Publications by authors named "Kavitha Rajsekar"

12 Publications

  • Page 1 of 1

Development of an EQ-5D Value Set for India Using an Extended Design (DEVINE) Study: The Indian 5-Level Version EQ-5D Value Set.

Value Health 2022 Jul 5;25(7):1218-1226. Epub 2022 Jan 5.

Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Objectives: This study aimed to develop the Indian 5-level version EQ-5D (EQ-5D-5L) value set, which is a key input in health technology assessment for resource allocation in healthcare.

Methods: A cross-sectional survey using the EuroQol Group's Valuation Technology was undertaken in a representative sample of 3548 adult respondents, selected from 5 different states of India using a multistage stratified random sampling technique. The participants were interviewed using a computer-assisted personal interviewing technique. This study adopted a novel extended EuroQol Group's Valuation Technology design that included 18 blocks of 10 composite time trade-off (c-TTO) tasks, comprising 150 unique health states, and 36 blocks of 7 discrete choice experiment (DCE) tasks, comprising 252 DCE pairs. Different models were explored for their predictive performance. Hybrid modeling approach using both c-TTO and DCE data was used to estimate the value set.

Results: A total of 2409 interviews were included in the analysis. The hybrid heteroscedastic model with censoring at -1 combining c-TTO and DCE data yielded the most consistent results and was used for the generation of the value set. The predicted values for all 3125 health states ranged from -0.923 to 1. The preference values were most affected by the pain/discomfort dimension.

Conclusions: This is the largest EQ-5D-5L valuation study conducted so far in the world. The Indian EQ-5D-5L value set will promote the effective conduct of health technology assessment studies in India, thereby generating credible evidence for efficient resource use in healthcare.
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http://dx.doi.org/10.1016/j.jval.2021.11.1370DOI Listing
July 2022

Cost of Surgical Care at Public Sector District Hospitals in India: Implications for Universal Health Coverage and Publicly Financed Health Insurance Schemes.

Pharmacoecon Open 2022 Jun 22. Epub 2022 Jun 22.

Government Medical College, Jammu, Jammu & Kashmir, India.

Background: In low- and middle-income countries (LMICs), provisioning for surgical care is a public health priority. Ayushman Bharat Pradhan Mantri-Jan Aarogya Yojana (AB PM-JAY) is India's largest national insurance scheme providing free surgical and medical care. In this paper, we present the costs of surgical health benefit packages (HBPs) for secondary care in public district hospitals.

Methods: The costs were estimated using mixed (top-down and bottom-up) micro-costing methods. In phase II of the Costing of Health Services in India (CHSI) study, data were collected from a sample of 27 district hospitals from nine states of India. The district hospitals were selected using stratified random sampling based on the district's composite development score. We estimated unit costs for individual services-outpatient (OP) visit, per bed-day in inpatient (IP) and intensive care unit (ICU) stays, and surgical procedures. Together, this was used to estimate the cost of 250 AB PM-JAY HBPs.

Results: At the current level of utilization, the mean cost per OP consultation varied from US$4.10 to US$2.60 among different surgical specialities. The mean unit cost per IP bed-day ranged from US$13.40 to US$35.60. For the ICU, the mean unit cost per bed-day was US$74. Further, the unit cost of HBPs varied from US$564 for bone tumour excision to US$49 for lid tear repair.

Conclusions: Data on the cost of delivering surgical care at the level of district hospitals is of critical value for evidence-based policymaking, price-setting for surgical care and planning to strengthen the availability of high quality and cost-effective surgical care in district hospitals.
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http://dx.doi.org/10.1007/s41669-022-00342-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9216290PMC
June 2022

Economic Evaluation of Implementing a Rapid Point-of-Care Screening Test for the Identification of Hepatitis C Virus under National Viral Hepatitis Control Programme in Tamil Nadu, South India.

J Glob Infect Dis 2021 Jul-Sep;13(3):126-132. Epub 2021 Aug 31.

