The Health Economics and Epidemiology Research Office (HE 2 RO): An overview of research methods and results

Transcription

1 The Health Economics and Epidemiology Research Office ( ): An overview of research methods and results Gesine Meyer-Rath Lawrence Long Kathryn Schnippel

2 Introducing Collaboration between Wits and BU Established in 2004 conducts applied, policy- and program-relevant research and evaluation on issues of public health of importance in South Africa. Focusing on HIV and TB, it works at the intersection of health economics and epidemiology to help understand the effectiveness, benefits, and costs of interventions. Partnered with Funded by

3 INADS HIV care and treatment: linkage, retention, and outcomes TB/HIV: casefinding, diagnosis, and treatment Service delivery models and treatment guidelines Cost and budget modeling Sexual and Reproductive Health NACM NTCM Capacity Development

4 Epi analyses: Methods All epidemiological analyses are based on primary data Most analyses are based on data from the Themba Lethu Clinic cohort (Helen Joseph Hospital) currently 38,000 patients on ART collected in TherapyEdge real-time database part of IeDEA network New large cohort planned including 9 clinics across Gauteng

5 Epi analyses: Summary of studies Treatment outcomes Impact of d4t dosing tenofovir older age down-referral switching to second-line Eligibility at 200 vs 350 CD4 cells/microl 7-year outcomes Loss to initiation and treatment Meta-analysis of loss between testing and treatment Update of mortality estimates with vital registry data

6 Cost analyses: Methods All cost analyses are based on primary data Resource use from a sample of patient files Consecutive sample All resources used (visits, drugs, lab tests, other diagnostics) collected Fixed cost per visit calculated based on number of all visits to clinic (includes cost of space, equipment, utilities, non-patient facing staff) Unit costs for all resources based on financial and HR records at clinic/ hospital or public records (drugs tenders, NHLS prices)

7 Cost analyses: Results NB: Please refer to the published papers for full details before using these estimates, on Item Year Sample size Unit cost per Adult ART (outpatient, op) - Nurse managed ART $492 pt yr - Doctor managed ART $551 pt yr - Second-line ART $1037 pt yr Adult ART (inpatient, ip) $131 pt yr Adult HIV (ip) $72 (pre-art), $117 (ART) pt yr Paediatric ART (op) $ (yr 1), $ (yr 2) pt yr Paediatric HIV (ip) (first year of life only) $346 (early tx), $1237 (deferred), $2523 (routine) Adult - MDR-TB (ip) $17,164 pt Diagnostic tests - Xpert MTB/Rif 2012 $18 (R166) test - CD4 POC (Pima) 2012 $24 test pt yr

8 Future cost analyses HIV: NIMART (op) adult HIV (ip, by diagnosis) TB diagnosis: active case finding Xpert for diagnosis of extra-pulmonary TB TB treatment: drug-sensitive TB (ip + op) decentralised MDR-TB (op) Cervical cancer diagnosis: Pap smear/ visual inspection with acetic acid/ HPV DNA

9 Budget models: Methods National ART Cost Model (NACM): ART, PMTCT, HIV testing; adults and children National TB Cost Model (NTCM): TB diagnosis and treatment (drug sensitive/ resistant TB; PTB, adults only) Population models with health-state transition kernel Fixed time period (NACM: 2009/10 to 2016/17; NTCM: 2011/12 to 2016/17) Allow for change of guidelines and slow or fast scale-up of new interventions/ coverage

10 National ART Cost Model (NACM) Number of patients initiating ART from NSP model (Leigh Johnson, UCT) Transition probabilites and rates of mortality, loss to follow-up, and firstline treatment failure based on 2 large Johannesburg cohorts: Themba Lethu Clinic Cohort (n= 9,502) Harriet Shezi Children s Clinic (n= 3,748) Transition probabilities and rates depend on CD4 cell count/ percentage and on time on treatment Cost from bottom-up cost analyses in the same clinics, regulalry updated to current tender prices etc

