Publications by authors named "James Kahn"

233 Publications

Moving away from the "unit cost". Predicting country-specific average cost curves of VMMC services accounting for variations in service delivery platforms in sub-Saharan Africa.

PLoS One 2021 22;16(4):e0249076. Epub 2021 Apr 22.

University of California Berkeley, Berkeley, CA, United States of America.

Background: One critical element to optimize funding decisions involves the cost and efficiency implications of implementing alternative program components and configurations. Program planners, policy makers and funders alike are in need of relevant, strategic data and analyses to help them plan and implement effective and efficient programs. Contrary to widely accepted conceptions in both policy and academic arenas, average costs per service (so-called "unit costs") vary considerably across implementation settings and facilities. The objective of this work is twofold: 1) to estimate the variation of VMMC unit costs across service delivery platforms (SDP) in Sub-Saharan countries, and 2) to develop and validate a strategy to extrapolate unit costs to settings for which no data exists.

Methods: We identified high-quality VMMC cost studies through a literature review. Authors were contacted to request the facility-level datasets (primary data) underlying their results. We standardized the disparate datasets into an aggregated database which included 228 facilities in eight countries. We estimated multivariate models to assess the correlation between VMMC unit costs and scale, while simultaneously accounting for the influence of the SDP (which we defined as all possible combinations of type of facility, ownership, urbanicity, and country), on the unit cost variation. We defined SDP as any combination of such four characteristics. Finally, we extrapolated VMMC unit costs for all SDPs in 13 countries, including those not contained in our dataset.

Results: The average unit cost was 73 USD (IQR: 28.3, 100.7). South Africa showed the highest within-country cost variation, as well as the highest mean unit cost (135 USD). Uganda and Namibia had minimal within-country cost variation, and Uganda had the lowest mean VMMC unit cost (22 USD). Our results showed evidence consistent with economies of scale. Private ownership and Hospitals were significant determinants of higher unit costs. By identifying key cost drivers, including country- and facility-level characteristics, as well as the effects of scale we developed econometric models to estimate unit cost curves for VMMC services in a variety of clinical and geographical settings.

Conclusion: While our study did not produce new empirical data, our results did increase by a tenfold the availability of unit costs estimates for 128 SDPs in 14 priority countries for VMMC. It is to our knowledge, the most comprehensive analysis of VMMC unit costs to date. Furthermore, we provide a proof of concept of the ability to generate predictive cost estimates for settings where empirical data does not exist.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0249076PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8062035PMC
April 2021

State-level prevalence estimates of latent tuberculosis infection in the United States by medical risk factors, demographic characteristics and nativity.

PLoS One 2021 1;16(4):e0249012. Epub 2021 Apr 1.

Consortium to Assess Prevention Economics, Philip R Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, United States of America.

Introduction: Preventing tuberculosis (TB) disease requires treatment of latent TB infection (LTBI) as well as prevention of person-to-person transmission. We estimated the LTBI prevalence for the entire United States and for each state by medical risk factors, age, and race/ethnicity, both in the total population and stratified by nativity.

Methods: We created a mathematical model using all incident TB disease cases during 2013-2017 reported to the National Tuberculosis Surveillance System that were classified using genotype-based methods or imputation as not attributed to recent TB transmission. Using the annual average number of TB cases among US-born and non-US-born persons by medical risk factor, age group, and race/ethnicity, we applied population-specific reactivation rates (and corresponding 95% confidence intervals [CI]) to back-calculate the estimated prevalence of untreated LTBI in each population for the United States and for each of the 50 states and the District of Columbia in 2015.

Results: We estimated that 2.7% (CI: 2.6%-2.8%) of the U.S. population, or 8.6 (CI: 8.3-8.8) million people, were living with LTBI in 2015. Estimated LTBI prevalence among US-born persons was 1.0% (CI: 1.0%-1.1%) and among non-US-born persons was 13.9% (CI: 13.5%-14.3%). Among US-born persons, the highest LTBI prevalence was in persons aged ≥65 years (2.1%) and in persons of non-Hispanic Black race/ethnicity (3.1%). Among non-US-born persons, the highest LTBI prevalence was estimated in persons aged 45-64 years (16.3%) and persons of Asian and other racial/ethnic groups (19.1%).

Conclusions: Our estimations of the prevalence of LTBI by medical risk factors and demographic characteristics for each state could facilitate planning for testing and treatment interventions to eliminate TB in the United States. Our back-calculation method feasibly estimates untreated LTBI prevalence and can be updated using future TB disease case counts at the state or national level.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0249012PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8016318PMC
April 2021

Risk of HIV acquisition among men who have sex with men infected with bacterial sexually transmitted infections: A systematic review and meta-analysis.

Sex Transm Dis 2021 Mar 16. Epub 2021 Mar 16.

Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California, USA Consortium to Assess Prevention Economics, University of California, San Francisco, San Francisco, California, USA Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, Atlanta, Georgia, USA Centers for Disease Control and Prevention, Division of STD Prevention, Atlanta, Georgia, USA.

Background: Men who have sex with men (MSM) who have bacterial sexually transmitted infections (STIs) are at increased risk for HIV infection. We enhanced and updated past summary risk estimates.

Methods: We systematically reviewed (PROSPERO #CRD42018084299) peer-reviewed studies assessing risk of HIV infection among MSM attributable to: Chlamydia trachomatis (CT), Mycoplasma genitalium (MG), Neisseria gonorrhoeae (NG), Treponema pallidum (TP), and/or Trichomonas vaginalis (TV). We searched three databases through December 2017. We excluded studies with self-reported data or simultaneous STI and HIV assessment. We conducted dual screening and data extraction, meta-analytically pooled risk ratios (RR), and assessed potential risk of bias.

Results: We included 26 studies yielding 39 RR (k) for HIV acquisition due to one of TP, NG, or CT. We did not identify eligible data for MG or TV nor for HIV transmission. HIV acquisition risk increased among MSM infected with TP (k=21, RR 2.68, 95% CI 2.00-3.58), NG (k=11, RR 2.38, 95% CI 1.56-3.61), and CT (k=7, RR 1.99, 95% CI 1.59-2.48). Sub-analysis RR for all three pathogens were >= 1.66 and remained statistically significant across geography and methodological characteristics. Pooled RR increased for data with the lowest risk of bias for NG (k=3, RR 5.49, 95% CI 1.11-27.05) and TP (k=4, RR 4.32, 95% CI 2.20-8.51). We observed mostly moderate to high heterogeneity and moderate to high risk of bias.