Department of Public Health and Preventive Medicine, Directorate of Medical and Rural Health Services, Government of Tamil Nadu, Chennai, Tamil Nadu, India.

Introduction: Viral hepatitis is a crucial public health problem in India. Hepatitis C virus (HCV) elimination is a national priority and a key strategy has been adopted to strengthen the HCV diagnostics services to ensure early and accurate diagnosis.

Methods: To conduct an economic evaluation of implementing a rapid point-of-care screening test for the identification of HCV among the selected key population under the National Viral Hepatitis Control Programme in Tamil Nadu, South India. Economic evaluation of a point-of-care screening test for HCV diagnosis among the key population attending the primary health care centers. A combination of decision tree and Markov model was developed to estimate cost-effectiveness of point-of-care screening test for HCV diagnosis at the primary health care centers. Total costs, quality-adjusted life years (QALYs) of the intervention and comparator, and incremental cost-effectiveness ratio (ICER) were calculated. The model parameter uncertainties which would influence the cost-effectiveness outcome has been evaluated by one-way sensitivity analysis and probabilistic sensitivity analysis.

Results: When compared to the tertiary level diagnostic strategy for HCV, the point-of-care screening for selected key population at primary health care level results in a gain of 57 undiscounted QALYs and 38 discounted QALYs, four undiscounted life years and two discounted life years. The negative ICER of the new strategy indicates that it is less expensive and more effective compared with the current HCV diagnosis strategy.

Conclusions: The proposed strategy for HCV diagnosis in the selected key population in Tamil Nadu is dominant and cost-saving compared to the current strategy.
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http://dx.doi.org/10.4103/jgid.jgid_394_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8491813PMC
August 2021

An economic evaluation of implementing a decentralized dengue screening intervention under the National Vector Borne Disease Control Programme in Tamil Nadu, South India.

Int Health 2022 05;14(3):295-308

Department of Public Health and Preventive Medicine, Government of Tamil Nadu, 359, Anna Salai, Chokkalingam Nagar, Teynampet, Chennai 600006, India.

Background: Lack of effective early screening is a major obstacle for reducing the fatality rate and disease burden of dengue. In light of this, the government of Tamil Nadu has adopted a decentralized dengue screening strategy at the primary healthcare (PHC) facilities using blood platelet count. Our objective was to determine the cost-effectiveness of a decentralized screening strategy for dengue at PHC facilities compared with the current strategy at the tertiary health facility (THC) level.

Methods: Decision tree analysis followed a hypothetical cohort of 1000 suspected dengue cases entering the model. The cost-effectiveness analysis was performed at a 3% discount rate for the proposed and current strategy. The outcomes are expressed in incremental cost-effectiveness ratios (ICERs) per quality-adjusted life years gained. One-way sensitivity analysis and probabilistic sensitivity analysis were done to check the uncertainty in the outcome.

Results: The proposed strategy was found to be cost-saving and ICER was estimated to be -41 197. PSA showed that the proposed strategy had a 0.84 probability of being an economically dominant strategy.

Conclusions: The proposed strategy is cost-saving, however, it is recommended to consider optimal population coverage, costs to economic human resources and collateral benefits of equipment.
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http://dx.doi.org/10.1093/inthealth/ihab045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9070504PMC
May 2022

Development of National Cancer Database for Cost and Quality of Life (CaDCQoL) in India: a protocol.

BMJ Open 2021 07 29;11(7):e048513. Epub 2021 Jul 29.

Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India.

Introduction: The rising economic burden of cancer on healthcare system and patients in India has led to the increased demand for evidence in order to inform policy decisions such as drug price regulation, setting reimbursement package rates under publicly financed health insurance schemes and prioritising available resources to maximise value of investments in health. Economic evaluations are an integral component of this important evidence. Lack of existing evidence on healthcare costs and health-related quality of life (HRQOL) makes conducting economic evaluations a very challenging task. Therefore, it is imperative to develop a national database for health expenditure and HRQOL for cancer.

