Publications by authors named "Shankar Prinja"

177 Publications

What is the Out-of-Pocket Expenditure on Medicines in India? An Empirical Assessment using a Novel Methodology.

Health Policy Plan 2022 Jul 21. Epub 2022 Jul 21.

Department of Community Medicine and School of Public Health, PGIMER, Chandigarh, India.

The share of expenditure on medicines as part of the total out-of-pocket (OOP) expenditure on healthcare services has been reported to be much higher in India than in other countries. This study was conducted to ascertain the extent of this share of medicines expenditure using a novel methodology. OOP expenditure data were collected through exit-interviews with 5252 out-patient department (OPD) patients in three states of India. Follow-up interviews were conducted after day 1 and 15 of the baseline to identify any additional expenditure incurred. In addition, medicine prescription data were collected from the patients through prescription audits. Self-reported expenditure on medicines was compared with the amount imputed using local market prices based on prescription data. The results were also compared with the mean expenditure on medicines per spell of ailment among non-hospitalized cases from National Sample Survey (NSS) 75th round for the corresponding states and districts, which is based on household survey methodology. The share of medicines in OOP expenditure did not change significantly for organized private hospitals using patient-reported versus imputation-based method (30.74% to 29.61%). Large reductions were observed for single-doctor clinics, especially in case of Ayurvedic (64.51% to 36.51%) and Homeopathic (57.53% to 42.74%) practitioners. After adjustment for socio-demographic factors and types of ailments, we found that household data collection as per NSS methodology leads to an increase of 25% and 26% in reported share of medicines for public and private sector out-patient consultations respectively, as compared to facility based exit interviews with imputation of expenditure for medicines as per actual quantity and price data. The nature of health care transactions at single-doctor clinics in rural India leads to an over-reporting of expenditure on medicines by patients. While household surveys are valid to provide total expenditure, these are less likely to correctly estimate the share of medicines expenditure.
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http://dx.doi.org/10.1093/heapol/czac057DOI Listing
July 2022

Cost of National Vector Borne Disease Control Programme in North India.

Indian J Med Res 2022 01;155(1):22-33

Department of Community Medicine & School of Public Health, Postgraduate Institute of Medical Education & Research, Chandigarh, India.

Background & Objectives: Despite significant resources being spent on National Vector Borne Disease Control Programme (NVBDCP), there are meagre published data on health system cost upon its implementation. Hence, the present study estimated the annual and unit cost of different services delivered under NVBDCP in North India.

Methodology: Economic cost of implementing NVBDCP was estimated based on data collected from three North Indian States, i.e. Punjab, Haryana and Himachal Pradesh. Multistage stratified random sampling was used for selecting health facilities across each level [i.e. subcentres (SCs), Primary Health Centres (PHCs), community health centres (CHCs) and district malaria office (DMO)] from the selected States. Data on annual consumption of both capital and recurrent resources were assessed from each of the selected facilities following bottom-up costing approach. Capital items (equipment, vehicles and furniture) were annualized over average life span using a discount rate of 3 per cent. The mean annual cost of implementation of NVBDCP was estimated for each level along with unit cost.

Results: The mean annual cost of implementing NVBDCP at the level of SC, PHC and CHC and DMO was ₹ 230,420 (199,523-264,901), 686,962 (482,637-886,313), 1.2 million (0.9-1.5 million) and 9.1 million (4.6-13.5 million), respectively. Per capita cost for the provision of complete package of services under NVBDCP was ₹ 45 (37-54), 48 (29-73), 10 (6-14) and 47 (31-62) at the level of SC, PHC, CHC and DMO level, respectively. The per capita cost was higher in Himachal Pradesh (HP) at SC [₹ 69 (52-85)] and CHC [₹ 20.8 (20.7-20.8)] level and in Punjab at PHC level [₹ 89 (49-132)] as compared to other States.

Interpretation & Conclusions: The evidence on cost of NVBDCP can be used to undertake future economic evaluations which could serve as a basis for allocating resources efficiently, policy development as well as future planning for scale up of services.
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http://dx.doi.org/10.4103/ijmr.IJMR_2011_18DOI Listing
January 2022

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

Cost Effectiveness of Ribociclib and Palbociclib in the Second-Line Treatment of Hormone Receptor-Positive, HER2-Negative Metastatic Breast Cancer in Post-Menopausal Indian Women.

Appl Health Econ Health Policy 2022 07 10;20(4):609-621. Epub 2022 May 10.

Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

Background: In this study, we evaluate the cost and outcomes of cyclin-dependent kinase 4/6 inhibitors (CDK4/6i) plus fulvestrant, fulvestrant alone, and conventional chemotherapy as the second-line therapy for hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2-) metastatic breast cancer (MBC) in India.

Methods: Using a Markov model, the clinical effectiveness of managing HR+, HER2- MBC in postmenopausal women with either a CDK4/6i (either ribociclib or palbociclib) and fulvestrant, fulvestrant alone, and chemotherapy (single-agent paclitaxel or capecitabine) was measured in terms of quality-adjusted life-years (QALYs). The costs were estimated from two different points of view: scenario I, as per the prevailing market prices of the drugs; and scenario II, as per the reimbursement rates set up by the publicly financed national health insurance scheme. Incremental cost per QALY gained with a given treatment option was compared against the next best alternative and was assessed for cost effectiveness using a threshold of 1-time the per capita gross domestic product (GDP) in India from a societal perspective.