Conclusion: MSM infected with TP, NG, or CT have twice or greater risk of HIV acquisition, although uncertainties exist due to data heterogeneity and risk of bias.
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http://dx.doi.org/10.1097/OLQ.0000000000001403DOI Listing
March 2021

Cost-effectiveness of statins for primary prevention of atherosclerotic cardiovascular disease among people living with HIV in the United States.

J Int AIDS Soc 2021 Mar;24(3):e25690

Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.

Background: Expanding statin use may help to alleviate the excess burden of atherosclerotic cardiovascular disease in people living with HIV (PLHIV). Pravastatin and pitavastatin are preferred agents due to their lack of substantial interaction with antiretroviral therapy. We aimed to evaluate the cost-effectiveness of pravastatin and pitavastatin for the primary prevention of atherosclerotic cardiovascular disease among PLHIV in the United States.

Methods: We developed a microsimulation model that randomly selected (with replacement) individuals from the Data-collection on Adverse Effects of Anti-HIV Drugs study with follow-up between 2013 and 2016. Our study population was PLHIV aged 40 to 75 years, stable on antiretroviral therapy, and not currently using lipid-lowering therapy. Direct medical costs and quality-adjusted life-years (QALYs) were assigned in annual cycles and discounted at 3% per year. We assumed a willingness-to-pay threshold of $100,000/QALY gained. The interventions assessed were as follows: (1) treating no one with statins; (2) treating everyone with generic pravastatin 40 mg/day (drug cost $236/year) and (3) treating everyone with branded pitavastatin 4 mg/day (drug cost $2,828/year). The model simulated each individual's probability of experiencing atherosclerotic cardiovascular disease over 20 years.

Results: Persons receiving pravastatin accrued 0.024 additional QALYs compared with those not receiving a statin, at an incremental cost of $1338, giving an incremental cost-effectiveness ratio of $56,000/QALY gained. Individuals receiving pitavastatin accumulated 0.013 additional QALYs compared with those using pravastatin, at an additional cost of $18,251, giving an incremental cost-effectiveness ratio of $1,444,000/QALY gained. These findings were most sensitive to the pill burden associated with daily statin administration, statin costs, statin efficacy and baseline atherosclerotic cardiovascular disease risk. In probabilistic sensitivity analysis, no statin was optimal in 5.2% of simulations, pravastatin was optimal in 94.8% of simulations and pitavastatin was never optimal.

Conclusions: Pravastatin was projected to be cost-effective compared with no statin. With substantial price reduction, pitavastatin may be cost-effective compared with pravastatin. These findings bode well for the expanded use of statins among PLHIV in the United States. To gain greater confidence in our conclusions it is important to generate strong, HIV-specific estimates on the efficacy of statins and the quality-of-life burden associated with taking an additional daily pill.
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http://dx.doi.org/10.1002/jia2.25690DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7982504PMC
March 2021

Alone, lonely, and missed.

Authors:
James Kahn

Lancet Respir Med 2021 06 5;9(6):565-566. Epub 2021 Mar 5.

Stanford University School of Medicine, Palo Alto, CA 94304, USA; Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA, USA. Electronic address:

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http://dx.doi.org/10.1016/S2213-2600(21)00038-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8172168PMC
June 2021

Interpersonal psychotherapy delivered by nonspecialists for depression and posttraumatic stress disorder among Kenyan HIV-positive women affected by gender-based violence: Randomized controlled trial.

PLoS Med 2021 01 11;18(1):e1003468. Epub 2021 Jan 11.

KEMRI, Nairobi, Kenya.

Background: HIV-positive women suffer a high burden of mental disorders due in part to gender-based violence (GBV). Comorbid depression and posttraumatic stress disorder (PTSD) are typical psychiatric consequences of GBV. Despite attention to the HIV-GBV syndemic, few HIV clinics offer formal mental healthcare. This problem is acute in sub-Saharan Africa, where the world's majority of HIV-positive women live and prevalence of GBV is high.

Methods And Findings: We conducted a randomized controlled trial at an HIV clinic in Kisumu, Kenya. GBV-affected HIV-positive women with both major depressive disorder (MDD) and PTSD were randomized to 12 sessions of interpersonal psychotherapy (IPT) plus treatment as usual (TAU) or Wait List+TAU. Nonspecialists were trained to deliver IPT inside the clinic. After 3 months, participants were reassessed, and those assigned to Wait List+TAU were given IPT. The primary outcomes were diagnosis of MDD and PTSD (Mini International Neuropsychiatric Interview) at 3 months. Secondary outcomes included symptom measures of depression and PTSD, intimate partner violence (IPV), and disability. A total of 256 participants enrolled between May 2015 and July 2016. At baseline, the mean age of the women in this study was 37 years; 61% reported physical IPV in the past week; 91% reported 2 or more lifetime traumatic events and monthly income was 18USD. Multilevel mixed-effects logistic regression showed that participants randomized to IPT+TAU had lower odds of MDD (odds ratio [OR] 0.26, 95% CI [0.11 to 0.60], p = 0.002) and lower odds of PTSD (OR 0.35, [0.14 to 0.86], p = 0.02) than controls. IPT+TAU participants had lower odds of MDD-PTSD comorbidity than controls (OR 0.36, 95% CI [0.15 to 0.90], p = 0.03). Linear mixed models were used to assess secondary outcomes: IPT+TAU participants had reduced disability (-6.9 [-12.2, -1.5], p = 0.01), and nonsignificantly reduced work absenteeism (-3.35 [-6.83, 0.14], p = 0.06); partnered IPT+TAU participants had a reduction of IPV (-2.79 [-5.42, -0.16], p = 0.04). Gains were maintained across 6-month follow-up. Treatment group differences were observed only at month 3, the time point at which the groups differed in IPT status (before cross over). Study limitations included 35% attrition inclusive of follow-up assessments, generalizability to populations not in HIV care, and data not collected on TAU resources accessed.

Conclusions: IPT for MDD and PTSD delivered by nonspecialists in the context of HIV care yielded significant improvements in HIV-positive women's mental health, functioning, and GBV (IPV) exposure, compared to controls.