Methods And Analysis: The present study proposes to develop a National Cancer Database for Cost and Quality of Life (CaDCQoL) in India. The healthcare costs will be estimated using a patient perspective. A cross-sectional study will be conducted to assess the direct out-of-pocket expenditure (OOPE), indirect cost and HRQOL among cancer patients who will be recruited at seven leading cancer centres from six states in India. Mean OOPE and HRQOL scores will be estimated by cancer site, stage of disease and type of treatment. Economic impact of cancer care on household financial risk protection will be assessed by estimating prevalence of catastrophic health expenditures and impoverishment. The national database would serve as a unique open access data repository to derive estimates of cancer-related OOPE and HRQOL. These estimates would be useful in conducting future cost-effectiveness analyses of management strategies for value-based cancer care.

Ethics And Dissemination: Approval was granted by Institutional Ethics Committee vide letter no. PGI/IEC-03/2020-1565 of Post Graduate Institute of Medical Education and Research, Chandigarh, India. The study results will be published in peer-reviewed journals and presented to the policymakers at national level.
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http://dx.doi.org/10.1136/bmjopen-2020-048513DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8323373PMC
July 2021

National Methodological Guidelines to Conduct Budget Impact Analysis for Health Technology Assessment in India.

Appl Health Econ Health Policy 2021 11 29;19(6):811-823. Epub 2021 Jun 29.

Department of Humanities and Social Sciences, Centre for Technology and Policy (CTaP), Indian Institute of Technology, Madras, India.

Objective: Our paper aims to present Budget Impact Analysis (BIA) guidelines for health technology assessment (HTA) in India.

Methodology: A Systematic Literature Review (SLR) was conducted to retrieve information on existing BIA guidelines internationally. The initial set of principles for India were put together based on an interactive process between authors, taking into consideration the existing evidence on BIA and features of Indian healthcare system. These were reviewed by Technical Appraisal Committee (TAC) of Health Technology Assessment in India (HTAIn) for their inputs. Three rounds of consultations were held before finalising the guidelines. Finally, user feedback on the draft guidelines was obtained from the policy makers and programme managers involved in the budgeting decisions.

Results: We recommend a payer's perspective, which will include both a multi-payer (depicting the current situation in India) and a single-payer scenario (which reflects a futuristic universal health care situation). A time horizon of 1-4 years is recommended. For estimation of eligible population, a top-down approach is considered appropriate. The future and current mix of interventions should be analysed for different utilisation and coverage patterns. We do not recommend discounting; however, inflation adjustments should be performed. The presentation of results should include total and disaggregated results, segregated year-wise throughout the chosen time horizon, as well as segregated by the type of resources. Deterministic sensitivity analysis and scenario analysis are recommended to address uncertainty.

Conclusion: Our recommendations, which are tailored for the Indian healthcare and financing context, aim to promote consistency and transparency in the conduct as well as reporting of the BIA. BIA should be used along with evidence from economic evaluation for decision making, and not as a substitute to evidence on value for money.
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http://dx.doi.org/10.1007/s40258-021-00668-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8238667PMC
November 2021

Adapting health technology assessment for drugs, medical devices, and health programs: Methodological considerations from the Indian experience.

Expert Rev Pharmacoecon Outcomes Res 2021 Oct 3;21(5):859-868. Epub 2021 May 3.

Department of Health Research, Ministry of Health and Family Welfare, Government of India, New Delhi, India.

Introduction: Heterogeneity in methods of economic evaluation makes the use of health technology assessment (HTA) evidence difficult. Thereby, several countries including India have developed their own standard guidelines for conducting HTAs. However, diverse HTA studies involving drugs, medical devices, health programs, and platforms require an adaptation of the standard methods.

Areas Covered: This review presents the specific characteristics of HTAs involving medical devices and health programs requiring adaptation of the standard guidelines. We use recent HTA studies in India to illustrate specific issues. These considerations involve the nature of decision-making problems, multiple scenarios in case of health programs, and specific attention to costing and the valuation of consequences. In case of medical devices, we discuss the issue of costing application of devices, multiple usage, learning curve for achieving effects, long causal path for health outcomes, and the issue of valuing false positives.

