.4% 2 3.8% 2.1% 2 3.8% 0.3% % General medicine % 11.3% % 11.2% 8 2.9% 8.2% % 8.2% % Health economics/ policy/ methods % 6.4% % 7.0% 9 3.5% 9.3% % 18.5% % Pediatrics/perinatal medicine % 22.2% % 30.8% % 27.8% % 15.2% % Pharmacology 2 3.9% 1.0% % 1.9% 1 2.0% 1.0% % 2.4% % Public health % 20.2% % 10.9% 5 1.6% 5.2% % 13.0% % Sub-specialty medicine % 32.0% % 33.7% % 44.3% % 39.6% % Other 5 8.5% 2.5% % 2.1% 2 3.4% 2.1% % 2.7% % TOTAL % 100.0% % 100.0% % 100.0% % 100.0% % Abbreviations: CBA = cost benefit analysis; CEA = cost-effectiveness analysis; CMA = cost-minimization analysis; CUA = cost-utility analysis 10

20 3.4 Intervention Type Economic evaluations may be conducted for a wide range of types of interventions. Of the nine categories of interventions considered in this analysis (dental, detection, diagnosis, educational, health care delivery, health program, health treatment, health prevention, surgical), economic evaluations were most frequently conducted for health prevention, health treatments and detection interventions (31.7%, 24.2% and 15.9%, respectively. This trend was observed in both early ( ) and late periods ( ) (Table 6). However, the overall distribution of the type of intervention on which economic evaluations are conducted changed significantly over time (X 2 p<0.0001). In the late period compared with the early period, an increase in the evaluation of health prevention interventions from 25.0% to 34.7% was observed, accompanied by small decreases ( 5%) that were distributed across the other interventions. Table 6. Publications in early ( ) and late ( ) periods by intervention type (n=2630) Intervention Category Early ( ) Late ( ) TOTAL n col% row% n col% row% n % Dental % 45.6% % 54.4% % Detection % 35.9% % 64.1% % Diagnosis % 32.5% % 67.5% % Educational % 19.0% % 81.0% % Health care delivery % 32.4% % 67.6% % Health program % 42.3% % 57.7% % Health treatment % 30.8% % 69.2% % Health prevention % 24.2% % 75.8% % Surgical % 33.8% % 66.2% % TOTAL % 30.8% % 69.2% % When the analytic technique used for each of the intervention types was considered (Table 7 and Figure 2), it was observed that CBAs were most frequently conducted for health prevention interventions (49.8%), CEAs were most frequently conducted for health treatment and health prevention interventions (25.5% and 24.2%, respectively), CUAs were most frequently conducted on health prevention interventions (50.5%) and CMAs were most frequently conducted for health treatment interventions (41.8%). Although CEAs were frequently used to analyze all intervention types, diagnostic and surgical interventions were predominantly studied using CEAs (81.8% and 80.5%, respectively). 11

21 Table 7. Publications by intervention type and by analytic technique ( ) (n=2630 records) Intervention Type CBA CEA CMA CUA TOTAL n row% col% n row% col% n row% col % n row% col% n % Dental % 4.9% % 3.1% 3 4.4% 3.1% 3 4.4% 0.5% % Detection % 26.1% % 17.0% 8 1.9% 8.2% % 10.8% % Diagnosis 3 3.9% 1.5% % 3.7% 2 2.6% 2.0% % 1.4% % Educational 5 6.3% 2.5% % 3.1% 2 2.5% 2.0% % 3.2% % Health care delivery 3 1.8% 1.5% % 7.7% % 14.3% % 3.6% % Health program % 8.9% % 9.4% % 13.3% % 3.6% % Health treatment % 4.9% % 25.5% % 41.8% % 24.4% % Health prevention % 49.8% % 24.2% 2 0.2% 2.0% % 50.5% % Surgical 0 0.0% 0.0% % 6.3% % 13.3% % 2.1% % TOTAL % 100.0% % 100.0% % 100.0% % 100.0% % Abbreviations: CBA = cost benefit analysis; CEA = cost-effectiveness analysis; CMA = cost-minimization analysis; CUA = cost-utility analysis 12