Results: In scenario I, an MBC patient was found to incur a lifetime cost of Indian Rupees (₹) 2.54 million ($34,644), ₹2.53 million ($34,496), ₹512,598 ($6,984), ₹326,026 ($4,442) and ₹237,115 ($3,230) for the ribociclib and palbociclib combination arms, fulvestrant monotherapy, single-agent paclitaxel and the single-agent capecitabine treatment arms, respectively. The lifetime cost for CDK4/6i (ribociclib and palbociclib) combination therapy, fulvestrant monotherapy, paclitaxel, and capecitabine arms was estimated to be ₹1.94 million ($26,459), ₹1.92 million ($26,220), ₹315,387 ($4,296), ₹187,392 ($2,553) and ₹153,263 ($2,088), respectively, in scenario II. The mean QALYs lived per MBC patient with CDK4/6i (either ribociclib or palbociclib) combination therapy, fulvestrant, paclitaxel and capecitabine were estimated to be 1.4, 1.0, 0.9 and 0.7, respectively. None of the treatment arms are cost effective at current prices and reimbursement rates at a threshold of 1-time the per capita GDP of India. However, a 78% reduction in the current market price or a 72% reduction in the reimbursement rate of fulvestrant in the government-funded insurance program will make it a cost-effective treatment option for HR+, HER2- MBC patients in India.

Conclusion: CDK4/6i (ribociclib and palbociclib) therapy is not a cost-effective treatment option for MBC patients. A 72% reduction in the reimbursement rate for fulvestrant monotherapy will make it a cost-effective treatment option in the Indian context.
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http://dx.doi.org/10.1007/s40258-022-00731-2DOI Listing
July 2022

COVID-19 management: The vaccination drive in India.

Health Policy Technol 2022 Jun 5;11(2):100636. Epub 2022 May 5.

Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

Objective: We undertook the study to present a comprehensive overview of COVID-19 related measures, largely centred around the development of vaccination related policies, their implementation and challenges faced in the vaccination drive in India.

Methods: A targeted review of literature was conducted to collect relevant data from official government documents, national as well as international databases, media reports and published research articles. The data were summarized to assess Indian government's vaccination campaign and its outcomes as a response to COVID-19 pandemic.

Results: The five-point strategy adopted by government of India was "COVID appropriate behaviour, test, track, treat and vaccinate". With respect to vaccination, there have been periodic shifts in the policies in terms of eligible beneficiaries, procurement, and distribution plans, import and export strategy, involvement of private sector and use of technology. The government utilized technology for facilitating vaccination for the beneficiaries and monitoring vaccination coverage.

Conclusion: The monopoly of central government in vaccine procurement resulted in bulk orders at low price rates. However, the implementation of liberalized policy led to differential pricing and delayed achievement of set targets. The population preference for free vaccines and low profit margins for the private sector due to price caps resulted in a limited contribution of the dominant private health sector of the country. A wavering pattern was observed in the vaccination coverage, which was related majorly to vaccine availability and hesitancy. The campaign will require consistent monitoring for timely identification of bottlenecks for the lifesaving initiative.
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http://dx.doi.org/10.1016/j.hlpt.2022.100636DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9069978PMC
June 2022

Health system readiness for roll out of the Health and Wellnes Centres - Early experiences from Punjab State.

J Family Med Prim Care 2022 Apr 18;11(4):1354-1360. Epub 2022 Mar 18.

Department of Community Medicine and School of Public Health, Chandigarh, India.

Background: The Government of India launched the (AB) program in 2018 which aims to transform 150,000 existing Sub Health Centres and Primary Health Centres into Health and Wellness Centres (HWCs). In this study, we assessed health system readiness for establishment of HWCs.

Methods: The assessment comprised of a cross sectional facility assessment and a knowledge assessment of community health officers (CHOs) and female multipurpose health workers also known as auxiliary nurse midwives (ANMs), in 26 HWCs in one community development block of Punjab state. HWCs were assessed for key input and process parameters such as a human resource, physical infrastructure, supplies, capacity building etc., and processes including health promotion, community participation, digitization of management information system, and service delivery.

Results: It was observed that only 7 of the 26 HWCs had all human resources as per guidelines. The median knowledge score of CHOs and ANMs was 54% and 51% respectively. 11 of the 26 HWCs were co-located with SHCs. Out of the 15 standalone HWCs, while 9 had independent buildings, 5 were located in buildings of other community level institutions. 50 percent of the HWCs were not able to perform diabetes screening due to lack of glucometers or testing supplies. While services for non-communicable diseases were available, a two-way referral tracking system for patients was missing. The mean job satisfaction rated by the newly appointed CHOs was 3.12 on a scale of 1 to 5, where 5 represented very high job satisfaction.

Conclusion: The operationalization of HWCs requires State and local level interventions for strengthening of existing physical infrastructure, ensuring a regular supply of medicines and consumables, development of referral mechanisms for patients and enhancing community participation.
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http://dx.doi.org/10.4103/jfmpc.jfmpc_2560_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9067184PMC
April 2022

Comparative performance of verbal autopsy methods in identifying causes of adult mortality: A case study in India.

Indian J Med Res 2021 04;154(4):631-640

Department of Community Medicine & School of Public Health, Post Graduate Institute of Medical Education & Research, Chandigarh, India.

Background & Objectives: Cause of death assignment from verbal autopsy (VA) questionnaires is conventionally accomplished through physician review. However, since recently, computer softwares have been developed to assign the cause of death. The present study evaluated the performance of computer software in assigning the cause of death from the VA, as compared to physician review.

Methods: VA of 600 adult deaths was conducted using open- and close-ended questionnaires in Nandpur Kalour Block of Punjab, India. Entire VA forms were used by two physicians independently to assign the cause of death using the International Statistical Classification of Diseases and Related Health Problems (ICD)-10 codes. In case of disagreement between them, reconciliation was done, and in cases of persistent disagreements finally, adjudication was done by a third physician. InterVA-4-generated causes from close-ended questionnaires were compared using Kappa statistics with causes assigned by physicians using a questionnaire having both open- and close-ended questions. At the population level, Cause-Specific Mortality Fraction (CSMF) accuracy and P-value from McNemar's paired Chi-square were calculated. CSMF accuracy indicates the absolute deviation of a set of proportions of causes of death out of the total number of deaths between the two methods.