Expert Opinion: While standard guidelines are essential, specific features of health programs and medical devices need to be considered while undertaking HTAs. Additionally, the context in which the HTA is being undertaken, characteristics of the health system, methods of financing healthcare, and demand-side characteristics of healthcare utilization should be reflected in the HTA for health programs and medical devices.
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http://dx.doi.org/10.1080/14737167.2021.1921575DOI Listing
October 2021

Translating Research to Policy: Setting Provider Payment Rates for Strategic Purchasing under India's National Publicly Financed Health Insurance Scheme.

Appl Health Econ Health Policy 2021 05 19;19(3):353-370. Epub 2021 Jan 19.

Department of Health Research, Ministry of Health and Family Welfare, Government of India, New Delhi, India.

Background: In 2018, the Government of India launched Ayushman Bharat Pradhan Mantri-Jan Aarogya Yojana (AB PM-JAY), a large tax-funded health insurance scheme. In this paper, we present findings of the Costing of Health Services in India (CHSI) study, describe the process of use of cost evidence for price-setting under AB PM-JAY, and estimate its fiscal impact.

Methods: Reference costs were generated from the first phase of CHSI study, which sampled 11 tertiary public hospitals from 11 Indian states. Cost for Health Benefit Packages (HBPs) was estimated using mixed (top-down and bottom-up) micro-costing methods. The process adopted for price-setting under AB PM-JAY was observed. The cost of each HBP was compared with AB PM-JAY prices before and after the revision, and the budgetary impact of this revision in prices was estimated.

Findings: Following the CHSI study evidence and price consultations, 61% of AB PM-JAY HBP prices were increased while 18% saw a decline in the prices. In absolute terms, the mean increase in HBP price was ₹14,000 (₹450-₹1,65,000) and a mean decline of ₹6,356 (₹200-₹74,500) was observed. Nearly 42% of the total HBPs, in 2018, had a price that was less than 50% of the true cost, which declined to 20% in 2019. The evidence-informed revision of HBP prices is estimated to have a minimal fiscal impact (0.7%) on the AB PM-JAY claims pay-out.

Interpretation: Evidence-informed price-setting helped to reduce wide disparities in cost and price, as well as aligning incentives towards broader health system goals. Such strategic purchasing and price-setting requires the creation of systems of generating evidence on the cost of health services. Further research is recommended to develop a cost-function to study changes in cost with variations in time, region, prices, skill-mix and other factors.
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http://dx.doi.org/10.1007/s40258-020-00631-3DOI Listing
May 2021

Economic evaluation of implementing a decentralised Hepatitis B virus diagnostic intervention under National Viral Hepatitis Control Programme in Tamil Nadu, South India.

Trop Med Int Health 2021 03 10;26(3):374-384. Epub 2020 Dec 10.

Department of Public Health & Preventive Medicine, Government of Tamil Nadu, Chennai, India.

Objective: To assess the cost-effectiveness of decentralised diagnostic programme for hepatitis B virus (HBV) implemented in Tamil Nadu, South India with specific focus on a selected key population at increased risk of HBV.

Methods: A combination of decision tree and Markov model was developed to compare cost-effectiveness of the new and standard strategy. Cost and health outcomes were calculated based on the proportion of cohort in each respective health state. Total costs, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratio (ICER) of the intervention and comparator strategies were calculated. The model parameter uncertainties were evaluated by sensitivity analysis.

Results: Considering decentralised HBV diagnosis followed by early treatment and vaccination for negatives for a cohort of 1000 population resulted in 505 QALYs gained and incremental cost-saving of 180749 ($2620). The decentralised diagnostic strategy could avert 294 deaths, gain 293 life years and reduce out-of-pocket expenditure of 3274 ($47) per person for HBV management.

Conclusion: Decentralised HBV diagnosis followed by early treatment and vaccination for negatives in Tamil Nadu can save lives and reduce out-of-pocket expenditures compared to standard strategy.
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http://dx.doi.org/10.1111/tmi.13528DOI Listing
March 2021

Establishing reference costs for the health benefit packages under universal health coverage in India: cost of health services in India (CHSI) protocol.