Trial Registration: Clinical Trials Identifier NCT02320799.
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http://dx.doi.org/10.1371/journal.pmed.1003468DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7799784PMC
January 2021

Pricing Universal Health Care: How Much Would The Use Of Medical Care Rise?

Health Aff (Millwood) 2021 01;40(1):105-112

James G. Kahn is an emeritus professor in the Philip R. Lee Institute for Health Policy Studies at the University of California San Francisco, in San Francisco, California.

The return of a Democratic administration to the White House, coupled with coronavirus disease 2019 (COVID-19) pandemic-induced contractions of job-based insurance, may reignite debate over public coverage expansion and its costs. Decades of research demonstrate that uninsured people and people with copays and deductibles use less care than people with first-dollar coverage. Hence, most economic analyses of Medicare for All proposals and other coverage expansions project increased utilization and associated costs. We review the utilization surges that such analyses have predicted and contrast them with the more modest utilization increments observed after past coverage expansions in the US and other affluent nations. The discrepancy between predicted and observed utilization changes suggests that analysts underestimate the role of supply-side constraints-for example, the finite number of physicians and hospital beds. Our review of the utilization effects of past coverage expansions suggests that a first-dollar universal coverage expansion would increase ambulatory visits by 7-10 percent and hospital use by 0-3 percent. Modest administrative savings could offset the costs of such increases.
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http://dx.doi.org/10.1377/hlthaff.2020.01715DOI Listing
January 2021

Change in Condom Use in Populations Newly Aware of HIV Diagnosis in the United States and Canada: A Systematic Review and Meta-Analysis.

AIDS Behav 2021 Jun 2;25(6):1839-1855. Epub 2021 Jan 2.

Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, 3333 California Street, Suite 285, San Francisco, CA, 94118, USA.

HIV-infected individuals "aware" of their infection are more likely to use condoms, compared to HIV-infected "unaware" persons. To quantify this likelihood, we undertook a systematic review and meta-analysis of U.S. and Canadian studies. Twenty-one eligible studies included men who have sex with men (MSM; k = 15), persons who inject drugs (PWID; k = 2), and mixed populations of high-risk heterosexuals (HRH; k = 4). Risk ratios (RR) of "not always using condoms" with partners of any serostatus were lower among aware MSM (RR 0.44 [not significant]), PWID (RR 0.70) and HRH (RR 0.27); and, in aware MSM, with partners of HIV-uninfected or unknown status (RR 0.46). Aware individuals had lower "condomless sex likelihood" with HIV-uninfected or unknown status partners (MSM: RR 0.58; male PWID: RR 0.44; female PWID: RR 0.65; HRH: RR 0.35) and with partners of any serostatus (MSM only, RR 0.72). The association diminished over time. High risk of bias compromised evidence quality.
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http://dx.doi.org/10.1007/s10461-020-03113-8DOI Listing
June 2021

Cost-effectiveness analysis of magnetic resonance-guided focused ultrasound ablation for palliation of refractory painful bone metastases.

Int J Technol Assess Health Care 2020 Dec 3;37:e30. Epub 2020 Dec 3.

Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA94143, USA.

Objective: The aim of this study was to determine if magnetic resonance-guided focused ultrasound (MRgFUS) is cost-effective compared with medication, for refractory pain from bone metastases in the United States.

Methods: We constructed a Markov state transition model using TreeAge Pro software (TreeAge Software, Inc., Williamstown, MA, USA) to model costs, outcomes, and the cost-effectiveness of a treatment strategy using MRgFUS for palliative treatment of painful bone metastases compared with a Medication Only strategy (Figure 1). Model transition state probabilities, costs (in 2018 US$), and effectiveness data (quality-adjusted life-years [QALYs]) were derived from available literature, local expert opinion, and reimbursement patterns at two U.S. tertiary academic medical centers actively performing MRgFUS. Costs and QALYs, discounted at three percent per year, were accumulated each month over a 24-month time horizon. One-way and probabilistic sensitivity analyses were performed.

Results: In the base-case analysis, the MRgFUS treatment strategy costs an additional $11,863 over the 2-year time horizon to accumulate additional 0.22 QALYs, equal to a $54,160/QALY ICER, thus making MRgFUS the preferred strategy. One-way sensitivity analyses demonstrate that for the base-case analysis, the crossover point at which Medication Only would instead become the preferred strategy is $23,341 per treatment. Probabilistic sensitivity analyses demonstrate that 67 percent of model iterations supported the conclusion of the base case.

Conclusions: Our model demonstrates that MRgFUS is cost-effective compared with Medication Only for palliation of painful bone metastases for patients with medically refractory metastatic bone pain across a range of sensitivity analyses.
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http://dx.doi.org/10.1017/S0266462320001907DOI Listing
December 2020

Comparison of the costs of HPV testing through community health campaigns versus home-based testing in rural Western Kenya: a microcosting study.

BMJ Open 2020 10 27;10(10):e033979. Epub 2020 Oct 27.

Duke Global Health Institute, Duke University, Durham, NC, USA.

Objectives: To estimate the cost of human papillomavirus (HPV)-based screening through community health campaigns (CHCs) and home-based testing.

Setting: CHCs and home-based testing in six communities in rural Western Kenya.

Participants: CHCs and home-based screening reached 2297 and 1002 women aged 25-65 years, respectively.

Outcome Measures: Outcome measures were overall cost per woman screened achieved through the CHCs and home-based testing and the cost per woman for each activity comprising the screening intervention.

Results: The mean cost per woman screened through CHCs and home-based testing were similar, at $37.7 (range $26.4-$52.0) and $37.1 (range $27.6-$54.0), respectively. For CHCs, personnel represented 49% of overall cost, supplies 25%, services 5% and capital goods 23%. For home-based testing, these were: personnel 73%, supplies 25%, services 1% and capital goods 2%. A greater number of participants was associated with a lower cost per participant.

Conclusions: The mean cost per woman screened is comparable for CHC and home-based testing, with differences in type of input. The CHCs generally reached more eligible women in the six communities, whereas home-based strategies more efficiently reached populations with low screening rates.

Trial Registration Number: NCT02124252.
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http://dx.doi.org/10.1136/bmjopen-2019-033979DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7592277PMC
October 2020

The cost-effectiveness of MDMA-assisted psychotherapy for the treatment of chronic, treatment-resistant PTSD.

PLoS One 2020 14;15(10):e0239997. Epub 2020 Oct 14.

Multidisciplinary Association for Psychedelic Studies (MAPS), Santa Cruz, California, United States of America.