Results: The overall agreement between InterVA-4 and physician coding was 'fair' (κ=0.42; 95% confidence interval 0.38, 0.46). CSMF accuracy was found to be 0.71. The differences in proportions from the two methods were statistically different as per McNemar's paired Chi-square test for ischaemic heart diseases, liver cirrhosis and maternal deaths.

Interpretation & Conclusions: In comparison to physicians, assignment of causes of death by InterVA- 4 was only 'fair'. Hence, it may be appropriate to continue with physician review as the optimal option available in the current scenario.
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http://dx.doi.org/10.4103/ijmr.IJMR_14_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9205010PMC
April 2021

Health-Related Quality of Life Among Liver Disorder Patients in Northern India.

Indian J Community Med 2022 Jan-Mar;47(1):76-81. Epub 2022 Mar 16.

Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Objective: The present study aims to determine the health-related quality of life (HRQoL) among liver disorder patients being treated in tertiary care hospital in north India and exploration of factors affecting HRQoL.

Methodology: The HRQoL was assessed among 230 patients visiting either the outpatient department (OPD) or those admitted in high dependency unit (HDU) or liver intensive care unit (ICU) using direct measuring tools such as Euro QoL five-dimension questionnaire (EQ-5D) and EQ visual analog scale. Multivariate regression was used to explore the factors influencing HRQoL.

Results: Mean EQ-5D scores among chronic hepatitis and compensated cirrhosis patients were 0.639 ± 0.062 and 0.562 ± 0.048, respectively. Among those who were admitted in the ICU or HDU, mean EQ-5D score was 0.295 ± 0.031. At discharge, this score improved significantly to 0.445 ± 0.055 ( < 0.001). The multivariate results implied that HRQoL was significantly better among patients with lower literacy level ( = 0.018) and those treated in OPD settings ( < 0.001).

Conclusion: HRQoL is impaired among patients suffering from liver disorders specifically those admitted in ICU. Further, there is a need to generate more evidence to explore the impact of determinants and treatment-associated costs on the HRQoL.
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http://dx.doi.org/10.4103/ijcm.ijcm_1033_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8971888PMC
March 2022

Cost Effectiveness of Bevacizumab Plus Chemotherapy for the Treatment of Advanced and Metastatic Cervical Cancer in India-A Model-Based Economic Analysis.

JCO Glob Oncol 2022 03;8:e2100355

Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

Purpose: Patients with advanced and metastatic cervical cancer have a poor prognosis with a 1-year survival rate of 10%-15%. Recently, an antiangiogenic humanized monoclonal antibody bevacizumab has shown to improve the survival of these patients. This study was designed to assess the cost effectiveness of incorporating bevacizumab with standard chemotherapy for the treatment of patients with advanced and metastatic cervical cancer in India.

Methods: Using a disaggregated societal perspective and lifetime horizon, a Markov model was developed for estimating the costs and health outcomes in a hypothetical cohort of 1,000 patients with advanced and metastatic cervical cancer treated with either standard chemotherapy alone or in combination with bevacizumab. Effectiveness data for each of the treatment regimen were assessed using estimates from Gynecologic Oncology Group 240 trial. Data on disease-specific mortality in metastatic cervical cancer, health system cost, and out-of-pocket expenditure were derived from Indian literature. Multivariable probabilistic sensitivity analysis was undertaken to account for parameter uncertainty.

Results: Over the lifetime of one patient with advanced and metastatic cervical cancer, bevacizumab along with standard chemotherapy results in a gain of 0.275 (0.052-0.469) life-years (LY) and 0.129 (0.032-0.218) quality-adjusted life-years (QALY), at an additional cost of $3,816 US dollars (USD; 2,513-5,571) compared with standard chemotherapy alone. This resulted in an incremental cost of $19,080 USD (7,230-52,434) per LY gained and $34,744 USD (15,782-94,914) per QALY gained with the use of bevacizumab plus standard chemotherapy.

Conclusion: Addition of bevacizumab to the standard chemotherapy is not cost effective for the treatment of advanced and metastatic cervical cancer in India at a threshold of 1-time per-capita gross domestic product.
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http://dx.doi.org/10.1200/GO.21.00355DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8932481PMC
March 2022

Cost of Illness Due to Severe Enteric Fever in India.

J Infect Dis 2021 11;224(Supple 5):S540-S547

Christian Medical College, Vellore,India.

Background: Lack of robust data on economic burden due to enteric fever in India has made decision making on typhoid vaccination a challenge. Surveillance for Enteric Fever network was established to address gaps in typhoid disease and economic burden.

Methods: Patients hospitalized with blood culture-confirmed enteric fever and nontraumatic ileal perforation were identified at 14 hospitals. These sites represent urban referral hospitals (tier 3) and smaller hospitals in urban slums, remote rural, and tribal settings (tier 2). Cost of illness and productivity loss data from onset to 28 days after discharge from hospital were collected using a structured questionnaire. The direct and indirect costs of an illness episode were analyzed by type of setting.

Results: In total, 274 patients from tier 2 surveillance, 891 patients from tier 3 surveillance, and 110 ileal perforation patients provided the cost of illness data. The mean direct cost of severe enteric fever was US$119.1 (95% confidence interval [CI], US$85.8-152.4) in tier 2 and US$405.7 (95% CI, 366.9-444.4) in tier 3; 16.9% of patients in tier 3 experienced catastrophic expenditure.

Conclusions: The cost of treating enteric fever is considerable and likely to increase with emerging antimicrobial resistance. Equitable preventive strategies are urgently needed.
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http://dx.doi.org/10.1093/infdis/jiab282DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8892542PMC
November 2021

Peritoneal dialysis-first initiative in India: a cost-effectiveness analysis.

Clin Kidney J 2022 Jan 15;15(1):128-135. Epub 2021 Jul 15.

The George Institute of Global Health, New Delhi, India.