22 Axis Title 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% CUA CMA CEA CBA Figure 2. Analytic technique according to type of intervention studied 3.5 Outcome Measures A wide variety of outcomes (n=1280) were measured across the 2630 publications in PEDE. When considering the primary outcome in each publication, the most frequent types of outcomes were QALYs or similar units, cases of non-infectious disease/condition/abnormality, cases of infectious disease/condition/abnormality and life years (22.0%, 18.6%, 13.6% and 13.2%, respectively). When comparing the early ( ) and late periods ( ), an increase in the use of QALYs was observed over time (4.9% versus 29.5%) paralleling the increased frequency of CUA (Table 8). 13

23 Table 8. Publications in early ( ) and late ( ) periods by outcome category (n=2630) Outcome Category Early ( ) Late ( ) TOTAL n col% row% n col% row% n % Cases of complications/ % 44.9% % 55.1% % adverse events Cost 0 0.0% 0.0% % 100.0% % Cases of % 49.7% % 50.3% % cures/improvements/healing Cases of infectious % 42.9% % 57.1% % disease/condition/abnormality Cases of injury 9 1.1% 45.0% % 55.0% % Life years % 31.6% % 68.4% % Cases of non-infectious % 40.8% % 59.2% % disease/condition/abnormality Other 6 0.7% 24.0% % 85.0% % Changes in physiologic measure % 37.1% % 62.9% % Changes in % 25.9% % 74.1% % behavioural/psychosocial QALYs, or similar unit % 6.9% % 93.1% % Changes in quality of life 3 0.4% 14.3% % 85.7% % Surrogate health outcomes 5 0.6% 17.9% % 82.1% % Time outcomes* % 24.3% % 75.7% % Unspecified 0 0.0% 0.0% 6 0.3% 100.0% 6 0.2% Cases of vaccination % 41.9% % 58.1% % TOTAL % 30.8% % 68.7% % *This category refers to days in a state or days absent from a state, time to achieve an outcome or to recover When the outcome category was grouped by analytic technique (Table 9), as expected, the outcome most frequently reported for CUAs were QALYs or similar measures (88.0%). For CEAs, the most frequently reported outcome measures were cases of non-infectious disease/condition/abnormality and life-years (23.2% and 18.1%, respectively). For CBAs, the most frequently reported clinical outcomes were cases of infectious disease/condition/abnormality and cases of non-infectious disease/condition/abnormality (35.0% and 33.5%, respectively); these outcomes were then monetized as is the standard approach in a CBA. For CMAs, cases of cures/improvements/healing were most frequently reported (28.6%). 14

24 Table 9. Number of publications by outcome category and by analytic technique (n=2630 records) Outcome Category CBA CEA CMA CUA TOTAL n row% col% n row% col% n row% col% n row% col% n % Cases of complications/adverse 5 3.4% 2.5% % 7.5% % 14.3% 1 0.7% 0.2% % events Cost % 3.0% % 0.9% % 4.1% 1 3.8% 0.2% % Cases of cures/improvements 7 3.9% 3.4% % 8.5% % 28.6% 2 1.1% 0.3% % Cases of infectious % 35.0% % 15.4% 3 0.8% 3.1% % 3.5% % disease/condition/abnormality Cases of injury % 1.5% % 0.9% 1 5.0% 1.0% 0 0.0% 0.0% % Life Years % 5.4% % 18.1% 7 2.0% 7.1% % 3.5% % Cases of non-infectious % 33.5% % 23.2% % 14.3% % 2.4% % disease/condition/abnormality Other 2 5.0% 1.0% % 2.0% 3 7.5% 3.1% 1 2.5% 0.2% % Changes in physiologic measure 5 2.5% 2.5% % 10.8% % 11.2% 3 1.5% 0.5% % Changes in behavioral/ psychosocial % 6.9% % 3.6% 4 4.9% 4.1% 2 2.5% 0.3% % QALYs, or similar unit 4 0.7% 2.0% % 1.1% 0 0.0% 0.0% % 88.0% % Changes in QOL 0 0.0% 0.0% % 1.0% 0 0.0% 0.0% % 0.6% % Surrogate Health Outcomes 1 3.6% 0.5% % 1.4% % 3.1% 1 3.6% 0.2% % Time Outcomes 0 0.0% 0.0% % 4.1% 2 2.7% 2.0% 2 2.7% 0.3% % Unspecified % 1.0% % 0.1% % 2.0% 0 0.0% 0.0% 6 0.2% Cases of vaccination % 2.0% % 1.5% 2 6.5% 2.0% 0 0.0% 0.0% % TOTAL % 100.0% % 100.0% % % % Abbreviations: CBA = cost benefit analysis; CEA = cost-effectiveness analysis; CMA = cost-minimization analysis; CUA = cost-utility analysis 15

