COSTEFFECTIVENESS OF SURGERY IN DEVELOPING COUNTRIES

1
COST-EFFECTIVENESS OF SURGERY IN DEVELOPING
COUNTRIES

• RICHARD A GOSSELIN MD, MPH, MSc
• Institute for Global Orthopedics and Traumatology
• UCSF dept Orthopedic Surgery
• BoSD meeting, Chicago, 5/21/2009

2
WHY?

• Really cost-utility
• Inform resource allocation process
• Provide baseline data
• Compare intervention to self over time
• Compare different interventions at one
• point in time

3
DCPDC Surgery Chapter- almost no data from
developing countries- a few procedures were C/E
(cataracts, elective inguinal hernia)-
McCord Chowdhury, 2003 11/ DALY averted-
look at C/E of the activity, not the procedure
4
DCPDC Estimates as District Hospital Level
(2x more C/E than community
clinic)

• best worse (/DALY averted)
• EAP 30-130
• EEur-CA 45-140
• LAC 50-165
• MEC 35-180
• SEA 25-70
• SSA 20-100

5
HOW?

• WHO Guidelines for CEA, GBD years life lost
  tables (YLLs)
• and disability weights
• Select a sample period
• Review all hospital activity (every in and out
  patient, with
• cross-reference)
• Sum of all fixed and variable costs
• Assess effectiveness (anticipated, not real)

6
SCORING SYSTEM
Weight

• Severity of disease
• - gt95 fatal or disabling w/o tx
  1.0
• - lt95 and gt50
  0.7
• - lt50 and gt5
  0.3
• - lt5
  0.0
• Effectiveness of Tx
• - gt95 chance of survival/cure 1.0
• - lt95 and gt50
  0.7
• - lt50 and gt5
  0.3
• - lt5
  0.0

7
Examples

• 20 yo male with tension pneumothorax
• 35.24 x 1.0 x 1.0 35.24 DALYs averted
• 20 yo male, isolated femur
• 35.24 x 0.7 x 0.7 x 0.272 (long-term d.w.)
• 4.70 DALYs averted

8
Results in /DALY averted - Bangladesh
11 - Sierra Leone 38 - Cambodia
78 - Nigeria 172 - Haiti
223
9
Big Drivers

• Salaries/benefits to national staff
• (when adjusted Nigeria 116, Haiti 119)
• Fixed costs (MSF rents, Emergency builds)

10
BIASES

• Too many to count!
• Is sample period representative?
• Quality of data, charts, collection tool
• Accuracy of costing data
• Subjectivity of scoring system
• Value and validity of disability weights

11
Not sure if other CEAs in developing countries
are any better

• 540/DALY averted rotavirus vaccination
• in Vietnam
• 53/DALY averted therapeutic feeding
• program in Zambia
• 400/DALY averted ARV tx in TB patients

12
NEXT

• This methodology is still awaiting
• independent (in)validation
• The upcoming new disability weights will
• make old CEAs obsolete
• How do we translate this information into
• action/advocacy?
• Is there any need for more studies??

13
THANK YOU