Background: The increasing burden of kidney failure (KF) in India necessitates provision of cost-effective kidney replacement therapy (KRT). We assessed the comparative cost-effectiveness of initiating KRT with peritoneal dialysis (PD) or haemodialysis (HD) in the Indian context.

Methods: The cost and clinical effectiveness of starting KRT with either PD or HD were measured in terms of life years (LYs) and quality-adjusted life years (QALYs) using a mathematical Markov model. Complications such as peritonitis, vascular access-related complications and blood-borne infections were considered. Health system costs, out-of-pocket expenditures borne by patients and indirect costs were included. Two scenarios were considered: Scenario 1 (real-world scenario)-as per the current cost and utilization patterns; Scenario 2 (public programme scenario)-use in the public sector as per Pradhan Mantri National Dialysis Programme (PMNDP) guidelines. The lifetime costs and health outcomes among KF patients were assessed.

Results: The mean QALYs lived per KF person with PD and HD were estimated to be 3.3 and 1.6, respectively. From a societal perspective, a PD-first policy is cost-saving as compared with an HD-first policy in both Scenarios 1 and 2. If only the costs directly attributable to patient care (direct costs) are considered, the PD-first treatment policy is estimated to be cost-effective only if the price of PD consumables can be brought down to INR70/U.

Conclusions: PD as initial treatment is a cost-saving option for management of KF in India as compared with HD first. The government should negotiate the price of PD consumables under the PMNDP.
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http://dx.doi.org/10.1093/ckj/sfab126DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8757426PMC
January 2022

Cost-effectiveness of Tamoxifen, Aromatase Inhibitor, and Switch Therapy (Adjuvant Endocrine Therapy) for Breast Cancer in Hormone Receptor Positive Postmenopausal Women in India.

Breast Cancer (Dove Med Press) 2021 27;13:625-640. Epub 2021 Nov 27.

Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Background: Breast cancer is the leading cause of cancer among women in India. Treatment with hormone therapy reduces recurrence. We undertook this cost-effectiveness study to ascertain the treatment option offering the best value for money.

Methods: The lifetime costs and health outcomes of using tamoxifen, AI and switch therapy were measured in a cohort of 50-year-old women with HR-positive early stage breast cancer. A Markov model of disease was developed using a societal perspective with a lifetime study horizon. Local, contralateral, and distant recurrence were modelled along with treatment related adverse effects. Primary data collected to obtain estimates of out-of-pocket expenditure (OOPE) and utility weights. Both health system cost and OOPE were included. The future costs and consequences were discounted at 3%. A probabilistic sensitivity analysis was used.

Results: The lifetime cost of hormone therapy with tamoxifen, AI and switch therapy was to be ₹1,472,037 (I$ 68,947), ₹1,306,794 (I$ 61,208) and ₹1,281,811 (I$ 60,038). The QALYs lived per patient receiving tamoxifen, AI and switch were 13.12, 13.42 and 13.32. tamoxifen was found to be more expensive and less effective. As compared to switch therapy, AI for five years incurred an incremental cost of ₹259,792 (I$12,168) per QALY gained. At the willingness to pay equals to per capita GDP of India, there is 55% probability of AI therapy to be cost-effective compared to switch therapy.

Conclusion: In postmenopausal women with HR-positive early-stage breast cancer, switch therapy is recommended for use on the basis of cost-effectiveness.
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http://dx.doi.org/10.2147/BCTT.S331831DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8636459PMC
November 2021

Economic Impact And SafetY of Same-Day Discharge Following Percutaneous Coronary Intervention: A Tertiary-Care Centre Experience From Northern India (EASY-SDD).

Cardiovasc Revasc Med 2022 07 8;40:71-77. Epub 2021 Nov 8.

Department of Cardiology, Advanced Cardiac Centre, Post Graduate Institute of Medical Education & Research, Chandigarh 160012, INDIA.

Background: The literature about the safety and feasibility of same-day discharge (SDD) following complex percutaneous coronary intervention (PCI) and in acute coronary syndrome (ACS) is scarce. The economic impact of SDD has not been evaluated in this geographical region. We in the present study evaluated the safety, feasibility, and economic impact of SDD following PCI at a tertiary care centre of north India.

Methods: It was a single-centre, non-randomized, prospective study, in which all consecutive PCI patients during the study period of 15 months were evaluated for SDD using a "patient-centred" approach. The patients who were discharged on the next calendar day were included in the next day discharge (NDD) group. The baseline demographic data including coronary risk factors, clinical presentation, and management details were noted for all patients. All patients were followed up for 6 weeks. The Indian health system is only partially insured, hence most of the expendable costs are borne by patients. In the present study, we computed the total societal expenditure of each PCI which includes both the health system costs and the expenditure borne by the patients. A standardized tool and bottoms up costing method were used for recording out-of-pocket expenditure (OOPE) by the patients and health care expenditure respectively.

Results: Out of a total of 675 PCI patients, 617 patients were enrolled in the study, and 132/617 (21.39%) patients were discharged the same day. Sixty-five % of patients (86/132) in the SDD cohort and 70% of patients (337/485) in the NDD cohort presented with ACS. Baseline characteristics in the two cohorts were identical. A higher syntax score, greater number of stents, and longer stented segment predicted the NDD. The mean length of stay after PCI in patients with SDD and NDD was 8.71 ± 2.48 and 21.76 ± 2.42 h, respectively. In the SDD group, there were no readmissions or adverse events after discharge till 6 weeks of follow-up. The total mean cost of PCI (health care system and OOPE) for SDD and NDD was Indian Rupees (INR) 129,322.14 [United States dollar (US$) 1810.51] and INR 165500.71 [US$ 2317.01] respectively. An amount of INR 36178.57 (health system cost: INR 10242.76 and OOPE: INR 25935.71 was saved for each SDD. Besides 100 cardiac unit bed days including 85 intensive cardiac care bed days were saved with 21% SDD in the present cohort.