25 3.6 Age Group The pediatric population is a heterogeneous group that is often classified and studied according to standard age groups related to periods of maturation and development. These age groups are typically perinate (antenatal period), neonate (newborn to < 1 month), infant (1 month to < 1 year), child (> 1 year to 12 years), adolescent (13 to 18 years), and adult (19 and older). The inclusion of adults age groups occurred i) in studies where interventions were targeted at pregnant or breastfeeding women and where outcomes were measured in offspring, or ii) in studied with lifetime time horizons. The most frequently studied age group was the child at 40.6% of publications, which was consistent across both early ( ) and late periods ( ) (Table 10). However, the overall distribution of the age groups studied changed significantly over time (X 2 p<0.0001). In the late period compared with the early period, economic evaluations of children increased from 35.7% to 42.9% while they decreased in perinates from 13.1% to 5.1% with small fluctuations (<5%) observed in other age groups. Table 10. Publications in early ( ) and late ( ) periods by age category (n=2630 records) Age Early ( ) Late ( ) TOTAL n col% row% n col% row% n % Perinate % 54.9% % 45.1% % Neonate % 27.1% % 72.9% % Infant % 34.6% % 65.4% % Child % 28.2% % 71.8% % Adolescent % 31.8% % 68.2% % Adult % 44.2% % 55.8% % TOTAL % 32.1% % 67.9% % Each record may contain multiple age groups; a total of 3863 age groups were studied When the type of intervention studied was categorized by age group (Table 11), diagnostic interventions were most frequently evaluated in perinates (41.4%), health prevention and detection interventions were most frequently studied in neonates (29.3% and 26.9%), health prevention interventions were most frequently studied in infants (43.6%), health prevention and health treatment interventions were most frequently studied in both children (33.0 and 29.8%) and adolescents (26.9% and 29.15). For adults included in these publications, health prevention interventions were most frequently studied (48.1%). 16

26 Table 11. Publications by intervention type and by age group (n=2630 records) (A = Perinate, Neonate, Infant; B = Child, Adolescent, Adult, Total) A INTERVENTION Perinate (antenatal period) Neonate (newborn to < 1 month) Infant (1 month to < 1 year) n row% col% n row% col% n row% col% Dental 0 0.0% 0.0% 1 1.0% 0.2% 7 7.3% 1.0% Detection % 41.4% % 26.9% % 7.5% Diagnosis 5 3.9% 1.7% % 3.2% % 4.0% Educational 0 0.0% 0.0% 7 6.4% 1.1% % 1.9% Health Care Delivery % 8.1% % 8.2% % 7.6% Health Program % 10.8% % 11.1% % 7.9% Health Treatment % 12.9% % 16.5% % 20.1% Health Prevention % 24.1% % 29.3% % 43.6% Surgical 3 1.4% 1.0% % 3.2% % 6.3% TOTAL % 100.0% % 100.0% % 100.0% B Intervention Type Child (> 1 year to 12 years) Adolescent (13 to 18 years) Adult (19 and older) TOTAL n row% col% n row% col% n row% col% n % Dental % 4.1% % 4.0% 0 0.0% 0.0% % Detection % 7.2% % 8.7% 7 1.4% 13.0% % Diagnosis % 3.3% % 3.3% 2 1.6% 3.7% % Educational % 3.7% % 5.0% 1 0.9% 1.9% % Health Care Delivery % 6.2% % 7.7% 2 0.7% 3.7% % Health Program % 6.4% % 7.0% 3 1.0% 5.6% % Health Treatment % 29.8% % 29.1% % 18.5% % Health Prevention % 33.0% % 26.9% % 48.1% % Surgical % 6.3% % 8.2% 3 1.4% 5.6% % TOTAL % 100.0% % 100.0% % 1.0% % Each record may contain multiple age groups; a total of 3863 age groups were studied) 17