Background: Chronic posttraumatic stress disorder (PTSD) is a disabling condition that generates considerable morbidity, mortality, and both medical and indirect social costs. Treatment options are limited. A novel therapy using 3,4-methylenedioxymethamphetamine (MDMA) has shown efficacy in six phase 2 trials. Its cost-effectiveness is unknown.

Methods And Findings: To assess the cost-effectiveness of MDMA-assisted psychotherapy (MAP) from the health care payer's perspective, we constructed a decision-analytic Markov model to portray the costs and health benefits of treating patients with chronic, severe, or extreme, treatment-resistant PTSD with MAP. In six double-blind phase 2 trials, MAP consisted of a mean of 2.5 90-minute trauma-focused psychotherapy sessions before two 8-hour sessions with MDMA (mean dose of 125 mg), followed by a mean of 3.5 integration sessions for each active session. The control group received an inactive placebo or 25-40 mg. of MDMA, and otherwise followed the same regimen. Our model calculates net medical costs, mortality, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. Efficacy was based on the pooled results of six randomized controlled phase 2 trials with 105 subjects; and a four-year follow-up of 19 subjects. Other inputs were based on published literature and on assumptions when data were unavailable. We modeled results over a 30-year analytic horizon and conducted extensive sensitivity analyses. Our model calculates expected medical costs, mortality, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio. Future costs and QALYs were discounted at 3% per year. For 1,000 individuals, MAP generates discounted net savings of $103.2 million over 30 years while accruing 5,553 discounted QALYs, compared to continued standard of care. MAP breaks even on cost at 3.1 years while delivering 918 QALYs. Making the conservative assumption that benefits cease after one year, MAP would accrue net costs of $7.6 million while generating 288 QALYS, or $26,427 per QALY gained.

Conclusion: MAP provided to patients with severe or extreme, chronic PTSD appears to be cost-saving while delivering substantial clinical benefit. Third-party payers are likely to save money within three years by covering this form of therapy.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0239997PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7556534PMC
December 2020

Estimated costs for the delivery of safer conception strategies for HIV-discordant couples in Zimbabwe: a cost analysis.

BMC Health Serv Res 2020 Oct 12;20(1):940. Epub 2020 Oct 12.

Department of Epidemiology and Biostatistics, University of California, San Francisco, USA.

Background: In recent years, safer conception strategies have been developed to help HIV-serodiscordant couples conceive a child without transmitting HIV to the seronegative partner. The SAFER clinical trial assessed implementation of these strategies in Zimbabwe.

Methods: As a part of the SAFER study, we estimated the costs (in 2017 $US) associated with individual and combination strategies, in the trial setting and real-world practice, from a healthcare system perspective. Safer conception strategies included: 1) ART with frequent viral load testing until achieving undetectable viral load (ART-VL); 2) daily oral pre-exposure prophylaxis (PrEP); 3) semen-washing with intrauterine insemination; and 4) manual self-insemination at home. For costs in the trial, we used a micro-costing approach, including a time and motion study to quantify personnel effort, and estimated the cost per couple for individual and combination strategies for a mean of 6 months of safer services. For real-world practice, we modeled costs for three implementation scenarios, representing differences from the trial in input prices (paid by the Ministry of Health and Child Care [MOHCC]), intervention intensity, and increments to current HIV prevention and treatment practices and guidelines. We used one-way sensitivity analyses to assess the impact of uncertainty in input variables.

Results: Individual strategy costs were $769-$1615 per couple in the trial; $185-$563 if using MOHCC prices. Under the target intervention intensity and using MOHCC prices, individual strategy costs were $73-$360 per couple over and above the cost of current HIV clinical practices. The cost of delivering the most commonly selected combination, ART-VL plus PrEP, ranged from $166-$517 per couple under the three real-world scenarios. Highest costs were for personnel, lab tests, and strategy-specific consumables, in variable proportions by clinical strategy and analysis scenario. Total costs were most affected by uncertainty in the price of PrEP, number of semen-washing attempts, and scale-up of semen-washing capacity.

Conclusions: Safer conception methods have costs that may be affordable in many low-resource settings. These cost data will help implementers and policymakers add safer conception services. Cost-effectiveness analysis is needed to assess value for money for safer conception services overall and for safer strategy combinations.

Trial Registration: Registry Name: Clinicaltrials.gov.

Trial Registration Number: NCT03049176 . Registration date: February 9, 2017.
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http://dx.doi.org/10.1186/s12913-020-05784-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7552466PMC
October 2020

Potential Contributions of Clinical and Community Testing in Identifying Persons with Undiagnosed HIV Infection in the United States.

J Int Assoc Provid AIDS Care 2020 Jan-Dec;19:2325958220950902

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention, Atlanta, GA, USA.

Background: An estimated 166,155 individuals in the United States have undiagnosed HIV infection. We modeled the numbers of HIV-infected individuals who could be diagnosed in clinical and community settings by broadly implementing HIV screening guidelines.

Setting: United States.

Methods: We modeled testing for general population (once lifetime) and high-risk populations (annual): men who have sex with men, people who inject drugs, and high-risk heterosexuals. We used published data on HIV infections, HIV testing, engagement in clinical care, and risk status disclosure.

Results: In clinical settings, about 76 million never-tested low-risk and 2.6 million high-risk individuals would be tested, yielding 36,000 and 55,000 HIV diagnoses, respectively. In community settings, 30 million low-risk and 4.4 million high-risk individuals would be tested, yielding 75,000 HIV diagnoses.

Conclusion: HIV testing in clinical and community settings diagnoses similar numbers of individuals. Lifetime and risk-based testing are both needed to substantially reduce undiagnosed HIV.
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http://dx.doi.org/10.1177/2325958220950902DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7475783PMC
September 2020

Modeling the Impact of Recommendations for Primary Care-Based Screening for Latent Tuberculosis Infection in California.

Public Health Rep 2020 Jul/Aug;135(1_suppl):172S-181S

8785 Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, CA, USA.

Objective: Targeted testing and treatment of persons with latent tuberculosis infection (LTBI) is a critical component of the US tuberculosis (TB) elimination strategy. In January 2016, the California Department of Public Health issued a tool and user guide for TB risk assessment (California tool) and guidance for LTBI testing, and in September 2016, the US Preventive Services Task Force (USPSTF) issued recommendations for LTBI testing in primary care settings. We estimated the epidemiologic effect of adherence to both recommendations in California.