Conclusion: Post PCI SDD is safe and feasible in selected ACS/chronic stable angina patients using the "patient-centred" approach. Besides, decreasing OOPE for the patients, SDD also helps in the efficient use of scarce health system resources.
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http://dx.doi.org/10.1016/j.carrev.2021.11.005DOI Listing
July 2022

Cost-effectiveness of population-based screening for diabetes and hypertension in India: an economic modelling study.

Lancet Public Health 2022 01 12;7(1):e65-e73. Epub 2021 Nov 12.

Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

Background: India faces a high burden of diabetes and hypertension. Currently, there is a dearth of economic evidence about screening programmes, affected age groups, and frequency of screening for these diseases in Indian settings. We assessed the cost effectiveness of population-based screening for diabetes and hypertension compared with current practice in India for different scenarios, according to type of screening test, population age group, and pattern of health-care use.

Methods: We used a hybrid decision model (decision tree and Markov model) to estimate the lifetime costs and consequences from a societal perspective. A meta-analysis was done to assess the effectiveness of population-based screening. Primary data were collected from two Indian states (Haryana and Tamil Nadu) to assess the cost of screening. The data from the National Health System Cost Database and the Costing of Health Services in India study were used to determine the health system cost of diagnostic tests and cost of treating diabetes or hypertension and their complications. A total of 962 patients were recruited to assess out-of-pocket expenditure and quality of life. Parameter uncertainty was evaluated using univariate and multivariable probabilistic sensitivity analyses. Finally, we estimated the incremental cost per quality-adjusted life-year (QALY) gained with alternative scenarios of scaling up primary health care through a health and wellness centre programme for the treatment of diabetes and hypertension.

Findings: The incremental cost per QALY gained across various strategies for population-based screening for diabetes and hypertension ranged from US$0·02 million to $0·03 million. At the current pattern of health services use, none of the screening strategies of annual screening, screening every 3 years, and screening every 5 years was cost-effective at a threshold of 1-time per capita gross domestic product in India. In the scenario in which health and wellness centres provided primary care to 20% of patients who were newly diagnosed with uncomplicated diabetes or hypertension, screening the group aged between 30 and 65 years every 5 years or 3 years for either diabetes, hypertension, or a comorbid state (both diabetes and hypertension) became cost-effective. If the share of treatment for patients with newly diagnosed uncomplicated diabetes or hypertension at health and wellness centres increases to 70%, from the existing 4% at subcentres and primary health centres, annual population-based screening becomes a cost saving strategy.

Interpretation: Population-based screening for diabetes and hypertension in India could potentially reduce time to diagnosis and treatment and be cost-effective if it is linked to comprehensive primary health care through health and wellness centres for provision of treatment to patients who screen positive.

Funding: Department of Health Research, Government of India.
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http://dx.doi.org/10.1016/S2468-2667(21)00199-7DOI Listing
January 2022

Health related quality of life among Rheumatic Fever and Rheumatic Heart Disease patients in India.

PLoS One 2021 29;16(10):e0259340. Epub 2021 Oct 29.

Department of Cardiology, Advanced Cardiac Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Background: Measurement of health-related quality of life (HRQOL) of people with chronic illnesses has become extremely important as the mortality rates associated with such illnesses have decreased and survival rates have increased. Thereby, such measurements not only provide insights into physical, mental and social dimensions of patient's health, but also allow monitoring of the results of interventions, complementing the traditional methods based on morbidity and mortality.

Objective: The present study was conducted to describe the HRQOL of patients suffering from Rheumatic Fever (RF) and Rheumatic Heart Disease (RHD), and to identify socio-demographic and clinical factors as predictors of HRQOL.

Methodology: A cross-sectional study was conducted to assess the HRQOL among 702 RF and RHD patients using EuroQol 5-dimensions 5-levels instrument (EQ-5D-5L), EuroQol Visual Analogue Scale and Time Trade off method. Mean EQ-5D-5L quality of life scores were calculated using EQ5D index value calculator across different stages of RF and RHD. Proportions of patients reporting problems in different attributes of EQ-5D-5L were calculated. The impact of socio-economic determinants on HRQOL was assessed.

Results: The mean EQ-5D-5L utility scores among RF, RHD and RHD with Congestive heart failure patients (CHF) were estimated as 0.952 [95% Confidence Interval (CI): 0.929-0.975], 0.820 [95% CI: 0.799-0.842] and 0.800 [95% CI: 0.772-0.829] respectively. The most frequently reported problem among RF/RHD patients was pain/discomfort (33.8%) followed by difficulty in performing usual activities (23.9%) patients, mobility (22.7%) and anxiety/depression (22%). Patients with an annual income of less than 50,000 Indian National Rupees (INR) reported the highest EQ-5D-5L score of 0.872, followed by those in the income group of more than INR 200,000 (0.835), INR 50,000-100,000 (0.832) and INR 100,000-200,000 (0.828). Better HRQOL was reported by RHD patients (including RHD with CHF) who underwent balloon valvotomy (0.806) as compared to valve replacement surgery (0.645).

Conclusion: RF and RHD significantly impact the HRQOL of patients. Interventions aiming to improve HRQOL of RF/RHD patients should focus upon ameliorating pain and implementation of secondary prevention strategies for reducing the progression from ARF to RHD and prevention of RHD-related complications.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0259340PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8555809PMC
December 2021

Costing of Essential Health Service Packages: A Systematic Review of Methods From Developing Economies.

Value Health 2021 11 19;24(11):1700-1713. Epub 2021 Aug 19.

Post Graduate Institute of Medical Education and Research, Chandigarh, India. Electronic address:

Objectives: Although an increasing number of countries are adopting essential health service packages (EHSPs) and undertaking their cost assessment, standardization of the costing methods and their reporting are imperative to instill confidence in the use of findings of EHSPs as evidence for decision making and resource allocation. This review was conducted to synthesize the EHSP costing reports, focusing on the key costing methods and their reporting standards.