27 When outcome measures were categorized by age group (Table 12), cases of non-infectious disease/condition/abnormality were most frequently reported for perinates (39.0%). For neonates, life-years, QALYs or similar measures and cases of non-infectious disease/condition/abnormality were the most frequently reported outcomes (22.5%, 22.3% and 21.2%, respectively). For infants, QALYs or similar measures and cases of infectious disease/condition/abnormality were the most frequently reported outcomes (20.7% and 18.0%, respectively). Among both children and adolescents, the most frequently reported outcomes were QALYs or similar measures (23.2% and 19.1%). For adults included in these publications, cases of infectious disease/condition/abnormality was the most frequently reported outcome (24.1%). 18

28 Table 12 Publications by summary outcome and by age group (n=2630 records) (A = Perinate, Neonate, Infant: B = Child, Adolescent, Adult, Total) A Perinate (antenatal period) Neonate (newborn to < 1 month) Infant (1 month to < 1 year) OUTCOMES n row% col% n row% col% n row% col% Cases of complications/adverse events 9 3.8% 3.1% % 3.6% % 6.9% Cost 2 5.3% 0.7% % 0.6% % 1.3% Cases of cures/improvements/healing 4 1.4% 1.4% % 3.8% % 7.3% Cases of infectious disease/condition/abnormality % 15.3% % 13.0% % 18.0% Cases of injury 1 3.0% 0.3% 3 9.1% 0.5% % 0.7% Life Years % 15.3% % 22.5% % 15.0% Cases of non-infectious disease/condition/abnormality % 39.0% % 21.2% % 14.6% Other 2 3.6% 0.7% % 1.3% % 1.0% Changes in physiologic measure % 12.2% % 6.5% % 5.0% Changes in behavioural/psychosocial 1 0.9% 0.3% % 1.9% % 1.4% QALYs, or similar unit % 10.5% % 22.3% % 20.7% Changes in QOL 0 0.0% 0.0% 0 0.0% 0.0% % 1.0% Surrogate Health Outcomes 2 4.7% 0.7% % 1.1% % 0.9% Time Outcomes 0 0.0% 0.0% 8 6.4% 1.3% % 4.2% Unspecified 0 0.0% 0.0% % 0.2% % 0.3% Cases of vaccination 2 4.9% 0.7% 1 2.4% 0.2% % 1.6% TOTAL % 100.0% % 100.0% % 100.0% 19

29 Table 12, continued B OUTCOMES Child (> 1 year to 12 years) Adolescent (13 to 18 years) Adult (19 and older) TOTAL n row% col% n row% col% n row% col% n % Cases of complications/adverse events % 6.8% % 8.0% 4 1.7% 7.4% % Cost % 1.1% % 0.8% 0 0.0% 0.0% % Cases of cures/improvements/healing % 9.4% % 8.5% 5 1.8% 9.3% % Cases of infectious disease/condition/abnormality % 13.0% % 14.0% % 24.1% % Cases of injury % 1.1% % 1.2% 0 0.0% 0.0% % Life Years % 9.9% % 9.4% 6 1.2% 11.1% % Cases of non-infectious disease/condition/abnormality % 14.7% % 14.7% 8 1.2% 14.8% % Other % 1.8% % 1.7% 0 0.0% 0.0% % Changes in physiologic measure % 7.2% % 8.4% 3 1.1% 5.6% % Changes in behavioural/psychosocial % 3.6% % 6.2% 0 0.0% 0.0% % QALYs, or similar unit % 23.2% % 19.1% 9 1.1% 16.7% % Changes in QOL % 1.2% % 1.8% 2 5.1% 3.7% % Surrogate health outcomes % 1.3% % 1.3% 0 0.0% 0.0% % Time outcomes % 3.9% % 4.0% 3 2.4% 5.6% % Unspecified % 0.3% % 0.3% 0 0.0% 0.0% 9 0.2% Cases of vaccination % 1.5% 3 7.3% 0.5% 1 2.4% 1.9% % TOTAL % 100.0% % 100.0% % 100.0% % 20