Methods: We used an individual-based Markov micro-simulation model to estimate the number of cases of TB disease expected through 2026 with baseline LTBI strategies compared with implementation of the USPSTF or California tool guidance. We estimated the risk of LTBI by age and country of origin, the probability of being in a targeted population, and the probability of presenting for primary care based on available data. We assumed 100% adherence to testing guidance but imperfect adherence to treatment.

Results: Implementation of USPSTF and California tool guidance would result in nearly identical numbers of tests administered and cases of TB disease prevented. Perfect adherence to either recommendation would result in approximately 7000 cases of TB disease averted (40% reduction compared with baseline) by 2026. Almost all of this decline would be driven by a reduction in the number of cases among non-US-born persons.

Conclusions: By focusing on the non-US-born population, adherence to LTBI testing strategies recommended by the USPSTF and the California tool could substantially reduce the burden of TB disease in California in the next decade.
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http://dx.doi.org/10.1177/0033354920927845DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7407051PMC
September 2020

Monetary incentives for improving smartphone-measured oral hygiene behaviors in young children: A randomized pilot trial.

PLoS One 2020 30;15(7):e0236692. Epub 2020 Jul 30.

Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, United States of America.

Aims: To assess feasibility, acceptability, and early efficacy of monetary incentive-based interventions on fostering oral hygiene in young children measured with a Bluetooth-enabled toothbrush and smartphone application.

Design: A stratified, parallel-group, three-arm individually randomized controlled pilot trial.

Setting: Two Los Angeles area Early Head Start (EHS) sites.

Participants: 36 parent-child dyads enrolled in an EHS home visit program for 0-3 year olds.

Interventions: Eligible dyads, within strata and permuted blocks, were randomized in equal allocation to one of three groups: waitlist (delayed monetary incentive) control group, fixed monetary incentive package, or lottery monetary incentive package. The intervention lasted 8 weeks.

Outcomes: Primary outcomes were a) toothbrushing performance: mean number of Bluetooth-recorded half-day episodes per week when the child's teeth were brushed, and b) dental visit by the 2-month follow-up among children with no prior dental visit. The a priori milestone of 20% more frequent toothbrushing identified the intervention for a subsequent trial. Feasibility and acceptability measures were also assessed, including frequency of parents syncing the Bluetooth-enabled toothbrush to the smartphone application and plaque measurement from digital photographs.

Findings: Digital monitoring of toothbrushing was feasible. Mean number of weekly toothbrushing episodes over 8 weeks was 3.9 in the control group, 4.1 in the fixed incentive group, and 6.0 in the lottery incentive group. The lottery group had 53% more frequent toothbrushing than the control group and 47% more frequent toothbrushing than the fixed group. Exploratory analyses showed effects concentrated among children ≤24 months. Follow-up dental visit attendance was similar across groups. iPhone 7 more reliably captured evaluable images than Photomed Cannon G16.

Conclusions: Trial protocol and outcome measures were deemed feasible and acceptable. Results informed the study protocol for a fully powered trial of lottery incentives versus a delayed control using the smart toothbrush and remote digital incentive program administration.

Trial Registration: ClinicalTrials.gov identifier NCT03862443.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0236692PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7392266PMC
September 2020

The changing HIV epidemic: a view from the front line in the United States.

Authors:
James Kahn

AIDS 2020 08;34(10):1437-1438

VA Palo Alto Health Care System and Department of Medicine, Stanford University Palo Alto, California, USA.

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http://dx.doi.org/10.1097/QAD.0000000000002560DOI Listing
August 2020

Drones and digital adherence monitoring for community-based tuberculosis control in remote Madagascar: A cost-effectiveness analysis.

PLoS One 2020 7;15(7):e0235572. Epub 2020 Jul 7.

Institut Pasteur de Madagascar, Ambohitrakely, Antananarivo, Madagascar.

Background: Continuing tuberculosis control with current approaches is unlikely to reach the World Health Organization's objective to eliminate TB by 2035. Innovative interventions such as unmanned aerial vehicles (or drones) and digital adherence monitoring technologies have the potential to enhance patient-centric quality tuberculosis care and help challenged National Tuberculosis Programs leapfrog over the impediments of conventional Directly Observed Therapy (DOTS) implementation. A bundle of innovative interventions referred to for its delivery technology as the Drone Observed Therapy System (DrOTS) was implemented in remote Madagascar. Given the potentially increased cost these interventions represent for health systems, a cost-effectiveness analysis was indicated.

Methods: A decision analysis model was created to calculate the incremental cost-effectiveness of the DrOTS strategy compared to DOTS, the standard of care, in a study population of 200,000 inhabitants in rural Madagascar with tuberculosis disease prevalence of 250/100,000. A mixed top-down and bottom-up costing approach was used to identify costs associated with both models, and net costs were calculated accounting for resulting TB treatment costs. Net cost per disability-adjusted life years averted was calculated. Sensitivity analyses were performed for key input variables to identify main drivers of health and cost outcomes, and cost-effectiveness.

Findings: Net cost per TB patient identified within DOTS and DrOTS were, respectively, $282 and $1,172. The incremental cost per additional TB patient diagnosed in DrOTS was $2,631 and the incremental cost-effectiveness ratio of DrOTS compared to DOTS was $177 per DALY averted. Analyses suggest that integrating drones with interventions ensuring highly sensitive laboratory testing and high treatment adherence optimizes cost-effectiveness.

Conclusion: Innovative technology packages including drones, digital adherence monitoring technologies, and molecular diagnostics for TB case finding and retention within the cascade of care can be cost effective. Their integration with other interventions within health systems may further lower costs and support access to universal health coverage.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0235572PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7340291PMC
September 2020

Statins for atherosclerotic cardiovascular disease prevention in people living with HIV in Thailand: a cost-effectiveness analysis.

J Int AIDS Soc 2020 06;23 Suppl 1:e25494

Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.

Introduction: People living with HIV (PLHIV) have an elevated risk of atherosclerotic cardiovascular disease (CVD) compared to their HIV-negative peers. Expanding statin use may help alleviate this burden. However, the choice of statin in the context of antiretroviral therapy is challenging. Pravastatin and pitavastatin improve cholesterol levels in PLHIV without interacting substantially with antiretroviral therapy. They are also more expensive than most statins. We evaluated the cost-effectiveness of pravastatin and pitavastatin for the primary prevention of CVD among PLHIV in Thailand who are not currently using lipid-lowering therapy.