Methods: A systematic review of English language literature (peer-reviewed as well as gray) was conducted. PubMed, Embase, Scopus, NHS Economic Evaluation Database, Google Scholar, and websites of key institutions were reviewed (2000-2020). Publication characteristics, costing methods, valuation sources, quality, transparency, and reporting standards were assessed and synthesized.

Results: A total of 29 studies from 19 countries were included. Most studies were government reports (69%) and reported the use of "bottom-up" approach (76%), OneHealth tool (38%), had international funding (79%), and reported both normative and empirical cost estimates (41%). Six studies (21%) scored "excellent" in conduct and reporting. Stand-alone costing of EHSP had higher mean quality score (80). The projected increase in government budget to implement EHSP ranged from 17% to 117%. Limited availability of reliable data on resources, prices, and coverage of interventions were identified as major limitations for costing of EHSPs.

Conclusions: Substantial differences in the costing methods and reporting standards of EHSPs made comparisons across countries difficult. Existing costing guidelines and checklists should be adapted for EHSPs with more specific methodological guidance to allow harmonization of methods and reporting.
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http://dx.doi.org/10.1016/j.jval.2021.05.021DOI Listing
November 2021

What and how much do the community health officers and auxiliary nurse midwives do in health and wellness centres in a block in Punjab? A time-motion study.

Indian J Public Health 2021 Jul-Sep;65(3):275-279

Professor, Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Background: The Government of India introduced a new cadre of Community Health Officers (CHOs) in the primary health-care system through the Ayushman Bharat Health and Wellness Centres (HWCs) program.

Objectives: The study aimed to assess the activities performed and time spent by the existing and new primary health-care team members at the HWC level.

Methods: A time and motion study was undertaken in four HWCs in Punjab over a period of 3 months, to assess the time spent by auxiliary nurse midwives (ANMs) and CHOs on different services and activities. Data were collected through direct continuous observation of four CHOs and four ANMs during working hours for a period of 6 consecutive days of a week, along with structured time allocation interviews of all participants.

Results: The CHOs spent 5.7 (5.6-5.9) hours per day on duty of which 57% was productively involved in service delivery. The average time spent by ANMs was 4.9 (4.5-5.3) hours per day, with nearly 62% productive time. While the CHOs spent nearly 40% of their time on services for non-communicable diseases (NCDs), the ANMs spent 51% of their time on maternal, infant, child, and adolescent health services.

Conclusion: The introduction of HWCs and CHOs has nudged the health system toward comprehensive primary health care by placing a renewed emphasis on NCDs. The study provides useful evidence for staff, program implementers, and policymakers, to aid informed decision-making for human resource management.
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http://dx.doi.org/10.4103/ijph.IJPH_1489_20DOI Listing
October 2021

An analysis of affordability of cigarettes and bidis in India.

Indian J Tuberc 2021 18;68S:S55-S59. Epub 2021 Aug 18.

Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

Background: Easy affordability of tobacco products is one of the reasons for increased tobacco consumption. The study attempts to project the affordability of cigarettes and bidis from 2017 to 2025 in India.

Methods: The affordability was measured in terms of Relative Income Price (RIP) and the price of smoked tobacco products. RIP depends upon per capita gross domestic production (GDP) required to purchase 100 packets of cigarettes. The GDP per capita was calculated using data from National Accounts Division, Central Statistics Office, 2017. The price of cigarettes and bidis was calculated using data from WHO global report on tobacco epidemics, 2017. The projections were done from 2017 to 2025 assuming constant rise of per capita GDP as in the year 2017 (7%) and price rise of cigarette and bidis due to inflation (4%). Four and Six scenarios for cigarettes and bidis respectively, of different tax rises (0%-200%) in the years 2017-2025 were taken.

Results: Bidis were more affordable at lower increments in tax as compared to cigarettes. Affordability for cigarettes decreased to - 9.9% after a 100% increase in tax whereas affordability of bidi decreased to - 8.61% after a 200% increase in tax by the end of 2025.

Conclusion: Since bidis are more easily affordable than cigarettes, an adequate increase in taxes of bidi should be made to make it less affordable.
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http://dx.doi.org/10.1016/j.ijtb.2021.08.020DOI Listing
December 2021

Combatting the imbalance of sex ratio at birth: medium-term impact of India's National Programme of Beti Bachao Beti Padhao in the Haryana State of India.

Health Policy Plan 2021 Nov;36(10):1499-1507

Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India.

The Government of India initiated the Beti Bachao Beti Padhao (B3P) programme in 2015 as a flagship initiative to reduce gender imbalance in sex ratio at birth (SRB) and to ensure social protection of girls. The present study was conducted to evaluate the medium-term impact of B3P implementation in Haryana state, from 2015 to 2019, on SRB. Monthly data on SRB were collected for the entire state of Haryana through a civil registration system. Segmented time series regression analysis was used to estimate the variations in SRB after the B3P programme with the help of Winter's additive interrupted time series model. The SRB in Haryana increased from 876 girls per 1000 boys in 2015 to 923 in 2019. The results of the model demonstrated that before the inception of intervention (pre-slope), there was a significant monthly change in SRB of 0.217 (95% confidence interval: 0.144-0.290). Following the B3P programme, SRB was found to increase by 0.835 per month, which implied that an increase of 0.618 (confidence interval: 0.338, 0.898) every month in SRB can be attributed to the B3P programme. This indicated that SRB for the state of Haryana increased at the rate of 7.42 units per year as a result of the B3P programme. B3P has led to a significant improvement in SRB in Haryana state. The continuity of efforts in the same direction with a sustained focus on behaviour change will further help achieve the goal of gender parity in births and child survival.
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http://dx.doi.org/10.1093/heapol/czab111DOI Listing
November 2021

Modelling the impact of increase in sugar prices on dental caries in India.

Community Dent Oral Epidemiol 2021 Aug 26. Epub 2021 Aug 26.