30 3.7 Disease category Established disease classifications schema were applied to the publications in PEDE. Over the period covered by the database ( ), both ICD-9-CM and ICD-10 schema (18, 19) were used and are merged in this analysis. Overall, infective and parasitic diseases were most frequently studied in pediatric populations (29.2%), a trend which was consistent in both early and late periods (Table 13). Table 13. Publications in early ( ) and late ( ) periods by ICD9/10 disease category (n=2630) ICD 9/10 DISEASE Early ( ) Late ( ) TOTAL CLASSIFICATION n col% row% n col% row% n % Accidents, poisonings, and violence % 52.2% % 47.8% % Blood and blood-forming organs % 22.1% % 77.9% % Certain conditions originating in the % 70.0% % 30.0% % perinatal period Infective and parasitic % 24.9% % 75.1% % Pregnancy, childbirth and the % 44.4% % 55.6% % puerperium Circulatory system % 26.9% % 73.1% % Congenital anomalies % 46.8% % 53.2% % Dental % 97.0% 1 0.1% 3.0% % Digestive system % 30.1% % 69.9% % Nervous system and sensory organs % 22.1% % 77.9% % Genitourinary system % 24.7% % 75.3% % Musculoskeletal system 4 0.5% 16.0% % 84.0% % Skin and sub-cutaneous tissue 3 0.4% 11.5% % 88.5% % Respiratory system % 17.4% % 82.6% % Endocrine, nutrition and metabolism, % 30.3% % 69.7% % and immunity disorders External causes of morbidity and 0 0.0% 0.0% % 100.0% % mortality Factors influencing health status and 3 0.4% 3.2% % 96.8% % contact with health services General health % 62.3% % 37.7% % Mental disorders % 14.1% % 85.9% % Neoplasms % 36.1% % 63.9% % Symptoms, Signs and Ill-defined % 33.3% % 81.8% % Conditions Other 2 0.2% 66.7% 1 0.1% 33.3% 3 0.1% TOTAL % 30.7% % 69.1% % 21

31 When the ICD-9/10 disease classification was categorized by analytic technique (Table 14), CEAs and CUAs were most frequently conducted on infectious and parasitic diseases (24.6% and 40.6%, respectively). No CUAs were conducted in the area of dental diseases or general health conditions. In all disease categories, CEAs were most frequently conducted with the lowest proportion of CEAs being 39.3% for external causes of morbidity and mortality. 22

32 Table 14. Publications by ICD-9/10 disease classification and by analytic technique (n=2630 records) ICD 9/10 DISEASE CLASSIFICATION CBA CEA CMA CUA TOTAL n row% col% n row% col% n row% col% n row% col% n % Accidents, poisonings, and violence 6 8.7% 3.0% % 3.0% % 7.2% 5 7.2% 0.8% % Blood and blood-forming organs 4 3.1% 2.0% % 5.0% 5 3.8% 5.2% % 5.9% % Certain conditions originating in the 4 4.0% 2.0% % 4.5% 5 5.0% 5.2% % 2.4% % perinatal period Infective and parasitic % 40.9% % 24.6% % 10.3% % 40.6% % Pregnancy, childbirth and the puerperium % 5.9% % 9.0% 8 4.2% 8.2% % 2.7% % Circulatory system 3 5.8% 1.5% % 2.2% 3 5.8% 3.1% % 1.4% % Congenital anomalies % 13.3% % 8.1% 6 3.2% 6.2% % 2.9% % Dental % 2.0% % 1.6% 2 6.1% 2.1% 0 0.0% 0.0% % Digestive system 1 1.4% 0.5% % 3.5% 4 5.5% 4.1% % 1.4% % Nervous system and sensory organs 4 2.6% 2.0% % 5.1% 7 4.5% 7.2% % 8.9% % Genitourinary system 3 3.7% 1.5% % 2.5% 6 7.4% 6.2% % 4.6% % Musculoskeletal system 0 0.0% 0.0% % 1.1% 2 8.0% 2.1% % 0.6% % Skin and sub-cutaneous tissue 0 0.0% 0.0% % 1.0% 1 3.8% 1.0% % 1.3% % Respiratory system 2 1.1% 1.0% % 7.3% 3 1.7% 3.1% % 7.8% % Endocrine, nutrition and metabolism, and % 7.9% % 6.1% 4 2.6% 4.1% % 5.1% % immunity disorders External causes of morbidity and mortality % 2.5% % 0.6% 1 3.6% 1.0% % 1.7% % Factors influencing health status and % 5.4% % 3.1% 3 3.2% 3.1% % 4.6% % contact with health services General health % 4.9% % 3.2% 5 7.2% 5.2% 0 0.0% 0.0% % Mental disorders 5 5.9% 2.5% % 2.9% 3 3.5% 3.1% % 4.3% % Neoplasms 1 1.4% 0.5% % 2.7% % 10.3% % 2.5% % Symptoms, Signs and Ill-defined Conditions 2 3.7% 1.0% % 2.7% 2 3.7% 2.1% 4 7.4% 0.6% % Other 0 0.0% 0.0% % 0.2% 0 0.0% 0.0% 0 0.0% 0.0% 3 0.1% TOTAL % 100.0% % 100.0% % 100.0% % 100.0% % Abbreviations: CBA = cost benefit analysis; CEA = cost-effectiveness analysis; CMA = cost-minimization analysis; CUA = cost-utility analysis 23