Methods: We developed a discrete-state microsimulation model that randomly selected (with replacement) individuals from the TREAT Asia HIV Observational Database cohort who were aged 40 to 75 years, receiving antiretroviral therapy in Thailand, and not using lipid-lowering therapy. The model simulated each individual's probability of experiencing CVD. We evaluated: (1) treating no one with statins; (2) treating everyone with pravastatin 20mg/day (drug cost 7568 Thai Baht ($US243)/year) and (3) treating everyone with pitavastatin 2 mg/day (drug cost 8182 Baht ($US263)/year). Direct medical costs and quality-adjusted life-years (QALYs) were assigned in annual cycles over a 20-year time horizon and discounted at 3% per year. We assumed the Thai healthcare sector perspective.

Results: Pravastatin was estimated to be less effective and less cost-effective than pitavastatin and was therefore dominated (extended) by pitavastatin. Patients receiving pitavastatin accumulated 0.042 additional QALYs compared with those not using a statin, at an extra cost of 96,442 Baht ($US3095), giving an incremental cost-effectiveness ratio of 2,300,000 Baht ($US73,812)/QALY gained. These findings were sensitive to statin costs and statin efficacy, pill burden, and targeting of PLHIV based on CVD risk. At a willingness-to-pay threshold of 160,000 Baht ($US5135)/QALY gained, we estimated that pravastatin would become cost-effective at an annual cost of 415 Baht ($US13.30)/year and pitavastatin would become cost-effective at an annual cost of 600 Baht ($US19.30)/year.

Conclusions: Neither pravastatin nor pitavastatin were projected to be cost-effective for the primary prevention of CVD among PLHIV in Thailand who are not currently using lipid-lowering therapy. We do not recommend expanding current use of these drugs among PLHIV in Thailand without substantial price reduction.
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http://dx.doi.org/10.1002/jia2.25494DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7305414PMC
June 2020

Systematic Review of Cost-Effectiveness Analyses in U.S. Spine Surgery.

World Neurosurg 2020 10 21;142:e32-e57. Epub 2020 May 21.

Philip R. Lee Institute for Health Policy Studies, UCSF School of Medicine, San Francisco, California, USA.

Background: Increasing costs put the value of spine surgery under scrutiny. In health economics, cost-effectiveness analyses (CEA) are used to compare the value of competing procedures. However, inconsistent methodology prevents standardization and implementation of recommendations. The goal of this study is to perform a systematic review of all U.S. CEAs in spine surgery reported to date, highlight their strengths and weaknesses, and define metrics essential for high-quality CEAs.

Methods: We followed AMSTAR systematic review methods, identifying all U.S. spine surgery CEAs reported to March 2019 with a structured, reproducible search of PubMed, Embase, and the Tufts CEA Registry.

Results: We identified 40 CEA studies. Twelve (30%) used outcome data from a randomized controlled trial. To calculate costs, 22 (55%) used allowed charges but costing methods were often unclear or imprecise. Studies applying discounting had mean follow-up of 5.92 years compared with 3.00 years for studies without. Eleven of 15 (73%) cervical studies compared cervical disc arthroplasty with anterior cervical discectomy and fusion, finding cervical disc arthroplasty to be cost-effective (<$100,000/quality-adjusted life year) for 1-level and 2-level procedures. Eleven of 25 lumbar studies (44%) compared operative with nonoperative interventions for intervertebral disc herniation, lumbar stenosis, and lumbar spondylolisthesis. Lumbar studies comparing surgical with nonoperative intervention found surgery at least cost-effective for intervertebral disc herniation and lumbar stenosis, but cost-effective only for lumbar spondylolisthesis at 4 years follow-up. Most studies (70%) lacked appropriate sensitivity analyses.

Conclusions: Costing methodology remains obscure and inconsistent and incremental cost-effectiveness ratio results incomparable. The language of costing methodology must be standardized and sensitivity analyses of outcome and cost inputs mandatory for publication.
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http://dx.doi.org/10.1016/j.wneu.2020.05.123DOI Listing
October 2020

The imperative for universal healthcare to curtail the COVID-19 outbreak in the USA.

EClinicalMedicine 2020 Jun 17;23:100380. Epub 2020 May 17.

Center for Infectious Disease Modeling and Analysis (CIDMA), Yale School of Public Health, New Haven, CT, United States.

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http://dx.doi.org/10.1016/j.eclinm.2020.100380DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7231536PMC
June 2020

Productivity losses among individuals with common mental illness and comorbid cardiovascular disease in rural Karnataka, India.

Int J Noncommun Dis 2019 Jul-Sep;4(3):86-92. Epub 2019 Sep 27.

Department of Medicine, University of California, San Francisco, California, USA.

Context: Common mental disorders (CMD) and cardiovascular diseases (CVDs) frequently co-occur. Productivity losses due to these diseases are substantial in high-income countries. Similar data from the developing world are lacking.

Aims: This study aims to quantify productivity losses among individuals with comorbid CMD and CVD in rural Karnataka, India.

Settings And Design: A cross-sectional study was done among patients with a dual diagnosis of a comorbid CMD and CVD in a district in Karnataka, India.

Subjects And Methods: Three hundred and three patients were administered the iMTA Productivity Cost Questionnaire to measure losses of productivity at paid work (absenteeism and presenteeism) and unpaid work.

Statistical Analysis Used: Valuation of productivity losses was done by multiplying the number of days of lost productivity by the standard value of productivity based on the minimum wage for agricultural work.

Results: Among individuals with dual CMD and CVD, 76% had productivity losses. These losses were higher at unpaid (62%) than at paid work (32%). At paid work, losses due to presenteeism were greater than those due to absenteeism. The total days of productivity loss were 1204, amounting to 14.2% of the available person-days. The total productivity loss among 303 individuals with mental illness and comorbid CVD over a 4-week period amounted to 30.3 INR (0.47 USD) per person per day, representing 9.9% of total potential productivity.

Conclusions: Productivity losses due to common mental illnesses and CVDs are high. There is a need to conduct more studies in this field.
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http://dx.doi.org/10.4103/jncd.jncd_17_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7221215PMC
September 2019

I'm Sorry.