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

Objectives: This study aims to assess the impact of raising the price of sugar and/or sugar-sweetened beverages (SSBs) on caries incidence in the Indian population.

Methods: A tooth-level decision-analytic model was developed to evaluate a change in caries increment after increasing the price of Sugar and SSBs. The transition of a tooth from a caries-free state to the state of tooth loss in both scenarios was modelled with the help of a Markov model for a time horizon of 63 years, ranging from 2021 to 2083 for the 12-year-old population cohort of India. A conceptual framework was designed to implicate the possible effects of an increase in sugar prices on the reduction of caries incidence. Health effects were estimated in terms of the number of carious lesions and tooth-loss in both the scenarios and modelled as a product of the dose-response relationship between sugar intake and caries incidence. The model was thus used to establish the number of caries lesions prevented, and tooth-loss avoided. Uncertainties in the parameters were assessed using probabilistic sensitivity analysis. The Monte Carlo method was used for simulating the results 999 times.

Results: A 20% rise in the price of sugar is expected to result in the prevention of an average of 1.32 teeth in a lifetime of an individual and prevent 27.96 million tooth-loss incidents among the population cohort of India that will eventually lead to a saving of INR (₹) 3116.32 billion (US$ 42.69 billion) on account of dental caries treatment. Similarly, increasing-price of SSBs by 20% will lead to a 0.86% reduction in carious teeth incidence in an individual's lifetime.

Conclusion: Increasing the cost of sugar and/or SSBs will reduce the daily intake of sugar, which will reduce caries incidence and subsequent progression, thereby preventing caries-attributed tooth-loss and saving treatment costs.
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http://dx.doi.org/10.1111/cdoe.12694DOI Listing
August 2021

Burden of Group A Streptococcal Pharyngitis, Rheumatic Fever, and Rheumatic Heart Disease in India: A Systematic Review and Meta-Analysis.

Indian J Pediatr 2022 07 11;89(7):642-650. Epub 2021 Aug 11.

Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India.

Objective: To estimate the burden of group A streptococcal pharyngitis (GAS) pharyngitis, rheumatic fever (RF), and rheumatic heart disease (RHD) in India using existing data sources, as well as to recognize the most serious gaps in GAS disease burden data.

Methods: Four electronic databases-PubMed, Scopus, Embase, and Web of Science were searched using a comprehensive search strategy. Data were identified primarily from observational studies including school surveys, community-based and hospital-based studies. The standard methodological procedures as per Cochrane guidelines were used. Eligible studies were pooled for estimating prevalence, incidence, and case fatality rate using R software version 3.3.3. The protocol was registered with PROSPERO; registration number CRD42018075742.

Results: The pooled prevalence of GAS pharyngitis among asymptomatic children and pharyngitis cases aged 5 to 15 y was estimated as 2.79 percent [95% Confidence interval (CI): 1.58-4.89] and 13 percent (95% CI: 3.18-41.97), respectively. The prevalence rate of rheumatic fever was found to be 0.04% (95% CI: 0.01-0.17). The pooled prevalence rate of RHD among children aged 5-15 y using clinical auscultation and echocardiography was estimated as 0.36 percent (95% CI: 0.02-7.52) and 0.28 percent (95% CI: 0.08-1.03), respectively.

Conclusion: The study emphasizes the importance of developing a population-based surveillance framework to track patterns, management strategies, and outcomes in order to develop informed recommendations for launching contextual measures to regulate RF and RHD.
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http://dx.doi.org/10.1007/s12098-021-03845-yDOI Listing
July 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

Health-related quality of life in transplant eligible multiple myeloma patients with or without early ASCT in the real-world setting.

Leuk Lymphoma 2021 12 16;62(13):3271-3277. Epub 2021 Jul 16.

Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

There is no comparative health-related quality of life (HR-QoL) data of transplant eligible (TE) multiple myeloma (MM) patients undergoing early autologous stem cell transplantation (ASCT) and those without in the era of novel drugs. This study prospectively evaluated the serial HR-QoL in TE-MM using the EORTC QLQ-C30 and MY20 questionnaires. Barring the transient worsening in QoL one-month after ASCT, there was a comparable improvement in most QoL domains in both early-ASCT and no-early ASCT cohorts. Post-early-ASCT patients had higher global health scores (71.9 vs. 60.8,  < .05) than no-early ASCT at 12-months. Patients belonging to lower socioeconomic status (SES) were more likely not to undergo ASCT than middle-high SES patients (38.6% vs. 74.5%,  < .05). While age, gender had no impact on QoL, performance status, staging, and induction therapy impacted QoL. This study shows that early ASCT maintains QoL and should be encouraged in all TE-MM patients.
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http://dx.doi.org/10.1080/10428194.2021.1953011DOI Listing
December 2021

Adherence to country-specific guidelines among economic evaluations undertaken in three high-income and middle-income countries: a systematic review.

Int J Technol Assess Health Care 2021 Jul 1;37(1):e73. Epub 2021 Jul 1.

Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh160047, India.

Objective: To assess the adherence of economic evaluations to the recommendations on principles of economic evaluation as stated in the country-specific guidelines for three countries across different income groups, namely, Canada, South Africa, and Egypt.

Methods: Searches were undertaken in three databases to identify economic evaluations meeting predefined inclusion criteria. Methodological and reporting standards listed in the country-specific guidelines were converted into discrete binary variables to calculate mean adherence scores. Quality appraisal was done using Drummond's checklist. Stratified analysis was undertaken to identify independent variables affecting adherence.

Results: We identified forty-four, seventy-nine, and sixteen economic evaluations for Canada, South Africa, and Egypt, respectively. The mean adherence score was the highest for Canada (71%), followed by South Africa (65%) and Egypt (60%). Adherence to guidelines was positively correlated with quality of studies, r = .72. Furthermore, the mean adherence score was significantly (p < .05) higher for studies using a cost-utility analysis design (72%), having local/national funding aid (72%), undertaken by a health economist (71%) and for pharmacoeconomic evaluations (70%).