33 When the ICD-9/10 disease classification was categorized by intervention type (Table 15), some associations were observed. For example, detection interventions were most frequently studied in congenital abnormalities (24.9%) while health prevention interventions were most frequently studied in infective and parasitic diseases (66.0%). 24

34 Table 15. Publications by ICD-9/10 disease classification and by intervention type (n=2630 records) (A = Detection, Diagnosis, Educational; B = Health Care Delivery, Health Care Program, Health Treatment; C = Surgical, Dental, Total) A ICD 9/10 DISEASE CLASSIFICATION Detection Diagnosis Educational n row% col% n row% col% n row% col% Accidents, poisonings, and violence 6 8.7% 1.4% 1 1.4% 1.3% 2 2.9% 2.5% Blood and blood-forming organs % 8.1% 4 3.1% 5.2% 0 0.0% 0.0% Certain conditions originating in the perinatal period % 3.1% 3 3.0% 3.9% 0 0.0% 0.0% Infective and parasitic % 16.0% % 18.2% 7 0.9% 8.9% Pregnancy, childbirth and the puerperium % 10.0% 1 0.5% 1.3% 1 0.5% 1.3% Circulatory system % 3.3% 4 7.7% 5.2% 2 3.8% 2.5% Congenital anomalies % 24.9% % 18.2% 1 0.5% 1.3% Dental 2 6.1% 0.5% 0 0.0% 0.0% 0 0.0% 0.0% Digestive system 6 8.2% 1.4% 6 8.2% 7.8% 1 1.4% 1.3% Nervous system and sensory organs % 11.7% 6 3.9% 7.8% 0 0.0% 0.0% Genitourinary system 4 4.9% 1.0% 7 8.6% 9.1% 0 0.0% 0.0% Musculoskeletal system % 0.7% 1 4.0% 1.3% 0 0.0% 0.0% Skin and sub-cutaneous tissue 0 0.0% 0.0% 1 3.8% 1.3% 2 7.7% 2.5% Respiratory system 7 3.9% 1.7% 4 2.2% 5.2% % 12.7% Endocrine, nutrition and metabolism, and immunity % 10.5% 4 2.6% 5.2% % 13.9% disorders External causes of morbidity and mortality 2 7.1% 0.5% 0 0.0% 0.0% % 5.1% Factors influencing health status and contact with health 3 3.2% 0.7% 0 0.0% 0.0% % 25.3% services General health 1 1.4% 0.2% 0 0.0% 0.0% 3 4.3% 3.8% Mental disorders 7 8.2% 1.7% 1 1.2% 1.3% % 13.9% Neoplasms % 2.2% 2 2.8% 2.6% 1 1.4% 1.3% Symptoms, signs and ill-defined conditions 1 1.9% 0.2% 4 7.4% 5.2% 3 5.6% 3.8% Other 0 0.0% 0.0% 0 0.0% 0.0% 0 0.0% 0.0% TOTAL % 100.0% % 100.0% % 100.0% 25