BMJ Open 2020 07 20;10(7):e035170. Epub 2020 Jul 20.

Department of Health Research, Ministry of Health & Family welfare, New Delhi, India.

Introduction: To achieve universal health coverage, the Government of India has introduced a large tax-funded national health insurance scheme for the provision of secondary and tertiary care services in public and private hospitals. AB - PMJAY reimburses care for 1573 health benefit packages (HBPs). HBPs are designed to cover the treatment of diseases/conditions with high incidence/prevalence or which contribute to high out-of-pocket expenditure. However, there is a dearth of reference cost data against which provider payment rates can be assessed.

Methods And Analysis: The CHSI (Cost of Health Services in India) study will collect cost data from 13 Indian states covering 52 public and 40 private hospitals, using a mixed economic costing methodology (top-down and bottom-up), to generate unit costs for the HBPs. States will be sampled to capture economic status, development indicators and health service utilisation heterogeneity. The public sector hospitals will be chosen at secondary and tertiary care level. One tertiary facility will be selected from each state. At secondary level, three districts per state will be selected randomly from the district composite development score ranking. The private sector hospital sample will be stratified by nature of ownership (for-profit and not-for-profit), type of city (tier 1, 2 or 3) and size of the hospital (number of beds). Average costs for each HBP will be calculated across the different facility types. Multiple scenarios will be used to suggest rates which could be negotiated with the providers. Overall, the study will provide economic cost data for price setting, strategic purchasing, health technology assessment and a national cost database of India.

Ethics And Dissemination: The approval has been obtained from the Institutional Ethics Committee and Institutional Collaborative Committee of the Post Graduate Institute of Medical Education and Research, Chandigarh, India. The results shall be disseminated in conferences and peer-reviewed articles.
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http://dx.doi.org/10.1136/bmjopen-2019-035170DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7375634PMC
July 2020

Polymorphic variants in DC-SIGN, DC-SIGNR and SDF-1 in high risk seronegative and HIV-1 patients in Northern Asian Indians.

J Clin Virol 2008 Oct 4;43(2):196-201. Epub 2008 Sep 4.

Department of Biochemistry, Room No. 3002, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.

A single nucleotide polymorphism (SNP) in SDF-1, the natural ligand for the HIV-1 coreceptor CXCR4, is implicated to have protective effects against HIV-1 infection. Dendritic cells are the first to encounter HIV-1 at mucosal sites and virus binding occurs via receptors known as DC-SIGN. Variations in the number of repeats in the neck region of DC-SIGN and DC-SIGNR are reported to possibly influence host susceptibility to HIV-1 infection. We examined the SNP of SDF1-3'A by PCR-restriction fragment length polymorphism (RFLP) and repeat region polymorphisms in DC-SIGN and DC SIGNR by PCR in healthy HIV seronegative individuals, high risk STD patients seronegative for HIV, and HIV-1 seropositive patients from northern India. The detected polymorphisms were confirmed by cloning and sequencing. The genotypic frequency of SDF1-3'A/SDF1-3'A in the 100 HIV-seronegative healthy individuals, 150 HIV seronegative STD patients, and 100 HIV-1 seropositive patients were 4%, 18% and 7%, respectively. A significantly higher frequency of SDF1-3'A/SDF1-3'A was observed in high risk STD patients as compared to HIV seropositive (p=0.014) and healthy HIV-1 seronegative tested individuals (p=0.001), suggesting a protective role of SDF1-3'A in HIV-1 infection. DC-SIGN polymorphism was rare and genotype 7/7 was predominant in all groups studied. DC-SIGNR was highly polymorphic and 11 genotypes were observed among the different study groups. The precise role of the polymorphic variants of DC-SIGNR needs to be elucidated in the population.
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http://dx.doi.org/10.1016/j.jcv.2008.06.005DOI Listing
October 2008
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