Conclusion: The quality of economic evaluations improves with adherence to country-specific guidelines. Locally funded and health-economist led health technology assessments (HTAs) should be encouraged for greater adherence to the guidelines. The HTA researchers and the HTA bodies should lay emphasis on adherence to the country-specific guidelines for improving the quality of HTA evidence.
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http://dx.doi.org/10.1017/S0266462321000404DOI Listing
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

Cost effectiveness of typhoid vaccination in India.

Vaccine 2021 07 10;39(30):4089-4098. Epub 2021 Jun 10.

Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India. Electronic address:

Introduction: World Health Organization has prequalified the use of typhoid conjugate vaccine (TCV) in children over six months of age in typhoid endemic countries. We assessed the cost-effectiveness of introducing TCV separately for urban and rural areas of India.

Methods: A decision analytic model was developed, using a societal perspective, to compare long-term costs and outcomes (3% discount rate) in a new-born cohort of 100,000 children immunized with or without TCV. Three vaccination scenarios were modelled, assuming the protective efficacy of TCV to last for 5, 10 and 15 years following immunization. Incidence of typhoid infection estimated under 'National Surveillance System for Enteric Fever' (NSSEFI)' was used. The prices of vaccine and cost of service delivery were included for vaccination arm. Both health system cost and out-of-pocket expenditures for treatment of typhoid illness and its complications was included.

Results: TCV introduction in urban areas would result in prevention of 17% to 36% typhoid cases and deaths. With exclusion of indirect costs, the incremental cost per QALY gained was ₹ 151,346 (54,730-307,975), ₹ 61,710 (-5250 to 163,283) and ₹ 45,188 (-17,069 to 141,093) for scenario 1, 2 and 3 respectively. While, with inclusion of indirect costs, all 3 scenarios were cost saving. Further, in rural areas, TCV is estimated to reduce the typhoid cases and deaths by 19% to 36%, with ICER (incremental cost per QALY gained) ranging from ₹ 2340 (1316-4370) to ₹ 3574 (2057 - 6691) thousand (inclusive of indirect costs) among the 3 vaccination scenarios.

Conclusion: From a societal perspective, introduction of TCV is a cost saving strategy in urban India. Further, due to low incidence of typhoid infection, introduction of TCV is not cost-effective in rural settings of India.
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http://dx.doi.org/10.1016/j.vaccine.2021.06.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8256879PMC
July 2021

Financial Burden in Families of Children with West Syndrome.

Indian J Pediatr 2022 Feb 26;89(2):118-124. Epub 2021 May 26.

Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Objective: To evaluate the illness-related expenditure by families of children with West syndrome (WS) during the first year of illness and to explore the potential determinants of the financial drain.

Methods: This cross-sectional study was conducted at a tertiary care hospital between July 2018 and June 2020. Eighty-five children with WS who presented within one year from the onset of epileptic spasms were included. The details of the treatment costs (direct medical and nonmedical) incurred during the first year from the onset of epileptic spasms were noted from a parental interview and case record review. Unit cost was fixed for drugs and specific services. Total cost was estimated by multiplying the unit cost by the number of times a drug or service was availed. The determinants of the financial burden were also explored.

Results: The median monthly per-capita income of the enrolled families (n = 85) was INR 3000 (Q1, Q3, 2000, 6000). The median cost of treatment over one year was INR 27035 (Q1, Q3, 17,894, 39,591). Median direct medical and nonmedical expenses amounted to INR 18802 (Q1, Q3, 12,179, 25,580) and INR 6550 (Q1, Q3, 3500, 15,000), respectively. Seven families had catastrophic healthcare expenditure. Parental education and choice of first-line treatment were important determinants driving healthcare expenses. The age at onset of epileptic spasms, etiology, treatment lag, the initial response to treatment, and relapse following initial response did not significantly influence the illness-related expenditure by the families.

Conclusion: WS imposes a substantial financial burden on the families and indirectly on the healthcare system.
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http://dx.doi.org/10.1007/s12098-021-03761-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8149262PMC
February 2022

Impact of COVID-19 on Outcomes for Patients With Cervical Cancer in India.

JCO Glob Oncol 2021 05;7:716-725

Department of Radiation Oncology, Government Medical College and Hospital, Chandigarh, India.

Purpose: The COVID-19 pandemic has placed unprecedented demands on the health system. This led to delays in the initiation and completion of cancer treatment. We assessed the long-term health consequences because of the delay in diagnosis and treatment for cervical cancer due to COVID-19 in India.

Methods: We used a Markov-model-based analysis assessing the lifetime health outcomes of the cohort of women population at risk from cervical cancer in India. The decrease in survival for those with the treatment interruption was calculated based on the number of days the treatment was extended beyond the standard duration. Furthermore, to model the impact of late diagnosis and delayed treatment initiation, the patients were assumed to have upstaged during the delay period, as per natural progression of disease.

Results: We estimate 2.52% (n = 795) to 3.80% (n = 2,160) lifetime increase in the deaths caused by cervical cancer with treatment restrictions ranging from 9 weeks to 6 months, respectively, as compared to no delay. On the contrary, 88-238 deaths because of COVID-19 disease are estimated to be saved during this restriction period among the patients with cervical cancer. Overall, the excess mortality because of cervical cancer led to 18,159-53,626 life-years being lost and an increase of 16,808-50,035 disability-adjusted life-years.

Conclusion: Delays in diagnosis and treatment are likely to lead to more cervical cancer deaths as compared to COVID-19 mortality averted among the patients with cervical cancer. Health systems must reorganize in terms of priority setting for provision of care, starting with prioritizing the treatment of patients with early-stage cervical cancer, increasing use of teleconsultation, and strengthening the role of primary care physicians in provision of cancer care.
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http://dx.doi.org/10.1200/GO.20.00654DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8162960PMC
May 2021
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