35 Table 15, continued B ICD 9/10 DISEASE CLASSIFICATION Health Care Delivery Health Program Health Treatment n row% col% n row% col% n row% col% Accidents, poisonings, and violence % 4.1% % 3.3% % 4.3% Blood and blood-forming organs 4 3.1% 2.4% 0 0.0% 0.0% % 10.1% Certain conditions originating in the 8 8.0% 4.7% % 10.4% % 5.8% perinatal period Infective and parasitic % 9.4% % 17.0% % 11.3% Pregnancy, childbirth and the % 16.5% % 17.0% % 4.9% puerperium Circulatory system 4 7.7% 2.4% 1 1.9% 0.5% % 3.0% Congenital anomalies % 5.9% 2 1.1% 0.9% % 2.8% Dental 0 0.0% 0.0% 0 0.0% 0.0% 0 0.0% 0.0% Digestive system 5 6.8% 2.9% 1 1.4% 0.5% % 2.8% Nervous system and sensory organs 4 2.6% 2.4% 3 1.9% 1.4% % 11.0% Genitourinary system 5 6.2% 2.9% 0 0.0% 0.0% % 3.0% Musculoskeletal system 0 0.0% 0.0% 0 0.0% 0.0% % 1.7% Skin and sub-cutaneous tissue 1 3.8% 0.6% 0 0.0% 0.0% % 2.4% Respiratory system % 10.0% % 6.1% % 12.3% Endocrine, nutrition and metabolism, % 7.6% % 8.5% % 6.9% and immunity disorders External causes of morbidity and % 2.4% 2 7.1% 0.9% % 0.5% mortality Factors influencing health status and 8 8.4% 4.7% % 5.7% % 1.6% contact with health services General health % 7.6% % 13.7% 5 7.2% 0.8% Mental disorders 5 5.9% 2.9% % 8.5% % 5.4% Neoplasms 5 6.9% 2.9% 3 4.2% 1.4% % 6.5% Symptoms, Signs and Ill-defined % 6.5% % 3.8% % 3.0% Conditions Other % 1.2% % 0.5% 0 0.0% 0.0% TOTAL % 100.0% % 100.0% % 100.0% 26

36 Table 15, continued C ICD 9/10 DISEASE CLASSIFICATION Surgical Dental TOTAL n row% col% n row% col% n % Accidents, poisonings, and violence 2 2.9% 1.5% 0 0.0% 0.0% % Blood and blood-forming organs 8 6.1% 6.0% 0 0.0% 0.0% % Certain conditions originating in the perinatal period 3 3.0% 2.3% 0 0.0% 0.0% % Infective and parasitic 5 0.7% 3.8% 0 0.0% 0.0% % Pregnancy, childbirth and the puerperium 3 1.6% 2.3% 0 0.0% 0.0% % Circulatory system 5 9.6% 3.8% 0 0.0% 0.0% % Congenital anomalies % 24.8% 0 0.0% 0.0% % Dental 0 0.0% 0.0% % 45.6% % Digestive system % 17.3% 1 1.4% 1.5% % Nervous system and sensory organs % 7.5% 1 0.6% 1.5% % Genitourinary system % 12.8% 0 0.0% 0.0% % Musculoskeletal system % 6.8% 0 0.0% 0.0% % Skin and sub-cutaneous tissue 1 3.8% 0.8% 0 0.0% 0.0% % Respiratory system 1 0.6% 0.8% 0 0.0% 0.0% % Endocrine, nutrition and metabolism, and immunity 5 3.2% 3.8% 0 0.0% 0.0% % disorders External causes of morbidity and mortality 1 3.6% 0.8% 0 0.0% 0.0% % Factors influencing health status and contact with 3 3.2% 2.3% % 32.4% % health services General health 0 0.0% 0.0% % 16.2% % Mental disorders 0 0.0% 0.0% 2 2.4% 2.9% % Neoplasms 3 4.2% 2.3% 0 0.0% 0.0% % Symptoms, Signs and Ill-defined Conditions 1 1.9% 0.8% 0 0.0% 0.0% % Other 0 0.0% 0.0% 0 0.0% 0.0% 3 0.1% TOTAL % 100.0% % 100.0% % 27

37 When ICD-9/10 disease classification was categorized by age group (Table 16), diseases of pregnancy, childbirth and the puerperium and congenital anomalies were the most frequently studied conditions in perinates (37.6% and 24.4%, respectively). Among the remaining age groups - neonates, infants, children, adolescents and adults - infective and parasitic diseases were the most frequently studied conditions (25.9%, 44.6%, 34.6%, 28.9% and 51.9%, respectively). 28