Authors:
James S Kahn

JAMA 2020 May;323(17):1692-1693

Medical Services, VA Palo Alto Health Care System, Palo Alto, California; and Department of Medicine, Stanford School of Medicine, Palo Alto, California.

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http://dx.doi.org/10.1001/jama.2020.2882DOI Listing
May 2020

Hypertension testing and treatment in Uganda and Kenya through the SEARCH study: An implementation fidelity and outcome evaluation.

PLoS One 2020 15;15(1):e0222801. Epub 2020 Jan 15.

University of California, San Francisco, San Francisco, California, United States of America.

Background: Hypertension (HTN) is the single leading risk factor for human mortality worldwide, and more prevalent in sub-Saharan Africa than any other region [1]-although resources for HTN screening, treatment, and control are few. Most regional pilot studies to leverage HIV programs for HTN control have achieved blood pressure control in half of participants or fewer [2,3,4]. But this control gap may be due to inconsistent delivery of services, rather than ineffective underlying interventions.

Methods: We sought to evaluate the consistency of HTN program delivery within the SEARCH study (NCT01864603) among 95,000 adults in 32 rural communities in Uganda and Kenya from 2013-2016. To achieve this objective, we designed and performed a fidelity evaluation of the step-by-step process (cascade) of HTN care within SEARCH, calculating rates of HTN screening, linkage to care, and follow-up care. We evaluated SEARCH's assessment of each participant's HTN status against measured blood pressure and HTN history.

Findings: SEARCH completed blood pressure screens on 91% of participants. SEARCH HTN screening was 91% sensitive and over 99% specific for HTN relative to measured blood pressure and patient history. 92% of participants screened HTN+ received clinic appointments, and 42% of persons with HTN linked to subsequent care. At follow-up, 82% of SEARCH clinic participants received blood pressure checks; 75% received medication appropriate for their blood pressure; 66% remained in care; and 46% had normal blood pressure at their most recent visit.

Conclusion: The SEARCH study's consistency in delivering screening and treatment services for HTN was generally high, but SEARCH could improve effectiveness in linking patients to care and achieving HTN control. Its model for implementing population-scale HTN testing and care through an existing HIV test-and-treat program-and protocol for evaluating the intervention's stepwise fidelity and care outcomes-may be adapted, strengthened, and scaled up for use across multiple resource-limited settings.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0222801PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6961918PMC
April 2020

Projected costs of single-payer healthcare financing in the United States: A systematic review of economic analyses.

PLoS Med 2020 01 15;17(1):e1003013. Epub 2020 Jan 15.

UCSF School of Medicine, University of California, San Francisco, San Francisco, California, United States of America.

Background: The United States is the only high-income nation without universal, government-funded or -mandated health insurance employing a unified payment system. The US multi-payer system leaves residents uninsured or underinsured, despite overall healthcare costs far above other nations. Single-payer (often referred to as Medicare for All), a proposed policy solution since 1990, is receiving renewed press attention and popular support. Our review seeks to assess the projected cost impact of a single-payer approach.

Methods And Findings: We conducted our literature search between June 1 and December 31, 2018, without start date restriction for included studies. We surveyed an expert panel and searched PubMed, Google, Google Scholar, and preexisting lists for formal economic studies of the projected costs of single-payer plans for the US or for individual states. Reviewer pairs extracted data on methods and findings using a template. We quantified changes in total costs standardized to percentage of contemporaneous healthcare spending. Additionally, we quantified cost changes by subtype, such as costs due to increased healthcare utilization and savings due to simplified payment administration, lower drug costs, and other factors. We further examined how modeling assumptions affected results. Our search yielded economic analyses of the cost of 22 single-payer plans over the past 30 years. Exclusions were due to inadequate technical data or assuming a substantial ongoing role for private insurers. We found that 19 (86%) of the analyses predicted net savings (median net result was a savings of 3.46% of total costs) in the first year of program operation and 20 (91%) predicted savings over several years; anticipated growth rates would result in long-term net savings for all plans. The largest source of savings was simplified payment administration (median 8.8%), and the best predictors of net savings were the magnitude of utilization increase, and savings on administration and drug costs (R2 of 0.035, 0.43, and 0.62, respectively). Only drug cost savings remained significant in multivariate analysis. Included studies were heterogeneous in methods, which precluded us from conducting a formal meta-analysis.

Conclusions: In this systematic review, we found a high degree of analytic consensus for the fiscal feasibility of a single-payer approach in the US. Actual costs will depend on plan features and implementation. Future research should refine estimates of the effects of coverage expansion on utilization, evaluate provider administrative costs in varied existing single-payer systems, analyze implementation options, and evaluate US-based single-payer programs, as available.
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http://dx.doi.org/10.1371/journal.pmed.1003013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6961869PMC
January 2020

Implementation research for public sector mental health care scale-up (SMART-DAPPER): a sequential multiple, assignment randomized trial (SMART) of non-specialist-delivered psychotherapy and/or medication for major depressive disorder and posttraumatic stress disorder (DAPPER) integrated with outpatient care clinics at a county hospital in Kenya.

BMC Psychiatry 2019 12 28;19(1):424. Epub 2019 Dec 28.

Department of Psychiatry, University of California, San Francisco, CA, USA.

Background: Mental disorders are a leading cause of global disability, driven primarily by depression and anxiety. Most of the disease burden is in Low and Middle Income Countries (LMICs), where 75% of adults with mental disorders have no service access. Our research team has worked in western Kenya for nearly ten years. Primary care populations in Kenya have high prevalence of Major Depressive Disorder (MDD) and Posttraumatic Stress Disorder (PTSD). To address these treatment needs with a sustainable, scalable mental health care strategy, we are partnering with local and national mental health stakeholders in Kenya and Uganda to identify 1) evidence-based strategies for first-line and second-line treatment delivered by non-specialists integrated with primary care, 2) investigate presumed mediators of treatment outcome and 3) determine patient-level moderators of treatment effect to inform personalized, resource-efficient, non-specialist treatments and sequencing, with costing analyses. Our implementation approach is guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework.

Methods/design: We will use a Sequential, Multiple Assignment Randomized Trial (SMART) to randomize 2710 patients from the outpatient clinics at Kisumu County Hospital (KCH) who have MDD, PTSD or both to either 12 weekly sessions of non-specialist-delivered Interpersonal Psychotherapy (IPT) or to 6 months of fluoxetine prescribed by a nurse or clinical officer. Participants who are not in remission at the conclusion of treatment will be re-randomized to receive the other treatment (IPT receives fluoxetine and vice versa) or to combination treatment (IPT and fluoxetine). The SMART-DAPPER Implementation Resource Team, (IRT) will drive the application of the EPIS model and adaptations during the course of the study to optimize the relevance of the data for generalizability and scale -up.