11 Total cost [millions ZAR] NACM: Example output The cost of the old guidelines vs guidelines vs. full WHO guidelines 140, ,000 4,000,000 3,500,000 Total cost (Full cost) Total cost (Reduced cost) Total patients initiated on ART 100,000 80,000 60,000 40,000 20, % Old Guidelines New Guidelines Full WHO Guidelines With the new drug purchasing mechanism and task-shifting, -25% -16% 3,000,000 2,500,000 2,000,000 1,500,000 1,000, ,000 the total cost of the ART programme under the New (2010) Guidelines will be 25% less than under the Old Guidelines, while reaching 15% more patients; implementing the Full WHO Guidelines will be 16% cheaper than continuing the Old Guidelines, while reaching 24% more patients. 0 Total patients

12 NACM: Uses and results New ART guidelines 2010 and 2011, task-shifting, new drug tenders Doubling of conditional grant (CG) budget between 2009/20 and 2011/12 Aids2031 Global Fund proposals for round 10 NSP ; PSPs CG budget/ provincial business plans 2009/10 to 2012/13 Currently working on CG budget for 2013/14

13 NACM: Why use a moving average cost? 2012/ / / / /2017 Year starting 1 April of ART (adults) Total patients on ART at end of year 2,167,938 2,683,206 2,989,228 3,190,005 3,365,005 Total cost [million 2011 ZAR] 10,600 13,291 14,986 16,192 17,276 Cost per patient 4,889 4,953 5,013 5,076 5,134 ART (children) Total patients on ART at end of year 122, , , , ,472 Total cost [million 2011 ZAR] 847 1,001 1,193 1,411 1,649 Cost per patient 6,902 6,918 7,043 7,135 7,251 ART (all patients) Total patients on ART at end of year 2,290,615 2,827,832 3,158,581 3,387,731 3,592,477 Total cost [million 2011 ZAR] 11,447 14,291 16,178 17,603 18,925 Cost per patient 4,997 5,054 5,122 5,196 5,268

14 National TB Cost Model (NTCM) Represents diagnostic pathway from TB suspect to TB diagnosis/ treatment Old algorithm (sputum/ smear) Xpert MTB/Rif algorithm (scaled up by end 2014) Population data: national-level electronic TB register (ETR) (n=57,688) 10% sample of NHLS TB database (n=83,977) Xpert implementation studies Cost data: ingredients costing of Xpert literature

15 NTCM: Example output The cost and yield of the old vs. the Xpert diagnostic algorithm Results by 2014 (full Xpert scale) Smear + culture Number of suspects TB cases diagnosed (% of suspects) Resistant TB cases diagnosed (% of all PTB) 338,407 (13%) 5,032 (1.5%) Xpert scenario 2.6 million 426,588 (17%) 12,628 (3.0%) % change +26% +151% % of patients diagnosed by second visit 46% 87% +89% Treatment initiated (% of diagnosed) 258,770 (66%) 359,271 (85%) +39% Cost per TB suspect tested $48 $60 +24% Cost per TB patient initiated on treatment $468 $456-3% Total annual cost of first-line TB diagnosis and treatment $283 million $348 million +23%

16 NTCM: Uses and results Planning of and budgeting for Xpert MTB/Rif roll-out by NHLS NSP ; PSPs Analysis of placement of Xpert in labs vs. clinics Analysis of alternative options for diagnosing TB in Xpert negative patients

17 Future model analyses HIV: Test and Treat/ Treatment as Prevention Cost-benefit analysis of national ART programme Update NACM Add provincial populations from Spectrum (March 2013) Extend until 2020/21 More detail to second line and treatment failure populations Scale-up of NIMART TB treatment: Centralised vs. decentralised MDR-TB

18 resources Publications Policy briefs Model manuals NACM/ NTCM training for NDoH/ NT/ SANAC/ anyone else

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