38 Table 16. Publications by ICD-9/10 disease classification and by age group (n=2630 records) (A = Perinate, Neonate, Infant; B = Child, Adolescent, Adult, Total) A ICD 9/10 DISEASE CLASSIFICATION Perinate (antenatal period) Neonate (newborn to < 1 month) Infant (1 month to < 1 year) n row% col% n row% col% n row% col% Accidents, poisonings, and violence 0 0.0% 0.0% 5 7.2% 0.8% % 3.4% Blood and blood-forming organs % 5.1% % 5.9% % 3.5% Certain conditions originating in the perinatal period % 5.4% % 11.3% % 2.8% Infective and parasitic % 7.5% % 25.9% % 44.6% Pregnancy, childbirth and the puerperium % 37.6% % 12.2% 6 3.2% 0.9% Circulatory system 2 3.8% 0.7% % 1.7% % 1.5% Congenital anomalies % 24.4% % 12.2% 6 3.2% 0.9% Dental 0 0.0% 0.0% 0 0.0% 0.0% 3 9.1% 0.5% Digestive system 0 0.0% 0.0% % 1.7% % 3.8% Nervous system and sensory organs 3 1.9% 1.0% % 5.3% % 6.7% Genitourinary system 2 2.5% 0.7% % 1.8% % 2.8% Musculoskeletal system 1 4.0% 0.3% 2 8.0% 0.3% % 0.5% Skin and sub-cutaneous tissue 0 0.0% 0.0% % 0.6% % 1.7% Respiratory system 9 5.1% 3.1% % 5.0% % 8.1% Endocrine, nutrition and metabolism, and immunity disorders % 3.4% % 5.6% % 4.4% External causes of morbidity and mortality 2 7.1% 0.7% % 0.8% % 0.8% Factors influencing health status and contact with health services 2 2.1% 0.7% % 3.5% % 3.4% General health % 9.2% % 2.9% % 1.8% Mental disorders 1 1.2% 0.3% 2 2.4% 0.3% 5 5.9% 0.8% Neoplasms 0 0.0% 0.0% 3 4.2% 0.5% % 3.2% Symptoms, Signs and Ill-defined Conditions 0 0.0% 0.0% % 1.5% % 3.5% Other 0 0.0% 0.0% % 0.2% % 0.5% TOTAL % 100.0% % 100.0% % 100.0% 29

39 Table 16, continued B Child (> 1 year to 12 years) Adolescent (13 to 18 years) Adult (19 and older) ICD 9/10 DISEASE CLASSIFICATION n row% col% n row% col% n row% col% n % Accidents, poisonings, and violence % 4.2% % 4.4% 2 2.9% 3.7% % Blood and blood-forming organs % 5.2% % 6.9% 3 2.3% 5.6% % Certain conditions originating in the perinatal period % 0.7% 1 1.0% 0.2% 0 0.0% 0.0% % Infective and parasitic % 34.6% % 28.9% % 51.9% % Pregnancy, childbirth and the puerperium 2 1.1% 0.1% 8 4.2% 1.4% 1 0.5% 1.9% % Circulatory system % 2.1% % 3.9% 2 3.8% 3.7% % Congenital anomalies 2 1.1% 0.1% 8 4.3% 1.4% 1 0.5% 1.9% % Dental % 2.1% % 2.5% 0 0.0% 0.0% % Digestive system % 4.2% % 3.5% 0 0.0% 0.0% % Nervous system and sensory organs % 7.2% % 4.2% 1 0.6% 1.9% % Genitourinary system % 4.0% % 4.4% 1 1.2% 1.9% % Musculoskeletal system % 0.9% % 2.5% 2 8.0% 3.7% % Skin and sub-cutaneous tissue % 1.4% % 1.2% 0 0.0% 0.0% % Respiratory system % 8.3% % 7.4% 5 2.8% 9.3% % Endocrine, nutrition and metabolism, and immunity % 6.6% % 5.4% 4 2.6% 7.4% % disorders External causes of morbidity and mortality % 1.3% % 1.5% 0 0.0% 0.0% % Factors influencing health status and contact with health % 4.3% % 3.9% 1 1.1% 1.9% % services General health % 1.5% % 1.2% 1 1.4% 1.9% % Mental disorders % 4.0% % 7.9% 0 0.0% 0.0% % Neoplasms % 4.3% % 4.4% 2 2.8% 3.7% % Symptoms, signs and ill-defined conditions % 2.6% % 2.5% 0 0.0% 0.0% % Other % 0.2% % 0.3% 0 0.0% 0.0% 3 0.2% TOTAL % 100.0% % 100.0% % 100.0% % Total 30