Discussion: The results of this research will be significant in three ways: 1) they will determine the effectiveness of non-specialist delivered first- and second-line treatment for MDD and/or PTSD, 2) they will investigate key mechanisms of action for each treatment and 3) they will produce tailored adaptive treatment strategies essential for optimal sequencing of treatment for MDD and/or PTSD in low resource settings with associated cost information - a critical gap for addressing a leading global cause of disability.

Trial Registration: ClinicalTrials.gov NCT03466346, registered March 15, 2018.
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http://dx.doi.org/10.1186/s12888-019-2395-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6935499PMC
December 2019

HPV-based cervical cancer screening in low-resource settings: Maximizing the efficiency of community-based strategies in rural Kenya.

Int J Gynaecol Obstet 2020 Mar 9;148(3):386-391. Epub 2020 Jan 9.

Department of Epidemiology and Biostatistics and Institutes for Health Policy Studies and Global Health Sciences, University of California, San Francisco, CA, USA.

Objective: To characterize the efficiency of screening through high-volume community health campaigns (CHCs) by comparing the costs and population reach and identify factors associated with gains in efficiency. Access to effective cervical cancer screening remains limited in low-resource settings, especially in rural areas. Periodic CHCs are a novel method of offering screening for HPV at lower costs and higher population coverage than health facilities.

Methods: A micro-costing study was conducted within a cervical cancer screening trial to measure efficiency (cost per woman screened) and population uptake of HPV-based screening offered through CHCs in Migori County, Kenya between January and September 2016. Regression analysis assessed relationships between population size and efficiency. Structured observations and qualitative interviews identified implementation factors that affected efficiency in individual campaigns.

Results: Communities screening through CHCs had costs per woman screened ranging from US $22.06 to $30.21. Efficiency was directly correlated to overall numbers of women screened, but not to proportion of population screened. Modifiable factors that acted as context-specific facilitators and barriers with a potential impact on efficiency were identified.

Conclusion: There was substantial variation in efficiency among CHCs. Cultural factors, health beliefs, and poor coordination among implementation partners as potential key barriers to screening uptake were identified.
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http://dx.doi.org/10.1002/ijgo.13090DOI Listing
March 2020

Nesting at the End of Life.

Authors:
James S Kahn

J Palliat Med 2019 12;22(12):1617-1618

Stanford Medical School, Palo Alto, California.

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http://dx.doi.org/10.1089/jpm.2019.0282DOI Listing
December 2019

Economic analyses to inform public health decision-making for tuberculosis: the role of understanding implementation.

BMC Med 2019 11 29;17(1):224. Epub 2019 Nov 29.

Consortium to Assess Prevention Economics, Institute for Health Policy Studies, University of California San Francisco, 3333 California Avenue, San Francisco, California, 94118, USA.

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http://dx.doi.org/10.1186/s12916-019-1468-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6883591PMC
November 2019

A meta-analysis approach for estimating average unit costs for ART using pooled facility-level primary data from African countries.

Afr J AIDS Res 2019 Dec;18(4):297-305

National Institute of Public Health, Cuernavaca, Mexico.

To estimate facility-level average cost for ART services and explore unit cost variations using pooled facility-level cost estimates from four HIV empirical cost studies conducted in five African countries . Through a literature search we identified studies reporting facility-level costs for ART programmes. We requested the underlying data and standardised the disparate data sources to make them comparable. Subsequently, we estimated the annual cost per patient served and assessed the cost variation among facilities and other service delivery characteristics using descriptive statistics and meta-analysis. All costs were converted to 2017 US dollars ($). We obtained and standardised data from four studies across five African countries and 139 facilities. The weighted average cost per patient on ART was $251 (95% CI: 193-308). On average, 46% of the mean unit cost correspond to antiretroviral (ARVs) costs, 31% to personnel costs, 20% other recurrent costs, and 2% to capital costs. We observed a lot of variation in unit cost and scale levels between countries. We also observed a negative relationship between ART unit cost and the number of patients served in a year. Our approach allowed us to explore unit cost variation across contexts by pooling ART costs from multiple sources. Our research provides an example of how to estimate costs based on heterogeneous sources reconciling methodological differences across studies and contributes by giving an example on how to estimate costs based on heterogeneous sources of data. Also, our study provides additional information on costs for funders, policy-makers, and decision-makers in the process of designing or scaling-up HIV interventions.
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http://dx.doi.org/10.2989/16085906.2019.1688362DOI Listing
December 2019

Developing the Global Health Cost Consortium Unit Cost Study Repository for HIV and TB: methodology and lessons learned.

Afr J AIDS Res 2019 Dec;18(4):263-276

Philip R Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, USA.

Consistently defined, accurate, and easily accessible cost data are a valuable resource to inform efficiency analyses, budget preparation, and sustainability planning in global health. The Global Health Cost Consortium (GHCC) designed the Unit Cost Study Repository (UCSR) to be a resource for standardised HIV and TB intervention cost data displayed by key characteristics such as intervention type, country, and target population. To develop the UCSR, the GHCC defined a typology of interventions for each disease; aligned interventions according to the standardised principles, methods, and cost and activity categories from the GHCC Reference Case for Estimating the Costs of Global Health Services and Interventions; completed a systematic literature review; conducted extensive data extraction; performed quality assurance; grappled with complex methodological issues such as the proper approach to the inflation and conversion of costs; developed and implemented a study quality rating system; and designed a web-based user interface that flexibly displays large amounts of data in a user-friendly way. Key lessons learned from the extraction process include the importance of assessing the multiple uses of extracted data; the critical role of standardising definitions (particularly units of measurement); using appropriate classifications of interventions and components of costs; the efficiency derived from programming data checks; and the necessity of extraction quality monitoring by senior analysts. For the web interface, lessons were: understanding the target audiences, including consulting them regarding critical characteristics; designing the display of data in "levels"; and incorporating alert and unique trait descriptions to further clarify differences in the data.
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http://dx.doi.org/10.2989/16085906.2019.1680398DOI Listing
December 2019